Indian Journal of Palliative Care
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Table of Contents 
Year : 2014  |  Volume : 20  |  Issue : 1  |  Page : 39-40


Department of Anesthesiology, Wayne State University/Detroit Medical Center, Detroit, Michigan, United States

Date of Web Publication21-Jan-2014

Correspondence Address:
Deepak Gupta
Department of Anesthesiology, Wayne State University/Detroit Medical Center, Detroit, Michigan, United States

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-1075.125556

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How to cite this article:
Gupta D. Commentary . Indian J Palliat Care 2014;20:39-40

How to cite this URL:
Gupta D. Commentary . Indian J Palliat Care [serial online] 2014 [cited 2020 Jul 11];20:39-40. Available from:

Although "Stress among care givers - The impact of nursing a relative with cancer" [1] brings forth the unappreciated stress in the care-giving, it is worthwhile to understand the origin (evolution) and current state of care-giving among human beings. [2] I once heard a sincere life-philosophy story with few versions in lighter veins joking about popular alcoholic beverage, beer [3] or water. [4] The life-philosophy story adapted for the current viewpoint reads as "Rock, Pebble, Sand … and Beer (Water)".

This story can be analogously applied to quality of life among human beings. If we consider individual's "Life" as a vessel, "Rocks" are individual's personal will power and beliefs; "Pebbles" are family's, next of kin's and friends' support; "Sand" is societal support in forms of professional helps and overseers; and "Beer (Water)" is the mesmerizing abundance of available research and booming information guiding individuals how to live life better. So if you fill the vessel with "Beer (Water)" first, there is no room for "Rocks" or "Pebbles" or "Sand" without spilling some or lot of "Beer (Water)" out of the vessel. Similarly if you place "Sand" before "Rocks and Pebbles", you will require a lot of "Sand"; and "Sand" alone on its own cannot provide stability for the "Life" in question (there are abundance of examples reflecting the state of human beings who are dependent solely on society for their survival irrespective of whether they are living or dying). Finally, if you place "Pebbles" before "Rocks", you will require much more number of "Pebbles" to fill the vessel of "Life"; and that enormous number reflects the taxation on the care-giving capacity of family, next of kin and friends. Therefore, hierarchical sequence for the vessel of "Life" should be maintained as long as physically possible for the individual in question because "Rock, Pebble, Sand … and then Beer (Water)" maintained structure is akin to good quality of life even in the times of end-of-life care.

This hierarchical sequence does not mean that care-giving has to follow strict and thick-walled rules because sometimes "Sand" settles down in the form of "Pebbles", and sometimes "Pebbles" disintegrate into "Sand" which is again all related to passion vs. taxation of involved care-giving for a particular patient. Further, a few words of appreciation (for their care-givers) and a few steps towards acceptance (for their pathophysiologies) can always dilute the burdensome care-giving of individuals. Expectations of basic virtues in-spite of physical and psycho-physiological limitations at the end-of-life ascertain that living (including dying) is not only about sustenance of personal control but observance of personal responsibility for facilitating better quality of life even in the event of personal end-of-life care.

While understanding care-giving, we have to understand that we as adults have outgrown of infancy stages long times ago. One flip side of the coin is that we have to always try resisting our regression to infancy and total dependency even in the end-of-life stages. The other flip side of coin is that we always need to be supported in our quest to sustain independency and total control on our bodies and our lives even in the end-of-life stages. The answers to these needs lie in the history of our evolution as human beings. The evolution of Homo sapiens sapiens as the supreme (and only surviving extant) hominid species required Homo sapiens sapiens (Modern humans) to be more creative, more organized [5] and more care-giving in compared to now-extinct other hominid species like Neanderthals (Homo sapiens neanderthalensis) during evolution of humanity. The gifts (and sometimes perceived as curses) of being human (humanity) involve creativity, organizational behavior and care-giving; [6],[7] and hence the survival of Homo sapiens sapiens as species and humanity as creation will depend on the continuity of personal care-giving ("Rocks") then familial care-giving ("Pebbles") then societal care-giving ("Sand") and thereafter much beyond ("Beer (Water)").

  References Top

1.Kulkarni P, Kulkarni P, Ghooi R, Bhatwadekar M, Thatte N, Anavkar V. Stress among Care Givers: The Impact of Nursing a Relative with Cancer. Indian J Palliat Care 2014;20:31-39.  Back to cited text no. 1
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2.Bell LG, Bell DC. Positive relationships that support elder health and well-being are grounded in midlife/adolescent family. Fam Community Health 2012;35:276-86.  Back to cited text no. 2
[PUBMED] [homepage on the Internet]. Andersson G [updated 2012 January 1]. Rocks, pebbles, sand; [about 1 screen]. Available from: [Last accessed on 2013 Nov 19].  Back to cited text no. 3 [homepage on the Internet]. San Bruno, California: YouTube, LLC; c2013 [updated 2013 March 12]. JR Ridinger: Rocks, pebbles, sand and water; [about 1 screen]. Available from: [Last accessed on 2013 Nov 19].  Back to cited text no. 4 [homepage on the Internet]. San Bruno, California: YouTube, LLC; c2013 [updated 2012 June 2]. Ape to Man (History Channel); [about 1 screen]. Available from: [Last accessed on 2013 Nov 19].  Back to cited text no. 5
6.Bell DC. Evolution of parental caregiving. Pers Soc Psychol Rev 2001;5:216-29.  Back to cited text no. 6
7.Bell DC. The evolution of caregiving and attachment. In: The Dynamics of Connection: How evolution and biology create caregiving and attachment. Lanham, Maryland: Lexington Books Publishers; 2010. p. 51-86.  Back to cited text no. 7


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