When Breath Becomes Air

by Paul Kalanithi

One night on the sofa in my apartment, while studying the reams of wavy lines that make up EKGs, she puzzled over, then correctly identified, a fatal arrhythmia. All at once, it dawned on her and she began to cry: wherever this “practice EKG” had come from, the patient had not survived. The squiggly lines on that page were more than just lines; they were ventricular fibrillation deteriorating to asystole, and they could bring you to tears.

The days when someone was simply “killed in a car accident” were long gone. Now those words opened a Pandora’s box, out of which emerged all the images: the roll of the gurney, the blood on the trauma bay floor, the tube

A son’s death already defies the parents’ ordered universe; how much more incomprehensible is it when the patient is brain-dead, his body warm, his heart still beating?

Before operating on a patient’s brain, I realized, I must first understand his mind: his identity, his values, what makes his life worth living, and what devastation makes it reasonable to let that life end. The cost of my dedication to succeed was high, and the ineluctable failures brought me nearly unbearable guilt. Those burdens are what make medicine holy and wholly impossible: in taking up another’s cross, one must sometimes get crushed by the weight.

Most lives are lived with passivity toward death—it’s something that happens to you and those around you. But Jeff and I had trained for years to actively engage with death, to grapple with it, like Jacob with the angel, and, in so doing, to confront the meaning of a life. We had assumed an onerous yoke, that of mortal responsibility. Our patients’ lives and identities may be in our hands, yet death always wins.

Years ago, it had occurred to me that Darwin and Nietzsche agreed on one thing: the defining characteristic of the organism is striving.

“Can you breathe okay with my head on your chest like this?” His answer was “It’s the only way I know how to breathe.”

It never occurred to me that you could love someone the same way after he was gone, that I would continue to feel such love and gratitude alongside the terrible sorrow, the grief so heavy that at times I shiver and moan under the weight of it.