Nuland Quotes

The greatest dignity to be found in death is the dignity of the life that preceded it. This is a form of hope we call all achieve, and it is the most abiding of all. Hope resides in the meaning of what our lives have been.

-when the human spirit departs, it takes with it the vital stuffing of life. Then, only the inanimate corpus remains, which is the least of all the things that make us human.

The art of dying is the art of living. The honesty and grace of the years of life that are ending is the real measure of how we die. It is not in the last weeks or days that we compose the message that will be remembered, but in all the decades that proceeded them. Who has lived in dignity, dies in dignity.

The life sciences contain spiritual values which can never be explained by the materialistic attitude of present day science

The very old do not succomb to disease-they implode their way into eternity. (How We Die)

Empires fall, ids explode, great symphonies are written, and behind all of it is a single instinct that demands satisfaction.

The belief in the probability of death with dignity is our, and society’s, attempt to deal with the reality of what is all too frequently a series of destructive events that involve by their very nature the disintegration of the dying person’s humanity. I have not often seen much dignity in the process by which we die.

Though biomedical science has vastly increased mankind’s average life expectancy, the maximum has not changed in verifiable recorded history.

Hope can still exist even when rescue is impossible.

For many of the dying, intensive care, with its isolation among strangers, extinguishes their hope of not being abandoned in the last hours. If fact, they are abandoned, to the good intentions of highly skilled professional personnel who barely know them.

The lesson is never learned—there will always be those who persist in seeking the Fountain of Youth, or at least delaying what is irrevocably ordained.

The dignity we create in the time allotted to us becomes a continuum with the dignity we achieve by the altruism of accepting the necessity of death.

Dying begins with the first act of life.

Every life is different from any that has gone before it, and so is every death.

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.

We die so that the world may continue to live. We have been given the miracle of life because trillions upon trillions of living things have prepared the way for us and then have died—in a sense, for us. We die, in turn, so that others may live. The tragedy of a single individual becomes, in the balance of natural things, the triumph of ongoing life.

We are not well served by being lulled into unjustified expectations.

Share your optimisms and keep your pessimisms to yourself.

Human beings are capable of the kind of love and loyalty that transcends not only the physical debasement but even the spiritual weariness of the years of sorrow.

Every triumph over some major pathology, no matter how ringing the victory, is only a reprieve from the inevitable end.

Not death but disease is the real enemy, disease the malign force that requires confrontation. Death is the surcease that comes when the exhausting battle has been lost.

Nature is being kind without knowing it, as nature can be cruel without knowing it.

But the fact is, death is not a confrontation. It is simply an event in the sequence of nature's ongoing rhythms. Not death but disease is the real enemy, disease the malign force that requires confrontation. Death is the surcease that comes when the exhausting battle has been lost. Even the confrontation with disease should be approached with the realization that many of the sicknesses of our species are simply conveyances for the inexorable journey by which each of us is returned to the same state of physical, and perhaps spiritual, nonexistence from which we emerged at conception. Every triumph over some major pathology, no matter how ringing the victory, is only a reprieve from the inevitable end.

My mother died of colon cancer one week after my eleventh birthday, and that fact has shaped my life. All that I have become and much that I have not become, I trace directly or indirectly to her death. ... In my professional and personal life, I have lived with the awareness of death's imminence for more than half a century, and labored in its constant presence for all but the first decade of that time.

Hope is an abstract word. In fact, it is more than just a word; hope is an abstruse concept, meaning different things to each of us during different times and circumstances of our lives. Even politicians know its hold on the human mind, and the mind of the electorate.

We live today in the era not of the art of dying, but of the art of saving life,

There is no way to deter old age from its grim duty, but a life of accomplishment makes up in quality for what it cannot add in quantity.

When we mourn, it should be the loss of love that makes us grieve, not the guilt that we did something wrong.

Before you conclude that your options are limited, you need evidence that you cannot do something, rather than just deciding that you cannot do it.

The kind of child our society resembles just now is one whose intelligence far exceeds his maturity. Every teacher and every parent knows what a formula for disaster that can be.

Nuland remembered Sir Thomas Browne’s Religio Medici: “With what strife and pains we come into the world we know not, but ’tis commonly no easy matter to get out of it.

Shep Nuland still lectured there, but I knew him only in my capacity

Nuland was a renowned surgeon-philosopher whose seminal book about mortality, How We Die,

Shakespeare has Julius Caesar reflect that: Of all the wonders that I yet have heard, It seems to me most strange that men should fear; Seeing that death, a necessary end, Will come when it will come.

Leonardo, with his profound knowledge of art, commenced various undertakings, many of which he never completed, because it appeared to him that the hand could never give due perfection to the object or purpose which he had in his thoughts, or beheld in his imagination - since in his mind he frequently formed some difficult conception, so subtle and so wonderful that no hands, however excellent or able, could ever give it expression

The dignity that we seek in dying must be found in the dignity with which we have lived our lives. Ars moriendi as ars vivendi: The art of dying is the art of living. The honesty and grace of the years of life that are ending is the real measure of how we die. It is not in the last weeks or days that we compose the message that will be remembered, but in all the decades that preceded them. Who has lived in dignity, dies in dignity.

The only certainty, whether spoken or not, is that the doctors, nurses, and technicians are fighting not only death but their own uncertainties as well. In most resuscitations, those can be narrowed down to two main questions: Are we doing the right things? and, Should we be doing anything at all?

The more knowledge we have about the realities of lethal illness, the more sensible we can be about choosing the time to stop or the time to fight on, and the less we expect the kind of death most of us will not have. For those who die and those who love them, a realistic expectation is the surest path to tranquillity.

That enormously complex biological interactions are so flawlessly coordinated as to result in such obvious manifestations as human thought or the electrical activity that dries the heartbeat is as exciting to me -- actually more exciting -- than such phenomena were when I was a small boy and thought them divinely (in the supernatural sense) driven.

We die so that the world may continue to live. We have been given the miracle of life because trillions upon trillions of living things have prepared the way for us and then have died — in a sense, for us. We die, in turn, so that others may live. The tragedy of a single individual becomes, in the balance of natural things, the triumph of ongoing life.

These days (if I may steal a term from the jargon of the contemporary rialto), it is not politically correct to admit that some people die of old age.

The virus has robbed them of their youth, and it is about to rob them of the rest of their

the last hours. In fact, they are abandoned, to the good intentions of highly skilled professional personnel who barely know them.

bioengineers but by those who know who we are.

It is also the recognition that the real event taking place at the end of our life is our death, not the attempts to prevent it.

To the wise advice that we live every day as though it will be our last, we do well to add the admonition to live every day as though we will be on this earth forever.

Beyond the curiosity and the problem-solving challenge fundamental to good research, I believe that the fantasy of controlling nature lies at the very basis of modern science.

Nature will always win in the end, as it must if our species is to survive.

Moths and flames, mankind and death--there is little difference.

How much of the "good death" is for the person dying and how much for the person helping him?

Though everyone may yearn for a tranquil death, the basic instinct to stay alive is a far more powerful force

knowledge without wisdom is a clear and present danger

if peace and dignity are what we delude ourselves to expect, most of us will die wondering what we, or our doctors, have done wrong.

The patient dies alone among strangers: well-meaning, empathetic, determinedly committed to sustaining his life - but strangers nonetheless.

unattended and isolated. For it is the promise of spiritual companionship near the end that gives us hope, much more than does the mere offsetting of the fear of being physically without anyone.

I remember Nuland, in the opening chapters of How We Die, writing about being a young medical student alone in the OR with a patient whose heart had stopped. In an act of desperation, he cut open the patient’s chest and tried to pump his heart manually, tried to literally squeeze the life back into him. The patient died, and Nuland was found by his supervisor, covered in blood and failure.

Persistence can only break the hearts of those we love and of ourselves as well, not to mention the purse of society that should be spent for the care of others who have not yet lived their allotted time.

Today the law defines death, with appropriate blurriness, as the cessation of brain function. Though the heart may still throb and the unknowing bone marrow create new cells, no man's history can outlive his brain.

So it was like the old scenario that so often throws a shadow over the last days of people with cancer: we knew—she knew—we knew she knew—she knew we knew—and none of us would talk about it when we were all together.

Although it is not always admitted, the hospital has offered families a place where they can hide the unseemly invalid whom neither the world nor they can endure. … The hospital has become the place of solitary death.

When my time comes, I will seek hope in the knowledge that insofar as possible I will not be allowed to suffer or be subjected to needless attempts to maintain life; I will seek it in the certainty that I will not be abandoned to die alone; I am seeking it now, in the way I try to live my life, so that those who value what I am will have profited by my time on earth and be left with comforting recollections of what we have meant to one another.

The ultimate aim of the scientist is not only knowledge for the sake of knowledge, but knowledge with the aim of overcoming that in our environment which he views as hostile. None of the acts of nature (or Nature) is more hostile than death.

Whatever mystery attaches to such a death is imposed on it by those who live. It is a tribute to the human spirit that the life preceding triumphs over the ugly events that most of us will experience as we die, or as we move toward our last moments.

No matter the technological sophistication of ultramodern molecular research, and no matter the increasingly abstruse terminology of its current literature, the circle of knowledge always returns to its starting point: In order to live, man must have air.

Unless we are aware that we are dying and so far as possible know the conditions of our death, we cannot share any sort of final consummation with those who love us. Without this consummation, no matter their presence at the hour of passing, we will remain

The three are: a sense of mutual caring and connectedness with others; the maintenance, insofar as we can influence it by our own actions, of the physical capability of our bodies; and creativity. Each of the three requires work; each of the three brings immense rewards.

This is the period when hard decisions are faced by families, having to do with the insertion of feeding tubes and the vigor with which medical measures should be taken to fend off those natural processes that descend like jackals—or perhaps like friends—on debilitated people.

Though their doctors dutifully record such distinct entities as stroke, or cardiac failure, or pneumonia, these aged folk have in fact died because something in them has worn out. Long before the days of scientific medicine, everyone understood this. On July 5, 1814, when he was seventy-one years old, Thomas Jefferson wrote to the seventy-eight-year-old John Adams, "But our machines have now been running seventy or eighty years, and we must expect that, worn as they are, here a pivot, there a wheel, now a pinion, next a spring, will be giving way; and however we may tinker them up for awhile, all will at length surcease motion.

Cancer cells are fixed at an age where they are still too young to have learned the rules of the society in which they live. As with so many immature individuals of all living kinds, everything they do is excessive and uncoordinated with the needs or constraints of their neighbors… they are reproductive but not productive.

The difference between CVA as a terminal event and CVA as a cause of death is the difference between a worldview that recognizes the inexorable tide of natural history and a worldview that believes it is within the province of science to wrestle against those forces that stabilize our environment and our very civilization.

Self-assurance, optimism, productivity, attachments of caritas to others, pride in our physical selves—these are all philosophies that enhance living. They are wellsprings largely of our own making, and they can grow in significance as we let their energies pour into the ever-widening, deepening channel of experience and wisdom.

These are two different belief systems. There is no reason in the world that the religious have to explain their faith on a scientific basis. It makes no sense. What is needed between science and religion is not a debate but a conversation, each one saying: you're here to stay, and I'm here to stay, so let's find out how our relationship can be of greatest benefit to this world.

Since human beings first began to write, they have recorded their wish for an idealized ending some call the "good death," as if any of us can ever be sure of it or have any reason to expect it. There are pitfalls of decision-making to be sidestepped and varieties of hope to seek, but beyond that we must forgive ourselves when we cannot achieve some preconceived image of dying right.

Far from being irreplaceable, we should be replaced. Fantasies of staying the hand of mortality are incompatible with the best interests of our species and the continuity of humankind's progress. More directly, they are incompatible with the best interests of our very own children. Tennyson says it clearly: "Old men must die; or the world would grow moldy, would only breed the past again.

reasons that one generation must give way to the next, as made clear in another of the letters Jefferson wrote to the equally venerable John Adams near the end of his life: “There is a ripeness of time for death, regarding others as well as ourselves, when it is reasonable we should drop off, and make room for another growth. When we have lived our generation out, we should not wish to encroach on another.

Carolyn had told me that while he was still able, Bob had arranged to have his favorite words from his favorite work of Dickens inscribed on his grave marker, but still I was unprepared for their effect when actually seen. Engraved across the granite face of the footstone was the epitaph by which Bob DeMatteis had chosen to be remembered: "And it was always said of him that he knew how to keep Christmas well.

transparent model of the aorta filled with water to observe the swirls and flow. The experiments showed that the valve required “a fluid dynamic control mechanism which positions the cusps away from the wall of the aorta, so that the slightest reversed flow will close the valve.” That mechanism, they realized, was the vortex or swirling flow of blood that Leonardo had discovered in the aorta root. “The vortices produce a thrust on both the cusp and the sinus wall, and the closure of the cusps is thus steady and synchronized,” they wrote. “Leonardo da Vinci correctly predicted the formation of vortices between the cusp and its sinus and appreciated that these would help close the valve.” The surgeon Sherwin Nuland declared, “Of all the amazements that Leonardo left for the ages, this one would seem to be the most extraordinary

Whether the result of wear, tear, and exhaustion of resources or whether genetically programmed, all life has a finite span and each species has its own particular longevity. For human beings, this would appear to be approximately 100 to 110 years. This means that even were it possible to prevent or cure every disease that carries people off before the ravages of senescence do, virtually no one would live beyond a century or a bit more.

Mine is not the first voice to suggest that as patients, as families, and even as doctors, we need to find hope in other ways, more realistic ways, than in the pursuit of elusive and danger-filled cures. In the care of advanced disease, whether cancer or some other determined killer, hope should be redefined. Some of my sickest patients have taught me of the varieties of hope that can come when death is certain. I wish I could report that there were many such people, but there have, in fact, been few. Almost everyone seems to want to take a chance with the slim statistics that oncologists give to patients with advanced disease. Usually they suffer for it, and they die anyway, having magnified the burdens they and those who love them must carry to the final moments. Though everyone may yearn for a tranquil death, the basic instinct to stay alive is a far more powerful force.

Endorphin elevation appears to be an innate physiological mechanism to protect mammals and perhaps other animals against the emotional and physical dangers or terror and pain. It is a survival device, and because it has evolutionary value it probably appeared during the savage period of our prehistory when sudden life-threatening events occurred with frequency. Many a life has no doubt been saved by the absence of panicky response to sudden danger.

Perhaps the mere existence of things undone should be a sort of satisfaction in itself, though the idea would appear to be paradoxical. Only one who is long since dead while still seemingly alive does not have many "promises to keep, and miles to go before I sleep," and that state of inertness is not to be desired. To the wise advice that we live every day as though it will be our last, we do well to add the admonition to live every day as though we will be on this earth forever.

Nowadays, very few of us actually witness the deaths of those we love. Not many people die at home anymore, and those who do are usually the victims of drawn-out diseases or chronic degenerative conditions in which drugging and narcosis effectively hide the biological events that are occurring. Of the approximately 80 percent of Americans who die in a hospital, almost all are in large part concealed, or at least the details of the final approach to mortality are concealed, from those who have been closest to them in life.

It is through the eyes of youth that everything is constantly being seen anew and rediscovered with the advantage of knowing what has gone before; it is youth that is not mired in the old ways of approaching the challenges of this imperfect world. Each new generation yearns to prove itself—and, in proving itself, to accomplish great things for humanity. Among living creatures, to die and leave the stage is the way of nature—old age is the preparation for departure, the gradual easing out of life that makes its ending more palatable not only for the elderly but for those also to whom they leave the world in trust.

The originator of the literary form we call the essay, the sixteenth-century Frenchman Michel de Montaigne, was a social philosopher who viewed mankind through the scrutinizing lens of unadorned and unforgiving reality and heard its self-deceits with the ear of the skeptic. In his fifty-nine years, he gave much thought to death, and wrote of the necessity to accept each of its various forms as being equally natural: "Your death is a part of the order of the universe, 'tis a part of the life of the world...'tis the condition of your creation." And in the same essay, entitled "To Study Philosophy Is to Learn to Die," he wrote, "Give place to others, as others have given place to you.

But the fact is, death is not a confrontation. It is simply an event in the sequence of nature’s ongoing rhythms. Not death but disease is the real enemy, disease the malign force that requires confrontation. Death is the surcease that comes when the exhausting battle has been lost. Even the confrontation with disease should be approached with the realization that many of the sicknesses of our species are simply conveyances for the inexorable journey by which each of us is returned to the same state of physical, and perhaps spiritual, nonexistence from which we emerged at conception. Every triumph over some major pathology, no matter how ringing the victory, is only a reprieve from the inevitable end.

All along the way, family members have been experiencing feelings of ambivalence, helplessness, and crisis. They fear what they are seeing, as well as what they have yet to see. No matter how often they are reminded, many people persist in believing they are permitting conscious suffering. And yet, it is always so hard to let go. Such legal instruments as living wills and durable power of attorney may function as so-called advance directives, but all too often they do not exist; a grieving wife or husband, or children already struggling with family problems of their own, are adrift in a sea of conflicting emotions. The difficulty of deciding is compounded by the difficulty of living with what has been decided.

And when he died, I was glad. I know it sounds terrible to say that, but I was happy he was relieved of that degrading sickness. I knew he never suffered, and I knew he had no idea what was happening to him, and I was grateful for that. It was a blessing—it was the only thing that kept me going, all of those months and years. But it was a horrible thing to watch happening to someone I loved so much. You know, when I went to the hospital after Phil died, they asked me if I wanted to see his body. I said no. My friend, who is a devout Catholic, had gone with me, and she couldn't understand my refusal. But I didn't want to remember that face dead. You have to understand—it wasn't for me that I felt that way. It was for him.

Of the many kinds of knowledge upon which wisdom is based, the foremost must surely be self-knowledge, hard-won and often difficult to face. As more than one wag has put it, “The trouble with self-knowledge is that it’s so often bad news.” Bad news or not, it must be dealt with. Like no other characteristic of wisdom, this one is elusive, and too often the very thing we try so hard to avoid. The self-knowledge we believe ourselves to possess may actually be the self-delusion behind which we hide. But we fool ourselves at our own peril, and the peril only increases as we age. The slightest admission to one’s conscience of such a truth is the beginning of self-knowledge and well worth the pursuing, difficult though it may be.

It is probably a universal teaching of all cultures that putting a name to a demon helps to decrease its fearsomeness. I sometimes wonder whether the real, perhaps culturally subconscious, reason that medical pioneers have always sought to identify and classify specific diseases is less to understand than to beard them. Confrontation, somehow, is safer once we have set a label on a thing, as if the very process makes the beast sit still for a while and appear susceptible to taming; it puts under some element of control what has previously been a wilderness of unrestrained terror. When we give sickness a name, we civilize it—we make it play the game by our own rules. Naming a disease is the first step in organizing against it.

It is incumbent on each of us to cultivate his or her own wisdom. So gradual a progression is the onset of our aging that we one day find it to be fully upon us. In its own unhurried way, age soundlessly and with persistence treads ever closer behind us on slippered feet, catches up, and finally blends itself into us—all while we are still denying its nearness. It enters at last into the depths of one’s being, not only to occupy them but to become their very essence. In time, we not only acknowledge aging’s presence within us, but come to know it as well as we knew—and still covet—the exuberant youth that once dwelt there. And then, finally, we try to reconcile ourselves to the inescapable certainty that we are now included among the elderly.

I recently discussed this with my school's professor of geriatric medicine, Dr. Leo Cooney, who later summarized his viewpoint in two pithy paragraphs of a letter: "Most geriatricians are at the forefront of those who believe in withholding vigorous interventions designed simply to prolong life. It is geriatricians who are constantly challenging nephrologists [kidney specialists] who dialyze very old people, pulmonologists [lung specialists] who intubate people with no quality of life, and even surgeons who seem unable to withhold their scalpels from patients for whom peritonitis would be a merciful mode of death. We wish to improve the quality of life for older individuals, not to prolong its duration. Thus, we would like to see that older people are independent and lead a dignified life for as long as possible.

Poets, essayists, chroniclers, wags, and wise men write often about death ut have rarely seen it. Physicians and nurses, who see it often, rarely write about it.

has George Soros’ Open Society Initiative for Europe. Serving on the International Advisory Board with Pinchuk is Obama’s director of national intelligence, James Clapper. Obama’s assistant secretary of state for European and Eurasian affairs, Victoria Nuland, who claims to have received the Steele dossier at the State Department and then passed it on to the FBI before the investigation started, has spoken at the Atlantic Council.

Even the confrontation with disease should be approached with the realization that many of the sicknesses of our species are simply conveyances for the inexorable journey by which each of us is returned to the same state of physical, and perhaps spiritual, nonexistence from which we emerged at conception

Even the confrontation with disease should be approached with the realization that many of the sicknesses of our species are simply conveyances for the inexorable journey by which each of us is returned to the same state of physical, and perhaps spiritual, nonexistence from which we emerged at conception

The magnificence of the energy of the human system impresses even the scientifically rigorous Dr. Nuland. He is convinced that the wisdom of the body is traceable to known biochemical processes, yet he writes, “The unheard din of living is the symphony before which the chorale of the spirit soars in song.”4 It also seemed to impress the much more vitalistic or vital force-believing Ralph Waldo Emerson when he wrote, “One moment of a man’s life is a fact so stupendous as to take the lustre out of all fiction.

I tried to make clear to her that the belief in the probability of death with dignity is our, and society’s, attempt to deal with the reality of what is all too frequently a series of destructive events that involve by their very nature the disintegration of the dying person’s humanity. I have not often seen much dignity in the process by which we die.

Again in How We Die, Dr. Nuland described the failing attempts of a CPR team to revive a patient who had suffered cardiac arrest in the hospital:

had read Sherwin Nuland in How We Die:

...my patient needed a great deal of reassurance that there had been nothing unusual about the way her mother died, that she had not done something wrong to prevent her mother from experiencing that "spiritual" death with dignity that she had anticipated. All of her efforts and expectations had been in vain, and now this very intelligent woman was in despair. I tried to make clear to her that the belief in the probability of death with dignity is our, and society's, attempt to deal with the reality of what is all too frequently a series of destructive events that involve by their very nature the disintegration of the dying person's humanity. I have not often seen much dignity in the process by which we die.