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    Extreme Measures: Finding a Better Path to the End of Life
    Unavailable
    Extreme Measures: Finding a Better Path to the End of Life
    Unavailable
    Extreme Measures: Finding a Better Path to the End of Life
    Audiobook11 hours

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

    Written by Jessica Nutik Zitter, MD

    Narrated by Jessica Nutik Zitter, MD

    4.5/5

    ()

    Currently unavailable

    Currently unavailable

    About this audiobook

    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.

    LanguageEnglish
    PublisherPenguin Random House Audio
    Release dateFeb 21, 2017
    ISBN9781524749743
    Unavailable
    Extreme Measures: Finding a Better Path to the End of Life

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    Reviews for Extreme Measures

    4.5/5

    23 ratings9 reviews

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    • 5/5
      A MUST READ for anyone and everyone---it IS about the future of each and every person in the United States. How will "I" die? What is involved? Absolutely beautifully written with examples that cover so many things the author has learned and continues to learn in her medical career. Truly centering on what is best for the patient has been so easily buried in the enormous increases in medical treatments and doctor specialists. Who watches out for the patient? Zitter explained it all.
    • 4/5
      First of all, EXTREME MEASURES is a very tough book to read. And this may be particularly true for a reader like myself who, might as well admit it, is already well into that eighth inning of life. Because Dr. Nutik Zitter makes painfully clear, with many well-documented and dramatically presented case studies, how our health and medical system has, for perhaps way too long, gone in the direction of try everything, do anything, just keep the patient alive, even if the quality of life has markedly decreased, or will.Early in her narrative, the author raises the picture of the kindly old grey-haired doctor so often seen in Norman Rockwell paintings, and admits -"When I think of who I want at my bedside when I'm sick, it is someone like those doctors - someone who knows me well and will sit with me as long as I need, with a watchful, concerned eye."Now instead of those old-fashioned doctors who treated the whole person, we have specialists and subspecialists who treat one organ, without taking into account the person. Although Nutik Zitter recognizes how unlikely it is that we'll ever get back to that country practitioner type, she does feel it is vitally important that the needs and the feelings of the patient take precedence again - that "patient autonomy implies that the patient is empowered to make decisions free from coercion." She stresses too the importance, in end-of-life situations, of "the ability to break bad news and reassess goals of care." Otherwise, too many patients end up on the medical and technological "conveyor belt" that leads to finishing their lives attached to machines and isolated from the warmth of family and human contact that might make death less frightening.EXTREME MEASURES is chock full of case studies of people who do end up on that conveyor, many of which will make you wince in shock or in recognition, particularly if you have witnessed the slow and steady decline of a loved on, as I have. The author describes several kinds of death in clinical terms. One I recognized, VSED (voluntary stopping of eating and drinking). It was the method my mother chose at the age of 96. Death does not take long when this happens. Nutik Zitter explains why people choose to die this way, noting -"Often this is due to the person's perception that her quality of life is no longer acceptable. The act may also provide a sense of control and autonomy at this most vulnerable time of life."Overall, EXTREME MEASURES forces the reader to look closely at the end of life and at the choices available, addressing the importance of, say, advance directives, living wills, or medical powers of attorney. Too often in our society, people still turn away from death, try to deny it. But it is, after all, where we are all headed. Reading this book may be a good way into "having the talk" with your family and loved ones. I will recommend it for that reason. Note: I gave the book four stars, but that is probably way too 'subjective,' just because, as I said at the outset, this is a very tough book to read. Nutik Zitter has done her homework. She pulls no punches. She admits to making many mistakes herself as a one-time ICU practicing physician. I commend her for tackling such a tough subject - one that most people would probably prefer not to discuss.- Tim Bazzett, author of the memoir, BOOKLOVER
    • 4/5
      Dr. Zitter has given us an important book on a very important topic, a book that remains easy to read with explanations that are easy to follow if one knows or learns only a few professional medical terms. She is a board-certified both as an ICU physician and as a palliative care physician. She has decades of experience with the heroic measures and machines used in the ICU to prolong life and with foregoing these measures and machines to allow terminally ill patients to die in comfort and dignity. She also has a great deal of experience helping patients and their families decide what should be done in each case. Heroic measures can give patients additional years or even decades of reasonably satisfying life. But if a patient is clearly in the process of dying, heroic measures can prolong suffering, pain, and anxiety, all at enormous expense to society or to individuals. While telling us stories about cases she has dealt with, Dr. Zitter explains the many facets of the usually complex decisions about treatment for terminal patients. She is wise, and she is humble, in addition to being experienced. It is difficult to give this thoughtful book too much praise.
    • 4/5
      This book was inspired by Atul Gawande's "Being Mortal", and since both physicians have worked at BWH, I was interested in reading this take on how doctors deal with terminal patients. It's pretty much of a memoir of how Zitter came to be a doctor and learned to overcome her training to become more of a patient focussed healthcare provider. She's worked in ICUs around North America and shares deidentified stories about how people make rushed and emotional decisions about treatment when life expectancy is low. She warns that you need to decide on how you want to end your life if you're dying in a hospital where you'll be subjected to the medical teams doing everything they can unless instructed otherwise. She goes into bloody detail about what CPR can do (one story was told of it breaking a vertebra on a patient with compromised bone density) and how important the two week "trach point" can be. If a patient is still on a breathing tube at that point in a hospital stay, the standard is to perform a tracheotomy to make a permanent hole, but the side effects are often glossed over. One of the main points that she makes is that the emergency and ICU doctors are rushed and that patients and family either don't question them or don't trust them. It seems to be one or the other, with standard procedures being pushed that aren't best for a terminal patient with regard to how comfortable they'll be in their last days or weeks (she flat out says that if you've got less than 6 months to live, don't do chemotherapy). But patients, family and surrogate decision makers fall into the emotional and moral pit of not wanting to give up before everything has been tried.Zitter had a defining moment with a family support team member questioning whether or not a procedure was going to be good for a patient or was just a sop to the doctor's conscience. She had to fight against a culture of "do everything you can" to even bring up the question of if they should do anything. Sometimes (most times?) managing pain and letting the patient die peacefully surrounded by loved ones is the best thing, rather than intubating them (and strapping them down so that they can't pull out the tubes) and isolating them in a hospital room, and sometimes that doesn't even gain them more time since the tubes and catheters are infection vectors.I finished this book while my uncle was in the hospital, and that same day I learned that he'd become weaker, developed pneumonia and passed away. He went quickly, they had hoped to send him home that day, but I'm having a hard time trusting that hospitals are the best place for my aging relatives to pass on.Zitter gives a good list of resources on creating Advanced Care Directives to let loved ones know your wishes (I want to make one of these because I have super strong feelings against long term intubation), Do Not Resuscitate orders (good for only hospital one stay), and Physician Order for Life Sustaining Treatment (notarised and stays with the patient). She also mentions Death Cafes and other ways to get conversations started.Not an easy book to read, but important.
    • 5/5
      I really enjoyed this book, watching the author's journey from treating symptoms to treating human beings. The examples from her experience were fascinating, and her descriptions of complicated medical terms and procedures were easily followed. This is a great book for those in the medical profession who might need to be reminded their patients are more than medical problems that can be fixed. Also important for those who might find themselves or a loved one as the patient with difficult decisions ahead. It is also a good reminder that medicine, like any science, is always evolving, and you may learn what you have been doing was wrong. The good doctors evolve with the evidence.
    • 5/5
      Engaging and informative, Jessica Zitter's examination of the current state of end-of-life treatments and how they might best be navigated is really excellent. Zitter is trained and experienced in both pulmonary/critical care medicine and palliative care medicine, and she balances these two perspectives to offer a nuanced look at the possibilities and dangers offered by medicine's technical “wonders” to those whose bodies are failing. Born into a family of physicians and surgeons, Zitter begins her book by telling of her early training in critical care medicine and her eagerness to save patients on the brink of death. Her gradual realization that the heroic measures which doctors, families, and patients typically assume are desirable might result in dramatically increased suffering and no true benefits, leads her to embrace an approach which focuses on allowing patients with “life-limiting” health situations to choose care that aligns with their values. I've been reading about death and illness lately, but there was some eye-opening stuff for me in this about critical care/ICU treatments, and also the LTAC (Long Term Acute Care) thing. Yikes. Tubes, lines, and pumps chugging along, sustaining bodies, sometimes, for far too long. Zitter is not dogmatic, and she does not discount the benefits of life-sustaining technologies for patients who may recover some or all abilities or who may feel that life of any quality is worth continuing. Her emphasis is on educating patients and their families about the realities of “extreme” medicine, and on making sure that patients are aware of the options offered by palliative medicine. As I read this I was overwhelmed with gratitude for the doctors who saw my mom after her unexpected diagnosis with metastatic lung cancer a couple months ago, in early November. All except the first one, at the ER, who came in and said that her seizure had not been the result of another urinary tract infection. No problems there. Oh, but there was a malignant node in her lung, and it appeared to have spread through her vertebrae. So we'd need to look into treatment options. And left. That guy was a jerk (I assume he still is a jerk.) But the rest of the doctors – pulmonary specialists, oncologists, primary care – have been marvelous. They looked at the whole patient, a frail woman with frontotemporal dementia, and at the progress of the cancer, and advised us of the options. Biopsies, surgeries, radiation were possible but they would ensure pain and sickness with no chance of cure and little in the way of longer life. And they told us about palliative care and Hospice. So now my mom is dying in her own home, relatively comfortable for the most part, nibbling the occasional little bites of crème brulee (minus the crispy sugar topping, so really just “creme,” I suppose), quiche, or hot cereal (my dad's specialty), being read aloud to, listening to music, and watching birds through the window. It's a very far cry from the life filled with friends, gardening, books, and so on that she Should be living now, but Zitter's book has made clear to me how much worse it could be. Her death seems to be rapidly approaching, and with FTD and metastatic lung cancer working their horrors in tandem it is not pleasant, but at least she is home, in the care of people who love her and who have been given the tools – medications, hospital bed, etc. – to keep her comfortable. She has Hospice nurses, aides, social workers, etc. on call, and they really Do come when needed, and even her wonderful primary care doctor (a last minute acquisition, who, fortuitously, has extensive experience in palliative care practice) makes house calls. All in line with her advance directive (Zitter's excellent appendixes provide links and tools to help readers make their end-of-life care wishes known to family and health care providers, and I intend to work mine out ASAP!), which is a great comfort to us. Highly recommended to readers inclined to read about this subject. Zitter offers a sensitive, nuanced, multifaceted look at issues to consider related to end-of-life care.
    • 5/5
      To me, this book represents an important area of contemplation and study. I have been close to family members who became ill for various reasons, and they got medical attention including surgeries. And later – either in spite of, or because of the medical treatments -- they got worse. At some point, medical intervention was not able to improve things and finally they died of their diseases. I witnessed their respective attitudes regarding the degree of medical care each desired. So different! It was remarkable to see how various people act and feel as they are growing down. It was complicated for me each time I strived to be there emotionally -- most were elderly, but some were much younger when health deteriorated.Brava, Dr. Zitter – for recognizing that sometimes standard medical treatments are not the best approach for all. Sometimes medical professionals can be too quick to force their own perspectives on a patient and his or her family. It can be intimidating.Many of the anecdotes in Extreme Measures are heartbreaking to read. If a person has lived through a period when a family member or close friend is struggling with difficult end of life experiences, this book is sure to bring much personal sadness to mind. Although sections of the text are very uncomfortable to read, they are quite moving. It was beneficial to read it and to recall what some of my dear ones have been through in the past … & realize that a caring health professional who can view growing down and death as a part of life can be preferable to others who try to extend life regardless of its quality.
    • 4/5
      During her second week as an intern, Zitter responds to her first Code Blue. She expects it to play out like a television scene with the miraculous resuscitation of the patient and the grateful family hailing the doctors as heroes. The reality is far different: the elderly patient's skin is a waxy gray-yellow, his frame skeletal and each chest compression produces the sickening grinding sound of cracking bone. Worse yet, Zitter is called upon to take over compressions and must fight the rising nausea she feels. Afterwards she describes the experience as "I have just assaulted a dead body."The majority of book comprises stories of patients who suffered meaninglessly because they (or their families) wanted everything done to prolong life. Some simply could not accept that death was inevitable. Cultural and language differences compounded the problem. Doctors and nurses were often guilty of the same impossible goal and it’s very difficult for them to stop treatment once it has begun. Even after transferring to Palliative Care, Zitter repeatedly has to fight against her instinct to "do something" because that is what doctors are trained to do and death means failure. "I came to see that in our zeal to save life, we often worsened death." Zitter describes the discomfort of tracheotomies and feeding tubes. Many patients must be sedated or restrained to that ensure they don't pull the tubes out. She points out that that nutrition is of no actual benefit to a dying patient (and if aspirated may cause pneumonia) but many families have trouble with the idea of withholding food which we tend to equate with love. Skin begins to break down leading to infections and sepsis. Life-support patients may be transferred to LTACs or long term acute care facilities which she likens to ventilator warehouses where unconscious patients lie in beds as machines take over basic functions. It all sounds like a scene from a dystopian movie.Zitter notes that doctors tend to die at home rather than tethered to machines in a hospital and they receive less intensive care before death. It is possible for the rest of us to avoid the pain and extension of the dying process if we can face the truth that we will die and prepare accordingly. The best part of the book is found in the Appendixes which give some resources about how to do just that. In addition to the more familiar Advance Directive and DNR (do not resuscitate) orders is the POLST or Physician Order for Life-Sustaining Treatment. That last one is a legal order which is "the only form that can release first responders like EMTs, paramedics, and ER doctors from an obligation to perform the treatment of life prolongation." Organizations and websites are listed including the intriguingly named Death Café and Death over Dinner both of which help facilitate conversations about how we want to be treated at the end of life.The initial chapters suffer a bit from the repeated use of the phrases "end-of-life conveyor belt" and "full court press" but the writing style improves and the later chapters provide valuable information about the realities of dying in hospital care. The final edition will be indexed.
    • 3/5
      Have you ever considered what it means to have a good death? What is a bad death? What kind of death would you envision for yourself, a parent or spouse? Perhaps you would prefer not to envision this possibility at all, but by avoiding the topic of death, we could be letting ourselves or our loved ones end up on the medical conveyor belt as described by Jessica Nutik Zitter, and ICU and palliative care specialist.She has seen many deaths and asks us to consider the quality of our end of life experience: strapped down to a bed with tubes delivering liquid nutrition; a machine keeping the body breathing? Or perhaps at home, dying naturally with those close to us at our side?In this book we are also asked to consider what quality of life we would find acceptable. Would medical measures that save your life but mean that you are incapacitated and unable to care for yourself be a life that you would find worth living?We have a tendency to look to medical science to provide immortality, but the desire to fend off death at all costs can lead to an unnecessarily painful end.Zitter shows us many cases, ask many questions and asks us to consider our responses to the end of life. Extreme Measures is a book that lay people and medical professionals will find thought-provoking and useful.We often think of the fight against death as heroic, and it can be. But Zitter considers another kind of heroism: "Heroism doesn’t always mean fighting. Sometimes it means acknowledging the reality on the ground, retreating from the fight, and receiving the support you need from those around you."