By Jessica Nutik Zitter Avery, 2017 Review by John Mullen on Oct 3rd 2017
I cannot recall reviewing a book that I recommend as enthusiastically and to as wide a readership as Extreme Measures. The author writes as a specialist in both intensive care medicine and palliative care medicine, practices that are often at odds during the end of life period. But the greatness of this book depends not so much upon the author's expertise as upon a deep respect for the possibilities that human life contains and a profound compassion for those, patients and loved ones, faced with its loss.
The book begins with some family history, the upshot of which is that Dr. Zitter is the child, grandchild, niece and grandniece of medical doctors. Rainy afternoons were spent investigating her father's "magic briefcase." She seems honestly humbled by her profession, by the good and the bad that can be effected through its practice. And too, her background includes a commitment to the traditions of a wise and compassionate Judaism, a culture filled with great doctors, at least since Moses Maimonides in the twelfth century.
To set the stage for what shakes Jessica Zitter to the core, consider the vivid picture she draws of her first "code blue", under the watchful eyes of her resident. "I lay eyes on the poor soul… the patient's skin is ashy grey-yellow with a waxy sheen. The abdomen is visible beneath the soiled sheets, deflated from years of malnourishment and disease … chest compressions … kneeling on the bed to get better leverage … with each compression there is a sickening click … his whole chest is breaking. This man is dead … like the cadavers in med school, only less healthy … not an ounce of fat or muscle … the stench of kidney failure, acrid and vinegary … 'More epi,' the resident calls… eight more minutes … 'Let's call it,' my resident says." It is this scene of violence, often pain, and patient aloneness, re-enacted countless times in countless hospital rooms and ICUs, upon patients soon to die in any case, that Dr. Zitter warns us against. In its place, she envisions a peaceful room, in hospital or home, with the dying person, no longer a patient, surround by those who care, after necessary final words are spoken, hands held, tears, stories, smiles … a gentle slipping away.
But how difficult it is to achieve this "good death" in a hospital. Most of the book is organized around case studies from Dr. Zitter's experiences, each with its own complicating barrier to Dr. Zitter's vision. In some, she is the ICU attending physician. In others, she is the palliative care consult. Each case is a lesson and a warning. A good death is difficult to arrange. There are forces militating against it. Here is a small sample of what can go wrong.
Physicians are (understandably, perhaps) reluctant to deliver the news that the patient is dying: Linda was a heart patient at a top hospital. Three months after surgery by the "A team" she was still in the ICU, attached to machines. Her engineer husband, John, had become learned in all the ins and outs of her problems and her care. Their communications were largely about these data. "John had no idea that his wife was dying… He had been distracted from his wife's impending death by the din of continued treatment… [as the doctors] … continued to shoot for the cure." The traditions of doctoring, especially in the ICU, do not include reassessing the basic goals of care. After the author delivered the news, Linda was removed from the machines and died peacefully shortly after. Dr. Zitter does not provide a general statement of her preferences for the death process. But the book is clear that it involves peace, companionship, touching and communication.
Fear of the law. Doctors aren't the enemy. A woman was being treated with daily transfusions for a rare skin disease that produced burning, bleeding lesions. She was dying and the doctors wanted to discontinue treatment, to make her comfortable. Her son insisted upon continued treatment "'Do it,' he told the attending, 'or I'll sue you.'" The doctors appealed to the ethics committee, but she died before a decision was made. "She was subjected to a bloody code in her final moments of death, administered by the same horrified doctors who had tried to spare her." The "Big Three" of emergency care are: breathing tubes, feeding tubes and CPR including electric shock and chest compressions. A fourth could be dialysis. "Most doctors feel powerless to withhold these if the patient or family insists." It is interesting that studies show how differently physicians die than do the general public; less likely to die in a hospital and less intensive care prior to death.
Trapped by your own words or Be careful what you wish for: Vincent was a "Frequent Flyer", whom Dr. Zitter met on his ninth visit of the year to the ICU from a nursing home close by. His vague advance directive was accompanied by a note, written with a shaky hand some years before, "To any doctor who will take care of me in the future. I want you to do EVERYTHING in your power to keep me alive AS LONG AS YOU POSSIBLY CAN!" Vincent's body was racked by infection, "… covered head to toe with tiny creatures, in his case, resistant bacteria." He had tubes sewn into his neck, stomach and bladder. He was incommunicative and he was "autodigesting … [his body] trying its hardest to die." Certain that Vincent could never have envisioned this scene, it was the first case where the author would, "… openly question our blind trust in patient autonomy." His treatment continued and he died a month later. Dr. Zitter has a concept, not elucidated, that the body seeks a certain type of death as its organs fail one after another. She seems to believe that it is a violation to deprive the body of this.
Leaving it up to the doctors: Jada came to the hospital unable to breathe, with metastasized breast cancer throughout her lungs. When asked if she wanted to be put on life support or have CPR if it came to that, she panicked and could not answer. With her symptoms relieved, she was able to consider the goals of her care. She talked about being with her son, her family and her church, but still refused to decide about emergency measures. In the end, the doctors told her what they would do, which did not include intubation, CPR and the like, and asked if that sounded right. She finally nodded yes. She went home to her brother's house and died with hospice care.
He's a fighter. The author does not discuss whether "being a fighter" extends life or its quality. But it's a common expression and I suppose those who use it believe it will make a difference. Don was a former Marine who had suffered from cancer for eight years. The author states that his was in, "… the active state of dying…" when she met him, he was in kidney failure, "…suffering from nausea, constipation … holding a basin up to catch the vomit …lost all his bulk … his belly was distended, his face was grey and his head was bald. His wife was beside him, gently wiping the spittle off his face." He had told the doctors he would, "… fight till I'm in the grave." His father was also military. He told her that Don was, "proud, strong, and a real fighter," but Don also knew when to retreat, "He wouldn't stay in a battle if he was losing his men." That was the turning point, though it took a one more call to the oncologist to convince Don's wife that Don was dying. Don died the next morning, "But he was free from pain, at peace, and surrounded by his family. His wife was able to lie next to him for most of the night, her arms around him."
There is much more in this book; more cases as well as discussions of doctors' and nurses' "moral distress" at facing death so often. There are cases of family dysfunction and cultural conflict that interfere with treatment decisions. There is an affecting story of the author weeping in a session where the leader asks each participant to imaging in detail his or her own death; who is there, what are their reactions, who will be crying. There is a discussion of a POLST, a physician's order for life saving treatment, created long before any life emergency, more binding than a living will and more enduring that a DNR. And the author writes about the culture of medical training. And there is more.
As a person who is officially "elderly", I found this book personally instructive. Any person who is likely to be making medical decisions for another person, especially the elderly, would learn a great deal that is helpful. This book is in no way a rant or an indictment of contemporary American medicine. Dr. Jessica Zitter has far too much respect for her profession for that. She is a fine writer whose presence, compassion and thoughtfulness comes through clearly to the reader.
John Mullen is the author of the recent novel, The Woman Who Hated Philosophers, Swallow Tail Press, 2017, as well as the widely read, Kierkegaard's Philosophy: Self-Deception and Cowardice in the Present Age.