When Breath Becomes Air recounts the life of Dr. Paul Kalanithi, a neurosurgeon diagnosed with lung cancer during his last year of residency. With elegant and beautiful prose befitting a novelist more than a doctor, Paul guides readers through his life before and after his diagnosis, a life marked by a search for understanding life, death, and meaning.
As a young man, Paul never considered becoming a doctor, a profession many in his family had chosen. Thanks to his mother’s determination to see her three sons surpass the boundaries that a rural education in Kingman, Arizona could provide, she instilled in them a love of books. Paul quickly became enraptured by literature and decided to follow that love through his undergraduate and graduate studies at Stanford University.
Along the way, Paul also became fascinated with the brain. He wanted to understand how this organism was involved in creating meaning in life. Therefore, coinciding with his literature studies, he also studied biology. These two passions would guide the rest of his life. Through literature, he wanted to find language that gave depth to human experiences. Through science, he wanted to find the boundary separating life from death and what constituted each. When words became insufficient, he decided to enroll in medical school to become a neurosurgeon.
Throughout the book, Paul takes us on his journey through medical school and into his practical training as a neurosurgical resident. He walks us through his work with patients, learning, sometimes the hard way, that there was more to being a doctor than merely diagnosing and treating. He became a beacon for his patients, providing a safe harbor for them to traverse the transition from the life they had to whatever lay on the other side after a traumatic brain injury or disease.
Paul’s work allowed him to face death on a daily basis. He didn’t view death as an enemy to be thwarted. Rather, he saw it as one side of the coin of life and often as the most humane decision for those whose lives would never be the same because of their diagnosis. In approaching death in this way, he was able to face his diagnosis of lung cancer with integrity.
When he was diagnosed, Paul learned the difference between facing death as a doctor and as a patient. Although he’d assisted patients and their families in learning how to move forward and forge a new life or accept the end of life, he wasn’t clear at first what his new life would be. His identity, a concept he cherished and used to guide his treatment of patients, was wrapped up in the future he’d planned with his wife, Lucy.
As that future slowly disintegrated, he had to determine who he could and should be with the time he had left. Should he dive into the...
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This summary of When Breath Becomes Air is written in a way that allows you to share in the experience provided by the memoir. Most of the beauty in this book comes from the relationship formed with Paul as you walk in his shoes. His personal stories and observations are strengthened by his thoughtful voice and elegant prose.
Therefore, simply reading about the content of the story seems insufficient in expressing the emotional journey. To really provide you with the sensation this book creates, we wrote in the first person, using a voice similar to his. The hope is you will be able to form that personal attachment with his story and be taken on a similar journey. As usual, if you enjoyed...
As a neurosurgical resident about to graduate and move into the role of doctor, I knew what the signs of cancer were. When I looked at the CT scan, at the lungs, the spinal cord, and the liver, the diagnosis became clear. I’d looked at similar scans over the years of my training, but those scans always belonged to others. They weren’t like this scan, which belonged to me.
My wife, Lucy, a doctor of internal medicine, and I had noticed the signs during the past 12 months, but neither of us vocalized our suspicions. I didn’t want to admit what the amount of weight I’d been losing or the immense back pain I had started experiencing added up to.
I’d had X-rays done because MRIs for the back were costly, and the results were normal. I knew that X-rays for cancer were more or less futile, but I still took the results and ran with them. Afterall, cancer at thirty-six was not common, especially cancer in the spine. I assumed it was a different type of spinal disorder because even if the odds of cancer were better, they still weren’t as good as other disorders. My training had taught me enough to know that. I accepted the explanation of aging and fatigue and went back to work.
Work was where I wanted to be. I’d spent ten years traveling a straight path from medical student to neurosurgical resident, and with graduation only a year and a half away, my rise to the more comfortable life of neurosurgeon and professor was almost realized. When that happened, my schedule would settle down. I could finally have a more stable life and a rested body and be the husband Lucy and I both wanted me to be.
But after another few weeks, the pain was not only in my back. I started experiencing significant chest pain. I was coughing relentlessly, and I dropped thirty pounds. I knew the odds were not in my favor.
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...
I didn’t want to be a doctor. I didn’t know what I wanted to be. Maybe a writer, but the time when I’d have to decide on a career was far off. I was getting ready to leave for college in less than a month, and the only thing I was concerned about was how much I couldn’t wait to leave my small community in Arizona and enter the shiny world beyond it.
Plus, so many people in my family were doctors, including my uncle and father. From what I knew about it, medicine seemed to equate to long hours and time away from your family.
My father had moved my two brothers, my mother, and me from Bronxville, New York, a picturesque community north of the city, to Kingman, Arizona several years earlier. Kingman wasn’t on anyone’s radar except for as a place to pass through. The desert town was walled in by two mountain ranges. My father had loved the weather, the more reasonable prices, and the opportunity to build his own medical practice.
How he’d convinced my mother to move there was a mystery. A Hindu from southern India, she was deathly afraid of snakes, which were prevalent in the Arizona desert, among other creatures. My friends and I ran freely, roaming the expansive land in search of treasures. Compared to our previous buttoned-up, quaint, Norman Rockwell community, I was enchanted with the unruly terrain.
My father still worked often. He was something of a passing mirage, appearing in the evenings and on the weekends to provide whatever combination of affection and edicts he could fit in that amount of time.
My mother, on the other hand, became ingrained in our educational upbringing. She feared the lack of opportunities a school district like Kingman could offer her sons. She was well-educated, having trained to be a physiologist before marrying my father. But her knowledge of books was scarce, and she was determined to change that in our lives.
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,...
While my friends headed east to become artists, I was still pondering the intersectionality of biology with literature, morality, and philosophy. I wasn’t sure what the future held for me. Then, one day, I had a sort of divine epiphany---only by being a doctor could I come to learn the answers to my questions. As Whitman had stated, the physician is the only one who can truly discover the physiological-spiritual man. Despite my misgivings as a young man, I was going to become a doctor.
This choice wasn’t an easy one to make. It would require another year of school to get the proper credits just to apply, as well as an 18-month application process. I would also have to turn away from literature. But in doing so, I could start to seek answers from a relationship with those facing life and death.
Some professors felt that leaving academia was a hasty decision. They suggested I use the time I had to study the history and philosophy of science. I was accepted into a program at Cambridge University and headed off to England.
During the program, I became more convinced that to be able to gauge the moral aspects of life and death, I had to address it firsthand. Words were no longer suitable on their own. I finished the year-long program and returned to begin medical school at Yale.
There’s no way to truly capture the essence of what dissecting your first cadaver is like. Every medical student must traverse through this choppy terrain between life and science. In front of you lies a human that once housed a mind, meaning, breath, and dreams. Yet, at the same time, you see a mere specimen that you will carve up over a period of months to further your educational agenda. The pendulum swings between disgust and misconduct and inspiration and excitement. Eventually, the humanity is drained from you until all that is left is the cold, hard, pitiless face of knowledge and proficiency.
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...
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The fourth year of medical school brought decisions about specialties. Many of my classmates were selecting less-intense specialties, those with better hours, more money, and less stress. In those specialities, the responsibility for life was low.
I opted to choose neurosurgery, one of the most demanding specialties there is. My decision was motivated by an experience I had witnessing a pediatric neurosurgeon discussing a child’s tumor with his parents. I listened as he transitioned from physician, detailing the medical implications, to companion, respecting the personal, moral implications and guiding them through their fears.
I saw how the parents, distraught and frightened, were able to find emotional stability and fortitude for the journey that lay ahead. I realized that life, death, and meaning were issues grappled with more often than not within the context of medicine, but beyond that, there were existential factors at play. The body is an organism that will eventually succumb to physical laws, but the meaning encompassed in that body takes on its own trajectory.
Thus, neurosurgeons treat not only the brain, but also the spirit of the person. Every procedure affects the organism and the identity, and this latter aspect must be considered. The judgment call required of the doctor, then, is not simply about whether the physical life can be saved. We must also contemplate the quality of the life saved. Patients are confronted with the meaning of life, and doctors can help provide the facts to help them discover the answer.
This field would not only force me to confront the questions I’d been asking since undergrad, but also place me squarely in the space where the answers could be found.
Lucy and I were married and shortly moved to California to begin our residences. I was back at Stanford to begin the first of seven years of training. I quickly formed relationships with other residents: Victoria, who was at the same point as I was, and Jeff, who had a few years under his belt.
At first, residency seemed to be...
Part of the neurosurgical residency training is taking time to train in another field. The standard of excellence is high in neurosurgery; thus, the expectation is for you to be well-rounded and excellent in all aspects of medicine to fully excel.
I chose to move into one of the most difficult, yet highly regarded roles: that of neurosurgeon-neuroscientist.
I moved to a laboratory at Stanford to work with scientists focused on the development of neural prosthetics. These devices could allow those without motor functions to control things in the outside world with their minds. The brain sends signals out to sensors that activate the command. What I wanted to do was the opposite. I wanted to manipulate the signals within the brain, a process called neuromodulation.
The possible benefits of neuromodulation were vast. Successful manipulation of neural activity could help treat a number of conditions of the brain and mind, such as OCD, depression, or Huntington’s disease. I set to work learning and experimenting with cutting-edge research. However, a year in, V, the head of the lab, told me he had pancreatic cancer. After he told me, he asked me if I thought he’d made the right choices---whether his life had meaning. I had always considered V to be a sort of moral guide, and it was shocking to hear him question meaning, as I had so often, now that he was facing death.
After a long and difficult treatment, V was in remission. He came back to work after a year, when I was preparing to head back to surgery. At the last of what had been weekly discussions, he told me that today was the first day the suffering he’d endured felt worth it. I understood then that no matter how far down I had to go to meet my patients where they were, I would never truly understand, as a mere doctor, their cost of living.
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...
I’d spent so much of my training learning to account for patients’ identities in my surgical decisions. Yet, in that familiar hospital room, now as a patient, with Lucy next to me, I could feel my identity, that of physician, slipping away. She and I both knew what my scans showed. Cancer lived inside me, had found a number of cozy corners to nestle into. The life I’d been working toward, the role I was going to play in the world, was disappearing.
I’d counseled a number of patients, guided them through the dark so they could see their new futures. But in that instance, I was no longer the guide. I was aimless, lost and unable to find a new path or even see what that new path should look like. My lung cancer diagnosis didn’t sharpen my view on life. It blinded me to life.
Death, which I had turned from a foe into a sometimes necessary associate, no longer waited at my side with deference. Death now sat across from me, and I didn’t know how to address it anymore. I didn’t know how to find the words with which to negotiate. It was as if I was being introduced to death for the first time, and the code of conduct was still unknown.
Lucy and I met with the doctor who would see me through my illness, Dr. Emma Hayward. She discussed the diagnosis with us, but she wouldn’t discuss a prognosis. She focused on how we should approach treatment so I could return to work. I thought she was out of her mind. Surely, returning to work was not an option. I knew it was an option I couldn’t even consider without knowing where I stood within the threshold I’d met so many patients at.
My network of support went to work, researching oncologists specializing in lung cancer to ensure I had the best care possible. The results of those searches all came back to the same place. 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. I couldn’t help but see the series of events that had...
All those times I’d referred patients to physical therapy, I never understood what I was sending them to. Just as you can imagine what losing a parent or child feels like but never understand it until it happens to you, doctors have no real gauge of what the sick go through until we are one of them. Physical therapy was hard, exhausting, and defeating.
I was physically diminished, and at first, just lifting my legs was a struggle. My physical therapist asked what I wanted to accomplish with therapy, and I said the ability to bike and run again, two things I’d regularly and readily enjoyed. Losing those abilities compounded my loss of identity. But each day that I made a tiny step in the direction of progress, I was seeing a possible path back to some semblance of the old me.
After a couple of months, I could sit for thirty-minute intervals more easily. After more time, I was able to socialize with friends again. The first time I got back on my bike, I went six miles. They weren’t the most graceful miles I’d ever ridden and barely accounted for a quarter of the distance I used to cover. But just being on the bike again was a victory.
Still, I didn’t know who I was out in the world. I wasn’t a neurosurgeon. I wasn’t a fit and capable man at the beginning of life. I wasn’t the husband my wife deserved. I had once been someone who could lead and make things happen. Now, I was someone who followed, a recipient rather than agent.
The only time I had any sense of being me was when I was in Emma’s office.
Emma challenged me to concentrate on my values and priorities, rather than my chances. These thoughts included those of being a father, and Lucy and I revisited our thoughts on having a child. We both felt that if human relationality was the foundation of a meaningful life, a child could only enhance that. She was concerned about whether raising a child was the right choice for me for whatever time I had left. I was concerned about whether raising a child alone and simultaneously caring for a sick husband was the right choice for her life.
We reasoned that...
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With my diagnosis nine months behind me, I attempted to recreate the trajectory of my pre-cancer life. I was weary and beaten down physically, but it was all worth it. In a just a couple of months, graduation would be upon me and life would settle into a manageable pace.
There was a job at a university in Wisconsin that encompassed everything I’d hoped for in a post-residency position. The pay was high. There was significant funding for a neuroscience lab. I would be in charge of my clinical service. There was time available, if needed, to address my illness. The position included a professorship with possible tenure. The town was quaint and beautiful. Lucy had a number of career opportunities to choose from. My dreams could be realized with this job.
I knew that without Emma, I could never have gotten back to this place. After my diagnosis, I couldn’t see a way back to who I was before, but she had kept my identity alive despite my misgivings. She had met me where I was and nurtured her moral obligation to lead me forward until I could see the path back to myself again.
Yet, despite the fantasy, I suddenly realized it wasn’t possible to ever be me again…not completely. I also knew there was no way I could take this job. Before, my identity was that of a man with an open playing field without borders. Now, there was a major border. Cancer was part of this new life, and it could return or wreak havoc at any time.
If we moved to Wisconsin, Lucy would be far away from her support system. She would be alone with a child and me to care for. My bravado of the past few months, in which I’d denied cancer any power in my life, smacked me in the face. The reality of life now made the fantasy of reclaiming that life vivid and foolish. No matter how many strides away from cancer I made, it was always trailing behind.
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...
Time has lost its meaning and luster for me. Each moment moves me farther away from the last relapse. But that same moment is another step toward another one or the final one. Death may still be far off, but I am certain it is not as far off as I would like. With this knowledge, it would be easy to try to cram as much “living” as I can into the time I have 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.
There is little to differentiate the days now. If time was arbitrary when I was operating, now it was meaningless. The time of day holds no weight, nor does the knowledge of whether it is Tuesday or Friday. I am static. I am simply existing.
I also don’t know how to think of myself, what tense to use. Was I or am I a doctor? Or perhaps I should think I was previously a neurosurgeon and might be one in the future? Graham Greene stated that you live for 20 years and reflect for the rest. Is this life, then, a reflection of the past already?
Most people either fulfill their hopes or leave them behind. Both states are past; thus, the future becomes the present. My present is all the future I have, but that is not the case for my daughter. I...
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 stopped working a few months earlier, at Christmas. He became weaker but kept living as best as he could. They had friends over for dinner, played with Cady, and continued to enjoy each other’s love and companionship. Paul also worked on this book. During his last months, finishing the book was of the utmost importance to him.
The transition to spring brought a resurgence of life in the natural world while Paul’s life continued to wane. In February, he was put on oxygen to help his breathing. More scans were done, showing the growing grip of the cancer in his lungs and the spreading of it to his brain. The new brain tumors brought a shortened life expectancy and would eventually lead to neurological deficits.
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.
The family was hoping Sunday would bring more of the same. More time to relax and enjoy each other’s company, maybe go to church. But Paul spiked a fever and slept for most of the day. By Sunday night, Paul’s health took a dramatic turn. He couldn’t breathe and was taken to the ER. He knew, as they all did, he was unlikely to leave the hospital again.
The doctors suggested intubating him, and Paul and Lucy discussed and struggled over the decision. Intubation would keep him...
Take a moment to reflect on this story.
What is one thing you learned from Paul’s journey? How does this knowledge change how you approach your life?