On beginning to read this book, I found myself thinking almost obsessively of not very funny doctor jokes, of the good news/bad news variety. Doctor: "I have bad news and good news." Patient: "Tell me the bad news first." Doctor: "You have terminal cancer." Patient: "What's the good news?" Doctor: "See that nurse down the hall? I'm making it with her."
Shortly thereafter, the book disappeared. I searched for it frantically, to no avail. Then quite as suddenly it reappeared. It had been in plain sight and I had not seen it. (Interestingly enough, at the time of its disappearance I was reading the chapter on Alzheimer's.) It was only then that I recognized what now seems obvious, that the book had evoked some characteristic defenses, first that manic streak which makes light of the dark, and when that failed, stark simple denial.
This book can do that to you. As its author, a professor of surgery at Yale, tells us, "dying is a messy business." Even fairly sudden deaths will seem messy when described graphically enough. In the first chapter, Nuland writes of his own rite of passage as a third-year medical student, when "it was my unsettling luck to encounter death and my very first patient at the same hour."
The patient was a fifty-two-year-old executive, hard-driving and high-living, who had had an infarction which was seemingly stabilized. Young Nuland was asked to help out at a busy time at the hospital with a simple admissions workup. He was eager to do so. He entered the room, introduced himself, and then the following event took place:
As I sat down at his bedside he suddenly threw his head back and bellowed out a wordless roar that seemed to rise up out of his throat from somewhere deep within his stricken heart. He hit his balled fists with startling force up against the front of his chest in a single synchronous thump, just as his face and neck, in the flash of an instant, turned swollen and purple. His eyes seemed to have pushed themselves forward in one bulging thrust, as though they were trying to leap out of his head. He took one immensely long, gurgling breath, and died.
Many of the descriptions of death and dying presented here have the same shocking clarity, whether the demise is sudden, as in this case, or painfully drawn out over many years.
Nuland's intention is not to frighten us or to appeal to a sort of mortuary prurience. He feels, rather, that the contemporary attitude to death is compounded of illusions, denials, and deceptions, so much so that we are unable to deal with it effectively. And so we are to take the book's title seriously. Nuland tells us, lucidly and precisely, just how we die, the mechanics and the dynamics. In particular, he takes us through the more common paths to death: heart disease; stroke; Alzheimer's; the traumas of homicide, suicide, and accidents; AIDS; the cancers. He chooses these because they are common but also because
they are representative of certain universal processes that we will all experience as we are dying. The stoppage of circulation, the inadequate transport of oxygen to tissues, the flickering out of brain function, the failure of organs. . . .
