The entire text of
How We Die
was read by several people of disparate backgrounds, whose comments proved extremely helpful in my own final scrutiny: Joan Behar, Robert Burt, Judith Cuthbertson, Margaret DeVane, and James Ponet. It goes without saying that Bob Massey and Sarah Peterson made numerous critical contributions as they reviewed the evolving work, chapter by chapter. Bob’s style is benevolent and diplomatic, but that Peterson woman is unsparing in her pursuit of what I have elsewhere called “the recognition of rambling and the discouragement of drift.” I always made the changes when she pointed them out—even
her
charity has its limits.
And finally, to my new friends in the world of publishing.
How We Die
originated in the vision of Glen Hartley—not only the idea but even the title was his. At Dan Frank’s suggestion, he and Lynn Chu sought me out and presented me with a mission I could not turn away from. The manuscript that ultimately resulted was passed through the filter of Dan’s skillful editorial mind; only his authors can fully appreciate the value of such guidance. Sonny Mehta carried this project in his own gentle hands from inception to conclusion, as its editor, publisher, and chief booster. If there is an all-star team in publishing, this must surely be it.
It is said that in the twentieth century there are no longer any Muses, but I have found one. Her name is Elisabeth Sifton, and I have tried to treat ideas and the English language in ways that will please her. I ask no greater reward than her approval.
There is a second of Laurence Sterne’s aphorisms that applies to
How We Die
. It is this: “Every man’s wit must come from every man’s soul, and no other body’s.” This is my book. No matter the inspiration and contributions of so many others, I declare every bit of it—every conception and every misconception, every truth and every error, every helpful thought and every useless interpretation—to be my own. They are no other body’s.
How We Die
is no other body’s because this book comes from my soul.
S.B.N.
Introduction
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 better to comprehend what is happening to a mortally stricken loved one—or more likely out of that id-borne fascination with death we all share—we are lured by thoughts of life’s ending. To most people, death remains a hidden secret, as eroticized as it is feared. We are irresistibly attracted by the very anxieties we find most terrifying; we are drawn to them by a primitive excitement that arises from flirtation with danger. Moths and flames, mankind and death—there is little difference.
None of us seems psychologically able to cope with the thought of our own state of death, with the idea of a permanent unconsciousness in which there is neither void nor vacuum—in which there is simply nothing. It seems so different from the nothing that preceded life. As with every other looming terror and looming temptation, we seek ways to deny the power of death and the icy hold in which it grips human thought. Its constant closeness has always inspired traditional methods by which we consciously and unconsciously disguise its reality, such as folk tales, allegories, dreams, and even jokes. In recent generations, we have added something new: We have created the method of modern dying. Modern dying takes place in the modern hospital, where it can be hidden, cleansed of its organic blight, and finally packaged for modern burial. We can now deny the power not only of death but of nature itself. We hide our faces from its face, but still we spread our fingers just a bit, because there is something in us that cannot resist a peek.
We compose scenarios that we yearn to see enacted by our mortally ill beloved, and the performances are successful just often enough to sustain our expectations. Faith in the possibility of such a scenario has ever been a tradition of Western societies, which in centuries past valued a good death as the salvation of the soul and an uplifting experience for friends and family and celebrated it in the literature and pictorial representations of
ars moriendi
, the art of dying. Originally,
ars moriendi
was a religious and spiritual endeavor, described by the fifteenth-century printer William Caxton as “the craft for to deye for the helthe of mannes sowle.” In time, it evolved into the concept of the beautiful death, truly the correct way to die. But
ars moriendi
is nowadays made difficult by the very fact of our attempts at concealing and sanitizing—and especially preventing—which result in the kinds of deathbed scenes that occur in such specialized hiding places as intensive care units, oncology research facilities, and emergency rooms. The good death has increasingly become a myth. Actually, it has always been for the most part a myth, but never nearly as much as today. The chief ingredient of the myth is the longed-for ideal of “death with dignity.”
Not long ago, I saw in my clinical office a forty-three-year-old attorney on whom I had operated for an early-stage breast cancer three years before. Although she was free of disease and had every expectation of permanent cure, she seemed oddly upset that day. At the end of the visit, she asked if she might stay a bit longer, to talk. She then began to describe the recent death in another city of her mother, from the same disease of which she herself had almost certainly been cured. “My mother died in agony,” she said, “and no matter how hard the doctors tried, they couldn’t make things easy for her. It was nothing like the peaceful end I expected. I thought it would be spiritual, that we would talk about her life, about the two of us together. But it never happened—there was too much pain, too much Demerol.” And then, in an outburst of tearful rage, she said, “Dr. Nuland, there was no dignity in my mother’s death!”
My patient needed a great deal of reassurance that there had been nothing unusual about the way her mother died, that she had not done something wrong to prevent her mother from experiencing that “spiritual” death with dignity that she had anticipated. All of her efforts and expectations had been in vain, and now this very intelligent woman was in despair. I tried to make clear to her that the belief in the probability of death with dignity is our, and society’s, attempt to deal with the reality of what is all too frequently a series of destructive events that involve by their very nature the disintegration of the dying person’s humanity. I have not often seen much dignity in the process by which we die.
The quest to achieve true dignity fails when our bodies fail. Occasionally—very occasionally—unique circumstances of death will be granted to someone with a unique personality, and that lucky combination will make it happen, but such a confluence of fortune is uncommon, and, in any case, not to be expected by any but a very few people.
I have written this book to demythologize the process of dying. My intention is not to depict it as a horror-filled sequence of painful and disgusting degradations, but to present it in its biological and clinical reality, as seen by those who are witness to it and felt by those who experience it. Only by a frank discussion of the very details of dying can we best deal with those aspects that frighten us the most. It is by knowing the truth and being prepared for it that we rid ourselves of that fear of the terra incognita of death that leads to self-deception and disillusions.
There is a vast literature on death and dying. Virtually all of it is intended to help people cope with the emotional trauma involved in the process and its aftermath; the details of physical deterioration have for the most part not been much stressed. Only within the pages of professional journals are to be found descriptions of the actual processes by which various diseases drain us of vitality and take away our lives.
My career and my lifelong experience of death confirm John Webster’s observation that there are indeed “ten thousand several doors for men to take their exits”; my wish is to help fulfill the prayer of the poet Rainer Maria Rilke: “Oh Lord, give each of us his own death.” This book is about the doors, and the passageways that lead to them; I have tried to write it in such a way that insofar as circumstances allow, choices may be made that will give each of us his or her own death.
I have chosen six of the most common disease categories of our time, not only because they include the mortal illnesses that will take the great majority of us but for another reason as well: The six have characteristics that are representative of certain universal processes that we will all experience as we are dying. The stoppage of circulation, the inadequate transport of oxygen to tissues, the flickering out of brain function, the failure of organs, the destruction of vital centers—these are the weapons of every horseman of death. A familiarity with them will explain how we die of illnesses not specifically described in this book. Those I have chosen are not only our most common avenues to death, they are also the ones whose paving stones are trod by everyone, no matter the rarity of the final disease.
My mother died of colon cancer one week after my eleventh birthday, and that fact has shaped my life. All that I have become and much that I have not become, I trace directly or indirectly to her death. When I began writing this book, my brother had been dead just a little more than a year, also of colon cancer. In my professional and personal life, I have lived with the awareness of death’s imminence for more than half a century, and labored in its constant presence for all but the first decade of that time. This is the book in which I will try to tell what I have learned.
Sherwin B. Nuland
New Haven
June 1993
AUTHOR
’
S NOTE
With the exception of Robert DeMatteis, the names of all patients and their families have been altered to preserve confidentiality. It should also be noted that “Dr. Mary Defoe,” who appears in Chapter
VIII
, actually represents a composite of three young doctors at the Yale–New Haven Hospital.
I
The Strangled Heart
E
VERY LIFE IS
different from any that has gone before it, and so is every death. The uniqueness of each of us extends even to the way we die. Though most people know that various diseases carry us to our final hours by various paths, only very few comprehend the fullness of that endless multitude of ways by which the final forces of the human spirit can separate themselves from the body. Every one of death’s diverse appearances is as distinctive as that singular face we each show the world during the days of life. Every man will yield up the ghost in a manner that the heavens have never known before: every woman will go her final way in her own way.
The first time in my professional career that I saw death’s remorseless eyes, they were fixed on a fifty-two-year-old man, lying in seeming comfort between the crisp sheets of a freshly made-up bed, in a private room at a large university teaching hospital. I had just begun my third year of medical school, and it was my unsettling lot to encounter death and my very first patient at the same hour.
James McCarty was a powerfully built construction executive whose business success had seduced him into patterns of living that we now know are suicidal. But the events of his illness took place almost forty years ago, when we understood a great deal less about the dangers of the good life—when smoking, red meat, and great slabs of bacon, butter, and belly were thought to be the risk-free rewards of achievement. He had let himself become flabby, and sedentary as well. Whereas he had once directed on-site the crews of his thriving construction company, he was now content to lead imperiously from behind a desk. McCarty delivered his pronouncements most of the day from a comfortable swivel chair that provided him an unobstructed view of the New Haven Green and the Quinnipiack Club, his favorite grillroom for midday executive gluttony.
The events of McCarty’s hospitalization are easily recalled, because the startling staccato with which they burst forth instantly and permanently imprinted them in my mind. I have never forgotten what I saw, and did, that night.
McCarty arrived in the hospital’s emergency room at about 8:00 p.m. on a hot and humid evening in early September, complaining of a constricting pressure behind his breastbone that seemed to radiate up into his throat and down his left arm. The pressure had begun an hour earlier, after his usual heavy dinner, a few Camels, and an upsetting phone call from the youngest of his three children, an indulged young woman who had just started her freshman year at a fashionable women’s college.
The intern who saw McCarty in the emergency room noted that he looked ashen and sweaty and had an irregular pulse. In the ten minutes it took to wheel the electrocardiogram machine down the hall and connect it to the patient, he had begun to look better and his unsteady cardiac rhythm had reverted to normal. The electrocardiographic tracing nonetheless revealed that an infarction had occurred, meaning that a small area of the wall of the heart had been damaged. His condition seemed stable, and preparations were made to transfer him to a bed upstairs—there were no coronary intensive care units in the 1950s. His private physician came in to see McCarty and reassured himself that his patient was now comfortable and seemed to be out of danger.
McCarty reached the medical floor at 11:00 p.m., and I arrived with him. Not being on duty that evening, I had gone to the rush party that my student fraternity held to inveigle entering freshmen into joining. A glass of beer and a lot of conviviality had made me feel especially self-confident, and I decided to visit the care division to which I had been assigned only that morning, the first of my clinical rotations on the Internal Medicine service. Third-year medical students, who are just starting out in their initial experience with patients, tend to be eager to the point of zealousness, and I was no different than most. I came up to the division to trail after the intern, hoping to see an interesting emergency, and to make myself helpful in any way I could. If there was an imminent ward procedure, like a spinal tap or the placement of a chest tube, I wanted to be there to do it.