End of life: A comma or a semicolon?

By Teresa ‘Teri’ McLean | 12/17/2014

A nurse reflects on the movie “Wit.”

Nurse walking quickly

The U.S. Patient Self-Determination Act (PSDA), passed in 1990, launched a nationwide effort to inform adult patients of their right to refuse life-sustaining measures in health care institutions. As a result, advance directive paperwork is now included in the hospital admission process. The purpose of an advance directive is to clarify patient preferences regarding resuscitation, intubation, mechanical ventilation, artificial nutrition, and hydration.
 
Unfortunately, despite the law’s intent, evidence indicates that many advance directive discussions are too superficial or occur too late (Yuen, Reid, & Fetter, 2011). One retrospective study determined that only 50 percent of chronically ill and hospitalized patients who verbally stated they did not want CPR actually had DNR orders on file (Robinson et al., 2012). Rarely are the concepts “natural death” or “comfort care” presented to clients.
 
Perhaps by revisiting the 2001 television movie “Wit,” nurses will feel more compelled to complete DNR paperwork. By reflecting on this movie, health care professionals will be inspired to build relationships, learn their patients’ wishes, and advocate for them accordingly.
 
Life and death
In the movie, patient Vivian Bearing, played by Emma Thompson, has metastatic Stage IV ovarian cancer and agrees to participate in a research study. The critically ill patient and her nurse, Susie Monahan (Audra McDonald), develop a trusting relationship upon which an end-of-life discussion can be built. Oncologist Harvey Kelekian (Christopher Lloyd) and his protégé, Jason Posner (Jonathan Woodward), supervise Bearing’s experimental chemotherapy and assure her that, by completing the therapy, she is making a great contribution to knowledge.
 
Kelekian, a research scientist, and Bearing, a scholar of 17th century poetry—both uncompromising academics—apply the forces of their intellects and wit to understand life and death. Bearing’s academic mentor, Evelyn E.M. Ashford, and nurse Monahan balance the intellectual with the humane by teaching the scholar the importance of acceptance. They help Bearing understand that death is not a barrier to conquer with intellect but a simple truth to embrace with dignity.
 
Like her literary hero John Donne, Bearing has devoted much of her academic career to analyzing life and death. Although a self-proclaimed expert on the subject—a “force” in the academic community—she has actually overcomplicated the subject, thereby misunderstanding the passage between life and death.
 
A matter of punctuation
In a flashback to Bearing’s graduate school days, Ashford points out the deficiency in her student’s thinking by calling attention to punctuation in one of John Donne’s metaphysical poems. An advocate for the poet, Ashford wisely observes that Bearing has relied on an inferior translation that uses incorrect punctuation in the stanza “Death be not proud, though some have called thee mighty and dreadful, for thou art not so. … Death shall be no more, death thou shalt die.” Instead of using a comma in the last sentence, which would have preserved the poet’s intent to communicate that death is just a pause between this life and the next, the editor of the specious translation has inserted a semicolon, which changes the meaning completely.
 
A semicolon is too dramatic, Ashford explains. A semicolon communicates that death is a struggle that one can defeat with intelligence. The semicolon is too hysterical in its portrayal of death. It makes the act of dying a spectacle, a Code Blue. A comma, on the other hand, reduces death to a simple, inevitable truth, just a pause between this life and eternal life. Death, suggests the comma, is not an insurmountable barrier to overcome, but a transition separated by a breath. The comma is natural death, facilitated by the DNR.
 
Shakespeare or Donne
If you want drama, a metaphor for resuscitation with the ACLS (advanced cardiovascular life support) team, study Shakespeare. If you want art, a metaphor for physiologic death, choose the holy sonnets of John Donne. And to learn about life and death, the mentor advises her protégé, visit friends rather than the library. The audience learns that this important life lesson is lost on Bearing when she, as a young student, forgoes developing relationships by returning to the library stacks.
           
Bearing’s lesson is not learned until, near the end of her battle with cancer, she learns to appreciate humanity and kindness through nurse Monahan. Although Monahan doesn’t know the definition of soporific and doesn’t hold an academic title, she emerges as the movie’s most powerful force.
 
Modeling values taught in nursing school—respect, dignity, rights, and advocacy—she provides tissues when Bearing cries and advocates for a patient-controlled analgesia pump. When the patient is in a morphine-induced coma, Monahan puts lotion on her hand. In juxtaposition stands young doctor Posner, who regards the patient as a vessel for his cancer cells. Bearing remarks that she is nothing but a petri dish in his important experiment. To Posner, talking to the patient is an inconvenient annoyance that interferes with his research. He is the least likely person to initiate a DNR.
 
In the dehumanizing environment of a teaching hospital, nurse Monahan provides perspective, finishing the life lessons that Professor Ashford started so many years before. In telling her patient how simple life and death can be, Monahan reminds the audience that death is simply the stopping of your heart, or your last breath. For the first time, Bearing understands that her death does not have to play itself out as a chaotic Shakespearian drama, but rather as a pause in a holy sonnet. Between licks on a Popsicle, she agrees to a DNR order. This is a beautiful scene. The compassion and kindness that Monahan shows while caring for her patient build the relationship that allows the nurse to broach the delicate subject of initiating a DNR.
 
A matter of timing
Hospital admission procedures often include canned DNR interview questions, conversations that are awkward and out of place because a trusting relationship has not yet been established. Perhaps this explains the low percentage of people who have DNRs on file at the hospital. As Glover (2013) observes, “The end-of-life conversation is an organic process—as health care providers and family members, you just have to be there, listening for those opportunities, and willing to gently pursue them when they arise.” The nurse, as modeled by Monahan in the movie, is in the perfect position to sense the right time to initiate the DNR/DNI discussion. In the correct context, the end-of-life conversation, like natural death itself, can be simple.
 
In the last scene, the ACLS team enters dramatically—complete with stage lighting. The intrusion of the loud strangers ripping Bearing’s gown off is both absurd and obscene. The audience feels relief when Monahan steps forward and, like an editor changing the obtrusive semicolon in the poor translation of Donne’s poem to a quiet comma, stops the chaos. The DNR empowers Monahan—and all health care practitioners—to become the ultimate patient advocate. It is a role nurses need to respect, embrace, and perform with pride. RNL
 
Teresa ‘Teri’ McLean, BSN, MA, is a second-career nurse who has been a member of the Honor Society of Nursing, Sigma Theta Tau International since 2011. Currently working toward adult-gerontology ARNP certification (MSN) at the University of Florida, she works on the cardiovascular unit at North Florida Regional Medical Center in Gainesville and serves on the Alumni Council of the University of Florida College of Nursing.
 
References:
Glover, T.L. (2013). A contrast in deaths. Manuscript submitted for publication. Retrieved from e-learning2.courses.ufl.edu/UFL-NGR6255-41328-52014
 
Donne, J. (2014). Death be not proud. The Biography.com website. Retrieved from http://www.biography.com/people/john-donne-9277090
 
Robinson, C., Kolesar, S., Boyko, M., Berkowitz, J., Calem, B., & Collins, M. (2012). Awareness of do-not-resuscitate orders: What do patients know and want? Canadian Family Physician, 58(4), 229-233.
 
Yuen, J., Reid, M., & Fetters, M. (2011). Hospital do-not-resuscitate orders: Why they have failed and how to fix them. Journal of General Internal Medicine, 26(7), 791-797.
  
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