Resisting the Urge to Do More

Dr. Jessica Nutik Zitter,
Palliative Care Specialist,
Highland Hospital, Oakland

Twenty-five percent of all elderly people die in the ICU and this number appears to be on the rise. Patients brought to the ICU are usually in critical distress and they need medical help immediately. TV hospital dramas like ER and Grey’s Anatomy portray the quick, rapid-fire response of the medical teams as they try to save lives. Dr. Jessica Nutik Zitter works in the ICU at Highland Hospital in Oakland. She questions whether automatic resuscitation is always the best response for the patient near death, when there’s little chance of recovery. Zitter says, “Part of the problem is, we don’t ask—we just assume. We assume that we should be defaulting to those technological escalations without asking.”

In addition to being an ICU doctor, Zitter is also a palliative care specialist. In her dual roles, Zitter tries to provide good end of life care to her dying patients. But sometimes, these efforts come into conflict with her impulse to save lives as an ICU doctor. Zitter’s concerns about end-of-life care in the ICU led her to chronicle some of her experiences in blog posts for The New York Times. In her article entitled “Resisting the Urge to Do More,” Zitter described a homeless woman near death who was taken to the ICU. Her organs were failing and her liver was almost completely shut down. When Zitter arrived at the ICU, the medical staff was doing everything to keep the woman alive—inserting large catheters in her veins, starting drips, and doing CT scans. “This woman really had lived hours past obviously where she would have lived, had she not received this very intensive care,” said Zitter.

But in the end, Zitter’s palliative care instincts prevailed. Zitter stopped all further treatments and tests and gave the woman pain medication to ease her suffering. She died within the next few hours. “It was really hard for my residents,” said Zitter, “They were saying, ‘But she’s got this A-line and it’s very easy to check the blood.’ And it was very hard to say ‘Wait—let’s not do that because it’s not going to significantly change what we do or improve the patient’s condition. The patient’s dying. Let’s attend to her symptoms and let her die.’ ”

Using palliative care techniques in the ICU is not common. “It goes against all of our culture,” said Zitter, “If you start backing off and saying ‘Okay, c’mon team—let’s sit down here for a second and talk about this. How is this really going to help?’ People are kind of uncomfortable with that. You know, we’ve got this team contract. We are here to save this life.”

But for dying patients, heroic measures can often do more harm than good. When nothing further can be done for the dying patients still alive, most of them are transferred from the ICU to long term acute care facilities. In her memoir Extreme Measures: Finding a Better Path to the End of Life, Zitter writes that the patients are tethered to ventilators, attached to IVs, feeding tubes, and catheters. They live out their final days alone and unresponsive, some perhaps in pain and discomfort, unable to speak or interact with their family. Perhaps these patients would not have chosen life-prolonging interventions, had they been asked. “In my experience, I’ve seen that patients really want to talk about what they want for themselves when it comes to the last chapter of their lives,” says palliative care specialist Dr. V.J. Periyakoil.

According to a 2011 survey by the California HealthCare Foundation, 80 percent of Californians polled say they would like to talk to a doctor about end-of-life care, but only 7 percent have had a doctor speak with them about it. “We doctors really have no idea what really matters to them,” said Periyakoil, “And so then what happens is the default takes over. Then all kinds of procedures and treatments are given to them. Because all this happens in a very short and very tense time, there’s no time to press pause and say ‘What matters to you? What do you want?’ ”

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