Grace is not what you’d expect to find in the room at Highland Hospital in Oakland, California where Donna, a middle-aged woman suffering from organ failure, is surrounded by her family and doctors debating whether she should be taken off her ventilator during an early scene in “Extremis.” She gave her family no specific directions on how to handle such a situation before being robbed of her voice and yet the family’s stoicism as they learn of the choice they need to make is remarkable to behold, so much so that you nearly forget that the only reason you’ve been allowed to witness it is through the finesse and sensitivity the filmmaker Dan Krauss draws on to capture it, making the impossible scenario all too tactile in the fleeting but impressive glimpses we’re given of hands, faces and medical equipment, the kind that stay with you when all you want to do is look away.
“One thing I focused on a lot in the way that I captured these scenes was finding the line between intimacy and intrusiveness because it would be very easy to cross over to intrusiveness where it felt like you were violating a sacred space,” says Krauss, whose resulting film was recently shortlisted in this year’s Oscar Best Documentary Short category. “That was partly a matter of placing myself physically at some distance to allow space and shooting a little bit more long lens and the other thing that I just naturally gravitate to as a filmmaker is people’s faces, so there’s a lot of closeups in this film.”
As a whole, “Extremis” acts as a closeup that manages to tell a far larger story than its 24 minutes should be able to hold. Following physicians into the breach as they inform patients and their families of their options when it appears the end of their loved one’s life is near, Krauss gets his arms around the difficult and unwieldy moment in which decisions that require deep soul searching and immediate recourse are made long after the point where scientific evidence can point one in the right direction. Since such decisions are made emotionally and cerebrally, it’s hard to imagine how they can be conveyed cinematically and yet Krauss, a gifted cinematographer long before making such acclaimed documentaries as ”The Death of Kevin Carter” and “The Kill Team,” is constantly able to take the temperature in the room, operating to two levels — tracking doctors, patients and members of their families individually as they work out internally whether they feel it’s time to let go and then watching as they test their opinion against others who bring a different perspective to bear. For a subject that may appear dour on the surface, “Extremis” becomes an unlikely celebration of compassion and rational thought as people are put to the ultimate test of their beliefs and generously take into consideration the counsel of others.
With the film available for all to see on Netflix after a much-lauded premiere at the Tribeca Film Festival, where it won the Jury Award for Best Documentary Short, Krauss spoke about entering such a fraught environment with a camera, deciding to stay only inside the ICU for the film, and what it’s been like for millions around the world to have instant access to the film.
How did this come about?
It’s funny because I didn’t come to this project with a preexisting interest in end of life issues. It’s something that intimidates me quite frankly and I was introduced to Dr. [Jessica] Zitter, the physician who’s featured in the film, and we struck up a conversation about our respective work. What really fascinated me is that, as an ICU physician, she is, on a daily basis, confronted with questions that really transcend medicine and science. I hadn’t thought about doctors having to take on the role of a counselor that has to help shepherd families and patients through the most fundamental questions of their core humanity. That’s not something that doctors are trained to do. It’s an incredible weight to bear and I was fascinated with how physicians, medical staff, families, and patients all have conversations that focus on questions that are, to put it mildly, very challenging and in some cases are really fundamentally unanswerable. So when I went into the ICU, I found it to be this place where science and faith collide in a fascinating way, and that was where I decided to put my focus.
While it might’ve been obvious to tell this from one point of view – perhaps Dr. Zitter’s – the film balances the perspectives on all sides of those conversations. Did you actually start out with that idea?
I was really hoping to capture both sides of that deliberation. It was important to show how the families would talk to their own loved ones about the decisions, and I also [that] they were not easy decisions for the doctors, either — in fact, you could see how emotionally affected the physicians are by having the burden of helping navigate these really, really difficult waters. I wanted to show the doctors be just as human as the patients because this is an environment in which everyone has to be fundamentally human. The doctors have to come down from the throne of having the commanding knowledge and scientific training to look eye to eye with patients and their families and talk to them just as human beings, [albeit] human beings who have had a lot of experience handling these questions, so therefore in a place to help families make the best decision because they can give perspective.
What I was hoping to capture are those moments of just utter humanity between patients and doctors that you don’t always think about when you think about interactions between patients and doctors. In my mind, the more typical conversation is that a doctor has a chart with data and test results on it, they deliver that information to the patients and the patients react to that in whatever way is appropriate. The conversations I was witnessing, the physicians and the families were in it together, both grappling with the same questions, both feeling the weight of those questions on their shoulders and finding moments of common humanity that transcended the typical doctor-patient dynamic.
How did you gravitate towards Donna as the main patient you focus on?
The overall strategy was to round with an ICU attending physician and then find appropriate moments to introduce myself and explain what I was doing in the ICU and have a conversation with some of the patients that were confronting some of these questions that I was hoping to capture. It was actually a different physician that I was rounding with that day that introduced me [to Donna] – Dr. [Monica] Bhargava, the Indian-American physician that you see in the film. During rounds, she said there’s a family here that you might want to talk to because they’re dealing with these questions and they’re very thoughtful about it. I went and spoke to Donna’s brother Gordon and immediately, he understood the value of the film. I didn’t have to convince him of anything. He instantly saw this was a way to connect with other people and that other people could derive value from understanding what they were going through.
When something like that happens as a documentary filmmaker, you just fall to your knees and thank whatever documentary gods you think are watching over you because it’s such a gift to be able to find someone who in the midst of such pain and hardship can understand the value of capturing the experience to share with other people. And even though [Donna] couldn’t talk, she was completely conscious. There were times when her family wasn’t there when she would just wave me in with her hand and we’d have a one-sided conversation because obviously she couldn’t respond to me, but she could nod and she was completely onboard with it from the very second I walked in the room. They were actually the first family that I really spent a lot of time with and that was very encouraging to me early in the process. You have to understand I am approaching people on what may be the worst day of their lives and asking to film them. It’s not an easy ask and to find someone like Donna and Gordon, who instantly understood the value of the film and were willing to make themselves vulnerable in order to share their story, that was a huge, huge gift.
While it’s a situation you instantly empathize with, you also are able to present everyone on camera in multidimensional terms, though you resist doing traditional sit-down interviews or asking about anyone’s backstory on camera. Was it difficult to achieve that?
Yeah, it was a question as I continued filming how much backstory I would present — would I go home with some of the patients’ families and capture that dimension of who they are and their life? It’s hard to explain creative impulses sometimes, but I just had the very strong feeling that the film wanted to live in the ICU, that it wanted to be present tense and it really wanted to focus on the process of decision making. The humanity of the patients and their families would be so strongly represented in those moments that their backstory would feel superfluous in a way.
What we are seeing is people who are confronting the most fundamental human questions in the moment and in my opinion, that tells you everything you need to know about a person. Part of the reason this is a short film is because what we infer about all these people, even when we see them in just short pieces only in the ICU, has more dimension, more humanity, more beauty than we would see if we spent an hour of screen time with them at home because what we’re capturing in those moments is really who they are at their core.
This may be a silly question, but you are able to set the scene quite effectively time to time with these evocative side views of the EKG machines and other medical monitors. How did those come into play?
That was actually something that came very late in the process. I went back to get it after the filming was done because in the moment of capturing these patients’ stories, all I’m thinking about is the people and I’m not focused on interstitial elements or transitions [for the film], so I didn’t have a lot of that kind of library of visual material. When we started to assemble it with editor Jeff Gilbert, we had this thought to use some of those machines [because] in a way, we’re talking about machines that sustain life in ways once thought unimaginable and we thought there’s something perhaps poetic about really absorbing those machines and giving them their own space. So I went back to the ICU some months after I finished filming and just spent a couple of hours going into some of the rooms where these machines were operating and getting those kinds of macro closeups. Those ended up being very useful.
This is the first documentary short to be released by Netflix. Has it been interesting to have that instant audience of millions – and by extension, an instant reaction?
Beyond interesting. This started as a self-funded side project — I mean, the hospital’s 10 miles from my house — that I was doing purely out of interest and I never imagined that it would find the platform and the audience that it has now. It’s been translated into dozens of languages and I get tweets and e-mails from all over the world, people responding to the film because this is something that touches everybody. There’s no human on the planet earth that escapes this issue and to have that platform, especially for a short film, is unbelievably gratifying.
I am so grateful that Netflix has I think the foresight to understand that we’re past the days of programming blocks and categorizing movies necessarily by their running time. I felt like I wanted to make this film exactly as long as it needed to be, and it’s a really interesting time not just for nonfiction filmmaking, but filmmaking broadly, to open up the form and see what happens in the next few years as filmmakers start allowing the story to start dictating the running time, not the demands of broadcast or theatrical exhibitors. Netflix, in their great wisdom, understood that and agreed that a 24-minute film could say everything that we wanted to say. And if we can say everything that we want to say in 24 minutes, why make the film one second longer?