Free How We Die by Sherwin B. Nuland Page B

experienced it. Gradually, too, every other cell in the body dies, including those newly alive in the marrow. The sequence of events by which tissues and organs gradually yield up their vital forces in the hours before and after the officially pronounced death are the true biological mechanisms of dying. They will be discussed in a later chapter, but first it is necessary to describe the prolonged form of dying that is old age.

III
    Three Score and Ten
    N O ONE DIES of old age, or so it would be legislated if actuaries ruled the world. Every January, just when the harsh autocracy of winter has tightened its hoary hold, the U.S. government releases its yearly “Advance Report of Final Mortality Statistics.” Neither among the top fifteen causes of death nor anywhere else in that soulless summary is there to be found a listing for those among us who just fade away. In its obsessive tidiness, the Report assigns the specific clinical category of some fatal pathology to every octo- and nonagenarian in its neat columns. Neither do those few whose age is recorded in three digits escape the orderly nomenclature of the tabulators. Everybody is required to die of a named entity, by order not only of the Department of Health and Human Services but also of the global fiat of the World Health Organization. In thirty-five years as a licensed physician, I have never had the temerity to write “Old Age” on a death certificate, knowing that the form would be returned to me with a terse note from some official record-keeper informing me that I had broken the law. Everywhere in the world, it is illegal to die of old age.
    Actuaries seem unable to accept a natural phenomenon unless it is so well defined as to fit neatly into a distinct and easily described classification. The annual report of the federal death accountants is very orderly—not very imaginative, and to my mind not completely reflective of real life (and real death), but nevertheless very orderly. I’m convinced that plenty of people do die of old age. Whatever scientific diagnoses I have been scribbling on my state’s death certificates to satisfy the Bureau of Vital Statistics, I know better.
    At any given moment, some 5 percent of our nation’s elderly reside in long-term care facilities. If they have been there longer than approximately six months, the vast majority of them will never leave these nursing homes alive, except perhaps for a brief terminal sojourn in a hospital, where some young house physician will eventually fill out one of those very proper death certificates. What do all of these old people die of? 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 a while, all will at length surcease motion.”
    Whether its overt physical manifestation appears in the cerebrum or in the sluggishness of a senile immune system, the thing that peters out is nothing other than the life force. I have no real quarrel with those who insist upon invoking the laboratory-bred specificity of microscopic pathology in order to satisfy the compulsive demands of their biomedical worldview—I simply think they miss the point.
    As soon as I became conscious of life, I began the long process of watching someone gradually die of old age. The statistician has not yet drawn breath who can convince me that my grandmother’s state-certificated Cause of Death was anything else than a legalized evasion of the greater law of nature. She was 78 years old at my