Published on: February 1, 2025

As I interact and speak to people dying of cancer I have come to infer that death or end of life has a different meaning for those who are living in urban India and a very different meaning for those who live in rural India.

 One of the facts about being at EOL when cancer is beyond being treated is that the shutting down of the body and its functions is an irreversible process. Supportive treatment can help alleviate the suffering/ side effects and the pain caused by the progressing cancer but it can’t prevent someone’s death.

The options available to the person dying and the family are– choose home-based care/hospital admission/ hospice. At this point, a HONEST conversation with the family can help them arrive at a decision. What is the decision they take or make depends on the conversation they have with the treating team. SHARED DECISION making is when both the HCP and the people under treatment and their families arrive at a suitable decision which ‘should’ be right for the patient.

What is right for the patient?

1. DEATH IN AN ICU surrounded by strange-looking people in hospital gowns and machines that in some way are inserted in the human body keeping one artificially alive

2. DEATH AT HOME surrounded by your loved ones, listening to your favourite song, looking out of your favourite window, being in your favourite bed or/and holding the hand of the one who you love.

3. HOSPICE CARE– India has very few hospices/people don’t understand hospice care/ they fear that they are abandoning the patient

Option 1 is how many chose death in Urban India. The reasons – following the advice of the treating doctor who will suggest ICU admission ( many times the advice of the palliative care team is not taken ) and /or the fear that taking care of the patient at home is not possible/ availability of modern hospitals and resources/ no Integration of palliative care ( even when it’s easily available)

In most cases, I would not be wrong in saying that money buys death in an ICU, in urban India.

Option 2 is how most people in villages or rural India chose to die. The reasons – they don’t have the money for ICU even when suggested/ Lack of resources and inequity of health-care services /End-of-life practices in India have historically been closely linked to spirituality and religion and dying at home is associated with these practices.

In my experience in the last so many years, I have seen a huge divide between the choices made by those dying in urban India and those in Villages. Some reasons I have listed above and some that I have observed in my practice ( my opinion only) are :

In urban India

1. The doctor’s reluctance to say that hospital admission at EOL is basically depleting your resources – financial and emotional (losing out on spending precious time together )

2. Poor death literacy

3. In many cases easily accessible resources lead people to think that death can be postponed or put on hold.

Yes, there are few in Urban India who still choose to die at home but the majority die in hospitals. 

In 10 years of my experience, I can cite many stories where wonderful people residing in villages die at home surrounded by loved ones and wonderful people from cities/ towns die in an ICU surrounded by machines ( the regret stories/ guilt experienced by the families stays with them forever)

Can I then say urban India is redefining death for a person with an irreversible illness like terminal cancer?

(Vandana Mahajan is a Palliative care counsellor with over ten years of experience in counselling and providing psychological support to cancer patients and their families. She is a passionate patient advocate and a dear friend of Pallium India.)

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