By Kenny Irby
Dallas Morning News
photographer Sonya Hebert and reporter Lee Hancock spent the past year
documenting death -- how we experience it and how it changes the way we
live -- for a five-part series called "At the Edge of Life." In
their exploration of end-of-life medical care, Hebert and Hancock
worked with Baylor University Medical Center's palliative-care team and
gained unprecedented access to clinicians, patients and families.
Hebert's
photos and video capture the stories of those they met -- the
granddaughter who just lost her grandma, the woman who can't bear to
leave her dying husband's bedside, the girl who struggles with an
eating disorder as she wonders whether her ill mother will survive.
To
find out more about these stories and what she learned from capturing
them, I interviewed Hebert, who won the ASNE Community Service
Photojournalism award for her work on the project and was nominated as
a 2009 Pulitzer finalist. Here is our edited exchange.
Kenny Irby: How did the "At the Edge Of Life" project originate, and how long have you done this kind of work?
Hebert: The concept of the project was born before I started working at the Morning News.
Our project began with personal loss. Reporter Lee Hancock's youngest
brother spent five years in and out of ICUs before succumbing in 2005
to complications from a fungal infection. She saw how everyone around a
hospital bed suffers when no one can talk openly about mortality.
Death
is the last great taboo, a subject few volunteer to explore intimately.
Our newsroom is no exception, as it routinely covers accidents,
violence and freakish tragedies but rarely examines how death comes
about for ordinary people. We felt compelled to look at our way of
dying and how we might cover the subject better.
The Dallas Morning News
is my first full-time job in journalism. And, this project is by far
the most intensive and in-depth work I've done. I studied
photojournalism at Ohio University from 2005-2007, during which time I
worked on short-term projects.
How much time did you put into the coverage?
Hebert:
I spent the bulk of a year working on this project. We negotiated with
Baylor University Medical Center's palliative care team to gain access
and then spent months haggling with the hospital's administrators and
lawyers. The palliative team director gave up at one point, saying we
couldn't overcome legal obstacles and fears about having a reporter and
photographer roaming Dallas' largest hospital. We kept pushing and
ultimately gained unfettered access.
We spent months attending
Baylor palliative care team meetings and meeting with doctors, nurses,
public relations staff and others individually to explain our goals and
build trust. We had planned to be
with the Baylor palliative care team over an intensive period. Before
doing so, we needed to ensure that the team members were on board with
the project and we had to allow them to become comfortable with their
role in initiating patient interactions for us.
We spent
months observing clinician visits with patients and families. In late
May and early June, we shadowed the team at Baylor intensively for
three weeks and met 38 patients who agreed to be a part of the project.
I shot stills and video. After the three-week period, we continued
until late September to document the stories of some of the patients
who left the hospital and families who lost loved ones.
Video
and print production began in August. With over 50 hours of video
footage, just scrubbing the video took many weeks of long hours. The
production of the four videos in total took four months.
How did the collaboration between you and your writing colleague evolve?
Hebert: Writers
and photographers have different processes for storytelling. This can
pose a challenge when both the writer and the photographer must
accomplish their storytelling under restrictions. Balancing our
individual needs was challenging. It was Lee's intention to tell the
story of end-of-life care at Baylor through the experiences and
interactions of team members and patients. I found it more compelling
to focus mostly on the patients. This posed a conflict, especially
given the requirement to be accompanied by a public relations staff
member at all times, which prohibited us from splitting up.
On
a typical day rounding with the palliative care team, nurse Min Patel
zipped from floor to floor, tracking down doctors, seeing patients, and
putting out fires. It was vital for Lee to stick to Min and follow her
every movement. On the other hand, there were times I needed to stay
with the patients to build rapport and shoot freely. As the embed
period progressed, we both learned how to accomplish what we needed
while helping the other to do the same.
How did you interact with your online staff? Was the Web presentation very different from the newspaper's presentation?
Hebert: I
had minimal contact with the online staff who produced the main page.
The project coordinator, photo editor Chris Wilkins, conferred with the
online department.
Were the goals different for online presentation from the print edition?
Hebert:
The print presentation was a five-day series, including over 40 photos,
that took readers on a journey into Baylor hospital rooms where
palliative care practitioners helped dying patients and grieving
families with the painful choices of life and death. It looked at the
human side of medical care and the role of technology in an era when
dying patients can be kept alive for months, even years, but never
cured.
The goal of the online presentation was to expand on
the print presentation through videos and additional resources for
readers. "Patients at the Edge"
is a compilation of vignettes of dying patients and their loved ones
that brings viewers into the universal experience of dying. The video about Penni Bourque gave viewers an intimate look at how palliative care can help people live fully until death. Judy Jackson's video examined how difficult it can be to let go of loved ones and come to terms with loss. "The Palliative Mission" offered explanation and understanding about what palliative care is and how it helps dying patients and families.
Join
Poynter Visual Journalism faculty member Kenny Irby, and ASNE winner
Sonya Hebert Monday, April 27, at 1 p.m. for a live chat on telling
stories about death with dignity. The interview continues below the
chat box.
The end of life period is a very difficult subject to explore in the American culture. How did your focus come about?
Hebert:
Initially, the project's focus was far-reaching and included three
areas of end-of-life care: the Baylor model, an established team of
doctors, nurses and practitioners; an out-patient palliative care
clinic at the county hospital, Parkland Hospital; and a look at
pediatric palliative care in the region as well. We chose to tackle
Baylor first because we had made great headway in access, and Baylor
had a well-established program.
After spending some time with
the Baylor palliative care team members, I knew I could best tell the
story of palliative care through the stories of individual dying
patients. I wanted to show what dying is like, what people go through
in this time of life that we will all face. Their stories became my
focus.
While we were preparing to embed with the team, we were
pursuing the other story leads as well. A pediatric hospice care nurse
introduced us to a couple preparing to have a baby who was not expected
to live long outside of his mother's womb. After meeting the soon-to-be
parents ... I chose to document their son's journey from life to death
as part of the pediatric portion of the project. Later in the year,
after extensively reporting at Baylor, we decided to hold the pediatric
story, quickly understanding that our initial scope was far too large.
In
addition to doing a piece on the dying experience featuring multiple
patients, I wanted to go deeper and document one or two individuals'
journeys at the end. When I met Penni Bourque and Judy Jackson, I
decided to focus on their stories. A fourth video would explain what
palliative care is doing to help dying patients and families.
What
were some of the challenges you faced? How did you overcome them? In
particular, how did you overcome the technical lighting challenges?
Hebert:
Working in a hospital is challenging. Despite the fact that we spent a
lot of time with the palliative care team, there was really no way to
help the rest of the Baylor staff to become comfortable with our
presence. The team makes rounds throughout the entire hospital, a
1,002-bed hospital. Multiple doctors see each patient. A lot of staff
got used to seeing us, but were still very protective of the space,
especially in ICUs.
There were many hours spent simply
standing out of the way trying not to push our luck. I was not allowed
to shoot unless I had written consent from all individuals in the
photos/video, which was difficult when following members of the team as
they rush from one floor to the next, one patient to the next. Shooting
the doctors and nurses while working was a challenge, even with the
assistance of PR. Some didn't want to be a part of the project. This
required constant explanation.
Juggling video and stills was
more difficult than I had anticipated. Not knowing what we'd be doing
each day, I had to bring both with me and make split second decisions
about what tool to use. As anyone who has shot video will say, shooting
too much is your worst nightmare. However not knowing which patients
would be in our final project or whether they would be alive the next
time we saw them, I tried to shoot as if I would never see these
individuals again. I ended up with over 50 hours of footage.
As
I mentioned earlier, the writer and I had very different needs to
accomplish our storytelling. Meeting our needs together was a challenge
given the restraints of the public relations team. Already extending
themselves by accompanying us all day, every day for three weeks, and
many times late into the night, they were not able to commit two staff
members to the project.
Lee and I had to stick together, and
often our needs would diverge. This required compromise and sometimes
not getting the picture. Not being able to spend as much time as I
needed with patients was difficult.
We relied on the palliative
care team to gain access to patients. As we followed them on rounds, we
would wait outside a patient's room while the team member requested on
our behalf their participation. There were days we saw no patients at
all. Some of the patients who were most interesting to us were off
limits due to ethics consultations, i.e., familial disagreement over
care decisions. This required a lot of faith in the process.
Meeting
patients and families and building rapport as they are coming to terms
with the idea of death was difficult. We observed nurse Min Patel's
first consultation with cancer patient Beverly Freeman on June 2.
Beverly had difficulty breathing. Her son and best friend were by her
side and were caught off guard by the change in her condition. We spent
a few minutes talking to Beverly and left feeling she could be a major
part of our project. I took a handful of photos of Beverly during her
interaction with nurse Min Patel.
Sonya Hebert/The Dallas Morning News
Suffering
from metastatic breast cancer, Beverly Freeman lies in her hospital bed
at Baylor. The next morning, Beverly was found collapsed by her bed.
Without a do-not-resuscitate order, the Baylor code team tried to
revive her. After nearly an hour, she was pronounced dead. “She’s never
been early to anything in her life, and now this. …God did what we
couldn’t do. We couldn’t let her go,” said her best friend, Gladys
Lowry. |
The next morning we
learned that Beverly passed away earlier that morning. As a
photographer and videographer, it's difficult to recreate what has
already happened. She could no longer be a major part of my
storytelling. We were not there for her death. Her family in disbelief
began to assemble at the hospital. Min Patel went into overdrive to
comfort them. We had not met most of them. This was a very delicate
situation. I didn't know how to approach Beverly's family as they
learned that the worst had happened. Journalists do this work every
day. But we don't do it in ICU waiting rooms with everyday folks.
Trying
to explain to them our project and Beverly's participation the night
before seemed inconsequential ... but at the same time a huge part of
the story. Lee was able to capture the details of Beverly's death and
the aftermath through medical records, interviews and observations. I
was not able to. The family gave consent to be photographed but it
still never felt right.
Technically, I tried to shoot with a
shallow depth of field to clean up backgrounds in the hospital. I also
tried to remember visual variety. One of the greatest challenges was
shooting the same visual situation repeatedly -- a patient in a bed. I
tried to shoot the patients' feelings of dying, rather than the literal
experience.
Photographic essay projects of this depth are not commonplace in newspapers these days. What value do you think they have?
Hebert:
Death is something that will affect all of us profoundly. Exploring the
dying experience addressed a great taboo in our culture. The project
helped to facilitate a conversation in our communities and with our
loved ones. The value of this kind of work lies in its potential to
touch people. It hopefully gets them feeling and thinking.
Sometimes
the value of what we do is a matter of impacting those we document. One
woman whose mother died after an unsuccessful "code-blue" resuscitation
later thanked us for treating her loved one's last moments "as
precious." Another wrote that our interactions with her husband helped
"give his life meaning" in his last six months.
Readers
responded as well. They thanked us for "courageous," "powerful" and
even "monumental" work. One called the series "compassionate,
informative and thought provoking ... on a topic that is really
hush-hush."
Medical professionals also praised the work.
National palliative care organizations recommended the series to their
members as a powerful educational tool. A nursing and bioethics
professor at Johns Hopkins University called it "incredible." The head
of an Indianapolis hospital's palliative team said the series was
"excellent ... insightful and heartfelt."
Stanford University
Hospital's palliative program manager wrote that her team wanted to use
it as a training tool. A local professor of law and medical ethics
wrote that we brought readers and viewers "as close as most of us will
get to the true in-hospital experience until it happens to one of us or
someone we love."
How do you go about gaining access and building relationships with the people you document?
Hebert:
Typically, I gain access and build relationships by spending time with
people. I try to be very open about my intentions, how I plan to tell
their story and why. I use every tool I can to build rapport -- verbal
language, body language and time. In this situation, we were dependent
on first, the palliative care team and second, the public relations
staff to secure access to patients, many of whom didn't agree to
participate.
If ideas are the
currency of the newsroom and photojournalists are equal to reporters in
the news gathering process, how did that attitude manifest itself
during this project?
Hebert:
Lee and I recognized that we could tell the story of death and dying in
different but complementary ways using our mediums, aiming to provide
readers with a well-rounded, comprehensive experience. All forms of our
storytelling offered readers an intimate look at the dying experience
and what palliative care is doing to help patients and families.
So
why black and white? It is clear that many hard-hitting photographic
projects are presented in black and white, when in fact they were
documented in color and the world that we live in is color.
Hebert:
We chose to change the images in print to black and white to avoid
distractions of mixed lighting in the hospital setting and maintain
consistency throughout the series. We contemplated using color on day
five to emphasize the dominant concept of Penni's story -- living fully
until you die. Most of the photos used on day five were outside of the
hospital setting. We thought this made it different enough to change to
color. However, in the end, we weren't able to use color due to press
issues.
Why are chapters four and five documented in color in the Web presentation?
Hebert:
Like the print version, "Patients at the Edge" and "The Palliative
Mission" were changed to black and white to maintain consistency and
avoid distractions of mixed lighting in the hospital setting. I thought
that readers could get to the content faster if not disrupted by the
color changes.
We chose to use color for Penni's and Judy's
videos to emphasize their difference from the other stories in that
they were intimate looks into individual's lives as they deal with
death in and out of the hospital. Because Penni was such an inspiring
story of living fully, we felt color was more appropriate than black
and white. But keeping only one of the four stories in color seemed
odd. Thus, we chose to keep the two videos about individuals in color,
while the other two were changed to black and white.
Tell me about the editing and selection process that you followed. How many images did you choose from?
Hebert:
I shot nearly 6,000 images for the project. After each shoot, the
stills project editor, Brad Loper, and I reviewed each image and did a
rough edit. It was difficult to finalize our edit for the print
presentation until an outline of the written narrative had been
finalized. Once we knew what characters were being presented on which
days, we were able to select the best images that helped to move the
print narrative along as well.
Video editor Ahna Hubnik, photo
editor Brad Loper and I selected the stills for the videos. Editing for
video was mostly on a scene-by-scene basis. Once the audio was nearly
finalized for each video, we chose the visuals, picking from both the
b-roll video and stills to help move the story along.
Who was included in your editing process and what role, if any, did a picture editor play?
Hebert:
Brad Loper worked as the primary photo editor on the project and worked
to select photos for the online presentation as well as the print
presentation. Director of Photography Leslie White and Assistant
Director of Photography Chris Wilkins weighed in on the final edit.
What are the more memorable lessons you learned during this assignment?
Hebert:
Have patience and trust in the process. There were a lot of unknowns in
this project. Would we get the access we needed? Would patients want be
a part of the project or would we spend all of our time sitting in the
hallways of the hospital? Which patients would be our primary
characters? Who should we spend our time with? Who's going to die
before we have a chance to document their story? These were scary
questions but in the end it all worked out. I think trusting the
process and yourself is vital to one's sanity while working on this
kind of project.
If you don't get everything you think you
need, that's OK. When shooting both video and stills, you will miss
things. In this case, I opted to bring both with me each day because I
never knew what would be happening each day. It worked out but was
overwhelming nonetheless to constantly think in terms of both video and
stills.
Edit video as well as stills as you go as much as
possible. This would've helped me refine my video shooting techniques
and made the editing process smoother. This would've helped me be more
selective in shooting video.
Don't underestimate the emotional impact the story may have on you and take care of yourself.
Communicate
your needs to the gatekeepers and writers beforehand. Make sure they
understand your needs so there are few complications and
misunderstandings while shooting.
Were there any major surprises for you while developing this project?
Hebert:
The project impacted me personally and spiritually in ways I didn't
expect. In retrospect, I don't know how you can contemplate death for a
year and not be impacted in these ways. Pondering death and our
impermanence is not an easy thing to do, but it is worthwhile. It
allows one to appreciate life and live it fully. Penni was an
inspiration in this way. I hope I can continue to take the hard lessons
I learned and apply them in my life and relationships.
What outcome did you desire and/or expect when this project began?
Hebert:
When the project began, the scope was so large that my main goal was to
narrow my focus and find individuals who would share their stories and
teach us something about the dying experience. It was my hope to find
multiple patients who in total would illustrate the comprehensive human
experience of dying.
What advice can you offer other photographers when it comes to being a visual reporter in such sensitive settings?
Hebert:
Be mindful of the impact your presence will have on those you
photograph. I traveled with Penni and her family to two states and
spent countless hours and some nights with them at their home. Doing
this kind of work, we become very close to the people we document. It's
impossible not to. Michelle, age 8, began to look to me as a mother
figure as she tried to negotiate in her mind the changes happening to
Penni. I think it's important to remind yourself and the people you
photograph of your role as documentarian.
Be grateful.
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