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.

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.

Presentation on Nuland’s Chapter 4, Doors to Death of the Aged

by poolerm …

This passage essentially describes the process of aging,  and the diseases that come with it which will eventually carry you on.

In this excerpt, I feel that Nuland focuses way too much on what could be classed as the ‘cellular level’ of death. I found that he did not deal in this chapter with the emotional side of the death of an elderly person, and for me, this level of detachment was startling, given that the author himself is a doctor, supposedly a person who is humane and compassionate.

I feel that the main issue raised in this chapter is accepting that ageing is the gateway to death, and raises the question should we push the limits when natural life has begun to fade? He appropriately voices this question in the phrase on page 70 ‘It lies in the power of man, either to permissively to hasten, or actively to shorten, but not to lengthen or extend the limits of his natural life’.

I think this is important because it is saying, in my opinion, that age is a natural process which we must all endure, and death is its final stage. I feel that trying to lengthen the life of an elderly person if the methods used will only cause more pain, or be detrimental in some other way, is pointless. It is trying to fight against nature’s plans for us. Death is an inevitable process, and I think it is ethically wrong to try to extend a person’s (be they elderly or young) life. Life’s natural course has been run, and the priority of physicians, in my opinion, should be to make sure that death occurs with dignity.

I feel that in this chapter, Nuland tries to offer some guidance on the topic of death, and tries to shed some light on the process itself. I think for the best part, he means well, but essentially, he is saying that death can never be the easy, painless affair we all hope for. He says that eventually, we will all be carried off by one of the seven horsemen of death, which include pneumonia. I find this to be quite unsettling, and strange that in certain literary reviews,this book has been recommended for reading by terminal patients. Personally, I think that knowing so much about your death and how it (according to Nuland) probably will be, only increases fear of death.

Nuland also raises the point that death is necessary for the progression of life and our species. The replacement of each generation is a natural process, which ultimately leads to the improvement of our race, as new knowlegde is obtained by new generations, etc. Death is essential for the growth and prosperity of new life.

I know that some of the group found the amount of detail included to be useful and interesting, and while from the point of view of a medical student I do agree, but if you were a lay person reading it the level of detail would put you off. That is one of the things I did not like about this particular extract.

Please feel free to leave your own comments on what you thought about the chapter!!!

And here are some of the points we raised in the discussion, if anyone would like to comment/tweet on those too!!!!


Does advancement in medical sciences make us fear death more?Ignorance is bliss?

Is it wrong for society to sustain life when it’s course has been run?

Should we as doctors prolong treatment when the patient is over 85?

Euthanasia: Should it be allowed or not??

And, if it were legallised, would it be abused by those who were not terminally ill?

Email from Sherwin B Nuland

I found an email address for the great man, and wrote a note to him requesting recommendations for powerful reading. He mistook me for a doctor!

—– Original Message —–

From: sherwin nuland

To: Paul O’Connor

Sent: Thursday, February 03, 2005 4:20 PM

Subject: Re: advice

Dear Dr. O’Connor,

    I’m honored that you would consider me qualified to respond to such a responsibility as the one you’ve assigned. I can only attempt to approach the goal, especially as so many would see it from other angles and directions.

    The passages that continue to inspire me come from such old war-horses as Osler, especially his “Aequanimitas” and “The Master Word in Medicine.” Of the more recent sages, I look to some of the writings of Lewis Thomas. But I still believe that the most meaningful single essay for medical students is the one by Francis Weld Peabody, addressing Harvard medical students in 1927, whe he himself was within months of dying from colon cancer. It’s the one about “the secret of the care of the patient is in caring for the patient,” and I’m sure it’s familiar to you.

    I hope you won’t think me self-serving for suggesting also that you look at the concluding paragraph of my own “Doctors: The Biography of Medicine.”  (1989) It’s a statement of what our calling has meant to me, and is very brief. You may also wish to look at the final 4 paragraphs of the Introduction to that book.   

                      I hope this will be of some help, in providing what may be the most meaningful hour of an entire medical curriculum

                                              My best,

                                       Sherwin Nuland