Extreme-measuresIn Extreme Measures: Finding a Better Path to the End of Life, Jessica Nutik Zitter, a Montreal-born physician and specialist in critical care medicine, gives a graphic insider’s account of how well-meaning critical care specialists like herself are all-too-apt to inflict futile, unnecessary and agonizing suffering upon dying patients in an intensive-care unit (ICU).

To begin with, Zitter describes her first attempt as a medical student to resuscitate a dying patient in Boston’s Brigham Hospital, an affiliate of the Harvard Medical School. She recollects: “The patient’s skin is an ashy gray-yellow with a waxy sheen. The abdomen is visible beneath the soiled sheets, deflated from years of malnourishment and disease.”

As Zitter entered the enfeebled patient’s room, she observed that a resident was already performing vigorous chest compressions. She relates: “With each compression, there is a sickening click, which I don’t recognize until I hear someone next to me whisper, ‘His whole chest is breaking.’ This man is dead. He looks like the cadavers in med school, only less healthy.”

At the direction of the physician in charge of the patient, Zitter took over and continued the compressions. Only after a full half-hour of this futile treatment was the ghastly procedure halted and the patient declared dead.

Meanwhile, Zitter has found that such tragic incidents are not unusual. Drawing upon years of experience as a critical care physician in at least 20 different hospitals, she testifies that all-too-frequently, the ICU simply functions “as an antechamber of death. It is often the final stage in what I have come to call the ‘end-of-life conveyor belt,’ where dying patients are hoisted onto what I imagine as a moving platform, receiving protocolized treatments to prop up their failing organs. For such patients, this conveyor belt moves inexorably toward a predictable destination in a pattern that has grown grimly familiar to me. By the time the patient dies, he is encased in life support, arms tied down to prevent accidental dislodgement of tubes, unable to eat, talk, or escape—other than through death.”

As an intensive care specialist, Zitter felt woefully unprepared to alleviate the suffering of her dying patients, so 10 years after beginning her training in medical school, she returned to study palliative care.

Now employed as a specialist in both areas, Zitter attests that as an intensive care physician, she still cherishes the opportunity to safeguard the lives of critically ill patients, young and old. As one example, she cites the case of an 85-year-old lady who recently arrived at her ICU in Oakland, California in a state of profound shock from an urinary tract infection. With an array of appropriate treatments, she was able to recover from the brink of death and return home  – albeit still in frail health  – to her family.

Zitter emphasizes that her image of the ICU as an end-of-life conveyor belt applies only to patients who can no longer benefit from curative treatments. As a palliative care specialist, she is dedicated to ensuring that these vulnerable and dying patients for whom there is no reasonable hope of recovery can get access to palliative care, both inside and outside the ICU.

Zitter is particularly concerned that many dying patients suffer needlessly even when palliative care services are readily available. She notes that sometimes, the fault lies with physicians who fail to make a timely recommendation of palliative care for a dying patient. However, often, it is the dying patient and his or her substitute decision makers who are primarily responsible for prolonging the agonies of death, by rejecting a physician’s recommendation of palliative care in the desperate hope that the continuation of patently futile, burdensome and sometimes even bone-crushing treatments might yet result in a miraculous cure.

Extreme Measures contains much sound advice for physicians, patients and substitute decision makers on how to protect dying patients from ending up on life-support in an ICU with no ability to beg for an end to burdensome treatments. But, alas, the book also contains an egregious error: On the last page of the text, Zitter condones physician-assisted suicide, albeit, she states: “My hope is that it is used only as a last resort for patients for whom everything else, including excellent palliative care, has been tried.”

Such hope is calamitously naive. As a palliative care specialist, Zitter should know that experience in Belgium, the Netherlands and Oregon has amply confirmed that euthanasia is like abortion in that once legalized, neither can be limited as originally intended to only the rarest and most extreme cases. Futile care