In the third month of Iván Ilych's illness, he and all those around him become aware that he is going to die. The only questions now are when. The sooner the better, as his death will leave a job open and release all from the burden of caring for him. Opium and morphine do not relieve the pain. Special foods are made for him, but they disgust him.
Iván Ilych can no longer take care of his own excretions. Oddly enough, this becomes a source of comfort, because the young man who has to take care of him is Gerásim. Gerásim is a young peasant land, on the stout side, who is clean, kind, and pleasant. The boy doesn't complain, and carries out the filthy duty of cleaning up Iván Ilych's excrement cheerfully and efficiently. One day, Iván Ilych apologizes for the filthiness of the job. The boy cheerfully says that it's nothing, and to be expected, as Iván Ilych is sick. Gerásim helps Iván Ilych to bring his pants up, and helps him to the sofa.
While Gerásim is lifting Iván Ilych's legs onto a chair, because elevation helps ease the pain, Iván Ilych feels that the higher his legs are, the easier the pain is. He asks for a cushion, to elevate his legs even higher. Iván Ilych feels that the only real relief comes when Gerásim is actually holding his legs. After that, Iván Ilych often asks Gerásim to hold his legs up. The young man's company is one of Iván Ilych's few pleasures: "Health, strength, and vitality in other people were offensive to him, but Gerásim's strength and vitality did not mortify but soothed him" (152).
Iván Ilych is mortified by the hypocritical illusion that all insist on maintaining, that he is not dying but is only ill. The lies feel degrading to Iván Ilych. They are in the service of the same decorum Iván Ilych once loved: "The awful, terrible act of his dying was, he could see, reduced by those about him to the level of a casual, unpleasant, and almost indecorous incident (as if someone entered a drawing-room diffusing and unpleasant odour) and this was done by that very decorum which he had served all his life long" (153). Others don't want to recognize the fact of death. Only Gerásim treats the dying man with real compassion, and only he refuses to pretend that Iván Ilych is not dying. One day, he says openly, "We shall all of us die, so why should I grudge a little trouble'" (153).
Secretly, Iván Ilych wants to be petted and comforted as a child is petted and comforted. Only the peasant boy comes close to treating him this way. With others, Iván Ilych must continue to play the role of distinguished older official, even as he is dying. "This falsity around him and within him did more than anything else to poison his last days" (154).
In the juxtaposition of Gerásim's attitudes to the other attitudes in the novel, Tolstoy is suggesting a relationship between one's treatment of death and one's attitude toward life. Gerásim glows with health and vitality. He understands kindness. He also does not deny death. He accepts it as part of life, and refuses to pretend that his master is merely ill. The others insist on the shared lie that Iván Ilych is not dying, not for Iván Ilych's comfort, but for their own.
Adherence to decorum and propriety, a theme the novel, proves a poor substitute for honest living and human decency. The rules of decorum seem to include dishonesty, especially when it comes to death. Decorum, as Tolstoy sees it, can only be superficial. It is an enemy of truth. Decorum is woefully inadequate in the face of mortality: people act as though Iván Ilych has merely committed an indecorous act. He spoils their surface thinking and living, and they resent him for it. His illness is a reminder of death, and they resent him for it. The lies poison the poor man's last days.
Iván Ilych needs real human comfort. When Gerásim helps to elevate his legs, Iván Ilych seems to feel relief not from the elevation alone. No height of elevation seems to help by itself; the pain only decreases when Gerásim actually touches him. Although Iván Ilych never seems to make the connection explicity, human contact seems to be the real medicine when Gerásim holds up his legs. This compassion, with the warmth of actual physical contact, is what Iván Ilych craves as his death approaches.
One morning, as Iván Ilych is mentally wrestling with death, Peter the footman offers him tea. Iván Ilych reflects that the footman wants things to be normal, as if no one is dying, but all Iván Ilych says aloud is no. All of Peter's questions annoy him, as Iván Ilych senses the motives behind each question, and sees hypocrisy in everything. Yet when Peter is leaving, Iván Ilych tries to find excuses to make Peter stay. He gets Peter to give him his medicine, but the taste repulses him, and he reflects on the futility of taking medicine at this point. He sends Peter to fetch tea. Peter helps him dress and take care of his teeth and hair. Iván Ilych's own face's appearance terrifies him, and he avoids looking at his own body when dressing. A moment of feeling refreshed ends with the tea, because Iván Ilych is reminded of the awful taste in his mouth.
The routine is awful: "Always the same. Now a spark of hope flashes up, then a sea of despair rages, and always pain . . ." (156). The doctor comes, and greets him blandly. Iván Ilych feels sick of the doctor's hypocrisy, and would like to say something about it, but instead only complains of his physical pain. The doctor examines Iván Ilych, but the examination is an empty ritual. ". . . Iván Ilych submits to it all as he used to submit to the speeches of the lawyers, though he knew very well that they were all lying and why they were lying" (157).
Praskóvya Fëdorovna arrives, and proceeds to try to prove that she has been up a long time already. Praskóvya Fëdorovna is characteristically hypocritical; she and the doctor chide Iván Ilych for not taking his medicine and lying with he legs propped up by Gerásim. Michael Danílovich and a specialist are coming: Praskóvya Fëdorovna insists that these extra consultations are for her own sake, but her husband reads different meanings into her words (see below). The new doctors come and go, always eluding the real issue.
Iván Ilych's pain is awful, and they give him an injection. He sleeps. He wakes that evening, and after dinner his wife enters his room dressed and in full makeup to take the children to the theatre. He had forgotten that they were going, and her dress irritates him, but he was the one who insisted that they get the tickets originally. Petríshchev, his daughter Lisa's fiancé, is also going with them. They are all going to see Sarah Bernhardt. Lisa's fiancé wants to come in to see Iván Ilych.
Lisa comes in, in a dress that shows off her healthy young flesh. She is impatient with her father because his illness interferes with her happiness. Her fiancé enters, dressed to the nines. And finally, Iván Ilych's young son Vladimir Ivánich (aka Vásya) enters. The boy looks pathetic and frightened, and has dark circles under his eyes. Iván Ilych feels that Vásya understands him, and has real sympathy for him.
As mother and daughter have a banal argument about Sarah Bernhardt's acting, Petríshchev watches Iván Ilych. The others eventually look too, falling silent. Iván Ilych is staring straight ahead, "with glittering eyes," apparently offended by their presence. Everyone is afraid to break the silence, because the truth will become evident. Lisa finally speaks up, saying it's time to go.
Iván Ilych feels slightly better when they're gone, but the pain grows worse. He keeps thinking of Death coming, and he has Peter the footman send for Gerásim.
This chapter is a sequence of moments in which Iván Ilych is disgusted by the gap between outward show and inner reality. This gap is an important theme of the novel, and can be phrased in different ways: hypocrisy, illusion, ritual without meaning. The footman, the doctors, and Iván Ilych's own family parade themselves before Iván Ilych, one after another, all saying and performing one set of things while feeling and thinking another. The hypocrisy is so deeply ingrained that Iván Ilych is probably the only one that notices the gap between inner and outer worlds. The others live with these two worlds fundamentally disconnected, and to Tolstoy this is one form of spiritual crisis.
Iván Ilych is able to recognize their falsity in part because he once used to live this way himself. When he's dealing with the doctors, Iván Ilych is reminded of his old life as a lawyer: ". . . Iván Ilych submits to it all as he used to submit to the speeches of the lawyers, though he knew very well that they were all lying and why they were lying" (157). Illness and mortality are horrible to contemplate, but at least this contemplation has separated Iván Ilych from the hypocrisy of his old life. His awareness of falseness, that of others and of his former self, is a painful but necessary step toward something deeper.