Roy Exum: Dr. Nuland: ‘How We Die’

Friday, March 7, 2014 - by Roy Exum
Roy Exum
Roy Exum

Ten years ago there was a book written that won the National Book Award for non-fiction and was a finalist for a Pulitzer Prize. Over a half-million copies were sold in several languages, yet it was so frank in its topic there were some readers who were unable to finish it. Dr. Sherwin Nuland, the author of “How We Die: Reflections on Life’s Final Chapter,” died earlier this week and his passing intrigued those who believe his book to be a medical classic.

His daughter told the Associated Press that the former surgeon and his family talked about his terminal illness (prostate cancer) and his impending death often and, predictably, said there were times when he seemed at peace and others when he appeared scared and sad. “He wasn’t scared of death itself,” she explained, “but he loved everything about his world and the people in his world and life and didn’t want to leave.”

I can’t think of many people who are eager to die but I hold the belief it is as natural as childbirth. As Dr. Nuland himself once wrote, “Nature will always win in the end, as it must if our species is to survive.” It was his view that life is lost due to old age and disease and in his book, which told pretty graphically what really happens in the last grim stages when people die of cancer or heart attack, he championed the fact death is a natural phenomenon.

That was why Dr. Nuland urged modern-day physicians to recognize when the time is right to let a patient die. While he did not advocate physician-assisted suicide, he was also a believer in death with dignity and there lies the rub. His book, “How We Die,” showed that rarely does death with dignity actually occur without proper knowledge and planning.

No, with medical technology as great and the quest to prolong death a physician’s sworn responsibility, “Living Wills” and “Advanced Directives” have never been as necessary to a death with dignity. Dr. Nuland urged those in his profession to recognize when further treatment is futile and rather than have a patient die surrounded by machines and tubes and strangers, to allow their patients to slip away “without suffering and surrounded by loved ones.”

“It’s unnatural to believe death usually has a beauty and a concordance and is usually a coming together of your life’s work,” he once said. “It leads to frustration for the patient. And it leaves grieving families convinced they did something wrong.”

Barbara Coombs Lee, a former ER and ICU nurse and physician assistant who coauthored the nation's first death-with-dignity law in Oregon, heads an end-of-life movement known as Compassion & Choices and praised Dr. Nuland for initiating an open discussion on death with his book.

"Dr. Nuland was heroic in bringing conversations about dying out of the closet. He openly acknowledged medically assisted dying exists in states like Connecticut where it is considered illegal. Our own fight is to legalize aid in dying and bring a surreptitious practice into the open, where it is safe and accessible to everyone," she said.

She quoted a paragraph from Dr. Nuland’s book: “Like so many of my colleagues, I have more than once broken the law to ease a patient's going, because my promise, spoken or implied, (to do everything possible to provide an easy death) could not be kept unless I did so."

Coombs Lee said Dr. Nuland recalled his brother’s death from colon cancer as a life’s guide. "Dr. Nuland learned from his brother’s death that physicians who urge futile treatments on patients with incurable, terminal diseases often cause great suffering," she said. “Ultimately, Dr. Nuland died as most doctors do, peacefully in his own home. He understood the end was near and opted to die gently in the loving arms of his family. And most Americans want to follow his example."

In the closing pages of Dr. Nuland’s book, where he yearned for dignity at the end, he wrote, “And so, if the classic image of dying with dignity must be modified or even discarded, what is to be salvaged of our hope for the final memories we leave to those who love us? The dignity we seek in dying must be found in the dignity with which we have lived our lives.”

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