A warning not to tinker with life's natural limits
FROM THE BEGINNING, SHERWIN NUland knew the man's advanced intestinal cancer was terminal. There was no hope of beating it, and scant likelihood of even delaying death for more than a few months. But the patient was his 62-year-old brother, Harvey, and Nuland—a veteran surgeon at Yale New Haven Hospital who should have known better—recommended a grueling, experimental course of chemotherapy that caused Harvey much pain and suffering before he died 10 months later in 1990. "I was trying to play the role of the big-shot doctor, and I bought into my brother's denial by not telling him the absolute truth," says Nuland, his voice still raw with grief. "Here I was, the kid brother whom he expected could gel him out of this. But I couldn't."
Nuland's sin wasn't merely that of a loving brother, he believes, but of the medical profession at large: Driven to prolong life at any cost, doctors are robbing us of a natural death with dignity—and heightening our fear of the end that awaits us all. Now a teacher at Yale University School of Medicine, Nuland, 63, has put a human face on death in an acclaimed new book, How We Die: Reflections on Life's Final Chapter (Knopf). In it he tries to demystify death by chronicling precisely what happens to the body as disease and aging lake their toll on various organs; he also describes the most common killers of our time—including heart failure, Alzheimer's disease and AIDS. Praising the book for its "unrelenting honesty and unsettling detail," Kirkus Reviews warned that it is "strong stuff—not for those who prefer to cling to comforting illusions about life's end."
But the grimness of the subject is offset by Nuland's profoundly poignant stories about the deaths of several family members—among them his parents and grandmother, as well as his beloved brother. "As I wrote, I realized I was reliving how I fell during all those years," says Nuland, who also found that the wisdom acquired during some three decades of practice had coalesced. The dignity we seek in dying is not to be found in one's final weeks, days or moments, he believes, but "in the way we live and how we are seen by those people whose lives we affect."
The child of Russian Jews who came to America in 1903, Nuland grew up in New York City, where his parents, Meyer and Vitsche, toiled in the sweatshops of the garment district. When he was 7, his mother developed intestinal cancer—an illness that would color his childhood for the next four years. He remembers the adults discussing her failing health in hushed whispers outside his parents' bedroom—which had been converted into a sickroom—in their tiny four-room Bronx apartment. And he recalls her frequent stays at the hospital; not permitted to visit her there, because he was a child, he would stand across the street from her room, looking up at her window and waving to her. When Vitsche worsened for the last time, he says, "I didn't even realize it was different. She was at home in the bedroom, and the nurse kept going in and out. When I understood that she had died, I just got sick."
Nuland took comfort with his older brother, with whom he was extremely close. But then his maternal grandmother—a strong, vibrant woman the family called Bubbeh, the Yiddish equivalent—began her descent into old age. Her steps became slower, her breathing labored at the slightest exertion, and her vision failed. Nuland was at home with Bubbeh when she suffered her first stroke while cleaning the kitchen table. "She seemed to be looking at something outside the window beyond my chair, and her unseeing eyes had the dullness of oblivion," he recalls. "I knew at that instant I had lost her." When she died several months later at 97—of a "cerebrovascular accident," according to the death certificate—"that diagnosis made little sense," says Nuland. "To tell me that the process I watched until I was 18 had ended in a named, acute disease was illogical. Hers was a slow death of chronic deterioration."
Nuland suffered one more loss just as he completed his studies at Yale—that of his father, who succumbed to a coronary embolism two days after his 28-year-old son was named chief resident of surgery al Yale Hospital. "He cried when I told him the news. It was a very special moment for me—and our very last moment together."
Nuland had been practicing for 30 years when he learned in 1989 that Harvey had the same cancer that had killed their mother—and endorsed the futile attempt to keep his brother alive. Nuland was still struggling with his grief when he began writing How We Die in 1991. "I'm very hard on myself in the book, but I don't know how I could have acted differently," he says. "Harvey's degree of denial would have meant bludgeoning him with reality, and I just couldn't have done that. If that's the way some people choose to die, we doctors have to go along with it."
But those who do wish to go gently should not be forced to do otherwise—and that, he argues, is rarely the case. Nuland notes that 80 percent of all deaths take place in hospitals, where doctors feel bound to marshall all forces to fight to the desperate end. "If you have a bunch of soldiers who stood a 90 percent chance of being killed, they wouldn't keep fighting," he says. "But that's what doctors insist on, which is stupid. And it's stupid for us to accept that attitude." Nuland recommends home or hospice care, in which the likelihood of a peaceful death in the company of loved ones—rather than a cold hospital room cluttered with medical paraphernalia—is far greater.
Retired from his practice since 1991, Nuland teaches medical humanities and history at Yale and is at work on a book that will not only be about his grandmother but will also be a childhood memoir. He prefers to spend his free time at home in Hamden, Conn., with his second wife, Sarah, 46, an actress. And when he isn't playing tennis to relax, he likes singing songs al the kitchen table with children Will, 12, and Molly, 9. (Nuland also has two grown children from a previous marriage.)
An agnostic, Nuland does not believe in the afterlife. For him death is simply part of nature's cycle, the method of making way for the next generation. Not that that eases his pain at the loss of his brother. Remembering Harvey—his lifelong friend and supporter whom he could always turn to when times were tough—Nuland lets the tears roll unchecked down his cheeks. "I just want to call him like I always did, but I can't. I can't," he whispers, resting his head in his hands. "Oh God, I miss him so."
S. AVERY BROWN in Hamden
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