I first watched this movie at a slumber party when I was in my early teenage years. It was long before I ever got into medicine and even longer before I even knew what palliative care was. I haven't seen or thought of this movie in awhile. So when I pulled it out and watched it again recently my first thought was, wow, what crazy 1990's hair. My second thought was, this is not nearly as scary as it was when I was 13. My third thought was how interesting this movie is from a palliative care perspective.

Flatliners was released in 1990 with the tagline "Some lines shouldn't be crossed" (Flatliners. Get it?). A group of 5 medical students are trying to answer that truly age old question (not to be cliche), what happens after death?

Nelson, played by Kiefer Sutherland, is the ringleader and starts the movie off with the line "Today is a good day to die". When asked why Nelson would do this he responds, "...To see if there is anything out there beyond death. Philosophy failed. Religion failed. Now it's up to the physical sciences. I think mankind deserves to know." They go about this by inducing clinical death for one to several minutes followed by a quick resuscitation by their colleagues. At first things go well and they feel very reassured that there is something out there.

The movie is categorized as a Thriller. The trouble starts when the students who have experienced near death begin seeing physical manifestations of their pasts while they're awake. "Somehow we've brought our sins back physically. And they're pissed." Coming to terms with their pasts (and getting beaten up a bit by them) seems the price they have to pay for the knowledge they want.

It's interesting to put this movie into the context of the times . In a 1990 review of the film, Rita Kempley of the Washington Post stated, "Movies about dying, grief and life after death are cropping up like corn in the Field of Dreams as a response to on-screen violence, a reaction to AIDS, a desire for something beyond materialism." Is she saying this is backlash from the '80s? It would be interesting to know if that were really true. Were there really more movies about dying at that time? And for those reasons? Or maybe its just like why there are so many vampire movies, books, television series coming out now: it just cycles through.

Some critics felt that Flatliners really pulled the punch when addressing life after death. It doesn't really answer the question of what is out there, the question that the medical students risked so much to find out. Others felt we are meant to believe that after death is a purgatory, a place to atone for one's sins. I tend to think that a campy '90s thriller probably isn't the best venue for such a debate.

Interesting movie trivia: Writer Peter Filardi was apparently inspired by the near death experience a friend had while on the operating table.

A young boy's parents are violently murdered. His mother, in fact, died protecting him from the murderer (Voldemort). His is sent to be raised by a family who at best neglects him, at worst abuses him. He continues to be stalked through his adolescence by the same murderer who took his parent's lives. Some pretty heavy stuff, especially for a series of children's books. In the Harry Potter series the theme of death comes up over and over again. (If you're not familiar with the series, please read the Wikipedia page linked to above.)

In one interview the author, JK Rowling, commented, "My books are largely about death. They open with the death of Harry's parents. There is Voldemort's obsession with conquering death and his quest for immortality at any price, the goal of anyone with magic. I so understand why Voldemort wants to conquer death. We're all frightened of it." Given that so much of her books are about death, I wanted to take a closer look at how death is viewed within the series.

First off, death in the series is irreversible. No spell can bring back the dead. In a world with so much magic, death seems to be one of the few absolutes. There are ghosts who are said to have feared death so much they didn't cross over. There is magic that allows the dead to be seen. But nothing that brings them back.

For the most part death is something carried out by the evil on the good. This is a tendency of many children's books/movies. Even given this, death isn't always portrayed here as the ultimate bad. "To the well-organised mind, death is but the next great adventure." (Sorcerer's Stone) There are conversations that suggest there are worse things than death, namely being unable to love.

Voldemort, the bad guy, has a fear of death and seeks to escape it, even to the point of killing others to achieve immortality. He even calls his followers Deatheaters. Interesting that this quest for immortality, seeing death as the worst thing that could possibly happen to you, is an evil quality in the books.

One issue that I did have with the books, the deaths tended to be glazed over a bit. When major characters are killed off, there is some initial anger, a little sadness, but then it really doesn't dwell too much. Maybe I'm expecting too much depth from a children's book.

Overall, I think Rowling handles a difficult topic reasonably well and in an entertaining fashion. I would probably give it an A for entertain value, a B for the treatment of death, but a C for the emotional follow-through. I would be interested to know how children reading the books would view it.

Iris is a 2001 film based on the life of Irish writer Iris Murdoch taken from the book Elegy for Iris, written by Iris Murdoch's husband, John Bayley. Murdoch died in 1999 after several years of suffering from Alzheimer's disease. The movie jumps back and forth between Murdoch's youth and the beginning of her relationship with Bayley and the later years of their marriage, as Murdoch's mind begins to slip away.

Iris Murdoch was an intelligent and independent young woman when she met John Bayley, a somewhat proper Oxford professor. He has a difficult time coming to terms with her free spirited nature and shady history(at least for the time) with men. He comments about the all different worlds Iris lives in. Later in life, as her Alzheimer's is getting worse, he again speaks about the different world she is falling into.

The film expresses the frustration and sadness of John as he watches his very intelligent wife slip into her own world. (Imagine a literary genius sitting in front of the television watching Teletubbies.) Things begin to fall apart as Iris at times becomes agitated and wanders off. John starts to fall apart as well. Below is a section from the movie. You can see how the issues of the past and present are interwoven. You can see how his frustration turns to rage and how events of the past seem to fuel this.


The way the film is structured, flashing back and forth, it compares the incidents of the past with those of the present. It compares the young, vibrant Iris with the older, demented Iris. One scene shows Iris riding on a bike with John trying to catch up with her. Then it shows the elderly John driving around town trying to find Iris who has wandered off. You see a young Iris swimming naked, carefree, then jump to an older Iris, with her husband struggling with her in the water as she becomes agitated.

I thought this movie was a good palliative care film because of how it deals with a chronic illness I see so often, Alzheimer's disease. It shows the extreme frustration that caregivers of people with dementia often feel. I also loved they way they meshed together the past and the present. I think it's intent is to bring out that even though Iris has changed so much, she is still the same person.

In the Bedroom is a 2001 film, based on the short story "Killings" by Andre Dubus. I don't recall anyone mentioning it, but definitely another one we should include as a top palliative care movie.

Frank Fowler is a young man spending the summer with his parents in Maine before he heads off to graduate school. He meets an older woman, Natalie, with two children and a violent ex-husband. Although he tells his mother this is just a summer fling, he seriously contemplates staying and taking a year off school.

He has just made the decision to go back to school when he is shot and killed by Natalie's ex-husband. The remainder of the film focuses on his parents, Ruth and Matt, as they try to pick up the pieces of their lives after the murder of their only child. This is made much more difficult when Frank's murderer gets out on bail and they see him walking around town, smiling at them. They find out that he will likely only be charged with manslaughter, as he claims the shooting was an accident. This pushes Matt and Ruth emotionally over the edge. We see a little of what ordinary people might be capable of in a very bad situation. I won't ruin the ending.

I really loved this movie. I loved that I felt we got to know and like Frank before he died. Although the movie was about the aftermath of his death, I felt that he was a main character from the beginning and remained a main character even after he was gone.

I loved the pace of this movie. It very slowly and carefully puts the story together and I think it makes it more real. It mixes in a lot of short scenes that at the time seem insignificant but aren't really. After Frank's death, the pace seems to slow down more, like the pace of grief. It does build to a climactic sort of ending, but after the action is over, it slows back down again. You see Matt in bed and Ruth yelling up to see if he wants coffee, just so normal.

The majority of the film deals with grief and the process by which these two people are trying to move through it. You see profound sadness, anger, guilt, blame, all the emotions you might expect. At first no one is talking to anyone. Just a lot of silent evenings in front of the TV. Then there are big blowups and finger pointing. The grief seemed very realistic to me. Ruth has an eloquent description of grief. "It comes in waves. And then nothing. Like a rest in music. No sound but so loud." (I loved the writing in this movie. Like poetry.)

So what's with the title? It seems provocative at first glance. (Again, I love the writing. So clever.) At the beginning of the film (in one of the scenes that seemed insignificant at the time), Matt, Frank and one of Natalie's children are out on a boat, trapping lobster. They find one with only one arm and this is how Matt explains what happened. "See the trap has nylon nets called heads. Two side heads to let the lobster crawl in and inside what they call a bedroom head to hold the bait and keeps them from escaping. You know the old saying twos company threes a crowd? Well, it's like that. You get more than two of these in the bedroom and chances are something like that's going to happen."

There is a vampire craze sweeping the nation. Can you think of a fictional monster that has been represented more in television, movies and books than the vampire? This isn't a new thing. From Dracula to Edward, vampires have been popular fiction for some time. It seems that new series are popping up all the time. The vampire is more and more becoming an icon of pop culture.

Before you think I'm being critical of this trend, here's my confession. I admit to watching True Blood. And perhaps I've read the books it is based on. I might also have read a little of Twilight...and the three other books of the series. I may have taken a day off work to see the Twilight movie the day it came out. It's a sickness, I know. I'm not the only one who has it. What is it that we see in these fictional beings? I mean, let's be honest, not exactly the most original stories out there. Mysterious, tormented vampire boy meets human girl. A difficult relationship ensues. That describes most of them.

There are a lot of different aspects to vampire lore that the media explores. Do they melt in the sunlight or just sparkle? Holy water? Crosses? Wooden stakes? There is a lot of variations out there. But one thing all the vampires do have in common is immortality. Is this the draw?

In a time of plastic surgery and anti-aging creams, it's not that surprising that we find the forever young and beautiful an interesting concept. In a society that often fears death, living forever seems alluring. This immortality is often depicted as a trade off for ones soul and bought at the expense of other's lives (drinking blood and all that). (I wonder how many people would trade their souls (or humanity, if you will) to be forever young and beautiful?)

I think what brought up this post now was a recent pondering of what the draw was for me. I am around death all day long. I wouldn't say I fear death (not as long as there is a good palliative care team around to adequately control my symptoms) or growing older. I never came up with a good philosophical answer. Probably just the romance and mystery paired with sexy actors, like everyone else. I tend to over think things.

Thanks to one of my nurses, Linda, for telling me about this film. Westerns aren't my usual movie fare but hearing about the plot of this one along with the all-star cast (John Wayne, Jimmy Stewart, Lauren Bacall, Ron Howard, Harry Morgan) convinced me to check it out.

John Wayne plays JB Books, an aging gunfighter, who comes to Carson City seeking a second medical opinion. He has gotten the diagnosis of cancer and comes to see a trusted physician, Doc Hostetler (played by Jimmy Stewart). In one of my favorite scenes, Books is told the bad news and is given about 2 months to live. (I couldn't find a clip, but below is the dialogue.)

Doc:Books, every few days I have to tell a man or a woman something I don't want to. I've been practicing medicine for 29 years and I still don't know how to do it well.
Books: Why don't you just say it flat out?
Doc: Alright, you have a cancer. Advanced. [portion removed]
Books: Can't you cut it out doc?
Doc: I'd have to gut you like a fish.
Books: Well, what can you do?
Doc:There's just very little I can do. When the pain gets too bad I can give you something.
Books: But you're trying to tell me is...
Doc:Yeah
Books: Damn
Doc: I'm sorry Books.
Books: You told me I was strong as an ox.
Doc: Well even an ox dies.
Books: How much time do I have?
Doc: 2 months, 6 weeks, less. There's no way to tell.
Books: What can I... What will I be able to do?
Doc: Anything you want at first. Then later on you won't want to.
Books: How much later?
Doc: You'll know when.

In another conversation with the doctor, Books asks about how it is going to go. Doc Hostetler tries to evade the question at first but then tells him "There'll be an increase in the severity of the pain in your lower spine, your hips, your groin. Do you want me to go on? The pain will become unbearable. No drug will moderate it. If you're lucky you'll loose consciousness and until then you'll scream." He goes on to tell Books, "I would not die a death like I just described... Not if I had your courage." This leads Books to try to go out in a blaze of glory. Hastened death by gun fight.

Much of the film is Books coming to grips with his terminal illness, fighting off those who want to take advantage of his death, settling his affairs, and imparting words of wisdom to a young man, Gillom (Ron Howard). Below is the film trailer.

This movie came out in 1976 and it was John Wayne's last film. It came out 12 years after he was diagnosed with lung cancer and 3 years before he died of gastric cancer. In many ways, the lives of Books and Wayne are very similar. Both very famous, facing illness and the end of their careers.

Also, Lauren Bacall (who stars as a sort of platonic leading lady in the film) had lost her husband, Humphrey Bogart, to esophageal cancer many years earlier. I wonder how this effected her performance in the film.

Something interesting from a historical palliative care perspective, they use laudanum (opium mixed with alcohol) for pain control. When Books takes a swig out of the bottle, the question is asked, "That's habit forming, isn't it?" Some things are timeless.

I will say, with some shame, that the book The Diving Bell and the Butterfly has been near the top of my need-to-read list for some time, but I haven't ever gotten around to it. When I heard they were making it into a movie, I was very excited. Watching the movie is just as good as reading the book, right?

In case you're not familiar, The Diving Bell and the Butterfly (Le Scaphandre et le Papillion) is a book written by Jean-Dominique Bauby. Bauby suffered from a stroke and developed locked in syndrome. The only part of his body not paralyzed was his eye (one of his eyes had to be sewn shut). He communicated entirely by blinking. His caregivers developed a system in which they recited the alphabet (in order of most to least commonly occurring) and he blinked when they said the right letter. He wrote an entire book about his experience with just one eye.

The movie starts when Bauby first awakens and is trying to figure out where he is and what is happening. When he first finds out the extent of his injury, he wants to die. He is filled with regrets about his life. A recurrent theme in the movie is Bauby imagining he is trapped in a diving bell.


He then realizes that his eye isn't the only part of him that still functions. He still has his memory and his imagination. Through these he is able to escape from his prison, thus the name of the film.


This is an excellent story about someone managing to find meaning and purpose in a very bad situation. Beyond that, this isn't just a story about how it must feel to be trapped in ones own body. It is the actual account of what Bauby felt and what he experienced. Part of that is a complete loss of control. Just look at the TV. The annoying test pattern screen left on all night. The game he is watching turned off. (It made me think of some of the crazy things we leave on in dying patient's rooms. What if they hate old westerns or Law and Order? To my family and friends, please don't leave CNN on all day to cycle the same stories over and over, and any CSI should not come on in the room at all. Maybe TV preferences should be included on an advanced directive.) You don't often get first hand accounts of things like this.

Maybe I'm a bit biased but while watching this movie, I couldn't help thinking "Where's the palliative care team?" "Does he want to go back to the hospital?" "Why isn't anyone asking him?"

After re-watching this movie today, I had to go back to our original Top 10 Palliative Care Movies post to remember if we had included it in our list. We didn't, but maybe we should have.

The Savages is an independent film released in 2007 and has been called a "coming of maturity" story. It's a very real picture of a family dealing with the illness of a parent. Siblings Jon and Wendy Savage are busy with their own complicated lives when the death of their estranged father's girlfriend forces them to back into his life. Their father, Lenny, is diagnosed with dementia and Parkinson's. In a short time, they have to move Lenny from Arizona to New York and find a nursing home to place him.

Below is the movie trailer.

One of my favorite scenes is when Jon and Wendy have to discuss advanced directives with Lenny.

Wendy: Okay. In the event... In the event something should happen- Um- How- How do you want us to... Um-
Jon: Dad, what if you were in a coma? Would you- would you- would you want a breathing machine to keep you alive?
Lenny: What kind of question is that?
Jon: It's a question we should know, in case.
Lenny: In case what?
Jon: In case something happens.
Wendy: Nothings gonna happen. Right now. Nothing new.
Jon: Right, it's- it's just procedure. It's something they want for the records.
Lenny: Who?
Wendy: The people who run the place. The Valley View.
Lenny: What the hell kind of hotel is it?

Jon and Wendy sort out their own social lives while, for the first time, having to take on the responsibility of caring for their aging parent. I found that this movie hits pretty close to the mark of the normal American family. It's very realistic how Jon and Wendy deal with a crisis in completely different ways, one more logical, one more emotional. Wendy has a lot of guilt over placing Lenny in a nursing home, even though she know it's really the only choice. Below is Jon talking to Wendy as she tries to get Lenny into a more exclusive nursing home.

"...You are the consumer they want to target. You are the guilty demographic. The landscaping, the neighborhoods of care; they're not for the residents, they're for the relatives. People like you and me who don't want to admit to what's really going on here...People are dying, Wendy! Right inside that beautiful building right now, it's a f***ing horror show! And all this wellness propaganda and the landscaping, it's just there to obscure the miserable fact that people die! And death is gaseous and gruesome and it's filled with shit and piss and rotten stink!"

I was struck by all the losses Lenny experienced: his girlfriend, his mental faculties, his independence, his dignity, his privacy... Another very realistic aspect of the movie.

On a side note, the nursing home staff has a very interesting prognostic sign. Apparently toes curling under means someone only has a few days left.

I remember when I was 4 or 5 years old going to the movie theatre with my family. I watched as Bambi ran toward the thicket away from the hunters and then turned around looking for his mother. My little 4 year old brain had no idea what was going on. I remember whispering to my mother in the theatre "What happened to Bambi's mommy?"



Does anyone else get teary eyed when they see this scene? Maybe I was just a slow child but I think there was a reason a four year old wouldn't get what happened in this scene. The death scene in Bambi is very subtle. They never come out and say, "Bambi's mother died" and they never show anything close to a death. How was young Bambi even to understand what happened? "Your mother can't be with you anymore." So, she had to go out of town? The response of my nephew (who was 5 at the time) was, "She's ok, right Mom. She's just hurt but she'll be ok." Denial.

Now compare that scene to this more contemporary Disney death scene.



Big difference. In The Lion King, nothing is subtle. You watch as Mufasa plunges to his death. In a totally heart wrenching scene you see the dead Mufasa as Simba tries to wake him up. Nothing left to the imagination. On a positive note, the grief response in The Lion King is much more appropriate. Poor Bambi gets just one tear then he has to turn around and walk away. You've had a whole 2 minutes to grieve, Bambi. Now it's time to move on.

This big shift in how death is dealt with in Disney films happened around the 1970's. Movies that were made before that (Bambi 1942) tended to have more implicit death scenes. After the 1970's, (The Lion King 1994) death scenes were more explicit, showing the actual death and/or the deceased. Maybe the thought was to shelter children from violence and death. Which approach is better?

In one study, Disney movies were taken at random and their death scenes analyzed. They found 23 death scenes in 10 movies. In these scenes, they looked at several different things including who died (antagonist vs protagonist), how the death was depicted (implicit vs explicit, permanent vs temporary), the emotional response, and the cause of the death (accidental, justified vs unjustified). While the study had relatively small numbers, they did find some interesting things. 39% of deaths lacked any emotional response. Although most of the deaths overall are portrayed as permanent, half of the protagonists that died come back in some way.

As the study points out, death in Disney movies is not all bad. The Lion King has been used as a tool to help teach children about death and grief. Movies can be used as a more comfortable way to bring up difficult discussions. But they could also send confusing messages to children about death and grief.

References: Cox M, et al. Death in Disney films: Implications for children’s understanding of death. Omega. 50(4). 2004-2005. 267-80.

If you're looking for a feel good movie, this is definitely not for you. The Seventh Seal is a 1957 Swedish film directed by Ingmar Bergman. There is a lot going on in this movie, so I'm writing about some of the main points. You could easily analyze each scene.

A knight and his squire return from the crusades to a plague ravaged Europe. When Death comes to take the knight, he challenges Death to a game of chess, with the stakes being the knight's life. The scene below is taken from the beginning of the movie and sets up the plot of the movie. (In subtitles for those who don't speak Swedish.)



The title of the film comes from the first line of the movie, which is a taken from the book of Revelations. This passage is repeated at the end of the movie. The movie is full of religious references and symbolism, as the knight struggles with death and his belief in God.

The chess game is worked in throughout the movie as the knight travels through the countryside, witnessing the horrors of the plague and how people react with facing their own mortality. Groups of people roam the country whipping themselves in penance and begging for God's mercy. A women accused of being a witch is burned for fear that she brought on the plague. (Did I mention this was a dark movie?)

In the end, the knight distracts death so that others may escape. After the chess match, he asks Death to reveal his secrets. Death responds "I have no secrets...I am unknowing." When death comes back for him, he is welcomed into the knight's home with a mixture of fear and awe (maybe even some happiness) by the knight and his friends.

I see the knight as a man who has essentially just gotten a terminal diagnosis. He makes a wager with Death, bargaining for his own life. He tries to buy more time.


But in the end, no one escapes Death (or death).

So, what are the pieces on our modern day chess board? Are modern medicines just more moves to buy time in a losing chess match? Interesting movie, but it doesn't leave you with the most pleasant thoughts.

As a side note, the painting referred to by the knight in the film clip is one in the Taby Kyrka, a medieval Swedish church, painted by Albertus Pictor in the 1480's. This is said to have inspired Bergman in the making of the film.

“A freedom that ends life is no freedom at all.”
“And a life that ends freedom isn’t a life either.”

“The Sea Inside” is a Spanish film, based on the true story of Ramon Sampedro, a quadriplegic who fought for 28 years for the right to end his own life. It won an Academy Award in 2004 for Best Foreign Language Film.