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: Corrina StegnerDirector: Richard Higson

Characters:

Patient Mr. James AldridgeRelative Miss Grace Aldridge (daughter)Nurse Stephen Junior Doctor Claire JeffreyConsultant Jonathan Evans

This script has been annotated in red to aid facilitation of learning following the showing of this film

Stage directions are given in capitals – these indicate non-verbal communication

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?

GRACEWhat 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. ALDRIDGEI just wanted some water.

I thought you were here coming after you dropped Layla at nursery?

GRACEYeah.It’s ten o’clock dad, I’ve justCome 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 today Consider 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

GRACEI’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 STEPHENHello 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 STEPHENMr 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 STEPHENOkay. 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

GRACEShall 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 STEPHENSorry 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 infection Consider how it comes across when someone has to refer to notes to answer you

NURSE STEPHENHe’s got some pain and he’s just not quite right?

DR. JEFFREYHave 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 STEPHENHe 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 CONVERSATION Think 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 STEPHENI 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. JEFFREYHello 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. JEFFREYDo you mind if I turn your music off while I listen to your chestJames?

MR. ALDRIDGENot at all. Do you like it?

DR. JEFFREYI do – I don’t know much about jazz,

But I’m enjoying this. Who is it?

GRACEIt’s him, my Dad. He used to play theTrumpet and I love hearing his old songs

DR. JEFFREYWow, that’s pretty cool James. We’ll have it back on in a moment once I’ve examined you What 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 down Consider how this examination is limited – why might that be?

DR. JEFFREYOk, You’re in a lot more pain todayaren’t you James?

MR. AldridgeI’m not getting any better Doctor

Think about how James answers the question

DR. JEFFREYWe 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. JEFFREYLet’s just get some tests done and we can go from there.

GRACESo 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. ALDRIDGELet the Doctor do her job love.

GRACE TUTS AND TURNS TO LOOK OUT THE WINDOW, SHE LOOKS OUTSIDE / AT SOMETHING

DR. JEFFREYI’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 weknow 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. EVANSHello 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.

GRACEWhat’s going on? Why does Grace ask this? What might she be thinking?

DR. EVANSTURNING TO GRACE

Hello Grace, I understand you are Mr Aldridge’s daughter? How are you? Good to check who is who

GRACEEr. 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. ALDRIDGEAs good as any, I ain’t going anywhere Consider how humour is used by patients and others even in difficult situations

DR. EVANSAre you happy for everyone who’s here to stay in the room? Another good check

MR. ALDRIDGE Of course

DR. EVANSFirstly, I’m glad the new doseof 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. ALDRIDGENo, I think I know where this is Leading

DR. JEFFREY’S PAGER GOES AND SHE HAS TO LEAVE THE ROOM

DR JEFFREYSorry, I’ve got to take this

DR JEFFREY LEAVES ROOM How do we handle interruptions? What would have been good preparation for this conversation?

DR EVANSMr. Aldridge, what’s your understanding of what’s causing you to be this unwell? Good question to establish were to start explanation

MR. ALDRIDGEWell the site of cancer is spreading and you cant stop it can you and my Kidney’s packing in too.

DR EVANSYour 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. ALDRIDGENot particularly, all I want to

know is, how long have I got?

GRACEDon’t speak like that Dad

How should we handle questions if someone else in the room tries to stop the conversation?

DR. EVANSNo, 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 EVANSI 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 guess its probably only days now)

DR. EVANSThere 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 EVANSDo 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. ALDRIDGEWell 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. EVANSLook, 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?

JAMESI’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 EVANSJust 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

GRACEDad I won’t let them give up on you How 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

GRACEI can’t give them permission to let you go Point 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 resuscitation wouldn’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. EVANSNODS

Thank you

PAUSE

JAMESSo 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?

DR EVANSWe’re keeping you on the oxynorm for pain but will only use as much as you need to be comfortable. However, I think we should continue with the antibiotics to help with symptoms of your chest if that’s okay by you? Although I don’t know if we can get rid of the infection, I think it might still help

GRACEI don’t understand, you’re still treating his chest infection, but not his cancer? Good point to get people to consider how they would explain the differences here e.g. addressing what is potentially reversible and why

DR EVANSAs I’ve said, you’re dad’s too weak for any treatment to target the cancer, our priority now is to make your father comfortable - the antibiotics, the painkillers, and the drip (point to it) can do that.

And it’s important to remember James that you can eat and drink whatever you like, although you may not feel like eating much.

Does that all make sense?

JAMES AND GRACE LOOK AT EACH OTHER AND NOD

MR. ALDRIDGESo does that mean I don’t need any more blood tests? I’m tired of being prodded

and poked all the time

DR EVANSI think that is very sensible. I’m not sure that regular blood tests are going to change the management of your symptoms at this stage. Importance of considering what to continue and what to stop and making sure everyone knows this

Now is there anything else I can help with?

MR ALDRIDGEWell, I don’t know, it‘s so much to take in...

NURSE STEPHEN

I can come back and see if you like to go over anything later if you like James... or I can ask one of the chaplains to come and see you – they will listen and chat to anyone – you don’t have to be religious...can be linked to discussion about spiritual and psychological needs

MR. ALDRIDGE I used to believe in God, But I’m not sure what I believe in anymore.

DR EVANS NODS

DR EVANSYou’re beginning to look tired James, shall we go now and let you get some rest?

MR ALDRIDGE Yes please

DR. EVANSOK, we’ll go now

HE STANDS & GRACE WALKS THEM TO THE DOOR

GRACEThank you Doctor

DR. EVANSI know this must have been very hard for

you Grace. The team can talk to you more if you want, or if you need any emotional support we can happily…..

GRACEI just want to be with my Dad,

while I still can. Importance of emphasizing offers of support

DR EVANS LOOKS TO NURSE STEPHEN AS THEY GO TO LEAVE THE ROOM

DR EVANSLet’s capture what we’ve just discussed here so that everyone knows the plan of care… How will this be done?

2.02

ROOM 12

LATER THAT EVENING

GRACE IS IN THE CHAIR BY HER DAD. HE IS SLEEPING. HE WAKES UP, COUGHING.

GRACEIt’s ok Dad, it’s ok, I’m here, (helps him turn on his side), there you go

You’re a fighter Dad, you’ll get through this.

(THOUGHT TRACK: You’ve beaten this thing before, you can do it again, I know you can)

PULL FOCUS BETWEEN THEM?

MR. ALDRIDGE

(Thought Track:Does she really understand what’s going on? I’m so worried about her.) How do we help

people who seem to not have come to terms with prognosis?

2.03

CAPTION: ‘TWO DAYS LATER’

ROOM 12

MR ALDRIDGE IS NOW UNCONSCIOUS – LYING HORIZONTALLY ON BED. NURSE STEPHEN ENTERS ROOM

NURSE STEPHENHello James, how are you today?

HE TOUCHES HIS ARM AND STRAIGHTENS HIS SHEETS.

NURSE STEPHENIt’s cold outside huh? It’s quite busy out there as well I hope the traffic isn’t keeping you up. What is Stephen doing here? E.g. normalizing / still connecting with his patient

HE PREPARES MOUTH CARE SPONGES. GRACE WALKS IN WITH A DRINK FROM A VENDING MACHINE.

NURSE STEPHENYour father’s having to put up with me rambling on, I’m sure he’s glad you’re here now. Aren’t youJames?

GRACECan he hear? I’ve been talking

to him all morning and it’s hard to know weather if it’s worth it

NURSE STEPHENWell I think it’s sometimes just as

good for us to talk to them as it is for them to listen to us. Here, we should put his music back on too, the CD’s finished. Hearing is probably still present even when a patient is otherwise unable to respond

NURSE STEPHEN CHANGES THE CD – PRESSES PLAY

GRACE

But then if he can hear us does that mean he can feel? What if he’s in pain and if he can’t tell you what he’s feeling.

NURSE STEPHENGood question. If he’s frowning or grimacing that may indicate that he isn’t comfortable, but we have the syringe pump here running with painkillers in it, his symptoms are well under control we will continue to monitor and care for him. I promise. Highlight non-verbal signs of distress

HE WALKS OVER AND BRUSHES ASIDE A STRAY HAIR ON MR. ALDRIDGES’ HEAD

Touch is important too, you can still touch him, or give him a hug Families may need explicit permission to do this

Don’t you agree James?

GRACE CORNERS NURSE STEPHEN IN THE CORNER, FURTHEST AWAY FROM JAMES’ BED. THEY TALK IN HUSHED TONES

GRACECan I erm just, talk to you?

NURSE STEPHEN

Yeah, of course

GRACE

Well what about, how will you know when....you know. I mean he’s sleeping so much already that I think he’s

already…

NURSE STEPHEN

Your father’s breathing is quite shallow

But it’s usual for people to get pauses in their breathing. I know It’s hard for you, but he won’t be aware of it.

Eventually his breathing will stop all togetherImportance of being clear in communication even when families cannot bring themselves to say the words – this has to be balanced against being sensitive. How does Stephen manage this?

GRACEI mean, is it the medication that’s doing this? Are you making him sleep?

NURSE STEPHENWe’re being very careful to only give him what he needs to prevent the pain and to stop him from being restless... He’s sleeping so much because his body is exhausted from fighting the disease. Good explanation in answer to a common question

This must be very difficult for you, do you have someone supporting you through all of this?

GRACEYeah, my friend, she, she’s been really good she, she has my daughter when I have been here.

NURSE STEPHENGood. He’s peaceful now. Why don’t you sit with him. I’ll pop back in later.

NURSE STEPHEN LEAVES THE ROOM

THERE’S A CRASH OUTSIDE AS SOMEONE DROPS SOMETHING, FOLLOWED BY A FEW PEOPLE LAUGHING

GRACE (THOUGHT TRACK:

I can’t believe it. Don’t they know there’s someone dying in here?)

FADE TO BLACKHighlights need for everyone on ward to have some awareness of situation, but also how life goes on – different perspective for everyone else

Scene 2.04

2 DAYS LATER

CORRIDOR

GRACE COMES OUT OF ROOM TWELVE. NURSE STEPHEN IS THERE

GRACE(Tearfully) Stephen.

STEPHEN Grace, you ok?

GRACECan you erm have a look I think he’s.

NURSE STEPHEN WALKS OVER AND PUTS HIS HAND ON HER SHOULDER, THEN WALKS WITH HER INTO ROOM 12

ROOM 12

NURSE STEPHEN WALKS OVER TO JAMES, LOOKS FOR A MOMENT AND CHECKS MR ALDRIDGES’ PULSE, THEN TURNS TO LOOK AT GRACE

NURSE STEPHEN I’m sorry, he has died. Clear choice of

words

GRACE WALKS SLOWLY OVER TO HER FATHER AND JUST STANDS BY THE BED.

NURSE STEPHENDo you want me to call

Somebody for you?

GRACE SITS ON A CHAIR BY THE BED AND TAKES HER FATHER’S HAND

GRACENo. I just want to be with him.

LEAVES THE ROOM. GRACE LOOKS AT HER FATHER WITH A TEAR IN HER EYE. SHE VERY QUIETLY HUMS THE JAZZ TUNE WE’VE BEEN HEARING. THIS LEADS INTO THE SONG ITSELF WHICH COMES IN OVER THE END CREDITS.

FADE TO BLACK - THE END