How We Die (Sherwin Nuland)
OVERVIEW
Sherwin Nuland was a Clinical Professor of Surgery at Yale University until his retirement at almost 80. “How We Die: Reflections on Life’s Final Chapter” is a medical exploration of… well, how we die. At a physiological level, how we die of heart disease, stroke, old age, Alzheimer’s, cancer, infection, etc. How the heart responds to lack of oxygen; how it tries to cope and how it fails. The biochemical and intracellular changes that accompany aging; how things wear down, stiffen, and lose functionality. What it’s like to drown, be murdered, commit suicide, or have a stroke. And why? Nuland believes that:
Only by frank discussion of the very details of dying can we best deal with those aspects that frighten us the most. It is by knowing the truth and being prepared for it that we rid ourselves of that fear of the terra incognita of death that leads to self-deception and disillusions.
But in addition to exploring how our cells, tissues, organs, and bodies eventually die, three accessory themes underscore the book:
1. Death is not an enemy
2. Death is almost always undignified. There is no “dignity in death.”
3. Death is necessary
Death is not an enemy
Like so many works that would succeed “How We Die,” (Atul Gawande’s “Being Mortal” comes instantly to mind), Nuland assures us that dying is not a disease that can be cured.
Death is not a confrontation. It is simply an event in the sequence of nature’s ongoing rhythms. Not death but disease is the real enemy, disease the malign force that requires confrontation. […] Even the confrontation with disease should be approached with the realization that many of the sicknesses of our species are simply conveyances for the inexorable journey by which each of us is returned to the same state of physical, and perhaps spiritual, nonexistence from which we emerged at conception. Every triumph over some major pathology, no matter how ringing the victory, is only a reprieve from the inevitable end.
Nuland invites us to embrace this so that when our lives reach terminal velocity, we can be thoughtful and honest in our end-of-life decisions – choosing whether to prolong aggressive treatments; realistically examining the pros and cons of intervention; carefully considering how we’d most like to live our final days, and frankly assessing whether the offered medical interventions increase or decrease the likelihood of achieving this reality.
Death is undignified
While many a physician-turned-author will tell you that medicine sometimes goes too far, what they likely won’t say is that “death with dignity” is an unrealistic hope and a source of misery for patients and families. “The quest to achieve true dignity fails when our bodies fail,” and only in very rare circumstances does death with dignity occur. Much more frequently, “the belief in the probability of death with dignity is our, and society’s, attempt to deal with the reality of what is all too frequently a series of destructive events that involve by their very nature the disintegration of the dying person’s humanity.” Dying may not be tranquil, peaceful, quiet, or controlled. Dying may be messy, loud, painful, and anguished; physically and mentally distressing. Life does not divorce easily. Like Sallie Tisdale, Nuland is highly skeptical of the “good death” and instead, like Tisdale, invites us to be realistic. “If peace and dignity are what we delude ourselves to expect, most of us will die wondering what we, or our doctors, have done wrong.” Instead, on dignity, Nuland offers that “the greatest dignity to be found in death is the dignity of the life that preceded it.”
Death is necessary
It’s natural for things to wear out and be replaced. Homo sapiens exists inside an ecosystem, and the health of that ecosystem relies on death – that infirmity, debility, ideas, and biases are replaced. Immortality would rob humanity of its best future. As Montaigne said, “give place to others, as others have given place to you.” While this may not be comforting to everyone, it is comforting to me. To be reminded that my life was purchased at the expensive of trillions and trillions of deaths, and that when my time comes, I must also make way for new life. I doubt this is any solace to those facing “untimely” death, but if I project myself into a future where I am old and used up, it is.
WHAT NOW? (actions for mortal atheists)
Discover dying
If you’re not completely overcome at even the thought, it is helpful to read about the process of dying. In addition to “How To Die,” David Kessler’s “The Needs of the Dying” is a good resource. I agree with Nuland that “demythologizing” dying removes some degree of terror – that understanding the biological and clinical reality of the process can relieve some fear (if only just fear of the unknown). In the same vein, I’d recommend Caitlin Doughty’s “Smoke Gets In Your Eyes” for getting more comfortable with death.
Make peace with an unpeaceful end
In learning more about how we die, I think it’s inevitable that we discover how hard it is to die. Even if the final moment amounts to nothing more than slipping away, it’s likely that the weeks or months preceding that moment were punctuated with pain and distress. Nuland’s gift is to set realistic expectations, so that we don’t find ourselves (or our family) feeling like we’re “doing it wrong.” I hope that if my dying involves a gradual, fraught, and undignified decline, I’ll remember Nuland’s consolation: this is normal.
IN SUM:
Is this book entirely secular? No.
If you had to describe the book in one sentence? A physiological examination of how we die.
Who should read this book? Anyone who agrees with Nuland that it’s “better to know what dying is like, and better to make choices that are most likely to avert the worst of it.”