Books & Comics

How We Die: Reflections on Life’s Final Chapter – Dr. Sherwin B Nuland


How We Die: Reflections on Life’s Final Chapter (1994)

The first thing I read this morning were the following tweets from respected journalist @kanchangupta (

  • After reading “How We Die“, I’d wanted to do a series ‘How I’d Like to Die’. My then Editor Vinod Mehta shot it down. I’ll revive it now.
  • If you haven’t read “How We Die –Reflections on Life’s Final Chapter” by Sherwin B Nuland, please do. You will no longer fear death.
  • Once you know how we die, death is robbed of its fearful darkness. It is demystified. Turning the page on life’s final chapter becomes easy.
  • In the end, no matter what leads to death, there is a certain similarity in How We Die. I strongly recommend the book. #Death
  • There should be no maudlin sentimentality attached to death. It’s the logical culmination of life. The Universal Truth. #Death

And then in the afternoon came the news of Rajesh Khanna‘s demise. Rajesh Khanna ( (born Jatin Khanna) (29 December 1942 – 18 July 2012), who was affectionately called Kaka  by those who were close to him, passed away in Mumbai, he was not well for a while and was hospitalized few weeks back. In some interviews recently he did said that it was the extreme alcohol consumption lasting over two decades which ruined his health. He appeared in 163 feature films of which 128 films saw him as the lead protagonist; he appeared in 17 short films as well. He won three Filmfare Best Actor Awards and was nominated for the same fourteen times. He received the maximum BFJA Awards for Best Actor (Hindi) – four times and nominated 25 times. In 1991, he was awarded the Filmfare Special Award for completing 25 years in the industry, appearing in a record 106 films as the single lead protagonist in a span of 25 years. In 2005, he was awarded the Filmfare Lifetime Achievement Award. He made his debut in 1966 with Aakhri Khat and rose to prominence with his performances in films like Raaz, Baharon Ke Sapne, Ittefaq and Aradhana. Rajesh Khanna is the “First Superstar” of Hindi cinema who was the main lead actor in a record consecutive string of 15 superhit movies in late 60’s and early 70’s. May Kaka Rest in Peace…

This dark and gloomy subject of ‘losing the loved ones’ has been the center of discussion with friends and family for last few weeks  (

The tweets have got me interested and I am going to read this book How We Die: Reflections on Life’s Final Chapter by Sherwin B Nuland.

I really want to salute those honest doctors who are transparent about their diagnosis of the patients health and are willing to discuss it openly with them. Its much better to prepare the patient & relatives for the future ahead rather then raising false hopes making it harder for them to let go…

Dr. Sherwin B Nuland is an experienced surgeon, in the book How We Die: Reflection of Life’s Final Chapter, published in 1994, he says that we will be less frightened by the prospect of death if we understand it as a normal biologic process. He pointed out that 80%  of deaths in USA occur in hospitals and are therefore “sanitized,” hidden from view, and from public comprehension.

He describes in detail the death process for six major killers:

  1. Heart disease
  2. Stroke
  3. AIDS
  4. Cancer
  5. Accidents/suicide
  6. Alzheimer’s disease.

The power of the book is in its intensely personal depiction of these events and in the lessons which Nuland draws from his experiences. The message is twofold: very few will “die with dignity” so that (1) it behooves us to lead a productive LIFE of dignity, (2) physicians, patients, and families should behave appropriately to allow nature to take its course instead of treating death as the enemy to be staved off at any cost. Only then will it be possible for us to die in the “best” possible way – in relative comfort, in the company of those we love/who love us.

Probably we are the only species on the earth which is being able to understand its own mortality and
keeps thinking about the purpose of life, how long the life will continue, what will happen when we die, the day of death, life beyond death, so on and so forth.

Sherwin B. Nuland shows, however, that while we conceptualize our eventual demise, most people have unrealistic expectations of their death. The ideal death that we all seem to envision for our self and our loved one is after a long, healthy and happy life, a noble death with loved ones gathered, final farewells, and then eternal slumber. This is the general perception about the death, a wish most of us would have for us and our loved ones, this is common though inaccurate mental image of what many people look forward to in their final moments.

How We Die has many themes which Nuland tries to explain patiently, the theme actually resonate with the Indian philosophy of Life in Death, the equal celebration of both Birth as well as Death, because Death in itself is nothing but a process which will ensure the continuation of the cycle of Life on this Plant Earth through Birth-Life-Death-Rebirth…

The primary theme is that of death, like birth, is a messy process. Though we may wish for the noble death, more likely we will die slowly from a lack of oxygen in the brain. This, in turn, will result from a failing heart, lungs, or blood vessels. Death does not come easy, and although the final moment is sometime serene and tranquil, months or weeks of painful physical degeneration often precedes it.

The second theme in Nuland’s book is that death is not only inevitable, it is necessary. While life should be fought for as long as possible, we should all realize that ultimately the battle will be lost. We will die. Nuland takes a dim view of heroic attempts to extend life beyond the point where the body has simply failed and death becomes not only inevitable, but also the proper way for nature to renew herself.

Nature uses death to clear the way for new generations, and just as we cannot experience the green buds of spring unless the leaves from last season fall to the ground, the very nature of life demands that when death becomes inevitable we exit the stage for the next generation.

Nuland’s third point is that the measure of a life is not found so much in how we die, but in how we live and how we are remembered. Few of us can control the way in which we die. For some of us it will be quick, for others death will linger and the process will be slow and painful. Some will find humiliation in the loss of bodily functions or mental facilities. However it comes to anyone of us, death is just a part of our lives and the real meaning in death is in the life remembered.

What makes this book such compelling reading is that Nuland brings to this subject all of the depth and breadth of his background  &  his deep concern for the human condition. His long career at a high-powered academic medical center (Yale), his knowledge of the history of medicine, of literature and philosophy, and his own personal losses are all woven into his thesis. He is thus highly convincing when he criticizes physicians for becoming seduced by the intellectual challenge of solving “The Riddle” and making recommendations not in the best interests of the patient/family.

He claims that those who choose to become doctors are more likely to have anxieties about death and may be particularly reluctant to “give up” on a patient (while he acknowledges that this may also be a strength). Particularly pertinent are the chapters about his brother’s death from colon cancer, and the concluding “The Lessons Learned” and “Epilogue.” The book won the National Book Award for non-fiction.

Dr. Sherwin Nuland (Born December 1930)

Dr. Nuland is an American surgeon and author who teaches bioethicshistory of medicine, and medicine at the Yale University School of Medicine and, upon occasion, bioethics and history of medicineat Yale College. Born in the BronxNew York City, in December 1930 to immigrant Jewish parents Meyer and Vitsche Nudelman, he was raised in a traditional Orthodox Jewish home,  he now considers himself agnostic, but continues to attend synagogue. Nuland is a graduate of New York University and Yale School of Medicine, where he obtained his M.D. degree and also completed a residency in surgery.

Nuland has written non-academic articles for The New YorkerThe New York TimesThe New RepublicTime, and theNew York Review of Books. Perhaps his greatest work, however, is his unforgettable first-generation American autobiography of his own painful coming of age as a son of immigrants, “Lost in America: A Journey with My Father.” He is both a fellow and board member of the Hastings Center, an independent bioethics research institution.

In a 2001 TED talk, Nuland spoke of his severe depression and obsessive thoughts in the early 1970s, probably caused by his difficult childhood and the dissolution of his first marriage. As drug therapy remained ineffective, a lobotomy was planned, but his treating resident suggested electroshock therapy instead, leading to ultimate recovery.

He currently resides in Connecticut with his second wife Sarah. He has four children, two from each marriage. His daughter Victoria Nuland, a career foreign service officer and the former U.S. ambassador to NATO, is since 2011 spokesperson for the Department of State.

How We Die: Reflections on Life’s Final Chapter was a New York Times Best Seller and won the National Book Award for Nonfiction.

Books by Dr. Nuland

  • The Soul of Medicine (New York: Kaplan Publishing, 2009) ISBN 1-60714-055-1
  • The Art of Aging: A Doctor’s Prescription for Well-Being (New York: Random House, 2007) ISBN 1-4000-6477-5
  • The Doctors’ Plague: Germs, Childbed Fever and the Strange Story of Ignac Semmelweis (New York: W.W. Norton, 2003) ISBN 0-393-05299-0
  • Doctors: The Biography of Medicine (New York: Knopf, 1988) ISBN 0-679-76009-1
  • How We Die: Reflections on Life’s Final Chapter (New York: Knopf : Distributed by Random House, 1994) ISBN 0-679-41461-4
  • How We Live (New York: Vintage Books, 1998) [originally published as The Wisdom of the Body in 1997] ISBN 0-09-976761-9
  • Leonardo Da Vinci (Penguin Lives) (New York: Viking, 2000) ISBN 0-670-89391-9
  • Lost in America: A Journey with My Father (New York: Knopf : Distributed by Random House, 2003) ISBN 0-375-41294-8
  • Maimonides (Jewish Encounters) (New York: Nextbook: Schocken, 2005) ISBN 0-8052-4200-7
  • Medicine: The Art of Healing (New York : Hugh Lauter Levin Associates, Inc. : Distributed by Macmillan, 1992) ISBN 0-88363-292-6
  • The Mysteries Within: A Surgeon Explores Myth, Medicine, and the Human Body (New York: Simon & Schuster, 2000) ISBN 0-684-85486-4
  • The Wisdom of the Body (New York: Knopf, 1997) ISBN 0-679-44407-6
  • The Uncertain Art: Thoughts on a Life in Medicine (New York: Random House, 2008) ISBN 1-4000-6478-3



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