Tolstoy’s short novel is more than a classic portrayal of dying and suffering. While those issues are central in most discussions of this work, an equally important and overlapping theme concerns choices made in life. Ivan, the protagonist, followed a well-traveled road, adhering to "comme il faut" (as is expected) or doing what one was supposed to do in career matters, selection of clothes, choosing a wife, raising children.

There is little to admire about this generally successful but thoughtless and selfish man. Ivan’s inability to invest meaningfully in family, social, or professional relationships leads to frightening consequences when he becomes gravely ill, probably with pancreatic cancer. Five different physicians with attitudes that range from arrogant to dishonest offer little assistance or compassion.

His family soon loses patience with his suffering and tends to blame him for the onset of illness. Only Gerasim, a peasant hired to assist him in his most basic needs, provides the kind of care and understanding required by the dying and increasingly isolated or deserted sufferer. The first chapter is masterful in its presentation of responses to death by friends and family members and prepares readers for the consequences of shallowness in an unlived life.