Our Healthcare System Is a Legacy Application

One of my favourite blogs is Brain Pickings, written by Maria Popova, which is a collection of thoughts spanning art, science, psychology, and almost every other subject I read voraciously. Recently I stumbled upon this gem, Sherwin B. Nuland’s How We Die1. It is a raw look at the biological processes that occur at the end of life, which resonated with me on many levels.

The biologist within was fascinated by Nuland’s ability to reduce the “ten thousand several doors for men to take their exits”2 to the same basic process of poor oxygenation and nutrition of vital tissues resulting in organ failure. Whether the process is long or slow, instigated by heart disease, Alzheimer’s disease, AIDS, accident, or old age, the end must come when the heart stops nourishing the brain.

As a Clinical Professor of Surgery at Yale University, Nuland became intimate with death and its increasingly dehumanizing circumstances. Life’s final chapter has become invisible to most of us. It is likely to be carried out in an intensive care unit, the person reduced to data on a screen, and the advancing disease perceived as a failure of management rather than a natural and inevitable process. He shares the lessons he learned about providing true patient care rather than solving a biological riddle (sometimes the best patient care is no care at all).

Most importantly, he calls attention to the deplorable state of healthcare today, where the “provider” has usurped the role of the physician:

[Our] present system of in-hospital care… has simply accreted by the constant piling on or insinuation of patches of not necessarily compatible structure to an edifice already jerry-built of competing needs.

Sounds remarkably like a long-lived legacy application that is impossibly complex and difficult to work in. The healthcare system is in need of a great refactoring, which isn’t without precedent (read about Abraham Flexner’s report Medical Education in the United States and Canada that started the movement to raise “American medical education… to the highest [status] in the civilized world”3)

How We Die won the National Book Award, was a finalist for the Pulitzer Prize, and perched atop the New York Times’ bestseller list for more than thirty weeks. This book answers a question we have all asked at some point — what will it be like to die? A hope many of us share is to have a dignified death with little suffering for ourselves and our families, but reflecting on his many years and experiences with death, Nuland has found that

the greatest dignity to be found in death is the dignity of the life that preceded it. This is a form of hope we can all achieve, and it is the most abiding of all. Hope resides in the meaning of what our lives have been.


  1. Nuland, Sherwin B. (2014-06-25). How We Die: Reflections on Life’s Final Chapter. Kindle Edition

  2. Webster, John. (1612) The Duchess of Malfi

  3. Flenxer, Abraham. (1910). Medical Education in the United States and Canada.