“I’m afraid of death,” says Dr. Jessica Nutik Zitter, a doctor at Highland Hospital in Oakland. “I cry a lot because I’m just so sad about death. However, what I see on a daily basis [in the intensive care unit] is so much worse than death.”
Zitter is so enmeshed in the topic of death that she spoke at a “Death Café” earlier this month.
About 20 congregants from her synagogue, Beth Jacob Congregation in Oakland, gathered in a private home for dinner and a conversation that focused on medical ethics, Jewish perspectives on dying and the practical matters associated with end-of-life issues. Rabbi Judah Dardik was another one of the speakers.
“Death Cafés” have been popping up around the country as a nonthreatening way for people to share information on a sensitive and often taboo subject.
Zitter, a palliative care physician and one of the critical care attending staff at Highland Hospital, started the evening with a story: She talked about being asked by a friend to visit the bedside of a wealthy, powerful and once-vigorous man in the last stages of pancreatic cancer.
“I saw this family in tremendous distress. I said, ‘Your husband is dying,’ and I used the word ‘dying’ because that’s a word people never hear.” The family was reluctant to call in hospice, because that would require discontinuing the regimen of disease-fighting therapies.
“They were afraid that he’d think they were giving up on him,” Zitter said.
After speaking with Zitter, the family decided to call in hospice, and not long thereafter, the man died peacefully, listening to opera with loved ones around him.
Zitter is an expert in the fairly new field of palliative care medicine, sometimes called hospice and palliative care. In a 2013 New York Times blog piece headlined “They call me Dr. Kevorkian,” she wrote that the field “advocates medical care that focuses on the overall well-being of the patient as opposed to just the optimization of organ function. Patients who receive palliative care tend to suffer far less, die at home and even live longer than those who don’t receive consultation.”
In another Times blog piece, “A ‘code death’ for dying patients,” she began with the sentence: “Sadly, but with conviction, I recently removed the breathing tubes from three patients in intensive care.”
Doctors have practiced palliative care of some sort for centuries, but it was not until 2008 that the American Board of Medical Specialties began official certification, and Zitter was one of the first physicians to be certified.
A 1992 graduate of Case Western Reserve University Medical School in Cleveland, she and her husband, health care entrepreneur Mark Zitter, are the parents of three teens.
Zitter grew up in Montreal, Canada’s oldest Jewish community, and relocated to the United States with her parents after the rise of the nationalistic Parti Québécois in the 1970s. Her father, neurosurgeon Dr. Stephen Nutik, and mother, internist Dr. Rhoda Nutik, are now retired from practice in Palo Alto. It was Zitter who encouraged her mother, then a microbiologist, to go back to school for a medical degree. Mother and daughter graduated from Case Western two years apart.
“I’m very Jewishly identified,” Zitter says. “I try to live my life according to Jewish values, the most important being tikkun olam.”
The Jewish tradition of constant questioning, of arguing a case back and forth, is especially meaningful to Zitter when she’s on duty in the intensive care unit, when she’s called on to provide her best professional judgment for patients, most of them low-income or indigent and on life support. She has to make eight to 10 such decisions a week, she says.
Her work is vastly different from most doctors today — doctors who were trained, she says, to have “a single-minded focus on preserving organ function. They don’t stop and think about the whole patient.”
Zitter reveres the Jewish tradition of “going against established wisdom. It’s hard at times. But to be my Jewish self, I have an obligation and have to do the right thing.”
At the Death Café, Dardik, Beth Jacob’s outgoing rabbi, supplemented Zitter’s talk from the vantage point of halachah and tradition. Conventional medicine, he said, says that life ends when brain function ceases, whereas in Jewish law it is subject to debate: Some authorities agree with the brain-function definition, but others require the cessation of cardiac function.
Dardik also emphasized tradition’s important distinction between “prolonging life and saving life.” While Jewish tradition forbids even removing a pillow if that would hasten death, it also permits, for example, ordering a woodchopper to cease work if the noise is serving to keep a departing soul anchored to the world.
Zitter, also a prolific writer, has received online comments from “evangelical Christians” and others criticizing her against-the-grain approach. She counters: “It’s the opposite of ‘playing God.’ I’m playing God if I’m working against a natural phenomenon and what a patient might want, if I’m doing stuff to a patient who might have said, ‘I don’t want that.’
“Give your doctor permission to be honest with you,” she adds, noting that many physicians hold back information, fearing they’ll be seen as cruel.
Zitter is “against euthanasia — I would never hasten someone’s death”— and sees her philosophy as “patient-centered.”
“Eighty percent of my patients are realistic,” she says. “If they really understand what I think is going to happen, they almost always choose” palliative care when the prognosis is terminal.
At the Death Café, Dardik and Zitter agreed that ongoing and very specific family discussions about end-of-life issues are vital. Zitter outlined specific points about advance directives and physicians’ orders for life-sustaining treatment, information available on JessicaZitter.com.
“Everyone’s going to die,” Dardik said. “And the people we love are going to die.” People need to ask themselves, “To what extent is that about me and to what extent about them?” Is a person “not prepared” for a loved one to be dead “even though their body is dying”?
Zitter is at work on a book with the working title “Straddling Two Worlds: Saving Lives and Midwiving Death.” Her work, she says, is “about honoring people and their own personal choices, after they have the information and the truth.”