When Breath Becomes Air: Pulitzer Prize Finalist

This brief memoir is interposed between a foreword by Abraham Verghese, the brilliant author of “Cutting for Stone” and an epilogue by author’s wife, Lucy Kalanithi. It is a beautifully, heartrending, deeply philosophical piece by an accomplished young man who dedicated heart and mind to his work and study in neurosurgery. He discovers that he has terminal lung cancer at the age of 36, just before completing his grueling neurosurgical residency and embarking on the career he has worked so hard to attain. The book is very thoughtful and reflective in nature, especially upon the meaning of life. It made me wonder if the author was truly always so interested in finding the meaning of life, or if only when told of this terminal diagnosis, that reflection back on his life made this search so apparent. As one nears death, what is most important, becomes glaringly more obvious, and Paul Kalanithi describes this so well. Abraham Verghese speaks in the foreword of how he had met Paul in person several times before his death, but it was not until he read his book that he felt he really knew him. I too, felt like I got to know Paul through this book. He is very open and honest about himself, his sickness, his relationships, and struggles and triumphs throughout the process of dealing with cancer. I find it interesting that Paul did not always think he wanted to be a physician, but rather thought he might be a writer. He may not have realized his full potential as neurosurgeon and professor, but he surely achieved his goal to be a writer. He has left behind a beautiful book that will be read for many years to come. It will be of great interest to those with life-threatening disease, their family members, and really everyone, because we will all be in those shoes at some point. He has also left behind a wonderful gift of himself to his daughter. She will not remember her time with him, but she will be able to know him through this book and well as through the memories that I’m sure his close relations will share with her. Aside from writing and even delving back into neurosurgery residency at one point, he spent the last years of his life following his diagnosis, building closer bonds with his family, and the love there was overflowing. Aside from being an important read for anyone facing a life-threatening illness themselves or loving someone who is, I think it is a very important read for all medical professionals. It puts a face behind a patient, who is clearly able to articulate the thoughts and feelings of being a patient in our medical system. It emphasizes and highlights the importance of the physician-patient relationship. I gave this book 5 stars for it’s thought provoking, beautiful prose, as well as for writing it’s way through a death with utmost dignity. He strengthens his belief systems, forges stronger relationships with family and loved ones, and finds greater meaning in life once he is given this terminal diagnosis. For discussion questions, please visit book-chatter.com

4.5 stars At age 36, in the last year of his neurosurgery residency, Paul Kalanithi discovered he had stage IV lung cancer. For the next 22 months, he and his wife Lucy, an internal medicine physician, awoke each day focused on living, not “living until...” When Breath Becomes Air was written largely because Dr. Kalanithi had the soul of a poet and turning to words to express any experience in life was as instinctive to him as breathing itself. His intent was that his story could aid in the healing of others and that one day his own daughter would read it and get a sense of the father she would never remember. The book’s format, like the author’s writing style, is simple, straightforward, eloquent, and unflinchingly honest – Prologue, Part I and Part II. In the prologue, Paul describes the first step in his diagnosis, getting x-rays for his recurring severe chest pain. It was 15 months prior to the end of his residency. He could see the light at the end of the long 10-year tunnel of preparation for his work in neurosurgery. There would be wonderful opportunities to practice as well as conduct research, offer of a professorship, a huge increase in income, a new home and starting a family with Lucy. The x-rays were fine, he was told. But he had lost weight and the pain was not letting up in severity. He began researching incidence of cancer in his age group. Things with Lucy were strained at that time, partly because he was not sharing his concerns about his condition. She decided against going with him on a vacation with old friends in order to sort out her own feelings about their relationship. He came home in severe pain after just a couple of days. She picked him up from the airport. After he told her about his symptoms and his self-diagnosis, she took him to the hospital that night where a neurosurgeon friend admitted him. Most of Part 1, In Perfect Health I Begin, describes life prior to the diagnosis, obviously back to his childhood. Both of his parents were immigrants from India, his father a Christian and his mother Hindu. Both families disowned them for many years. They moved their own family of three sons from Bronxville, New York to Kingman so Paul’s father could establish a cardiology practice, which he did very successfully. Paul’s mother had been trained as a physiologist in India before eloping with Paul’s father when she was 23. Her own father had defied the traditions of 1960s rural India and insisted that his daughter be educated and trained for a profession. She was horrified to discover that Kingman’s school district was among the lowest performing in the entire country. Her eldest son had been educated in Westchester County, New York schools, where graduates were assured of admission to the nation’s most prestigious universities. He had been accepted at Stanford before the move to Kingman. What would happen to 10-year-old Paul and his 6-year-old brother Jeevan? Instead of wringing her hands, Mrs. Kalanithi threw herself into supplementing her sons’ educations and improving that of all the children in the area. She gave Paul a reading list intended for college prep students and at age ten he read 1984, followed by many other modern and traditional classics. He discovered a love for words as an expression of the human spirit. His mom got elected to the school board and worked with teachers and others to transform the school district. After a few years their 30+% dropout rate was greatly reduced and graduates were getting accepted at universities of their choice. No doubt Paul was born with that poetic soul, but it was his mother’s guidance that led him to read the literary giants who nourished that soul. It was his parents’ examples of excellence in their own lives, their faith, and service to their community, in this strange land that they made their own, that formed Paul’s desire and need to serve. In When Breath Becomes Air, he writes of vocation, a term you rarely hear people use these days. A thousand years ago when I was growing up, vocation was ubiquitous. We were told time and again that discerning our vocation was one of our prime responsibilities as human beings. It was our reason for being here, what we were called to do in service to humankind. Teaching, medicine, religious ministry, musicianship, military, etc. By knowing our natural talents we could know our vocation. Paul had many talents and interests, complicating his vocation decision. He studied both English literature and human biology in college. “I still felt literature provided the best account of the life of the mind, while neuroscience laid down the most elegant rules of the brain.” Also a man of deep spirituality, Paul reflected, “Literature not only illuminated another’s experience, it provided, I believed, the richest material for moral reflection. My brief forays into the formal ethics of analytic philosophy felt dry as a bone, missing the messiness and weight of real human life.” The intersection of science and morality was of prime interest to Paul. The rest of Part I describes how Paul came to see medicine and then neurosurgery as his vocation. He forthrightly deals with the idealism of medical students and residents and how that idealism is dimmed or completely snuffed out by the realities of giving medical care to other human beings. His explanation of cadaver dissection and why physicians and their families do not donate their own bodies to medical science is eye opening. “Cadaver dissection epitomizes, for many, the transformation of the somber, respectful student into the callous, arrogant doctor.” This is the kind of honesty displayed throughout the entire book. He writes of his own loss of idealism and how the recognition of that affected his own self-image as well as his job performance. “I wondered if, in my brief time as a physician, I had made more moral slides than strides.” That earlier mentioned phrase, “the messiness and weight of real human life” describes this book. The author has given the world not a mere recollection of events or achievements, but has laid bare his soul, exposing the very marrow of his being. This book should be read by every premed student in the world before they commit to a decade or more of study and relentless hard work. In Part II , Cease Not till Death, the author details the diagnosis, the immediate aftermath, the determination to emphasize living not dying, the quest to conceive a child, and the agony involved in treatment. I think Part II should be experienced by each reader. Most readers will find it extremely compelling and very personal. It is the nitty gritty of this man’s inner being. Lucy, his wife, wrote an eloquent epilogue further detailing Paul’s experience while writing this book, the support they received from colleagues, friends, family, and others after his death on March 9, 2015. I found this book soul wrenching, but also witty, uplifting and hopeful. Without preaching, he reveals some deep flaws in the way we do health care and the price that not just patients but the care providers sometimes pay. In our war with cancer, it won a battle here by taking this remarkable man so early. He would have touched hundreds of students and thousands of patients with the professorship that would have been his. But When Breath Becomes Air is sure to touch millions of us. Cady Kalanithi will one day be able to read for herself just who her father really was. Rating: 4.50/5.0.

If I had the ability to clone myself and travel in time to the future, sending useful notes to myself in the present, the message I would send myself about this book would be: "Read Part I and, time permitting, the epilogue. Skip the rest." I say this only after considerable thought, reluctant to imply any disrespect to the author. Dr. Kalanithi was clearly not only very a gifted and intelligent individual but also an exceedingly decent human being. His premature and tragic death represents not only a loss at a personal level but a tremendous loss for the medical and scientific community, in view of all the good that he would certainly have been able to accomplish for humanity. At the same time, I think that Dr. Kalanithi himself would not want anyone to give him a pass on his literary endeavor, on the basis of empathy for his personal situation. The author is at his best in Part I, which offers readers an intimate, inside look into the world of a practicing neurosurgeon. Those not familiar with this world will find Dr. Kalanithi's account both fascinating and enlightening, in its authenticity and honesty. Part II (about half the book) chronicles the development of the author’s illness. The story tugs at the heartstrings and is certainly dramatic in the most visceral sense of the word. Here the author struggles to impart any clear message, however, often getting bogged down in cumbersome literary analogies and lengthy quotations from a variety of poets, philosophers and other writers throughout the ages. As the author acknowledges toward the end of Part II, "I've been reading science and literature trying to find the right perspective but I haven't found it." In my own careful reading of the book, the closest I could find to any clear message is the author's assertion that "each of us can see only a part of the picture," with the truth to be found "somewhere above" all the different interpretations. He also mentions having "returned to the central values of Christianity" and "the main message of Jesus … that mercy trumps justice every time." These are entirely legitimate and worthy thoughts but is it worth wading through a hundred pages for them? I suspect that a good editor at a top publisher like Random House would have sent such a manuscript back to the author for extensive revision, IF he were alive. But this book of course was published posthumously. The author did not have the luxury of the time he would have needed to make this book truly top-notch. In the context of his pain and suffering, it is admirable that he managed to write what he did. In her moving epilogue, the author's wife, Lucy, writes that her late husband "wanted to help people understand death and face their mortality." Certainly this book serves to remind us of our mortality and, in so doing, of the importance of making informed decisions about how to live our lives. In this sense, it can certainly be considered a success. Daniel K. Berman, Ph.D., Amazon author The Newest Story of O: How to Legally Pay 0% Interest on the Money You Owe & Eliminate Your Debt in a Fraction of the Time—Secrets to Making the Credit System Work in Your Favor

Reflections on “When Breath Becomes air” by Paul Kalanthini By Bob Steele December 25, 2016 I have read many books in my lifetime, likely several thousand, but this is one of the rare ones. It is a profound, beautifully written book that reached out and touched me on many levels. It triggered deep reflection about health and disease, living and dying, wisdom and folly. This is a sad story, a memoir written by a brilliant, young neurosurgeon who loses his fight with lung cancer. And yet I am so glad I read it and hope that my family and friends will do so. Paul Kalanithi deals with death, looking at its many facets, but never in a morbid or clinical way. Paul spent a third of his life in his quest to become a neurosurgeon. The book reflects some of the many lessons learned in that journey. It includes a helpful treatise on doctor-patient relationships that should be required reading for doctors, nurses, and caretakers for people who face terminal cancer/illness diagnosis. There are literally dozens of quotations that I want to share from this remarkable journey of self-growth as he transitioned from doctor to patient. However, I am resigned to citing these few. * * * * * I began to realize that coming in such close contact with my own mortality had changed both nothing and everything. I had started in this career, in part, to pursue death: to grasp it, uncloak it, and see it eye-to-eye, unblinking. Neurosurgery attracted me as much for its intertwining of brain and consciousness as for its intertwining of life and death. Amid the tragedies and failures, I feared I was losing sight of the singular importance of human relationships, not between patients and their families but between doctor and patient. Technical excellence was not enough…. When there's no place for the scalpel, words are the surgeon's only tool. In those moments, I acted not, as I most often did, as death's enemy, but as its ambassador. A tureen of tragedy was best allotted by the spoonful. How little do doctors understand the hells through which we put patients. You can't ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving. Doctors, it turns out, need hope, too. And finally for his infant daughter, Cady: When you come to one of the many moments in life where you must give an account for yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more but rests, satisfied. In this time, right now, that is an enormous thing. * * * * * More poignant words, I have yet to read. A sense of sadness fell over me as I reread the book to collect my thoughts and considered how many more lives he could have saved, how many more he could have touched with his new-found sense of empathy and wisdom. But then I realized that through this book he can reach out and touch the lives of so many more than he could have done as one of the best doctors. He has yet much to share and teach. Thank you, Paul.

We live in a society that esteems the young, beautiful and vibrant above all things. We live in a society that thinks it is invincible and that we will live forever. Doctors are Gods who bring us miracles every day and the advances that they lead are truly astounding. We turn away from death embarrassed, scared, and nervous. When the doctors fail us we sue them. We want them to do everything they can to save us without any examination of what that means. This book is so beautiful and profound because Paul Kalanithi and his wife Lucy stand tall in the face of illness and death and just talk about it. This book is refreshing for its honesty and especially for Paul's refusal to give in to platitudes like, "We are going to beat it!" "We will win!" I understand why people choose that approach, but I think Paul's book and the way he lived his life after his diagnosis shows what a disservice that can be to living the life you have been handed. This is best exemplified in the exchange between Lucy and Paul about whether or not to have a child: ""Will having a newborn distract from the time we have together?" she asked. "Don't you think saying goodbye to your child will make your death more painful?" "Wouldn't it be great if it did?" I said. Lucy and I both felt that life wasn't about avoiding suffering." That's not to say that Paul did not fight his cancer. He did. He desperately wanted to live. But as he said "...I would have to learn to live in a different way, seeing death as an imposing itinerant visitor, but knowing that even if I'm dying, until I actually die, I am still living." I also liked this book for the lessons that physicians can learn from how they talk about treatment and death. I have been blessed to have dealt with some fantastic health care providers in recent years. The doctors and nurses who cared for my father when he was dying last year were fantastic, especially his oncologist. But there were some doctors and nurses who still seemed to side-step the conversation. I know they do not want to be wrong and that there is always hope, but there were so many euphemisms. Instead of telling us that he was in fact dying, there was a lot of talk about labs, and phrases like, "He is a very sick man." When I pressed they agreed wholeheartedly that my brother should come now. But no one said "death." No one said "dying." Paul's desire to understand human relationality and death lead him to medicine. He is honest that he was seeking a kind of transcendence there. But he comes to learn that, "As a resident, my highest ideal was not saving lives - everyone dies eventually - but guiding a patient or family to an understanding of death or illness." And that, "Openness to human relationality does not mean revealing grand truths from the apse; it means meeting patients where they are, in the narthex or nave, and bringing them as far as you can." I could share quote after quote here, but that understanding and transcendence is the meat of this book. Go read it! This book was sad because Paul was so talented and he left behind so much. He was a brilliant and thoughtful doctor. He was also an incredible writer. As I read his book, I was fascinated by his time as a neurosurgeon, but I was equally sad that he would not be writing any more. I wished he had chosen a writing career so that we would have more of his words to read. A writer that can use the word "pluperfect" so well to make his point and to capture his struggle with tense is wonderful. This is another example of his talent: "At moments, the weight of it became palpable. It was in the air, the stress and misery. Normally, you breathed it in, without noticing it. But some days, like a humid muggy day, it had a suffocating weight of its own. Some days, this is how it felt when I was in the hospital: trapped in an endless jungle summer, wet with sweat, the rain of tears of the families of the dying pouring down." The book was also sad because it was so clearly not finished. It felt like the solid beginning of a book and as I neared the end I was a little let down. But Lucy Kalanithi's Epilogue saved it for me. Lucy is a talented writer in her own right. Lucy's Epilogue gave the book the balance and the ending that it needed. Lucy writes, "Although these last few years have been wrenching and difficult - sometimes almost impossible - they have also been the most beautiful and profound of my life, requiring the daily act of holding life and death, joy and pain in balance and exploring new depths of gratitude and love." Lucy signs off her epilogue, "I was his wife and a witness." I loved this book for allowing me to witness Paul's journey. I was honoured to witness his death from afar. I hope this book reminds us all what an honour it is to witness life, and death in particular, and to embrace that more.

An absolutely amazing book to read. I initially didn't want to read this book because I knew it would be sad. But then my dad was diagnosed with cancer and he would pass ten days later. The suddenness of it along with the hard reality of everything made me decide it was time to finally read this book, and I'm glad I did. The author's perspective on life and death is very refreshing and amazing to read. Dr Kalanithi was truly an inspiration that can revive some hope in humanity. I thought I would be sad for him, but I was more sad for everyone who lost him. He never talks about himself as being this or that, but just reading his words tell you so much about him and how he looked at life and death. The writing is very poetic, and visual. I would recommend this book to anyone and everyone and I'm thankful the Paul Kalanithi shared his story with us.

The book is very well written. Beautiful writing style. Important information for everyone. Touching and gripping. Excellent narration. I strongly recommend the book for everyone. I recommend the Audible version of the book highly.

The best book I have every read. Written in almost a poetic manner. Sad story told in a magnificent way. Will probably read it again. Perfect title for the book.

A really good read.

Um livro que traz lágrimas nos olhos… sensível e verdadeiro. Impossível não se emocionar e nos fazer pensar na finitude da vida.

5\5 Not a fraction less. As I finished this book tears rolled down both my cheeks. Breathing was hard for the last 40 pages, as I struggle to choke back the conflicting emotions I felt in reading Paul's last words and those his wife Lucy would conclude with. On the one hand I felt heartbroken with sorrow for the fate of this man who would strive so hard to help others live or to ease the agony of those who would die. Yet this book was as heart wrenching as it was beautiful. It was as uplifting as it was sad. This book deeply touched me on an emotional and what some would call a spiritual level. While I am not spiritual, I cannot deny the spirit of this man, who lived, loved, triumphed and accepted his fate with courage and strength, even as cancer weakened him physiologically. Paul died very near my own age. I struggle to find meaning in life, especially as I see others die around me every year. I also grapple with my own impending end which could come any moment, future or present. I began to question everything as I've aged. I fear perhaps I have made the wrong choices in life. I question what it is all for. Being an atheist is a blessing and a curse, for it gives life at times a hollow definition. We live to die. Most of us spend the majority of our lives dying, or declining until our last day. This does not have to be a sad thing though. This book has revealed to me that there is another way in which to die. That is, to live... until death. From the bottom of my heart I am thankful to Paul, for this book, and to Lucy for her epilogue, for her kind words which will touch my own spirit, my core being, until the end. It will forever remind me that our fate may not always be what we want it to be but our lives are what we will make of them. We will all die, some sooner, some later. This is a fact. While we live to die this does not mean we cannot also live to live, to live life appreciatively. While I do not share the expansive and loving family Paul did and while I feel at times vastly alone in this world, I have learned the deep lessons of this book. I have no one to truly comfort me in my sorrows as I grind through life. This book, these words, are my comfort. Alone we embrace, this philosophy and I. I am not dying such as Paul was. I am merely dying as life would naturally have it, as we all are, until something decides to speed this natural process up, like a cancer or some other malignance. I merely suffer the physiological strife that comes with working on a farm in rural Nova Scotia. I toil so others may not. Someone must till the soil, grow the food, harvest from life to give life. Though I often feel I should be doing more. My English degree hangs on a wall, a banner of achievement, yet a reminder of failure. I relate to Paul in that, like him, I want to help others. After all, there is no better feeling than having consoled or counselled another. I have often had the dream of using words to ease the pain of suffering. Paul has awakened me to the fallacy of how I see that piece of paper in the negative. Perhaps I will do no more than I have. Some do nothing. Some live and die, forgotten to the winds of time. The important thing is to understand that life is a treasure. It is a thing to be cherished, this consciousness, this awareness, our ability to think and see and question and comprehend. To compel or be compelled is to live. Whether alone or in the company of loved ones, we should hold dear this thing we call life. Find your happiness where you can. Be it within the pages of a book such as this or in the company of others, seek it and embrace it, for a life lived happily is to truly live. Whether short or long, alone or otherwise, we need not despair the eventuality of our end. Smile, my fellows, for were we not alive, we would not know what it is to live. Thank you Paul. Thank you Lucy. You have both, in death, and life, warmed my heart beyond what other words have elsewhere been able.

If one could caress or lovingly stroke the surface of another's heart then this is the writing in this book. Pain and pleasure live side by side with honor and simplicity. A moving account of a great soul which can in its truth pull the air from your lungs.

Not the easiest read but very well worth it. Makes you think about the meaning of life