Extreme Measures: the ICU and what palliative care offers

Extreme Measures: Finding a Better Path to the End of Life is written by Jessica Nutik Zitter, a physician who writes about both critical care and palliative care. We have not checked the book's publication details or her training against an approved source, so this page does not give them.

The book's central idea, as its subtitle and the author's term suggest, is what she calls "the End-of-Life Conveyor belt." It is the pattern in which treatment for dying patients escalates and grows more invasive by default, without an explicit decision that it is what the patient wants.

Some books are built around a single patient's story. This one is not. It uses individual cases to illustrate a broader pattern in the system.

It is not cancer-specific. The patients described include people with cancer and others with different serious illnesses.

The book moves between scenes from intensive care and the author's account of practicing palliative care. The ICU scenes show what aggressive care can look like, such as ventilators, feeding tubes and resuscitation attempts. Some sections look at how decisions get made, and how they sometimes never get made openly. The book also looks at communication and at what a good conversation about goals of care could sound like.

There is no step-by-step guide to advance directives. It describes a problem and a different way of practicing. It is not a how-to guide for your own paperwork.

The book's clearest strength is that it comes from inside the hospital. A physician describing care she has seen up close can show details an outside observer may miss.

The book makes the case for earlier palliative care. That fits how NCI frames the service. NCI says palliative care "may be provided at any point during cancer care, from diagnosis to the end of life." It adds that a person receiving palliative care may continue to receive cancer treatment.

The book pays attention to emotional and communicative failures. Those failures drive the conveyor belt. Conversations are unclear. Assumptions go unchecked. Defaults go unquestioned. That focus is a genuine contribution. It locates the problem partly in communication. Medical technology and institutional incentives are not the whole story.

The book is built mostly around intensive care scenes. The ICU is one specific setting for end-of-life decisions. Many cancer deaths and serious illnesses never pass through an ICU. If your situation is unfolding more slowly, at home or in hospice, not every scene will match your circumstances.

The book is written from Zitter's specific vantage point in American critical care. Hospitals differ, so do not assume yours handles these transitions the way the book describes.

Like any single physician's account, this book reflects one perspective. The area is hard. Reasonable clinicians disagree about where the line falls between appropriate aggressive treatment and unwanted intervention, and that line shifts case by case. The book's framing is grounded in real experience. It is still an argument rather than a settled consensus.

NCI describes palliative care as care that may be provided at any point during cancer care, from diagnosis to the end of life. A person can keep receiving cancer treatment while receiving it.

Hospice is different. NCI says it requires certification of a life expectancy of 6 months or less. The focus is comfort, not cure. NCI says certification comes from the attending doctor and the hospice medical director. Medicare says your hospice doctor and your regular doctor (if you have one) certify that you are terminally ill, with a life expectancy of 6 months or less. To elect Medicare hospice care you choose comfort-focused care instead of treatment aimed at curing the terminal illness. Medicare says hospice can typically be given in your home or the place where you live. It can be recertified if you live longer than 6 months.

For how families make this choice, see how families decide when to begin hospice and what to expect at the end of life.

The book's subject is what happens once serious illness is already underway. Screening for it in advance is not its topic. But a reader coming to this book often thinks about risk too. That may be their own risk, or a family member's. It is worth stating plainly what routine screening covers. The book does not address it.

USPSTF issues screening recommendations one cancer at a time. There is no single test for all cancers.

• Breast: a mammogram every two years for women aged 40 to 74.
• Colorectal: screening for adults aged 45 to 75. Ages 45 to 49 is Grade B, and 50 to 75 is Grade A.
• Cervical: starting at age 21. Women 21 to 29 are screened every 3 years with a Pap test (cytology). Women 30 to 65 have three options, including HPV testing every 5 years.
• Lung: adults aged 50 to 80 with at least a 20 pack-year smoking history who smoke now or quit within the past 15 years.

None of this decides who faces the situations the book describes. Cancer can reach an advanced stage even with appropriate screening. How care is handled once illness is serious matters regardless of when a diagnosis came.

The book is built around vivid ICU scenes and a clear moral argument. So it helps to weigh its claims carefully.

Zitter's argument comes from clinical experience. That carries weight. But it is one person's account of patterns she saw. It is not a controlled study of outcomes across many hospitals. For how common unwanted aggressive care is, look to published research. Narrative cannot stand in for that evidence. We have not checked any such figures for this page.

It suits a reader who wants to know why intensive, invasive treatment sometimes continues when it may not match a dying patient's wishes, and who wants an insider's account of an alternative. It can also help a family member who expects a loved one to be admitted to intensive care. It can prepare them for the decisions and default assumptions they may face there.

It suits some readers less well. One is a reader whose situation is unfolding outside a critical care setting. Another wants a procedural guide to advance directives or hospice enrollment. This is a narrative argument, not that. For the mechanics of that decision, another page is more direct. See is palliative care the same as hospice.

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• NCI — Palliative Care in Cancer Fact Sheet
• NCI — Hospice Care Fact Sheet
• Medicare — Hospice Care
• USPSTF — Breast Cancer: Screening
• USPSTF — Colorectal Cancer: Screening
• USPSTF — Cervical Cancer: Screening
• USPSTF — Lung Cancer: Screening

This page discusses Extreme Measures for education. It is not medical advice, and nothing here is a judgement of anyone's real medical care.