Paddleton

Paddleton. Director: Alexandre Lehmann, Producer: Duplass Brothers Productions, Length: 1 hour 29 minutes. Available on Netflix

Netflix's Paddleton is a dramatic comedy centered around two close friends, Mark and Andy, played by Mark Duplass and Ray Romano. The film follows the friends' six-hour road trip to a pharmacy that can dispense the medications Mark will use to end his life—a decision he has made after receiving a diagnosis of metastatic gastric cancer. As the pair plans the trip, they play a game called “Paddleton,” the origins of which are shrouded in mystery. In it, two players compete using tennis rackets to bounce a ball off a wall and into a barrel. The movie is a slow-paced emotional build from the first scene, balancing melancholic tones with the pair's awkward situational humor and playful debates about nothing.

To my knowledge, Paddleton is the first buddy comedy to explore medical aid-in-dying (MAID). Along with its raw look at the human experience of MAID, the film explores other themes generally relevant to death and dying. Light-hearted scenes of Mark and Andy playing Paddleton alternate with weighty discussions about Mark's preferences for care, which he expresses with clarity and conviction. “Before it gets bad…I want to end it,” he declares as they catch their breath after a game. Andy struggles to accept Mark's decision to pursue MAID, and begs him not to “give up.”

Although Andy eventually joins Mark on his trip to fill the prescriptions, conflict boils over as he makes multiple desperate, and at times laughable attempts to derail his best friend's plan. Andy's struggle to accept Mark's poor prognosis and his choice to pursue MAID serve as a prime example of anticipatory grief and its paralyzing grip on caregivers, family, and friends. On the surface, Andy's avoidant coping style manifests in hilarious ways, although it is clear that his deep sadness drives his behavior. Andy dreads his best friend's death and the impact it will have on his own life.

Without revealing spoilers, the climax of the film brings viewers into Mark's apartment to witness the incredibly private moment of preparing the medication for consumption. Paddleton realistically portrays the painstaking process of emptying a bottle's worth of barbiturate capsules to constitute an oral solution, usually taken after an antiemetic and anxiolytic. As they break open the capsules, with a grin, Mark asks Andy, “Do you think anybody has ever died while they were emptying these?” The film remarkably demonstrates that even in life's saddest and darkest moments, humor can shine through. Paddleton pulls off this delicate balance of contrasting emotions with a level of authenticity that is hypnotizing, leading you to forget that this is a fictional story and not a documentary. Ray Romano and Mark Duplass deliver spectacular performances, absorbing viewers into the small isolated world of their characters. Both actors are extremely convincing in their portrayal of these men, displaying a level of vulnerability compelling enough to bring one to tears.

It should be acknowledged that despite its realistic depiction of a very emotional experience, the film ignores certain details that are relevant, especially to a palliative care clinician. Specifically, Mark and Andy do not receive any guidance or support through the MAID process, other than a brief tutorial about the medications from a pharmacist. The men seem completely alone on this journey, which may evoke strong feelings of loneliness, emptiness, and isolation within the empathic viewer. Although their isolation is somewhat related to the absence of any family members or friends, which is entirely believable, there is a distinct void of resources that could be filled by an interdisciplinary palliative care or hospice team. In addition, this portrayal of MAID glosses over a few critical steps that are built into most laws to protect the patients who request it. It is almost universally required that a clinician thoroughly evaluates applicants for unaddressed physical, emotional, and existential symptoms, which if treated may decrease the desire or need to exercise this end-of-life option.

It is possible that these gaps in the film were intentional decisions of artistic license to prevent viewers from getting lost in the details rather than focusing on the emotional experience of the characters. However, by omitting mention of these resources and safeguards from the film, viewers may be left with an incomplete understanding of MAID. Despite these imperfections, Paddleton has the potential to serve as an incredible tool for educators within our field to use in teaching members of the public about MAID, as they highlight its truths and address its inaccuracies.

Regardless of one's stance on MAID, the film imparts a number of important lessons. First, it reminds us to pay close attention to what matters most to our loved ones and patients as they navigate life with a serious illness. Second, following Andy's example, we need to acknowledge our fear of death and the impact of anticipatory grief on our patients and their families. Lastly, when people speak so clearly about their goals, we need to listen to them. Mark summarizes his wishes by stating, “I wanna make some pizzas, I wanna watch some movies, I wanna play some Paddleton,” and Andy courageously honors them.