How We Die: Reflections on Life's Final Chapter

How We Die: Reflections on Life's Final Chapter



The Pequod Review:

Sherwin Nuland's How We Die is an honest and candid account of what the last days of our lives are really like. Nuland dispenses with happy platitudes and wishful thinking, and faces this often messy event head on:

The book you are about to read was conceived with no other plan in mind than that of conversing with people who want to know what it is like to die... to demythologize the process of dying. My intention is not to depict it as a horror-filled sequence of painful and disgusting degradations, but to present it in its biological and clinical reality, as seen by those who experience it. Only by a frank discussion of the very details of dying can we best deal with those aspects that frighten us the most. It is by knowing the truth and being prepared for it that we rid ourselves of that fear of the terra incognito of death that leads to self-deception and disillusions.

Drawing on his own experiences as a surgeon, Nuland describes in vivid detail the various ways that humans die. He focuses on the most representative causes of death — heart disease, cancer, diabetes, etc. — and shows that it is often a savage and undignified experience: 

A specific sequence of events takes place in people who bleed to death. At first, they will usually hyperventilate, which is the body's compensatory attempt to saturate the decreasing volume of circulating blood with as much oxygen as possible; the heart rate will speed up for the same reason. As more blood volume is lost, the pressure in the vessels begins to fall rapidly and the coronary arteries receive less and less of it. Were an electrocardiogram to be running, it would show evidence of myocardia ischemia; the ischemia causes slowing of the poorly oxygenated heart. When the blood pressure and pulse rate become low enough, the brain ceases to receive enough oxygen and glucose, and unconsciousness ensues, preceding brain death. Finally, the ischemic heart slows to a stop, usually without any fibrillation. With the stilling of the heartbeat, circulation is arrested, breathing ceases, there are a few atonal events, and clinical death has occurred. when a vessel the size of the carotid artery has been cut wide open, the entire sequence can take less than a minute.


A cancer cell does not engage in some of the more complicated metabolic activities of mature nonmalignant tissue. A cancer cell of the intestine, for example, doesn't help out in digestion as its adult counterpart does; a cancer cell of the lung is uninvolved in the process of respiration; the same is true of almost all other malignancies. Malignant cells concentrate their energies on reproduction rather than in partaking in the missions a tissue must carry out in order for the life of the organism to go on. The bastard offspring of their hyperactive (albeit asexual) "fornicating" are without the resources to do anything but cause trouble and burden the hardworking community around them. Like their progenitors, they are reproductive but not productive. As individuals, they victimize a sedate, conforming society.

Nuland's goal isn't to just offer a brutal retelling of his experiences witnessing death; instead, he wants us to understand that "death with dignity" is often an impossible desire and that end-of-life treatments often merely prolong the agony: 

The belief in the probability of death with dignity is our, and society’s, attempt to deal with the reality of what is all too frequently a series of destructive events that involve by their very nature the disintegration of the dying person’s humanity. I have not often seen much dignity in the process by which we die... The honesty and grace of the years of life that are ending is the real measure of how we die. It is not in the last weeks or days that we compose the message that will be remembered, but in all the decades that proceeded them. Who has lived in dignity, dies in dignity.


Mine is not the first voice to suggest that as patients, as families, and even as doctors, we need to find hope in other ways, more realistic ways, than in the pursuit of elusive and danger-filled cures. In the care of advanced disease, whether cancer or some other determined killer, hope should be redefined. Some of my sickest patients have taught me of the varieties of hope that can come when death is certain. I wish I could report that there were many such people, but there have, in fact, been few. Almost everyone seems to want to take a chance with the slim statistics that oncologists give to patients with advanced disease. Usually they suffer for it, and they die anyway, having magnified the burdens they and those who love them must carry to the final moments. Though everyone may yearn for a tranquil death, the basic instinct to stay alive is a far more powerful force...

[T]he fact is, death is not a confrontation. It is simply an event in the sequence of nature's ongoing rhythms. Not death but disease is the real enemy, disease the malign force that requires confrontation. Death is the surcease that comes when the exhausting battle has been lost. Even the confrontation with disease should be approached with the realization that many of the sicknesses of our species are simply conveyances for the inexorable journey by which each of us is returned to the same state of physical, and perhaps spiritual, nonexistence from which we emerged at conception. Every triumph over some major pathology, no matter how ringing the victory, is only a reprieve from the inevitable end.

Despite its subject matter, How We Die is ultimately a sensitive and humane book that aims to make our terminal years as painless as possible. ("A 'good death' is only a relative thing, and what it really means is decreasing the mess.") It is only by being honest with ourselves that we may be able to achieve some measure of this.