Student notes on Sherwin B Nuland How We Die extract

(by allanj)

First of all, I have chosen to look at the main themes and issues in this chapter. There are two main themes, the first is mortality and the second is the link between aging and death. Mortality is the theme which is constantly present throughout the chapter. The author uses a quote from Francis Quarles to emphasize this, ‘It lies in the power of man either permissively to hasten or actively to shorten, but not to lengthen or extend the limits of his natural life.’ He uses a personal experience to show us that everyone must die, using the example of his grandmother who died from a stroke. He tells us that her death was much the same as a lot of other people’s and ‘hardly unique’. He shows us that death happens to everyone, ‘it carried off James McCarty, it carried off my Bubbeh’.

When he speaks about mortality, there is a lack of sympathy from him. I believe that he uses the example of his grandmother to show us his humanity, because he himself has suffered through the death of someone close to him. I don’t think this attempt was successful however, or sufficient, as he still comes across as very unsympathetic. I researched who James McCarty was, as he is mentioned twice in the piece. I discovered that he was the author’s first patient, a fifty-two year old man who died of a heart attack while beside the author. As he died, he ‘roared’ out to the author, who did nothing, but realised after that McCarty was asking him to desist what was happening. He suggests later in the chapter that we should ‘eschew every bit of McCarty-like behaviour’ which shows his lack of sympathy towards the dying man looking for help and also comes across as quite judgemental of him. It is apparent from the chapter that the author himself is about the same age as James McCarty, if not older, so you would expect him to have a little more sympathy for the man.

He believes that everyone should die and should not try to prevent death. He includes a quote from Thomas Jefferson, ‘There is a ripeness of time for death, regarding others as well as ourselves, when it is reasonable as we should drop off and make room for another growth. When we have lived our generation out, we should not wish to encroach on another.’ His opinion is that it is older people’s duty to die as they should, and allow the younger generations to take over, ‘Old men must die, or the world would grow moldy, would only breed the past again.’ He says that the people who are researching gene therapy or growth hormone are faced with people who are hoping that these break-throughs will result in an extension of life span. ‘The lesson is
never learned-there will always be those who persist in seeking the fountain of youth’. He even goes as far as to say that wishing for a longer life span ‘demeans us’.

The second theme that is very prominent is the link between aging and dying. One quote which illustrates this theme is a quote from ‘a wise old lady’ who said ‘death keeps taking little bits of me’. He believes that death will occur regardless of disease, but with the presence of disease, death comes faster, ‘Aging may be said to be both independent and co-dependent in the sense that it certainly contributes to disease and may in turn be accelerated by it. But disease or no disease, the body continues to get older.’ He also believes that there is very little that can be done for an old person when they come in to a hospital. He asks us what should be done, if an old man presents with cancer. Should we treat him with debilitating chemotherapy only for him to die of something else a year later? Regarding treating old people, he says ‘Hope must always prove to be unjustified.’ In the end, they will die, of something, regardless of what they are in hospital for. This is a very true statement from him, but a negative and irrelevant one. You could also say that about a two month old baby who comes in with a disease, so his argument is unjustified.

I found that the author’s tone throughout the chapter was often very gleeful when talking about causes of death. He uses personification of the diseases, which I think gives him the tone of glee. He uses phrases such as ‘marauding power’, ‘of those so betrayed by their cerebral circulation’ and ‘suffocating the tissues of its victim.’ When speaking about pneumonia, he says ‘Pneumonia’s blitzkrieg has yet another way to kill- its putrid headquarters in the lung serves as a focus from which the murderous organisms can enter the bloodstream.’ I think he uses this personification to show us that it would be better to die. There are pages and pages in the chapter in which he simply describes the horrifying diseases and what they do to your body. He always describes the ‘worst case scenario’ making any illness seem horrific, to make us think that it would be preferable to die than to go through any of them ourselves. However, he is so gleeful when describing these diseases, it makes me think he could be exaggerating to emphasize his point, ‘If the stroke is extensive enough or if further complications ensue, such as decreased blood pressure or cardiac output due to failure or arrhythmia, recovery is prevented and the area of ischemia may actually increase. If it becomes large enough, the brain tissue begins to swell. Being compressed in the unyielding confines of the skull, a swollen brain is further damaged by being pushed up against its covering membranes and bony encasement, and part of it may actually be forced down through a fold in those membranes…….’ He always talks about the worst case scenario of all of these diseases, and tells us all the ‘gory’ details, which is why I think he has a gleeful tone.

He speaks quite critically of doctors, and their approach to treating geriatric diseases. He says that in the case of his grandmother, and because she died of two of the most common causes of death; stroke and pneumonia, while doctors read this chapter, ‘they may claim, her mode of death supports their worldview and argues for vigorous intervention to treat the named pathologies in order to prolong life. To me this is more sophistry than science.’ He is criticising even his medical readers, and patronisingly assuming he knows what they are thinking and criticises any who would disagree with him. He is concerned that doctors become ‘absorbed by the riddle of disease’ and want to solve the problem rather than do what is best for the patient and the hospital. However, he contradicts himself by saying, ‘The diagnosis of disease and the quest for overcoming it with his intellect are the challenges that motivate every specialist who is good at what he does.’ If a specialist is good, because he wants to solve the riddle of disease, then does that mean he wants not good doctors treating geriatric patients, because they have no motivation to solve the problem and will let the patients die? However, he then calls the doctors who know when to stop treating older patients ‘wise physicians,’ again contradicting himself.

His writing style at times is quite hard to follow. He jumps from one topic to another, and back again with no warning. For example, he opens talking about strokes and his grandmother. He describes strokes in detail, and the reader believes he has moved on Alzheimer’s disease, when he jumps back to talking about strokes. This happens in several different instances throughout the chapter, making it difficult to find any clear structure in the chapter, and at times, hard to follow his train of thought.

He is also hugely confident in his writing style, almost over confident, nearly forcing his opinions on his readers. He has an entire paragraph of questions beginning with, ‘Can there be any doubt…..?’ regarding to the points he has just made. He uses subtleties of language, such as the word ‘fortunately’ when telling us about the doctors that he agrees with, and ‘unfortunately’ when speaking about people who he disagrees with. There is an air of confidence throughout the whole chapter, leaving you less likely to question his ideas.

There is a small amount of humour throughout the chapter, which I believe he uses to lighten the dark descriptions of debilitating diseases he uses, as well as his pessimism of old age. For example, he tells us that ‘the bets assurance of longevity is to choose the right mother and father.’

Overall, I liked the themes and issues he chose to write about, mortality, aging and death. I disliked the tone with which he wrote about these themes, at times patronising and over confident. I liked hearing his perspective on geriatric doctors and what the right thing to do is involving elderly patients. I would like to read the rest of the piece, but I would read it critically, rather than believing it word for word, due to the apparent joy he takes in other people’s misery and his over confidence.

Images of illness on the web

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Dan Batson’s empathy-altruism hypothesis ‘claims that empathic concern (other-oriented emotion felt for someone in need—sympathy, compassion, tenderness, and the like) produces altruistic motivation (a motivational state with the ultimate goal of increasing the other’s welfare)’.

Mental illness – smashing the stigma

“While I was in the hospital getting well again, I met a number of people who didn’t have a single visitor during those long weeks. One lady confided that she had told her children she was away on holiday. Another person said he had told friends and family that he was off on a business trip.”

“Like me, they were very sick and were trying to get better but they had to go through this ordeal without any support. They were terrified of the stigma and the shame if news got around that they were receiving treatment for a mental illness. I can’t imagine how hard that must have been for them, to be in such a dark place and to be so alone.” (Irish >

Death is just as natural as life: thoughts on Sherwin B Nuland’s ‘How we die’

(by doylej15)

1.    The Author

  • Retired American Gastric Surgeon
  • Graduate of Yale University. Still teaches bioethics and history of medicine there.
  • Written quite a books, How we die being one of the most well-known.
  • A bit of a modern philosopher.

2. The book

  • In this book “How we die” he does literally go into the various ways in which how elderly people die but also not so much in this chapter how his grandmother whom he calls ‘bubbeh’ (grandmother in Jewish) and was obviously very close too, dies.
  • I later found out that he shared a room with his grandmum till he was 19 and she was in her 90s, and would be interested in reading about how he describes her journey to death and how it affected him because he seems to write very open and sincerely.
  • I found it an appealing read and was pleased to see that someone had put so much thought into this subject, the subject of dying.
  • As people going into the medical profession, it’s clearly a very significant subject and he talks about it in a natural way. This is refreshing to hear and I think as doctors he wants us and we should aspire to be able to confront the subject as he does.

3. How we die

  • He describes in detail the main ways in which the elderly die. He backs up his writing with statistics and illustrates the pathophysiology well. At times it has a danger of sounding like a text book but there are plenty of anecdotes which livens up the piece.
  • He talks about the two proposed theories of aging. The ‘Wear and Tear’ theory which emphasizes the progressive damage done to your body just by carrying out everyday functions. And the ‘genetic tape’ theory which proposes that ageing is determined by your genetic predisposition, the length of one’s life is already fixed and that the tape begins to run at the instant of contraception.
  • He supplements this with a nice quote from a 17th century figure Quarles who says ‘’It lies in the power of man, either permissively to hasten, or actively shorten his natural life.’’ Pg 70
  • This is where Nuland tries to make the point that life accomplishments make up in quality what life lacks in quantity.
  • Page 87 has a fantastic paragraph where Nuland is reflecting on this and says “When it is accepted that there are clearly defined limits to life, then life will be seen to have a symmetry as well. …The fact that there is a limited time to do the rewarding things in our lives is what creates the urgency to do them. Otherwise, we might stagnate in procrastination.”
  • He also leaves the best quote in my opinion to last, Montaigne- “The utility of living consists not in the length of days, but in the use of time; a man may have lived long, yet but lived but a little.”  It makes me think that as people in the medical profession, our initial reaction to someone dying is to try and keep them alive but we have no idea how ready they are to die. We don’t know if they are willing to go through suffering to cling on to life for a bit longer.
  • I think Nuland wants us to recognise that if we are reaching the limits of our natural life that the quality not quantity of our last days is in the doctors and patients priority.
  • He quotes his school professor of geriatric medicine Dr Cooney pg 71. He seems to hold geriatricians in very high regard because he sees them as the solution to the problem of the old family doctor who, in his words, knew his patients as well as he did his diseases.

4. Why we die

  • Nuland also questions why we die.
  • At first it seems like a stupid question and we brush it off, but if we actually try answering it, it is difficult and he discusses it very well. Using quotes from Homer *pg 73 and Thomas Jefferson  he makes us appreciate that again death is just as natural as life.

5.    Conclusion.

  • Another reason I enjoyed the text is because it got me thinking about death and what is would feel like and the journey towards it. It also got me thinking about euthanasia and whether our laws are correct in Ireland. Maybe we hesitate to pass such laws as we are afraid they will lead to more extreme laws.
  • So it was a thought provoking text and for that reason alone it is a worthwhile piece of writing and I could definitely see myself coming back to read the book at some point.
  • I’ll finish with a quote from Nuland which I think sums up want he wanted us to take from this chapter, it’s a quote taken from an interview with Yale Alumni magazine and he says “At the end, it is not the kindness of strangers we need, rather, it is the understanding of a long-time medical friend.” I think the ‘strangers’ are the surgeons, the pulmonologists rushing to dying elderly persons side to treat exactly what their blinkered view sees as wrong with them. The long-time family friend is the geriatrician who although may have only have met the person 2 weeks ago, has really known them for much longer.

Des O’Neill on how Molière’s satire can remind us of limitations of medicine

Medicine’s inadequacy was literature’s gain, as Molière found fantastic material for satire in these doctors, who feature in a major way in seven of his 36 plays. The material is wonderfully droll, the highest point in a lineage of medical satire that stretches from the Roman playwright Plautus, through Shaw’s Doctor’s Dilemma to the ever-entertaining Dr Hibbert in The Simpsons and Dr Kelso in Scrubs.

On the one hand, knockabout comedy – such as the vision of Lully in l’Amour Médecin , with an enema syringe in his hand, chasing a Molière who was hiding his backside with a hat around the stage – but on the other hand, his plays also give deep consideration of the fallibility of medicine, our retreat to rituals, and our habit to seek too much certainty in the future. (Times) >

Continue reading “Des O’Neill on how Molière’s satire can remind us of limitations of medicine”

Sylvia Thompson of Irish Times on Narratives of Health and Illness across the Lifespan conference

The idea of a patient being abandoned in a hospital system that is increasingly complex in terms of specialisations, technology and bureaucracy isn’t as ludicrous as it might seem initially. And, this conference showed how the introduction of the arts into healthcare settings and medical education can ease a patient’s journey in myriad ways.

Spiegel spoke about how she uses film, literary texts and reflective writing practices to cultivate the art of listening among medical students.

“An ill person needs a space to get things said and to ask questions,” she said. “This requires self-awareness among doctors and writing is an enormous resource to help them gain access to their own experiences.”

At the conference, she set everyone the task of writing for three minutes about one of their personal scars and then sharing what they had written with the person beside them.

“Talented writers should write about childbirth and stillbirth because their writing helps us understand our experiences,” said Prof Patricia Crowley from the Department of Obstetrics and Gynaecology at Trinity College Dublin (TCD). She spoke about how important it is for medical students to see their patients’ whole lives and relationships and not just their medical conditions.

“We need our sensitivities reviewed, our preconceptions challenged and our imaginations expanded and fiction writing helps us to do that,” she said.

Dr Amanda Piesse from the Department of English at TCD gave some beautiful examples of how children’s picture books tackle themes of ageing and death. Books such as Babette Cole’s Drop Dead , John Burningham’s Granpa and Peter Dickinson’s The Gift Boat examine relationships between grandparents and grandchildren with magical sensitivity. (Times) >>>

Continue reading “Sylvia Thompson of Irish Times on Narratives of Health and Illness across the Lifespan conference”