When Breath Becomes Air - Book Summary

Discover the deep entanglement of life, death, and the unexpected.

Are our lives going exactly as we thought they would? It's doubtful, isn't it? Many of us might have dreamed of a certain career, only to find ourselves driven towards another, often by circumstances beyond our control. Or maybe a simple decision we made years ago has had a ripple effect, drastically changing our life's trajectory. You could even be a high school student right now, believing that your future is a straight path laid out ahead of you.

Let's face it, life is inherently complicated, filled with unpredictable twists and turns. And you'll find no better demonstration of this unpredictability than in the life of Paul Kalanithi.

Paul's tale is intensified by his unique standpoint as a neurosurgeon — an occupation where minor decisions or unexpected occurrences can literally mean the difference between life and death. His own life took such a turn when he was diagnosed with terminal cancer.

As you journey with us through Paul's life, you'll uncover:

How your deepest existential questions might find answers in neuroscience,

Why it's often hard to discern if a surgical operation has been a success or a failure, and

How immense power is invariably tied to immense responsibility.

Diving into the tale of a man drawn to both literature and neuroscience.

As a young boy, Paul Kalanithi, our author, found himself enamored with literary greats such as Orwell, Camus, Sartre, Poe, and Thoreau. This early passion naturally led him to study literature in college, but fate — or perhaps a compelling summer read — had other plans for him. Before his first semester at Stanford, Paul was introduced to the riveting field of human biology.

A gift from his then-girlfriend, the book "Satan: His Psychotherapy and Cure by the Unfortunate Dr. Kassler, J.S.P.S" by Jeremy Leven, sparked his fascination. The concept of the brain as an organic computer, the very engine of the human mind, intrigued him. Compelled by this new interest, he enrolled in courses on biology and neuroscience.

However, his love for literature never waned. Through both his favorite novels and his neuroscience courses, Paul sought answers to the heavy questions that weighed on his mind — "What breathes life into our existence? What imbues our lives with meaning?"

Paul saw literature as an expression of the mental sphere of life, a showcase of human significance. Influenced by writers like T.S. Eliot and his seminal work "The Waste Land", Paul linked a lack of meaning to isolation and believed that authentic meaning emerged from human connections.

Yet, he understood that literature could only offer a portion of the larger puzzle. His experience visiting a facility for patients with brain injuries further cemented his belief in the essential role of the brain in our ability to form relationships.

This belief drove him deeper into the realm of neuroscience. He sought to decipher the laws that govern the brain, seeing them as critical to understanding the broader concept of meaning. And so, he took the leap into medical school.

But, as he would soon learn, the true meanings of life and death couldn't be comprehended merely through scholarly pursuits — they had to be experienced first-hand.

Through medical school, Kalanithi experiences the profound realities of life, death, and meaning.

The grueling process of medical school applications eventually bore fruit for Kalanithi with an acceptance from the prestigious Yale School of Medicine. His immersion in practical medicine — particularly in the anatomy lab — brought him face to face with the raw truths of life and death.

Hours turned into days and weeks as he meticulously dissected cadavers, slicing through layers of skin and tissue, cutting into bone. Despite the veiled faces and the anonymity of the bodies, a sense of their inherent humanity deeply moved Kalanithi. A poignant moment occurred when he discovered undigested pills within a cadaver's stomach — a symbol of lingering life within death's cold embrace.

Life and death, however, weren't confined to the anatomy lab, for a medical student like Kalanithi bore witness to these mighty forces in gritty, palpable detail on a regular basis.

Take his experiences in the labor and delivery ward. His first encounter with childbirth transformed into a tragic encounter with death.

It was Kalanithi’s maiden day in the ward. He was informed about an expectant mother carrying twins who’d been rushed in due to premature labor. The pregnancy had barely crossed 23.5 weeks — a critical stage. The medical team strained against time to keep it viable.

Unfortunately, an emergency C-section was deemed necessary. Kalanithi stood witness to the surgery, watching the delicate, almost translucent babies being brought into the world. But their premature state kept their tiny organs from functioning adequately, and sadly, the infants passed away. The fleeting glimpse of life was replaced with the stark reality of death, a rather heart-wrenching image etched in Kalanithi's memory.

As a resident, Kalanithi grapples with grave responsibilities and confronting ever-present death.

In his fourth year of medical school, Kalanithi chose to delve into the demanding discipline of neurosurgery. It was a daunting decision, but the allure of the field was too compelling to resist. Consequently, upon graduation, he commenced his seven-year residency stint at Stanford, stepping onto a challenging path.

His baptism by fire into the world of real medical responsibility wasn't far off. One case stands out vividly — a young boy named Matthew suffering from severe headaches had been diagnosed with a substantial brain tumor. The massive onus of deciding the course of treatment fell upon Kalanithi.

The complete removal of the tumor held the promise of returning Matthew to his normal childhood, but it wasn’t without risks. The tumor's proximity to the hypothalamus — the brain's control center for vital drives like hunger and sleep — meant that even a microscopic surgical slip could have disasterous outcomes. After a painstakingly arduous decision-making process, Kalanithi decided to operate and successfully excised the tumor.

Kalanithi's first year of residency, however, wasn't just about successful surgeries and saved lives. Death was an omnipresent entity, looming large over the hospital corridors. He witnessed fatalities resulting from head injuries, gunshot wounds, violent altercations, and horrifying car accidents. One haunting memory was an alcoholic man dying as his blood lost the ability to clot, causing him to bleed to death.

Tragedy struck closer to home when a seasoned pathologist succumbed to pneumonia. The irony wasn't lost on anyone when her body was sent for autopsy to the very lab where she had devoted years of her life studying diseases.

Even as his first year drew to a close, there was no respite on the horizon. The future held five further years of grueling challenges and harrowing experiences.

Caught between rising responsibilities and draining exhaustion, Kalanithi grapples with the human dimension of his work.

Kalanithi's second year of residency bestowed upon him the mantle of the on-call doctor. In the event of a medical emergency, he was now the first port of call. While he had gained proficiency in his field, the immense responsibility entailed weighing the ethics of life and death decisions.

In one particularly distressing instance, a patient with severe brain trauma was rushed into surgery. The team was able to stabilize him, but the aftermath left the patient unable to speak or eat independently. The damaged brain tissue was beyond repair, and he faced a life rooted in institutional care. Despite the patient's steady heartbeat, Kalanithi grappled with the moral ambiguity of whether saving his life had been the right course of action.

Compounding his emotional turmoil was the constant physical drain stemming from incredibly long working hours. Like others in his field, he clocked in around one hundred hours weekly, driven by a relentless ambition. Chronic fatigue started seeping in, manifesting in persistent headaches. Nights ran on an unhealthy diet of energy drinks, with short naps in his car providing some respite before the commute home.

Beneath the crushing pressure, Kalanithi found himself compromising on the essential human aspect of his work. One incident served as a potent reminder — while counseling a woman newly diagnosed with brain cancer, he hurried through the discussion, unable to fully absorb the gravity of her situation.

Rather than acknowledging her fear and confusion, he preemptively and unempathetically recommended surgery. The incident provoked a twinge of guilt in him, causing him to reflect on his motivations for joining the medical field. It had always been about the unique human connections fostered in the crucible of suffering and healing. He realized he needed to honor these relationships with his patients, preserving the delicate threads that bind humanity together.

Shifting between the neuroscience lab and the hospital, Kalanithi tackles greater responsibility and considers moral obligations.

In his fourth year as a resident, Kalanithi ventured into a territory beyond his primary specialization. He spent time in a neuroscience lab at Stanford, starting his journey into becoming a neuroscientist — an expert focused on exploring the intricacies of the nervous system, including the complex structures and biochemical underpinnings of neurons and their networks.

Balancing the challenging roles of a neurosurgeon and neuroscientist was a badge of honor as much as it was a herculean task. Moreover, Kalanithi chose a path divergent from that of his peers. While his fellow neuroscientists delved into designing technologies to assist paralyzed individuals in operating computers or robotic limbs, Kalanithi was captivated by the concept of neuromodulation.

His research revolved around the ambitious idea of transmitting signals from robotic appendages back to the brain. Successful strides in this direction could revolutionize prosthetic design, making artificial limbs capable of providing sensory feedback to the brain. For instance, an amputee navigating uneven ground could adapt their movement pattern based on information sent from the artificial foot.

However, the allure of the lab couldn't keep him from his fundamental calling. After nearly two years, Kalanithi returned to the hospital, stepping into the shoes of a chief resident.

This new position laid greater responsibilities upon his shoulders. Now, as a top-tier neurosurgeon, he was expected to exemplify skillful precision and proficiency.

It was during this stretch of his career that he became acutely aware of the moral obligation he carried, the indispensability of technical excellence. With patients’ lives hanging in the balance, intentions alone wouldn't suffice — skill was indispensable.

This reality hit home when he received the news that Matthew, the young boy who had survived the brain tumor operation years ago, was deteriorating rapidly. His behavior becoming violent and erratic, culminating in the necessity for permanent institutionalized care. The painful revelation sank in — during the removal of the tumor, Kalanithi had inadvertently inflicted damage to a part of Matthew's brain.

As his residency nears completion, Kalanithi encounters an alarming personal revelation.

Kalanithi's journey was marked by both triumphs and tribulations. Navigating a pressure-cooker environment, he leveraged his grit and determination to excel. Now, the finish line of his residency was within sight. Despite the grueling challenges and demanding operations, he had come out victorious. His accolades included esteemed awards and the respect of the senior doctors he worked alongside.

Stanford further recognized his unique talents and capabilities, carving out a custom role just for him. They envisioned him as a neurosurgeon-neuroscientist primarily working on neuromodulation.

However, fate was ready to deliver an unnerving detour. With merely 15 months left in his residency, Kalanithi was confronted with a personal health crisis. Over the past six months, he had been rapidly losing weight and experiencing severe back pain — a physical discomfort foreign to him. His doctor’s visit resulted in a series of X-rays and a rather dismissive diagnosis of overexertion from work.

Despite harboring doubts about the cursory examination, Kalanithi returned to his hospital duties, driven by an unwavering determination to complete his residency.

The respite was short-lived, and pain flared up again, originating from his chest this time. The continuous weight loss had dwindled him down to a meager 145 pounds, accompanied by a relentless cough. These symptoms rang the alarm bells in Kalanithi's mind, hinting at the possibility of cancer.

Ultimately, a follow-up examination of his chest scan revealed worrying blurriness. Kalanithi instantly decoded the sinister implications — his lungs were riddled with tumors. The image of his deformed spine and liver were stark testimonials to the cancer's relentless invasion across his body. His case was inevitably terminal.

In the face of terminal illness, Kalanithi explores life as a patient and the prospect of starting a family.

What path would you choose when faced with the knowledge that your stint on this earth will be prematurely curtailed?

This distressing dilemma hounded Kalanithi throughout his treatment. Not knowing how much time he had left caused him great uncertainty, creating a nebulous cloud of confusion over how to steer his life and career. Engaging in introspective conversations with his empathetic doctor, Emma, he reflected on how he would choose to spend his remaining time.

His choices hung in the balance between two extreme possibilities — if a span of decades lay ahead, he would invest his energies into neurosurgery. However, if he had just a year or two left, he would gravitate towards literature and writing, passions that still held a profound place in his heart. Guiding him through this mental fog, Emma advised him to anchor his decisions on what truly mattered to him.

His predicament was further complicated by his dual identity — a doctor morphed into a patient. His academic instincts drew him towards medical textbooks, seeking technical solutions, while his philosophical self sought succor in the wisdom buried in literature.

Running parallel to his professional quandary was a deeply personal dilemma — the question of fatherhood. Throughout his ordeal, his wife Lucy remained unwaveringly supportive. With time playing truant, they mulled over whether they should embark on the journey of parenthood.

Following his diagnosis, Kalanithi and Lucy reached out to a sperm bank to explore the safest, healthiest options. Although they had always envisioned becoming parents, the shadow of uncertainty over Kalanithi's lifespan made the decision arduously challenging.

Eventually, they tilted towards the vibrancy of life. To hedge against potential medication complications, they decided to freeze his sperm before starting the treatment. The subsequent insemination process was successful, and Lucy was gracefully wrapped around the nurturing warmth of pregnancy.

In the pallor of his dwindling health, Kalanithi embraces fatherhood and bids the world goodbye shortly after.

July 4, 2014, marked the arrival of a ray of hope in Kalanithi's life — the birth of his daughter, Elizabeth Acadia, lovingly known as Cady. Although fragile and beleaguered by his deteriorating health, Kalanithi was blessed with the opportunity to welcome his newborn into the world.

Lucy's labor found Kalanithi in a feeble state, barely holding on after multiple hospital rounds. Despite a fleeting phase of convalescence, his emaciated body lay prone on a cot in the delivery room — unable to stand, let alone support his laboring wife.

Emerging from the hospital, he returned home with his family. His vigor sapped and body frail, he grappled with the inability to perform rudimentary tasks such as sitting, reading, and drinking.

Come Christmas, five months post-Cady's birth, Kalanithi's condition plummeted rapidly. The relentless cancer had begun to defy the prescribed treatment, rendering the drugs and chemotherapy futile. The subsequent months saw an inevitable descent into debilitating weakness. Yet, amidst the enveloping gloom, his family found solace in simple life pleasures — hosting dinners with friends and cherishing baby Cady's playful antics.

By February, his health had reached a critical point — he was constantly fatigued, ridden with nausea, and had lost the will to eat.

The grim verdict from the hospital scans elucidated the extent of his disease. Not only had the cancer stridently colonized his lungs, but brain tumors had also made their ominous appearance. Given time, these brain invaders threatened to rob him of his cognitive faculties, his powers of rationality, and his quest for life's meaning.

Post Kalanithi's demise, his wife Lucy reminisces their shared journey with a blend of grief and gratitude.

Eight months into Cady's life, Kalanithi was raced to the emergency room, gasping for breath. This incident marked the onset of his final battle.

Hospitalized and succumbing to the grip of his disease, Kalanithi needed artificial breathing support. He realized that this was merely stalling the inevitable. After examining the potential treatment strategies, he requested to be relieved of life support. He was acutely aware that if he chose the ventilator, he may never be able to abandon its assistance. As the essence of his dwindling time ebbed away, he no longer saw the merit in mechanically sustaining his heartbeat.

Within a few hours, and surrounded by his family, he was eased off breathing support and administered morphine to alleviate his throbbing pain.

One by one, loved ones trickled in to express their heartfelt affection and offer their final respects. Soon after, Kalanithi surrendered to silence, his breathing reduced to erratic gasps. His earthly journey concluded at 9 p.m. on March 9, 2015 — he passed away at the tender age of 37.

While Kalanithi's untimely demise left Lucy grappling with waves of sorrow and despair, she chose to look back on their shared memories with love and value.

As they navigated the lead-up to his death, their bond fortified, echoing the intensity of their early days when their paths first intertwined as students.

Their families intertwined too, offering Kalanithi's unit of three unwavering support. Kalanithi's parents and siblings would visit the hospital, sharing light-hearted conversations about football, reading books aloud, and enjoying his mother's homemade Indian dosa.

Lucy sought solace in a mission — the publication of her husband's unfinished manuscript. Despite his deteriorating health, Kalanithi strived to pen down his manuscript as long as possible. While not completed in the intended sense, it outlined his candid confrontation with approaching mortality.

Lucy couldn't help but believe that through his book, Kalanithi had achieved his aspiration. He had managed to foster an understanding of impermanent life and the inevitability of death. More importantly, he demonstrated how one can lead a meaningful, dignified life, even when faced with the imminent certainty of death.

A closing contemplation

At the crux of the narrative:

Paul Kalanithi, a lover of literature and a neurosurgeon, led a life intricately entwined with the complexities of existence, the finality of death, and the pursuit of significance in both. His story unfurls as a riveting chronicle of human fragility, an inevitable dance with mortality, and the relentless quest for meaningfulness within this finite trajectory.