'Extremis' Takes an Emotional Journey Through the End of Life
Editor's note: Over the next few weeks, we at IDA will be introducing our community to the films that have been honored by the Academy of Motion Picture Arts and Sciences with an Oscar® nomination in the documentary category. You can see Extremis on Saturday, February 25 at 3:55 at the Writers Guild of America Theater as part of IDA's DocuDay.
Filmmaker Dan Krauss followed up his 2013 documentary The Kill Team, about war crimes committed by a US Army platoon in Afghanistan and the impact they had on one whistle-blowing soldier, with a strikingly different film: a short and emotionally wrenching journey into the end-of-life care unit at Highland Hospital in Oakland, California. It is here where families and doctors alike grapple with the most painful decisions of their lives: facing loss with dignity, compassion and strength.
We talked to Krauss by phone about observational docs, the challenges of getting good sound in a hospital, and how the experience of bearing witness to so much suffering transformed him as a filmmaker.
Extremis is not like the films you've made before. The Kill Team and The Death of Kevin Carter were fine examples of investigative storytelling and character portraits, but this film is quite different, by necessity. It's observational and meditative, taking into consideration the wrenching and deeply intimate subject that you're covering. Talk about the process of segueing from your previous project to this one.
I actually think that the films all share a common thread of characters grappling with very challenging moral questions that have no clear right or wrong answer, so I think [Extremis] is a continuation of that previous work. But you're absolutely right that in terms of form, it is very different, and one of the things that I thought a lot about after The Kill Team was doing a very observational film.
I spent many years as a cinematographer doing other people's movies, and I spent many, many hours shooting observational material for those directors. But I never had the experience of crafting a vérité film of my own, so I did have a deliberate objective of creating a purely observational film on the heels of The Kill Team, which culminates in observational and interview-based material and archival. But I wanted to do something that was pure and that tapped my skills that I had been loaning out to other directors for many years. Before becoming a filmmaker, I was a photojournalist. I've spent a lot of time capturing moments on screen, and I really wanted to have the experience of crafting a film that was entirely comprised of moments.
What led you to the palliative care unit at Highland Hospital?
Well, Dr. Jessica Zitter led me to Highland Hospital. She is featured in the film, and it was after meeting her that I was invited to visit the ICU. She really urged me to come to Highland. She said to me, "You need to see what's happening here. You need to hear the conversations that we're having with patients in this ICU." And it was with some reticence, but I agreed to accompany her because, frankly, this is not a topic that I'm entirely comfortable with. I don't think many Americans are comfortable talking about matters related to death and dying, and unless you work in an ICU or you're visiting a family member or you're a patient yourself, it's not a place where you want to spend time. There's a great deal of suffering; there are people who are in both physical and emotional pain.
And then I started to notice the moments of quiet beauty that showed me something unexpected happening in the ICU: Faith and science were colliding in a fascinating way and yielding questions that were profound and that really struck at the core of our humanness. That was something I hadn't anticipated and something that struck me and kept me coming back.
How long did you spend in the ICU without a camera when acclimating yourself to that particular environment?
I think it was two or three days; I rounded with Dr. Zitter and shadowed her and started to get a feel for the environment. I wasn't sure, quite honestly, whether there was a film to be made, and whether it was a film that anyone would want to watch, or whether it was a film that I felt I could emotionally support - and quite frankly, whether I could handle the experience of embedding in that ICU for weeks and months. I wanted to get a sense before bringing in the camera about what was there, and after I saw these moments that I described earlier, I decided to bring a camera and do a bit of pilot shooting, just to gauge my comfort level and the comfort level of the people in the ICU.
And almost immediately, I captured some riveting themes - themes that are actually in the movie. Like that discussion with all the doctors. There must be 20 doctors and medical staff huddled around discussing a case about a patient who has questionable capacity. That happened within a few minutes of the first filming I did there, and I thought instantly, "OK, there's something special happening here." I was instantly drawn in, and shortly after that, I met Donna and Gordon, who are the first family we meet in the film. Gordon and Donna are just beautiful people, beautiful human beings, and I was captivated with them. So I really felt I got lucky early on, and that really encouraged me to push ahead, even though it was, as I say, an uncomfortable place to film. You're asking people on what may be the worst day of their life to film them, and it's a very difficult position to be in.
How did you communicate your goals for the film to the families you filmed?
In all the films I do, I think part of the work is making yourself vulnerable to a subject, as vulnerable to a subject as your subjects are when they're being filmed. I think that's crucial. And in every film I've done, I've been willing to do that because I want my subjects to understand that this is a frightening process for me too, and that I feel the responsibility of telling these stories accurately and with sensitivity and that we're in this together. I give as much agency to my subjects that I can so that they don't feel like they're on the lower side of the power dynamic. And so I told them everything I just told you, about the notion that both patients and physicians are having incredibly human conversations in the ICU that a lot of people don't know about, don't get to experience. And I think the people who agreed to participate had certainly some awareness of the value of a film, but also saw the camera not as an intrusive presence but as an opportunity to connect with other people. A lot of these families and patients really relished the opportunity to feel alone in the process and transform what may be an experience of pure loss into something that may help other people and make them not feel like they're the only ones confronting these questions.
Filmmaker Peter Nicks is thanked in the credits. Highland Hospital was the central character of his film The Waiting Room, which played in theaters and aired on PBS. I assume that helped open doors for you and inspired Dr. Zitter to come to you?
Yeah, absolutely. I'm remiss in not mentioning that. I was introduced to Dr. Zitter through Peter Nicks, who's a close friend of mine, and so if The Waiting Room hadn't been made - and it's a magnificent film - this film never would've happened. Because of the terrific success of that film, not just in the film world but as a film that the Highland community felt accurately captured their experience in the safety net healthcare system, I don't think they would otherwise have been at all open to an idea of a film crew in their hospital.
In the process of filming, I'm sure there were moments where either the palliative teams or the families did not want to be filmed. Talk about the moments when you were asked to turn off the camera.
Most commonly, I was asked not to film when there were disagreements among family members, and that was something that occurred frequently. Everyone was coming from a place of love and empathy, and yet they had different ideas about what was the best decision, and when those conflicts would arise, family members would often not feel comfortable having those discussions in front of the camera. And of course, I respected that. I didn't feel like I was missing crucial material with those discussions because sometimes, those inter-family disputes were laden with personal baggage that was extraneous to the purpose of the film.
The other thing, I had a rule of my own, which was that I didn't want to film anyone actually dying and I didn't want to film people grieving over their deceased loved ones. That felt to me unnecessary and something that didn't need to be captured. That moment belonged to the families and their loved ones alone.
A couple of tech questions. You were both the DP and sound person?
Yes. Half and half. I did have some wonderful sound recordists to accompany me on some of the shoots, and then, often I would work as a one-man-band - for three reasons, really. One is that I was often running to the hospital on an ad-hoc basis. I wasn't able to schedule normal production days because events were unfolding in an unpredictable fashion. I needed to remain flexible, and it wasn't practical to phone up a sound recordist and expect them to show up at the hospital in the next 15 minutes when I needed to be there rolling.
Reason number two is I discovered even from a logistical standpoint that being behind the curtain in these rooms, it was a rather confined space, and it was not a hospitable environment for a crew.
The third reason, which is sort of connected to that, is it afforded a degree of intimacy that may not have been possible with a larger crew, even with a boom operator. A boom hovering overhead can sometimes be distracting. In those moments when I was recording sound on my own, I think I was able to keep my profile small enough that the room forgot about me and obviously, the decisions that were being contemplated in those moments far outweighed the distraction of my presence. But certainly, having a small profile and being simply a guy with a camera helped create an intimate space that would feel very different with a film crew.
Focusing on sound, there are so many different sounds in a hospital. There are the beeps from the machines, there is the PA system, there are the conversations among the medical teams, there are the conversations among the families. And there are the sounds of people suffering and dying. Talk about how you handled the challenges of capturing life in a hospital as well as those important conversations that are so crucial to the film.
Well, you're right. It is a noise-polluted environment, and some of the noises are wonderful to create a sense of place, and some of the noises can be incredibly frustrating. It can make editing more difficult. It can make perception of verbiage more difficult. I certainly want to give a shout-out to our post-production sound mixer, Jim LeBrecht, who had to, in some cases, really go into the audio files and extract sounds that were riding on top of our dialogue, and that was a very challenging process.
I'm amazed at what sound mixers can do, what their technology is capable of. I've been rescued a couple times by some of these incredibly precise filtering tools. And that certainly was something that helped us. I think because this was an observational film, the sounds were so crucial in providing a sense of environment and a sense of place, and we didn't have to work around them as often as one might think. If there's a loudspeaker blaring in the background or a machine beeping, those were elements that we put a lot of value in, actually, and it wouldn't have felt real if it had been a sound vacuum.
All of the beeping and whirring and the pumping of air through machines, sometimes we took pains to make sure that we got the wild sound of all of that machinery. After all, this is a film that poses the question of whether doctors and family members should sustain life using machinery, and the sound of that machinery was in itself a part of the character of the film.
Segueing to editing, you focus on two main characters and their respective families, in addition to Dr. Zitter. But there are some other minor characters that we see fleetingly throughout, and in one sequence we see a montage of several of them. Can you talk me through the editing process for this specific sequence?
The editor, Jeff Gilbert, who has cut documentaries like The Overnighters and other seminal films, is an incredibly talented, smart and sensitive editor who has a real understanding of narrative and character. He brought so much to this film. I give him so much credit, and we had a wonderful collaboration. I think we both felt that the two stories that appear in the film were played well against each other because they were families that were choosing very different paths for their loved ones and yet were both making the right decision for their family. From the earliest stages of editing, we recognized that those two stories playing next to each other told us almost everything we wanted to say, that faith and culture and love and empathy factor into this decision-making.
With that backbone in place, we wanted to fill out the film with a sense of a flood of humanity that was coursing through that ICU. Every day, I would walk into that ward, and as you walked down the hallway, each room is encased by this glass door, and it was like seeing a tableau of incredible human drama in every window. I wanted to capture that feeling in the film and incorporate many more faces and vignettes. I had filmed there for three or so months, and we had quite a bit of material.
We didn't know if this film wanted to be a feature or a short or something in between. We let the material tell us tell us how long the film was going to be, and we started to create organizing principles for these fragments, and the first set of vignettes. There are two main montages—and we even resisted the idea of calling them montages, but, rather, two different sequences that were thematically organized.
The first one had to do with the difficulty of decision-making, particularly when there are no family members or surrogates present. Some of that responsibility falls to the doctors, and that's where we see the homeless patient conferring with the doctors and the doctors discussing among themselves how to judge the man's capacity. We get a sense of the strain of decision-making when there are no clear directives in place, the ethical dilemma that, often, physicians are left to address. So that was the first grouping.
And then the second grouping of vignettes was really about saying goodbye and was much more tuned to be an emotional experience and less about making an intellectual statement or posing an intellectual question. And that is when we see the woman who says she's only 38, with her daughter. We see a man kissing his father on the forehead. We see two sisters encouraging their mother to keep fighting. That was really a sequence that was just built on emotion, and so much of what we saw in the ICU was people straining to say goodbye and let go and acknowledge the inevitability of that. We wanted to show that because it's accurate to the experience of being there; it was crucial to understanding what happened there.
You talked about the quandary of this being a short film or a feature film or something in between. How did you determine that what Extremis would work best as a short film?
Well, I felt once we had produced our first cut, it was roughly in the 30-minute range, and it said everything we wanted to say. I felt after watching the initial cut that Jeff put together that the profound questions that these patients and doctors were dealing with, the emotion that accompanied that decision-making, the scope of the humanity that was being processed through that unit: it was all there. And if the film was saying everything we wanted it to say in 24 minutes, the question then became, "Why would we make it a second longer?"
You bore witness to many profound transitions and passings. How did this experience transform you as a filmmaker and as a person?
Well, I witnessed moments of incredible human courage and dignity and compassion that gave me hope for humanity. This film really is about compassion and empathy. I had the great privilege of witnessing the compassion and courage of the families in the ICU, and I think we can all, especially today, take a page from that book. We live in an era where I think we could use more compassion and dignity, and I hope this film does a little something to highlight the examples set by the patients, their families and the medical staff.
Extremis screens as part of IDA's DocuDay on February 25 at 3:55 at the Writers Guild Theater in Beverly Hills.
Tom White is editor of Documentary magazine.