How We Die

by Sherwin B. Nuland

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 quest to achieve true dignity fails when our bodies fail.

death is not a confrontation. It is simply an event in the sequence of nature’s ongoing rhythms.

The claims of too many laboratory-based doctors to the contrary, medicine will always remain, as the ancient Greeks first dubbed it, an Art. One of the most severe demands that its artistry makes of the physician is that he or she become familiar with the poorly delineated boundary zones between categories of treatment whose chances of success may be classified as certain, probable, possible, or unreasonable. Those unchartable spaces between the probable and everything beyond it are where the thoughtful physician must often wander, with only the accumulated judgment of a life’s experiences to guide the wisdom that must be shared with those who are sick.

William Osler was of two minds about pneumonia in the elderly. In the first of fourteen editions of The Principles and Practice of Medicine, he called it “the special enemy of old age,” but elsewhere he stated something quite different: “Pneumonia may well be called the friend of the aged. Taken off by it in an acute, short, not often painful illness, the old escape those ‘cold gradations of decay’ that make the last stage of all so distressing.”

Those among us who think most clearly about death are usually such as philosophers or poets, not physicians. Nevertheless, there have been a few doctors who understood that death and its aftermath are not beyond the limits of the human condition and are, therefore, worthy of a healer’s attention. Such a one was Thomas Browne, who lived in that extraordinary seventeenth century when the scientific method and inductive reasoning first began to affect the thinking of educated people and made them question the truths so dear to their fathers. In 1643, Browne published a small literary jewel of contemplation, Religio Medici, “The Religion of a Doctor,” which he described as “a private exercise directed to myself.”

If one were to name the universal factor in all death, whether cellular or planetary, it would certainly be loss of oxygen. Dr. Milton Helpern, who was for twenty years the Chief Medical Examiner of New York City, is said to have stated it quite clearly in a single sentence: “Death may be due to a wide variety of diseases and disorders, but in every case the underlying physiological cause is a breakdown in the body’s oxygen cycle.”

Of those so betrayed by their cerebral circulation, William Osler is reported to have said, “These people take as long to die as they did to grow up.”

Of hundreds of known diseases and their predisposing characteristics, some 85 percent of our aging population will succumb to the complications of one of only seven major entities: atherosclerosis, hypertension, adult-onset diabetes, obesity, mental depressing states such as Alzheimer’s and other dementias, cancer, and decreased resistance to infection. Many of those elderly who die will have several of them. And not only that; the personnel of any large hospital’s intensive care unit can confirm the everyday observation that terminally ill people are not infrequently victims of all seven. These seven make up the posse that hunts down and kills the elderly among us. For the vast majority of those of us who live beyond middle age, they are the horsemen of death.

The very old do not succumb to disease—they implode their way into eternity.

There is a vanity in all of this, and it demeans us. At the very least, it brings us no honor. Far from being irreplaceable, we should be replaced. Fantasies of staying the hand of mortality are incompatible with the best interests of our species and the continuity of humankind’s progress. More directly, they are incompatible with the best interests of our very own children. Tennyson says it clearly: “Old men must die; or the world would grow moldy, would only breed the past again.” It is through the eyes of youth that everything is constantly being seen anew and rediscovered with the advantage of knowing what has gone before; it is youth that is not mired in the old ways of approaching the challenges of this imperfect world. Each new generation yearns to prove itself—and, in proving itself, to accomplish great things for humanity. Among living creatures, to die and leave the stage is the way of nature—old age is the preparation for departure, the gradual easing out of life that makes its ending more palatable not only for the elderly but for those also to whom they leave the world in trust.

Pathophysiology is the key to disease. To a physician, the word has connotations that convey both the philosophy and the aesthetic of poetry—not surprisingly, part of its Greek root, physiologia, has a philosophic and poetic meaning: “an inquiry into the nature of things.” When pathos—“suffering” or “disease”—is prefixed to it, we have a literal expression of the essence of the doctor’s quest, which is to make inquiry into the nature of suffering and disease.

“MAN IS AN obligate aerobe”: There, stated with the simple directness of any of the most quoted aphorisms of ancient Hippocrates, stands the secret of human life.

As early as the days of Hippocrates and even before, the ancient Greek physicians had a clear understanding of the ways in which a malignant growth so often pursues its inexorable determination to destroy life. They gave a very specific name to the hard swellings and ulcerations they so commonly saw in the breast or protruding from the rectum or vagina; they based that name on the evidence of their eyes and fingers. To distinguish them from ordinary swellings, which they called oncos, they used the term karkinos, or “crab,” derived, interestingly enough, from an Indo-European root meaning “hard.” Oma being a suffix referring to “tumor,” karkinoma was used to designate a tumorous growth that was malignant. Centuries later, the Latin word for “crab,” cancer, came into common usage. Oncos, meantime, came to be applied to tumors of any kind, which is why we call a cancer specialist an oncologist.

The greatest dignity to be found in death is the dignity of the life that preceded it. This is a form of hope we can all achieve, and it is the most abiding of all. Hope resides in the meaning of what our lives have been.

In one of his Precepts, Hippocrates wrote, “Where love of mankind is, there is also love of the art of medicine,” and that is as true as it has ever been; were it otherwise, the burden of caring for our fellows would soon prove unbearable.

Every scientific or clinical advance carries with it a cultural implication, and often a symbolic one. The invention of the stethoscope in 1816, for example, can be viewed as having set in motion the process by which physicians came to distance themselves from their patients. Such an interpretation of the instrument’s role was, in fact, considered by some medical commentators of the time to be one of its advantages, since not many clinicians, then or now, feel at ease with an ear pressed up against a diseased chest. That and its image as a visible evidence of status remain to this day unspoken reasons for the instrument’s popularity. One need only spend a few hours on rounds with young resident physicians to observe the several roles played by this dangling evidence of authority and detachment.

Medicine’s humility in the face of nature’s power has been lost, and with it has gone some of the moral authority of times past. With the vast increase in scientific knowledge has come a vast decrease in the acknowledgment that we still have control over far less than we would like. Physicians accept the conceit (in every sense of the word) that science has made us all-powerful and therefore the only proper judges of how our skills are to be used. The greater humility that should have come with greater knowledge is instead replaced by medical hubris: Since we can do so much, there is no limit to what should be attempted—today, and for this patient!

We bear more than pain and sorrow when we depart life. Among the heaviest burdens is apt to be regret, which deserves a word at this point. As inevitable as death is and as likely to be preceded by a difficult period, especially for people with cancer, there are additional pieces of baggage we shall all take to the grave, but from which we may somewhat disencumber ourselves if we anticipate them. By these, I mean conflicts unresolved, breached relationships not healed, potential unfulfilled, promises not kept, and years that will never be lived. For virtually every one of us, there will be unfinished business. Only the very old escape it, and even then not always.

To the wise advice that we live every day as though it will be our last, we do well to add the admonition to live every day as though we will be on this earth forever.

The clinical objectivity that should enter into our decisions must come from a doctor familiar with our values and the lives we have led, and not just from the virtual stranger whose superspecialized biomedical skills we have called upon. At such times, it is not the kindness of strangers we need, but the understanding of a longtime medical friend. In whatever way our system of health care is reorganized, good judgment demands that this simple truth be appreciated.

For those who die and those who love them, a realistic expectation is the surest path to tranquillity. When we mourn, it should be the loss of love that makes us grieve, not the guilt that we did something wrong.

The dignity that we seek in dying must be found in the dignity with which we have lived our lives. Ars moriendi is ars vivendi: The art of dying is the art of living. 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 preceded them. Who has lived in dignity, dies in dignity.

William Cullen Bryant was only twenty-seven years old when he added a final section to his contemplation on death, “Thanatopsis,” but he already understood, as poets often do: So live, that when thy summons comes to join The innumerable caravan, which moves To that mysterious realm, where each shall take His chamber in the silent halls of death, Thou go not, like the quarry-slave at night, Scourged to his dungeon, but, sustained and soothed By an unfaltering trust, approach thy grave, Like one who wraps the drapery of his couch About him, and lies down to pleasant dreams.