In Extremis: The Stark Reality of Life and Death in the ICU


The first time intensive care unit physician Jessica Zitter encountered the “family support team” — a precursor to the palliative care services now routinely found in hospitals — it didn’t go well.

Zitter felt threatened. She remembers thinking, “Who are these people getting in the middle of my relationship with my patients and telling me I’m not doing it well or not asking enough questions?”

Like many doctors early in their careers, Zitter was convinced her role was to save patients “from the jaws of death.” Over the years, however, she came to realize she was often causing more suffering, particularly for those who were dying or frail. But that was the paradigm in which she had been trained. “The way I had been taught,” she said, “was when this organ starts to fail, insert this catheter. And when that cardiac function isn’t working, use this medication. And when the person stops being able to breathe, insert a breathing tube.”

Zitter’s approach to care at the end of life has evolved in striking ways. Today she brings her intensity and self-effacing manner to both critical care and palliative care in the ICU. Her journey has been captured in a new Oscar-nominated short documentary, Extremis. The film, just 24 minutes, chronicles the painful reality of life and death in the ICU at Highland Hospital, a large Oakland public hospital best known for its trauma unit.

Directed by Berkeley filmmaker Dan Krauss, who pursued the project after Zitter spent several years imploring filmmakers to make it, Extremis is a powerful, gut-wrenching film that follows three dying patients and grief-stricken families grappling with enormous suffering and a lack of good choices.

In the film Zitter exhibits a dogged resoluteness in her work — a necessary prerequisite for someone who wants to change the world. Since being released in November by Netflix (the first short documentary acquired by the streaming media company), Extremis has garnered critical acclaim and been viewed in more than 100 countries, a level of visibility most documentary filmmakers only dream about. The California Health Care Foundation (CHCF), as part of its focus on encouraging appropriate care at end of life, plans to support her effort with a project that will screen Extremis for physicians and other audiences around the state.

While more Americans are talking candidly about death and expressing a desire for greater control over their final days, Zitter says too few people clarify what they want should they become critically ill and incapacitated. Once they are admitted to the ICU, it’s frequently too late to stop the express train of high-tech — and often futile — intervention.

Research conducted for the California Health Care Foundation and other groups bears this out. According to Final Chapter: Californians’ Attitudes and Experiences  with Death and Dying, 82% of Californians say it is important to have their end-of-life wishes in writing, but only 23% say they have done so.

What’s more, a 2016 national survey of physicians sponsored by CHCF, the John Hartford Foundation, and the Cambia Health Foundation found that nearly half report they frequently or sometimes feel unsure of what to tell patients and families and unprepared for these conversations.

Watch an interview with Dr. Zitter.

Changing How We Plan for Death

Zitter’s new book, Extreme Measures: Finding a Better Path to the End of Life (Penguin/Random House), is set for release Feb. 21. She describes it as a “combination memoir and exploration of my personal philosophy.” Some of her thinking was honed from essays that appeared in The New York Times.

Zitter believes that patients, physicians, nurses, chaplains, and social workers must work together to improve patient decisionmaking at the end of life. She wants to dispense with the image of the physician as the “lone warrior,” making all the decisions and shouldering all the responsibility.

If families and the medical community better understand the reality of the ICU, she says, more of them will start having these conversations before the momentum becomes unstoppable. Films like Extremis and her new book can only help.

For more about end-of-life care in California, see