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Learning with the cinema: a bridge between reality and ideas in the process of dying

María José Ortega Belmonte, Mar Rodríguez Membrive, Mercedes Sánchez Maldonado, Elena Bravo Muñoz, Ángel Corredera Guillén. María del Águila Ojeda Rodríguez, Virginia Ortega Torres, Vanesa Becerra Mayor

Centro de Salud Delicias. Unidad docente de Medicina de Familia. Málaga. (Spain).

Correspondence: Ángel Corredera Guillén. Centro de Salud Delicias. C/ Frigiliana sn. 29003. Málaga (Spain).

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Received 10 April 2007; accepted 23 October 2007


Summary

With a view to designing training scripts based on films addressing communication and the physician-terminal patient-family relationship, a cine-forum work with the philosophy of learning among peers was designed. The analysis is complemented with transcriptions from focus groups made with the families and carers of terminal patients. Five films were analysed: Wit, My Life Without Me, The Barbarian Invasions, Cést la vie and The Doctor. Here we present the results of the study and an example of a teaching script using Wit.

Keywords: Palliative care; Medical education; Cinema; Terminal patient.


Medical training focuses on students’ learning skills and their gaining the knowledge necessary to develop skills aimed at curing disease and saving lives. However, reality demands that we seek other types of solution when it is not possible to cure; solutions that day by day are increasingly demanded by patients, families, and society in general.

Palliative care forms part of the training curriculum of the Family Physician. In the program of this speciality (1), specific mention is made of the need to learn skills for communicating with terminal patients and their families, not overlooking -of course- skills in diagnosis and symptom control. The teaching methodology used for such training has been developed in theoretical-practical sessions in which techniques of dramatization are often used and in which literature and the cinema are attracting increasing attention.

The constructivist conception of teaching and learning has highlighted the importance of interactions among peers (over and above the teacher-student interaction, which was the only relevant one in traditional schools). What is needed is to structure this interaction in such a way that it will guarantee that those involved will really learn. On speaking of peers we are referring to people who occupy a similar status or social position. This is why here, under the term leaning among peers we are speaking of students who learn with students; teachers with teachers; professionals with professionals and in general volunteer people who interact to learn cooperatively1.

When speaking of learning among peers it is useful to use the three classic dimensions of Damon and Phelps2. At one end of the spectrum we have peer tutoring (teams, or generally couples, characterised by different levels of skills and some roles, tutor and tutee, who are clearly asymmetric). At the other end we have collaboration (the team members have a similar level skills, although different). In between, there is cooperation (teams with similar heterogeneous skills and symmetric roles).

For us, the term cooperation or cooperative learning is a blanket term that covers tutorial and collaborative practices, since if one observes a team working cooperatively over time carefully one learns that its members alternate these two types of function.

The cinema has been used for some time in education and is now a given, together with literature, in the most humanistic aspects of medical teaching. The view of society through such communications and opinion-based media will enrich our reflections on professional values, ethics…

Although the opinions of patients also appear in these literary and cinematographic arts, investigation –especially of the qualitative type- sheds light on the opinion and feelings of patients and their families, who are the true protagonists of the process.

In sum, here we report a work, which is pertinent from the point of view of the skills forming the training program, based on the pedagogical philosophy of peer learning, using the cinema as an element of analysis that expresses the social view of the problem, contrasting this view with the results of a work carried out with focus groups (a qualitative research technique) made up of carers (families and professionals) who were attending to terminal patients2.

Aims

The aim of this work was to compile a teaching script that would be useful for training students in communications skills and the physician-terminal patient-family trio based on the contents of some films.

Materials and Methods

The study was carried out at the teaching unit of Family and Community Medicine of Malaga between June and September 2006 by resident physicians of the unit: four from the first year, three from the third year and a tutor (monitor).

Material:

The films Wit (2001) by Mike Nichols; My Life Without Me (2003) by Isabel Croixet; The Barbarian Invasions (2003) by Denys Arcand; C’est la vie (2001) by Jean-Pierre Améris , and The Doctor (1991) by Randa Haines.

The views of the family members obtained from the transcriptions of focus groups (groups sessions)3.

Methods:

Reflection groups of professionals focused on the task. Cine-forum methodology for the analysis of the films.

Five cine-forum sessions were held, understanding these as “that group pedagogical activity which, based on the cinema as an axis, aims, from the establishment of an interactive dynamics among the participants, to discover, give life to, and reflect on the realities that obtain in the group or in society”4 with the methodology proposed by Almendro et al.5. The duration of the sessions varied, depending on the film analysed.

The results of the group comments were noted down and this information was related to and contrasted with that of the focus groups made up of patients’ relations and health professionals (the doctors and nurses looking after the patients).

Observation of group dynamics was performed by the tutor-monitor of the group.

Emerging ideas that elicited unanimity of a contrasting of opinions were recorded.

The final transcriptions and comments were ratified by the group members.

Results and Discussion

The most outstanding points of the analysis were used to constitute the different sections of the script, in which the observation, the comparative comments and the corresponding didactic contents were distributed.

Then, the topics most relevant for the observers and the comments relating to them extracted from the transcriptions of the focus groups were


1. The different ways of dying

“Ideal death” is represented in The Barbarian Invasions. In this film, the patient decides when, how and with whom he wishes to die. A death without pain, presided over by his loved ones (son, wife, lovers…: only the daughter lost at sea is missing and even from her he receives a recorded message); where he wishes (in a house close to an almost paradisiacal lake); at the time he decides and above all with no pain (by active euthanasia with drugs). The drama of this experience is softened with almost pleasant situations, and with complete availability of health, economic, personal and affective resources. Even the health resources are obtained from outside the usual channels (a special room with a function completely different from the rest of the centre is set up in a hospital) (Figure 1).

We see “the unwanted death” in C’est la vie. In it, the protagonist dies almost alone in a room in the hospital We see daily reality (the personal interests of the staff who attend the patient, represented by the doctor’s assistant who prioritises the research even beyond the decisions taken by the patient with respect to her resuscitation) An occult and isolated death, without family (in a restricted-entry ward owing to the immunosuppression resulting from her treatment).

Regarding “this” point of view of the professionals, the reflection made by a family member concerning dignified death in the focus group is relevant.

He lay back, he was very good, I was sitting with him. He said “take a bit of pillow, you’re very uncomfortable there, why don’t you go home?” – “No, no” I replied, “here’s your food tray; do you want me to feed you?” “I wanted him to talk, to say something” I gave him the tray, he picked up the spoon and went like this (as though he were trying to feed himself but couldn’t), he dropped the spoon and it fell on the tray. I got frightened, so I said “Speak!. Say something. Are you OK? Are you sleepy?”

I, I was completely back to front. I was a bit…. I was feeling down. I began to feed him, but he couldn’t swallow anything, the soup was falling all over him, I cleaned it off and said “No more soup, no more anything”. I saw that he was dying. He fell asleep and an hour later he awoke “I’m bursting my bladder!” I answered, “It doesn’t matter, wet yourself, you have a pad on, I’ll put another one on later. When he wet himself I felt sure the end was near -bang- he did not open his mouth or complain, he let his head fall back. And at 10:30 on Sunday he said “Ah, I’m falling, I’m falling, I’ve been asleep” “He threw his hand back, like this, and just stayed like that.

“An intermediate situation” is seen in C’est la vie. Death is presented within the context of life and also of its agreeable moments: an approach to the end amongst weddings, birthdays…, moment of fun, but also reflecting cruel reality.


2. The place of death

The ways of dying shown in the cinema are encompassed within the physical places aimed at providing a suitable background for the ideas discussed above. It is not worth going too deep into the description of the space, the colour, the dimensions, the decoration…, such images undoubtedly belong to the actual language of the cinema. The closed, aseptic spaces of Wit, the waiting rooms where the bad news is received in My Life without Me (Figure 2), and the journey from the shared room at the hospital to the house by the lake in The Barbarian Invasions, passing through the “transformed” room of the hospital.

In C’est la Vie, the institution closest to the “Hospice” model (the Anglo-Saxon model of Cecily Saunders) is presented.

In our group, the moment of going to the place of death emerged as a point of inflection in the establishment of terminality (the imminence of death). When does one have to go to that place “of death”? This is the question asked in C’est la Vie, with the entries and escapes of the patient, depending on the degree acceptance of the terminal phase.

For family members, the physical place of death is not so important; what is really important are the conditions in which the patients are in and whether it is possible to achieve as much care as is available. The place is accepted if possible in order to avoid suffering and satisfy the needs of the patient and carer.

This was the complaint of one family member who asked for help:

I called by phone several times, because I took my father there thinking that he would be seen by a doctor, not for him to be left alone on his own not for him to be abandoned, because we don’t have any experience. It is you who have it.


3. The role of the physician

Different models of doctors have passed through the cinema. In The Doctor and in Wit, the “Biologicist” model is presented and criticised; the doctor who becomes entrenched in the technological and pharmacological development of the profession. In My Life without Me, we see a more humane side of the profession in the person of a doctor who suffers when communicating the diagnosis of a terminal disease and a not-too-distant death. In C’est la Vie, a doctor with lumbago attends a terminal patient who seems to be healthier than the doctor himself.

We must also reflect on the alternatives suggested in The Doctor in order to develop empathy with these situations. Must we suffer illness in order to understand it and our patients, either in reality or by getting into bed with the patients and simulating their symptoms, as suggested at the end of the film? In sum, we are talking of how to train emotional skills such as empathy (Figure 3).

Where is the professional who “knows”; where is the “best” doctor? In Wit, we see this person as an accredited oncologist who shares the status of university lecturer with the patient; who apparently does not have any news of the daily suffering of his patient. His appearances are sporadic: at the time of the diagnosis; during the “great round”, surrounded by his students; on a visit destined more to his own students than to the sick person in a crisis situation.


4. The “more or less informal” carers

In the films analysed, there are references to people in the patients’ surroundings who have different views of the process of death and who intervene from different points of view. They are more or less informal carers who play important roles in the films.

In The Barbarian Invasions, a view from the Christian side is offered through the person of the nun who tries to comfort the patient, who is an atheist, with her religious beliefs. Also striking in this film is the role of the drug addict, who seems to represent a person aware of her own continual dicing with death and, precisely because of this, is closer and better accepted by the patient.

In C’est la Vie, we learn of the physical and cheery care given by volunteers. This is the particular case of the protagonist’s carer, who refers to the need to care as autotherapy for her own grief at the death of her husband whom she was unable to care for herself (photo 4).

In The Doctor, we see the understanding of a terminal patient by other patients: June Ellis (Elizabeth Perkins), who with a high degree of awareness and acceptance of her own disease process appears to be the person best able to understand and make the protagonist think.


5. Emotions in patients and in family members

The loss of identity a person has before falling ill is a common thread in the films analysed. It is represented in the action of removing street clothes and replacing them with a hospital gowns; this affects all patients and perhaps strips them of some signs of the personal identity.

They will no doubt write about me. But I flatter myself. The article will not be about me... it will be about my ovaries. It will... be about my peritoneal cavity” says Vivian Bearing (Emma Thompson), the protagonist in Wit (Figure 5).

The allusions to unawareness of the patient’s name or to confusing one patient with another (in a humoristic key) is a constant in the cinema and also reflect that “ceasing to be” at that time.

In contrast to dressing the patients in gowns is the scene in C’est la vie , in which the carer cuts up a tee-shirt so that she can put it on the patient despite the tubes and catheters.

The range of experiences, emotions and reactions that the patient andrelations can perceive, express or fell is huge. Among them we have:

– The stealing of the right to decide one’s own life posited in The Doctor.

– Denial, incredulity, is very common among the usual reactions. In C’est la vie, the patient doesn’t believe in the reality of his demise; he doesn’t know how or when to start using the term “terminal”; he isn’t one of “them”; he is still asymptomatic.

– The resistance to seeing reality together with the fight to explore all possibilities and struggles against “collateral damage” (the Calvary) that this implies. This can be seen perfectly from the following: I didn’t hide anything, but I was not really aware of the severity of the situation. I saw it but I didn’t want to see it… He read everything, I didn’t hide anything from him… Apart from that text I didn’t see him so ill and neither did I want to attach too much importance to it. Later on yes, I saw him worse and worse but at the beginning I was full of hope. Hope is the last thing I lost, well until the moment arrived, I didn’t lose it. My husband had all kinds of doctors. I went through all the possibilities, even saw some quacks who I’d seen on the TV; Chinese medicine; paid rehabilitation, dietary products and natural stuff that cost me 300 euros a month… you explore literally everything you can, you go everywhere.

and the Calvary started,. The pain clinic, which didn’t do anything for him, the Carlos Haya Hospital, where they gave him radiation therapy, which didn’t do anything for him either… I went to speak with the family doctor and I said “Doctor, what’s he got?” Then I went to another doctor, who gave me a letter for Seville… All our tiny savings went on Seville, back and forth, doing tests all the time. From hospital to hospital, he was in the clinic twenty-three times.

Coinciding with this is the denial of the wife of one of the protagonist’s friends in The Barbarian Invasions: Disease is born in the mind and is cured in the mind, a comment appealing to hope in non-traditional knowledge.

– Fear of death is reflected in all the films and ranges from personal references in which the carers and accompanying persons are left out except, perhaps, for the other patients, Accompany him? Nobody can palliate or help to accept something that nobody is prepared to accept.

– The isolation and loneliness, which are magnificently portrayed in Wit, where even the number of actors is limited.

– The need to believe in “something higher”, which with a certain tone of envy the nun shows the dying person in The Barbarian Invasions.

– The need for control and the fear of losing it are reflected and made explicit in Wit and My Life without Me.


6. The symptoms

This is the aspect that has received the least attention in this analysis and, additionally, symptoms are only sketched in the films studied. Despite this, they must be addressed, even though only in passing, because they are essential both in medicine in general and in palliative care in particular, the latter dedicating more attention to them.

In general, the films show the most common symptoms in oncology: vomiting secondary to treatment, hair loss…. loss of appetite, fever, pain,… and the weakness the condemns the patients to life in a wheelchair or prostrated in bed (Figure 6).

The anorexia we see in The Barbarian Invasions is presented efficiently when we see the protagonist shy away from delicatessens, which also announced the closeness of the end.

Alterations in the fluid balance are seen in Wit like the assets and debts of a bank account that will inevitably end up in the red.

Patients and their symptoms in real life have a less artistic and ironic reality.


7. Communication and the issue of the words.

My only defence is the acquisition of vocabulary comments Vivian in Wit.

In the focus group of physicians the following comment was made: One of the things that these people most elicit in me is the issue of that on one hand you believe that the patient wishes to know and on the other the family want to hide the truth. You are in the middle of all this, between the family and the patient, and often you don’t know how to get your head around it all. On one hand the family covering things up and the patient, well you don’t really know… You’re caught between two fires, between a rock and a hard place….

In another group, one of the nurses commented: What’s clear is that we are not sure if they ought to known or not. This makes us feel very uncomfortable.

My Life without Me offers a magnificent representation of the anxiety of the doctor at these times (Figure 7), with all the nuances of a given situation but from our point of view highly generalizable.

The title of this article includes the phrase “in the dying process” and “process” is what best describes the development of the communication of bad news.

Several moments in this “action of going forwards” by giving bad news can be distinguished:

1.- At diagnosis: You have cancer. Miss Bearing, you have advanced metastatic ovarian cancer. (said by the oncologist to Vivian in Wit) Along the same line is the comment of the daughter of a deceased patient: Look, don’t worry. Your father is 79 years old and he has a tumour. At his age we can’t really operate. It’s a malignant cancer, he’s old…

2.- In the prognosis: the discussion established by the protagonist in Wit regarding the insidiousness of her cancer is another way of talking about the prognosis. In My Life without Me, the patient specifically asks about her prognosis and the time she has left. Patients also recall these aspects:When he was going to give us the results, he told us to come into the office, where he said that there was nothing to do; my husband was beyond recovery and that he would pass away soon.They said that his liver was completely invaded; that more tests had to be done because they didn’t know where the tumour was from. The fact is that they weren’t curing anybody. Upon notification of the closeness of death: the nurse who looks after the protagonist in Wit informs her about the situation and asks her about possible resuscitation or not at the time of death.


8. The family and the carer

In Wit and C’est la vie, one striking aspect is the absence of family and even of friends and acquaintances. The protagonists of

these films are people who live the dying process without close family (Figure 8).

The image of the principal carer in The Barbarian Invasions is clearly shown in the plot. He is the quasi-omnipotent son who is able to find the resources and adapt the needs of his terminally ill father to the reality of the situation. The “natural” carer, in our society, is usually the wife, daughter or daughter-in-law.So the son is perhaps a bit different in that rather than a “carer” he can be seen as a “manager” or “facilitator”.

This is ratified by the comment of one of the members of the focus carers’ group: My father-in-law said that he didn’t want to be with his son. He was his son and he wanted to be with me. God, he loved me!


9. Technical details of Wit

Table 1 shows, as an example, the teaching file of Wit resulting from the process described.

General objectives

Analysis of the personal characteristics of the health professional

Analysis of the caring environment of the terminal patient

Analysis of verbal and non-verbal communication

Analysis of information skills

Analysis of the professional role: the limits of technical interventions

Sequences

Didactic content

Central topic

Information of the diagnosis given by the oncologist at the start of the film

Communication of bad news at diagnosis

Information and bad news

Information from the nurse about the closeness of the end and the issue of resuscitation

Communication of bad news at prognosis

The assistant gives the patient a pelvic exam

Communication about interventions in the patient.

Vivian refers to what will be published after her death

Scene where the doctor speaks to her in the past.

The team goes on the rounds

Loss of identity as a person and becoming a “thing”

Respect towards the person.

The sick person at centre of the process

Reflection by the patient as regards the question “how are you”?

Later sequence in which the premonitions of the patient become real

Formality in the doctor-patient relationship

Characteristics of health professionals:

Empathy.

Transmitted in non-verbal and verbal communication.

The patient develops a pain crisis without a response from the doctor.

Absence of empathy

The assistant doctor, in training, explains the interest in studying cancer

The nurse informs about the terminal nature of the situation and the decision about resuscitation

Care close to the patient, therapeutic distance and assertiveness

Assertiveness, the role of the health professional.

Initial information about the process and request for the patient to enrol in a clinical trial

Information and informed consent

Ethics, the dilemmas between research are care

Vomiting, hair loss, weight loss…, …

The symptoms of the terminal patient

Image of the patient and their physical deterioration

Vivian reflects about the treatment and its side effects

The limits of the interventions

The role of caring as opposed to that of curing

Admission, a change of clothing and the first clinical history

The loss of identity

The patient’s emotions

Isolation and the visit by the patient’s former teacher

The emotions elicited by suffering

Protests about the tests

Anger and denial about the care (more or less right)

The chat with the nurse

Acceptance of the end


Conclusions

The methodology employed shares the virtues and defects of qualitative methods.

Research with qualitative techniques permitted the drafting of 5 scripts, from the same number of films, useful for fostering reflexive thought; thought open to many new contributions. The aim was not to deplete the possibilities of a film; not even the interpretations made of a single sequence.

It should be stressed that the appreciations of a reduced group of professionals gain validity for future generalisation in the sense that they address more spontaneous aspects than those that the scientific literature establishes as priorities and that, sometimes, are not perceived as such. Therefore, the satisfaction of the needs of the person who is learning has been prioritized over the excess information coming from someone who “already knows”.

The teaching dossiers thus compiled perhaps come closer to the way of thinking about other “equals”,who is turn can develop these contents by cooperating in a learning model that is more constructive and less dependent upon established knowledge, although not separate from it.

In sum, we describe a working experience with a model developed with familiar tools, easy to apply, not overly time-consuming, which in themselves bring learning to the authors themselves. A model that offers a small facet of the vast extent of knowledge in this field. Its efficiency in the training of other professionals requires further studies involving other groups.


References

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Figure 1: The Barbarian Invasions is an example of the “ideal death”. The protagonist decides, when, how and with whom he is to die (American poster)

Figure 2: In My Life without Me the bad news is received when the protagonist is sitting down in a hospital waiting room (American poster)

Figure 3: ¿Must doctors get sick to be able to understand their patients, as happens in The Doctor? (American poster)

Figure 4: Patient and carer (French poster)

Figure 5: They will no doubt write about me. The article will not be about me; it will be about my ovaries. It will be about my peritoneal cavity. (American poster)

Figure 6: Vivian’s hair falls out, she suffers prostrated in the bed

Figure 7: The anxiety of the doctor when communicating a fatal diagnosis in My Life without Me

Figure 8: Dimitri (Jacques Dutronc) the protagonist of C’est la Vie dies alone