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Key insights from
When Breath Becomes Air
By
Paul Kalanithi
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What you’ll learn
As Paul Kalanithi neared his graduation from
Stanford Medical School, he knew he was physically ill. Subsequent
testing confirmed that he had stage IV lung cancer. This book became his
final project, an attempt to convey what dying means to a person who is
still living. Paul chronicles those things that brought him a sense of
significance throughout his life and especially in his last days.
Read on for key insights from When Breath Becomes Air.
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1. At a young age,
Paul decided medicine was not for him.
When Paul was ten years old, his family moved from the
affluent village of Bronxville, New York, to the tiny town of Kingman,
Arizona. His father, a cardiologist, wanted to establish his own practice
in a less expensive area. With three sons, each of whom was expected to go
to college, he needed more room in the budget for education.
Paul was the middle son, with a brother two years younger
and the other two years his senior. What Paul remembers most about this
time in his life was how little he saw of his dad and how infrequent their
interactions were. The practice consumed most of his father’s time. A
largely absent father convinced Paul that medicine was not the career for
him.
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2. His mom’s love
of learning helped shape Paul’s future.
While Paul’s dad was finding success with his practice, his
mom was investing time and energy in the education system of Kingman. She
joined the local school board with the aim of forging a path that her sons
could follow to prestigious universities; she did not want to see them end
up at Kingman Community College.
She had trained in India as a physiologist, a career she had
put aside to care for her three boys when she and her husband moved to
America. Their inter-religious marriage—he was Catholic and she was
Hindu—was met with such outrage by both families that they emigrated to
escape the fury. And though Kingman was a tiny, impoverished school
district, Paul’s mom vowed that her children would never be deprived of a
good education.
So, at the age of ten, his mom had Paul reading all the
classics of English literature that he could possibly comprehend. A couple of
years later, his older brother, now at the university, began sending home
books he had finished so Paul could read them, too. Later in life, Paul
attributed his love of literature to these early influences.
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3. Paul’s innate
curiosity pushed him to go deeper in his studies.
With his family's guidance, Paul decided to go to Stanford
and major in English Literature. Casually reading a horror story that
summer before university caused him to rethink things a bit. While his mom
had only exposed him to the classics, this mundane novel held his attention
and entertained him. He wondered about the relationship between the brain
and the mind: what were the differences, and how did they affect one
another? That night, Paul pored through the Stanford course catalog and
added classes in biology and neuroscience.
As he neared graduation, Paul found himself searching for a
deeper understanding of life’s meaning. Literature seemed to provide an
account of the mind, while neuroscience concerned itself with an
explanation of how the brain functioned. As to the question of meaning,
Paul decided that the answer was inextricably bound up in human
relationships and morality. Through his course work in literature, biology,
philosophy, and neuroscience, Paul sought to grasp how the brain could
allow an organism to define meaning for itself in this world.
During his senior year, Paul's neuroscience class visited an
institution for people who had suffered severe brain injuries. Aside from
the ever-present wailing and violent rocking exhibited by so many patients,
what struck Paul as odd was that there were no other visitors. He asked the
guide if this was common. She confirmed that it was: family visits tend to
taper off after a couple months. Eventually, most families come for
birthdays and Christmases, and then stop visiting altogether. This response
angered Paul, but it reinforced his understanding that the brain gives us
the ability to forge relationships with other humans and thus add meaning
to life. If the mind becomes broken, relationships are all but impossible
to maintain.
Paul's college thesis, Whitman and the Medicalization of
Personality, dealt with elements of psychiatry and neuroscience, as
well as literary criticism. After completing it, he realized that the next
step for him would be the pursuit of medicine, for, as Whitman had
concluded, it was the physician who could truly understand "the
Physiological-Spiritual Man."
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4. Paul realized
authentic medicine can truly benefit others.
After a year at Cambridge studying the philosophy and
history of medicine, Paul was accepted at Yale and returned to the United
States to begin medical school. Early on, he came to understand that the
body is matter and mechanism. By manipulating that matter and mechanism,
medicine can ease profound pain and even correct abnormalities.
As Paul began to rotate shifts through various departments
of the hospital and was called upon to make decisions regarding the
wellbeing of patients, the field of medicine assumed a more complex and
metaphysical nature. Life and death were no longer abstract concepts to be
debated in the classroom; rather, they were realities that surgeons had to
deal with every day. A surgeon needed training and intelligence, surely,
but moral clarity was essential, too. And as if the mental rigors weren’t
challenging enough, the physical demand—being on one’s feet for lengthy
shifts—was grueling. One unexpected benefit of attending Yale was that
Lucy, his future wife, was also enrolled there.
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5. In
neurosurgery, Paul found the challenge for which he had been searching.
Four years into medical school, Paul watched as fellow
classmates began to specialize in less demanding areas of medicine, such as
dermatology. The medical community had termed these areas of medicine
“lifestyle” specialties, as they tended to produce high salaries without
high stress. For Paul, though, neurosurgery would be his choice since
medicine was more of a calling for him than a job.
One night, while listening to another pediatric neurosurgeon
speak to the parents of a young child with a large brain tumor, Paul was
struck by the need for a surgeon not only to provide the clinical facts,
but also to give caring guidance. While he had not fully considered it
before, Paul now saw that the issues of life, death, and meaning usually
arise in a medical context.
One issue in particular that the neurosurgeon must confront
is the major impact brain surgery might well have on a patient’s quality of
life. The question isn’t simply whether a patient will live or die, but
whether life post-surgery will be worth living. What would one be willing
to sacrifice to stop epileptic seizures? The loss of the right hand’s
functions? Might the patient accept a visual blind spot to eliminate the
slight chance of a brain hemorrhage? How much neurological pain would a
parent allow his or her child to suffer before death becomes preferable?
Paul had found the confluence of life, death, and meaning in
the field of neurosurgery. “They are not only the best surgeons, but the
best doctors in a hospital,” his chief resident told him. Here in med
school, Paul had truly hit his stride.
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6. For Paul, the
pursuit of excellence in all things became a moral obligation.
On breaks and holidays, Paul and Lucy would travel from New
Haven to Kingman to visit Paul's family. Often, the three of them would do
medical rounds together at his dad's clinic. What Paul was discovering at
Yale was being modeled by his dad in his interactions with patients.
Technical procedures were first rate, and patient care was always
well-informed, deeply empathetic, and leavened with kindness.
Because Paul’s father had been largely absent in his youth,
he never held his dad up as a role model. But now he was inspired by the
way his father handled patients, laughing with them and gaining their
trust. Paul was beginning to look on his dad with admiration for the first
time.
"Excellence in all things" is the mantra of
neurosurgeons. Paul took this to heart and put it into practice. By the
last year of his residency, he had become the chief resident at the
Stanford Hospital. Every responsibility, every decision, rested on his
shoulders. His experience over the past nine years had taught him that
technical excellence was a moral obligation, that even after an exhausting
operation, it wasn't over until the paperwork was properly completed and
filed. Even the smallest detail couldn't wait until tomorrow. And yet, with
all the care, planning, and knowledge, mistakes did occur in the operating
room, a reality he had witnessed over the years when fellow surgeons had
missed the mark by one or two millimeters. Such mistakes left patients
mute, paralyzed, or emotionally depressed.
With his time as chief resident drawing to a close, Paul
knew he had mastered all the core cranial procedures. His research in
generating signals into the brain was drawing much praise and attention.
Not a day went by that he didn’t receive a job offer. And it was an open
secret that Stanford was creating a new position for a
neurosurgeon-neuroscientist that was Paul's for the asking.
He knew well that a human being can never reach perfection,
but one should always strive to come as close as possible.
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7. Paul vowed to
live until he dies.
Lying in a hospital bed next to Lucy, Paul reviewed the CT
scan images showing that a number of his organs had been invaded. Despite
the fact that Paul had never smoked, the diagnosis was lung cancer. His
first thought was about all the potential within himself that would go
unrealized. Death, an enemy he had helped so many others confront, was now
visiting him. Statistically, only 0.0012 percent of thirty-six-year-olds
get lung cancer.
When Paul's oncologist first visited him, he asked her to
review the Kaplan-Meier estimator. This is a collection of data that
describes the survival characteristics associated with various diseases. In
short, it predicts life expectancy after treatment. His doctor minced no
words. "No," she said. "Absolutely not."
This stunned Paul. Life on the other side of the white coat
was different. He was no longer in control. While laid up in the hospital,
he took some time to research the various treatment approaches, but the
pain in his back had become excruciating and the medication kept him
groggy.
As his oncologist discussed the medical options, she asked
if returning to surgery was important to him. As Paul had spent almost a
third of his life preparing for it, the simple answer was ‘yes.’ But there
was every chance that he would not defeat this enemy. As the tests came
back, they showed that Paul had stage IV lung cancer. There was very little
hope of survival.
One topic Paul and Lucy had been discussing was having a
baby. They decided to wait until Paul finished his residency. That
discussion now rose to the top of the list. Unsure of exactly how long he
had to live, Paul was averse to Lucy raising a baby alone. And yet, not
having a child seemed unthinkable. Since the effects of the cancer drugs on
Paul's body were not fully known, they decided to visit a sperm bank and
make the arrangements before his treatment began. When the woman helping
them asked who would legally own the sperm if one of them was to die, Lucy
burst into tears.
Paul's initial test results ruled out chemotherapy as the
primary treatment. He was able to start taking an oral medication called
Tarceva, which had far less drastic side effects than chemo. As the months
passed, Paul began to feel stronger. He attended physical therapy every
day. The idea of returning to work as a surgeon was looking like a real
possibility. The future Paul had envisioned came back into focus as death
seemed to be retreating into the shadows.
The positive response to treatment also bolstered his and
Lucy's desire to have a child. It was something they had both wanted and
now it seemed that it would further cement their love for one another,
despite Lucy likely being the sole parent. A child would bring joy to the
entire family. Saying goodbye to a baby would surely be painful, but the blessings
far outweighed the drawbacks in both their minds. The decision made, they
advised the clinic and began the process of impregnating Lucy through in
vitro fertilization.
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8. Paul learned to
cope with the emotional roller-coaster that is cancer.
During his recuperation, Paul started to read everything he
could that dealt with mortality. His hope was to learn a new vocabulary
that would define and make sense of death. He found that he very much
needed inspirational language to help him move forward. Seven words from
Samuel Beckett became his motto: “I can’t go on. I’ll go on.”
Paul continued to grow stronger. Since he was still alive,
he wanted to add worth and value to his life. He decided a return to
the operating room would accomplish that. This meant he needed to refocus
his physical therapy to concentrate on micro-manipulation of small objects,
pronation exercises, and rebuilding the leg strength needed to stand for
hours at a time.
During this time, Paul’s tumors had begun to shrink. In a
meeting with his oncologist, she said that based on these recent results, a
life expectancy of another seven to ten years was not out of the question.
Lucy was also supportive of his choice to get back to the OR. The program
director gave his blessing, and Paul was on the rotation schedule again.
Before his first operation, he reviewed all the necessary textbooks, the
relevant anatomy, and each step of the process just to be certain.
As he began the procedure the next day, all the muscle
memory came flooding back. He drilled three perfect holes in the patient’s
skull, keeping the drill cool as he worked. He sliced through the dura with
a sharp knife, exposing the brain. But suddenly his field of vision
darkened and his legs felt weak. He told the attending resident that he
felt faint and had the junior resident finish the procedure. After resting
for twenty minutes in the lounge, Paul decided it was just a case of his
nerves getting the better of him. He vowed tomorrow would be better.
And it was better. His strength improved, as did his
technique and procedural memory. Within a month he was working at
three-quarter capacity. By the end of the day, though, his muscles were on
fire and he was exhausted. Worse, the work that had once brought so much
joy and satisfaction was now drudgery; his focus was solely on fighting off
the effects of nausea, fatigue, and searing pain.
With Lucy now in her first trimester of pregnancy, a steady
income assumed a new importance. Furthermore, in order to graduate, Paul
needed to take on the full load of a chief resident to satisfy the demands
of the medical faculty. Paul admitted to his fellow surgeons that he had
slacked off due to the intense physical demands of the OR. He decided to
return to his full-time schedule to ensure his graduation and to prove to
himself he could do it.
Seven months after returning to work, Paul reviewed the
latest results of his CT scan and saw the faintest trace of a new, large
tumor filling his right lung. That night, he and Lucy began mapping out the
next steps of his treatment, as he wouldn't see his oncologist until the
following week. It became clear now that chemotherapy would be necessary.
The enormity of the moment weighed on him as he prepped for
what would likely be his final operation. Chemotherapy, and the attendant
decline in bodily strength, would prohibit him from working as a surgeon.
He wanted this final procedure to go perfectly, and it did. He even sewed
up the patient with a nylon stitch, which is more difficult than using
staples.
Chemo began the next Monday. By Tuesday, Paul started to
feel all the effects he had read about and seen over the years working in a
hospital. Why should he be different? He experienced deep fatigue, constant
weariness, an inability to eat, the ever-present taste of salt in his
mouth, piercing nausea, and uncontrollable vomiting. Paul was so ill he
could not attend his own graduation. And Lucy was due in two short weeks.
The symptoms worsened and Paul had to be admitted to the
ICU. The diarrhea and vomiting worsened and his kidneys began to fail. It
was here in the ICU that Paul turned over complete control of his recovery
to his oncologist. He was willing to play the role of the patient now, no
longer second-guessing her suggestions.
After two weeks, Paul was finally released from the
hospital. He had lost more than forty pounds. His skin was paper thin and
any physical activity tired him immediately. A couple days after discharge,
Lucy's contractions began. Paul returned to the hospital in a wheelchair to
be with her. On July 4, at 2:11 a.m., Elizabeth Acadia (Cady) made her way
into the world. The nurse wrapped her in blankets and laid her in Paul's
arms.
A new energy entered the Kalanithi household that July, as
did an appreciation of the double-edged nature of time: as Paul's days grew
appreciably shorter, Cady's lengthened and grew fuller. Cady was all about
the future; Paul's end was imminent. He wondered if the beautiful baby girl
nestled in the crook of his arm would have any memory of him. His fondest
wish for her was that one day she’d realize that she brought joy beyond
measure to a dying man's final days.
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9. “ The life of
the dead is placed in the memory of the living.” - Cicero
Paul died on Monday, March 9, 2015, with his family at his
side. Besides caring for his wife, Lucy, and his newborn daughter, he
worked as much as possible on this book during his final months. While the
decline of his body was devastating, he did retain mental acuity up until
the last few weeks.
This book was his last project, a bridge to reach those who
were suffering from states similar to his, but also to relate what living
with death felt like. A surgeon, a scientist, a writer, a husband, a
father, a son, a brother, and, at the last, a terminal patient—he explains
how he views mortality from each of those perspectives.
In Lucy’s words, “I will tell Cady, when she is ready, that all
the wonderful things people said about her dad were really true. He was
that good and that brave.”
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Endnotes
These insights are
just an introduction. If you're ready to dive deeper, pick up a copy of When
Breath Becomes Air here. And since we get a commission on
every sale, your purchase will help keep this newsletter free.
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