How We Die: Reflections Of Life's Final Chapter (2015) - Plot & Excerpts
My Dad is ninety-three. I bought this book to share with him some time ago as we have been grappling with the Inevitably of Death for some time now. He is relatively healthy and he has always counted on living at least until ninety-six, the age his father died. But this past year his sharp mind has begun to notice his body lagging somewhat. He likes to have his “four wheeler” to help him get around and dozes more frequently sitting in his chair. “Maybe I won’t make it to ninety-six,” he says.I travel from Virginia to Michigan to visit him in his assisted living facility every six to eight weeks. He devoured How We Die: Reflections on Life’s Final Chapter in several days during one of my visits last year. But I had never read it until now.This 1993 book is over twenty years old and with the medical advances in that time you might think that makes this book out of date. But that is not completely true. For example, the book states that “coronary heart disease is America’s number one killer, as it is in every industrialized country of the world.” This is still the case today. In 1993, stroke was the third leading cause of death; today it ranks fourth. The life expectancy (all races, both sexes) was 75.5 years in 1993 and 78.7 years in 2010. (Source: http://www.infoplease.com/ipa/A000514...) This 4.2% increase in longevity, while a significant change in when we die, does not, I think, change how we die. I will speak more of the out-of-date factor at the end of the review.We sometimes laugh about death and dying. I think that is a good sign. It shouldn’t scare us to death, if I can use that phrase. My Dad and I have laughed about it as well as talking about his Living Will and DNR order. Here is something from a GR review that shows how we joke about death: Man visits his doctor. Doctor says “I’ve got some bad news, and I’m afraid I’ve got some even worse news.” Guy says “Okay, I’ll have the even worse news first.” Doctor says “Okay, you have terminal cancer. The other news is that you also have Alzheimer’s.” Guy takes a deep breath and says “Okay – well, at least I haven’t got terminal cancer.” It is January 2014 and singer Pete Seeger has just died at the age of 94. One report is that he died of “natural causes.” You do not hear that very often; it seems we are not allowed to officially die of simple old age. “He was just chopping wood last week,” we are told. And we are pleased to hear that.Everyone wants a dignified death. But author, Dr. Sherwin Nuland, is not much of a believer in death with dignity, thinking from his experience that it “should not be expected by any but a very few people.” He says at the outset, “The quest to achieve true dignity fails when our bodies fail.” Is it possible that dignity is something that has become more achievable with the passage of time, medical advances and the availability of skilled hospice care?At the end of the book he talks about The Riddle: Every medical specialist must admit that he has at times convinced patients to undergo diagnostic or therapeutic measures at a point in illness so far beyond reason that The Riddle might better have remained unsolved. Too often near the end, were the doctor able to see deeply within himself, he might recognize that his decisions and advice are motivated by his inability to give up The Riddle and admit defeat as long as there is any chance of solving it. Though he be kind and considerate of the patient he treats, he allows himself to push his kindness aside because the seduction of The Riddle is so strong and the failure to solve it renders him so weak. What is the job of the doctor and what is Dr. Nuland trying to do in this book?We can only give people the hope they will not die alone if we are totally honest with them about what is happening to their bodies. If a physician from the very beginning of a patient's downhill course allows that patient to become a partner in the knowledge of what is going on, there is no sudden moment when he has to say, 'well, there is nothing more we can do"; there is no sudden moment when she has to turn to a family and say, 'shall I tell this patient?' Dr. Nuland is trying to share with the reader what is going on with the bodies suffering from the most common causes of death. But the fact is that this book contains medical information that is over twenty years old. The success and validity of the approach is threatened by the use of information that the reader is not able to trust to be the most accurate and thus may not be the most empowering.How We Die gives us a glimpse of an approach that can benefit the dying when put into practice by a medical system equipped with the most up to date information. I need to go right now and reread Sherwin Nuland’s 2007 book The Art of Aging . In the meantime, I am going to give How We Die only two stars: four stars for the concept but one star for being significantly out of date with the implementation data. I hope Nuland’s 2007 book brings his idea successfully into the 21st century.So who is this pessimist about finding a dignified death, this Dr. Nuland? I was surprised to find him on the World Wide Web giving a TED talk about, get this, HOPE! See his twelve minute 2003 talk at http://www.ted.com/talks/sherwin_nula....
This National Book Award winner came out in 1993, but I recently read it after a recommendation by a friend. Dr. Sherwin B. Nuland, the author, who passed away from colon cancer in 2014, combined stories of the difficult illnesses and deaths of family members and patients with the facts of what physically occurs during a fatal illness such as heart disease, stroke, or cancer. His primary point to be made was that people now die more often in a hospital than they do at home and that wishing for a comfortable, spiritual passing at home is pointless because death was intractable and almost always messy and humiliating.At the time, his words made quite a stir, adding to the national dialog that was revving up about how current society views death and deals with it by trying to convince the terminally ill to submit to lengthy and often painful procedures in an effort to extend their lives by a small margin.Having been through the deaths of my parents, my husband, several friends, and younger relatives, I was most taken with the stories Dr. Nuland related out of his own experience. The descriptions of the processes by which people die were less interesting to me because I had already researched most of them. Of course, people did not have access to the bounty of information now available via the internet about those processes and now, thanks to blogging, there is also a multitude of first-person experiences to be had. But in the early 90s, no such comprehensive resources existed, and Dr. Nuland's book provided a frank and somewhat shocking review of what happens during a catastrophic illness. If I had been able to read this in the 1980s and known about it in the 1990s, I'm certain I would have found it both enlightening and a cause for some sorrow.At this time, many terminally ill people are choosing hospice to try to find that 'good death' that Dr. Nuland saw as unachievable in the 80s and 90s. There is no doubt that the debilitation attending a drawn-out death is often messy and frequently painful as well as humiliating, but hospice care does attempt to provide an experience as close to a 'good' death as it is possible to get. And with a growing movement of physician-assisted deaths for terminal patients, some people are finding it possible to pass over without having to go through the most difficult parts of the dying process. I found myself wishing that How We Die could have been updated to address Dr. Nuland's thoughts on these alternatives to a hospital-based prolongation of life.
What do You think about How We Die: Reflections Of Life's Final Chapter (2015)?
Sherwin Nuland, MD, was a well known and successful surgeon at Yale Medical Center for many years. In this book he begins to describe, literally, the way we die. In detail, he explains how infection and cancer and heart disease ravage the body and cause essential systems to fail. As a physician, I found it interesting, but I did not think I would finish the book if that was all there was to it.Then the book began to hold my attention as it developed into an exploration of how people deal with dying, a very different question from how we physically die. Dr. Nuland does a beautiful job with Alzheimer's disease using the slow deterioration of a friend as his example. He helps the reader understand not only the disease, but what the disease process does to the family and friends of the one afflicted. What was most interesting to me as he made his segue into HIV/AIDS, was how his own values as an old time surgeon began to conflict with evolving codes of ethics, patient and family expectations and modern medical practice. After all, while he trained in the era when the doctor and family could collude to keep the true nature of an illness hidden from a patient, he also was part of a generation of surgeons who saw incredible progress in his field. He repeatedly recognizes that modern medicine can go too far, causing and prolonging suffering when treatment is futile, and yet he tells poignant stories about his own close family in which he cannot stop himself from offering that last sliver of hope even if it means risky surgery or incapacitating chemotherapy.He is honest. He admits that sometimes physicians are more interested in solving "The Riddle" of the patient's illness even if diagnostic and treatment efforts are unlikely to help relieve suffering. This type of care and thinking are most often to be found in the academic medical center such as the one in which he worked. Academic physicians have a duty to the patient, but they also have a duty to learn and study. Helping the dying patient to an easy death may not always be their priority. But times are changing. The pendulum has swung from the paternalistic physician who could withhold critical information or pursue treatment regardless of the patient's wishes to the empowered patient who can demand treatment even when it is futile or refuse treatment even when it might be life saving. Nuland recognizes the value of the primary care physician to help guide patients through confusing and complicated medical decisions but he only gives this recognition one sentence. He doesn't trust the empowered patient to make correct decisions. He reserves the right to argue, and he admits to using some unfair tactics to get his way. The physician still has power in the relationship.As a primary care physician I had to cringe as he put his own brother through dangerous and difficult surgery even though the chance of cure was close to zero. He asks himself why, after the fact, but he has no good answer. He didn't want to admit, given all the tools of modern medicine and his own prowess as a surgeon (he did not do the surgery) that nothing could be done to save him. He did not want to give up hope, so instead he held out false hope. This book is very easy to read and understand. Nuland does a great job making complex pathophysiology understandable. Unfortunately he could not get past his own guilt and we spend too much time hearing rationalizations for his aggressive (think academic surgeon) treatment of some of his patients. I recommend the book for those interested in how the body works, or doesn't, and how people think about and react to illness and dying. The section on Alzheimer's disease is excellent and beautifully written. The book also gives insight into the mind of the academic surgeon.And, should you ever be in a life threatening situation where difficult decisions have to be made, if time permits I would also recommend a conversation with your primary care physician. It is good to get more than one opinion.
—Jeffrey
a well-written book. Dr. Nuland writes from years of experience on the topic of death, and how really there is no dignity to it. he explores this myth of 'ars moriendi' (the art of dying) and both the pathophysiology and mental/emotional states that accompany it. he argues against the modern 'hospital' death devoid of feeling, he reproaches biomedicine for it's mistakes in prolonging the lives of their patients for their benefit in solving the Riddle, and not for the patient's best interest... "I have no real quarrell with those who insist upon invoking the laboratory-bred specificity of microscopic pathology in order to satisfy the compulsive demands of the biomedical worldview - I simply think they miss the point." he explores both his mental processes and emotional ones with personal vignettes. he writes with knowledge of pathophysiology, etymology, history, literature and most importantly, humanity. "it is inherent in the art of medicine to appreciate that the testing and medications are of limited usefulness without the talking." "The diginity that we seek in dying must be found in the dignity with which we have lived our lives. Ars moriendi is ars vivendi: the art of dying is the art of living."
—Alexis
How We Die is a sometimes raw look at the different ways we will all face death and End of Life issues. The author, a surgeon, doesn't hold back, even when it means facing his own failings as a doctor and brother (his brother died of colon cancer a few years before the book was written).The Dr. Nuland's discomfort with the vast amount of intervention at the end of life often mirrored my own thoughts and concerns as my convictions on childbirth have migrated to End of Life decisions. “Beyond the medical establishment – and beyond even the capability of one’s own physician, no matter his beneficence – is the power that rightfully belongs to the patient and those who love him.”Sadly, far too often, patients and families are given false hopes. Either they are not given all the information to make these painful decisions, or they take upon themselves the belief that, hope upon hope, the medical establishment can restore their terminal loved one. It is a delicate dance.Not to say I always agreed with the author. He believes that in rare situations terminal patients should be allowed to hasten their own death. No matter how much I sympathize with the suffering of those facing painful deaths, I cannot go that quite that far. I feel similarly about trying to prolong our lives. It was easy enough to skim through the chapters on the main medical illnesses that befall mankind. However, I found that last three chapter’s to be invaluable and would highly recommend everyone to read the book just for the lessons to be learned there. The book is nearly 20 years old, and while some of the medical information is now dated, I feel the basic message is still salient.
—Debbi
