How We Die: Reflections on Life's Final Chapter

by Sherwin B. Nuland

Everywhere in the world, it is illegal to die of old age.

Tennyson says it clearly: “Old men must die; or the world would grow moldy, would only breed the past again.”

There is no dignity in this kind of death. It is an arbitrary act of nature and an affront to the humanity of its victims. If there is wisdom to be found, it must be in the knowledge that human beings are capable of the kind of love and loyalty that transcends not only the physical debasement but even the spiritual weariness of the years of sorrow.

As a confirmed skeptic, I am bound by the conviction that we must not only question all things but be willing to believe that all things are possible. But while the true skeptic can exist happily in a permanent state of agnosticism, some of us have a wish to be convinced.

to establish a general principle; namely, that when the ultimate end is as inevitable as it now appears to be, the individual has a right to ask his doctor to end it for him.”

The room’s overhead illumination had been turned off and the blinds were closed against the glare of midday autumn sunshine, bathing the entire space in a uniformity of subdued daylight.

To imagine extracting a scrap of dignity from this kind of death is beyond the comprehension of most of us. And yet the indignity itself sometimes brings out moments of nobility that overcome for a while the reality of anguish—arising from sources so deep, they can only be marveled at, for they surpass understanding.

A care unit for terminal AIDS patients is peopled by emaciated, wraithlike men and women whose shrunken eyes look dully out from cavernous sockets, their faces often without expression, their bodies wizened with the shriveled frailty of prematurely advanced age. Most are beyond courage. The virus has robbed them of their youth, and it is about to rob them of the rest of their lives.

The summer just passed was rainy, and perhaps for that reason the hills surrounding my friend’s farm have taken on those heartbursting effusions of color that are almost more than my city-bred soul can comprehend or contain.

I resolved during those postoperative days that I would protect my brother from the anguish suffered by those who know there is no hope for cure. In retrospect, I now realize that I was trying to protect myself as well.

Denial protects while it hinders, and softens for a moment what it eventually makes more difficult.

every experienced clinician knows that some patients never, at least overtly, progress beyond denial;

There was something in him that refused the evidence of his senses. The clamor of his wish to live drowned out the pleadings of his wish to know.

Harvey paid a high price for the unfulfilled promise of hope. I had offered him the opportunity to try the impossible, though I knew the trying would be bought at the expense of major suffering.

Though everyone may yearn for a tranquil death, the basic instinct to stay alive is a far more powerful force.

At dinner, he sat at the head of the happy, noisy table and pretended to eat, although he was long past being able to take sufficient food to get proper nourishment. Every two hours during the course of the long evening, he agonizingly dragged himself into the kitchen so that Carolyn might give him a shot of morphine to control his pain.

So it was like the old scenario that so often throws a shadow over the last days of people with cancer: we knew—she knew—we knew she knew—she knew we knew—and none of us would talk about it when we were all together. We kept up the charade to the end. Aunt Rose was deprived and so were we of the coming together that should have been, when we might finally tell her what her life had given us. In this sense, my Aunt Rose died alone.

In her case, a patronizing contempt was the basis on which she convinced herself that her husband’s death would be easier for both of them if it went undiscussed.

Too often near the end, were the doctor able to see deeply within himself, he might recognize that his decisions and advice are motivated by his inability to give up The Riddle and admit defeat as long as there is any chance of solving it,

It is a dignity that proceeds from a life well lived and from the acceptance of one’s own death as a necessary process of nature that permits our species to continue in the form of our own children and the children of others. It is also the recognition that the real event taking place at the end of our life is our death, not the attempts to prevent it.

Every doctor and many laymen can tell of individuals who survived weeks beyond the most extreme expectations in order to have one last Christmas or to await the sight of a dear face arriving from some distant land.

Like other highly talented people, they require constant reassurance of their abilities. To be unsuccessful is to endure a blow to self-image that is poorly tolerated by members of this most egocentric of professions.

Or, having lost the major battle, the doctor may maintain a bit of authority by exerting his influence over the dying process, which he does by controlling its duration and determining the moment at which he allows it to end. In this way, he deprives the patient and family of the control that is rightfully theirs. These days, many hospitalized patients die only when a doctor has decided that the right time has come.

Every time a patient dies, his doctor is reminded that his own and mankind’s control over natural forces is limited and will always remain so. Nature will always win in the end, as it must if our species is to survive.

Nature has a job to do. It does its job by the method that seems most suited to each individual whom its powers have created.

I have had my share of sorrows and my share of triumphs. Sometimes I think I have had far more than my share of both, but that impression probably stems from the inclination we all share, which makes each of us see our own existence as a heightened example of universal experience—a life that is somehow larger than life, and felt more deeply.

The tragedy of a single individual becomes, in the balance of natural things, the triumph of ongoing life.

Hope is definitely not the same thing as optimism. It is not the conviction that something will turn out well, but the certainty that something makes sense, regardless of how it turns out.

“To Study Philosophy Is to Learn to Die”: “The utility of living consists not in the length of days, but in the use of time: a man may have lived long, and yet lived but a little.”

The real truth of healing lies in the nurture.