“Extremis” means the crucial point before death.
It’s measured by the level of stress and the length of time patients suffer as they die. You often hear people express consolation to the family with the kind words “at least he didn’t suffer” or “she died with dignity.”
In the short-film “Extremis,” Dan Krauss brilliantly depicts how patients endure tremendous suffering and loss of dignity through the efforts of well-intentioned physicians and family members.
The documentary begins with Dr. Jessica Zitter, an intensive care and palliative physician, who is trying to determine a patient’s wishes. The anonymous patient can’t speak and appears to be incompetent. Dr. Zitter’s creative attempts include having the patient scribble answers on a clipboard and spell out words in the air. These efforts are futile and border on being cruel. Is it ethical to question patients in extremis? Why ask a patient anything when the physician knows the appropriate answer?
The documentary allows the viewer to peek in on several ICU patients at Highland Hospital in Oakland, Calif. Two are on life support with family members at their bedsides.
The ICU is often described as a place of limbo. Strong doubts exist as to whether any of these patients will recover, yet hope abounds. Hope, however, comes at a cost – the amount and time a patient has to suffer and the increasing risk that a patient’s dignity will not be respected. Subjecting terminal patients to this level of care appears more like punishment than palliative medicine. Yet, this has become standard practice for end-of-life care. The documentary should leave viewers frightened and shaking their heads – saying, “ain’t it a shame – someone ought to do something.”
Dr. ZItter offers a resounding story about a nurse who challenged her practice of medicine. Dr. Zitter was inserting a large IV into the neck of a critical patient when the nurse standing in the doorway looked her straight in the eyes and shouted, “Call the police. The doctor is torturing the patient.” The bombshell that saving certain lives is criminal gives viewers a wake-up call. The ignorance and bullying that exists in the healthcare care system is overshadowed by the claim that “This is for your own good.”
Patient autonomy and self-determination allow patients to formulate a personal statement, “Someone ought to do the right thing for my own good.” A self-respecting person completes an advance directive. An intuitive husband understands how to love his wife as he does himself. An astute physician has the wisdom to know the difference between torture and respect.
Having to contend with God, physicians, and family members in the moment of extremis raises issues the patient needs to address well before admission to the ICU.
A person who wants to be responsible for their own their end-of-life care must do so when they are of sound mind, body and spirit. What to think, do, and feel after watching “Extremis” can leave you feeling helpless. But consider it a valuable lesson.
In this four-part series over the next three issues of Dr. H’s Clipboard weeks, I’ll discuss a holistic approach to “Extremis.” You’ll learn about mindful considerations, practical considerations and spiritual considerations that dictate how the patient should be treated, or left to die.
Being of sound mind, body, and spirit insists that you are prepared for the inevitable. Believing that you are invincible is foolhardy and adds to pain and suffering. Only you can guard against the loss of dignity that so often occurs during extremis. Take the steps necessary to make sure that you receive compassionate end-of-life care through advance care planning.
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