When Breath Becomes Air

by Paul Kalanithi

profoundly influence the lives of others after you are gone, by your words.

At age thirty-six, I had reached the mountaintop; I could see the Promised Land, from Gilead to Jericho to the Mediterranean Sea.

And with that, the future I had imagined, the one just about to be realized, the culmination of decades of striving, evaporated.

Suddenly there was a feeling in our high school that the two mountain ranges that bounded the town no longer defined the horizon: it was what lay beyond them.

The camp delivered on its promise, concentrating all the idylls of youth: beauty manifest in lakes, mountains, people; richness in experience, conversation, friendships. Nights during a full moon, the light flooded the wilderness, so it was possible to hike without a headlamp. We would hit the trail at two A.M., summiting the nearest peak, Mount Tallac, just before sunrise, the clear, starry night reflected in the flat, still lakes spread below us. Snuggled together in sleeping bags at the peak, nearly ten thousand feet up, we weathered frigid blasts of wind with coffee someone had been thoughtful enough to bring. And then we would sit and watch as the first hint of sunlight, a light tinge of day blue, would leak out of the eastern horizon, slowly erasing the stars. The day sky would spread wide and high, until the first ray of the sun made an appearance. The morning commuters began to animate the distant South Lake Tahoe roads. But craning your head back, you could see the day’s blue darken halfway across the sky, and to the west, the night remained yet unconquered—pitch-black, stars in full glimmer, the full moon still pinned in the sky. To the east, the full light of day beamed toward you; to the west, night reigned with no hint of surrender. No philosopher can explain the sublime better than this, standing between day and night. It was as if this were the moment God said, “Let there be light!” You could not help but feel your specklike existence against the immensity o...

The look on his face, his inability to vocalize his sadness, taught me more about medicine than any lecture I would ever attend.

Medical school sharpened my understanding of the relationship between meaning, life, and death.

Sir Thomas Browne’s Religio Medici: “With what strife and pains we come into the world we know not, but ’tis commonly no easy matter to get out of it.”

“I don’t know. What I do know—and I know you know these things, too—is that your life is about to—it already has changed. This is going to be a long haul, you understand? You have got to be there for each other, but you also have to get your rest when you need it. This kind of illness can either bring you together, or it can tear you apart. Now more than ever, you have to be there for each other. I don’t want either of you staying up all night at the bedside or never leaving the hospital. Okay?”

Diseases are molecules misbehaving; the basic requirement of life is metabolism, and death its cessation.

While all doctors treat diseases, neurosurgeons work in the crucible of identity: every operation on the brain is, by necessity, a manipulation of the substance of our selves, and every conversation with a patient undergoing brain surgery cannot help but confront this fact. In addition, to the patient and family, the brain surgery is usually the most dramatic event they have ever faced and, as such, has the impact of any major life event. At those critical junctures, the question is not simply whether to live or die but what kind of life is worth living. Would you trade your ability—or your mother’s—to talk for a few extra months of mute life? The expansion of your visual blind spot in exchange for eliminating the small possibility of a fatal brain hemorrhage? Your right hand’s function to stop seizures? How much neurologic suffering would you let your child endure before saying that death is preferable? 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?

The hypothalamus regulates our basic drives: sleep, hunger, thirst, sex.

Rushing a patient to the OR to save only enough brain that his heart beats but he can never speak, he eats through a tube, and he is condemned to an existence he would never want…I

I came to see this as a more egregious failure than the patient dying.

He’d assess the abdomen, then ask for my prognosis on a patient’s cognitive function. “Well, he could still be a senator,” I once replied, “but only from a small state.” Jeff laughed, and from that moment on, state population became our barometer for head-injury severity. “Is he a Wyoming or a California?” Jeff would ask, trying to determine how intensive his care plan should be. Or I’d say, “Jeff, I know his blood pressure is labile, but I gotta get him to the OR or he’s gonna go from Washington to Idaho—can you get him stabilized?”

With that kind of head injury, we all murmured in agreement, death was to be preferred.

dehiscent

wound as he yelped in pain, telling myself he’d had it coming. Nobody has it coming.

Amid the tragedies and failures, I feared I was losing sight of the singular importance of human relationships, not between patients and their families but between doctor and patient.

guiding a patient or family to an understanding of death or illness.

When a patient comes in with a fatal head bleed, that first conversation with a neurosurgeon may forever color how the family remembers the death, from a peaceful letting go (“Maybe it was his time”) to an open sore of regret (“Those doctors didn’t listen! They didn’t even try to save him!”). When there’s no place for the scalpel, words are the surgeon’s only tool.

The families who gather around their beloved—their beloved whose sheared heads contained battered brains—do not usually recognize the full significance, either. They see the past, the accumulation of memories, the freshly felt love, all represented by the body before them. I see the possible futures, the breathing machines connected through a surgical opening in the neck, the pasty liquid dripping in through a hole in the belly, the possible long, painful, and only partial recovery—or, sometimes more likely, no return at all of the person they remember. In these moments, I acted not, as I most often did, as death’s enemy, but as its ambassador. I had to help those families understand that the person they knew—the full, vital independent human—now lived only in the past and that I needed their input to understand what sort of future he or she would want: an easy death or to be strung between bags of fluids going in, others coming out, to persist despite being unable to struggle.

Had I been more religious in my youth, I might have become a pastor, for it was the pastoral role I’d sought.

I had met her in a space where she was a person, instead of a problem to be solved. She chose surgery. The operation went smoothly. She went home two days later, and never seized again.

But brain diseases have the additional strangeness of the esoteric.

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?

The root of disaster means a star ...

One of my patients, upon being diagnosed with brain cancer, fell suddenly into a coma. I ordered a battery of labs, scans, and EEGs, searching for a cause, without result. The definitive test was the simplest: I raised the patient’s arm above his face and let go. A patient in a psychogenic coma retains just enough volition to avoid hitting himself.

The treatment consists in speaking reassuringly, until your words connect and the patient awakens.

Cancer of the brain comes in two varieties: primary cancers, which are born in the brain, and metastases, which emigrate from somewhere else in...

it is important to be accurate, but you must always leave some room for hope.

it is irresponsible to be more precise than you can be accurate.

Openness to human relationality does not mean revealing grand truths from the apse; it means meeting patients where they are, in the narthex or nave, and bringing them as far as you can.

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.

The implications of writing signals into the brain, or “neuromodulation,” however, were far more wide-reaching than that: being able to control neural firing would conceivably allow treatment of a host of currently untreatable or intractable neurological and psychiatric diseases, from major depression to Huntington’s to schizophrenia to Tourette’s to OCD…the possibilities were limitless. Putting surgery aside now, I set to work learning to apply new techniques in gene therapy in a series of “first of its kind” experiments.

One could count on V to always choose the honest (and, often, self-effacing) way forward. While most scientists connived to publish in the most prestigious journals and get their names out there, V maintained that our only obligation was to be authentic to the scientific story and to tell it uncompromisingly. I’d never met someone so successful who was also so committed to goodness. V was an actual paragon.

He paused. “Paul,” he said, “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.

resident’s surgical skill is judged by his technique and his speed. You can’t be sloppy, and you can’t be slow.

One day, Matthew, the little boy with the brain tumor who had charmed the ward a few years back, was readmitted. His hypothalamus had, in fact, been slightly damaged during the operation to remove his tumor; the adorable eight-year-old was now a twelve-year-old monster. He never stopped eating; he threw violent fits. His mother’s arms were scarred with purple scratches. Eventually Matthew was institutionalized: he had become a demon, summoned by one millimeter of damage. For every surgery, a family and a surgeon decide together that the benefits outweigh the risks, but this was still heartbreaking. No one wanted to think about what Matthew would be like as a three-hundred-pound twenty-year-old.

Then the patient’s voice, confused, rose above our affirmative murmurs: “I feel…overwhelmingly sad.” “Current off!” I said. “Oh, now the feeling is going away,” the patient said. “Let’s recheck the current and impedance, okay? Okay. Current on…” “No, everything…it just feels…so sad. Just dark and, and…sad.” “Electrode out!”

We pulled the electrode out and reinserted it, this time two millimeters to the right. The tremor went away. The patient felt, thankfully, fine.

Doctors in highly charged fields met patients at inflected moments, the most authentic moments, where life and identity were under threat; their duty included learning what made that particular patient’s life worth living, and planning to save those things if possible—or to allow the peace of death if not. Such power required deep responsibility, sharing in guilt and recrimination.

And even though I no longer really knew what it was, I felt it: a drop of hope.

Any part of me that identified with being handsome was slowly being erased—though, in fairness, I was happy to be uglier and alive.

The man who loved hiking, camping, and running, who expressed his love through gigantic hugs, who threw his giggling niece high in the air—that was a man I no longer was. At best, I could aim to be him again.

Then I recalled the times I had been wrong: the time I had counseled a family to withdraw life support for their son, only for the parents to appear two years later, showing me a YouTube video of him playing piano, and delivering cupcakes in thanks for saving his life.

My senior peers were living the future that was no longer mine: early career awards, promotions, new houses.

Shouldn’t terminal illness, then, be the perfect gift to that young man who had wanted to understand death?

What better way to understand it than to live it?

Lost in a featureless wasteland of my own mortality,