Murder and Serenity
How We Die:
Reflections on Life's Final Chapter
by Sherwin B. Nuland
Vintage Books

Although viability of the brain is currently the legal criterion by which mortality is determined, there is still usefulness in the time-honored way in which clinical physicians have always diagnosed death. Clinical death is the term used to encompass that short interval after the heart has finally stopped, during which there is no circulation, no breathing, and no evidence of brain function, but when rescue is possible. If this stoppage occurs suddenly, as in cardiac arrest or massive hemorrhage, a brief time remains before vital cells lose their viability, during which measures such as cardiopulmonary resuscitation (CPR) or rapid transfusion may succeed in resuscitating a person whose life has seemingly ended-- the time is probably no more than four minutes. These are the dramatic moments we read about and see portrayed on our television screens. Although the attempts are usually futile, they succeed just often enough that, under the appropriate circumstances, they should be encouraged. Because individuals most likely to survive clinical death are those whose organs are healthiest and who do not have terminal cancer, for example, or debilitating arteriosclerosis or dementia, their continuing existence is still possible and potentially most valuable to society, at least in terms of ability to contribute. It is for this reason that the principles of CPR should be taught to every motivated person.


Clinical death is often preceded (or its first evidences are accompanied) by a barely more than momentary period termed the agonal phase. The adjective agonal is used by clinicians to describe the visible events that take place when life is in the act of extricating itself from protoplasm too compromised to sustain it any longer. Like its etymological twin, agony, the word derives from the Greek agon, denoting a struggle. We speak of "death agonies," even though the dying person is too far gone to be aware of them, and even though much of what occurs is due simply to muscle spasm induced by the blood's terminal acidity. Agonal moments and the entire sequence of events of which they are a part can occur in all the forms of death, whether sudden or following upon a long period of decline into terminal illness, as in cancer.

The apparent struggle of the agonal moments are like some violent outburst of protest arising deep in the primitive unconscious, raging against the too-hasty departure of the spirit; no matter its preparation by even months of antecedent illness, the body often seems reluctant to agree to the divorce. In the ultimate agonal moments, the rapid onset of final oblivion is accompanied either by the cessation of breathing or by a short series of great heaving gasps; on rare occasions, there may be other movements as well, such as the violent tightening of James McCarty's laryngeal muscles into a terrifying bark. Simultaneously, the chest of shoulders will sometimes heave once or twice and there may be a brief agonal convulsion. The agonal phase merges into clinical death, and thence into the permanence of mortality.

The appearance of a newly lifeless face cannot be mistaken for unconsciousness. Within a minute after the heart stops beating, the face begins to take on the unmistakable gray-white pallor of death; in an uncanny way, the features very soon appear corpse-like, even to those who have never before seen a dead body. A man's corpse looks as though his essence has left him, and it has. He is flat and toneless, no longer inflated by the vital spirit the Greeks called pneuma. The vibrant fullness is gone; he is "stripped for the last voyage." The body of the dead man has already begun the process of shrinking-- in hours, he will seem "to be almost half himself." Irv Lipsiner reenacted the deflation by blowing his breath out through pursed lips. No wonder we say of the recently deceased that they have expired.

©Copyright Sherwin B. Nuland, 1993. All Rights Reserved. No portion of this work may be reporoduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage or retrieval system now or hereafter invented, without permission in writing from the Publisher.