Dying with Dignity: A Call for Change in End-of-Life Care in India
As doctors, we are faced with the sacred responsibility of helping our patients navigate some of the most difficult moments of their lives. We are the ones who hold their hands when they are in pain, who offer hope when they are uncertain, and who make decisions on their behalf when they cannot do so themselves. But there is a profound aspect of our responsibility that we often overlook — end-of-life care. It is a topic that is often avoided, a conversation that many of us hesitate to start, yet it is just as important as any other medical decision we make.
The Fear of Confronting Death
Ask yourself, what happens when a family asks us what should be done when their loved one is no longer improving? When the patient’s condition is critical, when recovery is no longer possible, what do we, as doctors, do? Often, we tell the family to take the patient home, or we push them towards Leave Against Medical Advice (LAMA). But what does this really mean for the family? We, as doctors, place the burden of this decision on them, forcing them into a situation that is not only emotionally draining but also socially challenging.
In India, where family and social reputation play a massive role, the decision to take a loved one home from the hospital, or to withdraw treatment, is often burdened with guilt and societal judgment. Relatives may accuse the primary caregiver of being “miserly” or “uncaring” for not wanting to continue treatment, not understanding the complexity and difficulty of the situation. This is a reality we need to confront as healthcare professionals.
By avoiding these crucial conversations about end-of-life care, we are not helping the families in front of us. We are not providing them with clarity, and we are leaving them in the dark, without guidance. Instead of helping them make informed, compassionate decisions, we burden them with a choice that is not truly theirs, under the weight of societal pressure and financial hardship.
The Emotional and Financial Toll of Continuing Treatment
One of the hardest truths we, as doctors, must accept is that not everyone can be saved. Medical treatment has its limits, and in some cases, there is no hope for recovery. Yet, we often continue life-sustaining treatments, not because they benefit the patient, but because we are too afraid to let go. We tell families to take their loved ones home, under the guise of giving them more time or waiting for a miracle, but in reality, this only prolongs the suffering.
I’ve seen it happen time and time again in the ICU. Patients who are terminally ill, whether from advanced cancer, traumatic brain injuries, or organ failure, remain hooked to ventilators and life support for days, weeks, or even months, with no meaningful recovery in sight. And while this may give families the illusion of hope, the reality is that it only deepens the emotional toll, and drains them financially.
Many families, especially in India, are forced to sell their land, borrow money, or struggle to make ends meet in order to afford continued ICU care for a loved one who is beyond recovery. The financial toll is not just from hospital bills; it can affect insurance claims. If the family opts for LAMA, medical insurance may not cover the claim. Similarly, life insurance policies or term plans might refuse to pay out, as they often require the patient to be on life support at the time of death for the claim to be valid. Families are left in a tragic bind, continuing costly treatment in hope of receiving an insurance payout, but with no realistic chance of recovery. This leads to families burning through their savings, taking out loans, and sometimes even selling assets to keep the patient on life support, just to meet the insurance requirements. This is not only financially unsustainable, but it also keeps families in denial—denying the inevitable and prolonging their grief.
In an era where the ethics of care are inextricably tied to the economics of access, we must occasionally reflect on how well-intentioned persistence in medically futile cases can place a quiet but significant burden on state-sponsored health provisions such as Bhamashah, RGHS, CGHS, and ESIC.
While these schemes were conceived to democratize access and uphold the principle of justice in healthcare, their silent overstretch in cases with no foreseeable benefit invites us to reconsider the delicate balance between compassion and responsible stewardship. The question is not of denying care, but of ensuring that dignity and discernment walk hand in hand—especially when resources, like life, are finite.
The Unspoken Pressure of LAMA
Instead of openly discussing end-of-life care, we often tell families to take LAMA, which places incredible emotional pressure on the primary caregiver. The very act of taking LAMA becomes a highly stressful decision, one that forces the family to feel like they are somehow abandoning their loved one. They are burdened with the stigma of having to justify their decision to other family members and friends, who may accuse them of not trying hard enough or not spending enough on treatment.
This is an unfortunate reality for many families, and it is time for us to acknowledge our role in facilitating these conversations. We are not doing families any favors by avoiding difficult conversations. Instead, we are adding to their burden, forcing them into an emotional quagmire with no way out.
What the NHS Taught Me About Letting Go
During my two years working with the National Health Service (NHS) in the UK, I witnessed a radically different relationship between medicine and mortality—one grounded not in denial, but in dialogue and dignity. We spoke openly to patients about their preferences for care at the end of life, using tools like the ReSPECT form—a structured conversation, not just a form, that allowed patients to voice whether they would want resuscitation, intubation, or ICU admission if the situation arose.
At first, I hesitated. How could I ask someone to contemplate their own decline? But to my surprise, patients wanted these conversations. Many expressed, clearly and calmly, that they would not want CPR or ventilatory support if it meant prolonging suffering without purpose. Some even brought advance directives with them—signed, witnessed, and proudly owned. In those moments, I realised that dying well is not about giving up; it's about choosing how not to suffer.
That experience shifted something deep within me. It showed me that compassion isn’t always about doing more—it’s about knowing when to stop. And it convinced me that such conversations are not only possible in India—they are desperately needed.
The Solution: Providing Compassionate End-of-Life Care
The solution is simple, yet profoundly impactful. We, as doctors, need to start taking responsibility for initiating conversations around end-of-life care. We need to educate families about the reality of the situation, helping them understand that dying with dignity is as important as living with dignity. By having these conversations early on, we can guide families in making decisions that are both ethically sound and compassionate.
The primary medical board can make a difference in these situations by formalizing the decision. If the board decides that further treatment is futile, then the family is no longer left to carry the burden of the decision alone. We, as healthcare providers, must respect the autonomy of our patients, and that includes respecting their right to die peacefully when there is no hope of recovery.
Once we acknowledge this, we can facilitate a compassionate death by offering palliative care, which focuses on providing comfort rather than extending life at all costs. Palliative care ensures that patients die in peace, surrounded by loved ones, without the fear of dying alone or suffering unduly. The two greatest fears of those who are dying are: not wanting to die alone and not wanting to suffer. By providing proper palliative care, we address both of these fears, offering comfort and peace in a time that is often filled with pain and uncertainty.
Honoring Cultural and Spiritual Perspectives
In India, many people’s views on death are shaped by religious and spiritual beliefs. For example, in Hinduism, death is seen as part of the natural cycle of life, and there is an understanding that the soul is eternal. The Bhagavad Gita teaches that we are not our bodies, but souls that transcend life and death. Many Hindus believe in dying at home, surrounded by loved ones, and not in the sterile environment of a hospital. Similarly, in Jainism, there is the practice of Santhara, a voluntary spiritual death ritual, which teaches that choosing death peacefully is a path to liberation.
By understanding and respecting these cultural and spiritual perspectives, we can approach end-of-life care with more empathy and mindfulness. We can align our medical practices with the values that matter most to our patients and their families, ensuring that they die in accordance with their beliefs and wishes.
The Conversation We Owe Our Families
In India, we rarely talk about living wills or advance medical directives—as if death, by not mentioning it, will politely pass us by. But the truth is, not having that conversation is not just negligence, it’s selfishness. When we fail to document our wishes, we leave our families to make the most painful decisions alone, in moments of crisis, with guilt, fear, and confusion clouding their every move.
We owe it to them—not just to love them in life, but to ease their burden in death. Make your decisions. Write them down. Tell your family what you would want, and what you wouldn’t. Whether it's no CPR, no ICU, or no artificial ventilation—be clear. Because if you don't, someone else will have to decide for you. And that burden may stay with them forever. This isn’t just about dying with dignity—it’s about letting your loved ones grieve without guilt.
As Monika Halan says in her book
Let’s Talk Money, not planning for our financial assets is selfish—how much more selfish is it, then, to avoid planning for our final medical wishes?
A Call to Action for All Doctors
I appeal to all doctors—let us stop being afraid. Let us educate ourselves on the laws surrounding end-of-life care, the ethical principles behind withdrawing life-sustaining treatments, and the importance of providing compassionate palliative care. These are not issues to be avoided; they are vital aspects of compassionate, patient-centered care.
We must normalize conversations about death. We must lead the discussion on end-of-life care, and ensure that we are providing our patients with the opportunity to die with dignity—just as they lived. It’s time to recognize that dying with dignity is not an act of giving up; it’s an act of respecting the patient’s wishes and recognizing when further treatment will only cause harm.
Absolutely, Dr. Srishti. That’s a powerful and essential thought. Here’s the revised version, now including the point that when we continue ventilation in medically futile cases, we are not preserving life—we are merely postponing the natural process of dying.
Letting a Dying Patient Die—With Dignity, Not Intervention
We must also have the courage to explain to families that withdrawal is not assisted dying—it is simply allowing nature to take its course. It is not about hastening death, but about acknowledging that the dying process has already begun. When we know that the ventilator is not prolonging life but merely postponing natural death, we must ask ourselves what compassion truly looks like. Our role, then, is to ensure comfort—to anticipate symptoms, manage pain, and offer calm. We must gently communicate the likely timeline, reassure them that breath may slow, consciousness may fade, but suffering will not take center stage.
This is not about giving up—this is about not prolonging the inevitable in distress. It is about letting a life come to a close with softness, with dignity, and without unnecessary struggle.
Explaining the Process of Withdrawal Compassionately
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Withdrawal of life-sustaining treatment is not assisted dying.
It is a medically, ethically, and legally accepted process of allowing the natural course of death in a patient where no meaningful recovery is possible.
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The patient is already in the dying phase.
Withdrawal means stepping back from invasive interventions that no longer serve the patient's best interests.
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Ventilation is not prolonging life—it is postponing death.
Continuing mechanical support in the face of confirmed futility does not change the outcome; it only delays the inevitable, often at the cost of suffering.
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This is not about “giving up.”
It is a conscious shift in goals—from extending life to ensuring peace, dignity, and comfort in the final hours or days.
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We must provide excellent palliative care.
Pain relief, breathlessness control, anxiety management, and emotional support are non-negotiable and should begin before withdrawal and continue throughout.
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Families should be informed of the likely timeline.
It’s essential to explain that after withdrawal, the patient may pass within minutes to hours—or sometimes longer—but always under our vigilant, compassionate care.
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Reassure them the patient will not suffer.
The medical team will be present to ensure the transition is as peaceful and symptom-free as possible. They will not die alone.
Conclusion: Let’s Start the Conversation Today
We have the knowledge, we have the tools, and now we must have the courage. Let’s not allow the fear of making the wrong decision to keep us from doing what is right. Let’s ensure that we honor our patients in their final moments, not just as doctors, but as humans.
Together, we can ensure that every patient is given the opportunity to die with dignity. This is not just about healthcare—it’s about humanity. It’s about offering our patients the respect they deserve in their final moments, and ensuring that they are not subjected to unnecessary suffering, just because we are afraid to let go.
Let’s start the conversation today. Let’s give our patients and their families the care they deserve in their final moments.
This article is an emotional call to action for doctors to embrace end-of-life care discussions and provide a more compassionate and humane approach to death. By following legal and ethical guidelines, and by understanding cultural and spiritual needs, we can make a significant difference in the lives of our patients and their families during their final moments.
Acknowledgement:
With deep gratitude to Dr. R.K. Mani, whose unwavering guidance and compassionate wisdom have shaped my understanding of ethical end-of-life care in India. Sir has been a constant pillar of support—always available to share his insights, patiently explain the nuances, and generously offer his time whenever I reached out. His belief in this cause has strengthened my own.
I also remain indebted to my time in the NHS UK—especially at Manchester Royal Infirmary and the Wythenshawe Heart and Lung Transplant Centre—for teaching me that true compassion in medicine is not just about saving life, but knowing when to let go with grace and empathy.
