Authors: Sherwin B Nuland
How We Die (43 page)
When at last the moment comes and the perception is inescapable that we have reached the point where, with Browning’s Jochanan Hakkadosh, our “feet tread the way of all flesh,” it is incumbent on us to remember that it is not only the way of all flesh but the way of all life, and it has its own plans for us. Though we find clever ways to delay, there is no way to undo those plans. Even suicides yield to the cycle, and for all we know the stimulus for the action they take has been designed in some vast scheme that is just another example of the immutable laws of nature and its animal economy. Shakespeare has Julius Caesar reflect that:
Of all the wonders that I yet have heard,It seems to me most strange that men should fear;Seeing that death, a necessary end,Will come when it will come.
Epilogue
I
AM MORE
concerned with the microcosm than the macrocosm; I am more interested in how a man lives than how a star dies; how a woman makes her way in the world than how a comet streaks across the heavens. If there is a God, He is present as much in the creation of each of us as He was at the creation of the earth. The human condition is the mystery that engages my fascination, not the condition of the cosmos.
AM MORE
concerned with the microcosm than the macrocosm; I am more interested in how a man lives than how a star dies; how a woman makes her way in the world than how a comet streaks across the heavens. If there is a God, He is present as much in the creation of each of us as He was at the creation of the earth. The human condition is the mystery that engages my fascination, not the condition of the cosmos.
To understand the human condition has been the work of my life. During that life, which is now into its seventh decade, I have had my share of sorrows and my share of triumphs. Sometimes I think I have had far more than my share of both, but that impression probably stems from the inclination we all share, which makes each of us see our own existence as a heightened example of universal experience—a life that is somehow larger than life, and felt more deeply.
There is no way to foretell whether this is to be my last decade or whether there will be more—good health is a guarantee of nothing. The only certainty I have about my own death is another of those wishes we all have in common: I want it to be without suffering. There are those who wish to die quickly, perhaps with instantaneous suddenness; there are those who wish to die at the end of a brief, anguish-free illness, surrounded by the people and the things they love. I am one of the latter, and I suspect I am in the majority.
What I hope, unfortunately, is not what I expect. I have seen too much of death to ignore the overwhelming odds that it will not occur as I wish it. Like most people, I will probably suffer with the physical and emotional distress that accompany many mortal illnesses, and like most people I will probably compound the pained uncertainty of my last months by the further agony of indecision—to continue or to give in, to be treated aggressively or to be comforted, to struggle for the possibility of more time or to call it a day and a life—these are the two sides of the mirror into which we look when afflicted by those illnesses that have the power to kill. The side in which we choose to see ourselves reflected during the last days should reveal an image that is tranquil in its decision, but even that is not to be counted on.
I have written this book as much for myself as for everyone who reads it. By trooping some of the army of the horsemen of death across the field of our vision, I hope to recall the things I have seen, and make them familiar to everyone else. There is no need to look at the whole long line of mounted murderers; there are far more cavalrymen than any of us could have the stomach for. But they all use weapons not much different from those you have been reading about.
If they become just a bit more familiar, perhaps these horsemen will also become less frightening, and perhaps those decisions that must be made can be sought out in an atmosphere less charged with half-knowledge, anxiety, and unjustified expectations. For each of us, there may be a death that is the right death, and we should strive to find it, while accepting that it may prove ultimately to be beyond our grasp. The final disease that nature inflicts on us will determine the atmosphere in which we take our leave of life, but our own choices should be allowed, insofar as possible, to be the decisive factor in the manner of our going. Rilke wrote:
Oh Lord, give each of us his own death,The dying, that issues forth out of the lifeIn which he had love, meaning and despair.
The poet states it as a prayer, and, like all prayers, it may not be possible to answer it, even for God. For too many of us, the manner of death will prove to be beyond control, and no knowledge or wisdom can change that. During the dying of someone we love or of ourselves, it is valuable to know that there are still far too many things about which circumstance does not allow choices, even with the finest and most beneficently motivated of the forces of modern biomedical science on our side. It is not a judgment upon the many that they are fated to die badly, simply the nature of the thing that kills them.
The great majority of people do not leave life in a way they would choose. In previous centuries, men believed in the concept of
ars moriendi
, the art of dying. Those were times when the only possible attitude to the approach of death was to let it happen—once certain symptoms made their appearance, there was no choice but to die the best way possible, at peace with God. But even then, most people went through a period of suffering that preceded the end; there was little but resignation and the consolation of prayer and family to ease the final time.
ars moriendi
, the art of dying. Those were times when the only possible attitude to the approach of death was to let it happen—once certain symptoms made their appearance, there was no choice but to die the best way possible, at peace with God. But even then, most people went through a period of suffering that preceded the end; there was little but resignation and the consolation of prayer and family to ease the final time.
We live today in the era not of the art of dying, but of the art of saving life, and the dilemmas in that art are multitudinous. As recently as half a century ago, that other great art, the art of medicine, still prided itself on its ability to manage the process of death, making it as tranquil as professional kindness could. Except in the too-few programs such as hospice, that part of the art is now mostly lost, replaced by the brilliance of rescue and, unfortunately, the all-too-common abandonment when rescue proves impossible.
Death belongs to the dying and to those who love them. Though it may be sullied by the incursive havoc of disease, it must not be permitted to be further disrupted by well-meant exercises in futility. Decisions about continuation of treatment are influenced by the enthusiasm of the doctors who propose them. Commonly, the most accomplished of the specialists are also the most convinced and unyielding believers in biomedicine’s ability to overcome the challenge presented by a pathological process close to claiming its victim. A family grasps at a straw that comes in the form of a statistic; what is offered as objective clinical reality is often the subjectivity of a devout disciple of the philosophy that death is an implacable enemy. To such warriors, even a temporary victory justifies the laying waste of the fields in which a dying man has cultivated his life.
I say these things not to condemn high-tech doctors. I have been one of them, and I have shared the excitement of last-ditch fights for life and the supreme satisfaction that comes when they are won. But more than a few of my victories have been Pyrrhic. The suffering was sometimes not worth the success. I also believe that had I been able to project myself into the place of the family and the patient, I would have been less often certain that the desperate struggle should be undertaken.
When I have a major illness requiring highly specialized treatment, I will seek out a doctor skilled in its provision. But I will not expect of him that he understand my values, my expectations for myself and those I love, my spiritual nature, or my philosophy of life. That is not what he is trained for and that is not what he will be good at. It is not what drives those engines of his excellence.
For those reasons, I will not allow a specialist to decide when to let go. I will choose my own way, or at least make the elements of my own way so clear that the choice, should I be unable, can be made by those who know me best. The conditions of my illness may not permit me to “die well” or with any of the dignity we so optimistically seek, but within the limits of my ability to control, I will not die later than I should simply for the senseless reason that a highly skilled technological physician does not understand who I am.
Between the lines of this book lies an unspoken plea for the resurrection of the family doctor. Each one of us needs a guide who knows
us
as well as he knows the pathways by which we can approach death. There are so many ways to travel through the same thickets of disease, so many choices to make, so many stations at which we may choose to rest, continue, or end the journey completely—until the last steps of that journey we need the company of those we love, and we need the wisdom to choose the way that is ours alone. The clinical objectivity that should enter into our decisions must come from a doctor familiar with our values and the lives we have led, and not just from the virtual stranger whose superspecialized biomedical skills we have called upon. At such times, it is not the kindness of strangers we need, but the understanding of a longtime medical friend. In whatever way our system of health care is reorganized, good judgment demands that this simple truth be appreciated.
us
as well as he knows the pathways by which we can approach death. There are so many ways to travel through the same thickets of disease, so many choices to make, so many stations at which we may choose to rest, continue, or end the journey completely—until the last steps of that journey we need the company of those we love, and we need the wisdom to choose the way that is ours alone. The clinical objectivity that should enter into our decisions must come from a doctor familiar with our values and the lives we have led, and not just from the virtual stranger whose superspecialized biomedical skills we have called upon. At such times, it is not the kindness of strangers we need, but the understanding of a longtime medical friend. In whatever way our system of health care is reorganized, good judgment demands that this simple truth be appreciated.
And yet, even with the most sensitive medical ombudsman, real control requires one’s own knowledge about the ways of sickness and death. Just as I have seen people struggle too long, I have also seen others give up too early, when there is still much that can be done to preserve not only life but enjoyment as well. The more knowledge we have about the realities of lethal illness, the more sensible we can be about choosing the time to stop or the time to fight on, and the less we expect the kind of death most of us will not have. For those who die and those who love them, a realistic expectation is the surest path to tranquillity. When we mourn, it should be the loss of love that makes us grieve, not the guilt that we did something wrong.
A realistic expectation also demands our acceptance that one’s allotted time on earth must be limited to an allowance consistent with the continuity of the existence of our species. Mankind, for all its unique gifts, is just as much a part of the ecosystem as is any other zoologic or botanical form, and nature does not distinguish. We die so that the world may continue to live. We have been given the miracle of life because trillions upon trillions of living things have prepared the way for us and then have died—in a sense, for us. We die, in turn, so that others may live. The tragedy of a single individual becomes, in the balance of natural things, the triumph of ongoing life.
All of this makes more precious each hour of those we have been given; it demands that life must be useful and rewarding. If by our work and pleasure, our triumphs and our failures, each of us is contributing to an evolving process of continuity not only of our species but of the entire balance of nature, the dignity we create in the time allotted to us becomes a continuum with the dignity we achieve by the altruism of accepting the necessity of death.
How important, then, is the actual deathbed scene of serenity and leave-taking? For most of us, it will prove to be an image of wishfulness, an ideal to be striven for, perhaps even approached, but usually not attained except by comparatively few, whose circumstances of terminal illness permit it to come to pass.
The rest of us must make do with what we will be given. Through an understanding of the mechanisms by which the commonest mortal diseases kill, through the wisdom that comes of realistic expectations, through a new understanding with our physicians that we do not ask of them what they cannot give, the end can be managed with the greatest degree of control allowed by the pathological process that kills us.
Though the hour of death itself is commonly tranquil and often preceded by blissful unawareness, the serenity is usually bought at a fearful price—and the price is the process by which we reach that point. There are some who manage to achieve moments of nobility in which they somehow transcend the indignities being visited on them, and these moments are to be cherished. But such intervals do not lessen the distress over which they briefly triumph. Life is dappled with periods of pain, and for some of us is suffused with it. In the course of ordinary living, the pain is mitigated by periods of peace and times of joy. In dying, however, there is only the affliction. Its brief respites and ebbs are known always to be fleeting and soon succeeded by a recurrence of the travail. The peace, and sometimes the joy, that may come occurs with the release. In this sense, there is often a serenity—sometimes even a dignity—in the act of death, but rarely in the process of dying.
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 that we seek in dying must be found in the dignity with which we have lived our lives.
Ars moriendi
is
ars vivendi
: The art of dying is the art of living. 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 weeks 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. William Cullen Bryant was only twenty-seven years old when he added a final section to his contemplation on death, “Thanatopsis,” but he already understood, as poets often do:
Ars moriendi
is
ars vivendi
: The art of dying is the art of living. 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 weeks 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. William Cullen Bryant was only twenty-seven years old when he added a final section to his contemplation on death, “Thanatopsis,” but he already understood, as poets often do:
So live, that when thy summons comes to joinThe innumerable caravan, which movesTo that mysterious realm, where each shall takeHis chamber in the silent halls of death,Thou go not, like the quarry-slave at night,Scourged to his dungeon, but, sustained and soothedBy an unfaltering trust, approach thy grave,Like one who wraps the drapery of his couchAbout him, and lies down to pleasant dreams.
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