Die, Reflections on Life's Final Chapter by Sherwin B. Nuland

Although the ultimate outcome for all living things is death, the aging and dying process and the terminal consequences of mortality are understood in very different ways by different people. From a strictly biological perspective, all things begin dying as soon as they are born, of course, but few people wish to dwell on this aspect of their lives, preferring to postpone consideration of the inevitable for as long as possible. Moreover, innovations in medicine, the elimination of many diseases and improvements in healthcare delivery have extended the human life span considerably in recent years, further postponing the inevitable outcome of the human experience as well as the need to consider its implications. In response to these trends, Dr. Sherwin B. Nuland's book, How We Die, Reflections on Life's Final Chapter, examines how people tend to regard the process of dying to develop an informed and insightful approach to helping people cope with this stage in their lives. To determine his credentials and what Dr. Nuland has to say about how people die, this paper provides a review of his book, followed by a summary of the research and important findings in the conclusion.

Review and Analysis

Author's Credentials

According to the brief biography that prefaces his book, Dr. Nuland, is a prolific Author, having written Doctors: The Biography of Medicine and The Origins of Anesthesia (included in a volume of the Classics of Medicine Library) as well as contributing to publications such as The New Yorker, The New Republic and Discover. In addition, Dr. Nuland reports that he is a Clinical Professor of Surgery and the History of Medicine, and a Fellow of the Institution for Social and Policy Studies at Yale School of Medicine where he obtained his medical degree, as well as the literary editor of Connecticut Medicine and chairman of managers for the Journal of the History of Medicine and Allied Sciences. Furthermore, at 81 years old today, Dr. Nuland does not appear to be slowing down either. For example, beginning in 1998, his column, "The Uncertain Art," began regular appearances in the prestigious peer-reviewed journal, American Scholar (Nuland, 1998).

Salient Points

In his book, Dr. Nuland makes the point that dying and death are much like a sore tooth. People will push on it with their tongues just to experience the pain and to make sure it is still there, but they may not know why they relish the painful experience. In this regard, according to Nuland, "Everyone wants to know the details of dying, though few are willing to say so. Whether to anticipate the events of our own final illness or to better comprehend what is happening to a mortally stricken loved one -- or more likely out of that id-borne fascination with death that we all share -- we are lured by thoughts of life's ending" (p. xv). Using this universal fascination as a point of departure, Dr. Nuland presents a series of illustrative vignettes and real-world examples concerning the perceptions that humankind has developed concerning death over the millennia to demonstrate the pervasiveness of the age-old human interest in and fascination with dying and death.

As humans have gained decades of additional life compared to the life spans of a century or so ago, they become susceptible to an increasingly wider array of diseases and frailties that can adversely affect the quality of their lives, as well as how they regard the ultimate outcome of these infirmities. Just as there are "no atheists in foxholes," Dr. Nuland suggests that when push comes to shove, even the most ardent nonbelievers may seek spiritual solace in preparation for the hereafter.

The most interesting point to emerge from this discussion, though, was the author's observation that this redemptive element has been becoming less important in recent years as people appear to have been influenced by the Age of Information where reports of death and dying around the world are commonplace and fewer people are attending organized religious observances as part of their personal value system. While it is reasonable to suggest that billions and billions of people around the world continue to receive this redemptive element during their end-life stages, the general trend today is in marked contrast to the past. For instance, the author emphasizes that, "In ages past, the hour of death was, insofar as circumstances permitted, seen as a time of spiritual sanctity, and of a last communion with those being left behind. The dying expected this to be so, and it was not easily denied them" (Nuland, 1994, p. 256).

This veritable greediness and desperation for solace during the final hours in people's lives is perhaps more readily understandable given the shorter lifespans that were characteristic of the era and the centrality that religion played in many societies. In this regard, Nuland notes that, "It was their consolation and the consolation of their loved ones for the parting and especially for the miseries that had very likely preceded it. For many, this last communion was the focus not only of the sense that a good death was being granted them but of the hope they saw in the existence of God and an afterlife" (p. 256).

The events that followed the dawn of the 21st century made it abundantly clear that this century was going to be a dangerous one, so these trends in rejecting the solace available through organized religion are ironic if not perplexing. For instance, Dr. Nuland writes, "It is ironic that in redefining hope, I should find it necessary to call attention to what was until recently the very precinct in which most people would seek it. Much less commonly than at any other time do the dying nowadays turn to God and the promise of an afterlife when the present life is fading" (p. 256). This trend is due in large part to the manner in which people tend to die in the modern world. In contrast to ages past, rather than being surrounded by loved ones at home, people today are containerized in hospitals and hospices where the dirty work is done by others and visitors can come and go as they please, clucking their tongues in grief as they leave. For example, Dr. Nuland points out that, "We have created the method of modern dying. Modern dying takes place in the modern hospital where it can be cleansed of its organic blight and finally packaged for modern burial" (p. xv).

Notwithstanding these general modern trends in rejecting age-old views concerning how people should die a "good death," Dr. Nuland also makes it another important point that even today, many people may experience a change of heart when it comes to their religious beliefs when they are faced with their ultimate mortality. As the author points out, "Agnostics and even atheists have been known to find solace in religion at such times, and their drastic changes of heart are to be respected" (p. 256). Although the author makes it clear the healthcare professionals, family members, and close friends alike should respect such "foxhole conversions," Dr. Nuland also makes it clear that a "good death" can only truly be achieved by living a "good life." In this regard, the author concludes that, "The honesty and grace of the years of life that are ending is the real measure of how we die. It is not in the last week or days that we compose the message that will be remembered, but in all the decades that preceded them. Who has lived in dignity, dies in dignity" (1994, p. 268).

A final point made by Dr. Nuland was the uniqueness of the death experience. Irrespective of the other commonalities that are characteristic of theā€¦