Jottings - slice of life - 199 ( A narrative on dying and death - Dr Sherwin Nuland’s classic)

Jottings - slice of life - 199 ( A narrative on dying and death - Dr Sherwin Nuland’s classic)
There are innumerable books on How to live, but very few on How to die. It is strange why not, considering our entire lives are spent relentlessly stalling death, insuring against it, working to leave a mark beyond it, trying not to think about it or building strong theories on surviving it. Yet, there is no proper literature which speaks about those last moments of life before the body becomes inanimate, shrunken, useless and - starkly lifeless. Though millions die each day; our near and dear ones slip away at a steady rate, and we consciously feel our own bodies losing their vitality each passing day - we still don’t wish to look at death straight on the face, understand and study its manifestations and accept it for what it is.
One of the brutally philosophic compositions in world religions - the Bhaja govindam - of Shankara, encapsulates the stupidity of not seeing death as a great revelation. he says in one arresting couplet
यावत्पवनो निवसति देहे
तावत्पृच्छति कुशलं गेहे ।
गतवति वायौ देहापाये
भार्या बिभ्यति तस्मिन्काये
Roughly translated and paraphrased:
“As long there is life pulsating though your vigorous and virile body, admirers and well wishers surround you;
The moment the breath of life oozes out of your pores in one decaying moment,
Even your wife who yearned, prayed and wished for your physical proximity,
Will hover around your lifeless body with trepidation, treat it as a piece of decrepit flesh with fear and nothing more.
Therefore, my friend, arise and learn to look at life and death with equal gaze, respect and introspection.”
This couplet has always haunted me in its directness. As a society, we expect our deaths to be peaceful. “To die peacefully, without any pain or suffering..” is our daily prayer, but the reality is never so. The best people to talk to us about those final moments of death are the Doctors and nurses around us. Unfortunately, not many of them are articulate enough to do so, or even if they are, they quickly become acclimatized to daily rigors of death. They dont find time or the interest to sufficiently reflect or contemplate on nature of death; much less write about it.
There are few exceptions. In 1992, Dr Sherwin Nuland, a surgeon , produced one of the greatest books of the century. It is titled “ How we die - reflections on life’s final chapter”. Its a book about death and the agents directly responsible it. After a life time battling critical cases in the ER, rising above his own depressions and failed marriage, Dr Nuland brings to focus in this short book the process of physical death and the onset of that final mile in human life. The heart, the blood vessels, the brain, oxygen and chemical levels, the blast of viral attacks, loss of immunity and myriad other causes that lead to death , can be traced down to to few important biological processes that stop; when that happens, life as we know it exists no more, and we are left with mere decaying flesh that barely resembles the living flame that existed moments ago. And rarely does death occur without pain, not only for the victim, but for others caring for them. In some cases such as heart attack, death is swift and incisive; in others like Parkinson’s, it is prolonged, traumatic and demeaning. The difference is only one of quality and quantity; pain remains constant.
Dr Nuland’s book, surprisingly, went on to become a bestseller. It won the national book award that year. Not only was his candid treatment of the subject appealing, but his language and style as well. Never before has anyone written so eloquently and sensitively about death in all its minute details. If books can transform, this definitely can. Since then, doctors such as Siddharta Mukherjee, Atul Gawande have written beautifully about disease, care and death; but when one reads Dr Nuland, there is a sense of reading a man who has distilled years of looking at death with care and loving eyes, and not as something alien, uninvited and always need to be fended of. Even a heart attack becomes a enjoyable, intricate process in the voluptuous language of Dr Nuland. The beauty of the human organism, the creative and astounding coordination of processes, its unwritten and unsolicited healing mechanisms, its holistic existence - gives us sense of dignity to live well, and less of unhappiness in watching it die. For good things cannot go on for ever. An organism of such intricate beauty has to disintegrate, give way and merge into its source; otherwise life becomes repetitive and artificial. The sheer beauty of life is that it is temporal - like a rainbow in the sky, which comes together due to a confluence of different attributes , and should disappear soon. A static rainbow will not be half as beautiful as a transient and evanescent one.. Similarly, each human body comes together and operates in an incredibly mysterious and miraculous process. To cherish this miracle, it is necessary to respect and understand its dissolution too.
One of the greatest moral dilemma’s of Man is to understand when to let someone we love die, and not subject them to medical treatment. Its a difficult decision; but the more we understand the processes of death itself, the less burdensome it becomes. Questions on ethics, morality, compassion are fine at one level, but the subjective experience of the patient, who lies in bed with tubes and needles sunk into them, and every bodily process yearning to stop, presents a different question altogether. How long do we prolong care? How much do we keep our loved ones medicated and artificially alive? And lastly, are we even doing them justice. Given a choice, is this what they would have wanted? These are deep questions, and answers dont come easily. When Ramana’s (mystic from India) mother was dying, he sat quietly near her looking into her face and stroking her head. Devotees and well-wishers advised more medical help. He quietly silenced them, and said “ Look at her. she is passing away peacefully, knowing I understand, and I am with her..” There was tear in his eye, and so was one in hers too. The end came gracefully.
In Dr Nuland's book, one find such deep sympathy clothed in stark medical terms.
God bless..
yours in mortality,
Bala

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