Cómo morimos: Reflexiones sobre el último capítulo de la vida

by Sherwin B. Nuland

Tema tan rehuido como atrayente, la muerte es una experiencia compartida por todos los hombres. Cirujano y profesor en la Facultad de Medicina de la Universidad de Yale, Sherwin B. Nuland desmitifica en Cómo morimos el proceso de morir a través de una descripción sin concesiones ni sensiblerías de la realidad clínica, biológica y psicológica de la muerte. Y es que sólo conocer la verdad, familiarizarnos con los actuales " jinetes de la muerte " -cáncer, SIDA, enfermedades cardiacas, accidentes cerebro-vasculares, Alzheimer, vejez y agresiones violentas- puede ayudar a liberarnos del miedo a ese ámbito desconocido que lleva en último término al autoengaño y a la decepción.

Genres: Nonfiction, Medicine, Science, Death, Philosophy, Medical, Health

252 pages, Hardcover

First published January 25, 1994

About the author

Sherwin Nuland was an American surgeon and author who taught bioethics and medicine at the Yale University School of Medicine. He was the author of The New York Times bestseller and National Book Award winning How We Die, and has also written for The New Yorker, The New York Times, The New Republic, Time, and the New York Review of Books.

His NYTimes obit: http://nyti.ms/1kxNtQC

Reviews

[BlackOxford · Rating 5 out of 5]

The Ultimate Indignity

Either our end will be painful but mercifully quick; or it will be gradual and exceptionally uncomfortable. Medical science makes the latter increasingly likely. Quite apart from the pain involved, the process of dying is always acutely humiliating. I trust Nuland when he says,“I have not often seen much dignity in the process by which we die.”

Perhaps this is why warrior cultures promote the idea of courageous violent death. Such an idea fetishises death which is otherwise an insignificant natural event. Perhaps this fantasy of a courageous end, even among non-combatants, is meant to take the edge off what Thomas Hobbes pointed out, “... that continual fear and danger of violent death; and the life of man solitary, poor, nasty, brutish, and short.”

Nuland wants to deflate the myth of death as a confrontation that should be engaged in with courage, fortitude, and spiritual energy. For him, “Death is the surcease that comes when the exhausting battle has been lost.” One might even say that death is a kind of victory over the attempts of medical science, pharmaceutical companies, and self-concerned families to avoid it. The release from pain, distress, and worry is in this light our ultimate blessing.

The core of Nuland’s book is the detailed description of the mechanisms by which most of us will die - heart disease, cancer, and infections of infinite variety. In addition to preparing the reader for more productive conversations with his or her end-of-life consultant physician, the text is mesmerising in its upbeat account of lethal bodily processes. I find his casual insistence about the inevitability of such processes to be oddly comforting. In dying, the abnormal is normal. Knowing that one is more likely to be better off cooperating with nature sounds to me like pretty good advice.

[Abeer Hoque · Rating 4 out of 5]

On the back of "How We Die" Doris Lessing writes it's a must read for anyone over 50. I say anyone over 35. Because you might still have time then to internalise all the dying lessons Dr. Nuland has to teach, and you're past those forever twenties.

We've got three score and ten years and most of that could be healthy, but after that, the remainder of our body life is borrowed and breaking down. Towards that end, Dr. Nuland urges us to measure quality of life against mechanical extensions of life, value peace of mind over medical miracles (because your surgeon sure as hell won't), and hold our connections with loved ones above everything. Live your life well, he says, because the end will probably not be pretty, and you want the people around you to remember everything else.

Chapter by morbid chapter, and with intimate compassion and poetry, Dr. Nuland charts the major ways we die, all of which have to do with failures of oxygen supply, one way or another: heart attacks and strokes, old age, suicide, murder, accident, Alzheimers, AIDS and other viruses, cancer. The title alone was enough to give me (and everyone around me) pause, when I pulled the book out in public.

We should all learn as much as we can about our bodies, their strengths, and their inevitable failings. It will help us deal more gracefully, or at least more knowingly, with the end. This book is as good a place as any to start.

[Jamie Collins · Rating 4 out of 5]

This book is an attempt by the author, a surgeon, to de-mystify the process of death. He feels that our modern expectation of a "death with dignity" leads to increased suffering when we confront the ugly reality: most people don't experience a peaceful, pain-free death; they don't die at home surrounded by their loved ones; they don't utter profound last words of comfort to those they leave behind.

He offers detailed, technical descriptions of the most common mechanisms of death, including vivid, disturbing details of the various indignities experienced by the dying. He enhances his narrative with deeply moving stories of the end-of-life experiences of his own patients, friends and family members.

Alongside the medical details and anecdotes the author waxes philosophical. He talks about the need for the old to die so that the young can prosper. He is appreciative of modern medicine's ability to improve and prolong life, but he expresses concern that a doctor's drive to diagnose and cure can override his duty to provide the most appropriate care when the end of his patient's life becomes inevitable.

The book was published in 1993 but only seems out of date in the anguished chapter on AIDS.

I was entranced by the technical details and moved to tears by some of the author's personal stories, but his philosophical musings seemed a bit repetitive after a while. Overall a very good book, 4.5 stars.

[Paul Corrigan · Rating 4 out of 5]

I felt compelled to reread HOW WE DIE, starting with the chapters on Cancer, after my wife passed away from an aggressive form of breast cancer. Doctor Nuland is right on when he talks about how the specialists, for whom a disease such as cancer becomes a great riddle to solve, somehow withdraw from the patient's presence when the disease they are trying to interdict cannot be stopped with the assortment of chemo drugs and radiation therapy they have in their tool box. Yes, tool box seems like an appropriate metaphor because chemo therapy with the way it devastates the body gives the whole process of treatment a clunky rattling sense to it. Even in the best of treatment centers with the caring technicians, nurses and doctors, the process of getting well is not very pretty, doling out its share of suffering and pain. Doctor Nuland knows this only too well and his sensitive prose explores that point in such treatment when it is best to start exploring other options, such as hospice care. I must say, however, that my wife's oncologists were caring and sensitive, while she was the subject of their attempts to find the right chemo drugs to slow down, and even beat back for a time, the relentless onslaught of an aggressive, triple negative tumor. It was after she was released and returned home, to die shortly after the last treatment at the cancer center, that the oncologists seem to lose interest. Dr. Nuland talks at length about the moment when the specialists pack up their tool kits and it becomes time for the generalists, the GP's and the hospice care nurses and therapists to work their compassion and relieve the pain that the disease has wrought. It is in this arena that Doctor Nuland's humanity and compassion shines through.

[Dan · Rating 4 out of 5]

“Malignant cells concentrate their energies on reproduction rather than in partaking in the missions a tissue must carry out in order for the life of the organism to go on. The bastard offspring of their hyperactive (albeit asexual) “fornicating” are without the resources to do anything but cause trouble and burden the hardworking community around them. Like their progenitors, they are reproductive but not productive. As individuals, they victimize a sedate, conforming society.
Cancer cells do not even have the decency to die when they should. All nature recognizes that death is the final step in the process of normal maturation. Malignant cells don’t reach that point—their longevity is not finite.”

Excerpt From
How We Die
Sherwin B. Nuland

This book is full of difficult subject matter on end of life causes and it won the National Book Award for Non-Fiction some 25 years ago.

Although this read feels dated today, since both cancer treatments and treatment of HIV have progressed significantly, the conclusions about awareness of end of life decisions and hospice are still spot on.

The author, Stewart Nuland, who has since passed away from prostate cancer was the head of the Yale Medical School. He suffered from mental depression. I don’t know if he wrote this book in a dark place but although it is science based, it is also brutally frank about the pain and discomfort that most dying patients face in their last days and months.

4 stars. Very informative book that is both enlightening and sobering. Best read when in the right place emotionally.

[Chuột Thổ cẩm · Rating 5 out of 5]

Rất khó khăn để đọc xong được cuốn sách này. Vì đọc thấy sợ; sợ bị già đi, sợ bệnh Alzheimer, sợ đột quỵ, sợ mất quá nhiều máu, sợ bị ung thư. Sợ chết. Nhưng hơn cả sự hù doạ không mong muốn, Nuland khiến suy nghĩ của mình về cái chết trở nên thay đổi. “Chân giá trị lớn lao nhất được tìm thấy trong cái chết chính là chân giá trị của cuộc sống đã có trước đó. (...) Hi vọng nằm trong ý nghĩa của cách ta đã sống cuộc đời mình.” Không hoa văn và màu mè, Nuland chỉ ra cách để không sợ cái chết, đấy là xem nó như cái tất yếu của cuộc đời một con người, thay vì sợ, hãy sống “chất lượng hơn là số lượng.” Cuốn sách còn chứa đựng nhiều suy nghĩ giữa mối quan hệ của một bác sĩ với những bệnh nhân đang hấp hối, về tính nhân văn trong cái chết của một người bệnh. Một cuốn sách xứng đáng được truyền tay nhau đọc, để thêm yêu quý việc được sống.

[Richard Kramer · Rating 5 out of 5]

If you are alive, and might someday die, or know anyone who is alive and might someday
die, this might be one of those books you have to read. It takes the piss out of heroics,
and science, and the Dignified Death; it harshly regards the coldness of medical personnel dedicated to solving what
the author calls the Riddle and ignoring the needs of the person that provides it. He is hard on doctors, and hard on himself. Some books please, some entertain, some disappoint. Few,though, change you, and this is one of them. It came at a time when I needed it, when I was
in the process of losing a dear family member. It made me value her life more and, also, my own.

[Larry Bassett · Rating 2 out of 5]

My Dad is ninety-three. I bought this book to share with him some time ago as we have been grappling with the Inevitably of Death for some time now. He is relatively healthy and he has always counted on living at least until ninety-six, the age his father died. But this past year his sharp mind has begun to notice his body lagging somewhat. He likes to have his “four wheeler” to help him get around and dozes more frequently sitting in his chair. “Maybe I won’t make it to ninety-six,” he says.

I travel from Virginia to Michigan to visit him in his assisted living facility every six to eight weeks. He devoured How We Die: Reflections on Life’s Final Chapter in several days during one of my visits last year. But I had never read it until now.

This 1993 book is over twenty years old and with the medical advances in that time you might think that makes this book out of date. But that is not completely true. For example, the book states that “coronary heart disease is America’s number one killer, as it is in every industrialized country of the world.” This is still the case today. In 1993, stroke was the third leading cause of death; today it ranks fourth. The life expectancy (all races, both sexes) was 75.5 years in 1993 and 78.7 years in 2010. (Source: http://www.infoplease.com/ipa/A000514...) This 4.2% increase in longevity, while a significant change in when we die, does not, I think, change how we die. I will speak more of the out-of-date factor at the end of the review.

We sometimes laugh about death and dying. I think that is a good sign. It shouldn’t scare us to death, if I can use that phrase. My Dad and I have laughed about it as well as talking about his Living Will and DNR order. Here is something from a GR review that shows how we joke about death:

Man visits his doctor. Doctor says “I’ve got some bad news, and I’m afraid I’ve got some even worse news.” Guy says “Okay, I’ll have the even worse news first.” Doctor says “Okay, you have terminal cancer. The other news is that you also have Alzheimer’s.” Guy takes a deep breath and says “Okay – well, at least I haven’t got terminal cancer.”

It is January 2014 and singer Pete Seeger has just died at the age of 94. One report is that he died of “natural causes.” You do not hear that very often; it seems we are not allowed to officially die of simple old age. “He was just chopping wood last week,” we are told. And we are pleased to hear that.

Everyone wants a dignified death. But author, Dr. Sherwin Nuland, is not much of a believer in death with dignity, thinking from his experience that it “should not be expected by any but a very few people.” He says at the outset, “The quest to achieve true dignity fails when our bodies fail.” Is it possible that dignity is something that has become more achievable with the passage of time, medical advances and the availability of skilled hospice care?

At the end of the book he talks about The Riddle:

Every medical specialist must admit that he has at times convinced patients to undergo diagnostic or therapeutic measures at a point in illness so far beyond reason that The Riddle might better have remained unsolved. Too often near the end, were the doctor able to see deeply within himself, he might recognize that his decisions and advice are motivated by his inability to give up The Riddle and admit defeat as long as there is any chance of solving it. Though he be kind and considerate of the patient he treats, he allows himself to push his kindness aside because the seduction of The Riddle is so strong and the failure to solve it renders him so weak.

What is the job of the doctor and what is Dr. Nuland trying to do in this book?

We can only give people the hope they will not die alone if we are totally honest with them about what is happening to their bodies. If a physician from the very beginning of a patient's downhill course allows that patient to become a partner in the knowledge of what is going on, there is no sudden moment when he has to say, 'well, there is nothing more we can do"; there is no sudden moment when she has to turn to a family and say, 'shall I tell this patient?'

Dr. Nuland is trying to share with the reader what is going on with the bodies suffering from the most common causes of death. But the fact is that this book contains medical information that is over twenty years old. The success and validity of the approach is threatened by the use of information that the reader is not able to trust to be the most accurate and thus may not be the most empowering.

How We Die gives us a glimpse of an approach that can benefit the dying when put into practice by a medical system equipped with the most up to date information. I need to go right now and reread Sherwin Nuland’s 2007 book The Art of Aging . In the meantime, I am going to give How We Die only two stars: four stars for the concept but one star for being significantly out of date with the implementation data. I hope Nuland’s 2007 book brings his idea successfully into the 21st century.

So who is this pessimist about finding a dignified death, this Dr. Nuland? I was surprised to find him on the World Wide Web giving a TED talk about, get this, HOPE! See his twelve minute 2003 talk at http://www.ted.com/talks/sherwin_nula....

[Michael Perkins · Rating 3 out of 5]

Lest there be any doubt, it was doctors who created the opioid epidemic. Big Pharma was there, ready to pounce, but it was foolish, god-like thinking that set it up....

https://www.vox.com/2017/6/5/15111936...

=======

My father practiced medicine for 40 years, retiring at the end of 1982. Subsequent generations of doctors now consider my dad's time the golden era of primary care. He was a master diagnostician (he loved to say that it was no accident that the author of the Sherlock Holmes stories and the real-life character Holmes was based on were both medical doctors). His era afforded him enough time with patients to really get to know them.

The author explains why this is important...

"Family history, dietary and smoking patterns, probability of compliance with medical advice, plans and hopes for the future, dependability of a support system of family and friends, personality type, and potential for modification if necessary—these are all factors that must be given proper weight in making decisions about treatment and long-term prognosis. It is his or her skill as a physician that enables them to befriend the patient and to know him—it is inherent in the art of medicine to appreciate that the testing and medications are of limited usefulness without the talking."

===============

The first time I read this book was when it came out in the mid-90's, not long after I lost my father. And, given my mother's health, I knew there wasn't much time left for her, either. (She was suffering from congestive heart failure, a product of decades of smoking, but she would not convey anything of what the doctor said to her to me. My sister, also a lifelong heavy smoker, was taking my mother to her appointments and was in denial about its effects on my mother. She's still in denial. My mother died of lung cancer).

This book is rather clinical. At the time, I found that helpful in better understanding the maladies that afflicted my parents.

But this time around, I better understand my daughter's critique of this author's writing. She earned a Masters of Science in Health Policy and Management at the Harvard School of Public Health. They did not read his books there, but when she gave them a shot, at my request, she was not impressed with them. She likened them to unedited grad theses, as opposed to fully formed and edited books. Indeed, she was right. For one thing he is verbose and highly repetitive, especially about pet concepts.

A much better alternative was penned by a member of the Harvard Public Health faculty, surgeon and contributor to The New Yorker, Atul Gawande, "Being Mortal."

https://www.goodreads.com/book/show/2...

[david · Rating 5 out of 5]

A beautifully written account by one who has witnessed many deaths, as a retired surgeon, in a hospital setting.

A scholarly and reflective depiction on the process of quietus.

Great insight for anyone who is concerned that one day they might die.

[Jef Sneider · Rating 4 out of 5]

Sherwin Nuland, MD, was a well known and successful surgeon at Yale Medical Center for many years. In this book he begins to describe, literally, the way we die. In detail, he explains how infection and cancer and heart disease ravage the body and cause essential systems to fail. As a physician, I found it interesting, but I did not think I would finish the book if that was all there was to it.

Then the book began to hold my attention as it developed into an exploration of how people deal with dying, a very different question from how we physically die. Dr. Nuland does a beautiful job with Alzheimer's disease using the slow deterioration of a friend as his example. He helps the reader understand not only the disease, but what the disease process does to the family and friends of the one afflicted.

What was most interesting to me as he made his segue into HIV/AIDS, was how his own values as an old time surgeon began to conflict with evolving codes of ethics, patient and family expectations and modern medical practice. After all, while he trained in the era when the doctor and family could collude to keep the true nature of an illness hidden from a patient, he also was part of a generation of surgeons who saw incredible progress in his field. He repeatedly recognizes that modern medicine can go too far, causing and prolonging suffering when treatment is futile, and yet he tells poignant stories about his own close family in which he cannot stop himself from offering that last sliver of hope even if it means risky surgery or incapacitating chemotherapy.

He is honest. He admits that sometimes physicians are more interested in solving "The Riddle" of the patient's illness even if diagnostic and treatment efforts are unlikely to help relieve suffering. This type of care and thinking are most often to be found in the academic medical center such as the one in which he worked. Academic physicians have a duty to the patient, but they also have a duty to learn and study. Helping the dying patient to an easy death may not always be their priority.

But times are changing. The pendulum has swung from the paternalistic physician who could withhold critical information or pursue treatment regardless of the patient's wishes to the empowered patient who can demand treatment even when it is futile or refuse treatment even when it might be life saving. Nuland recognizes the value of the primary care physician to help guide patients through confusing and complicated medical decisions but he only gives this recognition one sentence. He doesn't trust the empowered patient to make correct decisions. He reserves the right to argue, and he admits to using some unfair tactics to get his way. The physician still has power in the relationship.

As a primary care physician I had to cringe as he put his own brother through dangerous and difficult surgery even though the chance of cure was close to zero. He asks himself why, after the fact, but he has no good answer. He didn't want to admit, given all the tools of modern medicine and his own prowess as a surgeon (he did not do the surgery) that nothing could be done to save him. He did not want to give up hope, so instead he held out false hope.

This book is very easy to read and understand. Nuland does a great job making complex pathophysiology understandable. Unfortunately he could not get past his own guilt and we spend too much time hearing rationalizations for his aggressive (think academic surgeon) treatment of some of his patients.

I recommend the book for those interested in how the body works, or doesn't, and how people think about and react to illness and dying. The section on Alzheimer's disease is excellent and beautifully written. The book also gives insight into the mind of the academic surgeon.

And, should you ever be in a life threatening situation where difficult decisions have to be made, if time permits I would also recommend a conversation with your primary care physician. It is good to get more than one opinion.

[Patrick Peterson · Rating 3 out of 5]

6 Jan. 2019 - Wow - what a book.
I read this book because my folks are 89 and having difficulties, plus many aunts, uncles and pretty close friends died this last year and another friend wrote a very short, but very compelling review here on Goodreads (Reena Kapoor - Thanks Reena). This book was DEFINITELY worth reading for the reasons I mentioned above. But reading it, I found many more reasons why it was worth spending the time to savor it. Here are just some of the reasons, even though I know this is a fairly long list:

- The opening description of the author's contact with his first patient... and first death - an incredibly "gripping" in more ways than one description of a heart attack.

- Amazing prose. The author has a fantastic style of writing. REALLY good.

- Seneca quotation on suicide - excellent. Wise relevant words from this ancient philosopher.

- Personal, intimate additional descriptions of various deaths that explain what was medically going on. His descriptions were indeed shocking, but not like a slasher movie. They were clinical but also very compassionate. Hard to describe how he did it, but you will probably be amazed and impressed and enlightened too.

- One of the biggest reasons why he wrote the book, and what I was hoping to get out of it, which I did, is that he tried explicitly to explain the facts about what actually happens to people and their loved ones, as well as doctors and nurses while people die. This knowledge can turn into power, since it takes away the terror of the unknown! Think about this. Isn't the terror of the unknown what many people are so frightened about? When they learn about the facts of what actually happens, they become stronger and more able to deal with it.

I remember how anxious I was about cataract surgery before I went through it. Well, the Dr. who operated on my eyes was fantastic about realizing this, not just for me but for most of his patients, so he wrote a book about:
- all the details about how to prepare,
- what is actually going to happen during the operation and
- what happens afterwards!
Bingo - that did the trick. It lessened my anxiety (if not fear) about the operation at least 50%. He also put some extra info and videos of actual operations and diagrams, etc. on his website that I (and other patients) could view, answering even more questions I had that the book could not quite do the job on. Those lessened my remaining anxiety even more. All this was in addition to the verbal descriptions of everything from him and his assistants. Fantastic. That is partly what this book does too for dying people and their loved ones who care so much about them.

-More information about sepsis and how deadly this can be - But I still need more info on this.

- The compassion the author shows toward the dying and their loved ones and medical staff - AND how this did not get in the way of his being ruthlessly honest about some motivations of some doctors and the reasons why they may act the way they do. Very insightful and helpful for all. Not always right, but I will explain my critique a bit later.

Some questionable things about the book:
--------------------------------
It was written in 1994, so quite a few things have changed since then, technology, medicines, techniques, procedures, mores, economic conditions such as the general wealth of society, etc.
He gave his readers an update in the edition I read's final "Coda" chapter, and that helped a lot in clarifying what he thought was important to change, what did and did not change and some specific things that put his philosophy in more clarity than in the rest of the book. And for the most part, I was MUCH more disappointed about his values and lack of insight or foolish ideas on economics, and what can and does make conditions better for medical patients in general and on many specifics.

- Economics is about acting man/woman and their choices - it is NOT just about $ and cents. It is NOT just about capital and companies. Because the author was ignorant of basic economics, he misstated some very important problems and his "solutions" were well off the mark and some actually more harmful than helpful. Despite his wonderful economic insight when stating: "that perennial solvent of reluctance, a handful of dollars." he was far from consistent about his economic statements. He far too often showed a very nasty bias against private voluntary economic incentives and benefits, especially vis a vis coercive government involvement. He seemed almost totally oblivious to coercive government mandates, licenses, regulations, subsidies, etc. as the cause of so much wrong in healthcare. He conflated some bad reactions in the private sector with those government causes. Sure they do appear to be all mixed up and interrelated. But there are primary causes and secondary reactions. Confusing the two certainly creates harm by making things worse.

- I really liked much of the author's philosophy on dying and suicide, but I think he equivocates on some specifics and acts a bit 'holier than thou' in his scorn for some individuals and organizations. That is not to say that his cautions for action on assisted suicide are not genuine and important, they seem to be. But he also seemed to fudge certain issues in my mind.

- his statistics and discussion of guns/gun control was very sad and not well done - especially in light of the situation these days, when so many foolish and counterproductive laws are being proposed and/or passed about guns.

- I am not sure about this statement: "suicide—a very large proportion of the elderly men and women who kill themselves do it because they suffer from quite remediable depression. With proper medication and therapy, most of them would be relieved of the cloud of oppressive despair that colors all reason gray, would then realize that the edifice topples not quite so much as thought, and that hope of relief is less hopeless than it seemed. I have more than once seen a suicidal old person emerge from depression, and rediscovered thereby a vibrant friend. When such men or women return to a less despondent vision of reality, their loneliness seems to them less stark and their pain more bearable because life has become interesting again and they realize that there are people who need them. " I need more information on this. Does a "very large proportion of the elderly" that commits suicide actually "suffer from quite remediable depression" - or are they just being more realistic than Dr. Nuland thinks? Is this statement true or just showing his arrogance at how realistically depressing some situations actually are?

- His history of the Flexner Report and the government controls, licensing and involvement that it recommended and which came about from it showed the worst part of Sherwin Nuland's philosophical, historical and economic understanding. This was probably one of the worst things to hit the American public, the opposite of what Nuland believes. But to understand why would take quite a bit. So other books and articles are needed.

I have much more to say about this book, positive and negative, but I have gone on too long as it is.
I bet you can tell that I recommend the book pretty highly. But don't read it without some caution, since he slips in some significant errors that can be harmful from time to time. As Hippocrates said: "First, do no harm."

If the book had no Coda chapter, I probably would have given it 4 stars, which is usually my highest rating. But since the Coda chapter brought out so many errors in the philosophy political/economic, if not moral, by the author, I really can't give it more than three stars, despite how good all the book before that was (except for some select little parts).

Here is the author on why he wrote the book, and the biggest value I got out of it, though I got more of this too, and really appreciated all:
Early in the book: "I have written this book to demythologize the process of dying." and about half-way through: "Accurate knowledge of how a disease kills serves to free us from unnecessary terrors of what we might be fated to endure when we die. We may thus be better prepared to recognize the stations at which it is appropriate to ask for relief, or perhaps to begin contemplating whether to end the journey altogether."

2024-01-14 edited fairly lightly for clarity.

[Lyn Elliott · Rating 5 out of 5]

A remarkable book which my mother, my husband and I all read when my mother developed the heart condition from which she eventually died about 8 years later. Sherland combines scientific knowledge, medical experience, ethical concern and emotional sensitivity as he describes the stages people go through when they are dying of the most common conditions that kill us. It helped us all live with Mum's condition, has since helped through the passing of other close people and I hope will help us in turn to understand what is likely to happen. For me, warmth and compassion are much easier when I'm not troubled by anxiety about not knowing what is happening.

[Rebecca · Rating 4 out of 5]

A truly enlightening read for those who want to either know more about the physiological processes of terminal diseases, those with a family member or loved one suffering from one of the six common pathways to death Nuland outlines, or even those who simply wish to expose themselves in a relatively removed environment to the mysterious process of their ultimate fate, How We Die explores just that- the physical, mental, and emotional processes one goes through on the journey to the other side. Nuland attempts to break down the myth of dying as a dignified process so often described by "poets, essayists, chroniclers, wags, and wise men," who "often write about death but have rarely seen it...[whereas] Physicians and nurses, who see it often, rarely write about it." Stripped to the core, the ultimate death encountered by all is the deprivation of oxygen which shuts down our core vital centers. No matter which disease or illness one is dying from, our existence as obligate aerobes is our ultimate death sentence, for without oxygen we have no life.

For those unaware of the physical turmoils each of these six detailed death sentences encompasses- heart disease, stroke, Alzheimer's (dementia), murder (including suicides and accidents), AIDS, and cancer- Nuland provides an opportunity to walk away with perhaps a more proper dose of understanding and empathy in a world that isolates these victims almost as easily and ambitiously as one quarantines a leper. For those, including myself, who have had the opportunity to observe and endure the deaths of both loved ones and strangers, this book offers validation and biological reasoning to the emotions one feels and the physical signs one witnesses as life passes over from one world to another.

Although Nuland's intentions were to "demythologize the process of dying," it is quite difficult to walk away from this book leaving death's grandeur as a mere image of the past. Though he does an excellent job, for both the medically-minded and lay readers, of explaining the undignified physical and physiological tolls disease takes upon one's body, I still remain in awe of this completely natural and life-changing process- both literally for the victim and figuratively for the observer. I cannot deny the immense suffering we as family members and they as victims endure, no amount of literature or scientific proof can ever ease this experience of pain. However, my medical mind cannot deny the abstract beauty that is the process of our cellular beings shutting down- the literal inability for hemoglobin to carry oxygen to keep our most vital centers functioning, the ultimate lack of circulation to bring blood to our hearts and glucose to our brains. These simple acts we take for granted everyday without giving a second thought to them are the same simple acts that cause our hearts to stop beating. And perhaps they are not simple at all, but rather so intensely intricate that true understanding of our design by the ultimate Creator can never be really be grasped.

No matter what your beliefs, thoughts, or opinions are on the process of dying, I highly recommend this book to any and all who wish to understand in more detail their time on this earth and their connection to the rest of humanity.

[India M. Clamp · Rating 4 out of 5]

Tenacity cannot be taught! It is a skill indicative of what a physician must be (having ability to impart life/death in seconds) to wield a knife, put in a central line or even slicing skin on humble, poor and forgotten patients in the grips economic hell. Dr. Sherwin Nuland instructs us in "How We Die."

Just engaging. Dr. Sherwin Nuland's description of Heart attack as "failure of a Valentine" was literary martini with olive on toothpick. In this book journey he dictates process of observing a friend in the process of dying and using his tools of kindness, compassion and observation for a humane end.

Death is a natural and inevitable conclusion creeping up on the healthy and morbidly compromised patients. This book lays bare many end of life "options" and it's ability to impart clement solutions to a five-letter word that causes most anxiety ubiquitously. Buy, absorb and plan---while healthy.

[Julius · Rating 5 out of 5]

Todos queremos saber cómo es la muerte, aunque pocos estén dispuestos a admitirlo.

No sé ni cómo empezar la reseña de este libro. Me ha superado. Sherwin Nuland contó que «lo que importa no es cómo morimos, sino cómo hemos vivido"». La sacudida vida de Nuland salvó a muchas en el quirófano, enseñó a otras en sus clases universitarias e inspiró más a través de su bibliografía.

Rara vez he visto mucha dignidad en el proceso de morir.

Con esta obra, ganó el National Book Award y fue finalista de un premio Pulitzer. Con él empezó una interesante carrera literaria que le hizo abandonar la medicina para siempre.

Nuland te coge por el cuello, te sienta en una silla, y comienza a hablar de la fisiología de la muerte, de cómo fallan los órganos, de qué sienten los pacientes, de cuál es el rincón del corazón al que le ha tocado ser el eslabón más débil de la cadena. Y eso lo hace con diferentes formas de morir, una por capítulo: infarto, alzheimer, suicidio, la vejez, el SIDA, la demencia...

El doctor no escatima en detalles y describe cual maestro para material de examen todos los apuntes necesarios para que nos acordemos en el examen de nuestras últimas horas. O en el examen de alguien allegado a nosotros. No es un libro para hipocondríacos. Parece que puedan fallar tantas cosas, que lo milagroso sea estar vivo.

Pero al mismo tiempo, Nuland habla sobre experiencias personales, cómo afrontan los médicos la muerte, episodios donde el familiar al que hubo que asesorar sobre el mejor tratamiento en sus últimos meses, fue el suyo. ¿Qué es mejor: resolver el enigma de la muerte, saber exactamente qué está fallando en el paciente e intentar alargarle un poco la vida, sin conocer a ciencia cierta el coste, o recomendarle que no merece la pena luchar?

La puerta se abrió y Dave entró precipitadamente en la habitación. Con una mirada captó toda la escena y la comprendió. Mis hombros se estremecían y mi llanto era ya descontrolado. Bordeando la cama se dirigió a donde yo estaba y, entonces, como si fuésemos actores de una vieja película de la Segunda Guerra Mundial, me pasó el brazo por el hombro y me dijo muy suavemente: «Está bien, muchacho, está bien. Has hecho todo lo que has podido.»

Es una obra didáctica, cruda, de terror, a veces emociona, a menudo reflexiona sobre la esencia de lo humano, y en definitiva, esta obra no va de la muerte, sino de la vida.

Creo que es lo mejor que he leído en lo que va de 2024.

En un libro titulado Merchant and Fnar, el historiador del siglo XIX Sir A. Palgrave escribía: «En la primera pulsación, cuando las fibras se estremecen y los órganos cobran vida, está el germen de la muerte. Antes de que nuestros miembros cobren forma, está cavada la estrecha tumba en la que serán sepultados». Empezamos a morir con el primer acto de vida.

[Jose Moa · Rating 5 out of 5]

As Adan was expeled from paradise for chosing freedom and knowledge ,paid a high price and was punished by his election so we being inteligent beings also have to pay a high price for our inteligence and be punished,our punishment is that we are aware of our inexorable future death and destruction as individuals that we will be departed of our loved ones and we will dont enjoy terrenal future life nor will know future world.
It is a cruelty of the evolutive path that create us inteligent and mortal,when both things ought be incompatible,ever is a tragedy the death of a inteligent being.
Our life for no religious people is a brief interval of existence in a long line of nothingness,as the author says is a odd simetry between birth and death,we are born with pain and we die with pain,nothingness before birth and nothingness after death.

This is the firt book i have read on death,written by a agnostic medicine doctor,but for me is a very great book,a book no much about science but much about humanity,compasion,tolerance,solidarity,unselfishness and over all hope and dignity.

Using several emblematic mortal diseases,accidents,murders or suicide Nuland explain the phisiological process of death,but the book is much more is a book about the philosofy and ethics of death.
The author says that only rarely exist dignity and serenity in death,that the path to death is painful and full of stress for body and mind.He is against the heroic medicine that tortures the dying when is nothing to do.For him the good death is when one dies with the love and company of the relatives and friends and with paliative cares,but this is rarely the norm when so many people dies alone in the high technologic environement of intensive care units.
As in the Death of Ivan Ilich he is also against of not tell the truth and give false hopes that only contribute in this charade to the incomunication and loneliness of the terminal ill adding suffering because he knows that we know ,we know that he knows,everibody knows but nobody touchs the subject

He proposes the redefining of the meaning of hope as the meaning of a plenty full lived life and the love of the next ones.

Nuland shows a in his time open mind when talks about AIDS terminal ill, quoting a friend :
"A lot of the greater comunity really do feel that what is happening to us-its some kind of visitation on us for our sinful and abnormal ways.And so its in our mutual interest not leave someone alone with that judgement of society.Those of us who suffer from some kind of self-loathing may find it very easy to think of AIDS as a form of punishment,but even those of us who dont are aware that much of society does see it that way.To neglect our friends who have to deal with the disease themselves is somehow to abandon them to the judgement of the straight world".

Nuland also warns against a loss of the traditional values of medicine and Hipocrathic oath,drowned in technology and hurry,he is homesick of the family doctor that gives conseil and confort and has a exquisite regard by the nature in its wide meaning when textually says :
"A realistic expectation also demands our acceptance that ones alloted 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 beings have prepared the way for us and die.We die,in turn,so that others may live"
He is advocate of some restricted sort of eutanasia,and for finish he quotes Michel de Montaigne :
"The utility of living consists not in the lenght of days,but in the use of time : a man may have lived long and yet lived but a little"

A very good strongly recomended book

[Lệ Lin · Rating 5 out of 5]

[updated 2020 /english review]
-

I just realised I didn’t write an English review for this book after reading it almost two years ago but believe me, if I can recommend you only one book, this is the one.

Through the eyes of American surgeon Sherwin B. Nuland, the book examines the current state of healthcare (first published in 1994 but most of what he mentioned in the book is still applicable), analyses the moments when his patients walk on the thin string between life and death scientifically (his anecdote and narrative are both mesmerising and haunting), suggests how we can take control the final days of ourselves and our loved ones.

My deep dark fear for death does not be blown away after finishing this book but it has been altered since then, less fear but more acceptance, gratitude and self-improvement.

I read the Vietnamese edition (which has some minor errors in spelling and repetitive phrases) but I can't deny how impactful this book is to me, which is one of the very few books I can confidently say so.

___

[2019]
Cái chết luôn là một nỗi sợ hãi thường trực đầy ẩn khuất đối với riêng mình. Đến khi đọc quyển sách này, bản thân lại có một góc nhìn khoa học hơn, phần nào đó, mang tính chấp nhận và nguôi ngoai hơn.
Tác giả không chỉ chứng tỏ sự thông thái (và khiêm nhường) của một người xuất sắc trong ngành y mà còn ở cách viết còn vô cùng cuốn hút. Mình vô cùng hứng thú bởi các ví dụ được đưa ra. Thậm chí có một ví dụ về bé gái bị một gã xa lạ đâm chết cứ ám ảnh mình tới tận mấy hôm sau... Hơn cả, bác tác giả có một sự nhạy cảm mà khi đọc, không cần hô hào nhưng vẫn cảm giác được cái trăn trở làm nghề.
Mình cũng tự hỏi, không biết các sinh viên hay người làm lâu trong ngành y có biết gì về quyển này không? Vì nó thật sự đáng trong danh sách phải đọc. Có những điều, ví dụ như cứu chữa cật lực, chưa chắc đã là chuyện nên làm. Hơn 400 trang nhưng thật sự mình cứ chỉ muốn nó dày hơn nữa.

Tuy vậy, bản thân khi đọc sách dịch vẫn khó chịu ở các lỗi không đáng có. Dù quyển này dịch rất ổn nhưng lỗi chính tả ít nhưng vẫn rải rác; lỗi lặp từ thì cứ liên tục, nhất là vào chương cuối và câu cú vẫn dài loằng ngoằng.

Rating tuyệt đối cốt là để bày tỏ sự tôn trọng cho bản gốc của tác giả và lâu lâu đọc được sách y khoa hay thì sướng thật sự.

[Lydia · Rating 5 out of 5]

Nuland died last year at 94 years of age. He wrote “How We Die” as a surgeon in New Haven Connecticut in his 70s looking back on his career and his life. What makes this book stand above most others, is Nuland’s wisdom and wonderful ability to write about how death has affected him both personally when dealing with family members’ deaths, but also outlining how his patients have died from different types of diseases, giving us a full, frank picture of the details and ways we could die personally—what those final weeks and moments are like.

I assume most people turn to this book, when they have experienced a death of a family member and realize there is so much they don’t know about death. This was true for me. Nuland outlines the most common forms of death, step-by-step, arteriosclerosis, cancer, alzheimers, and the many forms each take, such as strokes, heart attacks, cancer, AIDS, pneumonia and the general implosion caused by aging. And he talks about why egocentric doctors go into medicine: it is to solve riddles and problems. Finally he has wonderful sections on “hope” and “lessons learned.” It is a gem of a book. The dignity we seek in dying must be found in the dignity, beauty and grace in which we have lived our lives. It takes chapters of kind explanation to arrive at this conclusion—for this reason, it is best to read this book when you need it. To listen to him talk about hope anytime, listen to his TED talk http://www.ted.com/talks/sherwin_nula...

[Alexis · Rating 4 out of 5]

a well-written book. Dr. Nuland writes from years of experience on the topic of death, and how really there is no dignity to it. he explores this myth of 'ars moriendi' (the art of dying) and both the pathophysiology and mental/emotional states that accompany it. he argues against the modern 'hospital' death devoid of feeling, he reproaches biomedicine for it's mistakes in prolonging the lives of their patients for their benefit in solving the Riddle, and not for the patient's best interest... "I have no real quarrell with those who insist upon invoking the laboratory-bred specificity of microscopic pathology in order to satisfy the compulsive demands of the biomedical worldview - I simply think they miss the point." he explores both his mental processes and emotional ones with personal vignettes. he writes with knowledge of pathophysiology, etymology, history, literature and most importantly, humanity.

"it is inherent in the art of medicine to appreciate that the testing and medications are of limited usefulness without the talking."

"The diginity 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."

[Remo · Rating 5 out of 5]

En esta obra se nos muestra cómo las distintas enfermedades, accidentes y traumatismos provocan la muerte (que, según el trivial, siempre termina debiéndose a la falta de riego del cerebro). El autor es un cirujano veterano que salpica su exposición con muchos ejemplos de su vida personal y profesional . El libro está muy bien, aunque el penúltimo capítulo lleva unas reflexiones sobre el ars morendi que son levemente tostónidas. El resto es muy aprovechable. Cáncer, SIDA, Alzheimer, coronarias... todas desfilan ante nosotros con gran cantidad de detalles médicos, sin entrar en el gore, desde el punto de vista ingenieril, casi fontaneril. Un libro muy interesante. Memento mori y entérate de cómo.

[Eshana Seshadri · Rating 5 out of 5]

This book is one that i spent most of the year reading and will definitely read again later in life.

Dr. Nuland brilliantly demythologizes the process of dying, presenting the human’s traversal towards death as a clinical reality — one that we should take interest in understanding. Interwoven with personal stories and philosophical interludes, he tackles the feat of examining the horsemen of death and its deeper scientific processes that we will one day face.

I’d shelve this book as a must-read for those interested in the field of medicine, but also for those with curiosities and anxieties about death as a whole — it can serve as a sort of ‘self-help’ book. (I don’t regret reading this now but also can understand why people may want to put off this read) Dr. Nuland also provides advice for the community surrounding patients entering their final chapter while also pushing for a better healthcare infrastructure that can guide us towards death.

I would add that Dr. Nuland is extremely detailed. His prose is elegant but oftentimes repetitive and this book is definitely not always a page-turner (understandable considering the topics at hand lol)

Overall a 4.5/5!!

“Where love of mankind is, there is also love of the art of medicine.”

[Erika · Rating 1 out of 5]

As Ned Stark says, "Nothing someone says before the word 'but' really counts." In this case, nothing in the book's title, before the colon, counts. Reviews on Goodreads, and blurbs about the book, led me to expect a neutral, unvarnished, and perhaps even helpful account of what to expect during the dying process. This is not that book.

These are Dr. Nuland's reflections. And he has a philosophical point he wants to make, which is unrelated to explaining the mechanics of the death process and might not even be a scientific or medical point.

The book is strongest in its detailed descriptions of how the body works and how it stops working. For instance, his explanation of the cardiovascular system, and the heart in particular, and what exactly happens in congestive heart failure, etc., will be super accessible to people complete outside the medical space. Some of the science (e.g., on Alzheimer's Disease) has advanced since he wrote this book more than 30 years ago. But those details are probably of less importance to the lay reader, anyway. From time to time he uses vernacular that undermines the book's ... well, I can't say credibility ... but it undermines the book's authoritativeness, in order to increase its accessibility, I suppose. Perhaps an acceptable tradeoff given the intended audience.

The book is most compelling and engaging in its autobiographical moments. Not so much the gruesome details of particular deaths he witnessed, but rather the stories from his childhood, within a poor Orthodox Jewish family that had immigrated from the Ukraine, and his grandmother's elderly years and eventual death. That was riveting.

But that's the surface. The agenda is deeper. He is trying to convince the reader of more fundamental points: (1) that the dying process -- not death, but dying, hence "how" we die -- is usually painful, humiliating, and terrifying [take a shot every time he describes a person's dying expression as "panicked" or wildly "desperate," and see if you make it through the first quarter without expiring of alcohol poisoning, go ahead, I dare you]; (2) that the body begins to decay, indeed begins to die, much earlier than the lay person realizes and that much has already happened even when all external appearances are to the contrary; and (3) that efforts to extend the human lifespan will be utterly futile, i.e., all of this is inevitable, including the timing. I believe this final point is actually his most important point, meaning the point most important to him. [Who wins, in a cage fight between Nuland and Aubrey de Grey? Google is your friend.]

He returns, over and over, to a more philosophical point -- that death is natural, because the old must make way for the new, because this is how trees work, and how the earth works, there must be turnover. Ecclesiastes 3:1-8 (for everthing there is a season...), and so forth. My gut tells me that this philosophical point was a foundation for him; it was the source spring from which the book, and perhaps much more, sprang. And it seemed more of a quasi-spiritual point than a scientific point. Much of the book's positive reception probably stems from people who find that message reassuring. For me, this message -- even if reassuring -- was utterly overwhelmed by the jackhammer of HUMILITATING DESPERATE PAINFUL PANICKY SUFFERING and the fact that the more descriptive portions (e.g., what is involved when the body is decaying and dying) are mind-numbingly repetitive. (He needs to flog the dead horse a few thousand times.)

It is easy to see why the book won a National Book Award and why it was a finalist for the Pulitzer. But I think he did the then-emerging field of anti-aging research a disservice, and I think the discoveries and developments of the last 30 years put the lie to some of what he insisted. Finally, many people who read this book will probably conclude that all is lost, and that there's nothing they can do to age more comfortably. And that is simply wrong.

[Mai Anh · Rating 5 out of 5]

Notes:
Từ thế kỷ XV, nghi thức tôn giáo "ars moriendi" được miêu tả là nghệ thuật của cái chết (một cái chết đẹp) khi coi cái chết là sự cứu rỗi của linh hồn, nâng đỡ tinh thần cho người thân còn sống, nhưng ngày nay cái chết bị che đậy trong bệnh viện, trong sự ngột ngạt và xa lánh của mọi người.

Cuốn sách viết về giai đoạn cuối của con người, thông qua việc tìm hiểu những căn bệnh chết người, hoặc nguyên nhân dẫn tới cái chết:
1/ Bệnh liên quan về tim mạch: bệnh xơ vữa động mạch có thể do nhiễm mỡ
2/ Tuổi già:
3/ Bệnh Alzheimer: không còn là căn bệnh của người già, Alzheimer ngày càng xuất hiện ở những người trẻ hơn. Nguyên nhân bắt đầu từ việc não bị tổn thương gây mất trí nhớ, và sau đó hoạt động của hệ thần kinh đi xuống tới mức những hoạt động và cơ chế tự nhiên trong cơ thể cũng dần dần dừng lại, và sau đó là cái chết
4/ Chết vì án mạng, tai nạn, tự tử, an tử:
- Bị sát hại hoặc tai nạn, tác giả đã từng biết một số câu chuyện về sự ra đi thanh thản mặc dù bị giết hoặc tai nạn (do cơ chế sinh ra endorphin trong những tình huống bị kích thích),
- Tự tử:
- An tử
5/ AIDS: cuốn sách xuất bản năm 1993 khi căn bệnh thế kỷ vừa xuất hiện không lâu trước đó, HIV AIDS là nguyên nh��n cho sự chấm dứt của cuộc đời rất nhiều người đặc biệt là người trẻ (tuy nhiên mình có tìm hiểu thì HIV hiện nay có thể xem là một căn bệnh mãn tính - không chữa được nhưng có thể kìm chế sự phát triển nếu dùng thuốc liên tục).
Khác với cơ chế xâm nhập của virus khác, HIV là một retrovirus (vật liệu gen của tế bào được tạo thành từ những chuỗi ADN chứa thông tin di truyền, khi ADN được sao chép thành chuỗi phân tử khác là RNA có chức năng điều khiển sản xuất các protein của tế bào mới, tuy nhiên retrovirus - HIV vật liên gen lại là RNA, khi xâm nhập vào vật chủ nó chuyển thành ADN và sau đó thì tiếp tục sao chép và nhân rộng. Chính sự "ngược đời" này đã cho phép virus này lọt qua hàng rào phòng thủ - hệ miễn dịch của con người mà không hề có một cơ chế phản kháng nào). Khi xâm nhập vào tế bào chủ, nó phá hoại và mở đường cho những virus và bệnh khác để cuối cùng những loại virus không thể tác động gì tới một người bình thường có thể nhanh chóng giết chết một người nhiễm HIV.

HIV: human immunodeficiency virus (virut suy giảm hệ miễn dịch ở người)
AIDS: acquired immune deficiency syndrome

6/ Ung thư
Ung thư được ví như một đứa trẻ ngỗ nghịch xâm nhập vào xã hội, nó không theo lề phép và phá hoại mọi nơi mà nó tới. Những khối u ác tính thâm nhập và phá hủy mô ở cơ quan này rồi lại tiếp tục di chuyển tới cơ quan khác (di căn) và cuối cùng cũng dẫn tới cái chết
...
Và chương cuối cùng là những bài học. Nếu chết mà vẫn còn nuối tiếc thì lúc sống nên sống có ý nghĩa hơn. Tìm hiểu những căn bệnh có thể gây chết người sẽ khiến chúng ta có đủ nhận thức khi nào thì tiếp tục điều trị và khi nào thì có thể thảo luận với bác sĩ và đưa ra quyết định. Có thể có người đã vẽ nên cái chết của mình như thế nào (một cái chết thanh thản yên bình) nhưng cũng có lúc sự thật là họ sẽ phải vật lộn trong đau đớn, hoặc nuối tiếc nhưng mỗi người cần nên tha thứ cho bản thân khi không thể giành được một hình ảnh tưởng tượng về cái chết mà mình đã định.

Cuốn sách thực sự có nhiều thông tin bổ ích cho những người tò mò về cái chết của chính mình hoặc giai đoạn cuối của những người thân. Mặc dù "cái chết" là một điều xui xẻo và thường bị né tránh, nhưng càng né tránh thì khiến chúng ta càng sợ hãi với việc chúng ta một ngày nào đó sẽ ra đi. Nhưng thực sự thì, sự ra đi của những cá nhân đơn lẻ là cơ hội của những sự sống mới ở thế hệ tiếp theo. Con người cũng là một phần của nhân loại, cũng sẽ phải theo quy luật của tự nhiên: sinh ra rồi chết đi như bản thân mọi vật sống khác cũng thế.
(Những đoạn để trống là mình vẫn chưa summarise được)

[Bob Hoffman · Rating 4 out of 5]

It’s not new (1993), but Sherwin Nuland’s How We Die is a timely treatise on what’s going on under the hood when humans die. We all have to leave this world sooner or later, whether by heart attack, stroke, cancer, or accident, but in our culture, it’s not that common to think about or speak of our own demises. Most of us act, instead, as if we will live forever.

In these days there is also a tendency to hide death from view, particularly in nursing homes and hospitals. (As of 1993, 80% of American deaths took place in hospitals, up from 50% in 1949.) And in many of those cases people live out their last days isolated from family and friends attached to ventilators in intensive care units. That isn’t what most of us envision for ourselves. Instead, the greatest percentage of Americans prefer to believe that they will die at home with family nearby.

Dr. Nuland’s message to readers is that it is time to take the blinders off. Enjoy life, by all means. Live life to the fullest. But also spend time learning about the ways that people die, and prepare while living for one’s end. We all want dignity in dying, he says. But 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.

I picked this up at a library book sale, expecting to read it and then give it back. Instead, I am putting it on my bookshelf. This is a book and a message that I want to keep nearby.

[Tran Hiep · Rating 5 out of 5]

Liệu có quá trẻ để đọc cuốn sách thế này?
Liệu có quá điên rồ để tìm hiểu về cái chết?
Một sự thật là chúng ta cố gắng tránh né cái kết tất yếu lắm bi thương này như một cách để ngăn chặn nó đến gần với ta. Nhưng dù ta có vờ như không để tâm đến nó thì định mệnh không thể tránh khỏi này vẫn sẽ xảy ra.
Thông điệp mà tác giả muốn truyền tải đến người đọc đó là con người cần chấp nhận quy luật tất yếu này của tự nhiên và cố gắng hiểu cách thức mà nó xảy ra với chúng ta để có thể đưa ra quyết định khôn ngoan nhất cho thời điểm thiêng liêng của đời người.
Với hơn 30 năm hành nghề y, tác giả chia sẻ những câu chuyện về nhiều cái chết khác nhau. Những bệnh nhân chết vì vấn đề tim mạch, chết vì lão suy, chết vì Alzheimer, chết vì tai nạn, chết vì AIDs, và vì ung thư. Những đặc điểm bệnh lý và con đường cuối cùng dẫn đến cái chết diễn giải vừa đủ bình dân để bất kỳ ai cũng hiểu được và vừa đủ chuyên môn để làm nổi bật đặc điểm của căn bệnh.
Bên cạnh đó những chia sẻ của những người trong cuộc khiến người đọc trải qua nhiều cung bậc cảm xúc khác nhau (chắc chắn rằng mỗi đọc giả sẽ có những trải nghiệm khác nhau). Tác giả cũng nêu lên quan điểm y khoa nhân văn hơn trong việc điều trị cho các bệnh nhân đang cận kề cái chết.
Cuốn sách bao hàm các kiến thức về y sinh và bệnh lý của những căn bệnh nổi tiếng là những kẻ giết người đáng sợ nhất. Và điều cốt lõi hơn của cuốn sách chính là triết lý về cái chết, khoảnh khắc hấp hối và cách sống để đưa đến "cái chết nghệ thuật".

[Diane · Rating 3 out of 5]

Interesting book, not what I thought it was going to be. A lot of technical information about death and the human body.

[Robin Goodfellow · Rating 3 out of 5]

3,5.
Este libro me fue recomendado despersonalizadamente por un metido del mundillo médico en una charla y a mí como me interesaba el tema, decidí leerlo. El libro es en su conjunto una recopilación de descripciones de procesos fisiopatológicos que conducen a la muerte, entre ellos se encuentra la Insuficiencia Cardiaca, Neumonía, SIDA, suicidio y Cáncer, mezclado con anécdotas clásicas divulgativas médicas y otros casos reales suyos personales o de su práctica clínica. Todo esto se encuentra mezclado con reflexiones acerca del proceso de morir, la dignidad humana en sus últimos momentos, la inevitabilidad de la muerte, la labor paliativa (o futil) de un médico, etc. La tesis que el autor nos quiere presentar es la falta de dignidad en la muerte. A menudo por la naturaleza de la enfermedad en sí misma, otras propiciadas por las acciones futiles de los médicos que se ensañan en librar una batalla contra lo inevitable: la muerte. Expone que muchos de ellos, en su instrucción por luchar por la vida causan más sufrimiento llevando a cabo medidas extraordinarias, altamente traumáticas, futiles y de dudoso beneficio. A pesar de que el libro esté escrito en los 90 estos temas se siguen debatiendo en los cuidados de UCI y son temas a la orden del día para los cuales no se han hallado solución.

Las reflexiones detrás de cada caso son los que realmente más me han gustado, sin embargo, las descripciones de cómo fallece un ser humano ya las conozco por la carrera y se me hacía un poco redundante en lo que buscaba del ensayo. Después de exponer esto, quiero remarcar que me ha parecido muy buen escrito de divulgación médica y que recomendaría sin duda a cualquiera que se haya planteado estos temas tan universales: la muerte, el "Ars morendi" o arte de morir o tenga curiosidad en general.

Me ha gustado también la cercanía del autor para contar historias tan personales como algunas de las que cuenta. Me han conmocionado algunas de las reflexiones e historias, en particular las de la epidemia del SIDA y cuando habla del cáncer, una enfermedad prevalente como es.

Por último, me ha parecido interesante comparar los relatos que expone del perfil del enfermo a principios de siglo XX, en los años 50 cuando él era estudiante, en su actualidad (los años 90), y mi perspectiva personal ahora en 2025. El autor reflexiona sobre el papel de la tecnología en el ámbito médico y cómo, a medida de que las terapias han ido avanzando, así lo ha hecho también la calidad de vida en la enfermedad. Sin embargo, la tecnología también nos ha facilitado separarnos de la persona a punto de morir, mantenidas a veces dolorosamente y enchufadas a maquinaria en vez de pasar sus últimos momentos en su casa rodeado de sus seres queridos aceptando el proceso tal y como es. Finalmente, el autor aboga por que se vuelva a recuperar la humanidad en el acto de morir, que las expectativas de los pacientes y sus familiares sean reajustadas a un límite razonable a pesar de las esperanzas puestas en el todopoderoso médico que les va a tratar, y que se vuelva a entender la muerte como lo que es: algo que no debe de pasar una persona en soledad.

Aquí dejo una de mis citas favoritas:

"Por tanto, si debemos modificar -o incluso rechazar- la imagen clásica de la muerte digna, ¿qué queda de las esperanzas que abrigamos respecto a los últimos recuerdos que dejamos a quienes nos aman? La dignidad que buscamos en la muerte puede hallarse en la dignidad con la que hemos vivido nuestra vida. El Ars morendi es el ars vivendi. La honestidad y la gracia de esta vida que se extingue constituyen la medida real de cómo morimos. No es en los últimos días o semanas cuando redactamos el mensaje que será recordado, sino en las décadas que los precedieron. Quien ha vivido con dignidad muere con dignidad."

[Lisa · Rating 5 out of 5]

I'm currently reading Being Mortal, and I thought back to How We Die and how profoundly it affected me. From the first page to the last, it had me in its grip.

And here's the thing. I read a review when the book was first published and rushed out to buy it. I was about 30. So the stories and vignettes highlighted in the book held a medical fascination for me. When I re-read the book 20 years later, wow. The perspective that the years bring really changed my experience. I had that "it tolls for thee" moment, and suddenly the stories in the book felt much more personal and possible for me.

When I read of Sherwin Nuland's own death, I thought, "Now he really knows what it's all about." But if I could talk to him, I'd say thank you. Because even though the book is literally about how we die, and the many modes of death, there's a comfort to it. The book demystifies death to a degree. And the ultimate message is, don't dwell on how you're going to die, but how you're living right now.

[Atila Iamarino · Rating 3 out of 5]

Um livro bem curto e bem denso de um médico falando sobre a morte, de pacientes e de entes queridos. Tem um tom de desabafo bem grande, de alguém que escreveu aquilo por passar pelo processo, o que deixa o livro bem tocante. Mas me parece acrescentar mais para profissionais da área de saúde (e em um tom pessoal) do que para o público em geral, ao contrário do Mortais: Nós, a medicina e o que realmente Importa no final.