Jessica Zitter speaks at MNHPC 2019

Jessica Zitter speaks at MNHPC 2019



this story shows a different way to approach the end of life certainly different from how I was trained and how many people continue to be trained Stephanie Rowe vyd her name is Marsha Greene in the epilogue but her real name is Stephanie Rowe vyd she was a 60 year old wife mother grandmother this was an exuberant woman she loved life she loved gardening she loved wine tastings she loved her family when she was diagnosed with lung cancer she vowed to fight it with everything she had she stopped smoking she started exercising she started making these green smoothie concoctions that apparently were disgusting to boost her immune system and she said to her oncologist bring on any and all chemotherapy and he did and she went through many many cycles of chemotherapy when she found out that the cancer had spread to her brain she just was determined to fight harder what Stephanie didn't realize was that cancer at this stage isn't curable she thought that if she just worked harder took more chemotherapy she could beat it and so she did and by the time I met her on my service in the ICU she was in shock her blood pressure so low we could not measure it and she was on death's door my team and I worked fast and we jacked up her blood pressure luckily before too much damage had been done and the next morning she was back success but I couldn't celebrate because I knew that it was just a matter of time before her blood pressure like a leaky tire went down again Stephanie needed the facts but I didn't really want to tell her do you know that her kids were treating her ICU room like it was command central and they had actually tacked up taped up a sign that said no bad news and in addition didn't they deserve a break this family had just been through so much couldn't the team on the floor tell her in a couple of days when things had settled down but you know what deep down I knew they weren't gonna tell her this woman had been in and out of our hospital multiple times over the previous couple of months and she had no idea what was going on and then the nurse walked up to me and I thought she was gonna say hey we need the bed but she didn't she looked at me and she said I think you need to tell her and I said you're right and I really didn't want to but I walked into her room and when I got there Stephanie's daughter Becky was giving her a pressure point massage for strength it actually reminded me of like getting a box are ready to go back into the ring and Becky looked at me and she said what's next we're ready to fight again and Stephanie looked exhausted but she nodded i sat down on the side of her bed I was very nervous I had to force the words out and as I was talking becky stopped massage mid pressure point and she was glaring at me and Stephanie her facial expression completely had changed and I couldn't tell if she was getting ready to scream at me or start sobbing and what happened was almost worse becky looked at me and she said please leave they transferred out to the floor and I couldn't stop thinking about it I felt horrible I felt I'd failed them on so many levels but I couldn't stop thinking about them and I knew I needed to go and check on them and so I went to her room on the floor I was dreading it but I reached her room I was in for a big surprise because there was Stephanie she was sitting in her wheelchair and she was smiling and it was her husband was packing up her room she had her iPad on her lap and her daughter Becky was at her house at Stephanie's house talking to Stephanie on the iPad and it turned out they had done a complete about-face I don't want to show you a quick clip of that moment looking at my yeah set up in my living room at home yeah and it's one of the hospital beds but oh my god or his go to fix with my quilt from home which is my favorite one to sleep under the dining table has room to extend out so everybody can come and still visit and I cannot wait to your phone right well I tell you what I want something nice so we'll start with a light red one and it'll also pick up heavier red one for later in the evening do the things that we love to do be what retired early my daughters put a job apply wherever you are you know so that we can spend this last year doing the things that we'd love to do I had no idea that I had choices or the power to say no I don't want to do this I want to do this or I didn't know these options were out there good little cheese table you mean you're not gonna want to sit here in this bed here no Joe anything I've ever done bringing power to reflect me that I had no I had that kind I didn't know what dr. doe yep yeah oh yeah you know yeah so they had heard what I had said they had taken it in and apparently the next day after transferring out of the ICU they had met with hospice and they decided to go home no more Hospital in the end they chose Cabernet over chemotherapy Stephanie enjoyed the last two months of her life with the support of hospice her family and several bottles of good wine and her funeral which I attended was filled with wonderful stories and not one ounce of regret the last couple of months of Stephanie's life could have looked very different she could have gone on to that last stop on the end-of-life conveyor belt but she chose not to we couldn't save Stephanie's life but we did save her humanity and I've come to see that as a new kind of heroism it's an approach that sees patients as people not a series of fires to be extinguished I know that everyone in this room knows that most patients aren't as lucky as Stephanie they don't ever get the chance to opt out so I want to finish up by giving a few strategies that I think will help make stories like Stephanie's more the rule than the exception first let's redefine success I used to think that success could only mean fighting the disease and winning our patients are going to follow us into battle if that is the only option we give them but over these past 15 years I have learned of many other types of success for patients like Stephanie being home with family being at peace physically spiritually not dying on machines and for doctors like me the success of treating a patient the way she tells me she wants to be treated Stephanie got to define success here not us second let's be honest there is a huge elephant in these hospital rooms patients and doctors on completely different realities I'm going to show you some data that shocked even me about patients who were on the verge of receiving a tracheostomy because they were too weak to come off the ventilator their loved ones actually thought the patient would do really well over the next year here's some of the data 93% of them thought that they would be alive 71 percent thought that they'd actually be living independently and 83 percent of them thought that there would be a good quality of life but the physicians they thought very differently this discrepancy is chilling and unacceptable the physicians were much more accurate about what was going to happen and yet it was the loved ones who were entrusted to make a decision for a surgery that almost always remains permanent and he's actually the first step I think on the end-of-life conveyor belt much of the time why is this happening I had to write a whole book about it it's very complicated but I think one of the biggest reasons is that doctors really have a hard time breaking bad news I think it's one of the hardest parts of my job remember Stephanie I almost didn't go back in her room and I'm a palliative care physician doctors we need to tell our patients the truth they can't plan for a good death if they don't even know they're dying good communication skills have to be thought of as important as running a good code or putting in a Quinton catheter patients and Families you also have a role to play here think about this do you want to know what the doctor is really thinking or do you just want to have good news that's an important question to ask yourself because if you want good news that's probably what you're gonna get let's now talk about one final critical element for a humane approach to the end of life a non conveyor-belt approach to the end of life and that is collaboration the hierarchical system that runs many of our ICUs and hospitals isn't working my two greatest mentors have not been doctors it was a nurse Pat Murphy who taught me that it was okay to learn from others that it was okay to ask for support and it was a chaplain Betty Clark who I've worked with for 10 years who taught me that the doctor often isn't the most important healer in the room if we stick to this hierarchical approach where the doctors driving and everyone else is sitting in the back seat we are just gonna keep making wrong turns right back on to the end-of-life conveyor belt we need a healthier a humane medical ecosystem where patients are treated like people and those of us doing this work can access our humanity these three approaches that I mentioned will get us there redefining success it's not about the protocol it's about the patient being honest with our patients our colleagues and ourselves and really working together because it takes a village to do this very very hard work and it's not gonna be easy because culture change is hard it's turning things on its head it's scary it's trying to learn skills that we're just not that good at and frankly it's making room at the table for other voices but I'm optimistic I really have seen firsthand that if we work together we can create a new kind of heroism one that I believe will save us all thank you [Applause]

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