Book Review: “Extreme Measures” by Jessica Nutik-Zitter, M.D.

An ICU physician discusses the American way of death and points towards a new approach

Book cover Extreme Measures“Extreme Measures” by Jessica Nutik-Zitter, M.D. is a book about America’s extraordinarily dysfunctional relationship with death. It is also, in many ways, a deeply personal memoir — a chronicle of an exceptionally bright and talented young doctor’s journey through the medical education system, from medical student to resident to attending physician in the ICU. And, perhaps most of all, it is a heartbreaking portrayal of what the author so aptly calls the “end-of-life conveyor belt” — the invisible mechanism of the ICU that catapults thousands of unwitting patients towards a lonely, painful, medicalized death.

Jessica Nutik-Zitter is a rarity in the medical world. Trained in pulmonary and critical care medicine, she began her career as an ICU physician — an “intensivist” whose goal was to keep the sickest of the sick alive at any cost. Yet even as a young resident, she had serious misgivings about the nature of her work.

In one of the early chapters of the book, she describes her first “Code Blue.” Running into the patient’s room, heart pounding, finally on the cusp of “saving a life,” she encountered the inert body of a frail, elderly man being set upon by a group of doctors, frantically pounding on his chest and using electric shocks to try to jump start his heart. She describes the sickening sound of cracking ribs as they administered CPR, and her profound dismay when she realized she and her colleagues were trying to revive a corpse. It was, she says, the first in a series of deeply disturbing experiences that shaped her values as a physician and the rest of her career.

Today, Dr. Zitter is board certified in two seemingly disparate specialties: critical care and palliative medicine and hospice care. She divides her time in the hospital equally between the two roles. But her goal as a physician is to bring the two specialties together under the overarching umbrella of holistic, patient-centered care — a philosophy that puts patient values and goals ahead of prolonging life at any cost. It’s that philosophy, she believes, that will put a stop to the end-of-life conveyor belt and give dying people and their families the freedom to choose a peaceful, natural death.

But the journey won’t be easy, she freely admits. Beginning with America’s “more is better” attitude and our collective delusion that death is something we can actually avoid, “Extreme Measures” details the many obstacles that stand in the way of “a good death.” The medical establishment is, of course, one. Doctors are indoctrinated into the belief that death is the enemy and that it is unethical and perhaps immoral to give up the fight until every weapon in their arsenal of machines and medicines has been used. But patients and their surrogates contribute nearly as much by avoiding the kind of frank, honest discussions about death that could stop the conveyor belt in its tracks. Culture, personal values and even race also play important roles.

Dr. Zitter, author of Extreme Measures

Dr. Jessica-Nutik Zitter

“Extreme Measures” is an extremely compelling read — a deep dive into the hidden world of intensive care medicine and the often tragic results of our cultural avoidance of death. Dr. Zitter includes dozens of moving accounts of people stuck on the end-of-life conveyor belt — tethered to machines, tubes in every orifice, surrounded by doctors who are trained to pay attention to numbers and lab values rather than human beings and their needs. Many of these stories are tragic and difficult to read. And far too many of them end with the patient dying in the ICU or being transferred to a long-term care facility, attached to a breathing machine for the rest of their lives.  

Occasionally, however, there are good outcomes. After meeting with the palliative care team, a woman with advanced ovarian cancer is able go home to her family in Guatemala after making a difficult decision to pursue surgery along with comfort care. A young man’s family comes to grips with the futility of continued efforts to save his life and agrees to remove his breathing tube so he can die a natural death. A grandmother with end-stage cancer leaves the ICU and spends several months at home with her family before she dies. But these victories seem far too few, and the battles that made them happen seem far too hard.

In the end, however, “Extreme Measures” provides a measure of hope — a glimpse into a future when doctors and patients will no longer feel compelled to use technology to prolong life at any cost. Attitudes are shifting, Dr. Zitter assures us. The institution of medicine is beginning, albeit slowly, to bridge the divide between doctors who do to their patients and those who work with their patients to identify goals of care. Communication, she says again and again, is the key to finding and eventually expanding a middle ground.

“Extreme Measures” is an extraordinary introduction to the grim realities of the American way of death. It’s my hope that it also serves as inspiration to those who read it; that it helps us acknowledge that there is a better path to the end of life, and that it begins with each of us. 

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Caregivers Rarely Screened for Depression and Anxiety, Study Shows

Early assessment and intervention for mental health issues may help caregivers cope
An exhausted caregiver sleeping next to her husband shows caregivers stress

Credit: ehospice.com.uk

Caring for a loved one with a terminal illness is exhausting and isolating. In many cases, caregivers are forced to quit their jobs and deplete their savings in order to care for an ailing family member in the home. According to the Caregiver Action Network, caregivers and their families are more likely to live in poverty than their non-caregiver counterparts. And many rely on Supplemental Security Income to meet their financial needs. An overwhelming majority also report skimping on sleep, diet, exercise and visits to their own doctor due to the time involved in attending to their loved one’s needs.

It should come as no surprise, then, that caregivers are subject to higher rates of depression and anxiety than the public at large. Yet, according to Debra Parker-Oliver, Ph.D., a professor in the Department of Family and Community Medicine at the University of Missouri School of Medicine, health care providers are not assessing this vulnerable population for mental health problems as thoroughly as they should.

“We have a population that is under immense stress and is not being acknowledged,” she said. “Basic assessment tools should be used to help increase the likelihood of early detection and treatment of depression and anxiety in family caregivers.”

A man feeds his wife soup

Credit: evidentlycochrane.net

Parker-Oliver was the lead investigator in a study conducted at the University of Missouri last year. Her team of researchers looked at the prevalence of depression and anxiety in 395 individuals who were caring for a terminally ill family member in the home. Published in the Journal of Palliative Medicine in December, 2016, the study showed that nearly one in four caregivers suffered from moderate to severe depression. Additionally, about one-third of the subjects had moderate to severe anxiety.

The study also identified a number of risk factors that increased the likelihood that a caregiver would become anxious or depressed. For example, younger caregivers suffered more mental health issues that older ones. And spouses caring for a loved one with a diagnosis other than cancer, such as Alzheimer’s disease, had a higher incidence of depression than other subjects.

Healthcare Workers Focus on the Patient

There are likely a number of reasons why caregiver depression and anxiety go unnoticed. Parker-Oliver believes that a major factor is that hospice providers focus on the patient rather than the family’s needs. Or they may notice the caregiver’s distress, but don’t intervene because the caregiver is not their patient — the dying person is. But, she adds, “In many scenarios, it is a family disease. It’s fair to say they have two patients: the caregiver and the person who is terminally ill.”

There are currently 34 million Americans partnering with hospice to care for dying loved ones in the home. Early mental health screening for family caregivers would allow for early intervention and greater psychosocial support for those at risk, Parker-Oliver believes.

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“If” by Bread

A memorial song with a romantic view of the end of life
A couple locks one finger together, each with anchor tattoos to represent their love for each other as in the song "If"

Credit: MaxPixel.com

It’s often difficult to put into words how much you care for someone important in your life. Many of us squander the small opportunities we get every day to express our gratitude and love for the people around us. And by the time the end arrives, we find ourselves at a loss for words. Bread’s “If” captures those deep feelings of love that can’t always be expressed, making it a touching memorial song for the most precious person in your life.

This short memorial song packs a ton of meaning and emotion into just a few stanzas. The narrator laments that his feelings are frustratingly complex. He has trouble “painting” the full picture of the person he loves because such a painting would gloss over the nuances that make his love special. It’s hard to distill years of adoration into a simple image or a handful of words.

Although the song has obvious romantic overtones, its themes apply to many different kinds of relationships. In one section of the song, the singer compares the person he loves to Helen of Troy, whose face could launch a thousand ships. Yet what he means by this comparison is not just that his lover is beautiful, but that he never wants to leave her side. His love makes him feel as if he’s always home. This is a feeling that most of us have for our romantic partners. But it’s also something that we feel for other people in our lives who make us feel safe and protected and loved.

Toward the end of the song, “If” becomes more like a ballad for a love lost. The narrator imagines the end of his life and wants nothing more than to be with the person he loves most. There’s a gleam of hope in the song when he sings,

If the world should stop revolving, spinning slowly down to die,
I’d spend the end with you.
And when the world was through,
Then one by one the stars would all go out,
Then you and I would simply fly away

Rather than looking at death as the end, Bread’s “If” is a memorial song that embraces the end with vigor. It romanticizes spending those last precious moments with the person you love most, making it a comforting thought instead of a worrying one.

Read the full lyrics for Bread’s “If” here.

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Study Finds Fewer American Automobile Fatalities Linked to Decreased Driving

Car crash deaths are down, but so is time spent traveling

A new study released by the American Journal of Preventative Medicine concludes that Americans drove less from 2003 to 2014. This decrease in road activity correlated directly with a decrease in automobile fatalities. However, less time spent behind the wheel did not mean that people became more active or switched to other modes of transportation. Rather, the study concludes that Americans traveled less, and chose to stay at home more often than in previous decades.

Picture of a busy highway Per capita automobile travel declined roughly 600 miles per year from 2003 to 2014. Young adults, particularly males aged 20-29, saw the largest per capita decrease. Car crash deaths across the board dropped significantly as well. Which makes sense, as fewer cars on the road means fewer opportunities for fatal accidents to occur.

Dr. Noreen McDonald, the study’s author, is a city and regional planning expert at the University of North Carolina, Chapel Hill. She wanted to see how American driving reduction impacted changes in both physical activity and motor vehicle fatalities.

“My analysis shows a drop in automobile travel from 2003 to 2014 with the largest decreases among young adults, particularly men,” she wrote. “Despite predictions to the contrary, a substantial decline in auto use has not been accompanied by an increase in time spent in active travel nor in reallocating travel time to exercise.” She explained further that, “Fatalities to motor vehicle occupants dropped significantly during the study period, particularly among millennials.”

Why Have Automobile Fatalities Declined?

Fewer car crash deaths is certainly an encouraging development. However, it is also important to look at why this is the case.

“Safer cars and better driving training could explain this decline,” McDonald wrote. However, her analysis seems to show that the “nearly unprecedented decade-long decline” in U.S. car crash deaths through 2014 was connected to less driving. This, of course, is good for overall public health and the environment, but is also an indicator of how well the economy is doing.

Dr. McDonald listed high gas prices, rising debt, stagnant incomes and increases of unemployment as the primary reasons for less driving. If this is the case, then a brighter economic future could mean more traffic-related deaths. This is an issue that we must face going forward, according to Dr. McDonald. “The challenge that we must all now work toward,” she concluded, “is how to maintain the safety record on American roads as population growth, low gas prices, and an improving economy lead to more travel.”

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“Forget safety. Live where you fear to live. Destroy your reputation. Be notorious.”

-Jalaluddin Rumi
Older women looking strong and dignified with bright pink hair

Credit: revelist.com

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Monday Hearts for Madalene

Page Hodel creates beautiful hearts as a tribute to lasting love
handmade heart of yellow flowers

Hearts and flowers remind me of you

It’s an honor for SevenPonds to share with our readers the story of the Monday Hearts for Madalene project, a true account of the power of love in the midst of death.The project’s origins take us to 2005: the moment Page Hodel encountered Madalene Rodriguez and fell “instantly, dizzyingly in love with her.” The couple’s first meeting was electric, and Page felt inspired to do something unique for the woman who captured her heart. So, she began leaving handmade hearts – made from flowers, leaves, and other materials – on Madalene’s doorstep.  The hearts became a ritual, and they were there to greet Madalene as she left for work every Monday.

“To start her week with a visual reminder of our beautiful love.” Page Hodel

Just seven months later, Madalene was diagnosed with ovarian cancer and passed away on June 20th, 2006. But Page’s love for her hasn’t ceased, and she continues to make a heart for her every Monday in celebration of her life.

If you would like, you can also receive Page’s “Monday Hearts for Madalene” by emailing her at page.hodel@gmail.com with “subscribe” written as the subject. Images of the hearts can also be purchased  in her beautifully compiled book, Monday Hearts for Madelene. Please also visit her website and Facebook  page. A portion of all sales will go to the Women’s Cancer Resource Center in Oakland, California (www.wcrc.org). See more Monday Hearts for Madalene here.

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