I loved reading the late Yale Medical School professor Dr. Sherwin Nuland’s highly-recommended book How We Die – which is not nearly as grim as it may sound. In fact, it’s an endlessly fascinating read. For heart patients, the concept of death can suddenly become far more personally compelling than most of us ever imagined it to be.
But we live in a death-denying society. People don’t want to think about death, much less talk about it. As Dr. Nuland wrote, death to most of us occurs “in sterile seclusion, cloaked in euphemism and taboo”. We don’t even like using the ‘D’-word. Instead of ‘dying’, some of us prefer to just “pass away” or “go to be with Jesus”.
Sometimes, it seems that we consider death to be a terrible mistake that should never ever happen to anybody, instead of the inevitable end result of being born. But let’s face it, my heart sisters: none of us is getting out of here alive. . .
My own personal view on the subject of death is just that – my personal opinions that you may or may not share.
Perhaps it was so many years working in end-of-life/palliative care (where our staff tends to chat comfortably about death and our own mortality compared to the average person on the street) that made me so intrigued by life’s final chapter.
I’ve seen really awful ways to die (my own Dad’s, for example).
I’ve been privileged to witness good deaths supported by caring professionals (skilled palliative care physicians, nurses and bereavement counselors).
And I know of anguishing examples of heroic yet futile efforts by some physicians to artificially prolong life, efforts that not only hold absolutely no hope of being successful, but often result in unspeakable suffering for both patients and their families.
Post-heart attack, after being discharged from the CCU (the Intensive Care unit for heart patients), I was afraid of dying. I worried that I would die in my sleep, that I might never wake up. Each evening, I tidied up the apartment, took out the recyling bin, wiped every counter down and scrubbed the bathroom. But after a few weeks of this, I realized how exhausting it is to dread death – especially death that doesn’t come.
I am also relieved and grateful to live in a time and place here in Canada, where Medical Assistance In Dying (MAID) is now legally available upon request for those who qualify under specific guidelines. It is my own personal wish to take advantage of a physician-assisted death one day if I’m ever in that state of intractable physical or mental suffering I can no longer tolerate. I’ve had a remarkably good life. And I spent 10 years of my life visiting my brilliant, funny, eccentric friend in a 5-bed longterm care ward after a catastrophic stroke that left her incapacitated, strapped into a wheelchair, incontinent, almost blind, nearly deaf, severely depressed. After the first four or five years of our regular visits, she started telling me, “I wished they had never saved my life.” I know that there are far worse things than death.
Unless a catastrophic accident gets me before I qualify for MAID, heart disease or its complications will very likely be implicated in my death. Dr. Nuland’s unique book looks at the medical physiology of how we die if we do die from illness – from cancer to Alzheimer’s and, yes, cardiovascular disease.
It’s still surreal to read Dr. Nuland’s description of our coronary arteries as “friends of the heart” when we are healthy, but “when they are diseased, they betray it at its most needful moments.” He explained:
“So commonly do coronary arteries betray the heart whose muscle they are meant to sustain, that their treachery is the cause of at least half of North American deaths.
“Problems with these ‘now I love you, now I don’t’ vessels begin when their victims are young. Varying degrees of vessel obstruction can be found in virtually every adult, having begun in adolescence and increasing with age.
“An individual myocardial infarction (heart attack)involves that part of the heart muscle wallsupplied by the particular coronary artery that is occluded (blocked), usually measuring two or three square inches in surface area.
“The culprit about half the time is the left anterior descending artery. Half of all infarctions thus involve the front wall of the left ventricle. The right coronary artery, supplying the back wall of the heart, accounts for 30-40% of occlusions; the left circumflex coronary artery, supplying the lateral wall of the heart, contributes 15-20% of all heart attacks.
“The left ventricle, the most powerful part of the cardiac pump and the source of the muscular strength nourishing every organ and tissue in the body, is injured in virtually every heart attack.
“When a coronary artery suddenly occludes, a period of acute oxygen deprivation ensues. If this period is long and severe enough that the stunned and bloodless heart muscle cells cannot recover, the pain of angina is replaced by infarction.
“The affected heart muscle tissue goes from the extreme pallor of ischemia to frank death.
“If the area of muscle death is small enough and has not killed the patient by causing electrical abnormality of heart rhythms, the involved heart muscle, now puffy and swollen, will be able to maintain a tenuous hold on existence until, with gradual healing, it is replaced by scar tissue. (See also: Time Equals Muscle During Women’s Heart Attacks).
“The area of this damaged tissue is incapable of participating in the forceful thrusting of the rest of the myocardium (heart muscle). Each time a person recovers from a heart attack of any size, he/she has lost a little more muscle to the increasing area of scar tissue, and the power of the ventricle becomes a bit less.
“Coronary occlusions or spasms in smaller branches of the main vessels may give few signals to announce themselves, but they continue to diminish the force of cardiac contraction. Thus it is the chronic disease of heart failure, and not the sudden cardiac arrest, that carries off about 40% of victims of coronary artery disease.
“But the heart is far more than just another stolidly stupid pump, but a responsive dynamic participant in life, capable of adaptation, accommodation, and sometimes even repair.
“Back in 1772, a properly designed exercise program to rebuild the heart’s ability to function was described like this by one observer:
“I know of one who set himself a task of sawing wood for half an hour each day, and was thus nearly cured of heart disease.”
“Although the handsaw has been now replaced by the treadmill, the principle is the same.
“A wide variety of cardiac medications are also available now to help the heart muscle and its conduction system. There are even drugs used within the first few hours of an occlusion to dissolve a brand new clot. There are drugs to decrease myocardial irritability, prevent spasm, dilate arteries, strengthen the heartbeat, diminish accelerations of heart rate, drive out excessive loads of water and salt, slow down clotting, decrease cholesterol levels in blood, lower blood pressure, allay anxiety – and every one of them carries with it the possibility of undesirable side effects.”
And there are, as Dr. Nuland described them, “the wizardries of technology” that allow cardiologists to:
- reroute blood around obstructions in coronary arteries (bypass surgery)
- widen narrowed vessels with balloons and stainless steel stents
- replace or repair malfunctioning heart valves
- zap wonky electrical circuits in those who skip beats (heart arrhythmia)
- have the whole heart chucked out and replaced with a healthy secondhand one (heart transplant)
All of these procedures, he said, have high rates of success, when the candidate is carefully chosen.
“And yet, after each one, the process of atherosclerosis continues to lick at life. Widened arteries frequently plug up again, grafted vessels develop occlusions, and ischemia symptoms too often return to their old myocardial haunts.”
And there’s the rub, my heart sisters: like all heart attack survivors, I do, alas, now live with a chronic and progressive disease diagnosis. See also: The Cure Myth
They can patch me up with invasive procedures, prescribe drugs to alter my heart rate, arterial flexibility or blood composition, pat me on the head and wish me well – yet in spite of those wizardries of technology, it’s a fair bet that at some point, I’ll be saying: ‘Hello again!‘ to the Coronary Intensive Care unit staff in our cardiac hospital. We know, after all, that a significant risk factor for having a heart attack is having already had one.
I’ll leave the last profound words on death and dying to Dr. Nuland:
“Nature has a job to do. It does its job by the method most suited to each person. It has made this one susceptible to heart disease, and that one to stroke, and yet another to cancer, some after a long time on this earth and some after a time much too brief.
“Death is not only the ‘way of all flesh’ but the way of all life, and it has its own plans for us. Though we find clever ways to delay, there is no way to undo those plans.”
And right now, my own plans are to head out the door to walk along the ocean in the sunshine so I can contemplate LIFE for a while. . .
Carolyn’s Note: Dr. Sherwin Nuland died of prostate cancer at the age of 83 on March 4, 2014 in his Connecticut home. His daughter recalled that he had told her he wasn’t ready for death because he loved life: ‘”’m not scared of dying, but I’ve built such a beautiful life, and I’m not ready to leave it.”
Q: Since your own diagnosis, have you thought about death more or less often than you ever did before?
UPDATE: I wrote more about the D-word (including my own absolute certainty during the early weeks post-heart attack that I would die in my sleep each night – a possibility I prepared for every evening by cleaning and tidying the apartment so that, in case I did die overnight, the paramedics would find my corpse in a nice clean place the next morning!) in my book “A Woman’s Guide to Living with Heart Disease“ (Johns Hopkins University Press, 2017)