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Stanford Report, October 15, 1997

Sherwin Nuland speaks at Stanford: 10/15/97

Nuland to caregivers: 'Get back to the
essence of what you are'

BY MIKE GOODKIND

Dr. Sherwin B. Nuland last week confronted emotionally charged questions from medical students and new physicians as directly as he confronts death ­ and as passionately as he tells doctors to return to their emotional roots.

Nuland, author of the best-selling "How We Die" (Knopf, 1994) and other books, delivered the seventh annual Jonathan J. King Lecture to a packed audience Oct. 7 in Fairchild Auditorium. He is a medical historian and clinical professor of surgery at Yale University School of Medicine who has gained a national reputation for his ability to help people confront death rationally by providing detailed clinical descriptions of how it occurs.

Tears were visible on many faces in the room as Nuland implored his audience to "empathize ­ look at the world through your patient's eyes. ... He looks into your eyes, and whom does he see? Are you living up to his expectations?"

And those expectations, particularly for the dying patient, seldom focus on the doctor's cutting-edge skills, Nuland noted.

He reminisced that as a 10-year-old boy with a terminally ill mother, he saw his family doctor as a hero who came to the house to reassure and to manage crises. This caregiver remained a role model until Nuland's medical school socialization led him to cast aside his early mentor in favor of a master diagnostician "on the cutting edge."

When asked by a student last week for "any words of wisdom" on how to achieve the requisite technical expertise and still remain empathetic, Nuland gave some practical advice.

"Get back to the essence of what you are before you became professionalized," he said. "We [faculty] ... homogenize it out of you. And your job is to resist that. And there are ways to resist that. And some of them are very pragmatic.

"Here is a simple thing: When you take a vacation, don't go to the Bahamas. ... Go home. Hang around your mom. Go for walks with your dad. If you are someone of religious faith and your minister has been an important factor in your life, go visit your minister."

Another trainee asked, "How do you work with patients who have not accepted that they are dying?"

Bring the issue out in the open, Nuland advised. "Let the patient know that death is something that can be talked about, that somehow you do understand and will never abandon them."

The agenda of the physician at the time of death is "almost always quite different from the agenda of the patient and family," he said.

"I think the real challenge for most physicians is intellectual. I think it has to do with what I call the riddle of disease, the challenge of making diagnosis, the challenge of treating a patient. Physicians tend to be very courteous and try to be as kind as they can, but what really fuels the engines of our finest people is the excitement of diagnosis" and then successful treatment, he said.

"But near the end of life, when chances are decreasing that anything positive can be done, that is not the time for a doctor to be focused on what it is that he can achieve," Nuland said.

Sometimes bluntly, he attacked several myths, including the ideal of a serene and meaningful death. It can happen, Nuland said, but usually "there is too much pain and too much Demerol."

"The real determinant of how we die is our disease; it is not what we have been or who we are or who our doctor is," he said. "It is not something that is controllable by patient, physician or family. This is a great source of frustration and guilt feelings for people, that they think you should die 'well.'"

When a talk show host once asked him, "What is the worst way to die?" Nuland summed it up in a single word: alone.

"I'm talking about emotionally alone, and when we do not share the knowledge that death is near, no matter what else we share, this person we love and care so much about will die alone. And that's the responsibility of the family, the responsibility of the doctor; it's everybody's responsibility."

Nuland said he regrets not telling an aunt, who died while he was a medical resident, "what her life had meant to us. If there is anything that is important near the time of death, it is to convey what someone's life means to us."

In an interview before his talk, Nuland had strong words for managed care. "I think managed care has to be stopped, and I think it will be stopped. People expect more from their doctors," he said.

On the need to spend quality time with patients, he said, "I don't know why everybody is so hung up on time. It doesn't take a lot of time to transmit a mood to a patient. You can sit at a patient's bedside and hold his hand and talk to him, or you can be at the foot of the bed and dictate something to him. Those are two different gestalts.

"We all know doctors who can be with you for two minutes, and when they leave you feel like they've been with you for half an hour. And just the opposite is true ­ a doctor can be with you for 15 minutes talking at you for gosh sakes all that time, and you come out frustrated, because they don't know you."

The King Lecture series was founded by friends and family of Jonathan King, a Palo Alto computer scientist with a passion for philosophy. Before his death from cancer in 1991, King defined key messages he hoped caregivers would keep in mind as they serve dying patients. Each speaker in the lecture series has addressed issues of sensitive caregiving inherent in King's broad messages.SR