Two more weeks pass by, and Ivan's physiological condition degenerates further. One morning Praskovya enters Ivan's room to tell him that their daughter's suitor has formally proposed. Finding Ivan's condition even worse, however, she chooses to tell Ivan to take his medicine rather than make the announcement. Ivan looks at his wife with extreme animosity and tells her to let him die in peace. Ivan greets the doctor with the same hostility, declaring that the doctor can do nothing for him. The doctor admits to Praskovya that Ivan's case is very serious, and that he can only administer drugs to ease the pain.
Yet more than his physical sufferings, Ivan's mental sufferings cause him the greatest torture. One night while looking at Gerasim's face, Ivan begins to doubt whether he has lived his life correctly. It occurs to him that his official life, the arrangement of his family, and all his social interests are actually false. He wants to defend his life path, but finds that there is nothing to defend. Realizing that the only truth in his life was when he attempted to struggle against the expectations and values of high society, Ivan realizes that his life "was not real at all, but a terrible and huge deception which had hidden both life and death." Seeing the footman, his wife, his daughter, and all the other people he comes across in his daily routine confirms to Ivan the truth of his realization. This consciousness increases his suffering "tenfold."
Praskovya insists that Ivan take communion, and Ivan consents. After the sacrament, Ivan feels some temporary relief and a desire to live. But Ivan's reprieve is short-lived, and his anger and pain are enflamed again by the thought of the falseness of Praskovya's life.
For the first time, Ivan recognizes the hypocrisy and artificiality of his life. He calls into question the values that he has lived by, and he honestly entertains the conclusion that the way he lived has obscured both life and death. A proper view of life, Ivan now understands, entails an acknowledgment of the inevitability of death, as well as an appreciation of the true joys of life. The two go hand in hand. By accepting unpleasantness as a fact of life, one can derive full benefit from life's joys.
Ivan's realization has affected a shift in the focal point and intensity of his spiritual suffering. Ivan no longer feels obliged to take part in the pretense around him. He confronts both Praskovya and the doctor with the truth of his condition. Now, however, Ivan's spiritual pain is caused by the possibility that his whole life has been in error. Yet despite Ivan's new knowledge, Ivan still does not wholly relinquish the hope that his life was lived rightly. Even though he is now keenly aware of the spiritual component of life, he is not yet ready to fully admit the error of his life. In a sense, he knows it, but does not acknowledge it. In this manner, Tolstoy paves the way for the resolution of the life and death of Ivan Ilych.