Dying with Dignity

My mother was born in 1926, when most births and deaths took place at home. I grew up listening to stories of labour that began in the family room, with midwives, aunts, and neighbours gathering around the expectant mother. Death, too, belonged to the household. Many people spent their final days in familiar surroundings and breathed their last in the very room where they had entered the world.

When I began my MD residency at Government Medical College, Nagpur, in the late 1970s, that world was already fading. Hospitals were becoming the centre of medical care. New specialities emerged, technology advanced rapidly, and illnesses that had once been managed at home increasingly moved behind hospital walls.

Over the next four decades, intensive care units became a defining feature of modern medicine. Ventilators, dialysis, invasive monitoring, and a growing array of sophisticated interventions saved countless lives. Patients who would once have died from severe infections, heart attacks, trauma, or organ failure could now be rescued and returned to their families.

Yet these advances also changed the way we die.

Intensive care units were created to treat acute, life-threatening illnesses from which recovery was possible. Gradually, however, they also became the place where many people spent their final days. What began as rescue medicine often evolved into prolonged life support. Death moved from the home to the hospital, from familiar faces to unfamiliar machines, from the rhythms of family life to the routines of an intensive care unit.

Medicine acquired an extraordinary ability to postpone death. Learning how to preserve dignity at the end of life has proved far more difficult.

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Watch the talk

This essay grew out of a talk I delivered in Nagpur on 31 May 2026 to an audience of physicians and cardiologists.

In the talk, I explore how our relationship with death has changed, why modern medicine struggles when cure is no longer possible, and what four decades of caring for patients at Sevagram have taught me about comfort, compassion, and dignity at the end of life.

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Wisdom We Once Understood

Long before modern medicine, Indian society lived with the fact of death. Our epics and scriptures did not treat it as failure. They saw it as part of life.

The Mahabharata contains one of the sharpest observations on human nature. When Yudhishthira is asked, “What is the greatest wonder in the world?”, he replies that people see death all around them, yet each believes that he will live forever.

Little has changed.

Doctors see death more often than most people, yet we are not always comfortable talking about it. Patients avoid the subject. Families change the conversation. Doctors often search for words that never seem adequate.

The Mahabharata offers another lesson through Bhishma. Mortally wounded and lying on a bed of arrows, he does not struggle against the inevitable. Blessed with the power to choose the time of his death, he waits for Uttarayana, the sun’s northward journey, before letting go. Whether one sees the story as history, faith, or myth is beside the point. What matters is the calm acceptance. Bhishma knows that death cannot be defeated. It can only be faced.

The Gita says much the same thing. Krishna tells Arjuna that people change bodies as they change old clothes. The body wears out; the self does not. For generations of Indians, this idea softened the fear of death and gave it meaning.

Jain philosophy takes the argument further. The practice of Santhara, or Sallekhana, allows a person who is approaching the end of life to gradually withdraw from food and worldly attachments. The goal is not escape from life but acceptance of its natural end, with awareness, restraint, and peace.

Buddhism begins with a simple observation: nothing lasts forever. Youth fades, health declines, relationships end, and every life comes to a close. Much of our suffering comes from refusing to accept this truth.

The Bible expresses the same idea with characteristic simplicity: “To everything there is a season … a time to be born, and a time to die.” The Quran reminds believers that every soul shall taste death and that life on earth is temporary.

Different traditions speak in different voices, but they arrive at the same conclusion. Death is neither an accident nor a defeat. It is part of being human.

For centuries, this understanding was woven into everyday life. Families cared for the dying at home. Children saw ageing and death up close. Communities developed rituals that helped people prepare for loss.

Modern medicine has become remarkably good at postponing death. In the process, however, we may have lost some of the wisdom that helped earlier generations come to terms with it.

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How Medicine Learns to Fear Death

Medical education equips young doctors with an extraordinary range of skills. We learn how to diagnose disease, interpret investigations, perform procedures, and manage medical emergencies. We are trained to save lives, and rightly so.

What receives far less attention is the care of patients whose illnesses can no longer be cured.

Death usually enters medical training as something to be prevented, postponed, or explained. Morbidity and mortality meetings focus, understandably, on identifying errors and improving outcomes. Yet many young doctors unconsciously absorb a broader message: death represents failure.

As a result, physicians often feel ill-prepared when cure is no longer possible. Conversations about prognosis become uncomfortable. Discussions about goals of care are delayed. Decisions that should ideally involve patients, families, and senior clinicians are sometimes deferred until a crisis occurs.

How Medicine Learns to Fear Death

Medical school teaches us many things. We learn how to diagnose disease, read investigations, perform procedures, and manage emergencies. We spend years learning how to save lives, and rightly so.

What we rarely learn is how to care for people who cannot be cured.

Death enters our training mostly as something to be prevented. If a patient dies, we ask what went wrong, what we missed, and what we could have done differently. Those are important questions. Medicine advances because we ask them.

But young doctors often absorb another lesson as well: death means failure.

The message is rarely spoken aloud. It sits quietly in the background. We hear it in case discussions. We see it in mortality meetings. We recognise it in the familiar sentence written in countless case records: “Despite our best efforts, the patient could not be saved.”

As a result, many doctors are uncomfortable when cure is no longer possible. Prognosis is discussed late. Difficult conversations are postponed. Families are given one more treatment option when what they may need is an honest discussion.

Fear plays a part too.

Doctors worry about complaints, court cases, newspaper headlines, social media campaigns, and, increasingly, violence. Families, faced with the prospect of losing someone they love, often plead that “everything” be done.

Yet that simple word deserves closer examination.

What does “everything” mean?

Does it mean every available machine, drug, and procedure? Or does it mean doing everything possible to relieve pain, reduce suffering, preserve dignity, and respect the wishes of the person lying in the bed?

The answer is not always straightforward. But it is a question medicine needs to ask more often than it does.This discomfort is compounded by legitimate fears. Doctors worry about complaints, litigation, media scrutiny, and, increasingly, the possibility of violence. Families, overwhelmed by grief and uncertainty, often ask that “everything” be done. Yet no one pauses to ask what that word actually means.

Does doing everything mean using every available technology? Or does it mean doing everything possible to relieve suffering, preserve dignity, and honour the wishes of the patient?

The answer is not always obvious, but it deserves far more attention than it receives.

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Three Ways India Dies

Over the years, I have realised that people do not die in the same way. The illness may be similar, but the experience is shaped by money, family, and where they happen to be when the end comes.

One pattern is common in large city hospitals.

When families can afford every available treatment, it becomes very difficult to stop. There is always one more option to try, one more procedure to consider, one more week on a ventilator. The desire to save a loved one is natural and deeply human. Yet there are times when treatment no longer prolongs life so much as it prolongs dying.

A different story is unfolding in middle-class India.

Many elderly parents now live alone while their children work in Mumbai, Bengaluru, Dubai, London, or the United States. When serious illness strikes, decisions are often made over hurried phone calls and video screens. The son or daughter sitting thousands of kilometres away carries a heavy burden of guilt and worry. The plea to “do everything” usually comes not from indifference but from love mixed with distance.

A few years ago, the oncologist Dr. Sankha Mitra made an observation that has stayed with me. He said that in India the poor die in agony in neglect, the middle class die in agony in ignorance, and the rich die in agony on a ventilator. The statement is deliberately provocative, but it contains enough truth to make us uncomfortable.

My own experience in Sevagram has shown me another side of the story.

Many of our patients are poor farmers, labourers, or villagers from nearby districts. They may lack money, but they are rarely alone. Relatives sit by the bedside. Neighbours drop in. Someone brings food. Someone recites a prayer. Someone spends the night on the floor beside the patient.

The illness remains the same, but the experience is different.

The patient stays connected to the people who matter most.

Over the years, this has taught me something important. Dignity at the end of life has surprisingly little to do with wealth, advanced technology, or the reputation of a hospital. It has much more to do with comfort, human presence, freedom from pain, and the chance to remain oneself until the very end.In villages and smaller communities, where resources may be limited, families are often physically present. Relatives remain at the bedside. Neighbours visit. Religious rituals continue. Conversations are not delegated to distant screens. The patient remains connected to the people who matter most.

These experiences have convinced me that dignity at the end of life is not determined by wealth, technology, or the prestige of a hospital. It is shaped by comfort, meaningful choice, human presence, and freedom from unnecessary suffering.

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Lessons from a Palliative Care Ward

Five years ago, we started a thirty-bed palliative care unit at Sevagram. Since then, we have looked after hundreds of patients whose illnesses could no longer be cured.

The ward feels very different from an intensive care unit.

There are no monitors flashing numbers through the night. No alarms demanding immediate attention. No rush to arrange another procedure before the day ends.

What you notice instead are people.

A daughter gently massaging her mother’s feet. A grandson reading from a prayer book. A wife adjusting her husband’s pillow. Someone sitting quietly beside a bed, holding a hand without saying a word.

Most patients arrive carrying thick bundles of papers—years of prescriptions, scans, investigations, operations, and hospital admissions. Many have spent a lifetime’s savings. Some have travelled from one hospital to another in search of a cure that never came.

By the time they reach us, they rarely need another test.

They need a conversation.

So we pull up a chair and sit down.

We ask questions that medical records rarely capture.

Are you comfortable?

What worries you most?

Is there someone you would like to see?

Is there something important you still wish to say?

The answers are seldom medical.

A farmer worries about an unmarried daughter. A grandmother hopes she will live long enough to attend a family wedding. A retired schoolteacher wants to know whether his wife will be cared for after he is gone.

The illness remains in the room, but it no longer occupies the whole room.

The person returns to the centre of the story.

We encourage our residents to read Atul Gawande’s Being Mortal and the writings of Dr. M. R. Rajagopal. Both remind us that medicine is not only about extending life but also about easing suffering. Yet the most important lessons are not found in books. They are found at the bedside.

Over the years, I have watched confident young doctors fall silent during these rounds. Some have been reminded of grandparents whose last days were spent behind ICU doors. Others have remembered parents who endured one hospital admission after another while the family searched desperately for a miracle.

A few have cried.

Those tears do not worry me.

They reassure me.

They tell me that these young doctors are beginning to understand something that medicine sometimes forgets. Caring and curing are not the same thing. When cure is no longer possible, the duty to care becomes even more important.I have watched confident young doctors become unexpectedly emotional during these rounds. Some have been reminded of grandparents whose final days were spent behind ICU doors. Others have recalled parents who endured repeated hospitalisations while families searched desperately for a cure that never came.

Their tears do not concern me. They reassure me.

They suggest that these young physicians are beginning to understand a truth that medicine sometimes forgets: caring and curing are not the same thing, and when cure is no longer possible, caring becomes more important than ever.

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The Promise of Living Wills

For many years, Indian doctors felt trapped between medical reality and legal uncertainty. We recognised that some treatments were futile and that suffering was being prolonged, yet we lacked a clear framework for discussing these issues openly.

Recent Supreme Court judgments recognising Advance Medical Directives, commonly known as Living Wills, have begun to change that landscape.

The principle is straightforward. While healthy and capable of making decisions, individuals can state what forms of treatment they would or would not wish to receive if they later lose the ability to communicate.

A Living Will is not a rejection of medical care. It is an affirmation of personal autonomy. It allows a patient’s values and preferences to guide decisions even when that patient can no longer speak.

Perhaps the most important question is not whether our patients should have Living Wills. It is whether we, as physicians, have had these conversations with our own families.

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The Final Choice

After more than four decades in medicine, I believe the most important decisions at the end of life are rarely medical alone. They are human decisions about comfort, presence, and meaning.

A good death is not defined by the presence or absence of machines. It is defined by comfort: pain relieved, a familiar hand held, the chance to say what must be said. Medicine cannot stop death—no doctor can—but we can prevent unnecessary suffering and restore dignity.

A few kilometres from here, in Pavnar, Vinoba Bhave spent his final days surrounded by those who loved him. In November 1983 I was posted at his ashram when he fell ill at age 87. He chose to stop food, water and medicines; he died ten days later in the ashram, among people who loved, admired and respected him, in the very surroundings where he had lived for decades. Four decades have passed, and I have not seen a death so serene, calm, dignified and beautiful. By contrast, thousands move from one ICU to another, their savings drained, while no one asks, “What would this patient actually want?”

As physicians, we must tell families honestly: “Our goal now is not to prolong life at any cost, but to preserve dignity and peace.” If we can do that, we will change not only how our patients die but how they live their final days — and that is the greatest gift we can offer.