The daily work of physicians and nurses in intensive care medicine is depicted in many fictional series, movies and in real-life documentaries. Extremis is such a documentary. It is a 24-min-long film about end-of-life care in the intensive care unit at Highland Hospital in Oakland, California. It was made and directed by Dan Krauss in 2016. The film provides insight into the daily ethical dilemmas which physicians, nurses, patients and their relatives face in the inevitability of death. The documentary follows a palliative care specialist, helping patients without hope of recovery. She prepares the patients to die. It shows, among others, a ventilated patient desperately trying to write her last wishes on a piece of paper. And Donna, a woman with myotonic muscular dystrophy who is eventually freed from her endotracheal tube so she can peacefully die in the presence of her loved ones. We also see the daughter of Selena who will not stop looking for another miracle, but her mother suffered severe cerebral damage after a circulatory arrest making such hope in vain. However, her daughter feels that stopping the mechanical ventilator is taking an active role in Selena’s death. The method of filming, the editing, the music, the emotions shown and deliberations make this film beautiful, heavy and heart-breaking to watch.
In our intensive care unit (ICU), we have half an hour of teaching during lunchtime, 5 days a week. One day we showed Extremis to a group of 25 intensivists, fellows, interns, and researchers. They gathered together in the conference room. Some of them were enjoying a good cup of coffee or a sandwich. During the documentary they all were quiet, so we observed them for nonverbal behaviour. We watched their facial expressions. We tried to read them. In the hours before they joined their colleagues in the conference room and before watching the documentary, most of them were in real life confronted with severely ill patients on the ward, facing disturbed and emotional confused relatives, and making treatment decisions. Now they were watching the same situations, but on a screen with music, and from a distance.
Extremis is emotionally provocative, as we observed on the faces of some of the attending (mostly female) doctors. But is watching a movie even more emotionally provocative than actually working with patients and their relatives in ICU? Do we, as professionals working in ICU, experience more mental pain when we are watching a film or documentary or reading a fictional book about suffering than when we experience this in real life? No, it seems that we experience empathy in another way. In patient care almost all healthcare workers experience empathy more at a distance in coping with the experience of suffering of others. Empathy seems then to be biased as we all are more prone to feel empathy for those who look like us or share the same background. Empathy connects us to particular, self-chosen, individuals. While watching a movie, a documentary and reading a novel we are more open in an empathic manner. We feel connected to the suffering individual which we choose to watch or read about. It seems that we choose to be emotionally moved when watching a movie or reading a book. We can feel another’s pain, but we do not always feel the pain of the patient and its relatives. For them we feel a non-empathic compassion, a more distant kindness and concern, which is morally desirable and right. Compassion and empathy are not the same. In empathy we mirror each other’s anguish, in compassion we only show concern.
Why do we want to read a novel or watch a movie about the pain and suffering of others in the first place? That we appreciate experiencing the kinds of emotions that we tend to consider unpleasant in daily life, like death, end-of-life, suffering, may seem rather illogical. This is called the ‘paradox of tragedy’. Julian Hanich and colleagues formulated the ‘being moved hypothesis’ in their essay ‘Why do we like to watch sad films? The pleasure of being moved in aesthetic experiences’ in 2014: People undergo a positive experience by feeling emotionally moved, and for that reason they seek out such films or read such books. The watcher or reader opens his/her mind to the feeling of being moved by experiencing an ‘overall positive emotional state’. This is something we do not allow ourselves when confronted with the same feelings during our real work in the ICU. We ‘simply liked to be moved’ with fiction or a documentary. We identify ourselves emotionally with the characters (emotional empathy), but obviously we do not identify ourselves emotionally with most of the patients and their relatives we care for in the ICU (some name this ‘cognitive empathy’ or compassion). The Dutch psychologist Emy Koopman wrote the book Reading Suffering, an empirical inquiry into empathic and reflective responses to literary narratives. She concluded that, contrary to most other book genres, ‘sad books’ serve both a need for feeling and for meaningmaking and that through repeated exposure to literary novels, readers train their ability to take another person’s perspective.
Compassion is needed in every healthcare provider–patient relationship. Compassionate helping is good for the healthcare professionals and the patients/relatives. We suppose that readers (of a novel on suffering) or watchers (of a movie or documentary) of suffering can become unsettled and after that consider the same suffering in real life in a different (more compassionate or empathic) way. Possibly this leads to better empathic understanding of events in real life. Research shows that exposure to films, documentaries and fictional literature can have a positive effect on compassionate and empathic understanding. In combination with sad music this effect is even stronger.
To conclude, we strongly believe that reading fiction and watching movies or documentaries on suffering can make healthcare professionals more compassionate, more understanding persons. For this reason, watching such documentaries and movies should be included in educational programs of ICU professionals. This trains them to take another person’s perspective. But on the other hand it will not make us more empathic as true empathic sharing is often lacking in the healthcare provider–patient relationship as we really feel empathy only for those near us, who look like us or share the same background. And most patients do not belong to that group.,
Intensive Care Medicine
Department of Intensive Care

Kompanje, E.J.O, van Mol, M.M.C, & Weigel, J. (2017). Will we become more compassionate or empathic intensive care professionals by watching films and documentaries about suffering?. Intensive Care Medicine, 43(4), 560–561. doi:10.1007/s00134-017-4693-4