Dr. Sherwin Nuland, Surgeon, Author of 'How We Die' is Dead at 83

This morning while browsing through my New York Times app (I’m so modern!), I was saddened to see the obituary for Dr. Sherwin B. Nuland, who wrote the impressive and ground breaking 1994 National Book Award winner, “How We Die: Reflections on Life’s Final Chapter” (Amazon Affiliate Link). I know many hospice and palliative care professionals likely have this black and white paperback sitting on their bookshelf. Maybe they picked it up at a used book sale like I did, or maybe it was passed onto them by a mentor, but I wonder how many of the current practicing generation of professionals have actually read this seminal work?

I read it in 2004 when I was a hospice and palliative care fellow and I was so hungry for any knowledge about how to be a better doctor for people at the end of life. It may be hard to believe, but in 2004 there wasn't a lot of readily available information like we have seen in the past few years. The lessons from the book still resonated, even though the book was a decade old at the time I read it.

As a surgeon he recognized that he had been fighting against death and instead over-medicalizing this universal human event throughout his career and was willing to say it publicly and call out the medical establishment for doing the same. The New York Times obituary points out that Nuland himself worked hard to give his brother hope for cure and survival before his death in 1990, which is a familiar story to anyone who has ever cared for a patient with health care professionals in the family.

The book rising to national prominence came when the country was grappling with issues of medical care and control over the end of life. If you know your end-of-life ethics history you will obviously recognize the year 1994 for its significance in ushering the United States first voter approved initiative for physician aid-in-dying with Oregon’s Death With Dignity act. (It was challenged in the courts and did not become implemented until 1997.) It was also not long after the Patient Self-Determination Act (1990) highlighted the need for advance care planning, and other important ethics cases such as Dr. Jack Kevorkian and Terry Schiavo.

His writing diversified but he always foucsed on combining his career of medicine with a little philosophy including books such as The Art of Aging, How We Live, and The Soul of Medicine, in addition to numerous articles in non-medical publications. You can watch him at a very early TED talk from 2003 on the Extraordinary Power of Ordinary Humans. Or watch him talking about his inspiration for "How We Die" and how 'Death was in the legend and lore of my family.'

One passage that stood out to me in my early career is his description of The Riddle. I saw this in myself as a medical resident looking backwards and have seen it since practicing as a palliative medicine doctor.

“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.”

If you decide to pick his book up and give it a fresh look now that it is 20 years old, let me know what you think of it. Maybe we could have a historical book club?