TitleHow We Die
AuthorSherwin B. Nuland
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How We Die

Sherwin B. Nuland
Page xvi

We compose scenarios that we yearn to see enacted by our mortally ill beloved, and the performances are successful just often enough to sustain our expectations. Faith in the possibility of such a scenario has ever been a tradition of Western societies, which in centuries past valued a good death as the salvation of the soul and an uplifting experience for friends and family and celebrated it in the literature and pictorial representations of ars moriendi, the art of dying. Originally, ars moriendi was a religious and spiritual endeavor, described by the fifteenth-century printer William Caxton as 'the craft for to deye for the helthe of mannes sowle.' In time, it evolved into the concept of the beautiful death, truly the correct way to die. But ars moriendi is nowadays made difficult by the very fact of our attempts at concealing and sanitizing—and especially preventing—which result in the kinds of deathbed scenes that occur in such specialized hiding places as intensive care units, oncology research facilities, and emergency rooms. The good death has increasingly become a myth. Actualy, it has always been for the most part a myth, but never as much as today. The chief ingredient of the myth is the longed-for ideal of 'death with dignity'.

Page xvii

I tried to make clear to her that 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.

Page 3

Every life is different from any that has gone before it, and so is every death. The uniqueness of each of us extends even to the way we die. Though most people know that various diseases carry us to our final hours by various paths, only very few comprehend the fullness of that endless multitude of ways by which the final forces of the human spirit can separate themselves from the body. Every one of death's diverse appearances is as distinctive as that singular face we each show the world during the days of life. Every man will yield up the ghost in a manner that the heavens have never known before: every woman will go her final way in her own way.

Page 10

But the 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 approahced withe 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, an perhaps spiritual, nonexistence from which we emerged at conception.

Page 39

It [heart failure] and pulmonary edema are by far the most common cardiac enemies that are perpetually being fought in the intensive care units and emergency rooms. The patients and their medical allies will win most of those battles, at least temporarily.

Having countless times watched those teams fighting their furious skirmishes, and having often been a participant or their leader in years past, I can testify to the paradoxical partnering of human grief and grim clinical determination to win that actuates the urgencies swarming through the mind of every impassioned combatant. The tumultuous commotion of the whole reflects more than the sum of its parts, and yet the frenzied work gets done and sometimes even succeeds.

Page 41

The tenacious young men and women see their patient's pupils become unresponsive to light and then widen until they are large fixed circles of impenetrable blackness.

Page 42

The experience of dying does not belong to the heart alone. It is a process in which every tissue of the body partakes, each by its own means and at its own pace. The operative word here is process, not act, moment, or any other term connoting a flyspeck of time when the spirit departs. In previous generations, the end of the faltering heartbeat was taken to indicate the end of life, as though the abrupt silence beyond it intoned a soundless signal of finality. It was a specified instant, recordable in the chronicle of life and marking a full stop after its concluding word.

Today the law defines death, with approproate blurriness, as the cessation of brain function. Though the heart may still throb and the unknowing bone marrow create new cells, no man's history can outlive his brain. The brain dies gradually, just as Irv Lipsiner experienced it. Gradually, too, every other cell in the body dies, including those newly alive in the marrow. The sequence of events by which tissues and organs gradually yield up their vital forces in the hours before and after the officially pronounced death are the true biological mechanisms of dying.

Page 52

The maximal rate attainable by a perfectly healthy heart falls by one beat every year, a figure so reliable that it can be determined by subtracting age from 220.

Page 121-122

Clinical death is often preceded (or its first evidences are accompanid) by a barely more than momentary period termed the agonal phase. The adjective agonal is used by clinicians to describe the visible events that take place when life is in the act of extricating itself from protoplasm too compromised to sustain it any longer. Like its etymological twin, agony, the word derives from the Greek agon, denoting a struggle. We speak of 'death agonies,' even though the dying person is too far gone to be aware of them, and even though much of what occurs is due simply to muscle spasm induced by the blood's terminal acidity. Agonal moments and the entire sequence of events of which they are a part can occur in all the forms of death, whether sudden or following upon a long period of decline into terminal illness, as in cancer.

The apparent struggles of the agonal moments are like some violent outburst of protest arising deep in the primitive unconscious, raging against the too-hasty departure of the spirit; no matter its preparation by even months of antecedent illness, the body often seems reluctant to agree to the divorce. In the ultimate agonal moments, the rapid onset of final oblivion is accompanied either by the cessation of breathing or by a short series of great heaving gasps; on rare occasions, there may be other movements as well, such as the violent tightening of James McCarty's laryngeal muscles into a terrifying bark.

Page 155

The Dutch Reformed Church has adopted a policy, described in its publication Euthanasie en Pastoraat—'Euthanasia and the Ministry'—that does not obstruct the voluntary ending of life when illness makes it intolerable. Their very choice of words signifies the churchmen's sensitivity to the difference between this and ordinary suicide, or zelfmoord, literally 'self-murder.' A new term has been introduced to refer to death under circumstances of euthanasia: zelfdoding, which might best be translated as 'self-deathing.'

Page 162

In matters touching on death, the clinical and the moral are never so far apart that we can look at one without seeing the other.

Page 226

There was no likelihood of guidance, or even understanding, from Harvey's doctors, who had by then shown themselves to be untouchably aloof and self-absorbed. They seemed too distanced from the truth of their own emotions to have any sense of ours. As I watched them strutting importantly from room to room on their cursory rounds, I would find myself feeling almost grateful for the tragedies in my life that had helped me to be unlike them.