The practice physicians need for end-of-life care

This is Part 6 of a 6-part series on death, dignity, and what medicine can learn from ancient wisdom.

It’s 11:30 PM.

I’m sitting in my car in the hospital parking lot. Engine running. Air conditioning humming. But I’m not going home yet.

Mr. Acharya died forty minutes ago.

Eighty-three years old. Three weeks in the ICU. His family finally agreed to comfort care. We removed the ventilator. He died peacefully, his children around him, my hand on his shoulder.

Now they’ve gone home. The nurses have completed their paperwork. Someone else is in his bed already.

But I’m sitting here. Engine running. Not crying. Not even particularly sad.

Just… heavy.

…

This is the part nobody tells you about in medical college.

They teach you how to read an ECG. How to run a code. How to break bad news. They give you protocols, frameworks, evidence-based guidelines.

They don’t teach you what to do with the weight.

The weight of every difficult conversation. Every family meeting where you guided people toward letting go. Every time you wondered if you guided them right.

Every patient whose face you remember at 3 AM, asking yourself: Did I do the right thing?

…

I’ve been doing this for twenty-seven years.

I’ve sat with hundreds of families in those small private rooms. I’ve watched the moment when they realize their parent isn’t coming back. I’ve held countless hands as monitors went flat.

I’ve gotten good at it. The conversations come easier. The clinical decisions feel cleaner. I know when to push for more treatment and when to advocate for letting go.

But the weight? The weight doesn’t get lighter.

It just accumulates.

…

Each death adds its own quiet layer.

Mr. Kumar, the family I sat with at the beginning of this series. Mrs. Vasanthi, septic shock, gone by 11 PM. Mrs. Shantha, the ripe cucumber who knew she was tired. Mr. Suhas, the brilliant lawyer trapped in a failing body, asking me to let him die with dignity. Mrs. Renuka, kept alive for eight months when her eyes had been pleading for release.

They’re all there. Folded into me. Their faces. Their families. The specific decisions I made about their care.

Most days, I don’t think about them.

But sometimes, late at night, in moments like this one in the parking lot, they’re all present at once.

…

Driving home, I keep replaying Mr. Acharya’s family meeting.

His son had wanted to continue treatment. I’d guided them toward comfort care. Was I right? Did I push them toward MY philosophy of a good death rather than respecting their fight?

I’ll never know for certain.

That’s the work. Making impossible decisions with incomplete information, knowing you’ll never be sure.

And then carrying it.

…

My wife is asleep when I get home. I don’t wake her.

I make a cup of chai. Sit in the kitchen. Don’t turn on the TV. Don’t check my phone.

Just sit.

This is part of the practice I’ve developed over the years. After a difficult death, I need stillness. Not distraction. Not someone to talk to. Just… silence.

Time to let the weight settle. To acknowledge it. To put it down before I sleep.

If I don’t do this, the weight follows me into the next day. Into the next patient. Into my interactions with my family.

…

Most doctors don’t have this practice.

We’re not taught it. We’re not given time for it. We’re expected to compartmentalize, to be professional, to move on.

And so we move on. Carrying everything. Until we break.

…

I see it in my colleagues. The burnout. The cynicism. The doctors who became hard, distant, mechanical. Who stopped seeing patients as people because seeing them as people hurts too much.

I see it in the suicide rates among physicians, higher than almost any other profession.

I see it in the divorces. The addictions. The early retirements.

We’re carrying too much. Without the tools to process it.

…

The thing is, our patients teach us how to do this. If we let them.

…

Mr. Bhat taught me.

He was 81. Prostate cancer, metastatic to bones. We’d managed his pain for three years. Good years. He’d traveled. Spent time with grandchildren. Written letters to friends he hadn’t seen in decades.

But the cancer progressed. The pain became harder to control. He was getting weaker.

One day he called me to his home. Not for a medical visit. Just to talk.

I sat in his living room. His wife brought chai. He looked at me directly.

“Doctor, I’m ready.”

I waited.

“I’ve lived fully. Loved deeply. Raised good children. Seen my grandchildren thrive. I’ve said everything I needed to say. Done everything I needed to do. I’ve forgiven everyone who hurt me. Asked forgiveness from everyone I hurt.”

He paused. Smiled.

“I’m ripe. I can feel it. The connection to this body is weakening. I’m not afraid. I’m… curious.”

I was forty-five at the time. Still figuring out what kind of doctor I wanted to be. Still scared of my own mortality.

And here was this man, just ahead of me on the path, showing me what it looked like to be ready.

…

“What do you need from me?” I asked.

“When the time comes… I don’t want the hospital. I want to be here. In my bed. With my family. Just keep me comfortable. Let me go.”

We arranged home hospice. Pain management. Oxygen for comfort.

He died two weeks later. His wife was reading the Gita. His children and grandchildren around the bed. His breathing slowed. Stopped.

The hospice nurse called me. “Doctor, it was beautiful. He smiled at everyone in the room. Then closed his eyes. That was it.”

…

That was anāyāsena maraṇam.

Not because he didn’t suffer. He had pain. Weakness. The indignities of a failing body.

But because he was ready.

The cucumber, finally complete, releasing from the vine. Effortlessly.

…

After Mr. Bhat’s death, I started paying attention differently.

I started watching for ripeness. Not just in dying patients, but in everyone. Including myself.

What does it mean to be ready? Not just for death, but for whatever comes? For change, for loss, for the inevitable transitions of life?

I noticed something. The people who died well, the ones who had anāyāsena maraṇam, weren’t lucky. They’d practiced.

Not consciously, perhaps. But through how they lived.

They’d packed light.

…

This is what I want to tell you. Not as a doctor giving advice. As someone who has watched a thousand deaths and seen which ones were anāyāsena and which ones weren’t.

The secret isn’t found in the ICU. It’s found in the years before.

It’s found in the daily choices. The conversations had. The grudges released. The love expressed. The dreams pursued. The unfinished business completed.

…

The patients who died well had usually forgiven everyone who’d hurt them. Not because those people deserved it. But because carrying grudges to your deathbed is exhausting. The peaceful deaths I’ve witnessed were not held back by old anger.

The patients who died badly often had things unsaid. Conversations they should have had with their children. Apologies they meant to make. Love they hadn’t expressed clearly enough.

I watched a man die at sixty-eight, still angry at his brother for something that happened forty years ago. They hadn’t spoken in three decades. As he was dying, he said: “Tell him…”

He died before he finished the sentence.

His brother attended the funeral. They never reconciled. Both of them carried that weight, separately, until they died.

What a waste.

…

The patients who died well had given things away. Possessions, yes. But more than that. They’d given of themselves. Time. Attention. Wisdom. Love. They didn’t approach death with their fists clenched around what they owned.

They’d held things loosely.

…

I’m not preaching. I’m describing what I’ve seen. Patterns that emerged over twenty-seven years of bedsides.

The people who left well had practiced leaving every day.

…

Sleep is practice for dying.

Every night, you release consciousness. You let go of control. You trust you’ll wake up.

Some nights you might not. None of us are guaranteed tomorrow.

But you’ve been practicing letting go your whole life, without realizing it.

…

Every exhale is practice too.

You empty your lungs completely, trusting the next breath will come. You don’t grip the air. You release it.

When the final exhale comes, will you be ready to release it? Or will you cling, trying to hold on to one more breath?

The practice is in the breath you’re taking right now. Releasing it completely. Trusting the next one will come. Until one day, it won’t.

That’s not morbid. That’s true.

…

The patients I see who die well have made peace with this truth. Not in some abstract way. In a practiced way.

They’ve sat with silence. They’ve meditated, or prayed, or simply paid attention. They’ve cultivated the ability to let go before letting go became required.

…

I’m trying to learn this myself. Not because I’m dying. But because I’m alive.

Every morning, before rounds, I sit for ten minutes. Sometimes I meditate. Sometimes I just drink chai and watch the light change. Sometimes I pray.

I’m not particularly religious. But I’m building the muscle of stillness. Of presence. Of acceptance.

Because I know what’s coming. Not soon, I hope. But eventually.

I want to be ready when it comes.

…

And for me, being ready means living differently now.

I tell my children I love them. Often. Not in performative ways. Just regularly, so they always know.

I’ve reconnected with friends I’d let drift. Sent messages. Made calls. Visited.

I’ve made peace with people I was angry at. Not by forgetting what they did. By choosing not to carry it.

I’ve simplified what I own. Given things away while I can see the joy of receiving.

I’m not perfectly there. There are still things I need to repair, conversations I need to have. But I’m working on it.

Because I don’t want to die mid-sentence, like that man and his brother.

…

This is what my patients have taught me.

They’ve been my teachers, all of them. The ones who died well. And the ones who didn’t.

Especially the ones who didn’t. They taught me what to avoid.

Their unfinished business became my warning. Their unspoken love became my reminder. Their unforgiveness became my caution.

I owe them. I really do.

…

So when I sit in my car at 11:30 PM, heavy with the day’s work, this is what helps:

Remembering that these patients aren’t just my work. They’re my teachers.

That every death I attend is teaching me how to die.

That every difficult family meeting is teaching me how to love my own family better.

That every moment of moral distress is sharpening my own moral compass.

The weight isn’t just burden. It’s also gift.

If I can carry it consciously. Process it. Learn from it.

…

I get out of the car eventually. Walk into my house. Stand in the kitchen for a moment, just breathing.

I’ll wake up tomorrow. There will be other patients. Other families. Other impossible decisions.

But tonight, Mr. Acharya got anāyāsena maraṇam. Death without struggle. Surrounded by family. Comfortable. Peaceful.

I helped that happen.

That has to be enough for tonight.

…

If you’re a doctor reading this, I want you to know: you can’t carry this work without processing it. You need rituals. You need silence. You need someone you can talk to. You need to acknowledge the weight, not pretend it isn’t there.

If you’re not a doctor, I want you to know: this practice is for you too. Not because you’ll attend deaths professionally. But because you’ll attend your own death someday. And your loved ones’ deaths along the way.

Ripening isn’t a job. It’s a practice.

…

Every day, I try to:

Say what needs saying. Repair what needs repairing. Let go of what doesn’t serve. Love without holding back. Give without counting cost. Forgive without keeping score.

Not because I might die tomorrow. Though I might.

Because this is how you ripen.

This is how you live in a way that, when the time comes, you’re ready.

…

Mr. Bhat taught me that. So did Mrs. Shantha, who said she was tired. So did Nagesh, whose 13-day ceremony showed me what release looks like. So did every patient who faced death with more grace than fear. So did the ones who faced it without grace, teaching me through their struggle.

Death is not the enemy.

Unlived life is the enemy.

Unspoken love is the enemy.

Unfinished forgiveness is the enemy.

…

So live fully. Love deeply. Forgive freely.

Ripen.

And when your time comes, when the connection to the vine naturally weakens, you’ll simply drop.

Not with violence. Not with terror.

But with the quiet grace of something complete.

…

Anāyāsena maraṇam, vinā dainyena jīvanam.

Death without struggle.

Life without indignity.

That’s not the end we fear.

That’s the end we pray for.

And maybe, if we live right and prepare well and receive a little grace, that’s the end we get.

…

The cucumber is ripe.

It drops.

Anāyāsena.

Effortlessly.

…

This is the end of the series.

But not the end of the work.

The work is in every conversation you have with your family. Every grudge you release. Every love you express. Every moment you practice letting go.

The work is in becoming ready.

For yourself. For those you love. For all of us, walking each other home.

…

Shashikiran Umakanth

Dr. Shashikiran Umakanth (MBBS, MD, FRCP Edin.) is the Professor & Head of Internal Medicine at Dr. TMA Pai Hospital, Udupi, under the Manipal Academy of Higher Education (MAHE). While he has contributed to nearly 100 scientific publications in the academic world, he writes on MEDiscuss out of a passion to simplify complex medical science for public awareness.