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.


‘If I want to die, why can’t I do so with dignity?’

“Since Marie and I have made the decision for her to end her own life when the pain becomes too much, we have been offered a second lease of life. Now we can live life again knowing that Marie will not have to die an undignified death. We get on with life — it is like an insurance policy. I know I will probably get into a lot of trouble if I do help her. If the time does come, the choice is hers, not mine. She may make up her mind or she may never make her mind. She may die quickly without any pain. In that case, we will not have to decide.”

Tom says he is kept going in this movement by knowing that freedom of choice is an important aspect of being a human being. “I am sure most families have been touched by a person dying of a painful illness, and it is a horrific experience for everyone involved. Now people want a choice.” (Examiner) >

The treatment doctors choose when given a terminal diagnosis

British medics share their reaction to Ken Murray’s essay on the treatment doctors choose when given a terminal diagnosis.

But some UK medical professionals feel Murray’s concern about futile treatments is amplified by the US medical system. Kevin Fong, a consultant anaesthetist, thinks that Murray’s characterisation of futile care is far too black-and-white: “It’s very difficult to define futility because that implies certainty; and certainty in medicine is very difficult to come by.”

“It’s a topic that isn’t talked about very often, and should be,” agrees Dr Clodagh Murphy, another GP, who practises in Northern Ireland. “Most people think there’s nothing worse than death – but we know that there is. That’s why it’s so difficult when you see an elderly patient with cancer; their natural instinct is to go for treatment, and you must respect that – but at the same time, you’re thinking, ‘So now you’re going to have an operation with a six-month recovery period, which might make the last three years of your life even more hellish than if you’d let the illness take its course.’ (Guardian) >

‘Giant’ put on display wanted burial at sea

A PROMINENT medical ethicist has called for the skeleton of Charles Byrne, the “Irish giant”, which has been displayed at the Royal College of Surgeons in London for almost 200 years, to be buried at sea.

Writing in the Christmas issue of the British Medical Journal , Prof Len Doyal, emeritus professor of medical ethics at the University of London, and Thomas Muinzer, of the school of law at Queen’s University Belfast, say it is not too late to grant Byrne’s wish to be sealed in a lead coffin and buried at sea. (Times) >

Skrabanek and McCormick on criticism

‘Because of its social function, medicine relies on authority and dogma, and those who threaten its beliefs are likely to branded nihilists, iconoclasts, or worse… The reaction of the medical profession to criticism sometimes seems to have an almost paranoid quality… The fact that these achievements [tackling mortality and morbidity in the West] have had little or no bearing on the lives of all those millions of our fellows which are still ‘nasty, poor, brutish, solitary and short’ ( Hobbes, Leviathan) is an indictment of our selfish world.

‘The collection which we have compiled may give the false impression that doctors are at best charlatans and at worst rogues, and that medicine is itself a major threat to health. Medicine only becomes a threat to health if it remains untempered by the use of rational inquiry and criticism. Such criticism is an important and relatively neglected task.’ (Follies and Fallacies in Medicine, p. 143.)

It’s time for an earlier introduction to ethics

In an increasingly multicultural and secular environment, which continues to undergo rapid change, it is crucial that formal education and training in the methods of ethical and moral reasoning and analysis be provided as early as possible in the education system. My experience up to and including third level was a dearth of such input. Talks with recent graduates and teaching staff suggest not much has changed.

Common topics of ethical concern include contraception, abortion, euthanasia, stem-cell research, in vitro fertilisation and recently, the conflict between Church and State with regard to the handling of child sexual abuse cases and the status of the seal of confession. There is also an evolving philosophical movement that concerns itself with future possibilities in science that are likely to generate new ethical challenges.

There have been a number of initiatives aimed at broadening discussion on ethical issues. The Irish Council for Bioethics, for example, produced a number of important reports and hosted debates on a range of topics including human enhancement. Unfortunately, it ceased operation in 2010 as a consequence of a Government decision to discontinue funding. (Times) >>>

Physicians should be less intimidating, survey finds

[From Irish Times >>>] DOCTORS NEED to dress down rather than in fancy suits to avoid intimidating patients and to communicate properly with them. They also need to let patients see them wash their hands, Minister for Health James Reilly has said.

He also said a communication module should be part of every medical professional’s training and part of “continuing professional development”.

Speaking at the launch of the largest-ever survey of patients receiving in-patient hospital treatment, Dr Reilly expressed his disappointment at the figures for healthcare staff washing their hands and for communicating with patients.

The survey found that just under 60 per cent of patients said hospital staff always washed their hands before treating them. It also revealed that almost 40 per cent of patients surveyed felt staff did not encourage them to voice their opinion or ask questions about their treatment and 62 per cent were unaware that there was a hospital complaints procedure.

The survey found 8 per cent of patients had to wait more than a year for their treatment. However, the survey showed 96 per cent of patients felt they had been treated with dignity and respect and a similar proportion trusted the hospital staff in charge of their care.

More than 5,000 patients who received in-patient treatment in 25 public and voluntary hospitals answered the questionnaire.

“A strategy will have to be put in place to ensure that doctors do wash their hands,” Dr Reilly said. He will talk to the HSE about an initiative where “at least a half a day is spent every six months inculcating people in the need for hand hygiene and how they communicate with patients”.

He said the evidence showed it would be far better and patients would be less intimidated if “doctors didn’t wear suits into the clinical area, if they wore short-sleeved shirts and didn’t wear a tie, and obviously wash their hands in between patients”.

Dr Reilly said healthcare staff conveyed messages all the time. “Any time a patient sees a member of a healthcare team wash their hands prior to carrying out an examination on them, what’s communicated to them is professional care. Any time they don’t see that, the message that’s sent is one of sloppy, unsafe practice.”

Asked afterwards about concerns that patients still treated their doctors like gods, Dr Reilly said while a number of colleges had communication training, all doctors do not. This should be uniform throughout” colleges and part of continuing development “so that people are maintaining their skills in terms of how they communicate with patients”.

He warned that “if the communication isn’t clear, confusion ensues and where there’s confusion, there can be chaos and catastrophe”.

Dr Hilary Dunne, chief executive of the Irish Society for Quality and Safety in Healthcare, which conducted the survey, said the most important finding was that 95 per cent of patients felt they were treated with dignity and respect. “If you’re treated with dignity and respect while you’re in hospital you are 17 times more likely to be satisfied overall.”

A numbers game …

By now a thesis might be emerging: that the classic, one-to-one model of treatment that makes the doctor so important a figure in an individual’s life, and gives her such rich and fascinating access to private narratives, and has raised her up on a pedestal of sorts in the eyes of the privileged people of the Western world, is in some ways a moral grey area.  It puts the needs of the one above those of the many to an extreme. And so, while so much time & money is spent in that model of healthcare in the West, there are millions of people in the “majority world” dying every year because of the neglect that arises as a result, whose (clearly, “less important”) lives could be saved if even a fraction of the money, medicines and manpower that we put into our systems were diverted to them.

Next week, in our final session, we will see the two forces (the needs of the one versus those of the many) played out dramatically in the story of Valentino Achak Deng as fictionalised by Dave Eggers in his novel What is the What? I am thrilled that Colman Farrell, CEO of Suas, will be joining us to hear Niall’s presentation and chat about his own experience of some of the issues raised.

In the papers

Doctor’s treatment ‘appalling’, mother tells court > When he put to Ms McGillin that the final decision on the medication was hers, she said: “Someone has to take responsibility for what happened to my daughter”. >> Independent

Surgeon with HIV seeking damages > Among claims in the case is that absence of mandatory screening of hospital patients for HIV exposed the surgeon to a risk of harm. >> Irish Times

Oscar the cat predicts 50 deaths in nursing home > Dr Dosa suggests that Oscar is able to detect chemical changes that accompany death >>Independent

Brain-injured patient’s thoughts ‘read’ by scanner > Dr Adrian Owen, assistant director of the Medical Research Council’s cognition and brain sciences unit at ­Cambridge University, believed that the patients who responded in the study were probably “perfectly consciously aware”, although he knew others would disagree >>Guardian