When Breath Becomes Air

by Paul Kalanithi

Because the brain mediates our experience of the world, any neurosurgical problem forces a patient and family, ideally with a doctor as a guide, to answer this question: What makes life meaningful enough to go on living?

When there’s no place for the scalpel, words are the surgeon’s only tool.

Any major illness transforms a patient’s—really, an entire family’s—life.

Patients, when hearing the news, mostly remain mute. (One of the early meanings of patient, after all, is “one who endures hardship without complaint.”)

Whether out of dignity or shock, silence usually reigns, and so holding a patient’s hand becomes the mode of communication.

Being with patients in these moments certainly had its emotional cost, but it also had its rewards. I don’t think I ever spent a minute of any day wondering why I did this work, or whether it was worth it. The call to protect life—and not merely life but another’s identity; it is perhaps not too much to say another’s soul—was obvious in its sacredness.

“do you think my life has meaning? Did I make the right choices?”

It was stunning: even someone I considered a moral exemplar had these questions in the face of mortality.

How little do doctors understand the hells through which we put patients.

Death comes for all of us.

Most lives are lived with passivity toward death—it’s something that happens to you and those around you.

It occurred to me that my relationship with statistics changed as soon as I became one.

I woke up in pain, facing another day—no project beyond breakfast seemed tenable. I can’t go on, I thought, and immediately, its antiphon responded, completing Samuel Beckett’s seven words, words I had learned long ago as an undergraduate: I’ll go on. I got out of bed and took a step forward, repeating the phrase over and over: “I can’t go on. I’ll go on.”

Because I could. Because that’s who I was. Because I would have to learn to live in a different way, seeing death as an imposing itinerant visitor but knowing that even if I’m dying, until I actually die, I am still living.

The tricky part of illness is that, as you go through it, your values are constantly changing. You try to figure out what matters to you, and then you keep figuring it out. It felt like someone had taken away my credit card and I was having to learn how to budget. You may decide you want to spend your time working as a neurosurgeon, but two months later, you may feel differently. Two months after that, you may want to learn to play the saxophone or devote yourself to the church. Death may be a one-time event, but living with terminal illness is a process.

The truth that you live one day at a time didn’t help: What was I supposed to do with that day? At some point, then, I began to do a little bargaining—or not exactly bargaining.

the physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.

Science may provide the most useful way to organize empirical, reproducible data, but its power to do so is predicated on its inability to grasp the most central aspects of human life: hope, fear, love, hate, beauty, envy, honor, weakness, striving, suffering, virtue.

Human knowledge is never contained in one person. It grows from the relationships we create between each other and the world, and still it is never complete.

Part of the cruelty of cancer, though, is not only that it limits your time; it also limits your energy, vastly reducing the amount you can squeeze into a day. It is a tired hare who now races. And even if I had the energy, I prefer a more tortoiselike approach. I plod, I ponder. Some days, I simply persist.

When you come to one of the many moments in life where you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more but rests, satisfied. In this time, right now, that is an enormous thing.

The attending physician stepped in with strengthening words: “Paul, after you die, your family will fall apart, but they’ll pull it back together because of the example of bravery you set.”