Milestones
An End of Life Care film
Casual Films for
UCLPartners
Script by Richard Foster
Script Consultants:
JJ Nadicksbernd, Kate Morgan, Sarah Yardley and Caroline Stirling
Producer: CorrinaStegner
Director: Richard Higson
Characters:
Patient Mr. James Aldridge
Relative Miss Grace Aldridge (daughter)
NurseStephen
Junior DoctorClaire Jeffrey
ConsultantJonathan Evans
SCENE ONE
1.01
ROOM 12
ABOVE THE BED IS A SIGN WITH THE WORDS: “PATIENT: JAMES”
Mr. Aldridge is half sat up in a hospital bed trying to reach for a jug of water to fill his empty glass. He’s wheezing and struggling for breath.
His daughter, Grace, enters the room holding a takeaway coffee and a pile of magazines.Note Grace’s facial expression – what might she be thinking?
GRACE
What are you doing dad,
let me do that.
Grace drops the magazines onto the table (almost spilling her coffee) and goes to help her dad pour a glass of water.
MR. ALDRIDGE
I just wanted some water.
I thought you were here coming
after you dropped Layla at
nursery?
GRACE
Yeah.
It’s ten o’clock dad, I’ve just
Come from there. Grace registers how unwell her Dad is
How are you feeling?
MR. ALDRIDGE
Tired. The drugs don’t
seem to be working that well todayConsider when patients talk – what might be the meaning behind what they say? Or what might they be thinking but not saying?
(THOUGHT TRACK:
I don’t want to scare her,
but it’s never been this
bad before, Patients and families often try and protect each other, when in fact, each is thinking the same thing – how can we help in this situation?
HE HOLDS HIS RIGHT SIDE AND APPEARS TO BE IN A LOT OF PAIN
GRACE NOTICES A PLATE OF UNTOUCHED FOOD BY THE BED
GRACE
You haven’t eaten,
Are, are you not hungry?Families often find it particularly distressing when a patient doesn’t want / can’t manage food and drink
MR. ALDRIDGE DOESN’T RESPOND. HIS EYES ARE CLOSED BUT HE’S MUMBLING UNDER HIS BREATH
(Thought Track:
Why’s no-one been in and
Seen he’s in pain?
how long’s he been lying
here on his own?)Note how fear / anxiety /distress can come across as anger
GRACE
I’ll go and get the nurse,
See if they can get you
Something more for the pain
GRACE LEAVES ROOM AND RETURNS WITH NURSE STEPHEN.
NURSE STEPHEN
Hello Mr. Aldridge
How are you feeling?Note how Stephen addresses James and the use of body language
NURSE STEPHEN TOUCHES MR. ALDRIDGE’S HAND AND GIVES IT A GENTLE SQUEEZE
NURSE STEPHEN
Mr Aldridge? Can you tell me how you’re feeling?
JAMES
(Through gritted teeth)
My side …and…my chest
NURSE STEPHEN
Right, has it
been like this before?
MR. ALDRIDGE
Not that bad,no.
NURSE STEPHEN
Okay. Well I will go and
get some pain killers for you and
will come back to check on you.
But I think the doctor should come
and see you because you’re clearly
in more pain.Stephen might think this is clear and efficient but note how Grace and James react – what might they be thinking?
NURSE STEPHEN WALKS AWAY – GRACE FOLLOWS HIM WITH HER GAZE UNTIL HE’S OUT OF SIGHT, THEN TURNS SLOWLY AND LOOKS TO HER DAD
GRACE
Shall I put the music back on Dad?
HE DOESN’T ANSWER. GRACE PRESSES PLAY ON THE CD PLAYER AND WE HEAR LIGHT JAZZ EMINATING FROM THE SPEAKER. GRACE LOOKS AT THE SPEAKER, CLOSES HER EYES AND SMILES SADLY. What might be going through Grace’s mind?
1.02
CORRIDOR
THE JUNIOR DOCTOR IS WALKING TOWARDS ROOM 12, NURSE STEPHEN APPROACHES HER AS SHE ENDS A PHONE CALL ON HER MOBILE.Consider what else might be going on
NURSE STEPHEN
Sorry to interrupt Doctor,
Do you know Mr. Aldridge?
(points to room behind him)
DR. JEFFREY
Let me see…(flicks through her notes to
find him)Oh, yes, the gentleman with lung cancer and COPD, admitted with renal failure and a chest infectionConsider how it comes across when someone has to refer to notes to answer you
NURSE STEPHEN
He’s got some pain and he’s
just not quite right?
DR. JEFFREY
Have you checked his obs? In what way
is he not right? Is it just the pain? Why might Dr Jeffrey be asking these questions (e.g. trying to assess urgency / priorities in a busy day)?
NURSE STEPHEN
He isn’t eating and he’s in
quite a lot of pain. His obs are fine, but in handover everyone has the sense that he’s just not improving. I just gave him some oxynorm which has helped. How do we explain when someone is ‘not improving’? What is not being said – how can you find ways to alert others of your concerns?
CUT TO ROOM 12, MR. ALDRIDGE LISTENING TO CONVERSATION OUTSIDE HIS DOOR, CONVERSATION JUST AUDIBLE – GRACE PUTS DOWN HER MAGAZINE & LOOKS AT HER DAD, FOLLOWS HIS GAZE AND ALSO LISTENS TO THE CONVERSATIONThink about where you have conversations and who can hear you
DR. JEFFREY REALISES THEY ARE TALKING OUTSIDE THE DOOR AND PUTS HER FINGER TO HER LIPS AND THEY MOVE OUT OF VIEW
DR. JEFFREY
It says here he was responding
well to fluids and the antibiotics. What’s changed?
NURSE STEPHEN
I don’t know, but he he’s very
weak
DR. JEFFREY
OK, I’ll go and see him.
NURSE STEPHEN
Thank you
THEY WALK TO ROOM 12
1.03
ROOM 12
DR. JEFFREY ENTERS ROOM. GRACE IS ANXIOUS AND HANGING ON EVERY WORD.
DR. JEFFREY
Hello James, I hear you’re in
quite a lot of pain today? Can
you tell me how you’re feeling?
GRACE
(THOUGHT TRACK:
Why can’t Dad just see the same
Doctor, who are all these people,
do they even know what they’re doing?)Although we often get a better sense of a situation from asking questions ourselves, think how this might feel to patients and families
DR. JEFFREY
Do you mind if I turn your music
off while I listen to your chest
James?
MR. ALDRIDGE
Not at all. Do you like it?
DR. JEFFREY
I do – I don’t know much about jazz,
But I’m enjoying this. Who is it?
GRACE
It’s him, my Dad. He used to play the
Trumpet and I love hearing his old songs
DR. JEFFREY
Wow, that’s pretty cool James. We’ll have it back on in a moment once I’ve examined youWhat is important about this interaction, when Dr Jeffrey talks to James about his life? What does she do well? What could be improved?
TURNS OFF MUSIC, THEN SHE LISTENS TO HIS CHEST, LISTENS TO HIS STOMACH, FEELS HIS ABDOMEN, SITS HIM UP AND LISTENS TO HIS BACK, CHECKS HIS OBS AND CHECKS HIS HEARTRATE
DR. JEFFREY
Ok that’s great and I am gonna
need a nice deep breath in….and out.
and one more time.
In and out again.
Fantastic, lets get yourself back downConsider how this examination is limited – why might that be?
DR. JEFFREY
Ok, You’re in a lot more pain today
aren’t you James?
MR. Aldridge
I’m not getting any better Doctor
Think about how James answers the question
DR. JEFFREY
We don’t know that for sure.
Let’s do some more blood tests and
check a few things out, alright?What might Dr Jeffrey think she is doing here? (e.g. not jumping to conclusions) and what impression does this give Grace and James? (e.g. avoiding the question)
GRACE
…I mean, can’t you try something else?
A different medicine? They stopped
the chemo because it was making him sick,
but what if it was working? Grace wanting the best for her Dad but unable to let go
MR ALDRIDGE
(Thought Track:
I can’t keep fighting anymore. I wish the doctors could just make it clear to her
that I’m getting worse)Links to James’ concerns about Grace – yet he doesn’t know how to talk to her
DR. JEFFREY
Let’s just get some tests done and we
can go from there.
GRACE
So you don’t actually have a clue why
he’s in more pain do you?What are helpful ways to address questions if you need to seek senior help, but don’t want patients and families to lose confidence / think you don’t care?
DR JEFFREY BEGINS TO LOOK WORRIED
MR. ALDRIDGE
Let the Doctor do her job love.
GRACE TUTS AND TURNS TO LOOK OUT THE WINDOW, SHE LOOKS OUTSIDE / AT SOMETHING
DR. JEFFREY
I’ll ask Dr. Evans to come and
see you and we can take it from
there OK?
MR. ALDRIDGE
It’s not looking good, right?
DR. JEFFREY
I’d really like to speak to the
consultant first - then we
know exactly what we’re looking at.
I‘ll be back as soon as I can ok.How might Grace, James and Dr Jeffrey be feeling at this point? What might have improved their interaction?
SCENE TWO
2.01
ROOM 12
Mr Aldridge is sitting lower on the bed than before, but not lying down completely. Grace is SAT ON THE END OF HIS BED READING A MAGAZINE. The nurse is fiddling with the pump
There’s a knock at the door, it slowly opens and DR. JEFFREY and DR. EVANS enter.
DR. EVANS
Hello all, is now a good time?Consider Dr Evans: tone, manner, approach
NURSE STEPHEN
I’m all done here (finishes up)
STEPHEN GOES TO LEAVE
DR. EVANS
(To Stephen)Do stay please.
GRACE
What’s going on?Why does Grace ask this?
What might she be thinking?
DR. EVANS
TURNING TO GRACE
HelloGrace, I understand you are Mr Aldridge’s daughter? How are you? Good to check who is who
GRACE
Er. Yeah, OK. What’s this about?
DR EVANS
MR. ALDRIDGE NODS AND LOOKS RELIEVED TO SEE FAMILIAR FACE – CONVEY ESTABLISHED RELATIONSHIP IN BODY LANGUAGE).
I’ve been speaking with Dr Jeffery and I thought it would be good to see where things are up to. Is now a good time?
MR. ALDRIDGE
As good as any, I ain’t going anywhereConsider how humour is used by patients and others even in difficult situations
DR. EVANS
Are you happy for everyone who’s
here to stay in the room? Another good check
MR. ALDRIDGE
Of course
DR. EVANS
Firstly, I’m glad the new dose
of oxycodone seems to have got on top
of your pain. However, I’m afraid
it’s not all good News.Having started well above Dr Evans now goes into information giving mode – speaking fast, why might this be?
GRACE LOOKS CONFUSED
DR EVANS’ FOLLOWING LINES Delivered CARELESSLY
Unfortunately the recent scan has shown that
the cancer has spread further through your lungs and that there are more sites of
disease in your bones. Also,
the kidneys aren’t getting any better. This explains why the
pain is worse, and why you are more sleepy and feeling nauseous
Do you have any questions so far?
What is the impact on Grace and James of all this technical detail? How do Dr Jeffrey and Stephen react? How are you feeling at this point when watching the film?
GRACE BECOMES MORE AND MORE UPSET, HER BODY LANGUAGE BECOMES TENSE AND TEARS START TO FALL (GRACE IS CONFUSED AND ANGRY?)
JAMES IS CRESTFALLEN, BUT TRYING TO BE STRONG, SOMEHOW RESIGNED….
MR. ALDRIDGE
No, I think I know where this is
Leading
DR. JEFFREY’S PAGER GOES AND SHE HAS TO LEAVE THE ROOM
DR JEFFREY
Sorry, I’ve got to take this
DR JEFFREY LEAVES ROOMHow do we handle interruptions? What would have been good preparation for this conversation?
DR EVANS
Mr. Aldridge, what’s your understanding
of what’s causing you to be this unwell?Good question to establish were to start explanation
MR. ALDRIDGE
Well the site of cancer is spreading and you cant stop it can you and
my Kidney’s packing in too.
DR EVANS
Your kidneys aren’t working so well
and the chest isn’t responding to
the antibiotics. The cancer’s
taken hold now and – eventually
it’s going to win.
GRACE
Win! Is this some kind of game to you?
A good point to discuss choice of language
DR EVANS
Er…do you mind if I sit down?What does this achieve?
MUSIC
I’m sorry, what I mean is I don’t
think we are going to be able to change what’s happening.We are dealing
with the cancer, the COPD, and the
kidney failure. I’m sorry, we have
been hoping for the best but I think it’s time now that we plan now for things not
working out as well as we all hoped.
GRACE
(softly) This can’t be right…
GRACE BEGINS TO CRY, Dr. Evans OFFERS HER A BOX OF TISSUES
DR. EVANS
(to Grace)
Are you OK for me to continue?
Highlight change in tone, manner, approach and benefits of this
GRACE NODS
DR. EVANS
We’re going to deal with your symptoms
now James. Would you like me to tell
you a little more about what to expect?
Note Dr Evans does not say ‘there is nothing more we can do’ – consider the difference in this
MR. ALDRIDGE
Not particularly, all I want to
know is, how long have I got?
GRACE
Don’t speak like that Dad
How should we handle questions if someone else in the room tries to stop the conversation?
DR. EVANS
No, it’s okay to ask.
What do you think James?
JAMES LOOKS AT GRACE, THEN LOOKS AWAY. HE TAKES A DEEP BREATH
JAMES
Not very long.
DR EVANS
I think you might be right James. It’s difficult to say for certain. What we look at is how quickly things are changing and things have deteriorated for you in these last few days. It’s difficult to say, but we may be looking at days or short weeks.Good example of checking and confirming understanding
GRACE SOBS LOUDLY AND SHAKES HER HEAD, DIGESTING THIS INFORMATION
JAMES
(THOUGHT TRACK:
Well I guessits probably only days now)
DR. EVANS
There are a few more things I’d like to discuss with you if that’s okay with you James.
Is it okay for me to continue?Continued focus on James as the centre of attention and lead for where the conversation should go
JAMES NODS
DR EVANS
Do you have any thoughts about
what is important to you, for
example where you’d like to be
cared for when things deteriorate?
JAMES LOOKS CONFUSED AND THINKs ABOUT THIS FOR A MOMENT
MR. ALDRIDGE
Well I always want to die at
Home like my wife but I don’t want to be moved around now and I don’t want no more more pain. Consider how people weigh up choices
DR. EVANS
Look, you don’t need to make a decision straight away, have a think together.[pause] now is there anything else that is important in regards to your care?
JAMES
I’ve got my daughter, and that is all I need. (reaches out for her hand)
I don’t want to be in pain anymore.
DR EVANS
Just so I’m sure what you’re saying,
it’s important to have your daughter
with you and you are concerned about
the pain.
[each nod back and forth]
Grace, you can stay here with
your dad.As for the pain, we can make
it a priority to make you as comfortable
as possible.
There is one more important thing to tell you about...
(SAID HESITANTLY)
has anyone ever talked to you
about resuscitation before? Discuss importance of using the word ‘resuscitation’ and changes in law post Tracey case
JAMES AND GRACE SHAKE THEIR HEADS
GRACE
Dad I won’t let them give up on youHow do you explain that a DNACPR is not about giving up? Good point to discuss / try out different phrases
DR EVANS
We’ll do everything that we think will help, but resuscitation is specifically about
what we do or don’t do if someone’s breathing stops or their heart stops...
JAMES AND GRACE LOOK EXPECTANTLY AT DR
GRACE
I can’t give them permission to let you goPoint to identify responsibility for DNACPR decisions and how to explain this to patients and families
DR EVANS
Grace, you need to understand
we’re only making this decision
because we don’t want to put your
dad through something that we don’t
believe will work. In your father’s case, it’s the cancer and the kidney failure that are making him unwell, and these are things we can’t reverse any more, so resuscitationwouldn’t be helpful in this case.
I have to make the call,
I’m responsible for the decision
about resuscitation with the other
staff here, I need to check what you think and make sure you both understand why I’m making this decision
JAMES
TAKES GRACES HAND AND LOOKS AT HER
I remember with your Mum, Grace
All this pulling around, if I have to go, let me go peacefully.
GRACE is tearful, but NODS
DR. EVANS
NODS
Thank you
PAUSE
JAMES
So there’s no more treatments. It’s just pain killers now.Consider language here – how should we explain that there is treatment for people and their symptoms even when we cannot continue to use treatments for disease?