PDF Summary:When Breath Becomes Air, by Paul Kalanithi

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The original book is written in two major parts. To make it more digestible, we’ve divided them into smaller chapters. Chapters 1-4 correspond to Part 1, and Chapters 5-8 correspond to Part 2.

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I turned to the Internet, researching cancer in people aged mid- to late-thirties. Lucy discovered the search results and was livid. Her anger stemmed from my secrecy, from the fact that she had been managing her fears while I’d been managing mine. She was angry about what felt like a betrayal, not of my confidence, but of the drastic change in the picture of our life I was meant to create for us.

Her anger was so severe, she decided she needed time away from me, from our home, from our marriage. She didn’t feel we were balanced in our approach to our marriage. She felt like I wasn’t connected, wasn’t sharing my feelings with her, wasn’t taking her feelings seriously.

In truth, my training to be a neurosurgeon, one of the most taxing and challenging of the medical fields, had taken its toll on our relationship. Despite the fact that both of our futures were bright, I was a ghost in her life, coming and going from work while she slept, too exhausted after the day to make it to our bed.

We’d been scheduled to visit old friends in upstate New York, a trip Lucy was now going to skip. I said I would stay home, go to therapy, be more honest about my feelings, but none of it...

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She dug up a list of recommended reading for prospective college students. She made sure we read each one on the list. At ten, I read 1984 by George Orwell, which helped curate my love for words. My brother, Suman, at college by the time I was twelve, also gave me the books he’d been reading. Brave New World instilled in me my moral compass. I would later write about it on my college applications, denouncing the popular belief that we only live to find happiness.

These books enriched my mind and became my guide for how to understand life.

Making sure we were well-read wasn’t the end of my mother’s pursuits. She became part of the school administration, organized the teaching staff, lobbied for advanced classes to be provided. She was a one-woman construction crew, and she reconstructed the Kingman school district into a place where the students started to feel like they had a chance. To ensure our chance at success, she drove us to Las Vegas a hundred miles away to take our placement tests.

A Spark of Destiny that Grows to a Flame

The summer before I left for Stanford, my girlfriend at the time gave me a book, _Satan: His Psychotherapy and Cure by the Unfortunate...

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For me, anchored in a pursuit of morality and meaning, this dichotomy was difficult. I found I would often inflate the morose details of anatomy work to friends so I could feign emotion, despite the antithetical reality of how I felt in class.

Still, at times, I couldn’t help but remember that this mass of muscles, cells, and organs had once been a life, even if that remembering was only an admission of disregard. All doctors must draw this line between life and science. The invasion of the body and individuality, the things that are sacred to humans, is what practicing medicine is all about. Thus, the body becomes a mere tool and human suffering the mode of operation. Anatomy class was the vessel that changed us from empathic souls to hardened professionals.

Then, one day, I sliced into my donor, as we were instructed to call them, opening the chest in a way not instructed so I could more easily access other organs. The proctor was beside himself, not because I had performed the procedure incorrectly, but because I had done it without batting an eye. The horror and sorrow in his expression was the most significant lesson I’d learned thus far in my medical training.

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At first, residency seemed to be about paperwork. There were never-ending papers that needed to be pushed here or there, and I didn’t leave the hospital for two days. But I quickly learned to get through the paperwork more efficiently, until the never-ending stack only took an hour.

It was on a Tuesday that my first patient died.

Mrs. Harvey was eighty-two years old and seemingly healthy. She underwent minor surgery to remove a blockage in her bowels, and I checked on her Monday night. I went home happy that she was awake and stable.

Later that night, I received a call and was told she was crashing. I blurted out a series of tests to run and hustled back to the hospital. Nothing I did seemed to make a difference. To compound the situation, I was constantly being paged as the only general surgery intern on duty. I was rushing back and forth between an ER patient in severe distress and Mrs. Harvey’s room. Around sunrise, the ER patient was taken to surgery, and Mrs. Harvey had stabilized.

Again, I left the hospital only to be called back. The doctors in the ICU were performing CPR, and Mrs. Harvey came around again. But an hour later, she died. I teetered between...

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The Illusion of Time

The concept of time ceases to exist in the OR, or at least not in the way it exists for everyone else. To be a good surgeon, you had to be efficient, swift, but not careless. It was a fine line, for the priority was on speed. Speed ensures that patients don’t experience distress or damage during long procedures. Speed also ensures that surgeon’s and supportive OR staff make it home in time for dinner.

One could approach surgery like the old story of the tortoise and the hare. You could move fast, seemingly out of control, making small movements at a time to ensure success. Or you could be more methodical, allotting time to organize your movements, then performing them perfectly and efficiently. Either way, there is no sense of how much time is going by while you’re in it. Time becomes an illusion, and you remember it only after you are finished, when the hours catch up to real time, knocking into you, knocking you down.

The Final Stretch

I became chief resident my final year, which meant more responsibility, and not just on my cases. The bar for success had been raised, and conversely, so had the ramifications of failure. Everything I had...

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I was beginning to deteriorate, my body weakening. The identity I’d had, that of pursuer of meaning and overseer of life and death, was being stripped away. The cancer was progressing, and I knew I was inching closer to death each day. That reality took over the responsibility I’d carried in my work. It felt like I’d been driving in search of a rest stop for miles only to lose my bladder the moment one came into sight. The need for me to be strong for my patients was gone. My body no longer needed to be resilient. It was letting go---giving up the fight.

Determining the Way Forward

Emma informed me of two possible avenues for treatment. There was the standard chemotherapy, attacking the cancer from the outside in. But there were other therapies, new discoveries that attacked the cancer from the inside out. I hadn’t realized how many advancements had been made in the treatment of certain types of cancer, and there was evidence that some of these newer therapies led to unthinkable survival rates for some.

This was the kind of discussion I’d had with so many patients. Explaining the approaches, outcomes, and option considerations. Emma was the kind of doctor I wanted---a...

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We reasoned that there was no way to know what the future held for me or us, but living in wait for death was not living at all. With our families’ approval, we decided to live despite death. We decided to live without a clear picture of the future, which was what everyone did. We were going to start a family.

There was irony in the process of creating life. With in vitro fertilization, multiple embryos would be created and implanted. Only those viable would survive. The rest would die. There was no escaping death, even when the goal was to introduce life.

The Light at the End of the Tunnel

I went in for new scans after six weeks of the Tarceva. My blurry lungs were clear save one tiny spot. My damaged spine appeared to be healing. My cancer was stable. I was grateful and relieved.

My biweekly appointments with Emma were reduced to every six weeks. Our discussions returned to my new possible future. The picture of my life was becoming visible again. My world was settling down and finding its place.

I attended a reunion of former Stanford neurosurgical residents. Everyone there was pushing forward down a successful path full of possibility. Their lives were so similar...

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The self-conceit I’d entertained as a physician, believing all I had to do was guide patients and families through the murky waters of death until they could either beat it or face it, was now apparent. Even if the surgery is a success and the patient is released to life once again, that life is forever changed.

Emma hadn’t helped me face death and reclaim my life. She’d helped guide me to a place where a new identity could be sought. I finally understood that that task was the only one at hand.

Only Human After All

The confluence of so many things were afoot seven months after I’d gone back to work. I went in for my last scan before graduation, before our baby was born, and before my new future self began. Unlike previous scans, when I reviewed them right away, I had to wait. Patients and duties of both the chief resident and physician needed my attention.

Two hours after my scan, I opened up the scans of my current patients, reviewing them and making plans for how to approach the following day. When I was finished, I pulled up my scans from earlier, going through them with the same casual attention I had with my patients’. I didn’t see it at first. But once I did,...

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In this place, where our lives intersect for a brief moment of time, I can only think of one appropriate message to leave her with: when life dictates you gather the evidence of your worth, as it will at various times, remember that by living, you helped me live. It is of no small consequence that you brought a peaceful calm to my dying days, one like I had never known. The joy you gave me is enough, and never doubt that it was everything.

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The doctors suggested intubating him, and Paul and Lucy discussed and struggled over the decision. Intubation would keep him alive, but at what cost? Could his current ailments improve to a point where he could come off ventilation? Or would he continue to deteriorate, his brain and organs shutting down?

The other option was comfort care, an action that was certain to lead to rapid death. Paul’s main question regarded his quality of life even if he was able to recover from the respiratory issues. With the cancer in his brain, was there a good reason to lengthen his time if he would not be lucid enough for it to have meaning? He signed a “Do Not Resuscitate” and decided to sleep on it.

In the morning, his attention turned again to comfort care and the possibility of dying at home. But Lucy knew his condition was delicate and that he might not make it home. It was decided that she would bring home to him. The only thing he wanted was Cady.

Paul lay with Cady in his arms while the doctors commiserated over what was left to do. But Paul knew what he wanted. He turned to Lucy and said, “I’m ready.”

Surrounded by his family, Paul became emotional as he communicated his love and...