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”

It was much more than a falling in love with the intricacies of the brain, much more than the satisfaction of training his hands to accomplish amazing feats—it was a love and empathy for those who suffered, for what they endured and what he might bring to bear. I

Be ready. Be seated. See what courage sounds like. See how brave it is to reveal yourself in this way. But above all, see what it is to still live, to profoundly influence the lives of others after you are gone, by your words.

Why was I so authoritative in a surgeon’s coat but so meek in a patient’s gown?

was my primary care doctor, calling with the chest X-ray result: my lungs, instead of being clear, looked blurry, as if the camera aperture had been left open too long. The doctor said she wasn’t sure what that meant. She likely knew what it meant. I knew.

the best-informed people—doctors—almost never donated their bodies.

remembered 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.”

Humans are organisms, subject to physical laws, including, alas, the one that says entropy always increases. Diseases are molecules misbehaving; the basic requirement of life is metabolism, and death its cessation.

every operation on the brain is, by necessity, a manipulation of the substance of our selves,

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?

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?

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

As residents, we were working as much as one hundred hours a week; though regulations officially capped our hours at eighty-eight, there was always more work to be done. My eyes watered, my head throbbed, I downed energy drinks at two A.M. At work, I could keep it together, but as soon as I walked out of the hospital, the exhaustion would hit me. I staggered through the parking lot, often napping in my car before driving the fifteen minutes home to bed.

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. 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 began to suspect that being so close to the fiery light of such moments only blinded me to their nature, like trying to learn astronomy by staring directly at the sun.

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.

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.

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.

“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.

“You know, today is the first day it all seems worth it. I mean, obviously, I would’ve gone through anything for my kids, but today is the first day that all the suffering seems worth it.” 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.

the OR, everyone’s eyes are always on the clock. For the patient’s sake: How long has he been under anesthesia? During long procedures, nerves can get damaged, muscles can break down, kidneys can fail. For everyone else’s sake: What time are we getting out of here tonight?

You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.

with the cancer progressing, I had grown noticeably weaker. My body, and the identity tied to it, had radically changed.

therein was the paradox: like a runner crossing the finish line only to collapse, without that duty to care for the ill pushing me forward, I became an invalid.

I began to realize that coming in such close contact with my own mortality had changed both nothing and everything. Before my cancer was diagnosed, I knew that someday I would die, but I didn’t know when. After the diagnosis, I knew that someday I would die, but I didn’t know when. But now I knew it acutely.

the person who could run half marathons was a distant memory—and that, too, shapes your identity. Racking back pain can mold an identity; fatigue and nausea can, as well.

began to look forward to my meetings with Emma. In her office, I felt like myself, like a self. Outside her office, I no longer knew who I

“Don’t you think saying goodbye to your child will make your death more painful?” “Wouldn’t it be great if it did?” I said. Lucy and I both felt that life wasn’t about avoiding suffering.

it had occurred to me that Darwin and Nietzsche agreed on one thing: the defining characteristic of the organism is striving. Describing life otherwise was like painting a tiger without stripes.

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

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.

Death may be a one-time event, but living with terminal illness is a process.

I thought about what Emma had told me. I had gone from being unable to believe I could be a surgeon to being one, a transformation that carried the force of religious conversion. She had always kept this part of my identity in mind, even when I couldn’t. She had done what I had challenged myself to do as a doctor years earlier: accepted mortal responsibility for my soul and returned me to a point where I could return to myself.

Freud started his career as a successful neuroscientist. When he realized neuroscience would need at least a century to catch up with his true ambition of understanding the mind, he set aside his microscope. I think I felt something similar.

No system of thought can contain the fullness of human experience.

With little to distinguish one day from the next, time has begun to feel static. In English, we use the word time in different ways: “The time is two forty-five” versus “I’m going through a tough time.” These days, time feels less like the ticking clock and more like a state of being.

There is perhaps only one thing to say to this infant, who is all future, overlapping briefly with me, whose life, barring the improbable, is all but past. That message is simple: 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.

Paul’s decision, we all expressed our love and respect. Tears glistened in Paul’s eyes. He expressed gratitude to his parents. He asked us to ensure that his manuscript be published in some form. He told me a last time that he loved me. 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.”

When Breath Becomes Air is, in a sense, unfinished, derailed by Paul’s rapid decline, but that is an essential component of its truth, of the reality Paul faced.

During the last year of his life, Paul wrote relentlessly, fueled by purpose, motivated by a ticking clock. He started with midnight bursts when he was still a neurosurgery chief resident, softly tapping away on his laptop as he lay next to me in bed; later he spent afternoons in his recliner, drafted paragraphs in his oncologist’s waiting room, took phone calls from his editor while chemotherapy dripped into his veins, carried his silver laptop everywhere he went. When his fingertips developed painful fissures because of his chemotherapy, we found seamless, silver-lined gloves that allowed use of a trackpad and keyboard. Strategies for retaining the mental focus needed to write, despite the punishing fatigue of progressive cancer, were the focus of his palliative-care appointments.

When Paul told me, immediately after his diagnosis, to remarry after he died, it exemplified the way he would, throughout his illness, work hard to secure my future. He was fiercely committed to ensuring the best for me, in our finances, my career, what motherhood would mean.

He knew he would never be alone, never suffer unnecessarily.

At home in bed a few weeks before he died, I asked him, “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.”

expected to feel only empty and heartbroken after Paul died. 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.