This book (mine was an early review copy via LibraryThing) was inspired by Atul Gawande’s “Being Mortal”, and since both physicians have worked at the same Boston hospital, I was interested in reading this take on how doctors deal with terminal patients. It’s pretty much of a memoir of how Zitter came to be a doctor and learned to overcome her training to become more of a patient focussed healthcare provider. She’s worked in ICUs around North America and shares deidentified stories about how people make rushed and emotional decisions about treatment when life expectancy is low. She warns that you need to decide on how you want to end your life if you’re dying in a hospital where you’ll be subjected to the medical teams doing everything they can unless instructed otherwise. She goes into bloody detail about what CPR can do (one story was told of it breaking a vertebra on a patient with compromised bone density) and how important the two week “trach point” can be. If a patient is still on a breathing tube at that point in a hospital stay, the standard is to perform a tracheotomy to make a permanent hole, but the side effects are often glossed over. One of the main points that she makes is that the emergency and ICU doctors are rushed and that patients and family either don’t question them or don’t trust them. It seems to be one or the other, with standard procedures being pushed that aren’t best for a terminal patient with regard to how comfortable they’ll be in their last days or weeks (she flat out says that if you’ve got less than 6 months to live, don’t do chemotherapy). But patients, family and surrogate decision makers fall into the emotional and moral pit of not wanting to give up before everything has been tried.
Zitter had a defining moment with a family support team member questioning whether or not a procedure was going to be good for a patient or was just a sop to the doctor’s conscience. She had to fight against a culture of “do everything you can” to even bring up the question of if they should do anything. Sometimes (most times?) managing pain and letting the patient die peacefully surrounded by loved ones is the best thing, rather than intubating them (and strapping them down so that they can’t pull out the tubes) and isolating them in a hospital room, and sometimes that doesn’t even gain them more time since the tubes and catheters are infection vectors.
I finished this book while my uncle was in the hospital, and that same day I learned that he’d become weaker, developed pneumonia and passed away. He went quickly, they had hoped to send him home that day, but I’m having a hard time trusting that hospitals are the best place for my aging relatives to pass on.
Zitter gives a good list of resources on creating Advanced Care Directives to let loved ones know your wishes (I want to make one of these because I have super strong feelings against long term intubation), Do Not Resuscitate orders (good for only hospital one stay), and Physician Order for Life Sustaining Treatment (notarised and stays with the patient). She also mentions Death Cafes and other ways to get conversations started.
Not an easy book to read, but important.