When Breath Becomes Air

by Paul Kalanithi

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Part 2, Section 1 Summary

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Part 2 (titled “Cease Not till Death”) opens with Paul and Lucy in a hospital bed together, both weeping at his CT scan results: Paul’s lung cancer has reached Stage IV and invaded multiple organ systems. He assumes that there is no hope and that he will never return to his practice. When his brother Jeevan tells Paul to take solace in the fact that he’s “accomplished so much,” Paul fails to appreciate the remark; he feels his future has been “firebombed” and the things he truly wanted to accomplish will never be his.

That night, Paul sees his oncologist, Emma Hayward. Their first proper meeting is scheduled for later that week, but Emma insists on introducing herself before picking up her children that evening. She says the lab is running a test on Paul’s tumor sample, and the result will determine if he has to undergo chemotherapy or not. Paul asks about the Kaplan-Meier estimation on his case, but Emma refuses to discuss it. This angers Paul, as it implies that she sees him as more a patient than a colleague (when he had appendicitis eighteen months previously, his doctors treated him more like the latter). However, Emma’s compassion and skill as an oncologist endear her to him, as does her implication that he might be able to return to work.

Paul grows more ill: even going to the bathroom requires “effort and planning.” He walks with a cane and takes multiple pain medications. These changes affect not only his body but also his sense of self: his pride in work and physical fitness no longer apply in his new state as an invalid. Looking at an image of himself and Lucy dancing, he is reminded of Laurie and the fiancé she left behind after her death.

Paul’s family does their best to help him adjust to his new situation by setting up an account with a mail-order pharmacy and modifying his sleeping arrangements with a bed rail and ergonomic mattress. Paul’s lack of income puts massive pressure on Lucy. Despite his father’s proclamation that Paul is sure to beat the cancer, Paul thinks of all the times he has heard patients’ families say the same thing, only to lose the battle anyway.

Paul and Lucy meet with Emma. She says that they may start chemotherapy the following week, depending on the results of genetic testing. Emma warns Paul that certain medications could have a permanent negative effect on his nervous system, affecting his ability to resume work as a neurosurgeon. Paul replies that he does not mind having to find another profession should his hands become damaged by the chemotherapy; however, Emma insists on using carboplatin over cisplatin, as one is not more likely to be more successful in killing the cancer cells than the other, and the carboplatin has less chance of ruining his surgery career. Once again, Paul asks about the survival chances, but Emma refuses to discuss it.

The following day, Paul and Lucy go to the sperm bank, because Paul’s treatment might have unknown effects on his ability to father a child. (They had originally planned to start a family after Paul finished his residency.) After they return home from the sperm bank, they learn that Paul has a treatable genetic mutation, which means he can take a pill instead of undergoing chemotherapy. The Tarceva medication allows Paul to put some weight back on, though his skin develops blemishes and bleeds easily.

Paul also starts biweekly appointments with Emma. During one session, she asks him if he wants to quit his job or go...

(This entire section contains 1024 words.)

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back to it. Many cancer patients retreat from the world to spend more time with their families, while others dedicate themselves to their work even more. Paul is unsure how to proceed and says if he had a general idea of how much time he had left, he could better choose a course:

If I had two years, I’d write. If I had ten, I’d get back to surgery and science.

However, Emma cannot give him a specific number. In addition to Paul’s oncology appointments, Paul and Lucy start seeing a couples therapist who specializes in cancer cases, but the therapist claims that the couple are so well-adjusted that he has no advice for them. Paul finds it ironic that his illness has repaired the rift in his marriage.

Aside from these sessions, Paul spends much of his time in physical therapy. He rides his bike and runs, determined to push his limitations as much as possible. He sets goals for himself so that, eventually, he can ride a bike for “six wobbly miles” and simply sit for half an hour before growing too tired. His slightly increased energy allows him to resume old activities, such as going out with friends. However, Paul is still disturbed by his loss of his old identity: he feels less like a human being with agency than a passive object others must treat. (As he notes, this feeling falls in line with the fourteenth-century philosophical meaning of the word patient: “the object of an action.”)

Among Paul’s most urgent concerns is the question of having a child. He does not want Lucy to be alone, should he die, but he also knows that it will be hard for her to raise a small child by herself. Lucy is concerned that having a newborn will only make Paul’s dying more painful, but Paul does not want to stop living just because parting will be hard, and so the two decide to have a baby.

Paul and Lucy visit a reproductive endocrinology clinic to undergo the insemination process. The specialist is professional but a bit awkward regarding their situation, as she is used to doing business with infertile couples rather than those dealing with terminal disease. The process requires the creation of a few embryos in vitro. Once the specialists are able to determine the healthiest embryo, it is implanted, and the others perish. Paul says,

Even in having children in this new life, death played its part.

Part 1, Section 2 Summary


Part 2, Section 2 Summary