When Breath Becomes Air

When Breath Becomes Air
Category: Medicine
Publisher: Vintage
Published: 1/5/2017
At the age of thirty-six, on the verge of completing a decade’s training as a neurosurgeon, Paul Kalanithi was diagnosed with inoperable lung cancer. One day he was a doctor treating the dying, the next he was a patient struggling to live.

Book Summary - When Breath Becomes Air by Paul Kalanithi

Key Insights

This memoir follows Paul Kalanithi through his development into a doctor and then through his tragic turn into a terminally ill patient. Kalanithi writes about how his love for literature shaped him into someone interested in the questions of meaning, morality, and humanity while his work brought him close to life and death. The story explores one man’s experiences with the ethical difficulties of the medical profession, the search for meaning, and the fragility of life.

Key Points

Literature offers a way to explore life’s meaning and to relate the mind’s struggle with the concepts of life and death. Often, literature shows us that meaning comes from relationships.

Paul Kalanithi never planned on becoming a doctor had come from a family where his father worked long hours in the profession. He instead fell in love with the books given to him by his mother. He idolized authors like Orwell, Poe, TS Eliot, Camus, and Thoreau, and wanted to follow in their footsteps and become a writer. In these books, Kalanithi found answers to and explorations of life’s big questions and a place for the mind to relate its existential struggles. He particularly likes TS Eliot’s The Wasteland and its exploration of meaninglessness in isolation; he found in many of his books that meaning seemed to arise through interpersonal relationships. In college, Kalanithi continued his pursuit with a degree in English Literature alongside his degree in biology.

Throughout the book, Kalanithi returns to his love for literature which sparked his interest in the questions of life and death and what makes for a beautiful and meaningful time in between. He ends his life as he started it: wanting to write and capture the way his mind dealt with impending death. In the end, his wish to become a published author came true, though only after he passed away. His book shows that stories can document existential struggles and help others understand how to cope with these difficult subjects and experiences.

Studying the body offers insight into how the mind shapes our life. This is another avenue to exploring how meaning arises and how our determined by the state of our bodies.

In college, Kalanithi studied Biology alongside English. He became fascinated with biological processes after reading Satan: His Psychotherapy and Cure, a book that exposed him to the brain’s role as the organ that allows the mind to exist. By studying the laws of the brain he could understand how people became capable or incapable of forming relationships. Kalanithi realized he could look to both literature and neuroscience for answers to questions about the mind’s search for meaning.

Throughout his time as a neurosurgeon, he found that those with permanent brain injuries struggle to make and maintain relationships. In one instance, a boy he operated on had his hypothalamus damaged, a part of his brain that controlled certain impulses. This brain damage induced violent and difficult behavior, leading him to become institutionalized and isolated from other people.

Kalanithi also experienced first hand the way the state of the body changes the direction of life, and consequently its meaning. As he became progressively sicker, Kalanithi was not able to perform like a star doctor or read books. He understood that changes in the body could create extreme changes to lifestyle, and therefore argued that in treatment of illness, doctors should consider how meaning is altered by their physical condition and by any sort of intervention.

Medical school gave Kalanithi a new perspective on life, the descent to death, and the doctor’s role in this process.

In medical school, Kalanithi saw death up close. In his anatomy lab, he saw cadaver slew out on tables and carved up. Despite the cloths over their faces, Kalanithi was moved by the humanity of these bodies.

He also saw life coming into the world in the labor ward of his hospital but also witnessed tragedy on his first shift. The first birth he saw, the delivery of premature infants by c-section, resulted in death. The infants were too young and soon died from underdeveloped organs. In this instance, Kalanithi witnessed a life beginning and ending within a day.

In his residency, Kalanithi had even more experience with death. He saw people come into the neurosurgery wing with devastating brain trauma from car accidents, bullet wounds, and overdoses. He saw many bodies sent into the autopsy lab, including bodies of people who used to work there. All this exposure to death made Kalanithi consider its inevitability, and also the doctor’s role as someone working in such close proximity to it.

Hard work, no matter how rewarding, can cause important relationships to suffer

Kalanithi entered his residency at Stanford where he stayed for seven years. He soon became a star talent in his work, earning awards and even becoming the chief resident. However, the hours became extremely demanding, up to 100 hours a week, and Kalanithi started to drag his feet. He experienced frequent headaches and lived off of energy drinks. He even had to nap in his car after leaving work to avoid falling asleep at the wheel on his drive home.

He started to notice that he was struggling to maintain the human side of his interactions with his patients. He would breeze through his conversations with them, neglecting to engage with sensitivity. He recalls in one instance gruffly telling a woman with brain cancer that surgery was the best option, despite her fear of surgeries. Kalanithi felt guilty for acting this way and decided that he needed to cherish the doctor-patient relationship, as it was his reason for becoming a doctor in the first place.

Doctors must commit to competence in order to be ethical.

Soon after Kalanithi became the chief resident at Stanford, he learned about the effects of one of his surgeries, the young patient who developed extremely difficult behavioral problems as a result. Kalanithi understood that a doctor’s competence is directly related to the ethics of their work. Incompetence can lead to suffering, and should, therefore, be avoided as a moral imperative.

Doctors should not only provide medications and options for their patients but understand they are treating the whole person. They should consider their patient’s lifestyles and work.

Before the end of his residency, Kalanithi’s life took a dramatic turn. He started to lose weight and had constant back pain. He desperately wanted to finish his residency, but his condition was worsening: chest pain, a cough. When he visited a doctor, the doctor told him he was probably just stressing himself too much at work. When the problems persisted, Kalanithi knew to suspect cancer.

During a later examination, Kalanithi saw a strange blur over scans of his chest and his heart sunk. He knew this to be cancer, which had already spread to a lot of his body. It turned out to be terminal.

In his treatment, he worked with a doctor who he ended up feeling very close to. He appreciated her ability to consider his lifestyle in her thoughtful assessment of his condition. For example, she asked him about what he wanted to do with his life now that he was terminally ill. She advised him to do what he’s always wanted to do. He told her he wanted to write, and she made sure to avoid prescribing him things that would affect the stability of his hands. Kalanithi expressed that if patients feel working adds meaning to their life, they should be allowed to keep working if possible

Kalanithi also explains that all doctors fail in the sense that everyone dies eventually. Doctors must keep this mind, but fight for their patients’ wellbeing anyway despite this inevitable defeat. He likened this to a favorite piece of literature: The Myth of Sisyphus by Albert Camus. Sisyphus was damned to push a rock up a hill for eternity, but that process turned into his life. Kalanithi says, keep pushing the rock because that is what you are given as a doctor. Meaning can be found in this struggle.

When we are faced with less time meaning and priorities shift dramatically. How would you spend your remaining days? Hint: people are the most important parts of our lives.

When Kalanithi realized he was terminally ill, he began writing again but most importantly, he grew closer to his family. He and his wife Lucy debated whether they should have children and ended up freezing his sperm before he had to undergo chemotherapy. Kalanithi was unsure whether he should commit to having a child with his impending death, but he and his wife decided that he could be there for their child’s birth if they moved quickly.

Lucy became pregnant with their child and he was able to see the birth of his child and through her first eight months of life. His wife remembers these last months as incredibly meaningful for their family.

Kalanithi’s terminal diagnoses drove him to consider what he needed to do to feel he had lived a full life. Such a consideration can be taken at any time, though the reality of a terminal diagnosis means patients must decide quickly. Kalanithi’s story reveals that understanding life’s priorities can lead to a fulfilling life no matter its length.

There are ways to find comfort, security, and meaning at the end of life. End-of-life care is an important and overlooked part of medicine, as death is inevitable. Only through experiencing pain can we really understand it, but we can be prepared for it.

In his final months, as his health deteriorated, Kalanithi couldn’t do basic things like stand, read, or ride a bicycle. He couldn’t even drink properly. When his cancer started resisting treatment he grew tired and nauseous and could not eat.

But in these last months, he spent time playing with his daughter and with his wife. He got to watch his wife’s birth, albeit laying in a cot at the edge of the room. He spent time with his family and worked diligently to finish the manuscript of his book. In the end, he decided to take himself off life support after speaking with doctors about the grim prospects. He realized that any heroic measures taken by doctors would be counterproductive, just extending his family’s suffering. His family remembers the last months of his life as full of love, and he managed to produce his most influential piece of work by writing a book about his experience and helping people come to terms with death.

In the end, Kalanithi died at the young age of 37. He advocated for the importance of end-of-life care to make death less difficult for both doctors and patients alike. By discussing end-of-life care with doctors, people can avoid pain and hardship associated with slow and difficult death or unnecessarily prolonged life. Kalanithi advised that patients have these conversations as soon as possible so they and their doctors can avoid unwanted measures at the end of life. He believed his dignified movement towards death should be available to all.

The Main Take-away

Kalanithi’s book explores the dramatic ups-and-downs of individual life and the contradictions within. Doctors eventually become patients and everybody deals with death. Kalanithi explains that this struggle does not have to be without meaning, and that meaning can be found in our work, our passions, and time spent with loved ones. Meaning can also be found in the pursuit of science, medicine, philosophy, literature, and in the midst of terrible experiences. Kalanithi’s story explores the sudden cruelty of some lives and the importance of acceptance and preparation for our deaths. He advocates for increased awareness around end-of-life planning and care, for doctors and patients alike, and a reevaluation of our priorities after understanding the inevitability of death. To doctors, Kalanithi expresses the importance of holistic care, considering the various human aspects of a person’s life. Work and lifestyle should be considered and preserved when deciding on treatment. Kalani’s story also reveals that as life shortens, time becomes treasured— life is short, fleeting, and therefore precious.

About the Author

Paul Kalanithi was an Indian-American neurosurgeon, neuroscientist, and writer. He grew up in Westchester, New York to a Christian family and attended Stanford University. After Stanford, he graduated from the University of Cambridge with a degree in the History and Philosophy of Science and Medicine. He then attended medical school at Yale School of Medicine before continuing to a residency at Stanford School of Medicine. There, he met his wife Lucy Goddard. He had a child, Elizabeth Acadia before his death. Before his death, he wrote various essays for The New York Times, Stanford Medicine Magazine, The New Yorker, and The Paris Review.


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