Scholars on Aging Series: The Art of Dying

Who’s Really in Charge When Your Number is Up?

On Aging
On Aging
Nov 8, 2019 · 5 min read

Death is a sad theme that most of us avoid talking about, but thinking about it is an obvious important aspect of our well-being as we grow old. Death is something I think none of us can easily come to grips with. Frankly, thinking about death, at least for me, brings anxiety, and older adults (Jimmy Carter comes to mind) who say they are not afraid of death, in my opinion, are lying to themselves as a coping mechanism. However, some of the research says otherwise. So, I admit I could be totally wrong, and I would love to see older adults respond to this article.

According to one study, for instance, only 14% of older adults say they are afraid of dying. What 100% really fear is dying a painful death, not death itself. The theory professed is that by the time we reach our 60s, we have more willingly accepted the inevitability of death and use that acceptance for enjoying life more fully. That certainly makes a lot of sense, but I’m still afraid of dying and, yes, of course, I don’t want to die in pain.

“How We Die”
An influential book on this matter of death and dying, published in 1993, was “How We Die: Reflections on Life’s Final Chapter,” by Sherwin B. Nuland, an award-winning American surgeon who taught bioethics at the Yale School of Medicine. His writing explores the essence of people beyond just anatomy. Nuland’s theme is that it’s rare to die with dignity today, due primarily to the way modern medicine is typically applied to our final days. He offers advice on how to die your own death, so to speak, as opposed to being dependent on what any hospital might have in store for you. (Editor’s Note: There’s lots of real-life depictions of people dying in Nuland’s presence, some of which are difficult and dreary. Additionally, being that this book was written more than 25 years ago, some of the medical innovations described no longer apply today.)

I feel his opening salvo in the first paragraph of the first chapter of his book set the stage perfectly. He wrote:

EVERY LIFE IS different from any that has gone before it, and so is every death. The uniqueness of each of us extends even to the way we die. Though most people know that various diseases carry us to our final hours by various paths, only very few comprehend the fullness of that endless multitude of ways by which the final forces of the human spirit can separate themselves from the body. Every one of death’s diverse appearances is as distinctive as that singular face we each show the world during the days of life. Every man will yield up the ghost in a manner that the heavens have never known before; every woman will go her final way in her own way.

So, the question becomes how do we ensure dying with dignity in our own way? “The greatest dignity to be found in death is the dignity of the life that preceded it,” Nuland explained. As for the efficacy of dramatic medical interventions to keep the dying alive, Nuland provided the following warning-like statement:

Pursuing treatment against great odds may seem like a heroic act to some, but too commonly it is a form of unwilling disservice to patients; it blurs the borders of candor and reveals a fundamental schism between the best interests of patients and their families on the one hand and of physicians on the other.

He detailed this further in a learned way of medical practice he called “The Riddle.” As a young doctor he learned how to identify “the crises of suffering organs,” a phrase from eighteenth-century pathologist Giovanni Morgagni. This identification process is called pathophysiology, defined by Merriam-Webster as “the physiology of abnormal states,” or “the functional changes that accompany a particular syndrome or disease.” The doctor’s job is to go on a quest to make a diagnosis and come up with a specific cure. That quest is Nuland’s Riddle, and “the satisfaction of solving The Riddle is its own reward, and that drives the clinical engines of medicine’s most highly trained specialists. It is every doctor’s measure of his own abilities; it is the most important ingredient in his professional self-image.”

He then throws in a monkey wrench:

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.

Nuland provided an example of when he allowed The Riddle to keep Miss Welch, a 92-year-old hospital patient with no friends or family to visit her, alive through surgery she was hesitant to get. She even told Nuland she would prefer that nature take its course and he simply let her die. But he convinced her otherwise, by winning over her trust. Unfortunately, the surgery did not turn out as Nuland expected. She lived for several more weeks in extreme discomfort and then died.

About this unfortunate set of circumstances, he wrote the following:

My treatment of Miss Welch was based not on her goals but on mine, and on the accepted code of my specialty. I pursued a form of futility that deprived her of the particular kind of hope she had longed for — the hope that she could leave this world without interference when an opportunity arose. No matter her lack of family, the nurses and I could have seen to it that she did not die alone, at least insofar as empathetic strangers can do this for a friendless old person. Instead, she suffered the fate of so many of today’s hospitalized dying, which is to be separated from reality by the very biotechnology and professional standards that are meant to return people to a meaningful life.

So, where does this leave us? Here we have a prestigious surgeon admitting to readers of his book that he had let the so-called Riddle guide his decision-making process, despite bad odds and instead of accepting a 92-year-old patient’s mindset and desires. In the end, however, he recognizes his mistake, letting us know that we have choices that are more in tune with what we may really and truly desire when we are nearing the end of our days, and that more doctors need to recognize that solving The Riddle sometimes (not always, of course) needs to be shelved.

In his Epilogue, Nuland writes that “the great majority of people do not leave life in a way they would choose. In previous centuries, men believed in the concept of ars moriendi, the art of dying.”

More to come in future Scholars on Aging posts. Here are links to some past posts under this category:

R U Cosmically Gerotranscendent?

Take Some “Otium”

Early Studies on the Psychology of Aging

How Art Promotes Human Well-Being

Transcendence for a Good Life

Thanks for stopping by,


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On Aging

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On Aging

Posts from George Lorenzo, writer, researcher, editor, designer, and curator of Old Anima.

The Startup

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