When Breath Becomes Air

Paul Kalanithi's memoir, When Breath Becomes Air, is essential and is a thought-provoking read for even the most seasoned palliative care clinician. It has been and will be widely read: your patients, spouses, friends, students, and book groups across the country are reading it, as are those working in palliative care. Along with a select few other essential and stirring texts, this book has instantly joined the palliative care canon. Those working with people with serious illness will value Kalanithi's memoir for the way it speaks to our multiple roles as clinicians, family members, and, ultimately, as patients ourselves. The book follows on the heels of Gawande's Being Mortal, which introduced palliative care concepts into the coffee shop and book club lexicon. Kalanithi's preamble to the book was his essay, published in the New York Times about a year before his death, titled “How Long Have I Got Left?”—a wrenching account of living with an uncertain prognosis. It mesmerized readers and brought Paul's personhood into our collective awareness as an introspective physician and person: He writes, “Faced with mortality, scientific knowledge can provide only an ounce of certainty: Yes, you will die. But one wants a full pound of certainty, and that is not on offer.”

Kalanithi possessed rare and exceptional qualities that blended medical expertise, literary sophistication, and heightened self-awareness into this small, but weighty book. His grand mastery of words led Abraham Verghese, in the book's foreword, to describe Kalanithi's writing this way: “out of his pen he was spinning gold.” Reviews of the book are consistently effusive: The Washington Post calls it “an emotional investment well worth making … despite its grim undertone, accidentally inspiring.” The New York Times calls it “unmissable… I guarantee that finishing this book and then forgetting about it is simply not an option.” Kalanithi is likened to other physician writers whose texts have brought to light the complexities and humanity of medicine: William Carlos Williams, Richard Seltzer, Oliver Sacks, Jerome Groopman, and Abraham Verghese. These writers and others have woven together in their essays, memoirs, or fiction their dual roles as people of medicine and as patients. They have written eloquently, compassionately, and honestly about human nature, mortality, and its intersection with medicine.

When one reads through both professional and lay reviews of the book as well as interviews with Kalanithi before his death, a motif emerges that strikes particularly close to the heart of the palliative care clinician. The reader's visceral response tracks with his disease, his arc of acceptance, and his proximity to death. Kalanithi calls the first part “Prologue,” and in it he describes his situation: a driven and talented neurosurgeon faces a catastrophic diagnosis and impending death. One's eyes and heart are calm when reading this part. Next: “In Perfect Health I Begin,” the pace of the book slows as Kalanithi describes his childhood, family of origin, and roots of his career path. One imagines that while penning this section, he may not have felt the press of his disease as strongly. The reader feels the relaxed pace through his developed descriptions of the Arizona desert and his meanderings within the halls of possible educational and career pathways.

Later, though, as the end of the book approaches, the reader too becomes enveloped in the sense of time accelerating. Like one nearing the final pages of Anne Frank's diary, the reader of Kalanithi's book cannot escape the sense of foreboding that comes with knowing how his story ends. Even the prescient Kalanithi himself muses about what verb tense to use as death nears: “What tense was I living in? Had I proceeded, like a burned-out Greene character, beyond the present tense and into the past perfect? The future tense seemed vacant and, on others’ lips, jarring.” Kalanithi's bond with his infant daughter Cady further complicates his relationship with the passage of time. The clichéd baby that “grows up so fast” is a two-edged blade for Kalanithi. In his words: “the faster Cady grows up, the faster I'm not there.” As we care for our patients, they are grappling with these same experiences: processing a new prognosis, reflecting on treatments failed or successful, recalibrating perceptions of identity and life milestones. Our patients, like Kalanithi, must forge new meanings of their lives within a collapsed or temporarily expanded time frame. Kalanithi's extraordinary self-awareness gives us a glimpse inside of this experience, which is part of the gift that this book offers.

With the clarity of hindsight, Kalanithi describes the dance of power between him and his beloved oncologist, who fills a decidedly challenging role as physician to surgeon-turned-patient. When they first meet, he challenges her to discuss survival statistics, which she skillfully sidesteps. In these moments, he brings his reader to the cusp of his transition from physician to patient. His indignant response to his denied request for Kaplan–Meier data: “How dare she? … I have a right to know.” Later, when she suggests making treatment decisions based on his singular priorities, including returning to the operating room, Kalanithi asks, “Was she delusional?” However, he soon begins to appreciate her both as a person and a skilled oncologist. When he later does return to the operating room, the anticipatory guidance she gave him rings with resonance.

Then, with jarring suddenness, the narrative ends. Paul's wife, Lucy, writes the epilogue, picking up where he leaves off. Her perspective and words continue the spirit of Paul's honest descriptions of his last weeks and days. When waiting for a summoned ambulance, his whispers are shared with the reader: “This might be how it ends.” She affirms her self-identified role as companion to him: “I'm here with you.” She bears witness to Paul's journey in his life, his diagnosis, his dying process, and his legacy. Paul's journey is undeniably his own, but it is marked by periods of connection and his concern for his family's long-term needs. Lucy's admiration is bared: “Paul's decision not to divert his eyes from death epitomizes a fortitude we don't celebrate enough in our death-avoidant culture.”

Why should we, palliative care professionals, spend our precious and scant free time reading this memoir? Because it blends so marvelously a breadth of literary, medical, philosophical, and cultural angles on the issues in which we are steeped. The book calls us to acknowledge the reality that at some time we, like Paul, will all become patients. Kalanithi's words tell the naked truth: that we are all mortal, vulnerable, and impermanent. The book is like a delectable meal that warrants savoring but is hard not to consume voraciously. When Breath Becomes Air is small and gem-like, imbued with moments of inspiration, humor, honesty, and unexpurgated details. Experiencing his life and reflections on how time expands and contracts with a catastrophic diagnosis may help us, his brethren in palliative care, develop a more empathic way to offer our patients what they need from us. The final role modeling comes in the book's concluding words, where Kalanithi explains that his young daughter and his impending death have brought him a “sated…joy that does not hunger for more and more, but rests, satisfied.”