Book review: “How We Die: Reflections on Life’s Final Chapter” by Sherwin B. Nuland

I originally read Sherwin B. Nuland’s book How We Die: Reflections on Life’s Final Chapter in 1995 when I was in my mid-forties and my mother was dying of congestive heart failure and a host of other diseases.

Ever since, I’ve recommended it to virtually anyone who would listen as one of the best books I’d ever read.

This time around, it was scarier. For one thing, I’m a couple decades closer to my own end than I was back in the ‘90s. For another, I’m the sort who takes descriptions of health problems and diseases much too much to heart, seeing each symptom in my body and getting anxious about it.

Fairly quickly, though, I got over that. Nuland describes in exquisite and vibrant detail so many symptoms and so many ways in which the body breaks down that I didn’t feel so threatened by them. Or, maybe better put, I felt equally threatened by all of them, so they sort of canceled each other out.

And his bottom-line message is still the same as I remembered it: Death is part of life.

This is it

Death — the coming end — is what gives life its meaning. It is what makes every moment priceless. There’s no time to procrastinate. There’s no fountain of youth. This is it. Make the best of it.

It is a message that gave me strength, perspective and succor when I had my own small dance with cancer two months after my mother’s death.

How We Die is brutal in its depiction of the dying process. It recognizes in a deep way that the human body is a biological mechanism that can easily go wrong. And Nuland makes clear that, even if nothing horrible happens, the body, after decades and decades of use, just wears out. Like any machine.

The end will come for each of us, and, despite the pretty parting words of Hollywood movie deaths, ours is likely to be painful and messy and disheartening.

A “good death”

Still, Nuland writes, we can exert some control. By working closely with our medical team and circle of family and friends, we can do much to choose how we go out — opting for quality of life rather than one more heroic attempt to defeat the forces of illness and decay.

And, even if we are wracked with pain or lost in a coma, we will find a “good death” if what has proceeded it has been a good life. Or, as Nuland writes, “The dignity that we seek in dying must be found in the dignity with which we have lived our lives.”

Sherwin B. Nuland in 1994 and 2013

Despite its subject, How We Die is a life-affirming book. Actually, after reading this book a second time, I’d say it is because of its subject.

Death, seen in the right light, isn’t an enemy to flee from. It is, rather, one often-misunderstood aspect in the miracle of life. We didn’t exist. Then we did. And there will come a time when we exist no more.

Look at the light the setting sun casts on the red brick wall of the building across the street. Soak in the beauty now. While you can.

Still one of the best

How We Die is the sort of book filled with sentences and paragraphs that I want to share. So that is what I will do with the rest of this review.

These quotations give a taste of Nuland’s evocative writing, clear insights and courage in the face of hard realities. How We Die is still one of the best books I’ve ever read.

The utility of living: “Montaigne believed, in that uncertain and violent era, that death is easiest for those who during their lives have given it most thought, as though always to be prepared for its imminence. Only in this way, he wrote, is it possible to die resigned and reconciled, ‘patiently and tranquilly,’ having experienced life more fully because of the constant awareness that it may soon come to an end. Out of this philosophy grew his admonition, ‘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 little.’ ”

Mob of misfits: “In the community of living tissues, the uncontrolled mob of misfits that is cancer behaves like a gang of perpetually wilding adolescents. They are the juvenile delinquents of cellular society…There comes a point at which home turf is not enough — offshoots of the gang take wing, invade other communities, and, emboldened by their unresisted depredations, wreak havoc on the entire commonwealth of the body. But, in the end, there is no victory for cancer. When it kills its victim, it kills itself. A cancer is born with a death wish.”

Trillions: “We die so that the world may continue to live. We have been given the miracle of life because trillions upon trillions of living things have prepared the way for us and then have died — in a sense, for us. We die, in turn, so that others may live. The tragedy of a single individual becomes, in the balance of natural things, the triumph of ongoing life.”

Useful and rewarding: “All this makes more precious each hour of those we have been given; it demands that life must be useful and rewarding. If by our work and pleasure, our triumphs and our failures, each of us is contributing to an evolving process of continuity not only of our species but of the entire balance of nature, the dignity we create in the time allotted to us becomes a continuum with the dignity we achieve by the altruism of accepting the necessity of death.”

The last voyage: “When Charles Lamb beheld the corpse of the popular English comedian R. W. Elliston, he was moved to write, ‘Bless me, how little you look. So shall we all look — kings, and Kaisers — stripped for the last voyage.’ ”

Everything rusts and crusts: “An individual’s specific kind of death seems to depend upon the order in which his tissues become involved in the process of degradation. The one common thread among [people who die at an advanced age], at least as it is reflected in the staccato multisyllables of a pathologist’s unique approach to an obituary, was the loss of vitality that comes with starvation and suffocation — as the arteries narrow, so does the margin between life and death. There is less nutriment, there is less oxygen, and there is less resiliency after insult. Everything rusts and crusts until life is finally extinguished.”

Chapel: “Dr. Defoe and I stepped into Ishmael’s room — noiselessly, though he was far beyond hearing any sound we might have made. It was more out of respect than necessity that we were so quiet. When a man is dying, the walls of his room enclose a chapel, and it is right to enter it in hushed reverence.”

His essence: “The appearance of a newly lifeless face cannot be mistaken for unconsciousness. Within a minute after the heart stops beating, the face begins to take on the unmistakable gray-white pallor of death; in an uncanny way, the features very soon appear corpse-like, even to those who have never before seen a dead body. A man’s corpse looks as though his essence has left him, and it has.”

Not what he’s trained for: “When I have a major illness requiring highly specialized treatment, I will seek out a doctor skilled in its provision. But I will not expect of him that he understand my values, my expectations for myself and those I love, my spiritual nature, or my philosophy of life. That is not what he is trained for and that is not what he will be good at. It is not what drives those engines of his excellence.”

Who know who we are: “From the wisdom of the legal documents called advance directives to the questionable philosophies of suicide societies, a range of options exists, and at the bottom the goal of each of them is the same: a restoration of certainty that when the end is near, there will be at least this source of hope — that our last moments will be guided not by the bioengineers but by those who know who we are. This hope, the assurance that there will be no unreasonable efforts, is an affirmation that the dignity to be sought in death is the appreciation by others of what one has been in life.”

His time: “In the oldest extant medical book of China…the learned physician Chi Po…tells [the reader]: ‘When a man grows old his bones become dry and brittle like straw, his flesh sags and there is much air within his thorax, and pains within his stomach; there is an uncomfortable feeling within his heart, the nape of his neck and the top of his shoulders are contracted, his body burns with fever, his bones are stripped and laid bare of flesh, and his eyes bulge and sag. When then the pulse of the liver can be seen but the eye can no longer recognize a seam, death will strike. The limit of a man’s life can be perceived when a man can no longer overcome his diseases; then his time of death has arrived.’ ”

A century: “Whether the result of wear, tear, and exhaustion of resources or whether genetically programmed, all life has a finite span and each species has its own particular longevity. For human beings, this would appear to be approximately 100 to 110 years. This means that even were it possible to prevent or cure every disease that carries people off before the ravages of senescence do, virtually no one would live beyond a century or a bit more.”

A ripeness of time: “And there are good reasons that one generation must give way to the next, as made clear in another of the letters [Thomas] Jefferson wrote to the equally venerable John Adams near the end of his life: ‘There is a ripeness of time for death, regarding others as well as ourselves, when it is reasonable we should drop off, and make room for another growth. When we have lived our generation out, we should not wish to encroach on another.’ ”

A kind of happiness: “The meaning that hope brings is perhaps best expressed by Samuel Johnson: ‘Hope,’ wrote England’s greatest authority on words, ‘is itself a species of happiness, and perhaps the chief happiness which this world affords.’ ”

My time: “When my time comes, I will 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 seeking it now, in the way I try to live my life, so that those who value what I am will have profited by my time on earth and be left with comforting recollections of what we have meant to one another.”

Patrick T. Reardon
5.22.13