1. McSteen, Kerstin RN, MS, APRN-BC, PCM

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Fanlight Productions, 4196 Washington Street, Boston, MA 02131 Tele: 800-937-4113, Fax: 617-469-3379 E-mail: [email protected] Web site: ISBN (DVD) 1-57295-802-2 Price: Available on DVD: $299.00


Once a month at the hospital where I work as a palliative care CNS, I provide a broad and brief presentation on ethics to all new nursing staff as part of their general orientation. I have tried various formats to present the material, including discussions based on written case scenarios or rather dry PowerPoint presentations. When I was presented with the opportunity to review "Ethics Thru Drama: A Three-Part Video Series," I immediately thought that this resource might provide me with another approach to encourage discussion and learning that would be interesting and stimulating for new nursing staff at our hospital.


Anyone who has seen either a stage performance or the widely acclaimed HBO film production of "WIT" can appreciate the power of drama and the human story to inform one's life and professional practice. "Ethics Thru Drama" was created to engage the healthcare provider or student in thinking about the complex personal and ethical issues people may experience at the end of life. The three-part video series was created by Helen Emmott and Julie Russell, both of whom are nurses and bioethics educators. Russell further describes herself as a "nurse dramatist" and is the performer for the dramatic monologues that present ethical and situational dilemmas of three patients. Each vignette is about 20 minutes long, and as Russell plays out each monologue, the viewer is quickly drawn in to the complexities of each woman and the effects of the illness on her life.


We are introduced to Tricia, a married mother of three young children who has breast cancer, as she is completing admission forms for her new oncologist, a change necessitated by a switch in her husband's insurance provider. The viewer immediately picks up on the burdens, big and small, that are experienced by a person who is thrown into the world of "serious illness." Beginning with the burden of paperwork, Tricia says in increasing disgust, "It's the repetition, the dates, the phone numbers, the policy numbers, the group numbers, the chronology of events[horizontal ellipsis]This just isn't my thing. It offends me! This paperwork offends me!" Quickly, however, Tricia's concerns and questions shift from the mundane to the existential. She initially tries to reason that her severe back pain is from sleeping in the wrong position but then wonders out loud if it isn't the cancer recurring: "Then what will I do? My husband will want me to keep treating." Tricia wonders if she is morally obligated to keep treating because she is young and a mother and has the financial resources to seek out the best care. She voices frustration and anger toward her friends who are praying for healing: "People die everyday. Good people, faithful people. Why should I even ask for healing?" It is hard not to be moved to tears toward the end, when Tricia says in desperation, "I don't know how to talk to my children or my husband or my parents or my friends. They all want my feet firmly planted on the ground. I'm not earth anymore. I'm air."


The subject of the second vignette is Sheila, a homeless woman who has obviously experienced many challenges in life, including being HIV positive. As we listen to Sheila's story, we think of all the "noncompliant" patients we have worked with. Her experiences provide a window into what it may be like to live on the edge, with very little support, and be an outsider and excluded from the mainstream. As she contemplates her own death, she thinks of how her grandmother died from cancer in excruciating pain and how her lover died from renal failure on his own terms.


In the final vignette, Claire, a registered nurse and divorced mother of a young teen daughter, is in the end stages of ovarian cancer diagnosed only months before. Her story holds a mirror up to all healthcare providers because much of it centers on what it's like to be on the other side of the bed rails. She speaks of the pain of being scolded by the clinic nurse about her delay in seeing a doctor, of being told of her diagnosis ("He said other things but I couldn't hear a single word he was saying."), of being roomed the day before her surgery with a woman who was scheduled to deliver her first baby by cesarean the following day, of being told she could not have morphine for the pain because of the need to "save it for later." She also spoke of the small kindnesses that made a difference, such as nurses knowing and calling by her name and being willing to sit with her for a few minutes when she was alone and frightened.


I found the impact of the videos to be subtle. Before my first viewing, I expected scenarios that depicted more of the ethics high drama of families demanding futile care, patients requesting assistance with suicide, or physicians withholding crucial information about a diagnosis. These vignettes are almost understated in their complexity and are much like real life; one really has to contemplate and reflect on what each character is presenting in their story before the ethical issues become clear. I found myself thinking back to Tricia's story days later and identifying yet another salient point or insight.


Included with the DVD is a study guide to assist the educator and the learner in the reflection process. There are two sets of questions for each vignette: (1) asking more foundational questions about ethics processes and (2) delving deeper into topics such as comparing competing or conflicting ethical principles, exploring the ethic of care, virtue ethics, and utilitarianism, and questioning the roles and responsibilities of the healthcare provider in the situations. If the educator has ample time, I would recommend having the audience watch a vignette first, then read the questions, view it again, and finally, have group discussion. I found that my reaction to the second viewing of each story was much deeper; my initial discomfort with the intimacy of the performance and the performer had softened so that I could truly listen to the story each character was telling.


Each vignette can stand alone, which allows the educator to choose whichever scenario might best fit the needs of the particular audience. Besides exploring moral dilemmas that involve ethical principles of autonomy, self-determination, beneficence, truth telling, justice, and proportionate/disproportionate means, "Ethics Thru Drama" would be particularly useful in helping to develop empathy and understanding in all healthcare professionals toward patients who are facing the multifaceted issues involved with being seriously ill. I look forward to trying it out on my next group of nurse orientees.