Sherwin Nuland, MD, Clear-eyed Witness to Death, Dies at 83

March 07, 2014

Sherwin "Shep" Nuland, MD, who died on March 3, was not the first person in the medical world to say that physicians, himself included, too often failed their dying patients by giving them false hope and futile treatment instead of the hard facts and comfort care.

End-of-life experts had made those points for years in academic journals, but "nobody noticed," said Robert Levine, MD, a professor of medicine and bioethicist at Yale School of Medicine in New Haven, Connecticut. Dr. Nuland, however, reached an enormous audience on this subject with his 1994 book, How We Die, which described the experience of death — from sepsis, heart failure, or knife wounds — with clinical depth and compassion.

"Most academic [writers] begin with principles," said Dr. Levine, a friend and long-time colleague of Dr. Nuland, in an interview with Medscape Medical News. "What Shep did was tell stories about real people."

How We Die not only won the National Book Award but also advanced the growth of palliative, end-of-life care.

"He was one of the pioneers," Donald Schumacher, president and chief executive officer of the National Hospice and Palliative Care Association, told Medscape Medical News. "He was one of the physicians early on who recognized the importance of looking at how we die and how we can support people who are dying."

"A Heroic and Courageous Soul"

Dr. Nuland was 83 years of age when he died at his home from prostate cancer, according to news accounts. He was a clinical professor of surgery at the Yale School of Medicine who, after his retirement in 1992, wrote extensively about medical history. His other works besides How We Die include Doctors: The Biography of Medicine (1988), Medicine: The Art of Healing (1992), and The Doctor's Plague (2003).

There also was a memoir, Lost in America (2003), that made his own often painful life an open book. He described his mother's death from colon cancer when he was 11 years old and the slower death of his maternal grandmother — and roommate — from old age. Then there was the death of his father, a Russian émigré, from syphilis, and Dr. Nuland's debilitating, midcareer depression.

"He had a hard life, but he was a heroic and courageous soul," said Joseph Fins, MD, division chief of medical ethics at Weill Cornell Medical College in New York City and another friend of Dr. Nuland. At the same time, the physician who explained in print how a person bleeds to death was not the morbid, dour sort.

"He had a very good sense of humor," Dr. Fins told Medscape Medical News. "There was a twinkle in his eye. He was fascinated by death as an intellectual question."

In How We Die, Dr. Nuland described dying mostly "as a messy business." Although people may wish for a peaceful death, or a sudden death, most will face a process "glutted with mental suffering and physical distress," he wrote.

"Better to know what dying is like, and better to make choices that are most likely to avert the worst of it," Dr. Nuland wrote.

His counsel for physicians in How We Die is to not make the dying person's suffering worse "with surgery of questionable benefit and high complication rate, chemotherapy with severe side effects and uncertain response, and prolonged periods of intensive care beyond the point of futility." In short, know when to throw in the towel.

Another legacy of Dr. Nuland's, in addition to his contribution to the bioethics of dying, is his body of literary work, said Dr. Fins.

"He brought art and beauty to all facets of medicine, whether he was writing about Ignaz Semmelweis or death," said Dr. Fins. "He was the greatest physician writer of his generation."

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