When Breath Becomes Air

by Paul Kalanithi

You that seek what life is in death, Now find it air that once was breath. New names unknown, old names gone: Till time end bodies, but souls none. Reader! then make time, while you be, But steps to your eternity. —Baron Brooke Fulke Greville, “Caelica 83”

yet now time was the very thing he had so little of.

All I knew was, if that was the price of medicine, it was simply too high.

assumption that the mind was simply the operation of the brain,

I still felt literature provided the best account of the life of the mind, while neuroscience laid down the most elegant rules of the brain. Meaning, while a slippery concept, seemed inextricable from human relationships and moral values.

Nabokov, for his awareness of how our suffering can make us callous to the obvious suffering of another.

If the unexamined life was not worth living, was the unlived life worth examining?

We are never so wise as when we live in this moment.

I learned that many of the residents had nearly drowned as young children.

Drowning = brain damage ?

brains give rise to our ability to form relationships and make life meaningful. Sometimes, they break.

There must be a way, I thought, that the language of life as experienced—of passion, of hunger, of love—bore some relationship, however convoluted, to the language of neurons, digestive tracts, and heartbeats.

Where did biology, morality, literature, and philosophy intersect?

Getting ready for medical school would take about a year of intense coursework, plus the application time, which added up to another eighteen months. It would mean letting my friends go to New York, to continue deepening those relationships, without me. It would mean setting aside literature. But it would allow me a chance to find answers that are not in books, to find a different sort of sublime, to forge relationships with the suffering, and to keep following the question of what makes human life meaningful, even in the face of death and decay.

the advice they gave us was to take one good look at our cadaver’s face and then leave it covered; it makes the work easier.

Prosopagnosia is a neurological disorder wherein one loses the ability to see faces.

In anatomy lab, we objectified the dead, literally reducing them to organs, tissues, nerves, muscles. On that first day, you simply could not deny the humanity of the corpse. But by the time you’d skinned the limbs, sliced through inconvenient muscles, pulled out the lungs, cut open the heart, and removed a lobe of the liver, it was hard to recognize this pile of tissue as human.

It was not a simple evil, however. All of medicine, not just cadaver dissection, trespasses into sacred spheres. Doctors invade the body in every way imaginable. They see people at their most vulnerable, their most scared, their most private. They escort them into the world, and then back out.

as medical students, we were barely allowed to touch patients, let alone open their chests. What had not changed, though, was the heroic spirit of responsibility amid blood and failure. This struck me as the true image of a doctor. —

It was becoming clear that learning to be a doctor in practice was going to be a very different education from being a medical student in the classroom.

I still had a lot of practical medicine to learn, but would knowledge alone be enough, with life and death hanging in the balance? Surely intelligence wasn’t enough; moral clarity was needed

At those critical junctures, the question is not simply whether to live or die but what kind of life is worth living.

How much neurologic suffering would you let your child endure before saying

that death is preferable?

“Always eat with your left hand. You’ve got to learn to be ambidextrous.”

From that point on, I resolved to treat all my paperwork as patients, and not vice versa.

Some patients you can’t save. Others you can:

Not all residents could stand the pressure. One was simply unable to accept blame or responsibility.

As my skills increased, so too did my responsibility. Learning to judge whose lives could be saved, whose couldn’t be, and whose shouldn’t be requires an unattainable prognostic ability. I made mistakes.

I was not yet with patients in their pivotal moments, I was merely at those pivotal moments. I observed a lot of suffering; worse, I became inured to it. Drowning, even in blood, one adapts, learns to float, to swim, even to enjoy life, bonding with the nurses, doctors, and others who are clinging to the same raft, caught in the same tide.

After thirty minutes, we let him finish dying. With that kind of head injury, we all murmured in agreement, death was to be preferred.

I feared I was on the way to becoming Tolstoy’s stereotype of a doctor, preoccupied with empty formalism, focused on the rote treatment of disease—and utterly missing the larger human significance.

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.

As a resident, my highest ideal was not saving lives—everyone dies eventually—but guiding a patient or family to an understanding of death or illness.

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.

Any major illness transforms a patient’s—really, an entire family’s—life. But brain diseases have the additional strangeness of the esoteric.

Sometimes the news so shocks the mind that the brain suffers an electrical short. This phenomenon is known as a “psychogenic” syndrome, a severe version of the swoon some experience after hearing bad news.

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.

Removing the tumor was satisfying—even though I knew that microscopic cancer cells had already spread throughout that healthy-looking brain.

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.

in taking up another’s cross, one must sometimes get crushed by the weight.

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

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

that technical excellence was a moral requirement. Good intentions were not enough, not when so much depended on my skills, when the difference between tragedy and triumph was defined by one or two millimeters.

Neurosurgery requires a commitment to one’s own excellence and a commitment to another’s identity. The decision to operate at all involves an appraisal of one’s own abilities, as well as a deep sense of who the patient is and what she holds dear.

mortal responsibility. Our patients’ lives and identities may be in our hands, yet death always wins. Even if you are perfect, the world isn’t. The secret is to know that the deck is stacked, that you will lose, that your hands or judgment will slip, and yet still struggle to win for your patients. You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.

“What are you most afraid or sad about?” she asked me one night as we were lying in bed. “Leaving you,” I told her.

Lucy and I both felt that life wasn’t about avoiding suffering.

Sitting there, I reminded myself of what Emma had said: even a small amount of tumor growth, so long as it was small, would be considered a success.