How One Intensivist (Unwittingly) Learned About Palliative Care

Stephanie Cajigal

Disclosures

August 03, 2017

Intensivist Jessica Nutik Zitter, MD, MPH, had spent two decades focused on keeping patients alive in the intensive care unit (ICU). But it wasn't until a nurse shamed her for placing a dialysis catheter in a dying patient that she began to think about how to improve the quality of life for patients with serious illnesses.

In her recent book, Extreme Measures: Finding a Better Path to the End of Life, Dr Zitter chronicles how she shifted from seeing her work as treating organs and diseases to caring for the whole patient. Her work is also featured in the Oscar-nominated short documentary Extremis (Netflix, 2016).

Dr Zitter completed a board certification in palliative care in 2010 and is currently a critical care and palliative care physician at Highland Hospital in Oakland, California. She is also cofounder of Vital Decisions, a telephone-based counseling service for patients with life-limiting illness.

Medscape recently spoke with Dr Zitter about how intensivists can incorporate palliative care into their work.

Medscape: What motivated you to write your book?

Dr Zitter: I've been writing about my medical experiences for many years. During residency, I wrote mostly for myself, in an attempt to process what I was going through. It's hard to care for sick and dying patients, especially in the beginning, when most of us are still shocked by the suffering inherent to our work.

I would write a piece, and sometimes share it with friends and family, but it was not meant for publication. I was writing about private and painful emotions, about my moral distress. Most of my pieces brought up sadness; ethical issues that I was wrestling with; or conflict that I may have had with the patient, the family, even a colleague.

It was only after I began to learn about palliative care, and to see a new way of doing things, one that actually worked better a lot of the time, that I began to try and share it. I encountered a lot of rejection—from publishers, newspapers, sometimes colleagues who didn't like what I was saying. But one article eventually led to another. I wanted to share my new knowledge with colleagues and patients. I felt that it time to write a book and put it all out there.

Medscape: Can you describe some of the changes you've seen in the ICU over the course of your career?

Dr Zitter: Starting in the 1950s, there was an exponential rise in the number of medical subspecialties that continues to this day. Now we have a veritable alphabet soup of options for the ICU—MICU, SICU, CCU, PACU, PICU. I could go on and on. I just learned about a gastrointestinal diseases ICU in a hospital in the South.

With each iteration, physicians became more focused on specific physiologies. To understand the physiology and figure out how to manipulate it from moment to moment in critical illness requires a kind of scientific focus that I think is essential to being good at those kinds of things. I know that when I started training in the ICU, we were focusing on turbo pressure and the vascular system. We were focusing on creatinine clearance, and we were focusing on all of these physiologic principles and trying to maximize them and string these organs together so that they kept the person alive, but we stopped paying attention to the person in the bed.

When I was training in the 1990s, 20%-40% of the patients coming in to the nation's ICUs were getting Swan-Ganz catheters.[1] I cannot tell you how many of these things I put in. It was sort of part of the experience of ICU care. We were spending $2 billion per year on these catheters at the height of their use.[1]

We found out that the Swan-Ganz catheter was not only not helping patients, but it was actually increasing mortality. It was such a shock, because this was one of our greatest offerings, or so we thought. There was a tremendous amount of disruption in the ICU community when articles starting to come out questioning the benefits of the Swan-Ganz catheter.[2]

Another big change has been the rise of the palliative care movement. We have two decades of real data, starting with the SUPPORT trial in 1996, that display the overly mechanized state of dying in America. Sadly, it is not getting any better with time. People have been dying, and continue to die, in ways they don't want to.[2] This was a shocking and ground-breaking study. And to tell you the honest truth, I didn't hear about it. I was in the middle of my ICU training at that time, and I didn't really hear about it until about a decade later, when I was just becoming part of the palliative care movement.

Medscape: When and how did you become involved in the palliative care movement?

Dr Zitter: I was hired at University Hospital in Newark, New Jersey, in March 2003, and by complete serendipity, they won a prestigious grant in May 2003 through the Robert Wood Johnson Foundation to study how to enhance communication in the ICU. So a "family support team" (which would, years later, become the palliative care team) was suddenly in our ICU, critiquing our every move.

I didn't do it willingly. It was really thrust upon me, and I joke about Pat Murphy. [Editor's note: Pat Murphy was a nurse with whom Dr Zitter worked with at University Hospital of Newark and who led the family support team.] But Pat had the personality that I needed so that I would take notes and listen.

There is not a lot of input from the nurses, from therapists, and I think that is one of the things we have to change. Pat was a real force of nature. She just called it like she saw it, and it took me months of knowing Pat and, honestly, being a little put off by what she was saying to finally having something just click.

Pat caught me in a situation where I was putting a dialysis catheter into a patient, and she said [pretending to be on a phone], "Call the police! They're torturing a patient in the ICU." I was so mortified that it allowed me to press a reset button, in a way.

Medscape: According to your book, this was a patient who was experiencing multisystem organ failure after a round of chemotherapy, correct?

Dr Zitter: Her kidneys had just started to fail; she was not yet on a ventilator, but she was really functionally debilitated from metastatic breast cancer and many rounds of chemotherapy and was close to death. Now her kidneys had started to fail, and they had asked me to put in a catheter so she could get dialysis.

The patient was lying under the drapes moaning while her husband was off in the waiting room. I was supposed to put in a catheter so we could clean up her blood from her kidney failure. I felt like I was doing my job, but there was just this inner discomfort that I hadn't really clarified to the husband that she was actually dying. You know, this catheter wasn't really going to change anything, so when Pat called me out, I just thought about that case and all of the other cases that had come before it where I hadn't really felt like what I was doing for the patient was going to do much more than cause them suffering, and I hadn't explained that carefully to the family.

So I said, "Pat, just teach me what you know; tell me what I should do differently," and it was a very humbling moment. It really was very, very much what I needed in order to move into this new world of learning new skills, which ultimately is what led me to being a palliative care doctor.

Medscape: What did you do to learn about palliative care?

Dr Zitter: It happened gradually and very informally. And not by choice; I was literally dragged into it by Pat. What she said was shocking, upsetting, even offensive. But I had been so resistant to her suggestions before that (about communicating better with my patients and their families, and about being more aggressive about treating pain and symptoms) that I suppose I needed to be shocked. And I can imagine her frustration with me too. That was my moment of epiphany and it was at that very moment that I decided I would do things differently. I asked Pat whether she would teach me a new way of caring for my patients, and she said yes. She became my mentor. A nurse taught me how to be a better doctor.

After that, I began my own training to become a palliative care clinician, with Pat's mentoring, and then eventually acquiring my boards. And then I took courses, such as VITALtalk, to learn enhanced communication skills and eventually became a writer and an advocate, so that I continue to hold myself accountable to doing this hard work, even when I don't want to.

Medscape: What exactly did you learn?

Dr. Zitter: I learned about the importance of breaking bad news, which I used to think would just rob patients of hope and make them die sooner. I now know that patients need this information. They appreciate this information. It's a matter of justice that they receive this information so that they can make the decisions that are right for them, not be placed on what I call the "end-of-life conveyor belt," which describes the state of being treated with increasing amounts of technology until you die without ever having been asked if that was okay with you. Other things I have learned from palliative care have to do with being able to stand strong, or at least still, in the face of emotions. It is normal for patients and families to react strongly in the face of bad news. We all have a tendency to avoid breaking it in the first place. But if you can stand still, count to three, or ten, or whatever you need to, people will usually take a deep breath and then engage and, ultimately, in my experience, be thankful for the truth. I also learned about managing symptoms of all sorts, physical, emotional, spiritual, something that was never stressed in my medical training but that is so key to being a compassionate healthcare provider.

Medscape: How can other critical care physicians improve their understanding of palliative care?

Dr Zitter: There are many organizations that are creating curricula for teaching communication skills to physicians and other healthcare providers, including VITALTalk and ACP Decisions. For those cases where communication is more difficult, conflict has arisen, or management of suffering requires more than the basic knowledge, I would refer the case to a palliative care team.

Most large hospitals, and many small ones, have a palliative care service, and they should be called in for any cases with complex issues around decision-making or management of severe symptoms. But I want to stress that much of what needs to happen for our patients can actually be accomplished by a non-palliative care physician with a little bit of training and practice.

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