Free How We Die by Sherwin B. Nuland Page A

things? and, Should we be doing anything at all?
    Far too often, nothing helps. Even when the correct answer to both questions is an emphatic yes , the fibrillation may be beyond correction, the myocardium unresponsive to the drugs, the increasingly flabby heart resistant to massage, and then the bottom falls out of the rescue attempt. When the brain has been starved of oxygen for longer than the critical two to four minutes, its injury becomes irreversible.
    Actually, few people survive cardiac arrest, and even fewer among those already seriously ill people who experience it in the hospital itself. Only about 15 percent of hospitalized patients below the age of seventy and almost none of those who are older can be expected to be discharged alive, even if the CPR team somehow manages to succeed in its furious efforts. When an arrest occurs elsewhere than the hospital, only 20 to 30 percent survive, and these are almost always those who respond quickly to the CPR. If there has been no response by the time of arrival in the emergency room, the likelihood of survival is virtually zero. The great majority of the responders are, like Irv Lipsiner, victims of ventricular fibrillation.
    The tenacious young men and women see their patient’s pupils become unresponsive to light and then widen until they are large fixed circles of impenetrable blackness. Reluctantly the team stops its efforts, and the entire scene becomes transformed from a vital image of imminent heroic rescue to the dejected gloom of failure.
    The patient dies alone among strangers: well-meaning, empathetic, determinedly committed to sustaining his life—but strangers nonetheless. There is no dignity here. By the time these medical Samaritans have ceased their strenuous struggles, the room is strewn with the debris of the lost campaign, more so even than was McCarty’s on that long-ago evening of his death. In the center of the devastation lies a corpse, and it has lost all interest for those who, moments earlier, were straining to be the deliverers of the man whose spirit occupied it.
    What has happened is the culmination of a straightforward series of biological events. Whether programmed by his genes, self-imposed by the habits of his life, or, as is usually the case, a combination of both, a man’s coronary arteries have been unable to bring sufficient blood to nourish the muscle of his heart; the heartbeat became ineffective, the brain went too long without oxygen, and the man died. Approximately 350,000 Americans suffer a cardiac arrest each year, and the vast majority of them die; fewer than one-third of the episodes occur in a hospital. Often, there is no warning of the imminence of that final exit. No matter how much ischemia a heart has endured in the past, its defection may be sudden. In some 20 percent of people, it may even happen, as it did for Lipsiner, without pain. 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.
    The experience of dying does not belong to the heart alone. It is a process in which every tissue of the body partakes, each by its own means and at its own pace. The operative word here is process , not act, moment , or any other term connoting a flyspeck of time when the spirit departs. In previous generations, the end of the faltering heartbeat was taken to indicate the end of life, as though the abrupt silence beyond it intoned a soundless signal of finality. It was a specified instant, recordable in the chronicle of life and marking a full stop after its concluding word.
    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. The brain dies gradually, just as Irv Lipsiner