Extreme Measures: Finding a Better Path to the End of Life

by Jessica Nutik Zitter M.D.

Overview

For readers of Being Mortal and Modern Death, an ICU and Palliative Care specialist offers a framework for a better way to exit life that will change our medical culture at the deepest level


In medical school, no one teaches you how to let a patient die.

Jessica Zitter became a doctor because she wanted to be a hero. She elected to specialize in critical care—to become an ICU physician—and imagined herself swooping in to rescue patients from the brink of death. But then during her first code she found herself cracking the ribs of a patient so old and frail it was unimaginable he would ever come back to life. She began to question her choice.

Extreme Measures charts Zitter’s journey from wanting to be one kind of hero to becoming another—a doctor who prioritizes the patient’s values and preferences in an environment where the default choice is the extreme use of technology. In our current medical culture, the old and the ill are put on what she terms the End-of-Life  Conveyor belt. They are intubated, catheterized, and even shelved away in care facilities to suffer their final days alone, confused, and often in pain. In her work Zitter has learned what patients fear more than death itself: the prospect of dying badly. She builds bridges between patients and caregivers, formulates plans to allay patients’ pain and anxiety, and enlists the support of loved ones so that life can end well, even beautifully.

Filled with rich patient stories that make a compelling medical narrative, Extreme Measures enlarges the national conversation as it thoughtfully and compassionately examines an experience that defines being human.

Product Details

ISBN-13:	9780525533412
Publisher:	Penguin Publishing Group
Publication date:	08/24/2021
Pages:	352
Sales rank:	440,888
Product dimensions:	5.50(w) x 8.20(h) x 1.10(d)

About the Author

Jessica Nutik Zitter, M.D., MPH, is an expert on the medical experience of death and dying. She attended Stanford University and Case Western Reserve Medical School, and completed her residency in internal medicine at the Brigham and Women’s Hospital in Boston. She was a fellow in pulmonary and critical care medicine at the University of California San Francisco. Zitter is double-boarded in the two specialties of pulmonary/critical care medicine and palliative care medicine—a rare combination. She writes for The New York Times, The Huffington Post, Pacific Standard, The Atlantic, and Journal of Palliative Medicine, and is featured in Extremis, an Oscar-nominated Netflix documentary about end-of-life decision-making in an ICU.

Table of Contents

Prefatory Note xiii

Chapter 1 Alone in the Trenches l

Chapter 2 The End-of-Life Conveyor Belt 19

Chapter 3 Abandoned in a Sea of Options 64

Chapter 4 The Illusion Collusion 103

Chapter 5 Where We Come From 147

Chapter 6 Who We Are 182

Chapter 7 The Personal Toll 208

Chapter 8 Sharing the Journey 233

Epilogue 279

Appendix 1 A Way Forward 289

Appendix 2 Avoiding Unnecessary Suffering 298

Resources 309

Notes 312

Acknowledgments 325

Index 328

Editorial Reviews

"Like Atul Gawande's Being Mortal, Zitter's book shows how knowing when do to nothing is as vital to being a good doctor as knowing when do to everything."
—New York Times Book Review

“Jessica here reveals a fuller truth of how the end-of-life plays out within our healthcare system. There’s nothing easy in these pages, but plenty to learn from, cautions to absorb, and material for creating a better way.” 
—BJ Miller, MD, Assistant Clinical Professor of Medicine at UCSF

"Part memoir, part exposé, this book is an insider's view of intensive care in America and its impact on how we die, written by a physician uniquely positioned to examine end-of-life care. Dr. Jessica Zitter’s wisdom derives from a career whose trajectory – she specializes in both ICU and palliative medicine – models a rethinking of care for the dying. Her book is a trenchant critique and a clarion call for end-of-life care that aligns with what each patient values most."
—Lucy Kalanithi, MD

"Dr. Zitter has pulled back the curtain on the needless suffering undergone by the dying in Intensive Care. Honest about her own uncertainties, mistakes and limitations, she spares no one, not even herself. The average person will learn much about the pitfalls of navigating the strange subculture of medicine close to the end of life.”
—Katy Butler, author of Knocking on Heaven's Door: The Path to a Better Way of Death and A Good End of Life: a Practical Guide
 
“America's healthcare system inadvertently makes things worse for dying patients and their families. This situation calls for Extreme Measures – and this book is the remedy we need. Dr. Zitter’s guidance is an elixir of medical sophistication, practical savvy, and timeless soulfulness.  She writes with the clinical mastery of an intensivist and the personal sensitivity of a trusted friend.”
—Ira Byock, MD, author of The Best Care Possible
 
"Required reading for every young medical student and every family member wondering how to help the people they love live well to the end." 
—Ellen Goodman, founder of The Conversation Project
 
"With compassion, intelligence, and a rare expertise, Jessica Zitter shines a light on some of the most difficult issues we face in our lives." 
—Angelo Volandes, MD, author of The Conversation: A Revolutionary Plan for End-of-Life Care
 
"You wouldn't take a trip to a foreign country without learning as much as you could about its rituals, its culture, and its landscape. The ICU, a place many of us will pass through at least once in our lives, is as foreign as it gets.  Thus Dr. Zitter provides an essential illumination for her fellow humans."
—Diane E. Meier, MD.  Director, Center to Advance Palliative Care
 
"A stunning portrait of the ways decisions in the intensive care unit shape the way we live—and die—now.  Whether we live with illness, love someone who is facing these decisions, or care for them professionally, Dr. Zitter has written a call to action that none of us can ignore.”
—Anthony Back MD, author of Mastering Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope
 
“Extreme Measures provides a gripping and intimate tour of the experiences and dilemmas  physicians, patients and families  face dealing with terminal illness in the modern ICU. A tour de force for those seeking to better understand and improve care of patients and families at end of life."
—James Mittelberger MD, MPH, FACP, FAAHPM, Optum Director and Chief Medical Officer, Center for Palliative Care and Supportive Care

"Clarity and compassion unite in this touching and convincing new conversation on comfortable, patient-centered end-of-life care."
—Kirkus Reviews 

From the Publisher

2016-12-19
End-stage patient suffering and distress inspire an early-career watershed moment for a sympathetic physician. Zitter's impassioned advocacy for increased palliative awareness in modern medical establishments is both immediate and heartfelt. She notes that both doctors and patients have a tendency to ignore death, and this often "fuels a tremendous amount of suffering." Her own enlightenment began during her medical internship, when she harbored serious second thoughts about her career choice (her father was a neurosurgeon) after being "dumbstruck by this Armageddon" of critically ill patients throughout her first years in trauma medicine. "I have rehearsed for the wrong performance," she thought during a crisis of conscience. After much soul-searching, Zitter moved in a new professional direction, focusing on compassionate palliative care rather than treating pain as an "on-off switch." The often wrenching, emotionally resonant patient cases she shares illuminate an urgent need for medical communities to more uniformly embrace standards of care that include palliative approaches to terminal patients. Empathy and patient dignity have a tendency to evaporate amid a hard-core push to medically prolong life without humane consideration for a patient's eroded quality of life. Zitter describes the origins of palliative care as well as her somewhat steep learning curve adjusting to a holistic care approach. She also addresses issues of physician burnout, the delicate politics of do-not-resuscitate orders, and the challenging time sensitivity of communicating terminal prognoses. Her affecting narrative is also educative, as the author aims to create a paradigm shift in terminal patient treatment and steer medical trends and attitudes about death and dying toward a more sympathetic perspective and one that will eventually consider it "unacceptable to practice without considering the patient's needs above all else." A list of useful resources and Zitter's six-step approach to one's own final health care choices serve as fitting codas. Clarity and compassion unite in this touching and convincing new conversation on comfortable, patient-centered end-of-life care.

Kirkus Reviews