How We Die

Published in 1994, Sherwin B. Nuland’s How We Die: Reflections on Life’s Final Chapter is a meditation on the nature of death and dying. In the book, the author presents distinct yet connected perspectives on death based on his own knowledge, experience, and character. Nuland draws from the medical knowledge he has garnered as a surgeon, his accomplished scholarship, his compassionate personality, his take on society, and his own experience with dying loved ones. In doing so, he presents a unique philosophy of living and dying that is comprehensive. More than just consolation, his words provide a new reflection on a pain-filled topic.

Nuland opens the book with an epigraph from seventeenth-century writer John Webster, “Death hath ten thousand several doors/For men to take their exits.” The author insists that dying begins upon a person’s birth because of its inevitability. The clock begins to tick as soon as we are born. No matter how much vitality we as humans possess, no one is exempt from decline and subsequent death.

Beginning with a clinical perspective, the author lists some of the most common ways human life is taken, including heart attack, cancer, AIDS, and stroke. He then describes what occurs medically as people die, be it through a criminal act, an accident, disease, or old age. Every form of death includes universal processes, such as organ failure and loss of brain function, all of which point to oxygen as the most vital component of life. The bottom line, says Nuland, is that one way or another, death eventually steals from us the breath that gives life.



Taking on the viewpoint of a scholar and historian, Nuland communicates that essentially little has changed since the days of Hippocrates, the so-called father of medicine. Though medical advancements have progressed tremendously, and we have been able to extend the length of human life by decades, we are still unable to conquer death or even the unpleasantness of aging, which includes degeneration and decay. The demise of the physical body may be delayed for a time, but dying is what it means to be human. This perspective gives readers an idea of the historical development of medicine while also acknowledging that this history reveals that nothing can stop death.

Nuland then turns to his experience as a doctor who takes care of both living and dying patients. He advises that refusing to accept death as inevitable is unwise and pointless. Individuals should focus, he says, on the quality of life rather than its duration. Though diseases should be cured and medical intervention used if possible, sometimes, such cures produce more suffering than the diseases. In those cases, says Nuland, doctors, patients, and loved ones should take the time to understand the options available and make realistic decisions about how they would like the patient to live out his or her final days.

Nuland expresses a true passion for life and the desire for it to be a good experience. However, as a doctor, he has seen more death than most, and he states that little dignity lies in the process of dying. Revealing many physical details about the actualities of death, the author maintains that modern medicine has done too much to isolate the dying person from the very process of dying. He further contends that there is nothing romantic about death. We fight, he says, until the end, even when the fight is a lost cause. The human body continues to “rage against the dying of the light,” in poet Dylan Thomas’s words. The notion of dying with dignity—very prominent at the time of the book’s release—is an idealistic possibility rather than the reality of death. In this attempt to remove the romance from death, Nuland takes his readers to scenes where he has witnessed people die from devastating diseases, often with no one by their side.



The author then reflects upon a line from the poet Rainer Maria Rilke, “Oh Lord, give each of us his own death.” Nuland does not cherish this line, however, because he thinks the request will be fulfilled in a way that can be controlled by man or God. Instead, he communicates that each and every person will have his or her own death and, as such, we should know how we die. This truth, he says, will allow us to live and die with less angst and unrealistic expectations, causing us to live more genuine lives.

In closing, Nuland stresses that we should make the most of life and do what we are capable of during our time on earth but then accept our fate so that others can have their time. Before we go, we should try to live in a way that no one has to die alone or in unnecessary agony. Finally, he says, we should try to have a life that is appreciated and remembered well by those around us.