Closing the Last Chapter

By John Elson

It is the "undiscover'd country," as Hamlet put it. It may be life's last mystery, the only truly private realm, since sex today is practically a spectator sport. What are the contours of this frightening place? What does it look like, feel like? How does it sound? These are questions that Dr. Sherwin B. Nuland seeks to answer in How We Die (Knopf; 278 pages; $24), a series of eloquent and uncommonly moving reflections on what his subtitle calls "life's final chapter."

Thousands of tomes have been composed about death, but few of them, the author notes, are by those who see the experience most often and up close: physicians and nurses. Nuland is a surgeon who also teaches the history of medicine at Yale. He has the rare ability -- like John McPhee exploring a geological fault -- to explain the abstruse in language that can be both meticulously exact and wondrously evocative. In a chapter on cancer, for instance, his description of how the cells operate contains this startling analogy: "In the community of living tissues, the uncontrolled mob of misfits that is cancer behaves like a gang of perpetually wilding adolescents. They are the juvenile delinquents of cellular society."

Nuland writes about death with unsentimental passion. In an opening episode -- which squeamish readers may find hard to get through without wincing -- he describes his first professional encounter with the phenomenon. As a third- year medical student, he was checking on a 52-year-old male who had entered the hospital with chest pains when the patient suddenly had a massive, life- ending heart attack. In a state of preternatural calm, Nuland responded as his training had taught him: he grabbed a scalpel and scissors, cut open the man's chest and began massaging the still twitching heart. The organ, he recalls, felt like "a wet, jellylike bagful of hyperactive worms."

The rescue effort was for naught. Venting a death rattle, the patient "threw back his head once more and, staring upward at the ceiling with the glassy, unseeing gaze of open dead eyes, roared out to the distant heavens a dreadful rasping whoop that sounded like the hounds of hell were barking." The intern on duty assured Nuland he had done all that could be done. Conscious only of his failure, the doctor-to-be wept uncontrollably.

How We Die contains vivid accounts, based on individual case histories, of death's major causes, from accidents to Alzheimer's to AIDS. One of Nuland's case histories involves a drug addict and AIDS victim he calls Ishmael Garcia. With chilling clarity, the author describes Garcia's gradual and painful "descent into the valley of fever and incoherence" via pneumonia, meningitis and lymphoma of the brain. As he lay dying, Garcia was taking 14 experimental medications, none of which slowed what Nuland calls "a jet- propelled pestilence." Death certificates require that attending doctors state a cause; Nuland points out that for most of the elderly the villain is old age. Bodies wear out like old machines, as Thomas Jefferson, then 78, sagely wrote to the 81-year-old John Adams in 1814: "We must expect that, worn as they are, here a pivot, there a wheel, now a pinion, next a spring, will be giving way: and however we may tinker them up for a while, all will at length surcease."

Nuland applauds the wonders achieved by modern high-tech medicine. Nonetheless, in several chapters he excoriates the arrogance and hubris of medical specialists, who so frequently take charge of patients with a terminal disease. Forgetting that most people in extremis want a peaceful and painless end, these experts see cancer or heart disease or whatever primarily as riddles to be deciphered. Thus they impose upon patients intrusive and painful procedures that marginally extend their days on earth but do little to enhance the quality of their fading life.

What of the Hippocratic oath -- the doctor's imperative to save lives whenever possible? Nuland argues that patients have the right to determine the proper time for them to go. He has no use for specialists in assisted suicides -- "accoucheurs to the grave," he scornfully calls them -- but considers it permissible for doctors to abet the process of dying in cases of unendurable pain. The ideal death, Nuland believes, takes place amid loved ones, in the familiar comfort of home or hospice. Sadly, 80% of the elderly die in hospitals, denied tranquillity by the whole armory of science. "The beeping and squealing monitors, the hissing of respirators and pistoned mattresses, the flashing multicolored electronic signals" -- all these conspire to deny patients a dignified departure.

Some doctors impose desperate, life-extending measures out of the conviction that to do otherwise would be to deprive people of hope. They are mistaken, argues Nuland. "The greatest dignity to be found in death is the dignity of the life that preceded it," he writes. "Hope resides in the meaning of what our lives have been." And death is meaningful for another reason, he insists. Humankind belongs to an ecosystem that is based on rebirth and renewal, with old lives passing away to make room for new ones. "In my end is my beginning," wrote T.S. Eliot, quoting Mary, Queen of Scots' motto. He could have added, In my end is their beginning also.