How We Die: Reflections on Life's Final Chapter.

"Every life is different from any that has gone before it, and so is every death....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" (p. 3). There are few reliable accounts of the ways in which we die. In this book, Sherwin Nuland details the vast majority of conditions related to how we die. Dr. Nuland a surgeon who resides in Hamden, Connecticut, presently teaches surgery and the history of medicine at Yale University. Two other books for which he is noted are; Doctors: The Biography of Medicine, and The Origins of Anesthesia.

This book focuses primarily upon the physiological aspects of death. Among the 12 chapters in the book: two deal with heart disease, two with cancer, two with aging, two with AIDS, and one each on Alzheimer's disease, murder, and accidental death and suicide. The final chapter entitled "The Lessons Learned", and the Epilogue, is a summary of the author's insights on the matter of dying, along with some of his personal feelings about the process. All chapters contain a smattering of statistics, physiology, case histories, philosophy, and personal reminiscence.

This book is full of interesting and informative tid-bits of biological facts and medical insights accompanied by a generous variety of statistical information throughout. As the writer progresses, the voluminous figures can become a bit confusing. It would have been helpful had Nuland included tables and diagrams for presenting some of the more complex and involved information. Despite the fact that in some places the close of new information is so concentrated as to become a bit overwhelming, the author makes a concerted effort to keep the layman's ear by sprinkling touching case histories throughout. This "humanizing" of the presentation of the process of dying by the inclusion of stories of real people makes the book more readable and appealing.

It is noteworthy that the author departs from the popular view that death is attributable to disease rather than the aging process per se. Nuland discusses the evidence that life has its natural limits resulting in a tapering off, and in essence, for some, life merely "sputters out". He concedes, however, that, "Aging may be said to be both independent and codependent [of disease], in the sense that it certainly contributes to disease and may in turn be accelerated by it."

The author does a nice job of describing and clarifying some of the body's more complex physiological processes at the cellular level, and relates them to such common conditions as heart disease, cancer, dementia, AIDS, and viruses. Overall Nuland impresses the reader with the critical role of some of our basic bodily functions related to blood flow, oxygenation, nutrition, purification, and waste management at the cell level. He also points out how most of these processes in one way or another are related to cardiovascular efficiency.

Nuland clarifies the definitions of legal and clinical death in a dissertation describing the processes common to both. He points out that in order for legal death to be declared there must be incontrovertible evidence that the brain has permanently ceased to function. Clinical death involves the cessation of heart function and respiration accompanied by a lack of evidence of brain function. However, he points out that between clinical death and legal death there is a brief period of time [approximately four minutes] before vital cells lose their viability, allowing for procedures such as cardiopulmonary resuscitation (CPR) or rapid transfusion to revive a person.

Linguistically this book is interesting for its detailed, yet understandable presentation of medical terminology. The author makes good use of Latin and Greek terms of origin in defining and enriching his description of medical conditions. At the same time he details some involved medical phenomenon with understandable lay terminology. For example, in his discussion of angina pectoris, he refers to this condition as essentially a cramp, or "Charlie horse" of the heart muscle. Nuland also emphasizes the important role that naming and classifying diseases or conditions plays in the process of advancing treatment and cure. One example he cites is the identification of Alzheimer's disease. Although this type of dementia has existed for many years, it was not until the actual labeling of Alzheimer's occurred that our society became motivated to focus on, and combat this disease with highly orchestrated research and treatment.

According to Nuland, "We rarely go gentle into that good night." He notes that many of us hold paradoxical views of how we wish to die. On one hand we hope for a quick death or a quiet death during sleep free of pain and suffering, yet at the same time we may adhere to a vision of our final moments that "combines grace with a sense of closure" (p. 8). The author postulates that it is not death per se that is the real enemy, but disease. Death is the peaceful giving over that comes after the battle with disease is lost. Disease is that force which confronts, denigrates, and eventually wins out over us, no matter how resounding our temporary victories over it may seem. The author leaves one with the notion that disease is what makes the process of dying so despicable, but death is a state of being that cannot be affected by disease, and is therefore unworthy of our fears.

Dr. Nuland provides some interesting statistical insights into how we die. He comments that among those Americans who die of natural causes, who are not institutionalized or homebound, 20-25% will die suddenly, or within a few hours of the onset of symptoms. Of these cases, 80-90% are cardiac in origin. Yet, he adds, that most who die of heart problems in the age of modern medicine die gradually, having experienced numerous warnings and much successful treatment over an extended period of time. He points out that approximately 80% will survive their first heart attack and take comfort in the fact that this treatable condition has been exposed. However, some may eventually be claimed by the disease via repeated episodes, which often facilitate the death of greater portions of the heart muscle.

This book is gruesome in places, such as the author's discussion of murder, suicide, and accidental death. However, Nuland always salvages the worst of scenarios with some intervening element of interest. For example, in the section describing death via murder, Nuland details the stabbing death of a young girl, but in the midst of the story, he provides a comforting editorial on the part of the young girl's mother, while simultaneously he describes the possible role of endorphins in abating pain during traumatic injury.

Nuland presents a touching sketch of AIDS. He provides an informative look at the etiology and evolution of the disease, and dramatizes it in a case history with which he is personally familiar. In the first of two chapters concerning cancer, Nuland provides a picturesque description and analysis of the dynamics of cancer within the human body. In the following chapter entitled Hope and the Cancer Patient, he presents the touching story of his own brother's struggle and eventual death from cancer. Nuland discusses in detail the concept of hope and the various sources from which it may be derived. He also discusses the dilemma of "truth telling" in regard to maintenance of hope, and criticizes himself and his profession for tending to think of hope as being exclusively synonymous with cure or remission. The author notes that, "some of my sickest patients have taught me of the varieties of hope that can come [even] when death is certain" (p. 233). This chapter is full of meaningful information and insight to stimulate the practicing counselor who must deal with the issues of death and dying. These issues become even more relevant to the field of rehabilitation with the advent of the independent living movement and greater inclusion of elders in the mix of consumers.

In the final chapter of the book, The Lessons Learned, Nuland reflects back on his many years of professional and personal experience related to the practice of medicine and dying. He provides a very frank discussion about physicians, egos and tendencies towards heroics; often at the expense of the patient's loss of control. He suggest that there is a tendency for many physicians to focus more on what he calls "The Riddle" (diagnosis and cure), rather than the patient. In this chapter, one can't help but be impressed with Nuland's candid self-disclosure regarding his personal shortcomings, second thoughts, and regrets which now shape his thinking. In my opinion this particular chapter should be required reading for all physicians and medical personnel.

I found Nuland's reflective comments toward the end of this book refreshing and highly meaningful. In the epilogue, he calls for a more humane approach to the process of dying. He touches on the idea that modern medicine has moved toward the art of saving life at the expense of moving away from the art of managing death and makes mention of the efficacy of dying within a family or community, as opposed to dying alone or in an institution. Nuland advocates for increasing the humanization of the practice of medicine by returning to a more primary care/physician centered model. He poignantly states; "The clinical objectivity that should enter into our decisions [related to life and death] 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" (p. 266).

In closing, Nuland reiterates that most of us may not be able to maintain meticulous control over the process by which we die, however, he emphasizes that it is not in our last days that we create a message by which we will be remembered, rather all of the years that precede those final days. Nuland aptly closes with these thoughts: "...there is often a serenity - sometimes even a dignity - in the act of death, but rarely in the process of dying... 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" (p. 268).

Barry C. Stephens, Ed.S., CRC, Research Assistant & Rehabilitation Specialist for Programs on Aging and Visual Impairment, Rehabilitation Research and Training Center on Blindness and Low Vision, Mississippi State University