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Death and Dying: How We Die, Reflections on Life’s Final Chapter

“Death belongs to the dying and those who love them.” This is a quote from Sherwin B. Nuland’s book How We Die, Reflections on Life’s Final Chapter. Throughout his book Nuland demonstrates this message; he takes us through the significant education he has received in his forty years as a physician. In his book, Nuland also relates his own experiences with family members and the lessons he gained. In his way, Nuland teaches us that life is to be lived to its fullest because death is inevitable. He does a brilliant job of using case histories to demonstrate the actual events that lead to the death of the body. This book also does an excellent job of describing a physician’s side of the death experience.

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In this paper, we will meet some of the characters from Nuland’s book and examine the lessons he learned from having been involved in their life’s final journey. We will look at some of the specific ways in which the body dies such as cancer, Alzheimer’s disease, and suicide. We will also examine the ethical and moral dilemma posed by the euthanasia controversy. By looking at all of the above issues we will determine the reasons that Nuland chose to write this book and his specific thoughts and feelings on these issues.

Characters from How We Die, Reflections on Life’s Final Chapter, and lessons learned

An interesting event occurred in the news this year; we all got a chance to watch the decline and eventual death of a reality star. Jade Goody chose to publicize the final chapter in her life in an attempt to bring awareness to others of the need for early diagnosis of cancer. “The media’s open season on Jade Goody’s cancer will have helped more people with cancer than expensive initiatives by the Department of Health ever could.”(Smith, 2009) Although these events were not prevalent when the book How We Die, Reflections on Life’s Final Chapter was published one of the main points of the book is the same, an attempt to teach others about death.

In his book, Nuland describes six major causes of death: heart disease, murder, AIDS, cancer, Alzheimer’s disease, and suicide. Let’s examine just a few of these and meet the people in the book and see what lessons Dr. Nuland learned from his patients and family. Cancer is a deadly disease it is called “the Enemy” even by physicians. “Cancer, far from being a clandestine foe, is in fact berserk with the malicious exuberance of killing.” (Nuland, 1994)

To make us understand the devastation that cancer can produce both physically and mentally Dr. Nuland tells us the story of his brother, Harvey. Harvey was diagnosed with incurable cancer when he was in his early 60’s. Even though Dr. Nuland knew the cancer was incurable he was unable to tell Harvey the truth and he clung to hopes that desperate measures, which he endorsed, would somehow postpone the inevitable.

“Harvey paid a high price for the unfulfilled promise of hope. I had offered him the opportunity to try the impossible, though I knew the trying would be bought at the expense of major suffering. Where my own brother was concerned, I had forgotten, or at least forsaken, the lessons learned from decades of experience.” (Nuland, 1994)

“Since being properly identified in 1907, Alzheimer’s disease is one of America’s leading killers.” (Nuland, 1994) This disease is particularly frightening as there is no cure and the disease is always fatal. An important issue brought up by Alzheimer’s is that of end-of-life care since this type of patient can’t die at home.

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“Families need to understand, and professionals need to explain, that advanced Alzheimer’s is a terminal illness. The patient who survives long enough will eventually develop such overwhelming neurological deterioration that they lose all voluntary physical functions, including the ability to take in food and fluid presented orally.” (Shannon, 2004)

As Nuland relates in his book through a story about Phil Whiting and his wife Nancy there comes a point where it is impossible to care for Alzheimer’s patients at home. “His wife Nancy wrote a book called The 36-Hour Day, where she states “Foolishly, I stayed in the house, and he began throwing me around.”(Nuland, 1994)

“Death engenders complex feelings and responses that contribute to the challenge faced when caring for those at the end of their life. Individuals have different meanings for the transition from life to death and, as such, the ways in which that transition is accepted, managed and experienced is also different for each individual.” (Leishman, 2008)

This is not the case for Alzheimer’s patients and their families who are left with only one alternative which is to surrender their loved ones to an institutional setting. This being the case family members can be comforted somewhat by the words of Elisabeth Kubler-Ross,

“Whatever you did, take comfort that you did it out of love and hope, trying to do the right thing when there was no clear right thing to do. You chose a direction in a medical world with too many mixed messages to understand what is and what is not the right decision.” (Kubler-Ross, 2005)

Ways the Body Dies

As stated earlier in his book Nuland discusses six major causes of death: heart disease, murder, AIDS, cancer, Alzheimer’s disease, and suicide. Nuland describes the cause and effect of each of the six causes of death; he does this in a somewhat technical matter but makes it easy enough for the nonprofessional to understand. The way he presents his material reminds us that death is a bodily function that cannot be altered in the end. The processes he describes are important health aspects of this work that demystify complicated things like how the heart works. When describing the aging of the heart he says; “The rapidity of circulation slows down. The left ventricle takes longer to fill and longer to relax after a contraction; each heartbeat pushes out less blood than it did a year earlier, and even a smaller fraction of its content.” (Nuland, 1994)

Even the reviewers of Nuland’s book have remarked on the way that he describes some of the processes of the human body. John Elson from Time magazine says;

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“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.” (Elson, 1994)

As we can see Nuland has a way with words.

The Euthanasia Controversy

Euthanasia is one of the moral issues that were brought up in Nuland’s book. William Beatty reviewed this book and noted “Nuland also has strong feelings about suicide and “assisted death”: the doctor should be prepared psychologically and practically to help the longtime patient slip off the scene in relative comfort.” (Beatty, 1993). Again Nuland shares an example of a case he is familiar with to highlight the ethics of euthanasia. He cites the case of Diane and her physician Dr. Timothy Quills. Diane was dying of cancer and convinced Dr. Quills that she “feared the debilitation of treatment and the loss of control of her body far more than she feared death.” (Nuland, 1994)

Other people of course have different viewpoints on this subject for instance “The ethical significance of euthanasia is revealed in the hubris of modern man’s desire to master death, the crushing of this will, and its enragement once it faces the limited solace offered by medicalized mastery.” (Lavi, 2008). Euthanasia by its very nature is controversial because it goes against all we have ever been taught, we are not brought up to believe that killing is justifiable for any reason.

It also begs the question, if we as a people condone this who there be to draw the lines between murder, suicide, and euthanasia. It is an interesting question and one which requires much thought and examination before it is made into a policy that we as a people should embrace. “In matters touching on death, the clinical and the moral are never so far apart that we can look at one without seeing the other.” (Nuland, 1994)

Evaluation of Nuland’s Approach

Nuland says “I have written this book as much for myself as for everyone else that reads it.” It does seem that throughout this book he is trying to remind himself and us that while death is inevitable if we focus on the here and now it is for the best. Nuland continually stresses that people should be remembered for their accomplishments in life and not for their deaths. As was stated at the very beginning of this paper, “Death belongs to the dying and those who love them.” (Nuland, 1994). By sharing his own experiences, even intensely personal experiences involving his family members, Nuland shows us many things. He shows us that even physicians, who should know better, still hold hope for the terminally ill. He shows that physicians also make mistakes in judgment and diagnosis; he shows that doctors are people too.

Dr. Nuland relates a lot of facts and figures concerning death. He also examines the major illnesses and explains them in-depth, in the hope that the reader can make an informed choice when it is his turn. Nuland is biased and it shows throughout the book he wants those who read this book to realize that life is to be lived.


This paper was a brief examination of the book How We Die, Reflections on Life’s Final Chapter by Sherwin B. Nuland. This was an excellent book with very moving examples of real people and real situations that did not come across as being made up or enhanced in any way. Throughout this paper, we have discussed a few of the many characters presented in this book including Harvey, Dr. Nuland’s only brother who died of cancer. We saw the grave error that Dr. Nuland made in judgment when dealing with his brother’s disease and diagnosis.

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We also briefly touched on specific ways the body dies and what the main diseases are. Another subject that was reviewed was the controversy of euthanasia, a subject which Nuland has strong opinions about as noted by an author who reviewed his book. Finally, this paper finishes with a summary of some of the main lessons that Nuland wanted the reader to learn, in particular, that life is to be lived to the fullest.


Beatty, W. (1993). “How We Die, Reflections on Life’s Final Chapter.” Booklist 90. n18: 730(1). GeneralOneFile. Gale. Coffee County Lannom Memorial Public. Web.

Elson, J. (1994). “How We Die.” Time. 143. n8: 66(1). Gale. Coffee County Lannom Memorial Public. Web.

Kubler-Ross, E. & Kessler, D. (2005). On Grief and Grieving: Finding the Meaning of Grief through the Five Stages of Loss. New York. Simon and Schuster.

Lavi, S. (2008). How dying became a ‘life crisis’. Daedalus. (Winter, 2008): 57-65.

Leishman, J.L. (2008). Older people Death, dying and end-of-life care. Quality in Ageing. n9: 4(7).

Nuland, S.B. (1994) How We Die, Reflections on Life’s Final Chapter. New York Alfred A. Kroft.

Shannon, T.A. (2004) Death and Dying: A Reader. Maryland. Rowman & Littlefield.

Smith, J. (2009). Power of Publicity. Nursing Standard. n 29:23(2).

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