It hasn’t ended. A half century later. Noland is a surgeon, author and professor of surgery and medical history at Yale University, and not a day goes by in which he doesn’t contemplate death. Not so much his, but ours. In his stunningly frank new book, How We Die (278 pages. Knopf $24). Nuland strips away the fantasy about what happens when the body stops. He is unsparing. Heart ,attacks, cancer, AIDS, Alzheimer’s, old age, even the murder of a 9-year-old-Nuland portrays them to the last gasp, hoping that patients and doctors in this high-tech world of medicine will learn when to let go. “It’s unnatural to believe death usually has a beauty and a concordance and is usually a coming together of your life’s work,” says Nuland, 63, sitting in his office in the Yale medical library. “it leads to frustration for the patient. And it leaves grieving families convinced they did something wrong.”
Nuland is no “Dr. Death.” His book is not a prescriptive like Derek Humphry’s 1991 “Final Exit,” which offered how-tos on everything from positioning a plastic bag over the head to storing lethal mixtures. Nor is his the eerie obsession of Dr. Jack Kevorkian, the steely champion of assisted suicide who, as a pathologist-in-training, peered into the eves of the terminally ill, hoping to pinpoint the moment of death. in his slouchy red cardigan and gray corduroys, Nuland looks like the kindly general practitioner you might have had if only this were a nation of general practitioners. Even his nickname, Shep, invites familiarity. Philosophically, he calls himself a Jewish agnostic, chuckling at the incongruity of belonging to a temple when he’s not even sure he believes in God. Still, his spirituality is intact. “When a man is dying,” he writes, “the walls of his room enclose a chapel, and it is right to enter it in hushed reverence.” Doctors, he says, have forgotten their “pastoral function”: to minister to the dying, not simply to stave off death at any cost.
Nearly 6,100 Americans die every day, yet most people, at once revulsed and transfixed, approach even an uneventful death as if it were a train wreck. That’s not surprising. “By and large,” says Noland, “dying is a messy business.” He learned that the day he met his first patient. Nuland was alone in a hospital room with James McCarty when the 52-year-old construction executive had a massive heart attack. Slitting McCarty from nipple to back, he grasped the failing heart in his hand–it felt like a bag of “hyperactive worms”–and massaged it. Nothing happened, but he kept going. “And suddenly,” he writes, “something stupefying in its horror took place–the dead McCarty, whose soul was by that time totally departed, threw back his head once more and … roared out to the distant heavens a dreadful rasping whoop that sounded like the hounds of hell were barking. Only later did I realize that what I had heard was McCarty’s version of the death rattle … It was his way, it seemed, of telling me to desist.”
Before the early 20th century, death was a member of the family. Doors on houses were built to accommodate a coffin, parlors were designed to hold mourners. The sights, sounds, smells of death were as ordinary as those of a baby being born on the kitchen table. When Grandma was dying, she was with her family. And when she was dead, they remembered her by who she was, not what killed her. All that changed as science became more proficient at prolonging life. Now Grandpa goes into a modern medical center to die, and The Man becomes The Disease. “We take away his clothes, we take away the fact that he once wrote a book or drove a truck 3,000 miles or knew how to make a particular tool,” Nuland says. “We treat patients as if they had no existence before we [doctors] met them, and we make their decisions for them because we’ve taken away the most important part of them-who they are.”
If the art of dying has disappeared, who’s to blame? Nuland points to a culture that cannot accept death as part of an inevitable cycle. Instead, scientists are modern warriors, cultural icons with the power to save anything. “People think everything is curable,” says Nuland, who argues that doctors are so unrelenting in their pursuit of a diagnosis and a cure–what he calls “The Riddle”–that they forget what’s best for the patient. Like the precocious child no one ever scolds, no doctor is ever told, “Enough!” Most patients, Nuland says, are so awed by the authority of medical science and so frightened of dying that they grab whatever shreds of hope are held out to them. They allow their doctors to sway them into often-painful treatments, even when their instincts tell them it’s too late. Out of 9,000 patients in 30 years, Nuland remembers only one or two who ever refused his advice to continue–and when they did, he dismissed them as “bizarre.”
More often they were as willing to please as Hazel Welch. When Nuland met Hazel, she was 92 and had just been diagnosed with a perforated digestive tract. He recommended surgery. And she refused, informing him that she’d lived long enough, thank you. Nuland insisted that while she had only a one-in-three chance of surviving, it was better than certain death. Finally, she relented, “but only”, she told Nuland, “because I trust you.” The damage was more severe than Nuland had predicted and the operation was more extensive. And though she survived, Hazel was furious with Nuland for not letting her use her illness as a gracious way finally to die. At the time, Noland didn’t understand. He does now. “We shouldn’t say, ‘You have a 1-in-1,000 chance of surviving.’ We should say, ‘You have only a 1-in-1,000 chance.’ We should be counselors, not advocates of biomedical science.”
Nuland doesn’t advocate holding back progress, but he does believe that the next step in social evolution is a collective acceptance that medicine can go only so far. Treason? Nuland expects that his ideas will infuriate the medical establishment. But while science has prolonged individual lives by 5, 10, even 50 years, he notes, the life span of the human species still caps out at 100 or so. “We’re never going to reach a time when we come to grips with every one of the forces put on earth to prune society.”
But such calculus ignores the human urge to stave off death, especially when it’s your mother or brother who’s dying. Nuland knows it too well. When his older brother, Harvey, was diagnosed four years ago with the same colon cancer that killed their mother, surgery couldn’t clear all of it away. That, Nuland writes, is when he ignored his own advice and enrolled Harvey in an experimental program that mixed potentially lethal combinations of drugs. The side effects were toxic: nausea, uncontrollable diarrhea, soaring fevers, near comas. The family finally pulled Harvey out of the program. Harvey paid a high price for unfulfilled hope. He died about when he would have anyway, and what remained of his life was vastly diminished.
The reasons Shep Nuland played the odds could never be set out in a textbook. They’re rooted in his childhood, but they’re also not unlike his patients’ reasons. “You remember you’re a little boy, your parents don’t read or write English and you live in an apartment in the Bronx. And there is only one person living through it as you did. You’ve gone to the same schools. He went through adolescence three years before you. You have the same kinds of friends. You go out into the world and your direction is different-you become worldly you become American … And one day you’re reminded of everything you come from because the one link is dying.”
When Nuland set out to write a book in 1992, a Year after his brother’s death, he expected the results would be coolly detached. But, soon enough, stories about his mother, his grandmother and his brother were filling the pages. Now, he realizes, even a doctor who has spent decades looking at death can learn. “By writing this book. I so familiarized myself with death that it is in no way the terra incognita it once was.” Nuland says. “Instead of my belonging to death, death now belongs to me.” After 50 years. the boy from the Bronx has come to terms with his mother’s death.
PHOTOS: Until the 20th century, death was a member of the family, says Nuland (left). The sights, sounds, smells of the dying were as ordinary as those of a baby being born on the kitchen table.
After he had been in the home a while, Phil [who had Alzheimer’s disease] began to gain weight, a total finally of forty-five pounds on his already-generous proportions. But then he stopped eating, forgot, in fact, how to chew. Janet would have to put her fingers in his mouth to extract bits of food lest he choke on them. By that time, he no longer remembered his name. Although his ability to chew returned, he never again knew who he was. Until he stopped talking altogether, he would every once in a while look at Janet, for just a brief moment, with the old gentleness. Choosing exactly the words he had used so many countless times during their half century life together, he would murmur, with all of the familiar softness and devotion of days long gone, “I love you–you’re beautiful, and I love you.” As soon as those words were uttered, he always crossed back to the other side, the side of oblivion.
