How ‘The Pitt’ Gets Death Right

[Warning: This story contains spoilers for Season one of The Pitt.]

Boasting 13 Emmy nominations and four recent TV Critics Association Award wins, HBO Max’s breakout medical drama The Pitt has been widely lauded for its hyperrealistic portrayal of a chaotic, underfunded hospital emergency department. Among the many things the show has been credited for getting right is its nuanced depiction of death and dying. The Pitt cuts deep into the heart of harrowing end-of-life decisions and conversations faced by patients, family members and physicians, as well as the messy emotional aftermath. The upside is the show’s positive real-life impact, which initially surprised executive producer and writer Joe Sachs.

Having worked for over 30 years in Northridge Hospital’s trauma center, Sachs tells The Hollywood Reporter that he brings his own expertise on death and dying to the writing table first. “But when I want to really make sure things are good and right, we reach for consultants,” he says. “The deeper you dig, the more interesting details you get that people are unaware of and that makes for fresh storytelling. USC Norman Lear Center’s Hollywood, Health & Society is our lifeblood and I email the most bizarre requests to [HH&S senior outreach specialist] Roberta Cruger, who I’ve worked with since my ER days.”

HH&S program director Kate Fob tells THR that for season one’s death and dying narratives, the organization connected The Pitt to organ donation programs and to palliative care expert Dr. Ira Byock. Now deep into season two, Fob says the show has tapped into a death doula’s expertise for an upcoming storyline.

“We had a lot of expert input from OneLegacy, the Southern California organ procurement organization, and CORE in Pittsburgh, about what is needed to help family members accept their loved one’s wishes for organ donation,” says Sachs, referring to the unintentional fentanyl overdose by a college student, a registered donor, and his parents’ struggle with the decision. “It shouldn’t have been an issue, because he was over 18 years old. But Dr. Robby [Noah Wyle] was wise enough to know that the parents needed to process this and have every test done to be absolutely certain that their son was brain dead. To have a counselor from the organ procurement organization and a priest brought in to get the parents to that place of acceptance was done with a lot of accuracy.” 

In episode 8, parents witness unsuccessful efforts to resuscitate their six-year-old daughter, who drowned. “In the old days, parents were told, ‘Wait in the waiting room. You’re going to be freaked out. You shouldn’t see this.’” says Sachs. “But to be there and see what’s happening, they understand that everything possible is being done until the pronouncement of the time of death.” The scene addresses the heartbreak of death and loss on multiple levels. Senior resident Heather Collins (Tracy Ifeachor) has just miscarried, while resident Mel King (Taylor Dearden), a caregiver for her own sister, asks the girl’s four-year-old sister, who can’t be in the room, to “say everything you want to tell your sister to the teddy bear and I’ll go put the bear on her bed.” Sachs tells THR he learned that teddy bear technique from emergency department social worker Thu Phung while working at LA’s Northridge Hospital.

A third end-of-life plotline features an elderly man with Alzheimer’s, pneumonia and sepsis, whose two adult children share durable power of attorney but choose to ignore their father’s advanced directive and request intubation. Explaining how “each step causes more suffering and minimal benefit,” Dr. Robby gently guides them to extubate and say final goodbyes in episode 4. “This medical story fit great because it’s topical and hasn’t been portrayed realistically [on TV],” says Sachs. “We wanted to show the downside of overly aggressive resuscitation in the elderly when there was not much chance for a quality outcome, and then deal with what you might call a ‘good death,’ meaning that families come together in a comforting way to express what they should at the time of death. And that relates to The Four Things That Matter Most, a book by Ira Byock, who we talked to.”

Byock joined a Zoom with The Pitt writers’ room to discuss tensions and storylines the team had in mind. Then he pitched his own experience, as an emergency department physician, when an older patient with a leaking abdominal aortic aneurysm refused surgery and chose to die. “With the man’s two daughters and wife present, I shared that other families had found value in saying four things to one another before goodbye: ‘Please forgive me. I forgive you. Thank you. I love you,’” says Byock. “It’s the rare family that has perfect relationships. Usually there’s some history of misunderstandings, hurt feelings or real transgressions. Another thing to say is, ‘I’m proud to be your mom, dad, son or daughter.’ This is the other side of emergency medicine. It is lots of blood and guts, but I told the writers to remember there are also tender moments and opportunities to help somebody heal on a much deeper level. Apparently Noah Wyle loved that story; he did a fabulous job making it his own.”

Coincidentally, Sachs says, technical medical advisor Dr. Lizzie Ferreira, who is of Hawaiian heritage, was on set during the filming of that episode and knew Ho’oponopono, a centuries-old Hawaiian variant of Byock’s four sentiments of reconciliation.

Six weeks after the episode aired, Sachs says, “An emergency doctor posted in a group chat on a social media site, saying, ‘I was working a night shift in the ER at two in the morning and a 92-year-old woman with a heart attack came in and was not doing well. The family said, You know, doctor, you can stop right there. We’ve been watching The Pitt and we’ve seen how much suffering can be caused by resuscitation efforts when there’s no meaningful hope, and we would just like to have comfort care.’ That blew my mind! The fact that the show gets people talking or taking real-life action is nothing I was prepared for.”

One of the primary forces behind The Pitt’s sensitive and groundbreaking portrayal of death is the non profit End Well — founded by Dr. Shoshana Ungerleider in 2017 to help improve cultural attitudes around end of life. (Among other contributions, the organization introduced the show’s creators to Byock.) Ungerleider, also a producer of end of life–focused documentaries (Robin’s Wish, End Game, Extremis), tells THR: “More accurate portrayals of serious illness and end-of-life on TV prepare audiences of all ages with a clearer idea of what really happens and what options exist beyond aggressive intervention. When I worked in the hospital, I can’t tell you how many times family members wanted CPR on a patient because they saw people get chest compressions on TV and pop up the next day and walk out the door. Trying to go up against the miraculous saves on every medical show was really hard. The Pitt provides kind of a master class in communication that viewers and health care workers can draw upon in their own lives.”

Fob says, “In a study we did with End Well, we found that people who had watched TV shows with end-of-life storylines were much more likely to initiate conversations about end of life with family members. Now our Media Impact Project is doing a separate study that examines the impact of the first season of The Pitt on a variety of topics, end-of-life being one of them, which will release later this fall.”

Sachs and The Pitt creator and showrunner R. Scott Gemmill co-wrote episodes 12 and 13, which drill down on death during a mass casualty incident after a musical festival shooting. “Every week you read about a mass shooting, somewhere in America, and it’s ‘thoughts and prayers, okay, let’s wait for the next one,’” says Sachs. “But to actually see into an emergency department with the impact on families and individuals, I don’t think has ever been done with the accuracy and the emotions that we played.”

These deeper stories of doctors and medical staff grappling with grief and guilt are rarely told with such emotional candor. “The fact that the show doesn’t shy away from showing the moral distress and grief when physicians lose patient after patient also helps people understand how healthcare workers aren’t emotionally detached from death,” says Ungerleider.  “We have to find ways to process the grief and then move on to show up for the next patient. It’s a very hard job.”