How we Die

Lexicographers have knock-down drag-out fights between descriptivists, who report how the language is actually used and proscriptivists, who try to assert what is correct usage. We're seeing similar confrontations regarding end of life issues.  A good few weeks ago, I finally ordered a copy of How We Die by Sherwin Nuland, whom we've met before a) deriving benefit from electro-convulsive therapy b) causing me to faint dead away on the bus.  I've been looking forward to this book for a long time because it is billed as telling-it-like-it-is that, to the nearest whole number per 100, there are no dignified exits from this world.  In contrast to the Hobbesian characterisation of the life of man as "nasty, brutish and short", the death of man appears normally to be nasty, brutish and long drawn out.

If you're hoping for the facts from a surgeon who has spent a life-time trying to keep people alive through his ministrations and ultimately failed in every case, then this is a good place to start your investigations.  If you're looking for objective data about an exit strategy, you can find it here also but under a stern and emotive look of disapproval because Dr Nuland doesn't approve of euthanasia.  He gets far crosser about one case of a young doctor helping a woman, at her request, over the threshold than he does about his own interventionist ministrations that prolonged the suffering of his own cancer-riddled brother. Although, in fairness, he bitterly regrets not staying his hand in his brother's case.

He notes that 85% of the aging population of the US will succumb to Seven Sisters of the Shadows : atherosclerosis, hypertension, adult-onset diabetes, obesity, dementia, cancer, and decreased resistance to infection . . . not infrequently all seven in the one wracked body.  There is a lesson in this for consultants. When the aged person presents with their first acute episode, it would be very useful for everyone if a health audit was carried out at that stage rather than barrelling in to deal with the symptoms and effects of the critical disease state. You can ream out the aorta, insert a stent to keep this key artery open, sew up and de-glove.  But what is the point if the patient is riddled with metastatic liver-cancer or has gangrenous extremities from diabetic septicemia or lost her marbles a long number of years ago. By fire-fighting in one part of the body, you're winning only a little time for the next consuming flare up elsewhere.

But here's the thing: we each of us die but once, so don't gather much data on Ars Moriendi the art of dying.  Doctors OTOH have overseen many deaths and read the literature on countless more and so are in a better position to advise the dying and their relatives as to what are the options. Although it may seem that the punter should have the final say, there are some data to suggest that they shouldn't have the only say. Elderly white men are 5x more likely to carry out a successful suicide than the general population but for many this is misinformed because, on foot of multiple changes in the psycho-neuro-immunological milieu as we age, elderly white men are much more likely to suffer from a clinical depression. If you medicate this, the old buffers become better company, make more friends and can live happy and fulfilled for years after they don't top themselves.

But Nuland also acknowledges a tendency to Doc Knows Best in a paternalistic, patronising and controlling way.  He is scathing about Derek Humphry, founder of the Hemlock Society, and his cook-book for finishing the race under your own terms.  Nuland worries that the group which has the highest prevalence of suicidal ideation, as well as attempted and successful suicide [young men] are likely to come across this 1991 best seller and actually off themselves rather than just thinking about it. If old men and young men are both above average in their suicidal behaviour I guess the hard working middle-aged just can't find the time for such luxuries.  The poor buggers are too busy earning enough money to a) give their student offspring a booze-allowance and b) employ a home-help for their aged parents. I won't tell you what the easy way out is but will advise that swallowing paraquat or paracetemol/tylenol is not it.  Aw, heck, just read How Not to Commit Suicide:the iconic and richly informative essay by Art Kleiner originally published in Co-evolution Quarterly. The advice there is more or less summarised by Dorothy Parker

Razors pain you;
Rivers are damp;
Acids stain you;
And drugs cause cramp.
Guns aren’t lawful;
Nooses give;
Gas smells awful;
You might as well live.

Nuland reflects on the fact that people who finish up as medical consultants are not a random selection from the population any more than are scout-masters or policemen.  Pedophiles don't just happen to like khaki uniforms and woggles and cops don't just happen to like guns.  Successful senior medics are ambitious and driven - they wouldn't have aced their Leaving Certificate at school and passed every exam in medical school otherwise. But their sense of self can get tied up in externals - the Mercedes, the stethoscope, gratitude from their successful cases, envy of their less successful peers.  They behave less well when their interventions are failing and too often aren't there at the very end - it's as if they lose interest when the battle is lost or that their self-esteem cannot take the assault of failure. It is really difficult for doctors to adopt a less-is-more approach to the care of the dying because all their training, and peer-pressure both formal and informal is about doing something. They may lose their jobs if they fail to act even when they know that action has so little chance of a successful outcome as to be messy, painful and . . . futile.

Shep Nuland died in March 2014 of prostate cancer at the age of 83. He died at home. I hope his carers listened to him.