Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
Brief Communication
Case Report
Case Series
Conference Abstract
Conference Editorial
Conference Proceedings
Current Issue
Editorial Commentary
General Medicine, Case Report
IAPCONKochi 2019 Conference Proceedings
Letter to Editor
Letter to the Editor
Letters to Editor
Narrative Review
Original Article
Palliative Medicine, Letter to the Editor
Personal Reflection
Position Paper
Position Statement
Practitioner Section
REPUBLICATION: Special Article (Guidelines)
Review Article
Short Communication
Short Report
Special Editorial
Special Review
Systematic Review
View/Download PDF

Translate this page into:

20 (
); 39-40


Department of Anesthesiology, Wayne State University/Detroit Medical Center, Detroit, Michigan, United States
Address for correspondence: Dr. Deepak Gupta, E-mail:

Read COMMENTARY-ARTICLE associated with this -


This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This article was originally published by Medknow Publications & Media Pvt Ltd and was migrated to Scientific Scholar after the change of Publisher; therefore Scientific Scholar has no control over the quality or content of this article.

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;[67] 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)”).


  1. , , , , , , . Stress among Care Givers: The Impact of Nursing a Relative with Cancer. Indian J Palliat Care. 2014;20:31-39.
    [Google Scholar]
  2. , , . Positive relationships that support elder health and well-being are grounded in midlife/adolescent family. Fam Community Health. 2012;35:276-86.
    [Google Scholar]
  3. [homepage on the Internet] updated 2012 January 1. Rocks, pebbles, sand; [about 1 screen] Available from:
    [Google Scholar]
  4. [homepage on the Internet] . Rocks, pebbles, sand and water. San Bruno, California: YouTube, LLC; updated 2013 March 12 about 1 screen. Available from: watch?v=38U_rLLW-qM
    [Google Scholar]
  5. [homepage on the Internet] . San Bruno, California: YouTube, LLC; updated 2012 June 2. Ape to Man (History Channel); [about 1 screen] Available from:
    [Google Scholar]
  6. , . Evolution of parental caregiving. Pers Soc Psychol Rev. 2001;5:216-29.
    [Google Scholar]
  7. , . The evolution of caregiving and attachment. In: The Dynamics of Connection: How evolution and biology create caregiving and attachment. Lanham, Maryland: Lexington Books Publishers; . p. 51-86.
    [Google Scholar]

    Fulltext Views

    PDF downloads
    View/Download PDF
    Download Citations
    Show Sections