Why Hospice Feels So Hard: Culture, Care, and the End of Life
At the end of life, medical decisions aren’t just about symptoms—they’re about meaning. In this reflection from a nursing home experience, I share how different cultures view hospice care, why some families resist it, and how Atul Gawande’s Being Mortal helped me understand the deeper questions patients and families face. Sometimes, the hardest part of medicine isn’t what to do—but how to let go, with dignity and understanding.
Sanjay Balasubramanian
4/3/20252 min read
“We’ve been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really, it is to enable well-being. And well-being is about the reasons one wishes to be alive.”
— Atul Gawande, Being Mortal
As a clinical Intern at Texas Inpatient Consultants (TIC), I was reminded again and again that death is not just a medical event, rather, a deeply cultural one. Each family we cared for brought their own definitions of suffering, dignity, and what it means to say goodbye the “right” way. No medical algorithm could predict how a family would react to the notion of hospice care, or when they would be ready to let go.
Dr. Sreshta, the physician I worked under, once shared an observation I found hard to forget: “In my experience, African American and Asian families are the most resistant to hospice care.” It wasn’t about misinformation or lack of access. It was about meaning. In many cultures, taking someone to hospice signals abandonment. It’s seen as surrendering, not just to death, but to the idea that nothing more can or should be done.
One case stood out. An elderly Asian man—frail, barely conscious, and kept alive only by supportive care—was clearly nearing the end. There was no intervention left that could reverse his decline. Still, the family was adamant: No hospice. They insisted on continuing aggressive in-hospital care. “He’s a fighter,” the daughter said. “We don’t give up on our elders like that.”
They weren’t being irrational. They were being faithful to their values, to their roles as children, and to a cultural belief that caregiving doesn’t end when medicine does. Even when the doctors gently explained that hospice could help the patient die in peace, the family saw it as betrayal.
What Atul Gawande Taught Me About Death
Reading Being Mortal by Atul Gawande profoundly shaped how I viewed these moments. Gawande argues that modern medicine has become so focused on prolonging life that we’ve lost sight of what makes life worth living. He doesn’t ask us to give up on care, but to redefine it.
He writes about how patients often don’t fear death itself, but the loss of control, meaning, and connection that can come in their final days. Hospice, he argues, isn’t about dying. It’s about living well until you die. It’s about making space for a final conversation, a last meal, or the simple dignity of being pain-free at home.
Gawande helped me realize that when families reject hospice, they’re not rejecting comfort. They’re rejecting a version of death that feels cold, clinical, and stripped of significance.
The challenge, then, is not to convince families to accept hospice, but to understand why they resist it and to offer a vision of end-of-life care that aligns with their values. At TIC, I saw that these decisions were never just medical; they were spiritual, familial, and cultural. What Gawande reminds us is that death isn’t just about how long we live, but how we live until the end.