"[T]oo many of the specialists from whom the elderly seek care retain their riddle and their fascination. They also believe they give patients some kind of hope, though in the end the hope must always prove to be unjustified."
As I understand it, Nuland believes specialists are trained to use their expertise to treat any malfunction of patients' tissues of their specialty. He suggests that specialists' view becomes myopic, with the declining function of aging tissues perceived as a treatable--even curable--problem, and not as part of a natural path to death.
He's not denying that specialists are behind most of the modern miracles of science that rescue otherwise healthy patients, even octagenarians, from life-altering and life-threatening ills. Or that such successes are good.
Trouble arises only when specialists direct the same expertise and aggressiveness to the care of every patient, even if their success cannot improve patients' overall health and, in fact, simply prolongs dying.
A key takeaway of How We Die is that competent, compassionate care depends on responding to specific problems in the context of patients' overall health and life. Elderly patients, their advocates and their primary care physicians can and must work together to use available interventions with discretion.