How do you decide when to give up the fight and focus on making the time you have left meaningful? Nuland, M. We should disabuse ourselves of the notion that there are definite physical or emotional symptoms which can predict with certainty that further hope of recovery is in vain. But in spite of the absence of such fool-proof substantiation of futility, there nevertheless are certain kinds of strongly suggestive evidence that almost always appear, as we are approaching the point where good sense urges that the struggle be discontinued. As time and treatment evolve in the late stages of a disease, there will come a point when our bodies begin to tell us that the benefit of the therapeutic method being used is proving itself to be less than has been predicted by the doctors. A variant of this situation is the recognition that the added suffering caused by the treatment is not justified by its meagre results.

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Like the Victorians with their hypocritical fascination with sex - that could not be talked about - Death is our modern taboo. This book is probably the best panacea for that widespread self-deception. Several chapters describe the major threats that are likely to kill most of us.

None-the-less, readers can learn to be braver and age with dignity, from reading this rare book. No one will escape the endings described here in exquisite detail by a compassionate and knowledgeable physician and teacher, unless killed by accident earlier or by suicide although these too are covered. Ignoring this information will not mean that you escape these exit-paths but doing so will result in you encountering a dreadful surprise. INTRODUCTION This short book pages nominally explores the common modes of dying in the modern era but it is also a deeply felt philosophical investigation of a poetical and empathetic medical practitioner, who has been haunted by death since his mother died of intestinal cancer when he was eleven years old.

This is the most personal of my reviews and essays, because I share some of my personal experiences and reactions to death in my life. He specialized in the history of medicine, medicine and bioethics. He was the author of over ten books, including this one that won the National Book Award for Non-fiction in and spent 34 weeks on the New York Times best-seller list. He changed his name to avoid anti-Semitic discrimination and to ensure college admission. His excellent memory helped him gain admission to the prestigious Bronx High School of Science.

He married twice and had four children two from each marriage ; one daughter Victoria became the U. Sherwin gave a very well received TED talk in , where he admitted to his spell with depression linked to his divorce and his cure using electroshock. He died on March 3, aged 84 at his home in Connecticut of prostate cancer. Nuland begins this superb book with some personal, philosophical musings on Death, claiming that everyone wants to know the details of dying but few are willing to say so, even though death remains a hidden secret to most people.

He remarks that none of us seems psychologically able to cope with the thought of our own death. He contrasts this with those traditions in Western societies that valued a "Good Death" achieved through the "Art of Dying". He admits that the good death has increasingly become a myth; sadly, even the longed-for ideal of "death with dignity" is becoming rarer.

He freely admits that he wrote this book to demythologize the process of dying by discussing it, in its biological and clinical reality. He hopes that these truthful descriptions will help readers prepare for the inevitable. As a historian of medicine, he artfully weaves in a few insightful snippets like the awful deaths less than years earlier, such as choking to death from diphtheria, the wild delirium of scarlet fever and the crazy convulsions of meningitis.

Although there is much here that covers the personal medical experiences of Dr. Nuland, he has deliberately sought out the medical opinions of several colleagues in the Yale-New Haven Hospital to confirm the accuracy of the information presented.

These chapters reflect the so-called "Survival Rule of Threes" that summarize the essential survival factors in extreme conditions. Their ranking illustrate the priority of our Survival Systems; they are presented in how long an average adult can survive when a critical input is absent: 3 minutes without air; 3 days without water; 3 weeks without food.

In the s, 4. All the regular medical staff had just been called away for a polio emergency when the man yelled out in extreme pain, clutching his chest, breathed once and died. This was in the s when not only was there no Crash-Cart to electrically stimulate the heart but external cardiopulmonary resuscitation CPR had not yet been invented, so poor Nuland had to resort for his first time to the then standard method of direct heart massage by slicing open the chest and manually squeezing the still fibrillating heart until a final whole body spasm ended the agony.

Nuland then offers a clinical explanation of the fatality. So, here he goes into the phenomenon of arteriosclerosis the hardening and narrowing of the coronary arteries that deliver oxygenated blood to the muscles of the heart - myocardium. This condition is mainly due to cigarette smoking, bad diet and lack of exercise. Many doctors still believe the theory that this condition is directly caused by an excess of cholesterol - a theory I reject as this molecule is one of the major productions of a normal liver for its numerous uses throughout the body.

This theory relies on the presence of blocking plaques consisting mainly of this substance. These plaques may wander all over the body but are usually found in the arteries of the heart and brain, where they are called strokes.

The immediate effect is a local lack of blood to the local tissues - this is medically called ischemia and it occurs almost anywhere in the body, such as the calf muscle where it is called a charley horse but in the heart the pain is medically called angina pectoris. Fortunately, when the heart is finally failing there is insufficient oxygen being picked up as it flows through the lungs, so the patient loses consciousness before all brain activity ceases.

In , there were about 42 million people who had survived a stroke, with about 7 million ischemic strokes per year and 3. Brain tissue ceases to function when deprived of oxygen for more than one minute. Each year, the U. This reflects the western intellectual tradition of assigning names to everything, even to phenomena we know little about. Nuland knows personally that many have just "worn out": a truth that was universally well-known, before modern medicine arrived. The most frequent cause of death for those over 85 is atherosclerosis and then infection.

He describes the slow decline of this beloved grandmother from congestive heart failure; now recognizing that this decline was aggravated by the reduced oxygen levels produced by her aged lung tissue. Woefully, the elasticity of our bladders diminish with age, so there arises more frequent bathroom visits while many unfortunates suffer from incontinence with age.

We can ignore the lower quality of our skin but our slowing brain is hard to dismiss. The brain is a major consumer of oxygen, reflecting its central role in our lives, but each of its trillions of neurons, like most cells in our body, do not replace themselves. Eventually, too many cells die off in their organs that are then inadequate to play their role in keeping the whole organism going, until one of the vital ones falls below its homeostatic minimum and fails, killing the whole organism.

Even the immune system is not immune to failing over time, so very old people often die of diseases they might easily have survived when younger - thus, no one ever dies of aging. This is particularly so for lung infections. Pneumonia is usually caused by bacteria, viruses and rarely other micro-organisms, such as fungi and parasites.

The commonest symptoms include dry cough no mucus , chest pain, fever and breathing difficulties. A bacterial infection can be treated with an antibiotic, oxygen may be given to help with breathing. There are a wide range of viruses that threaten the lungs, such as influenza virus, rhinoviruses, coronaviruses, parainfluenza and respiratory syncytial virus RSV. In developing countries and also among the very old, the very young and the chronically ill, pneumonia remains a leading cause of death often in the ICU.

This occurs when any toxic organism fungus, virus, bacteria, parasite infects the blood to the extent that it threatens the viability of a major organ. It is deadly and the third most frequent cause of death today one in five. There are often symptoms related to a specific infection, such as a cough with pneumonia or painful urination with a kidney infection.

This becomes critical when the blood pressure becomes too low, due to sepsis, and does not improve with fluid replacement: a condition known as Septic Shock. Sepsis requires immediate hospital treatment with intravenous fluids and antimicrobials.

Ongoing care often continues in an Intensive Care Unit ICU ; sometimes special medications are needed to raise blood pressure to counter toxic shock. In severe cases, mechanical ventilation and dialysis may be needed to support the function of the lungs and kidneys. Sepsis affected about 50 million people in with 11 million deaths. About 3 people per thousand are affected by sepsis in the developed world; rates of disease have been increasing: males are more susceptible than females.

Today, in North America, the staphylococci bacteria are believed to cause more than half the cases of sepsis, with the lungs being the major originating site. The early phase of sepsis is characterized by excessive inflammation often caused by a cytokine storm with a prolonged period of decreased function of the immune system: either of these phases may prove fatal. Nuland begins with a frank and personal story of the destruction of one of his oldest friends, who was stricken with this curse in his fifties.

Medicine now knows what happens to the stricken victim but has yet to trace it to a primary cause, which is not an automatic result of aging but is suspected of having a genetic component.

This plague continues to expand over time, so it endangers the health system and perhaps the nation. Sadly, there are no cures, so most victims finally die of starvation 3 to 9 years after diagnosis - a grim way to go.

Nuland summarizes the history of this disease since its first report in and the microscopic discovery in by Alois Alzheimer of characteristic plaques always found in the autopsies. Subsequently, these were found to be tangles of neuronal axons, clustered around a rare protein beta- amyloid. It seems that most victims may now be readily diagnosed without awaiting for autopsies. Nuland is obviously deeply disturbed by this formidable disease and admits that there is never any dignity in its related death.

Since most our bodies are made of fragile or weak tissues then violent changes to them may critically damage or disrupt their necessary inter-connections.

These acts of violence may occur at any age but statistics show they happen to the young more than others. The desire for novelty and adventure often lead youth taking more risks with unpleasant results with a cavalier disregard for numbers and wise advice.

The first American automobile fatality was a 68 year man killed by a passing automobile in New York City in Since then over 3 million Americans have died of motor vehicle injuries, with alcohol being involved in over half the deaths.

He reminds us that the number of firearm deaths in the USA is seven times those for the UK and most American suicides are also by guns. Sometimes, suicide is rational, as in the famous death in by gunshot of Percy Bridgeman, Harvard professor of physics and Nobel prizewinner, when he was in the final stages of incurable cancer at age Probably, this is the last day I will be able to do it myself. This leads to the subject of medically assisted suicide that Canada has agreed to when the victim is suffering from an incurable disease.

I agree that no doctor must be made to participate in this act, so fast painless poisons, like cyanide should be made available through designated pharmacists. In rational societies, like the Netherlands and Switzerland, euthanasia has become acceptable under stringent guidelines. The usual method is for the physician to induce deep sleep with barbiturates and then to inject a muscle-paralyzing chemical to cause cessation of breathing or stopping the heart. Nuland does give a quick summary of alternatives, such as barbiturates, heroin now fentanyl and arsenic describing the biological mechanisms involved; there are many toxic plants for the avid gardener.

I also suspect because it is not a likely death for most readers here, as its victims in North America are mainly male homosexuals and intravenous drug users, so it might be classified as a form of suicide but by in the Northeast of the USA, AIDS had become the leading killer of men between 25 and This disease has a most unusual profile: sometimes, it can take 8 to 10 years from initial infection to when the AIDS symptoms become critical but then they can be so dramatic that the victim dies within 2 years.

Nuland begins this chapter describing the final 18 months of one of his patients Ishmael from the time of his first positive blood test for HIV. Only a year later did this IV drug user begin showing a worsening dry cough, followed by fever and a shortness of breath. A chest X-ray confirmed that his lungs had been totally infected, so that his oxygen levels in his blood were abnormally low.

This was due to one of the common forms of pneumonia, caused by a parasite pneumocystis carinii that is almost never a problem when one has a functioning immune system. This virus integrates itself into the DNA of the CD4 lymphocyte white blood cell - the mainstay component in our immune system.

Once there, it finally kills too many of these cells that destroys the immune system. The virus can also hide in several other cells and also mutates extensively, defeating the usual vaccine strategy and an army of over possible drugs tested against it. The only one that showed promise was a very expensive, anti-cancer drug known as AZT that could decrease the frequency of opportunistic infections.

Initially, there was an international scandal with blood contaminated by infected blood donors - this was finally cleaned up in Surprisingly, HIV is a disease of low contagion, often needing multiple exposures but once acquired it is always fatal.


Sherwin B. Nuland

Sherwin B. Nuland in He was The cause was prostate cancer, his daughter Amelia Nuland said. To Dr.


Sherwin B. Nuland, Author of ‘How We Die,’ Is Dead at 83

Like the Victorians with their hypocritical fascination with sex - that could not be talked about - Death is our modern taboo. This book is probably the best panacea for that widespread self-deception. Several chapters describe the major threats that are likely to kill most of us. None-the-less, readers can learn to be braver and age with dignity, from reading this rare book. No one will escape the endings described here in exquisite detail by a compassionate and knowledgeable physician and teacher, unless killed by accident earlier or by suicide although these too are covered.


Sherwin Nuland



How We Die: Reflections of Life's Final Chapter


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