Resisting the Urge to Do More

Palliative care specialist
Dr. Jessica Nutik Zitter

Dr. Jessica Nutik Zitter is committed to improving end-of-life care. She chose to work in the Intensive Care Unit (ICU) because of her initial interest in saving lives. Zitter works at Highland Hospital in Oakland and is among the few ICU physicians who also specializes in palliative care. Zitter sees a lot of trauma on her shift—gunshot victims, AIDS patients, and homeless people. She writes about her ICU experiences in her New York Times blog posts.

In a recent post,9 Zitter wrote about a homeless woman near death, found under a bridge in Oakland. “Crucial organs were failing,” writes Zitter, “Her liver was almost completely shut down...her brain was profoundly and irreversibly damaged...the cells of her [brain] were swollen and dying. And there was no chance of reversing it. She would never again wake up.”

When Dr. Zitter arrived in the ICU that day, the medical staff was doing everything to keep the woman alive as long as possible, inserting large catheters in her veins and starting drips, even though she was near death. “This woman really had lived hours past obviously where she would have lived, had she not received this very intensive care,” said Zitter. She sat down with her staff to discuss stopping life-prolonging treatments, but it was not an easy conversation. “If you start backing off and saying ‘C’mon team, let’s sit down here and talk about this—how’s this really going to help?’ People are kind of uncomfortable with that,” said Zitter.

After consulting with her staff, Dr. Zitter made the decision to stop all further treatments and tests and gave the woman pain medication to ease her suffering. She died within the next few hours.

When It’s Time to Stop

Often the problem that confronts doctors is when to stop the heroic measures, if continuing further treatments is clearly futile. And what to tell patients and their families when asking for consent. In the case of Rebecca Mitchell’s mother Tess, her doctors didn’t want to be the bearers of bad news. Tess had stage four lung cancer and was hoping to beat it with chemotherapy. “Every doctor we saw during that period of time, they seemed positive, encouraging,” said Rebecca, “It was like okay, we’ve seen this before, we’re going to try this, we’re going to do this, this has worked before in the past.”

But Tess’s cancer had metastasized and was spreading everywhere. Her body was failing and she was in and out of the ICU. Despite evidence to the contrary, her doctors continued to remain optimistic and Tess held out hope that she could survive another five years. Jessica Zitter was Tess’ doctor during her last visit to the ICU. Rebecca was present when Dr. Zitter gave her mother an honest assessment—that her chances for long-term survival were not good. “Honestly, I think we all knew that,” said Rebecca, “Even the doctors in the ICU knew that. It just took somebody to acknowledge that. It’s okay to say ‘there’s an alternative to this.’ ”

Tess made the decision to stop further treatments. She went home and received palliative care through hospice until she passed away a month later. “I think she was just happy to be out of there and coming home and not have to find the energy to get dressed and do some new procedure or to get treated for something else,” said Rebecca, “That was a relief for her. Why would you want to go in a hospital bed or in a hospital room alone and fighting or hooked up? She just took control and said ‘I’m going to go home, I’m going to do the things I want, and when it’s time to go, I’m just going to fall asleep and not wake up.’ ”

Universal access to palliative care is still a long way off. But major health care systems, medical schools, and state health officials are taking steps to improve end-of-life care,10 making palliative training and services more widely available than ever before. And palliative care advocates are hopeful the medical system will move toward the holistic model pioneered by the hospice movement—patient-centered care that uses good communication with team work.

JoAnn Mar’s report is part of the End of Life Radio Project, supported by a grant from the Association of Health Care Journalists and The Commonwealth Fund.

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