Dr Saheb Sahu
In 1944, surgeon and writer Dr Sherwin B. Nuland of Yale University published a book titled, How We Die: Reflections of Life’s Final Chapter. The book was awarded the Pulitzer Prize for General Nonfiction.
I am a retired physician of 80 plus years of age. I have been writing on the topic of “death and dying’ since 2004. I have read this book twice, the last time few days ago. In this article, I will quote liberally from the book and add some of my own thoughts on the subject of ‘How We Die’.
Dr Nuland (1930-2014) believed that modern society often hides death behind hospital walls and use euphemisms like “passed away” or “departed”. Many people imagine dying as peaceful and serene, yet physicians and nurses frequently witness a more complex reality. By explaining the physiological mechanisms of dying, Dr Nuland sought not to frighten readers but to remove fear born of ignorance. He explained not only why people die, but how they die-medically, emotionally, and existentially. Knowledge, he argued, can help face mortality with greater dignity and understanding.
Leading Causes of Death
The top five leading causes of death in the United States are: heart disease, cancer, unintentional injuries (accidents), strokes and chronic lower respiratory diseases. The top five causes of death in India are: heart disease, chronic respiratory diseases like chronic obstructive pulmonary disease (COPD, lower respiratory infections like pneumonia and diabetes. (ICMR-INDIB).
Different illnesses produce different paths to death
. Heart Disease
Death from heart disease often occurs suddenly. A heart attack or fatal arrhythmia (irregular heart rate) may abruptly deprive the brain of oxygen. Within seconds consciousness fades, and irreversible brain damage follows within minutes. Contrary to popular belief, however sudden death is not always painless. Some individuals experience severe chest pain, breathlessness, or distress before losing consciousness.
. Cancer
Cancer usually follows a different trajectory. Rather than a sudden event, it is often a gradual process of systemic decline. Advanced cancer can cause weight loss, weakness, infections and organ failures. There are also all kinds of unwanted side effects from chemotherapy and radiation therapy like: nausea, vomiting, loss of appetite, hair loss and many more.
. Stroke
Large strokes can destroy critical areas of the brain responsible for consciousness and breathing. Some patients die quickly; others survive with neurological deficits. Similarly, Alzheimer’s disease leads to death not directly through memory loss but through complications such as infections, malnutrition, or inability to swallow. In this way dementia becomes a long farewell, progressively eroding the person’s physical and cognitive capacity.
. COPD
Patients with chronic obstructive pulmonary disease (COPD) do not die simply because they stop breathing suddenly. Rather, death typically results from one or more complications of progressively failing lungs- like pneumonia, viral infection like flu or corvid or congestive heart failure.
. Lower respiratory Infections
Lower respiratory infections include illnesses such a pneumonia, bronchitis, and bronchiolitis. Among older adults, the most serious lower respiratory infection is pneumonia. With lung infections blood oxygen levels fall and the person may experience shortness of breath, rapid breathing, fatigue and weakness, confusion or drowsiness. In frail older adults, pneumonia has historically been called “the old man‘s friend” because death may occur relatively quickly. However, this phrase can be misleading, as some people can experience severe breathlessness and distress.
. Diabetes
Diabetes itself rarely causes death directly. Rather it damages blood vessels, nerves, kidneys, eyes and other organs over many years, leading to complications that may be fatal. People with diabetes have a markedly increase risk of heart attack, stroke, heart failure, and kidney failure. The process of dying from diabetes therefor varies depending upon the complication involved.
The Major Themes of the Book
1- The Body Ultimately Wears Out
No matter how advance medicine becomes, death remains an inevitable part of life. Death usually occurs when or more vital organ systems- heart, lung, brain, or kidneys- can no longer function. Physicians can often postpone death, but they cannot eliminate mortality.
2- Different Diseases Have Different Modes of Dying
For example:
.Heart attack may cause sudden death or may lead to progressive heart failure.
.Cancer often leads to wasting, infection, or organ failure.
. Stroke can cause brain swelling, inability to breath and death.
. People with COPD die from lower respiratory infections like pneumonia.
. People with diabetes usually die from organ failure.
3- Medicine Has Limits
Aggressive treatment especially in cancer patients may prolong life but without improving the quality.
4- Understanding Death Reduces Fear
Fear often arises from uncertainty. Dr. Nuland believed that learning the biological realities of dying allows patients and families to make informed end-of-life decisions.
Some Direct Quotations from“How We Die”
. “A promise we can keep and a hope we can give is the certainty that no man or woman will be left to die alone”.
. “Pursuing treatments against great odds may seem like a heroic act to some, but too commonly it is a form of unwilling disservice to the patients”.
. “Some (patients and families) believe that doctors always know exactly what they are doing, and uncertainty is utterly alien to the super specialists who treat the most seriously ill people in the hospital”.
. “For many of the dying, intensive care, with its isolation among strangers, extinguishes their hope of not being abandoned in the last hours. In fact, they are abandoned, to the good intentions of highly skilled professional personnel who barely know them.”
. “Dying is ugly and dirty as the French social historian Philippe Aries pointed out, and we do not easily tolerate anymore what is ugly and dirty. Death is therefore to be secluded and to occur in sequestered place like hospitals”.
. “Agnostics and even atheists have been known to find solace in religion at such times, and their drastic changes in heart are to be respected”.
. “Hope lies not only in an expectation of cure or even of the remission of present distress. For dying patients, the hope of cure will always be shown to be ultimately false, and even the hope of relief too often turns to ashes. When my time comes, I will seek hope in the knowledge that in so far as possible I will not be allowed to suffer or subjected to needless attempts to maintain life; I will seek it in the certainty that I will not be abandoned to die alone…”
From Epilogue
. Good health is a guarantee of nothing. The only certainty I have about my own death is another of those wishes we all have in common: I want it to be without suffering. There are those who wish to die quickly, perhaps with instantaneous suddenness; there are those who wish to die at the end of a brief, anguish-free illness, surrounded by the people and things they love. I am one of the later, and I suspect I am the majority”.
. “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.”
Conclusion
I strongly recommend you to read Dr. Nuland’s book “How We Die” and Dr. Atul Gawande’s book “Being Mortal”. Both books examine aging, illness, and death, arguing that modern medicine often prioritizes extending life, leading to unnecessary suffering. Both authors recommend early use of palliative/or hospice care to alleviate pain and suffering. Gawande’s personal journey of caring for his dying father (who died from brain tumor), makes his book more personal and poignant. Indian readers will relate to his experience of taking his father’s ashes to Varanasi and immersing it in the Ganges.
We have no control over when we will die (except in situation of physician-assisted dying where it is legal), but we do have some control over where and how we will die. Everybody wants to have a good death: free from pain and suffering, and surrounded by loved ones. But a so called good death is rare. In real life,” dying is painful, messy and imperfect” says Dr, Nuland. For the sake of people we love, and for our own sake, we should take steps to plan for the final last chapter of our lives. Those steps should include: making our wishes clearly known to our family, friends and personal physician. Ideally, we should execute a living will stating whether or not we would want life-prolonging treatments like: tube feeding, cardio-pulmonary resuscitation (CPR), respirator(breathing machine), blood transfusion, physician assisted dying ( where it is legal), voluntary stoppage of eating and drinking(VSED). VSED or Pyopavesa is legal everywhere. We should also discuss organs and body donation and funeral rites. We should give someone we trust, “A medical durable power of attorney/ medical proxy” who will legally be able to make medical decisions on our behalves, in case we will be unable to do so. It is never too early to start these discussions especially for older individuals.
I will conclude this article with a quote from Shakespeare:
Of all the wonders that I yet have heard,
It seems to me most strange that men should fear;
Seeing that death, a necessary end,
Will come when it will come Shakespeare- Julius Caesar
Sources
1- Sherwin B. Nuland. How We Die: Reflections on life’s final chapter. Alfred A. Knopf, New York; 1993
2- Atul Gawande. Being Mortal: Medicine and what matters at the end. Metropolitan Books, New York; 2014
3- Saheb Sahu. Death A Necessary End Will Come When It Will Come. S.B.Trust; Sambalpur, Odisha: 2014
