The portrayal of coma in contemporary motion pictures
Eelco F.M. Wijdicks and Coen A. Wijdicks
Neurology 2006;66;1300-1303
DOI 10.1212/01.wnl.0000210497.62202.e9
This information is current as of May 8, 2006
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Views & Reviews
The portrayal of coma in contemporary
motion pictures
Eelco F.M. Wijdicks, MD; and Coen A. Wijdicks, BS
Abstract—Background: Coma has been a theme of screenplays in motion pictures, but there is no information about its
accuracy. Methods: The authors reviewed 30 movies from 1970 to 2004 with actors depicting prolonged coma. Accurate
depiction of comatose patients was defined by appearance, the complexity of care, accurate cause of coma and probability
of awakening, and appropriate compassionate discussion between the physician and family members. Twenty-two key
scenes from 17 movies were rated for accuracy by a panel of neurointensivists and neuroscience nurses and then were
shown to 72 nonmedical viewers. Accuracy of the scenes was assessed using a Likert Scale. Results: Coma was most often
caused by motor vehicle accidents or violence (63%). The time in a comatose state varied from days to 10 years. Awakening
occurred in 18 of 30 motion pictures (60%). Awakening was sudden with cognition intact, even after prolonged time in a
coma. Actors personified “Sleeping Beauty” (eyes closed, beautifully groomed). Physicians appeared as caricatures. Only
two movies had a reasonable accurate representation (Dream Life of Angels and Reversal of Fortune). The majority of the
surveyed viewers identified inaccuracy of representation of coma, awakenings, and conversations on the experience of
being in a coma, except in 8 of the 22 scenes (36%). Twenty-eight of the 72 viewers (39%) could potentially allow these
scenes to influence decisions in real life. Conclusions: Misrepresentation of coma and awakening was common in motion
pictures and impacted on the public perception of coma. Neurologic advice regarding prolonged coma is needed.
NEUROLOGY 2006;66:1300–1303
Neurologic disease has been featured in motion pictures mostly to highlight its crippling nature. Best
remembered are Awakenings (postencephalitic Parkinson disease), Hillarie and Jackie (multiple sclerosis), The Theory of Flight (ALS), and Lorenzo’s Oil
(adrenoleukodystrophy). Studies on representation of
neurologic disease as a side plot have rarely been
performed, but two studies, specifically about seizures in the movies, have been reported.1,2 Both studies concluded that seizure disorders in the movies
were overexaggerated, and actors impersonating patients with epilepsy played “bad or mad” characters.1,2 Moreover, neurosurgeons have expressed
concern about the portrayal of head injury in
movies.3
Unconsciousness has been a theme in motion pictures and has even been a major topic (e.g., Coma,
Critical Care). The agony of having a relative in a
comatose state along with the prospect of a changed
personality speak to the imagination of screen
writers.
Additional material related to this article can be found on the Neurology
Web site. Go to www.neurology.org and scroll down the Table of Contents for the May 9 issue to find the title link for this article.
We were interested in how coma was portrayed in
the movies. In addition, it is unclear how much of the
viewing public might be influenced by watching
these movies. This information has new relevance in
the wake of the Schiavo tragedy and public debate.4
We reviewed motion pictures distributed in the
United States from 1970 to 2004. To address the
potential effect on the viewing public, we performed
a survey showing key scenes to nonmedical viewers.
Methods. Review of movies. We searched an international
movie database (http://www.imdb.com/), using the key words
coma, comatose, brain death, and vegetative state. We excluded
made-for-television movies, “unrealistic” movies in the so-called
horror, vampire, science fiction, and animation categories, and
movies that showed coma but quick awakening upon arrival in the
hospital. Films in foreign languages that were not available for
review, not translated, or not distributed in the United States
were excluded. Movies specifically focused on chronic neurologic
disease and stupor were excluded (Awakening, Lorenzo’s Oil); they
have been discussed before.5,6
Our study was limited to movies distributed in the United
States, and we reviewed those available on VHS or DVD. Specific
attention was paid to the cause and situation of coma, demographics of the actor in coma, physician communication with proxy,
medical or intensive care of the comatose patient, awakening from
a comatose state, the role of the neurologist or neurosurgeon, and
possible therapies. The popularity of the movies was gauged by
awards at film festivals or other major events (e.g., Cannes Film
From the Division of Critical Care Neurology, Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN.
Disclosure: The authors report no conflicts of interest.
Received September 5, 2005. Accepted in final form January 19, 2006.
Address correspondence and reprint requests to Dr. E.F.M. Wijdicks, Division of Critical Care Neurology, Department of Neurology, Mayo Clinic College of
Medicine, W8B, 200 First St. SW, Rochester, MN 55905; e-mail: [email protected]
1300
Copyright © 2006 by AAN Enterprises, Inc.
Festival, Academy of Motion Pictures), and we recorded movie
ratings by the Motion Picture Association of America.
For a movie to be considered an accurate depiction of comatose
patients, all of the following criteria had to be fulfilled: 1) the
complexity of care of maintaining a patient in a comatose state; 2)
accurate cause of coma and probability of awakening; 3) appropriate compassionate discussion between the physician and family
members.
Survey of lay public. The second part of our study involved a
private viewing of 22 key scenes from 17 movies. We selected four
topics: the portrayal of coma (four scenes), awakening (nine
scenes), recovery after coma (three scenes) and physician, nurse,
and family conversations (six scenes). Using a 5-point Likert Scale
(strongly disagree, somewhat disagree, neutral, somewhat agree,
somewhat disagree), we asked viewers to rate the following six
statements: “I think this is how comatose patients look”; “I think
the awakening shown after being in a coma for a long time can
happen this way”; “After awakening from being in a coma for a
long period of time, you may be able to do this”; “I believe what
has been said is correct.” We finally asked to rate the following
statement: “If my family member would be in the same situation,
it is possible that I would remember what happened in the scene
and allow it to influence any decisions that I would make.”
The 72 viewers included 53 Mayo Clinic Rochester secretaries
and desk attendants and spouses and 19 members of the American Academy of Neurology supporting staff. These 22 scenes were
viewed by a panel of four neurointensivists and four intensive care
unit neuroscience nurses. Each scene was labeled accurate or inaccurate by consensus agreement.
Results. Cinematic details. We found 30 movie titles
with actors or actresses in a comatose state. (The major
findings are summarized in table E-1 on the Neurology
Web site; go to www.neurology.org.) We found the largest
number of movies with coma as a side or driving plot after
1990 (1971 through 1990, 5 movies; 1991 through 2000, 13
movies; 2001 through 2004, 12 movies). We reviewed six
movies in foreign languages. Four movies were in the comedy category, and the remaining movies were thriller or
dramas. Coma was caused by motor vehicle accidents (n ⫽
11), gunshot wounds (n ⫽ 4), violence causing brain injury
(n ⫽ 4), and other causes such as iatrogenic, carbon monoxide intoxication, hemorrhagic shock, drug overdose, and
cardiopulmonary resuscitation with anoxic–ischemic brain
injury. The majority of the movies were rated R (restricted)
(19/30; 63%), 10 movies were rated in the PG/PG 13 (parental guidance) categories, and 1 movie was not rated.
Depiction of coma in the movies. Most comatose patients were actors in their 30s to 40s (male, n ⫽ 13; female,
n ⫽ 14; 3 children). Despite many years of coma, all actors
except one remained well groomed with normal, muscular,
tanned appearance. The depicted patients in prolonged
coma looked similar as if they were sleeping and all had
their eyes closed (“Sleeping Beauty phenomenon”). The two
females in coma (4 years and 2 months) in Habla con Ella
(Talk to Her) were shown with a pleasant facial expression, no contractures, and often in sleeping positions. Eye
opening after prolonged coma is not known to screenwriters; and all comatose actors, except for one (Firelight),
kept their eyes closed. In Reversal of Fortune, Glenn Close
narrates the story of Sunny von Bülow and is shown in
many scenes with eyes closed and positioning her arms
and wrists to mimic contractures. Although reasonably accurate, the script confuses brain dead with persistent vegetative state.
There were multiple reasons why the depiction of coma
was chosen in the plot line. Revenge after awakening from
head injury (n ⫽ 7), suffering of a loving family (n ⫽ 4),
and end-of-life decisions (n ⫽ 4) were more common. The
time in coma varied from days to ten years. Awakening
occurred in 18 of 28 (64%) instances. Awakening included
sudden, sitting upright in bed (Kill Bill Volume 1), sudden
awakenings with stepping out of bed and pulling out catheters and walking out of the hospital (28 Days Later), and
sudden increase in pulse rate before eye opening (Face Off,
Hard to Kill). Often, awakening occurred by some prompt.
In Kill Bill, the “bride” awakens suddenly after a mosquito
bite. In Good-Bye Lenin, the mother has been 8 months’
comatose and ventilated after experiencing a postanoxic–
ischemic encephalopathy. Her son enters the room, flirts
with the nurse, and kisses her. At that very moment, his
mother’s arm starts to quiver and move, resulting in a
flower vase hitting the ground, followed by eye opening.
She smiles and is immediately lucid in subsequent scenes.
In Blind Horizon, a burning cigarette put out by a nurse in
a bedpan placed underneath the bed triggers nasal quiver,
smell, and awakening; In Winter Sleepers, awakening occurs after bright sunlight in the eyes; In Monkey Bone,
withdrawal of support has been decided, and the discontinuation of the mechanical ventilator— by pushing on a red
button— causes the patient to suddenly sit up in bed while
extubating himself, opening his eyes, and looking around
while some of the surrounding family faints.
Abnormal behavior after awakening from coma was emphasized and included psychic experiences (Dead Zone)
and murderous revenge (Lying in Wait, A Man Apart, Face
Off, and Hard to Kill).
Physicians discussed coma in some detail in six movies,
Table Notable physician dialogue lines in motion pictures about coma
Movie
Lines
Regarding Henry
“Mrs. Turner, your husband is incredibly lucky. The bullet wound to the head caused minimal damage. See,
it hit the right frontal lobe. That’s the only part of the brain that has redundant systems. I mean, if you’re
going to get shot in the head . . . that’s the way to do it.”
Lying in Wait
“He is no longer in a coma. He is in what we call a persistent vegetative state.” [Man (confused): “He said, ‘Help
me.’” “He cannot speak. The tests prove that, but you never know. One day Keith may sit up and recite the
Gettysburg Address” [telephone rings]. “Now, if you will excuse me.”
Paparazzi
“Now, let’s talk about this guy here. His vitals are good, but comas are a tricky thing. We just have to wait.”
Habla con Ella
Man: “So that means there is hope?” Doctor: “No. I repeat, scientifically, no. But if you choose to believe go ahead.”*
Blind Horizon
“Uh, 50% total recovery, 35% partial and 15% you plant him in the ground and watch him grow.”
Critical Care
“I have lettuce in my refrigerator that has a better chance of becoming conscious than this guy.”
* Translated from Spanish.
May (1 of 2) 2006 NEUROLOGY 66 1301
and they appeared as caricatures with little compassion
(table). Furthermore, the comedy Critical Care also suggests that physicians are not observant enough (failure to
recognize Morse code tapping by comatose patient). In Habla con Ella (Talk to Her), in a dialogue with a patient’s
friend, the physician suggests that awakening after 14
years has been noted while showing a magazine article.
Although the physician accurately discards recovery as an
improbability, he suggests to the patient’s friend to keep
hoping for recovery.
Other medical inconsistencies included EKG lead on
forehead (Lying in Wait) and sounds of respirator but nasal canula only (While You Were Sleeping). In Hard to Kill,
the actor has grown a sizable and nicely trimmed goatee
after 7 years. In Regarding Henry, the physician points to
a skull radiograph that shows a silhouette of an intact
bullet just underneath intact bone.
Dream Life of Angels depicted a comatose patient with
contractures, tracheostomy, and gastrostomy remarkably
well. In this film, the neurologist conversation was accurate with a great deal of compassion. “She is unconscious,
she can’t communicate. She can’t talk or move. She won’t
answer you. We are watching for any sign of her waking or
of an improvement. Spend some time with her. If the
sound of your voice triggers off a sign, let me or one of the
nurses know. It’s very important.”
Survey results. There were 33 male and 39 female reviewers. Forty-four of the 72 viewers (61%) were older
than 35 (range 18 to 65 years). Sixty-six of the 72 viewers
(92%) had at least some college or 2-year degree or more,
and 14 of 72 viewers (19%) had postgraduate studies. The
results of the survey are shown in the figure. The majority
of the viewers identified inaccuracy of representation of
coma in its appearance, awakenings, and conversations
about the experience of being in a coma, with notable exceptions (neutral, somewhat agree, or strongly agree) in
eight scenes. In addition, 31% would believe Morse code
signals were possible (neutral, somewhat agree, or
strongly agree) in a comatose patient. Twenty-eight of the
72 viewers (39%) would allow the scenes to influence
decisions.
Discussion. The depiction of comatose states in
motion pictures is misrepresented. We found only 2
of 30 reviewed motion pictures (Dream Life of Angels, Reversal of Fortune) with a reasonably accurate
representation of prolonged coma. Miraculous awakening from prolonged coma with no long-lasting effects was a typical feature.
Coma is frequently caused by injury and violence.
Few of the actors, despite being comatose for
months, were tracheotomized or displayed contractures; and none had feeding tubes, and most remained perfectly groomed with normal, muscular,
and tanned appearance, trivializing the depiction of
prolonged coma to a sleep-like state (“Sleeping
Beauty”). Sudden awakening from coma occurred in
nearly two-thirds of the actors and followed a characteristic pattern: Patients in coma for several years
awakened within seconds, similar to awakening from
a terrifying nightmare. Depicted patients were lucid
and without apparent cognitive deficit. Some awakenings were provoked by a stimulus (e.g., mosquito
1302
NEUROLOGY 66
May (1 of 2) 2006
Figure. Description of scenes and survey results (full bar
represents 100%). The assessment of the viewers is an extrapolation of the Likert Scale (see Methods).
bite, smoke). Some films depicted a major change in
personality after a prolonged coma (criminal or
psychic). Prevailing themes were revenge after
awakening but also included love, bonding, and companionship and end-of-life decisions.
The representation of a vegetative state has been
depicted in a few movies, most remarkably showing
beautiful female bodies as if asleep in Habla con Ella
(Talk to Her). Not showing the muscle atrophy, decubital ulcers, bladder and bowel incontinence, and
gastrotomy may be a conscious decision to maximize
entertainment but is a disservice to the viewer. Success of rehabilitation after many years of coma, discounting the catastrophic injury leading to prolonged
coma, is emphasized in some screenplays (Dead
Zone, Talk to Her).
Cinematic portrayal of physicians has increased in
recent years, but neurologists are in only 2% of 131
reviewed movies, dominated largely by surgeons and
psychiatrists.7 In this study, the attending physician
showed detachment and little compassion, and the
communication with the family was dramatic and
caricature. This is consistent with an earlier studies
on physician portrayal, often showing “egotistical
and materialistic traits.”7,8 Two comedies include a
sarcastic view of doctors’ inability to prognosticate
comatose states (Monkey Bone) and observe signs of
communication (Critical Care).
Our study is not a complete assessment of the
representation of comatose states in the movies. Our
method is imperfect, and we acknowledge we could
have neglected several movies. This would also require the review of movies in foreign languages.
However, it is likely these foreign movies would have
only limited appeal. Many of our reviewed movies
were award winning and successful. These are movies that are seen by most moviegoers, and this adds
to the concern that the viewing public is likely to see
movies with misrepresentations of coma.
We did not know how these movies affect viewers’
opinion and suspected the general viewer was capable of identifying inaccuracies. However, our survey
found that viewers were unable to identify important
inaccuracies in one-third of the selected scenes. Surprisingly, when confronted with a comatose person,
more than one-third of the viewers would potentially
let these scenes—showing fictional characters and
plots—influence their decisions. This finding alone
hints at the considerable impact movies may have on
public’s perception of coma. Our survey was skewed
toward an educated audience of mature age, and we
did not expect such high proportion of error. Surveys
of a random sample attending a theater may show
more pronounced results but pose major logistic
problems.
The representation of prolonged comatose states
in the movies is problematic. With a tangle of truths
(lack of consensus between family members about
level of support in Critical Care) and inaccuracies
(Morse code tapping in a comatose patient in Critical
Care), screenwriters give the audience a great deal to
consider. To imply full physical and cognitive recovery after prolonged coma is gratuitous. However,
screenwriters or directors, in a genre outside a documentary, do not have the moral obligation to present
factual representations. Screen writers, producers,
and directors may thus deviate from the norm or
reality in fictional films to produce a certain desired
effect and mostly to entertain. Extreme transgressions may be seen in science fiction or horror movies.
Movie critic Roger Ebert wrote, “I want moods,
tones, fears, imaginings, whims, speculations, nightmares. As a general principle, I believe films are the
wrong medium for fact. Fact belongs in print. Films
are about emotions.”9
We acknowledge that evaluation of an art form is
rarely truly objective, more often personal, and may
amass to pretentiousness. Criticism from neurologists is expected, but some audience may ignore the
inconsistencies. The public has become more sophisticated in its medical knowledge, and we presume
moviegoers would appreciate a more accurate display of devastating neurologic injury and a less stereotyped depiction of physicians. We are concerned
that the comatose states depicted in these movies
often can be misinterpreted as realistic representations. Yet we found that screenplays can be factual;
one movie in particular (Dream Life of Angels) was
truly able to convey the complexities of care surrounding a loved one in coma. Therefore, neurologic
advice regarding prolonged coma is needed. Historians, military experts, and even scientists have advised screenwriters, and with some success.10
Acknowledgment
The authors thank Jodie Bartz for editing of the key scenes,
Raquel J.S. Nelson for secretarial help, and Jeffrey Bell and Alberta Zais for organizing the survey.
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May (1 of 2) 2006 NEUROLOGY 66 1303
The portrayal of coma in contemporary motion pictures
Eelco F.M. Wijdicks and Coen A. Wijdicks
Neurology 2006;66;1300-1303
DOI 10.1212/01.wnl.0000210497.62202.e9
This information is current as of May 8, 2006
Updated Information &
Services
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