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.


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”

Irish Times editorial on medicalising death

WHEN IVAN Illich with his stern take on western medicine referred to the medicalisation of death, he touched a troubling sore. Medicine had in a sense lost its soul. It had become fixated with labelling diseases, with the implication that there was a cure for all ills.

Without that cure, medicine had failed and doctors had met the ultimate act of consumer resistance. No longer was death seen as a natural event, one that affects up to 30,000 people in Ireland every year. Society had lost the ability to accept dying and death as meaningful aspects of life and was entering the world of futile treatments and inappropriate resuscitations.

These and other issues will be highlighted at a conference in Dublin in October organised by the Forum on End of Life which is a project of the Irish Hospice Foundation. It will provide an opportunity to take stock of whether Ireland has improved its ability to deal with dying, death and bereavement. Has progress been made, for example, in ensuring that more people have the choice of dying at home rather than in hospitals or nursing homes? A national audit on end-of-life care in hospitals showed that about 25 per cent of them could if there were proper supports.

Participants may also scrutinise whether there have been sufficient advances in ending inequalities in the distribution of hospice care, and whether the Government will follow through with a five-year framework for palliative care. It will be hard for the Department of Health to gainsay persuasive evidence that increasing palliative care provision is not only better for patients and their families, it can be cost neutral or save money.

The funeral industry – where the forum’s national council has been seeking reform – also merits public discussion. In Dublin the average funeral costs €5,000, leading to suggestions of insufficient competitiveness between undertakers. Despite many good operators, an unregulated industry fails to inspire confidence. The forum has urged the Government to set up an office to regulate the sector, with frequent inspections of facilities and enforcement of mandatory training for funeral personnel. It is wrong that embalming, for example, can be carried out without training.

However, some advances in how Ireland deals with death have to be noted. The new children’s palliative care programme, the primary care-palliative care initiative, the Final Journeys project and the new ethical framework for end of life care, are all helping to ensure that more of us will have a good death.

Conference on arts and health, Royal Irish Academy 15-16 June

A major international conference with an arts in healthcare theme is to be held in June 2011 at the Royal Irish Academy, Dublin. Anyone with an interest in this important aspect of healthcare systems is invited to attend.

The conference, entitled Narratives of Health and Illness across the Lifespan, is organised by the National Centre for Arts and Health and is among the many academic activities marking the Tercentenary of the Trinity College Dublin Medical School. It is sponsored by the Meath Foundation.

This major international conference reflects the vitality of arts in health programmes at AMNCH and beyond, as well as featuring experts on medical humanities and arts therapies.

One of the highlights of the conference is the first public performance of composer Ian Wilson’s new work, Bewitched, which he made as part of an Arts Council funded residency in the stroke service at AMNCH.

Full details of the conference and registration can be found at

Group art workshop with Mark Storor

From Guardian: Director Mark Storor oversees rehearsals of For the Best in Liverpool. Photograph:Christopher Thomond for the Guardian

Let’s say you have an opportunity (o, joy!) to work with a bunch of people (children, adults, students, patients, friends, colleagues … whatever) who have the time and energy and the will to do something creative/imaginitive/artistic together, for fun and whatever else may come out of it; irrespective of what medium you plan to work in, how you plan to proceed, what you want to achieve, it seems like a good first step in the process to enable as much creativity, collaboration and flow of imagination as possible.

Mark Storor, whose work is often in a healthcare setting in hospitals and with patients, facilitated a workshop (organised by Helium and hosted at Red Rua South Dublin Arts Centre by Tallaght Community Arts) with us this morning to indicate how one might get such a group working together, using their imaginations, exploring their ideas and experiences of the world and selves, utilising their abilities, unfettering their creative energies.

This is not art as therapy, but art as a creative activity for its own sake, and the importance of being faithful to the process and where it takes you. With unfortunately limited time, Mark took us on a brief but wonder-filled and energised but calm journey through some of the steps that he uses with all the groups he works with in getting the process going:

The workshop started with a circle of people around a circle of newspapers and a wild story of shipwrecked strangers being spun around us by Mark, which involved taking away another outer layer of newspapers with each traumatic event and thereby the group having to fit onto a smaller and smaller area of paper, eventually squeezing right up into as tight a space as we could (lighter barefoot people standing on bigger booted people’s feet) in order to all survive on a raft being circled by sharks while waiting for a helicopter to lift us to safety (including sound effects). Great fun & best ice-breaker I’ve come across, but also drawing attention to some facinating aspects of collaboration and metaphors of the contexts in which people get the opportunity to discover things about themselves when challenged.

The next phase was to lie on our backs, eyes closed, while Mark led us on a mind’s-eye journey around our body, from toe to head, asking us to “see” & sense each part of it. Then, without opening our eyes, we each had to sit up & draw an image of our body on a blank page. We then sat around in a circle (eyes open again) and discussed the body images as art (not therapy): how different people approached the problem of not being able to see what marks the pencil was making; how different people emphasised or left out different elements (e.g. they were ALL drawn naked, as far as one could tell).

Next was to answer a series of questions about how we see/IMAGINE ourselves (what kind of colour, animal, plant, furniture, building? etc.). We then each positioned our body on a large area of paper in whatever shape we wished, and one of the others drew an outline around us onto the paper in a colour of our own choosing. We each then worked alone for a while at filling in that outline of our body with some kind of visual repsentation of the answers that we’d put down to the initial questions. We then sat around & discussed the “portraits” from a purely art perspective (NO THERAPY!) to see what themes & modes & media might then have been developed further by the group in the next stages of working together (although in this instance, because of time constraints, there were not going to be any next stages, unfortunately).

I think the next stages would have led us to work closer and closer together on common and more refined themes until eventually something with some artistic coherence might have emerged that could (with the help of someone like Mark) be shaped into something exciting & beautiful & satisfying … for us at least, if not for others.

I am exhilarated, helium-filled, by the experience, and for that thank Helene, Tony, Mark and all the participants I had the pleasure of working with briefly in the group. Here’s to being fluffy and beyond the Pale! Go, Mark, go!