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Less Is More
June 10, 2013

Pharmaceutically Less and Holistically More

Author Affiliations

Author Affiliations: KOSISH–The Hospice, Palliative Medicine, Jharkhand, India.

JAMA Intern Med. 2013;173(11):948. doi:10.1001/jamainternmed.2013.475

An 80-year-old woman had advanced malignant disease of the left scapula and shoulder joint and a large ulcerated mass in the axilla that bled frequently. She had received radiotherapy and chemotherapy, with the last treatment being given 14 months previously. She lived in a village in a tribal state of India and belonged to the lower socioeconomic class. Her health expenses were being paid by her son, who was the only wage-earning member in a large family of 16 members.

Our team received a call because she was experiencing pain. She was taking a combination of ibuprofen and paracetamol given 3 times daily, along with oral ranitidine given twice daily.

We found her reclining on her khatia (a local bed made of a bamboo frame and coconut rope) and gazing contently at her garden. She had a calm look about her and outwardly did not seem to be in pain. Her daughter-in-law was fussing around her, trying to make her comfortable.

As is customary in India, we greeted her with respect and sat down on the ground, cross-legged beside her khatia. We addressed her as “mata ji” (respected mother) and proceeded to introduce ourselves and asked what was bothering her. She said that her pain was getting unbearable and she could not sleep at night. She proceeded to clarify, however, that she had accepted her fate, it was a result of her karma (past deeds), and that she had no regrets about it.

Her main concern was that she could no longer tend to her garden, which she had so painstakingly tended, often guarding it ferociously from the attacks of hordes of monkeys . . . her eyes misted over as she stared out lovingly at her garden from her porch.

She then turned and asked her daughter-in-law to get us some tea and light up her chillum (a local pipe made of clay to smoke tobacco). Smoking her chillum with a look of contentment on her face, she began discussing the affairs of her family, with her children and grandchildren squatting beside her and listening attentively.

Ours being a resource-constrained rural setting, we offered her a locally available subcutaneous analgesic mixture, to which she grudgingly agreed, but only on an as-needed basis.

She made us realize the importance of addressing religious, spiritual, cultural, and familial issues in the management of chronic pain. We felt humbled in the presence of that great lady. We realized that although she was in physical pain, she effectively used the other components of pain management to gain control over her pain. We reflected on the culture of the joint family and the benefits it affords the dying. Hospices and long-term care facilities are but a dream in most parts of India.

Our team visited her weekly. The time came when she told her son that she was going to die soon and stopped eating. All her relatives gathered around her, and she died peacefully at home, on her porch, overlooking her garden, 2 days later.

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Article Information

Correspondence: Dr Dam, KOSISH–The Hospice, Palliative Medicine, 2120, Sector 4 C, Bokaro Steel City, Jharkhand 827004, India (

Published Online: April 22, 2013. doi:10.1001/jamainternmed.2013.475

Conflict of Interest Disclosures: None reported.