How We Die: Reflections of Life's Final Chapter

There are several themes that permeate Nuland's books. One theme is that death, like birth, is a messy process. Though we may wish for the noble death, more likely we will die slowly from a lack of oxygen in the brain. This, in turn, will result from a failing heart, lungs, or blood vessels. Death does not come easy, and although the final moment is sometime serene and tranquil, months or weeks of painful physical degeneration often precedes it.

The second theme in Nuland's book is that death is not only inevitable, it is necessary. While life should be fought for as long as possible, we should all realize that ultimately the battle will be lost. We will die. Nuland takes a dim view of heroic attempts to extend life beyond the point where the body has simply failed and death becomes not only inevitable, but also the proper way for nature to renew herself. Nature uses death to clear the way for new generations, and just as we cannot experience the green buds of spring unless the leaves from last season fall to the ground, the very nature of life demands that when death becomes inevitable we exit the stage for the next generation.

Nuland's third point is that the measure of a life is not found so much in how we die, but in how we live and how we are remembered. Few of us can control the way in which we die. For some of us it will be quick, for others death will linger and the process will be slow and painful. Some will find humiliation in the loss of bodily functions or mental facilities. However it comes to anyone of us, death is just a part of our lives and the real meaning in death is in the life remembered.

Chapters 1 and 2 focus on the heart, how and why it fails, and what are the consequences in terms of how death is precipitated. These chapters include some personal stories, but are mostly factual in nature. They make fascinating reading for anyone interested in how the body works, as well as those interested in death itself.

Chapter 3 is one of the most poignant and describes the author's personal experiences in the life and death of his Grandmother who raised him after his parents died when he was eleven. Nuland is a medical doctor, and he describes the deaths of many people in his book, including the death of his Grandmother and his brother. All these descriptions are stark. There is no attempt to cover up the messiness of death, yet the stories are told with such deep compassion and understanding of the human condition and suffering that they bring a deep upwelling in the soul.

Chapter 4 basically outlines Nuland's view that "Among living creatures, to die and leave the stage is the way of nature - old age is the preparation for departure, the gradual easing out of life that makes its ending more palatable not only for the elderly but for those also to whom they leave the world in trust."

Chapter 5 describes Alzheimer's disease, and is one of the most interesting chapters in the book. This book includes some of the history of Alzheimer's disease, how the disease manifests itself, and how it kills. Like many other topics in his book, Nuland illustrates the subject by describing the process of degeneration and death due to this disease through his personal experiences with individuals he knew.

The sixth chapter, titled "Murder and Scerenity," was difficult for me. It contains a vivid description of the death of a little girl by a knife-wielding maniac. The subject of the chapter is how the body produces chemicals that place it in a type of trance when under tremendous stress. The story of little Katie is very poignant. I hardly ever cry, but I did as I read of the way she died. Interestingly, though, I think that understanding the physiology described in this chapter can be a source of solace even for those who have lost loved ones through violent tragedy.

Chapter 7 discusses suicide and euthanasia. Nuland seems to take a dim view of suicide as promoted by some organizations, but he seems to hold open the possibility of doctors taking a more active roll in the final moments of death as patients ask for help in the process. This chapter brought some personal reflection to me, since I'm from Oregon. I voted with the majority of my fellow citizens to allow doctors to help their patients end their suffering (Oregon's law has abundant safeguards and cannot result in euthanasia or death for monetary relief). Ultimately, though, our voices could be rejected. Interestingly, Gordon Smith, a Senator from Oregon, has proven fundamental in overriding the Oregon voters on this issue.

Chapters 8 and 9 review the story of aids and how that disease kills it victims, while chapters 10 and 11 describe death by cancer. Chapter 12 summarizes, and leaves the reader contemplating the fact that it's all but certain we will each die by one or more of the processes described in Nuland's book. How we die, and how we will be remembered, however, are entirely up to each of us as individuals


Frank yet compassionate book about death & dying.   March 22, 2002
David J. Gannon (San Antonio, TX USA)
102 out of 105 found this review helpful

What actually happens during "clinical death"? Why do we age, and what happens to the body? This National Book Award winner Particularly recommended for anyone in a position to explain these difficult processes to others. This award-winning account describes in frank yet compassionate detail just what most of us are likely to face when the time comes, Sherwin B. Nuland's How We Die combines erudition and eloquence in a refreshingly unsentimental look at the processes of death. A distinguished surgeon and gifted writer, Nuland illuminates the mechanisms of cancer, heart attack, AIDS, and Alzheimer's disease with precision and compassionate awareness.

Why read such a book? Taking away the fear of the unknown can bring courage and peace in the face of a difficult time. This book presents unpleasant facts in simple language that anyone can understand.

Chapters cover different types of death, making clear the physiological changes and medical choices that go along with each one. It addresses both medical and emotional realities of common conditions such as cancer, heart disease, AIDS, Alzheimer's, severe trauma, and just plain wearing out. (Be prepared to cry, since reading this book may make you experience feelings associated with people you love.)

What makes this book such compelling reading is that Nuland brings to this subject all of the depth and breadth of his background AND his deep concern for the human condition. His long career at a high-powered academic medical center (Yale), his knowledge of the history of medicine, of literature and philosophy, and his own personal losses are all woven into his thesis. He is thus highly convincing when he criticizes physicians for becoming seduced by the intellectual challenge of solving "The Riddle" and making recommendations not in the best interests of the patient/family.

But the power of the book is in its intensely personal depiction of these events and in the lessons which Nuland draws from his experiences. The message is twofold: very few will "die with dignity" so that (1) it behooves us to lead a productive LIFE of dignity, (2) physicians, patients, and families should behave appropriately to allow nature to take its course instead of treating death as the enemy to be staved off at any cost. Only then will it be possible for us to die in the "best" possible way--in relative comfort, in the company of those we love/who love us.

A "must read" for those of us in the baby-boomer generation who, unfortunately, are going to have to deal with a lot of what's covered in this book over the remainder of our lives.


Don't be afraid to read this book   February 8, 2000
Toller Girl (Boston, USA)
58 out of 59 found this review helpful

I'm not sure what made me read "How We Die". It just appeared on my reader's radar a couple of years ago. First let me say that what I came away with was a profound sense of the awesomeness of human life and death, especially the awesomeness of physical death. The author explains in careful and graphic detail what happens to the body's systems under various scenarios that eventually result in the inevitable death of the body. Strangely, this information was more embracing and empowering than depressing and sad. Somehow, the knowledge of WHAT really happens when we die frees me to move on to HOW I feel about it and how I can deal with it. For me, the book stripped much of the power from various traditional, political, religous, legal, societal, and familial interpretations of this event, and allowed me to start to think it through for myself. Long after I finished the book, I found myself reflecting on the information presented by the author, and more importantly, digging deeply into my own psyche and soul to uncover what I really feel and believe. When my father died last year, I felt able to observe and participate in the process with less fear and dread, and more of a sense of power than if I had never read the book. While the events and circumstance of his illness and eventual death were extremely sad and difficult, I credit this book (and the mental and emotional effort I put into reading and reflecting on it) with allowing me to accept the fact that my father was going to die, and to deal with everything that had to be dealt with. Thank you, Dr. Nuland.


A Most Necessary Book About Death & Dying!   November 6, 2005
ellen (Detroit, MI)
16 out of 16 found this review helpful

What a simply amazing and compassionate book about death and dying. None of us wants to think about how or when we will die. For those of you who fear death, reading this book will help to ease many of your fears.
We often wonder just what a person feels or thinks about during the dying process and this book helps to answer alot of questions. It also addresses the question about just how long we should prolong a person's life.
I wish I had read this book before my mom died a few years ago. I was with her in the nursing home on her deathbed and I was left with so many questions that needed to be answered. This book would have been a great comfort.
After experiencing mom's struggle with Alzheimer's and being with her at the moment of death I started to prepare some type of document containing my final wishes. Before I read this marvelous book I had purchased a brilliant new publication by Renata Marie Vestevich called, "Grant Me My Final Wish: A personal journal to simplify life's inevitable journey." Ms. Vestevich has created a beautifully bound journal which will act as a person's ethical will. She gently guides the reader through the process of making their final wishes known. Inside the journal are places for you to leave behind your most precious photos as well as your most treasured memories. Long after you are gone your loved ones will be able to remember you through this beautiful journal. Use this journal along with this book to guide you through the process of having to one day, too, make that final journey. Prepare yourself now and rest assured when it is time for you to leave this earth that you will have made your wishes known as well as having left behind a living legacy for those you love.


No exceptions   September 27, 2005
Shalom Freedman (Jerusalem,Israel)
14 out of 14 found this review helpful

This is a sane and sensible treatment of a most painful subject. Nuland is not only a physician and writer, he is a compassionate human being and an educator. He aims in this work to teach us how to prepare for the inevitable, how to better understand how to deal with death when it comes.
As he understands it there is a tendency to romanticize the final moments, to imagine the end of the drama is a kind of bedside scene in which family and friends gather to say farewell to one who peacefully slips off. Nuland would disabuse us of that notion and teach that Death is ordinarily more messy prolonged and complicated than we would like. And that it often comes only through the deprivation of the dignity of the suffering patient.
He emphasizes that our human goal should be not to focus overmuch on the death of the person, but rather on their life and its remembrance.
He examines the major causes of death, Old Age, Cancer, Heart Disease, Trauma, Aids, Alzheimers. He gives us moving case - histories one of his own grandmother's passing from the world, the other of a young child suddenly killed. He underlines the point that no matter how healthy the person thinks they are they can never know when and how Death will come. No one has a guarantee of an easy way out.
He does not really touch upon any religious or spiritual consolation. And though he indicates that he did say the Jewish prayer of mourning Kaddish for his mother he gives no indication that he believes in an afterlife. "If there is a God," he says, "He is present as much in the creation of each of us as He was at the creation of the earth".
He again would have us focus on life. And so he warns against those who would struggle at any and all costs to artificially extend life through heroic measures i.e. he urges an acceptance of Death as inevitable and necessary. He on the other side he is in general against giving patients' the right to take their
own lives.
This work may tell some more than they ever want to know about death, and may help others better prepare for it.
The late William Saroyan on his deathbed was seen shaking his head. When he was asked what it is , he said," I knew everybody had to die , but in my case I thought they would make an exception'
They did not.
For each and every one of us one of the most chilling facts of life is that we too will not be an exception.
And as I write this I write it with a certain fear and a prayer to God for help.