Thoughts on Sherwin B Nuland’s How We Die

(by Jamie Peoples, first-year medical student, TCD)

–          From the start, the author sets out in stark terms the threat posed by stroke – 1/3 die, 1/3 left severely disabled

–          Engages reader by opening with a personal account stroke and it’s risk factors – “sedentary Jewish ladies”

–          Alludes to articles purpose – discussion of how elderly people die- “risk is 30x as great”

–          Discusses mechanics of stroke – defines as “deficit in neurologic function resulting from a decrease in blood flow through some specific artery supplying the brain” – “completion of atherosclerotic process” – “embolus (propelled up) into the brain plugging an already compromised vessel” … Here he invites the reader to see the common thread between stroke and many other causes of death – Ischemia – NYC chief Med. Ex. “every case …the underlying physiological cause is a breakdown in the body’s oxygen cycle.”

–          Occlusive stroke contrasted with haemorrhagic stroke- 40% mortality, ¼ of all strokes, with elderly cases typically due to hypertension

–          Importance of oxygen to the brain – Neuronal sensitivity to Ischemia – “within 15 to 30 minutes of the onset of deprivation” irreversible destructive changes begin

–          Cerebrovascular diseases make up range of commonest killers of elderly

–          Disagreement between (in general) statisticians/ lab-based doctors vs. Author and geriatricians – does life have its natural limits, beyond which people die even without disease/accident?

–          Dr Leo Cooney “ we wish to improve Q.of.Life, not prolong its duration”

–          Evidence from elaborate studies suggest “aging process goes on”

–          Author argues for appropriateness of classifying “Death form old age”

–          Frequent references throughout literary history suggest humanity’s longstanding awareness of this state of affairs e.g. Homer:  “As one generation flourishes, another decays,” Thomas Jefferson: “When we have lived our generation out, we should not wish to encroach on another.”

–          Process of replacement evidently is necessary in nature

–          Mechanism is currently unknown, though two main theories are “Wear and Tear” and “Genetic Tape.”

–          Former postulates that continual progressive damage to cells and organs by toxins, pollutants, microbes etc (or random DNA transmission errors) results in the cell being less able to transmit DNA to its daughter cells.

–          Latter proposes that aging process is dictated by genetic factors, laying out a “sequential program” which progressively shuts down necessary physiological functions, which perhaps occur at different rates in different individuals.

–          Genetic tape argument strengthened by Hayflick’s research, demonstrating orderly process of cell death in fibroblast cells. Also, humorous reference to “picking the right parents” alludes to a statistically significant correlation between parent and child age of mortality.

–          Various other factors also suggested, e.g. Lipofuscin, hormonal changes, cross linking of collagen etc. Apoptosis could also play role, and its process of initiation translation into protein of the myc gene is suggestive of an analogous “Death gene” with a wider remit

–          85% of aging population die of 1 out of 7 conditions : Decreased resistance to infection, mentally depressing states like Alzheimer’s + dementia, hypertension, atherosclerosis, adult onset diabetes, obesity or cancer

–          Frequently more than one factor is present at time of death, and the author personally asserts that these conditions are commonly seen by pathologists.

–          The author conducted research into 23 patients dying after the age of 84, and reports that he observed common failings & overall deterioration which amounted to a loss of vitality occasioned by starvation and suffocation of the tissues (common thread of atherosclerosis, either cardiac or cerebral.)

–          Author comments that death among the elderly is not a result of discreet disease but rather the inevitable consequence of a “progression called aging.”

–          Author hypothesizes there may be a common cause for all these interrelated conditions, and envisions the hypothalamus, which allows adaptation to environment by metabolically regulating  growth and development, could cause eventual aging

–          We are presented with a clinical circumstance, in which we are invited to question whether or not intervention should be attempted if the patient has underlying non-fatal, but possibly related condition. Author suggests examining various rates and extent of progression is desirable for the best outcome.

–          Author hypothesizes that life has a finite length therefore, of around 100-110 years, which is our species-dependent lifespan. Though life expectancy has increase, the author contends that maximum possible life expectancy has remained constant at this level, for example citing the oldest confirmed human being 114 years old.

–          Different apparent maximum lifespans in different species appear to be inversely proportional to the number of offspring, with the longer time for offspring to mature a potential factor in human longevity.

–          Desire to prolong life is evident throughout history, a mission characterised by the author as “those who persist in seeking the fountain of youth.”  HOWEVER author maintains that we should be replaced as part of the natural order “eyes of youth (allows for)…everything constantly being seen anew.” Tennyson is evoked to further this point: “old men must die; or the world would grow mouldy and would only breed the past again.”

–          In the author’s opinion, we should not attempt to persist beyond our given time, because the author feels this places an unacceptable emotional burden on relatives and financial burden on public resources.

–          Moreover, for the author, it is life’s very finiteness which gives impetus to attempt rewarding endeavours, and believes the natural order gives the framework necessary to evaluate our relationship with the generations which follow us

–          Closing his article with a quotation from the French social philosopher Michel de Montaigne (“the utility of living consists not in the length of days but in the use of time”), the author invites us to the conclusion that knowledge of life’s end is what confers the value of time and life.