Review: When Breath Becomes Air

When Breath Becomes Air, Paul Kalanithi. New York: Random House, 2016.

Summary: The memoir of Paul Kalanithi, a neurosurgery resident who becomes a patient when receiving a diagnosis of state IV metastatic lung cancer, the ways he and his wife respond at various stages, the care he receives, and his reflections on his illness and impending death.

You are a talented neurosurgery chief resident with a focus on research with brilliant job prospects ahead. It’s been a long journey from Kingman, Arizona, that began with avoiding embracing his father’s profession of medicine. Studies in both English literature and biology confront you with varying answers about the meaningful life, and avenues to pursue such a life. In the end, you come back, not only to medicine but neurosurgery, as you recognize how inextricably human consciousness, one’s “soul” is connected to the structures and functions of the brain. You subject yourself to the rigors of long days, developing precision in the surgical skills critical to his sense of calling. You are close to completion…and then. There is the persistent cough. The fatigue. The weight loss. The back pain growing more acute. Your mind goes to cancer but earlier X-rays didn’t reveal anything. Maybe it’s just the strain of the work. Until a visit to friends reveals how much you are in pain and fatigue. And you voice your fears.

The prologue of the book opens with Paul Kalanithi and his wife Lucy, also a resident, looking at CT scans of tumors in lungs, spine, and liver. From a hospital bed. As a patient. Preparing to meet his doctor. The narrative breaks off here to recap the journey that brought Paul to this residency, the advance of his skills, his hopes, and the strains on his marriage, much outlined “above. He recounts learning to treat his patients as people. One way he articulates this is when he says, “Before operating on a patient’s brain, I realized, I must first understand his mind: his identity, his values, what makes his life worth living, and what devastation makes it reasonable to let that life end.”

Now as patient, his own doctor, Emma Howard, asks him the same questions. It is not only the character of his cancer, but his own character, that will shape his course of treatment, and, just as no two cancers are alike, so there are no two people who can answer these questions in quite the same way. Does he want to try to return to work? Or step away? What does he value. He could live six months, two years, or even ten years. His physician refuses to say, focusing on next steps and what Paul values. He wrestles with how one makes decisions about such things. At first he thought this was the end of it all. And then a drug, Tarceva, shrank his tumors and he regained strength–enough to return to surgery and finish his residency. Do he and Lucy have a child using the sperm they had banked before he began treatment?

Kalanithi takes us through the journey so many cancer patients with metastatic cancer go through. The promising results from a drug…until it stops working. The rigors of chemo, temporarily stopping tumor growth, but nearly killing. The decisions of how long to go on, and how to spend the time that remains. A significant moment is when he relinquishes being the consulting physician and relinquishes his care to Dr. Howard. Paul chooses to write this memoir, and spend time with Lucy and his baby daughter and family…until the cancer takes him. His last words? “I’m ready.”

All but the epilogue was written by Paul. He had helped patients face death. Now he had to figure out how to do that himself–to face death with integrity. He turned to the literature he loved, references to which run through the work. This is such a good and important book. One not to wait to read until facing a diagnosis like Paul’s. We already know we will die–even if we are in denial. What was important was for him to answer the questions of meaning and value that would enable him to make most of the time remaining–whatever the length of that time. And so it is for all of us.