When Breath Becomes Air

by Paul Kalanithi

Only 0.0012 percent of thirty-six-year-olds get lung cancer. Yes, all cancer patients are unlucky, but there’s cancer, and then there’s CANCER, and you have to be really unlucky to have the latter. When she asked us to specify what would happen to the sperm if one of us “were to die”—who would legally own them in the event of death—tears began rolling down Lucy’s face.

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

It’s easier when the patient is ninety-four, in the last stages of dementia, with a severe brain bleed. But for someone like me—a thirty-six-year-old given a diagnosis of terminal cancer—there aren’t really words.

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.

“I had mapped out this whole forty-year career for myself—the first twenty as a surgeon-scientist, the last twenty as a writer.

Though I felt dissatisfied, at least I felt like somebody, a person, rather than a thing exemplifying the second law of thermodynamics (all order tends toward entropy, decay, etc.).

“Will having a newborn distract from the time we have together?” she asked. “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.

Years ago, 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.

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

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

(People often ask if it is a calling, and my answer is always yes. You can’t see it as a job, because if it’s a job, it’s one of the worst jobs there is.)

Commonly, epilepsy is caused by a misfiring hippocampus, which is located deep in the temporal lobe. Removing the hippocampus can cure the epilepsy, but the operation is complex, requiring gentle dissection of the hippocampus off the pia, the delicate transparent covering of the brain, right near the brain stem.

I kept myself limited to operating, leaving the administration, patient care, and night and weekend calls to Victoria and the other senior residents. I had already mastered those skills, anyway, and needed to learn only the nuances of complex operations to feel complete. I ended my days exhausted beyond measure, muscles on fire, slowly improving. But the truth was, it was joyless. The visceral pleasure I’d once found in operating was gone, replaced by an iron focus on overcoming the nausea, the pain, the fatigue.

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?

In February, I flew to Wisconsin for a job interview. They were offering everything I wanted: millions of dollars to start a neuroscience lab, head of my own clinical service, flexibility if I needed it for my health, a tenure-track professorship, appealing job options for Lucy, high salary, beautiful scenery, idyllic town, the perfect boss.

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. I

“In summer, you can swim or sail to work. In winter, you can ski or ice-skate.”

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.

minus outmoded concepts like souls, God, and bearded white men

It is to say, though, that if you believe that science provides no basis for God, then you are almost obligated to conclude that science provides no basis for meaning and, therefore, life itself doesn’t have any.

“The ancient covenant is in pieces; man at last knows that he is alone in the unfeeling immensity of the universe, out of which he emerged only by chance.”

instead of the high-energy pop music everyone liked to play in the OR, we’d listen exclusively to bossa nova. I put Getz/Gilberto on the radio, and the soft, sonorous sounds of a saxophone filled the room.

Eating, normally a source of great pleasure, was like drinking seawater. Suddenly, all of my joys were salted.

Reading was exhausting.

I could see that in Brad’s eyes I was not a patient, I was a problem: a box to be checked off.

Residency education regulations had forced most programs to adopt shift work. And along with shift work comes a kind of shiftiness, a subtle undercutting of responsibility. If he could just push it off for a few more hours, I would become somebody else’s problem.

Lucy, thirty-eight weeks pregnant, stayed with me by day and secretly moved into my old call room, steps from the ICU, so she could check on me at night. She and my father also lent their voices.

During lucid moments, I was acutely aware that with this many voices, cacophony results. In medicine, this is known as the WICOS problem: Who Is the Captain Of the Ship?

“You know how you offered to just be the doctor and I could just be the patient?” I asked. “I think that’s maybe a good idea. I’ve been reading science and literature trying to find the right perspective, but I haven’t found it.” “I’m not sure that’s something you can find by reading about it,” she replied.

“You have five good years left,” she said. She pronounced it, but without the authoritative tone of an oracle, without the confidence of a true believer. She said it, instead, like a plea. Like that patient who could speak only in numbers. Like she was not so much speaking to me as pleading, a mere human, with whatever forces and fates truly control these things. There we were, doctor and patient, in a relationship that sometimes carries a magisterial air and other times, like now, was no more, and no less, than two people huddled together, as one faces the abyss. Doctors, it turns out, need hope, too.

returned to the hospital, pushed by my father in a wheelchair.

Time for me is now double-edged: every day brings me further from the low of my last relapse but closer to the next recurrence—and, eventually, death. Perhaps later than I think, but certainly sooner than I desire. There are, I imagine, two responses to that realization. The most

obvious might be an impulse to frantic activity: to “live life to its fullest,” to travel, to dine, to achieve a host of neglected ambitions. 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.

Graham Greene once said that life was lived in the first twenty years and the remainder was just reflection.

Everyone succumbs to finitude. I suspect I am not the only one who reaches this pluperfect state. Most ambitions are either achieved or abandoned; either way, they belong to the past. The future, instead of the ladder toward the goals of life, flattens out into a perpetual present. Money, status, all the vanities the preacher of Ecclesiastes described hold so little interest: a chasing after wind, indeed.

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. EPILOGUE Lucy Kalanithi You left me, sweet, two legacies,— A legacy of love A Heavenly Father would content, Had he the offer of; You left me boundaries of pain Capacious as the sea, Between eternity and time, Your consciousness and me.

And, of course, Paul wrote, reclining in his armchair, wrapped in a warm fleece blanket. In his final months, he was singularly focused on finishing this book.

I envisioned his funeral as we held hands. I didn’t know that Paul would die within days.

Paul napped comfortably in the afternoon, but he was gravely ill. I started to cry as I watched him sleep, then crept out to our living room, where his father’s tears joined mine. I already missed him.

Paul managed to doze until sunrise, his father sitting vigil while I napped briefly in an adjacent room, hoping to preserve my mental strength, knowing that the following day might be the hardest of my life.

However, I said I would do everything possible to take him home if that was most important to him, nodding that yes, comfort care might be the direction we were headed. Or was there some way to re-create home here? Between BiPAP puffs, he answered: “Cady.” Cady arrived in short order—our friend Victoria had retrieved her from home—and began her own unwitting, cheerful vigil, happily nestled in the crook of Paul’s right arm, tugging at her tiny socks, batting at his hospital blankets, smiling and cooing, unbothered by the BiPAP machine as it continued to blow, keeping Paul alive.

“He doesn’t want a Hail Mary,” I said. “If he doesn’t have a chance of meaningful time, he wants to take the mask off and hold Cady.”

I returned to Paul’s bedside. He looked at me, his dark eyes alert above the nose bridge of the BiPAP mask, and said clearly, his voice soft but unwavering, “I’m ready.” Ready, he meant, to remove the breathing support, to start morphine, to die.

The family gathered together. During the precious minutes after 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 p...

With my heart breaking, I climbed into the last bed we would share.

The room, saturated with love, mirrored the many holidays and weekends we had all spent together over the years.

“Thank you for loving me.”

Just before nine o’clock, his lips apart and eyes closed, Paul inhaled and then released one last, deep, final breath.