End Game [subtitled in part]

End Game

I saw End Game as part of a five-film package of Academy Award nominated documentary short films, along with Black Sheep, A Night at the Garden, Lifeboat, and Period. End of Sentence. I liked three of the five quite a bit, and really all five are well-done and are on important subjects. But if I had to pick the best, I’d go with End Game. It’s 40 minutes long, and I was engrossed in it pretty much the whole way.

Set in San Francisco, End Game is about patients who are dying, and the way they, their families, and medical professionals approach end-of-life decisions. Filmed primarily at a University of California at San Francisco hospital and at a local hospice, we spend time with and get to know several patients, including a middle-aged Iranian woman and her husband and mother, and several doctors, nurses, and volunteers, including the triple amputee doctor who runs the hospice.

It’s an intelligent, respectful, emotionally moving film about people in extremely trying circumstances, and those who have made it their life’s work to assist those in extremely trying circumstances.

Scene after scene, moment after moment, in this film touched me.

I really liked the Iranian family. Sometimes the husband and the mother differ on the best course moving forward, but there is no animosity to it. Everyone is trying very hard to do the right thing, each in their way putting the dying woman before themselves.

Bruce, a terribly emaciated Chinese man brought to the hospice to die, is told by a staff member “I think you’re becoming quite popular around here,” a claim you can dismiss as just idle flattery to boost his spirits, since for all intents and purposes he can’t even move or speak, yet there is a kindness in his eyes and in his feeble attempt to smile that makes it somehow not ludicrous that there could be something about him that charms the people in the facility.

The triple amputee doctor is certainly an inspiring figure. Having lost both of his legs and most of one arm in an accident at 19, I’m not sure if it’s more impressive that he still completed a medical education or that he is such an upbeat, positive person. Clearly he has found his calling, helping people the way he does.

For that matter it’s striking how caring all these people are, and what fine bedside manners they have, and that includes many people doing this work on a volunteer basis. I always hope that people who work in a field like this will be able to resist the tendency for the extraordinary to eventually feel ordinary, to become jaded and treat as routine that which is a crisis for those experiencing it for the first time, but I also assume that doing so is nearly impossible, that you have to detach emotionally and not get caught up in the enormity of it all or you’ll burn out very rapidly. But as far as what we see in this film—which, granted, could be a product of how it’s edited—these people seem to be as caring and understanding toward the hundredth or thousandth dying person they’ve worked with as toward the first.

I note that more than one patient, or family member on behalf of a patient, expresses resolve to “fight this,” to hang tough and courageously battle their way back to health. On a certain level I like and respect that attitude, but I also am kind of saddened by the realization that it’s just not applicable in these circumstances.

That is, certainly there are a lot of illnesses, a lot of conditions, where how hard you’re willing to hang in there and fight really is causally relevant to your prognosis. But once you’ve passed a certain point with something like cancer, no psychological factor like that is relevant any longer. There’s no hope, and you can’t generate hope as a self-fulfilling prophecy. You’re about to die. You’re not Muhammad Ali trying to summon the will to leave his corner for one more round against Joe Frazier in Manila in 1975; you’re Ali standing in the center of the ring with a two-ton weight hurtling down just a split second above him. There’s no attitude you can adopt, no strength of resolve you can manifest, that’s somehow going to keep you from being crushed.

I think the whole “I’m going to hold out for a miracle” thing is misleading in just this way. Certainly there are plenty of anecdotes, from religious folks especially, about how “all the doctors insisted there was no hope,” but so-and-so believed and prayed and shocked them all by recovering in full. But what I think is typically going on there is that it’s a situation where a patient’s condition has deteriorated to where there’s a 70%, 80%, maybe 90% chance they’ll be dead shortly, and so their doctor has “the talk” with them to advise them that it’s time to prepare for death, to get their affairs in order, etc., and then in the 10%-30% of cases where, for reasons perhaps not yet fully understood medically, things don’t subsequently go as they usually do, those folks insist a miracle occurred that somehow refutes what their doctor told them.

There are other cases, though, like these patients in the film, where it’s 100%, where it’s too late for even a minority of people to go into remission, and those folks never get their “miracle.”

One of my best friends is an oncologist, and I’ll never forget the day he permitted me to be present when he told certain patients that their cancer was incurable, that it was now time to focus on end-of-life issues. One gentleman, an imposing 60-something retired blue collar worker as I recall, assertively told him that he and his wife were absolutely committed to fighting this thing all the way, that he would be the most cooperative patient a doctor ever had in doing anything and everything he was told to do to battle this cancer. “Doc,” he said, “We’re determined to whip this.”

I talked to my friend later about this patient, telling him how impressed I had been by his spirit. He agreed, and said that he really was a great guy, and would surely prove to be as determined as he had said he’d be. I asked if that indeed gave him a chance. He unhesitatingly, matter-of-factly, said, “No, not at all,” that his cancer was past the point of anything like that mattering. Perhaps it would make him feel better to think he was fighting it to the end, but it wouldn’t have the slightest impact on his cancer, which had spread widely throughout his body by then, or on his impending death. And he was in fact dead shortly thereafter.

Mostly the medical professionals in the film treat their dying patients with the respect of being honest with them. Their manner is very patient and understanding, but the actual substance of what they’re saying isn’t sugarcoated. They explain to them what’s what, talk to them about their options, listen to them, respond directly and understandably to their questions, etc. I like that. This isn’t a time for bullshit, even benevolently-intended bullshit.

One exception is when the hospice doctor is talking to a patient, and I sense that on the question of life after death, he kind of feels out the patient so that he can then agree with her. First he tentatively suggests that you shouldn’t let afterlife considerations affect your decisions, because there is no evidence at all about what happens after we die, nothing to base any beliefs on. But then he probes in the other direction, bringing up the near-death experiences many people have reported that seem to support the idea of an afterlife, and when the patient appears receptive to this, he continues on that track.

The problem is that the supernatural interpretation of those experiences is highly unlikely, as they are much better explained as delusions caused by impaired brain function. He presumably knows that (though perhaps not; even medical professionals aren’t completely immune to wishful thinking and he might well sincerely believe these experiences reveal what happens to us after we die), and is just saying whatever he has inferred will make the patient feel better.

Of course the overwhelming majority of people would have no problem with that, and would endorse that kind of paternalistic communication. You know, “The woman’s dying. Why not tell her what she wants to hear if it’ll make her feel better?” But I’m more hard core about truth, and so I like that this conversation is in fact an exception, that mostly the medical people in this film are very genuine with their patients.

I’m not saying one should go out of one’s way to blurt out truths that will cause further suffering to a dying patient. But if I’m the patient, or a family member, I don’t want to be patronized by someone strategically trying to ascertain what I want to hear. Just be straight with me.

Because I greatly admire the job these folks do, and how they’ve found a career where they can make a genuine positive difference in a lot of people’s lives, that caused me to think about whether I would or would not be suited to this kind of work.

I lean toward the view that it would not fit me, but interestingly it’s not for the reason I think most people would cite. As I mentioned, I have to think it would be an emotionally very difficult job, trying to remain engaged with every patient you work with, to never forget the enormity of what they’re going through, and yet to somehow not let this constant emotional engagement burn you out. I would think that challenge is what would keep most people away from this line of work. But that’s actually not the factor that most dissuades me from a profession like this.

Instead, I have a real problem with following the “rules” in dealing with people. That is, I need to be a hundred percent free to be myself and to deal with people as I believe is best at any given moment. But when you do something like this professionally, and you have to satisfy a licensing board, regulatory body, employer, insurance company, whatever, there are other people who have determined what is to be done, and—granted, with a certain amount of room for individual variation—you are required to do things that way.

These are rules and “best practices” that have typically been developed over time through processes that are positive in some respects (they can represent a sort of collective wisdom acquired through experience) and not so positive in others (they can be motivated by lawsuit avoidance and unjustifiably err on the side of covering your ass, for instance). If you’re an end-of-life counselor, or for that matter a therapist, teacher, what have you, you relinquish a certain amount of your autonomy to base your actions on your own best judgment in order to be accepted into the profession and be allowed to do that job.

Like I say, I really like how these professionals come across in this film. But even if I agree with them 80% or 90% or 98% of the time, that means a certain amount of time I don’t, and because I resist conformity I would have a real problem with behaving as the job requires in that minority of situations where I disagree with the prescribed methodology.

Ironically, it’s precisely because I value this kind of work that I would have the most difficulty pursuing a career in this field. If I were stacking shelves, and I thought it made sense to do it one way, but I was told that, no, we do it this other way, I wouldn’t think of it as an objectionable compromise to switch over to doing it the required way. But it’s different when it’s a matter of how to interact with a human being concerning important life issues.

I don’t want to come across as arrogant about it, like I know better than the people in a given profession who have risen to the level necessary to establish the standards that others must follow. I’m more than happy to consider any such standards, and I might well change my mind about some of them if they were accompanied by compelling arguments. I just don’t like being told that I have to interact with people in certain ways and not others regardless of what I think of the merits.

Compare it to parenting. Or friendship. No doubt there are better and worse ways to parent or be a friend. But I’d have serious misgivings about having kids if there were some governmental body that said you have to do this, this, and this, and cannot do this, this, and this. (I know that in a sense there is—Child Protective Services or whatever—but they generally only get involved in really extreme cases.)

Granted, most people suck at parenting, and in a sense it would likely be an improvement if everyone parented according to whatever is the current consensus among psychologists and such who specialize in parenting. But, again except in extreme cases, we let people parent as they think best, in all different styles and with all different philosophies, and would be justifiably very resistant to any kind of coercively enforced parenting policies.

So while in some ways I would welcome the opportunity to make people’s lives better by spending time with dying people, acting in a caring manner toward them, listening to them, etc., I wouldn’t want to have such a job where someone can tell me, “OK, we only bring up this topic at this stage of the process. We never call x this, but only that. If someone says such-and-such, you’re required to note it on this form and submit it in this way. Be sure to use only this tone of voice when discussing this. Any talk about such-and-such is confidential, so you can’t talk about it if anyone else is in the room,” etc.

Again, as suggestions a lot of such things likely have merit and I would be happy to consider them and the reasons offered in their support. But what I don’t like is, “We don’t have to justify it to you. These are the rules and this is the way you’ll do the job or you won’t be allowed to work in this field.”

I wouldn’t want someone telling me, say, how I’m required to be a friend. Like, “Never use sarcasm when talking to a friend. Affirm them in such-and-such a way, with at least such-and-such frequency. Be available to them at least such-and-such amount of time per week.” And so on. There’s no such script, or at least there shouldn’t be a mandatory one, for friendship.

Anyway, enough about that. I’m sure I’m articulating it poorly and anything I say will be easily dismissible as, “This guy wants to be an end-of-life counselor where he gets to do whatever he pleases, as if he somehow knows more about it than the leaders in the field. He’s completely ignoring all the trouble you can get in and all the damage you can do if you just leave everyone on their own in a profession to make it up as they go along.” Let’s just say I’m bad with structure and leave it at that.

Another thing that occurs to me in connection with this excellent film is that I’ll bet it would be a common concern of the patients and their families who participated, or of those who were given the opportunity to participate and declined, that it’s unfortunate that viewers will see these folks only as they’re dying, and not as they lived. You know, like, “So-and-so wasn’t always confined to a bed with numerous tubes stuck in her, barely able to function. You’re not seeing the whole life, the whole person that we know and love. She is so much more than just an unhealthy body wasting away.”

But in a strange way, I do somehow get an appreciation of their full personhood in contemplating these people.

Consider the Iranian woman. She is sometimes able to speak slowly and fairly coherently, but usually not even that. (I’m guessing she’s regularly zonked out on pain pills when the pain is too severe.) She’s bald. She never gets out of bed. She interacts only minimally with her family. We see a couple of still photos of her from before she got sick, but that’s it.

Yet listening to what her loved ones say about her, seeing how they behave toward her, watching her facial expressions, I get a clear sense that this is a full person who has lived a life that mattered, that touched the lives of numerous others.

Or take an extreme case like the Chinese guy Bruce. I have no clue whatsoever what he did for a living, how he treated his family, what he accomplished in his life that he’s most proud of, etc. But I don’t just see him as some shriveled up, malfunctioning body. His humanity, his personhood, his individuality shine through even in the very minimal amount he is able to interact with people.

Yeah, I don’t know the specifics of their lives, but no one has to remind me that, “These people weren’t always like this. They’re so much more than just their dying selves, and it’s a shame you never knew them as they were.”

Actually I have a few more thoughts about End Game, or at least about the topics that it raised in my mind, but what I’ve written already is a good indication of just how rich a subject matter this film addresses, and how well it does so.

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