PDF Summary:When Breath Becomes Air, by Paul Kalanithi

When Breath Becomes Air is the beautiful and heart-wrenching memoir of Dr. Paul Kalanithi, a neurosurgical resident diagnosed with lung cancer in the last year of his training. When the life Paul and his wife Lucy imagined for their futures ceases in the face of his diagnosis, he works to understand what his new life will look like and how long it will be. Through various treatments, his struggle to return to work, and the birth of his first and only child, Paul details his personal journey of discovering the meaning of life, death, and the thin line separating them. He explores what it means to save a life—not only his patients’, but his own, as well.

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Paul’s Diagnosis

In the final year of his residency, Paul began to experience symptoms like severe back pain and weight loss. He and his wife, Lucy, a doctor of internal medicine, both knew the symptoms could point to cancer. Sure enough, an X-ray eventually led to a diagnosis of lung cancer. Suddenly, Paul found himself on the other side of the doctor-patient relationship, lying in the same bed in which he’d cared for patients—guiding some through their final days and celebrating the successes of those who’d improved. Everything he’d worked for and the future he had envisioned suddenly vanished.

Being a Patient

Dr. Emma Hayward discussed the diagnosis with Lucy and Paul, but she wouldn’t discuss a prognosis. Emma was the best and was respected as such within the medical community. She wasn’t just respected for her skills as a physician, however. She was also considered to be the best gatekeeper, the best judge of not just treatment, but of identity, as well. To Paul, the confluence of events that had led him to be in the care of the best person in the world right when he needed it felt like more than a coincidence.

As he began to deteriorate, Paul felt that the identity he’d had—that of pursuer of meaning and overseer of life and death—was being stripped away. He was inching closer to death each day, and the need to be strong for his patients was gone. His body no longer needed to be resilient. It was letting go—giving up the fight.

Determining the Way Forward

They began to discuss potential treatments, including chemotherapy. Emma was the kind of doctor Paul wanted—a doctor like him. For Emma, the considerations surrounded his ability to go back to work. This consideration was less of a priority for him, and he told her so. He could forge a different path if he had to. He wanted the treatment that would work the best, even if it meant losing his ability to operate. His identity as a neurosurgeon had faded with his diagnosis, but here she was, telling him he could possibly be himself again. He started to believe perhaps he could be, and that belief was comforting.

With this possible regathering of his identity came a remembering of his ideals. He’d accepted that death was a part of life. He’d known it was something everyone experiences. That truth was no more true simply because he had cancer. He was always going to die, but that hadn’t stopped him from living. Just because the fact of death appeared before he thought it would didn’t mean he should stop now, either.

Planning for the Future

Knowing that cancer treatment could cause sterility, Lucy and Paul decided to freeze some of his sperm in case they decided to have children like they’d always wanted. Then they found out his cancer had a mutation that improved the odds of survival, and he began treatment with a pill called Tarceva rather than chemotherapy. The treatment was effective, but he still saw his old self and his ability to do the things he loved fading away.

He was a different person, a reality he had helped his patients and their families understand. He now understood, as they had, that he could only come close to resembling who he was again. But it was better than the alternative. His meetings with Emma started to clarify what his life’s narrative should be. He could follow the path that so many tended to follow—embrace the personal with everything he had left, such as family, friends, and experiences—or he could focus on becoming himself again.

He’d always envisioned becoming a writer after a career in medicine, but without knowing how much time he had left, he didn’t know which of these paths to follow. He told Emma this, but she still couldn’t give him a timeline. He knew that even when he’d given prognoses as a doctor, he was sometimes wrong, and patients lived much longer than he’d expected. He realized that how he spent the rest of his time shouldn’t be motivated by subjective barriers. He couldn’t rely on a prognosis to tell him whether he should work or cherish what he had left, or whether to have a child. He would have to look death in the eye and determine what was important to him, what gave his life meaning, and find a way to try to live that life in whatever way he could.

Regaining a Sense of Identity

Paul’s treatment was hard, exhausting, and defeating. He could barely lift his legs at first. His physical therapist asked what he wanted to accomplish with therapy, and he said the ability to bike and run again, two things he’d regularly and readily enjoyed. Losing those abilities had compounded his loss of identity. But each day that he made a tiny step in the direction of progress, he was seeing a possible path back to some semblance of his old self.

He began to regain his abilities, but he still didn’t know who he was in the world anymore. He wasn’t a surgeon, a fit young man, or the husband his wife deserved. He had once been a leader, but now he was a follower. The only time he had any sense of being himself was when he was in Emma’s office. Emma challenged him to concentrate on his values and priorities, rather than his chances. These thoughts included those of being a father, and Paul and Lucy revisited their thoughts on having a child. They both felt that if human relationality was the foundation of a meaningful life, a child could only enhance that. While they didn’t know what the future held, and they both had many fears, they decided to live despite death and start a family.

Returning to Literature

As Paul’s condition improved, he wondered whether he should try to return to medicine or plan to stay home with his child, writing and soaking in life. He thought that, after years of helping patients see the different paths laid out for them, he’d be able to see his own paths clearly and know which one to take, but instead he felt lost and confused. He returned to his first love for answers: literature. It became his lifeline. When the suffering became unbearable, the words of Samuel Beckett quelled the relentless uncertainty about what he should be doing. He thought, “I can’t go on.” Beckett’s words finished the thought: “I’ll go on.” He faced the day, one step at a time, repeating, “I can’t go on. I’ll go on.”

Everything became clear in that moment. Although he was dying, he wasn’t dead yet. He was still living, and the only person he knew how to be among the living was himself. And who he was was a surgeon. He would find a way to be that person again, whatever that looked like now, until death said for certain he couldn’t anymore.

Returning to Medicine

Paul’s physical therapy began focusing on regaining the physical aptitude for surgery. The cancer continued to shrink. Emma finally allowed for a hint at a prognosis, stating that an expectation of 10 years was not out of the realm of possibility. It wasn’t a certainty, but the possibility supported Paul’s intention to get back to work. However, with this possibility came apprehension. The prospect of being able to return to work made him realize what a relief it had been to not have that responsibility of life and death. However, he eventually returned to his calling, feeling that the moral responsibility he'd taken on as a neurosurgeon was greater than he was.

He was able to return to work, though it was difficult to manage the symptoms of his illness. He pushed on, wanting to reclaim the future he thought had become out of reach. His cancer was stable, and Lucy was pregnant and due around the time of Paul’s graduation. Life was moving forward, and he was determined to keep it moving. Paul learned that there were questions about his upcoming graduation and realized he needed to prove to his advisors that he could be a complete physician again. He began working harder, pushing himself to the limit and physically suffering. But being back with patients helped ease the strain. He found meaning again in his duties as a physician by reconnecting with his patients.

However, he couldn’t do everything. He had to pass up his dream job in a new town, realizing he couldn’t put Lucy in a position where she had to care for him and a new baby without her support system. The self-conceit he’d entertained as a physician, believing all he 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 him face death and reclaim his life. She’d helped guide him to a place where a new identity could be sought. He finally understood that that task was the only one at hand.

The Cancer Returns

Seven months after returning to work, a scan showed a new sizable tumor taking up the middle of his right lung. He and Lucy understood what would come next: biopsy, then chemotherapy. Things would be harder than last time, and they knew that whatever time he’d had left was now truncated. Paul knew that, whatever the future held, his work as a neurosurgeon would be on hold for a while. After leaving the hospital after what might be the last surgery he’d ever perform, he became emotional in his car. But when he got home, he stashed away the items that made him a doctor and turned to face another new future.

He was back on the opposite side of the doctor-patient relationship, back up against a foe that was proving how strong it was despite his strength. Still, Emma’s words were reassuring, as was her advice to simply be a patient, not a doctor involved in his own care, a role he had never considered. Paul began chemotherapy, which was brutal.

On the day of his graduation, a nausea like he’d never felt overcame him and he was rushed to the ER instead of taken to the ceremony. He stabilized, but his condition had deteriorated so badly that he couldn’t continue treatment until he improved. The next time Paul saw Emma, she told him that he likely had another five years ahead of him, but the words rang hollow. She was no longer the poised, assertive guide. She was a hopeful companion in the dark tunnel searching for light.

On Paul’s way home from meeting with Emma, Lucy went into labor, and on July 4, their daughter Elizabeth Acadia (Cady) was born. Still terribly ill, Paul held his swaddled baby and Lucy’s hand at the same time, both of them peering down into the face of life. The finality of Paul’s death was still a question, but instead of all the “what ifs,” holding Cady, he now saw a clean slate on which anything was possible.

Paul’s Final Act

Toward the end of his life, time had lost its meaning and luster for Paul. He didn’t know how much time he had left, but he knew it was less than he’d have liked. With this knowledge, it would be easy to try to cram as much “living” as he could into the time he had left. But cancer is a fickle companion. It doesn’t necessarily take away your time as fast as you think it will, but it makes your body too weak to enjoy it the way you’d like.

Paul wrote that he didn’t know how to think of himself, or whether he should refer to himself in the past or present tense. Paul’s present was all the future he had, but that was not the case for his daughter. In that place, where their lives intersected for a brief moment of time, he could 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.”

The Continuation of Life After Death

The final pages of When Breath Becomes Air are written by Paul’s wife, Lucy. She describes how Paul died on March 9, 2015, in the hospital with his loved ones by his side. Cady was eight months old. Paul’s treatment had stopped working around Christmas. As spring arrived, he was put on oxygen, and scans showed that the cancer had spread to his brain. The ensuing deterioration of his mind was particularly crushing for Paul, fearing the loss of meaning and independence. Thwarting these devastating effects became the main goal of whatever treatment he would receive.

Lucy remained strong for Paul, but on the inside, her heart was breaking. She didn’t know how much time they had left together, but she never thought it would only be a matter of days. For his final weekend, Paul’s family came to their house and spent time with him and Cady. Paul knew he wasn’t likely to finish his manuscript either due to time or his physical capacity. But he still put it aside that day, preferring to be present with his family.

That Sunday, Paul’s condition took a severe turn, and he was hospitalized. He couldn’t breathe, and Paul and Lucy struggled with the decision of whether or not to intubate him. 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?

Ultimately, he decided on comfort care. 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 gratitude. Before the supplemental oxygen was removed and morphine injected, Paul asked his family to ensure this book was published. He also told Lucy he loved her one final time. After another hour, Paul drifted into unconsciousness. Eventually, he inhaled and breathed out his last breath.

Paul’s Legacy

Like the final year of Paul’s life, this book carries a sense of urgency. There was a desire to communicate everything he’d learned as a doctor and patient about life, death, and meaning under a ticking clock counting down the minutes until he could say no more. He couldn’t help people as a doctor anymore, but he still wanted to guide them through that threshold he’d helped so many walk through.

Lucy knows that if Paul had survived, he would have contributed greatly to his field and medicine as a whole. Whenever she sees the hospital where he worked, where their daughter was born, and where he died, she thinks of all the people he would have helped. But in writing this book, she knows he will still contribute, still help, in a way that is uniquely Paul.

Lucy says the years since Paul’s death have been hard. Some days, her grief is so severe, she is inconsolable. But she’s also found beauty in remembering their love. She’s had to contemplate life and death every moment, and in doing so, she’s found peace and appreciation for what they shared. She says she didn’t expect to feel the power of love intertwined with her grief, but she does. She continues to love Paul with the same depth as she had when he was alive.

The integrity Paul showed throughout his illness, and especially in those final months, was not limited to his life with cancer. He lived his entire life this way. He faced death daily and sought the answers to how to live despite it. Lucy believes that Paul’s illness was devastating, but his life was not a devastation. He wondered whether it was possible to hold life and death in his hands and still live a meaningful and graceful life. Lucy knows the only answer possible is yes.