4.19

3

Jan 02, 2008

When I log on to my Goodreads home page I always see many notices saying things like

Brainiac the Magnificent is now friends with Death By Radiation

Is This Catching? is now friends with My Mother Has Turned Blue

Tiny Little Aardvark is now friends with The Biker who Eats Babies

The Seventeenth Beatle is now friends with Barkybarkywoofwoof

But really, that's got nothing whatsover to do with how we die. At least, I don't think so. Unless these are all the names of angels.

As regards the book itself, When I log on to my Goodreads home page I always see many notices saying things like

Brainiac the Magnificent is now friends with Death By Radiation

Is This Catching? is now friends with My Mother Has Turned Blue

Tiny Little Aardvark is now friends with The Biker who Eats Babies

The Seventeenth Beatle is now friends with Barkybarkywoofwoof

But really, that's got nothing whatsover to do with how we die. At least, I don't think so. Unless these are all the names of angels.

As regards the book itself, since I sold my copy via Amazon to some geezer in Salt Lake City years ago, I can't remember much about it, so I'm just kind of busking here. This is a bad review. Talking just to be talking, you know. Because I'm reading some long books right now & it'll be ages before I can say anything about those.

But that makes me wonder.

Because, how we die on Goodreads is .... we suddenly stop responding to messages... stop adding books ... never finish another "currently reading".... no, it's too awful to contemplate. Our partners (if book geeks actually have partners) would never bother logging into our GR account and posting "It is with deep regret that we announce the passing of Barkybarkywoofwoof from cirrhosis of the liver with complications, no flowers please".

Man visits his doctor. Doctor says "I've got some bad news, and I'm afraid I've got some even worse news." Guys says "Okay, I'll have the even worse news first." Doctor says "Okay, you have terminal cancer. The other news is that you also have Alzheimer's." Guy takes a deep breath and says "Okay - well, at least I haven't got terminal cancer."
...more

4

Sep 24, 2010

On the back of "How We Die" Doris Lessing writes it's a must read for anyone over 50. I say anyone over 35. Because you might still have time then to internalise all the dying lessons Dr. Nuland has to teach, and you're past those forever twenties.

We've got three score and ten years and most of that could be healthy, but after that, the remainder of our body life is borrowed and breaking down. Towards that end, Dr. Nuland urges us to measure quality of life against mechanical extensions of On the back of "How We Die" Doris Lessing writes it's a must read for anyone over 50. I say anyone over 35. Because you might still have time then to internalise all the dying lessons Dr. Nuland has to teach, and you're past those forever twenties.

We've got three score and ten years and most of that could be healthy, but after that, the remainder of our body life is borrowed and breaking down. Towards that end, Dr. Nuland urges us to measure quality of life against mechanical extensions of life, value peace of mind over medical miracles (because your surgeon sure as hell won't), and hold our connections with loved ones above everything. Live your life well, he says, because the end will probably not be pretty, and you want the people around you to remember everything else.

Chapter by morbid chapter, and with intimate compassion and poetry, Dr. Nuland charts the major ways we die, all of which have to do with failures of oxygen supply, one way or another: heart attacks and strokes, old age, suicide, murder, accident, Alzheimers, AIDS and other viruses, cancer. The title alone was enough to give me (and everyone around me) pause, when I pulled the book out in public.

We should all learn as much as we can about our bodies, their strengths, and their inevitable failings. It will help us deal more gracefully, or at least more knowingly, with the end. This book is as good a place as any to start. ...more

4

Sep 05, 2007

This book is an attempt by the author, a surgeon, to de-mystify the process of death. He feels that our modern expectation of a "death with dignity" leads to increased suffering when we confront the ugly reality: most people don't experience a peaceful, pain-free death; they don't die at home surrounded by their loved ones; they don't utter profound last words of comfort to those they leave behind.

He offers detailed, technical descriptions of the most common mechanisms of death, including vivid, This book is an attempt by the author, a surgeon, to de-mystify the process of death. He feels that our modern expectation of a "death with dignity" leads to increased suffering when we confront the ugly reality: most people don't experience a peaceful, pain-free death; they don't die at home surrounded by their loved ones; they don't utter profound last words of comfort to those they leave behind.

He offers detailed, technical descriptions of the most common mechanisms of death, including vivid, disturbing details of the various indignities experienced by the dying. He enhances his narrative with deeply moving stories of the end-of-life experiences of his own patients, friends and family members.

Alongside the medical details and anecdotes the author waxes philosophical. He talks about the need for the old to die so that the young can prosper. He is appreciative of modern medicine's ability to improve and prolong life, but he expresses concern that a doctor's drive to diagnose and cure can override his duty to provide the most appropriate care when the end of his patient's life becomes inevitable.

The book was published in 1993 but only seems out of date in the anguished chapter on AIDS.

I was entranced by the technical details and moved to tears by some of the author's personal stories, but his philosophical musings seemed a bit repetitive after a while. Overall a very good book, 4.5 stars. ...more

4

Dec 23, 2012

I felt compelled to reread HOW WE DIE, starting with the chapters on Cancer, after my wife passed away from an aggressive form of breast cancer. Doctor Nuland is right on when he talks about how the specialists, for whom a disease such as cancer becomes a great riddle to solve, somehow withdraw from the patient's presence when the disease they are trying to interdict cannot be stopped with the assortment of chemo drugs and radiation therapy they have in their tool box. Yes, tool box seems like I felt compelled to reread HOW WE DIE, starting with the chapters on Cancer, after my wife passed away from an aggressive form of breast cancer. Doctor Nuland is right on when he talks about how the specialists, for whom a disease such as cancer becomes a great riddle to solve, somehow withdraw from the patient's presence when the disease they are trying to interdict cannot be stopped with the assortment of chemo drugs and radiation therapy they have in their tool box. Yes, tool box seems like an appropriate metaphor because chemo therapy with the way it devastates the body gives the whole process of treatment a clunky rattling sense to it. Even in the best of treatment centers with the caring technicians, nurses and doctors, the process of getting well is not very pretty, doling out its share of suffering and pain. Doctor Nuland knows this only too well and his sensitive prose explores that point in such treatment when it is best to start exploring other options, such as hospice care. I must say, however, that my wife's oncologists were caring and sensitive, while she was the subject of their attempts to find the right chemo drugs to slow down, and even beat back for a time, the relentless onslaught of an aggressive, triple negative tumor. It was after she was released and returned home, to die shortly after the last treatment at the cancer center, that the oncologists seem to lose interest. Dr. Nuland talks at length about the moment when the specialists pack up their tool kits and it becomes time for the generalists, the GP's and the hospice care nurses and therapists to work their compassion and relieve the pain that the disease has wrought. It is in this arena that Doctor Nuland's humanity and compassion shines through. ...more

5

Oct 12, 2013

If you are alive, and might someday die, or know anyone who is alive and might someday
die, this might be one of those books you have to read. It takes the piss out of heroics,
and science, and the Dignified Death; it harshly regards the coldness of medical personnel dedicated to solving what
the author calls the Riddle and ignoring the needs of the person that provides it. He is hard on doctors, and hard on himself. Some books please, some entertain, some disappoint. Few,though, change you, and If you are alive, and might someday die, or know anyone who is alive and might someday
die, this might be one of those books you have to read. It takes the piss out of heroics,
and science, and the Dignified Death; it harshly regards the coldness of medical personnel dedicated to solving what
the author calls the Riddle and ignoring the needs of the person that provides it. He is hard on doctors, and hard on himself. Some books please, some entertain, some disappoint. Few,though, change you, and this is one of them. It came at a time when I needed it, when I was
in the process of losing a dear family member. It made me value her life more and, also, my own.
...more

4

Jun 25, 2017

It's hard not to compare this to Kalanithi's When Breath Becomes Air. Like Kalanithi, Nuland is a surgeon who has written a book exploring themes/ideas surrounding death. Nuland's account is a lot less personal; for one, he didn't experience dying as he wrote the text. His inspiration for writing was not his own mortality but rather the result of decades upon decades of watching his own patients suffer through the so-called "hidden" process of dying. Nuland explores the more common ways that It's hard not to compare this to Kalanithi's When Breath Becomes Air. Like Kalanithi, Nuland is a surgeon who has written a book exploring themes/ideas surrounding death. Nuland's account is a lot less personal; for one, he didn't experience dying as he wrote the text. His inspiration for writing was not his own mortality but rather the result of decades upon decades of watching his own patients suffer through the so-called "hidden" process of dying. Nuland explores the more common ways that most Americans die in his account, explaining the many possible processes of dying in scientific terms while also weaving in his personal experience and insight.

One thing I really liked was how Nuland pointed out how attitudes toward death have changed with the advents of modern medicine, how physicians today focus more on achieving victory in indivudalized cases rather than accepting death as inevitable. Not that this is necessarily a bad thing, but an consequence of this is that death has become more concealed from society, so to speak. Since we have the technology to stave off death longer and longer, physicians and society in general have a need to "hide" the process of dying in the cases where they fail to slow it, decreasing the frequency of their visits to patients once it's clear that they don't have much time left. This is a pretty stark contrast to the 19th century, where it was the norm for people to drop dead like flies, often in the comforts of their own homes. Doctors then focused more on helping patients die in a comfortable, dignified manner rather than try to combat death in the first place. Most people today still want their long-term dying process to be dignified, but Nuland points out that this often isn't the case, relating a memory where a man with Alzheimer's had to be cleaned of his own feces the year he died.

Nuland's conclusion that we try to have the best death possible by living the best life possible might seem unsatisfactory, but this is ultimately the most that anyone can hope for in the wildly unpredictable process of death. ...more

4

Sep 15, 2019

“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.
Cancer cells do
“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.
Cancer cells do not even have the decency to die when they should. All nature recognizes that death is the final step in the process of normal maturation. Malignant cells don’t reach that point—their longevity is not finite.”

Excerpt From
How We Die
Sherwin B. Nuland

This book is full of difficult subject matter on end of life causes and it won the National Book Award for Non-Fiction some 25 years ago.

Although this read feels dated today, since both cancer treatments and treatment of HIV have progressed significantly, the conclusions about awareness of end of life decisions and hospice are still spot on.

The author, Stewart Nuland, who has since passed away from prostrate cancer was the head of the Yale Medical School. He suffered from mental depression. I don’t know if he wrote this book in a dark place but although it is science based, it is also brutally frank about the pain and discomfort that most dying patients face in their last days and months.

4 stars. Very informative book that is both enlightening and sobering. Best read when in the right place emotionally. ...more

2

Dec 25, 2012

My Dad is ninety-three. I bought this book to share with him some time ago as we have been grappling with the Inevitably of Death for some time now. He is relatively healthy and he has always counted on living at least until ninety-six, the age his father died. But this past year his sharp mind has begun to notice his body lagging somewhat. He likes to have his “four wheeler” to help him get around and dozes more frequently sitting in his chair. “Maybe I won’t make it to ninety-six,” he says.

I My Dad is ninety-three. I bought this book to share with him some time ago as we have been grappling with the Inevitably of Death for some time now. He is relatively healthy and he has always counted on living at least until ninety-six, the age his father died. But this past year his sharp mind has begun to notice his body lagging somewhat. He likes to have his “four wheeler” to help him get around and dozes more frequently sitting in his chair. “Maybe I won’t make it to ninety-six,” he says.

I travel from Virginia to Michigan to visit him in his assisted living facility every six to eight weeks. He devoured How We Die: Reflections on Life’s Final Chapter in several days during one of my visits last year. But I had never read it until now.

This 1993 book is over twenty years old and with the medical advances in that time you might think that makes this book out of date. But that is not completely true. For example, the book states that “coronary heart disease is America’s number one killer, as it is in every industrialized country of the world.” This is still the case today. In 1993, stroke was the third leading cause of death; today it ranks fourth. The life expectancy (all races, both sexes) was 75.5 years in 1993 and 78.7 years in 2010. (Source: http://www.infoplease.com/ipa/A000514...) This 4.2% increase in longevity, while a significant change in when we die, does not, I think, change how we die. I will speak more of the out-of-date factor at the end of the review.

We sometimes laugh about death and dying. I think that is a good sign. It shouldn’t scare us to death, if I can use that phrase. My Dad and I have laughed about it as well as talking about his Living Will and DNR order. Here is something from a GR review that shows how we joke about death:
Man visits his doctor. Doctor says “I’ve got some bad news, and I’m afraid I’ve got some even worse news.” Guy says “Okay, I’ll have the even worse news first.” Doctor says “Okay, you have terminal cancer. The other news is that you also have Alzheimer’s.” Guy takes a deep breath and says “Okay – well, at least I haven’t got terminal cancer.”
It is January 2014 and singer Pete Seeger has just died at the age of 94. One report is that he died of “natural causes.” You do not hear that very often; it seems we are not allowed to officially die of simple old age. “He was just chopping wood last week,” we are told. And we are pleased to hear that.

Everyone wants a dignified death. But author, Dr. Sherwin Nuland, is not much of a believer in death with dignity, thinking from his experience that it “should not be expected by any but a very few people.” He says at the outset, “The quest to achieve true dignity fails when our bodies fail.” Is it possible that dignity is something that has become more achievable with the passage of time, medical advances and the availability of skilled hospice care?

At the end of the book he talks about The Riddle:
Every medical specialist must admit that he has at times convinced patients to undergo diagnostic or therapeutic measures at a point in illness so far beyond reason that The Riddle might better have remained unsolved. 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. Though he be kind and considerate of the patient he treats, he allows himself to push his kindness aside because the seduction of The Riddle is so strong and the failure to solve it renders him so weak.
What is the job of the doctor and what is Dr. Nuland trying to do in this book?
We can only give people the hope they will not die alone if we are totally honest with them about what is happening to their bodies. If a physician from the very beginning of a patient's downhill course allows that patient to become a partner in the knowledge of what is going on, there is no sudden moment when he has to say, 'well, there is nothing more we can do"; there is no sudden moment when she has to turn to a family and say, 'shall I tell this patient?'
Dr. Nuland is trying to share with the reader what is going on with the bodies suffering from the most common causes of death. But the fact is that this book contains medical information that is over twenty years old. The success and validity of the approach is threatened by the use of information that the reader is not able to trust to be the most accurate and thus may not be the most empowering.

How We Die gives us a glimpse of an approach that can benefit the dying when put into practice by a medical system equipped with the most up to date information. I need to go right now and reread Sherwin Nuland’s 2007 book The Art of Aging . In the meantime, I am going to give How We Die only two stars: four stars for the concept but one star for being significantly out of date with the implementation data. I hope Nuland’s 2007 book brings his idea successfully into the 21st century.

So who is this pessimist about finding a dignified death, this Dr. Nuland? I was surprised to find him on the World Wide Web giving a TED talk about, get this, HOPE! See his twelve minute 2003 talk at http://www.ted.com/talks/sherwin_nula....
...more

5

May 15, 2017

A beautifully written account by one who has witnessed many deaths, as a retired surgeon, in a hospital setting.

A scholarly and reflective depiction on the process of quietus.

Great insight for anyone who is concerned that one day they might die.

4

Apr 27, 2014

Sherwin Nuland, MD, was a well known and successful surgeon at Yale Medical Center for many years. In this book he begins to describe, literally, the way we die. In detail, he explains how infection and cancer and heart disease ravage the body and cause essential systems to fail. As a physician, I found it interesting, but I did not think I would finish the book if that was all there was to it.

Then the book began to hold my attention as it developed into an exploration of how people deal with Sherwin Nuland, MD, was a well known and successful surgeon at Yale Medical Center for many years. In this book he begins to describe, literally, the way we die. In detail, he explains how infection and cancer and heart disease ravage the body and cause essential systems to fail. As a physician, I found it interesting, but I did not think I would finish the book if that was all there was to it.

Then the book began to hold my attention as it developed into an exploration of how people deal with dying, a very different question from how we physically die. Dr. Nuland does a beautiful job with Alzheimer's disease using the slow deterioration of a friend as his example. He helps the reader understand not only the disease, but what the disease process does to the family and friends of the one afflicted.

What was most interesting to me as he made his segue into HIV/AIDS, was how his own values as an old time surgeon began to conflict with evolving codes of ethics, patient and family expectations and modern medical practice. After all, while he trained in the era when the doctor and family could collude to keep the true nature of an illness hidden from a patient, he also was part of a generation of surgeons who saw incredible progress in his field. He repeatedly recognizes that modern medicine can go too far, causing and prolonging suffering when treatment is futile, and yet he tells poignant stories about his own close family in which he cannot stop himself from offering that last sliver of hope even if it means risky surgery or incapacitating chemotherapy.

He is honest. He admits that sometimes physicians are more interested in solving "The Riddle" of the patient's illness even if diagnostic and treatment efforts are unlikely to help relieve suffering. This type of care and thinking are most often to be found in the academic medical center such as the one in which he worked. Academic physicians have a duty to the patient, but they also have a duty to learn and study. Helping the dying patient to an easy death may not always be their priority.

But times are changing. The pendulum has swung from the paternalistic physician who could withhold critical information or pursue treatment regardless of the patient's wishes to the empowered patient who can demand treatment even when it is futile or refuse treatment even when it might be life saving. Nuland recognizes the value of the primary care physician to help guide patients through confusing and complicated medical decisions but he only gives this recognition one sentence. He doesn't trust the empowered patient to make correct decisions. He reserves the right to argue, and he admits to using some unfair tactics to get his way. The physician still has power in the relationship.

As a primary care physician I had to cringe as he put his own brother through dangerous and difficult surgery even though the chance of cure was close to zero. He asks himself why, after the fact, but he has no good answer. He didn't want to admit, given all the tools of modern medicine and his own prowess as a surgeon (he did not do the surgery) that nothing could be done to save him. He did not want to give up hope, so instead he held out false hope.

This book is very easy to read and understand. Nuland does a great job making complex pathophysiology understandable. Unfortunately he could not get past his own guilt and we spend too much time hearing rationalizations for his aggressive (think academic surgeon) treatment of some of his patients.

I recommend the book for those interested in how the body works, or doesn't, and how people think about and react to illness and dying. The section on Alzheimer's disease is excellent and beautifully written. The book also gives insight into the mind of the academic surgeon.

And, should you ever be in a life threatening situation where difficult decisions have to be made, if time permits I would also recommend a conversation with your primary care physician. It is good to get more than one opinion. ...more

5

Jan 03, 2013

A remarkable book which my mother, my husband and I all read when my mother developed the heart condition from which she eventually died about 8 years later. Sherland combines scientific knowledge, medical experience, ethical concern and emotional sensitivity as he describes the stages people go through when they are dying of the most common conditions that kill us. It helped us all live with Mum's condition, has since helped through the passing of other close people and I hope will help us in A remarkable book which my mother, my husband and I all read when my mother developed the heart condition from which she eventually died about 8 years later. Sherland combines scientific knowledge, medical experience, ethical concern and emotional sensitivity as he describes the stages people go through when they are dying of the most common conditions that kill us. It helped us all live with Mum's condition, has since helped through the passing of other close people and I hope will help us in turn to understand what is likely to happen. For me, warmth and compassion are much easier when I'm not troubled by anxiety about not knowing what is happening.
...more

3

Jan 20, 2019

Interesting book, not what I thought it was going to be. A lot of technical information about death and the human body.

4

Jun 30, 2011

It’s not new (1993), but Sherwin Nuland’s How We Die is a timely treatise on what’s going on under the hood when humans die. We all have to leave this world sooner or later, whether by heart attack, stroke, cancer, or accident, but in our culture, it’s not that common to think about or speak of our own demises. Most of us act, instead, as if we will live forever.

In these days there is also a tendency to hide death from view, particularly in nursing homes and hospitals. (As of 1993, 80% of It’s not new (1993), but Sherwin Nuland’s How We Die is a timely treatise on what’s going on under the hood when humans die. We all have to leave this world sooner or later, whether by heart attack, stroke, cancer, or accident, but in our culture, it’s not that common to think about or speak of our own demises. Most of us act, instead, as if we will live forever.

In these days there is also a tendency to hide death from view, particularly in nursing homes and hospitals. (As of 1993, 80% of American deaths took place in hospitals, up from 50% in 1949.) And in many of those cases people live out their last days isolated from family and friends attached to ventilators in intensive care units. That isn’t what most of us envision for ourselves. Instead, the greatest percentage of Americans prefer to believe that they will die at home with family nearby.

Dr. Nuland’s message to readers is that it is time to take the blinders off. Enjoy life, by all means. Live life to the fullest. But also spend time learning about the ways that people die, and prepare while living for one’s end. We all want dignity in dying, he says. But 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.

I picked this up at a library book sale, expecting to read it and then give it back. Instead, I am putting it on my bookshelf. This is a book and a message that I want to keep nearby.
...more

3

Dec 26, 2013

Lest there be any doubt, it was doctors who created the opioid epidemic. Big Pharma was there, ready to pounce, but it was foolish, god-like thinking that set it up....

https://www.vox.com/2017/6/5/15111936...

=======

My father practiced medicine for 40 years, retiring at the end of 1982. Subsequent generations of doctors now consider my dad's time the golden era of primary care. He was a master diagnostician (he loved to say that it was no accident that the author of the Sherlock Holmes stories Lest there be any doubt, it was doctors who created the opioid epidemic. Big Pharma was there, ready to pounce, but it was foolish, god-like thinking that set it up....

https://www.vox.com/2017/6/5/15111936...

=======

My father practiced medicine for 40 years, retiring at the end of 1982. Subsequent generations of doctors now consider my dad's time the golden era of primary care. He was a master diagnostician (he loved to say that it was no accident that the author of the Sherlock Holmes stories and the real-life character Holmes was based on were both medical doctors). His era afforded him enough time with patients to really get to know them.

The author explains why this is important...

"Family history, dietary and smoking patterns, probability of compliance with medical advice, plans and hopes for the future, dependability of a support system of family and friends, personality type, and potential for modification if necessary—these are all factors that must be given proper weight in making decisions about treatment and long-term prognosis. It is his or her skill as a physician that enables them to befriend the patient and to know him—it is inherent in the art of medicine to appreciate that the testing and medications are of limited usefulness without the talking."

===============

The first time I read this book was when it came out in the mid-90's, not long after I lost my father. And, given my mother's health, I knew there wasn't much time left for her, either. (She was suffering from congestive heart failure, a product of decades of smoking, but she would not convey anything of what the doctor said to her to me. My sister, also a lifelong heavy smoker, was taking my mother to her appointments and was in denial about its effects on my mother. She's still in denial. My mother died of lung cancer).

This book is rather clinical. At the time, I found that helpful in better understanding the maladies that afflicted my parents.

But this time around, I better understand my daughter's critique of this author's writing. She earned a Masters of Science in Health Policy and Management at Harvard School of Public. They did not read his books there, but when she gave them a shot, at my request, she was not impressed with them. She likened them to unedited grad theses, as opposed to fully formed and edited books. Indeed, she was right. For one thing he is verbose and highly repetitive, especially about pet concepts.

A much better alternative was penned by a member of the Harvard Public Health faculty, surgeon and contributor to The New Yorker, Atul Gawande, "Being Mortal."

https://www.goodreads.com/book/show/2... ...more

4

Dec 31, 2011

A truly enlightening read for those who want to either know more about the physiological processes of terminal diseases, those with a family member or loved one suffering from one of the six common pathways to death Nuland outlines, or even those who simply wish to expose themselves in a relatively removed environment to the mysterious process of their ultimate fate, How We Die explores just that- the physical, mental, and emotional processes one goes through on the journey to the other side. A truly enlightening read for those who want to either know more about the physiological processes of terminal diseases, those with a family member or loved one suffering from one of the six common pathways to death Nuland outlines, or even those who simply wish to expose themselves in a relatively removed environment to the mysterious process of their ultimate fate, How We Die explores just that- the physical, mental, and emotional processes one goes through on the journey to the other side. Nuland attempts to break down the myth of dying as a dignified process so often described by "poets, essayists, chroniclers, wags, and wise men," who "often write about death but have rarely seen it...[whereas] Physicians and nurses, who see it often, rarely write about it." Stripped to the core, the ultimate death encountered by all is the deprivation of oxygen which shuts down our core vital centers. No matter which disease or illness one is dying from, our existence as obligate aerobes is our ultimate death sentence, for without oxygen we have no life.

For those unaware of the physical turmoils each of these six detailed death sentences encompasses- heart disease, stroke, Alzheimer's (dementia), murder (including suicides and accidents), AIDS, and cancer- Nuland provides an opportunity to walk away with perhaps a more proper dose of understanding and empathy in a world that isolates these victims almost as easily and ambitiously as one quarantines a leper. For those, including myself, who have had the opportunity to observe and endure the deaths of both loved ones and strangers, this book offers validation and biological reasoning to the emotions one feels and the physical signs one witnesses as life passes over from one world to another.

Although Nuland's intentions were to "demythologize the process of dying," it is quite difficult to walk away from this book leaving death's grandeur as a mere image of the past. Though he does an excellent job, for both the medically-minded and lay readers, of explaining the undignified physical and physiological tolls disease takes upon one's body, I still remain in awe of this completely natural and life-changing process- both literally for the victim and figuratively for the observer. I cannot deny the immense suffering we as family members and they as victims endure, no amount of literature or scientific proof can ever ease this experience of pain. However, my medical mind cannot deny the abstract beauty that is the process of our cellular beings shutting down- the literal inability for hemoglobin to carry oxygen to keep our most vital centers functioning, the ultimate lack of circulation to bring blood to our hearts and glucose to our brains. These simple acts we take for granted everyday without giving a second thought to them are the same simple acts that cause our hearts to stop beating. And perhaps they are not simple at all, but rather so intensely intricate that true understanding of our design by the ultimate Creator can never be really be grasped.

No matter what your beliefs, thoughts, or opinions are on the process of dying, I highly recommend this book to any and all who wish to understand in more detail their time on this earth and their connection to the rest of humanity. ...more

5

Oct 22, 2016

As Adan was expeled from paradise for chosing freedom and knowledge ,paid a high price and was punished by his election so we being inteligent beings also have to pay a high price for our inteligence and be punished,our punishment is that we are aware of our inexorable future death and destruction as individuals that we will be departed of our loved ones and we will dont enjoy terrenal future life nor will know future world.
It is a cruelty of the evolutive path that create us inteligent and As Adan was expeled from paradise for chosing freedom and knowledge ,paid a high price and was punished by his election so we being inteligent beings also have to pay a high price for our inteligence and be punished,our punishment is that we are aware of our inexorable future death and destruction as individuals that we will be departed of our loved ones and we will dont enjoy terrenal future life nor will know future world.
It is a cruelty of the evolutive path that create us inteligent and mortal,when both things ought be incompatible,ever is a tragedy the death of a inteligent being.
Our life for no religious people is a brief interval of existence in a long line of nothingness,as the author says is a odd simetry between birth and death,we are born with pain and we die with pain,nothingness before birth and nothingness after death.

This is the firt book i have read on death,written by a agnostic medicine doctor,but for me is a very great book,a book no much about science but much about humanity,compasion,tolerance,solidarity,unselfishness and over all hope and dignity.

Using several emblematic mortal diseases,accidents,murders or suicide Nuland explain the phisiological process of death,but the book is much more is a book about the philosofy and ethics of death.
The author says that only rarely exist dignity and serenity in death,that the path to death is painful and full of stress for body and mind.He is against the heroic medicine that tortures the dying when is nothing to do.For him the good death is when one dies with the love and company of the relatives and friends and with paliative cares,but this is rarely the norm when so many people dies alone in the high technologic environement of intensive care units.
As in the Death of Ivan Ilich he is also against of not tell the truth and give false hopes that only contribute in this charade to the incomunication and loneliness of the terminal ill adding suffering because he knows that we know ,we know that he knows,everibody knows but nobody touchs the subject

He proposes the redefining of the meaning of hope as the meaning of a plenty full lived life and the love of the next ones.

Nuland shows a in his time open mind when talks about AIDS terminal ill, quoting a friend :
"A lot of the greater comunity really do feel that what is happening to us-its some kind of visitation on us for our sinful and abnormal ways.And so its in our mutual interest not leave someone alone with that judgement of society.Those of us who suffer from some kind of self-loathing may find it very easy to think of AIDS as a form of punishment,but even those of us who dont are aware that much of society does see it that way.To neglect our friends who have to deal with the disease themselves is somehow to abandon them to the judgement of the straight world".

Nuland also warns against a loss of the traditional values of medicine and Hipocrathic oath,drowned in technology and hurry,he is homesick of the family doctor that gives conseil and confort and has a exquisite regard by the nature in its wide meaning when textually says :
"A realistic expectation also demands our acceptance that ones alloted time on earth must be limited to an allowance consistent with the continuity of the existence of our species.Mankind,for all its unique gifts,is just as much a part of the ecosystem as is any other zoologic or botanical form,and nature does not distinguish.We die so that the world may continue to live.We have been given the miracle of life because trillions upon trillions of living beings have prepared the way for us and die.We die,in turn,so that others may live"
He is advocate of some restricted sort of eutanasia,and for finish he quotes Michel de Montaigne :
"The utility of living consists not in the lenght of days,but in the use of time : a man may have lived long and yet lived but a little"

A very good strongly recomended book ...more

4

Sep 05, 2007

a well-written book. Dr. Nuland writes from years of experience on the topic of death, and how really there is no dignity to it. he explores this myth of 'ars moriendi' (the art of dying) and both the pathophysiology and mental/emotional states that accompany it. he argues against the modern 'hospital' death devoid of feeling, he reproaches biomedicine for it's mistakes in prolonging the lives of their patients for their benefit in solving the Riddle, and not for the patient's best interest... a well-written book. Dr. Nuland writes from years of experience on the topic of death, and how really there is no dignity to it. he explores this myth of 'ars moriendi' (the art of dying) and both the pathophysiology and mental/emotional states that accompany it. he argues against the modern 'hospital' death devoid of feeling, he reproaches biomedicine for it's mistakes in prolonging the lives of their patients for their benefit in solving the Riddle, and not for the patient's best interest... "I have no real quarrell with those who insist upon invoking the laboratory-bred specificity of microscopic pathology in order to satisfy the compulsive demands of the biomedical worldview - I simply think they miss the point." he explores both his mental processes and emotional ones with personal vignettes. he writes with knowledge of pathophysiology, etymology, history, literature and most importantly, humanity.

"it is inherent in the art of medicine to appreciate that the testing and medications are of limited usefulness without the talking."

"The diginity 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." ...more

5

Jan 15, 2015

Nuland died last year at 94 years of age. He wrote “How We Die” as a surgeon in New Haven Connecticut in his 70s looking back on his career and his life. What makes this book stand above most others, is Nuland’s wisdom and wonderful ability to write about how death has affected him both personally when dealing with family members’ deaths, but also outlining how his patients have died from different types of diseases, giving us a full, frank picture of the details and ways we could die personally Nuland died last year at 94 years of age. He wrote “How We Die” as a surgeon in New Haven Connecticut in his 70s looking back on his career and his life. What makes this book stand above most others, is Nuland’s wisdom and wonderful ability to write about how death has affected him both personally when dealing with family members’ deaths, but also outlining how his patients have died from different types of diseases, giving us a full, frank picture of the details and ways we could die personally—what those final weeks and moments are like.

I assume most people turn to this book, when they have experienced a death of a family member and realize there is so much they don’t know about death. This was true for me. Nuland outlines the most common forms of death, step-by-step, arteriosclerosis, cancer, alzheimers, and the many forms each take, such as strokes, heart attacks, cancer, AIDS, pneumonia and the general implosion caused by aging. And he talks about why egocentric doctors go into medicine: it is to solve riddles and problems. Finally he has wonderful sections on “hope” and “lessons learned.” It is a gem of a book. The dignity we seek in dying must be found in the dignity, beauty and grace in which we have lived our lives. It takes chapters of kind explanation to arrive at this conclusion—for this reason, it is best to read this book when you need it. To listen to him talk about hope anytime, listen to his TED talk http://www.ted.com/talks/sherwin_nula...

...more

0

Nov 24, 2018

I read this book because I have started to work as a healthcare professional, and in particular with countless clients who are "palliative." What I wanted to know was why, when I review the medical history of some of my clients (patients) with Chronic Heart Failure, and a history of a Cerebrovascular Accident (CVA), and Hypertension, and a CABG (bypass) in 2013, and kidney failure, and... what have these diagnoses done? Are they really dying of all of these things?

I don't know how to explain it. I read this book because I have started to work as a healthcare professional, and in particular with countless clients who are "palliative." What I wanted to know was why, when I review the medical history of some of my clients (patients) with Chronic Heart Failure, and a history of a Cerebrovascular Accident (CVA), and Hypertension, and a CABG (bypass) in 2013, and kidney failure, and... what have these diagnoses done? Are they really dying of all of these things?

I don't know how to explain it. I have a client right now, a sweet old lady, cute as can be, who laughs at the end of every breathless sentence she speaks. As is my job in the healthcare team, I ordered her a hospital bed - her doting daughter wishes to keep her at home - and a commode and a wheelchair and a cushion. I assess the redness developing on her coccyx (her bum) and recommend that she be turned at such and such time to prevent bedsores. Here I see an 87 year old lady dying, of course she is dying, and what she wants is rest and relaxation. So we set up her bed by the window, and she keeps her white nightgown on as her legs have edema (swelling), and she lays there with the head of the bed up to help her breath better, and the sunlight steams in, and every once in a while she groans and tries to shift her weight because she is uncomfortable in one position, and she looks positively like an angel.

And I know that inside her there is a battle against kidney failure, which is why her tummy is so huge and her organs are floating in that cavity we call the abdomen. And inside her too is heart failure, which likely has caused the kidney failure. And so she is fatigued, and she is heavy - she can't fit into her wheelchair anymore - and her heaviness is creating risk for pressure injuries on her bed. And I know that she has medications by the dozens, and that I recommended the daughter get a blister pack because at some point it is impossible to keep track of all these medications.

I know that this is a disease, or more accurately a plethora of diseases, each feeding off of the other - when one head is chopped off, the hydra grows another.

So I know why she is dying, I suppose. But she is 87. And is she really diseased? Isn't this just her aged body saying - enough. I have worked long enough, and now I wish to be comfortable as I leave this life. Despite the list of diagnoses that go on and on, and the list of surgeries that go on and on, and the list of medications that is even longer - isn't she dying of old age? It's just that simple. She isn't dying of disease. She is dying of the natural cycle of life - not just of human life, but of all life. She is dying of the cosmic principle that says - ye shalt not last! She is dying because nothing in this world is eternal, and even thousands of years old trees must one day die, and the lion eats the gazelle, and the cat chases the mouse, and age comes after us all.

So while she lies there and the healthcare team gently urges the daughter to move her mother to a hospice, I can't help but feel that somewhere along the line, by pathologizing, the dignity of old age - a dignity that is from understanding, not from the wheezing and heaving and overall grotesqueness of the last few months of life - is lost.

We all must die, and death will most likely be awful, and painful, and we will very likely be surrounded by strangers. And some deaths are a tragedy, while others are just this: that Life folds her hands and places them in her lap, and her sister Death opens hers and says to us, Embrace me now, for your earthly journey is complete, so come home. And the worms will eat your body but the face of God hangs eternal, looking over it all. ...more

3

Feb 04, 2018

It’s no secret or surprise that much of my processing and understanding of life happens through reading. I’ve been a bibliophile since birth (literally– one of my dad’s proudest moments as a father was reading to me on the day that I was born); books are the primary way in which I explore the world, grapple with emotion, and make sense of the human condition. So, naturally, after the death of my grandfather on January 26th, one of my first instincts was to find the right story for this time in It’s no secret or surprise that much of my processing and understanding of life happens through reading. I’ve been a bibliophile since birth (literally– one of my dad’s proudest moments as a father was reading to me on the day that I was born); books are the primary way in which I explore the world, grapple with emotion, and make sense of the human condition. So, naturally, after the death of my grandfather on January 26th, one of my first instincts was to find the right story for this time in my life.

‘How We Die’ is simultaneously a scientific and academic exploration of bodily processes and their various forms of breakdown, as well as a philosophical reflection on the ways in which we try to cope with the mortality of ourselves and those we love. Dr. Sherwin Nuland walks us through the most notorious killers – heart failure, Alzheimer’s, trauma, HIV/AIDS, cancer, etc. – so that we may better understand what’s really happening as the body fights for life and, ultimately, surrenders to death.

I think it’s important to note that while Nuland did add a brief coda in 2010, it’s possible that much of this book is outdated from a medical standpoint. I’m no doctor, but I do know that medicine advances every day as our understanding of the human body becomes more nuanced and our technologies allow for more efficient and effective treatments. Published in 1994, this book is obviously not reflective of knowledge gained in the last 25 years. It would be interesting to read an update knowing all that we do now about these same diseases, despite the fact that several seem to remain quite mysterious.

One thing I did find particularly interesting about this book (that is as timeless as it is fascinating) was Nuland’s focus on what it means to ‘die with dignity’ and whether or not that’s even possible or something we should obsess over to the extent that we do. He also explored the concept of hope and what that means in the context of terminal diagnoses.

My grandfather was 89 years old. Many things killed him, and now I have a better grasp of the mechanisms by which he died. Once again the right book found me at the right time in my life, and I am grateful. Obviously books don’t take away emotional pain or change the circumstances of real life, but they do have the power to put things in context, to shift perspective, or, if nothing else, simply to validate the struggles in which we find ourselves day after day as we do our best to navigate and exist in this strange, magnificent world. ...more

5

Apr 06, 2018

Important book

I read this as my 80 year old mom was rapidly dying from brain cancer. Some of the technical descriptions of major bodily functions are gripping, especially from the underlying perspective of their eventual failure towards death. Reading this as we sat for many days in vigil as my mom went through the dying process gave me a unique comfort that I’m deeply grateful for. It was comfort in the brutal transparency and absolute universal reality of death as someone I loved so deeply was Important book

I read this as my 80 year old mom was rapidly dying from brain cancer. Some of the technical descriptions of major bodily functions are gripping, especially from the underlying perspective of their eventual failure towards death. Reading this as we sat for many days in vigil as my mom went through the dying process gave me a unique comfort that I’m deeply grateful for. It was comfort in the brutal transparency and absolute universal reality of death as someone I loved so deeply was actually experiencing it. A must read. ...more

5

May 04, 2018

If I could give 'How we Die' more than 5 stars, I would. Having seen the deaths of some loved ones from close quarters, which gave rise to many difficult questions about the nature of death, the kind of death I want and more importantly why do doctors overreach their responsibilities ( is the reason only commercial or something deeper), this book helped answer many questions while explaining the logic and science behind them. Not only is Nuland's description of biology readable, he has the gift If I could give 'How we Die' more than 5 stars, I would. Having seen the deaths of some loved ones from close quarters, which gave rise to many difficult questions about the nature of death, the kind of death I want and more importantly why do doctors overreach their responsibilities ( is the reason only commercial or something deeper), this book helped answer many questions while explaining the logic and science behind them. Not only is Nuland's description of biology readable, he has the gift of language and depths of a philosopher to make the most morose and terrying subject of death read beautiful.

However, this like many powerful pieces of work will only draw you in when the time is right to receive.

' When my time comes, I seek hope in the knowledge that insofar as possible, I will not be allowed to suffer or be subjected to needless attempts to maintain life; I will seek it in the certainty that I will not be abandoned to die alone; I am seek it now in the way I live my life , so that those who value what I am will have profited from my time on Earth and be left with comforting recollections of what we have meant to one another' ...more

4

Jun 06, 2009

The purpose of this book is to help people have reasonable expectations about death and is a plea for more empathetic doctoring; namely more family practitioners and hospice workers.

The author explains the physical processes that occur during death, starting with the process of aging. He then goes into detail about the ways the body can shut down and why. This may be too much information for some and although a little morbid, I found it well worth understanding. He also covers some of the most The purpose of this book is to help people have reasonable expectations about death and is a plea for more empathetic doctoring; namely more family practitioners and hospice workers.

The author explains the physical processes that occur during death, starting with the process of aging. He then goes into detail about the ways the body can shut down and why. This may be too much information for some and although a little morbid, I found it well worth understanding. He also covers some of the most common types of death scenarios.

I agree with the author that most people do not know how to treat those who are dying or what is normal even. Our expectations(namely that people we can always be cured, that hope is lost if the disease is found to be incurable, or that their is a 'right' way to go) can affect how we view and thus react as friends, family, and doctors around those dying.

The peoples' stories in the book brought tears to my eyes and made me remember people who have died recently. I feel better prepared to recognize death and to react when I see it. ...more

5

Apr 09, 2018

I'm currently reading Being Mortal, and I thought back to How We Die and how profoundly it affected me. From the first page to the last, it had me in its grip.

And here's the thing. I read a review when the book was first published and rushed out to buy it. I was about 30. So the stories and vignettes highlighted in the book held a medical fascination for me. When I re-read the book 20 years later, wow. The perspective that the years bring really changed my experience. I had that "it tolls for I'm currently reading Being Mortal, and I thought back to How We Die and how profoundly it affected me. From the first page to the last, it had me in its grip.

And here's the thing. I read a review when the book was first published and rushed out to buy it. I was about 30. So the stories and vignettes highlighted in the book held a medical fascination for me. When I re-read the book 20 years later, wow. The perspective that the years bring really changed my experience. I had that "it tolls for thee" moment, and suddenly the stories in the book felt much more personal and possible for me.

When I read of Sherwin Nuland's own death, I thought, "Now he really knows what it's all about." But if I could talk to him, I'd say thank you. Because even though the book is literally about how we die, and the many modes of death, there's a comfort to it. The book demystifies death to a degree. And the ultimate message is, don't dwell on how you're going to die, but how you're living right now. ...more

4

Oct 03, 2012

A very well-written, unsentimental account of how it is that we actually die, what happens in our bodies, and which ailments are most likely to kill us. As Dr. Nuland points out, waxing eloquent about death is a very common theme among artists, but it is rare that we get to hear about death from someone whose actual business is living and dying. A thoughtful and important perspective. Recommended.