As my grandmother drew her final breath last Sunday, her face was peaceful and her body so relaxed. I had never witnessed someone die of nothing. She had no terminal illness. Her mind was clear. Grandma told us that this was her time and she was ready to go. She was a humble person, one who valued integrity in relationships and now felt complete. We mourn only for us because we will miss her, but the grief is soft and sweet.

Home hospice helped create the conditions that enabled her to die with dignity and grace. Her caretaker was sensitive and intuitive. She knew just when to be there and when to leave space during the fluid process. Once Grandma was admitted to hospice, she gave herself permission to let go and disengage from the work of life. It felt so natural.

Although there is a formal mechanism for patients to express their wishes for end-of-life decisions through advance health care directives, we still live in a society where the people tend to deny mortality as long as possible.

We marshal our resources to beat death rather than embrace it even when all indications are that one’s time has come. The process of medical education still leaves health providers with the feeling that they have failed when a patient dies. Too often, that drives highly expensive interventions and intensive care.

In a previous column we discussed The American Dream 2.0 and reviewed the fact that entitlements, namely Social Security and Medicare, are the single largest line item in the federal budget, much larger than the defense budget. Last week, Paul Krugman, economist and columnist for The New York Times, reminded us that Medicare is by far the larger of the two big entitlement programs.

Far too many dollars are drained from the system for Medicare at the end of life without clear justification, or attention, to the big picture, and often only questionably in the best interests of patients. At the same time, we now face proposals for dramatic cuts in Women, Infants and Children (WIC), a federally funded health and nutrition program for the underserved. This would adversely affect some of the most vulnerable Americans with their entire lives still ahead of them. Hawaii already has seen major cuts for the underserved who use mental health services, many of whom are homeless. Clearly, the government is not able to provide all things to all people, and tough decisions need to be made.

Appropriate end-of-life choices require care and collaboration among patients, health care providers and the community. Fortunately, the people of Hawaii have access to a rich array of hospice services which are highly sensitive to the cultural, spiritual and physical needs of residents.

It is not about pulling the plug on grandma, it’s about letting her die with dignity, on her own terms, when her time has come.

Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.