When Breath Becomes Air

by Paul Kalanithi

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Part 2, Section 2 Summary

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Six weeks after starting treatment, Paul undergoes another CT scan. The cancer appears stable, and his spine is healing. Furthermore, he can walk without a cane again. The following day, Emma says Paul is improving enough that they will only have to meet every six weeks and can begin discussing the future, though this is a subject that fills Paul with angst. At a meeting with fellow Stanford neurosurgery graduates, Paul feels envious that the others present can still look forward to a successful future that will likely never be his. No one asks him his plans, which is a blessing, as he has none. Paul begins reading books on mortality, from cancer patients’ memoirs to Tolstoy’s The Death of Ivan Ilyich, and the process is crucial in inspiring him to return to his surgery career. He feels that even if he is dying, he must continue to live his life—and return to his calling—as best he can.

For the next six weeks, Paul alters his physical therapy program so that he will be strong enough to return to the operating room. His next CT scan shows his tumor shrinking even more. Emma gives him further grounds for cautious optimism: another patient on the Tarceva pill has been living seven years since his diagnosis. He might have another decade or so to live. For Paul, this is further justification for returning to his work as a neurosurgeon.

Paul informs his program director of his intentions, and the director welcomes him back with enthusiasm. Paul only requests that a fellow resident be in the operating room should anything go wrong. Paul’s first surgery since his diagnosis is a temporal lobectomy. Initially, everything goes well, but then Paul suddenly has tunnel vision, forcing him to leave the rest of the procedure to the other resident. Though this near-fainting spell does not deter Paul from work and his next few operations go better, Paul does not find surgery as enjoyable as he used to and comes home exhausted every night. Paul also learns that a surgeon-scientist position he has long coveted at Stanford has just been filled. Even though the workload would be too much for him in his condition, he still mourns the lost opportunity.

The two shining spots during this period are Lucy, who is in her first trimester of pregnancy, and Paul’s stable condition. Though he does not know how long he has to live, he feels that he must continue on as though he were going to live a long time if he is to enjoy the time he has left fully.

Nine months following Paul’s diagnosis, he is more exhausted than ever, often too tired to eat after work. He has also developed a chronic cough. Nevertheless, he works hard, even going to Wisconsin for a job interview. The offer is attractive: a large salary, a neuroscience laboratory, flexible hours, tenure, a clinic, job opportunities for Lucy, and a gorgeous location in which to live and work. However, Paul declines the offer. Should he have a relapse, Lucy and their newborn child will have no family to go to for support.

Paul has an epiphany: he cannot regain his former life or pursue his former dreams of medical superstardom. Once again, he is unsure of how to proceed. He realizes that Emma’s talk of his future has nothing to do with resurrecting his pre-cancer existence:

Emma hadn’t given me back my old identity. She’d protected my ability to forge a new one. And, finally, I knew I would have to.

While attending a Lenten service with his...

(This entire section contains 1336 words.)

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family, Paul reflects on his changing views of religion. Though raised Christian, he was an atheist throughout college, turned off by literalist readings of Scripture and intrigued by a rational, materialist vision of the universe. However, Paul has come to find that disbelief in God makes life seem cold and without meaning. As someone who sees life as inherently meaningful, such a conception of the universe seems nonsensical to Paul.

Even though he claims that atheists, too, can believe in meaning, Paul feels that science (like religion) has its limits: it “cannot reach some permanent truth,” since scientific knowledge is always evolving. Another reason for Paul’s return to Christianity is his conception of Christ’s main message—that is, “that mercy trumps justice every time.” Such a message means that someone need not feel guilty about the inability to be perfect.

Seven months after Paul resumes his work as a neurosurgeon, he has another CT scan. A tumor is forming in his right middle lobe. Paul does not despair, but he and Lucy consider their next options. Treatments will be more grueling; however, Paul accepts this and decides to work in the operating room one last time. His last operation is performed on an elderly man with spine degeneration. Though Paul declined to take NSAIDs and his back and shoulder ache as a result, he wants the procedure to go as perfectly as possible. The procedure takes longer than normal when spinal fluid leaks into a wound, but Paul completes the surgery.

During Paul’s next visit with Emma, she informs him that if a bronchoscopic biopsy does not identify any targetable mutations, chemotherapy will be next. When Paul tells Emma he quit neurosurgery, she says she hopes he did not do so because of his health and assures him that “This is just the end of the beginning.”

The biopsy results identify nothing, so Paul is scheduled for chemotherapy. He is to go in every three weeks for four-and-a-half-hour infusion sessions. The process is dreary, filled with silence, small talk, and reading. The effects of the drug cocktail make it hard to eat or concentrate. The effects also make Paul too sick to attend his own graduation ceremony.

When Paul starts having serious diarrhea, Lucy takes him to the hospital to be rehydrated. Brad, the resident in charge of Paul’s case, is amiable at first, but when Paul observes that Brad forgot to order Tarceva, which prevents massive back pain, Brad becomes angry and defensive, claiming that Paul’s liver enzymes are too high to tolerate the pill. Paul offers him Emma’s opposing opinion, but Brad simply leaves the room and never orders the pill because he does not want to bother with the extra effort it would take to find a fellow to sign the order. Paul realizes that Brad is starting to lose empathy for Paul’s condition.

The next day, Paul continues to dehydrate to the point where he requires immediate medical attention. His diarrhea worsens, and part of his soft palate and pharynx dies and peels out of his mouth from lack of fluids. Lucy and Paul’s father make sure several specialists are brought in to deal with the issue. The sheer number of doctors makes Paul nervous, since no one is in charge, so he types out a detailed list of his symptoms so everyone will be on the same page. Emma is unable to be there, but when she returns, Paul has improved. He tells her he is ready to just be the patient, not a fellow doctor.

Two days after Paul is discharged from the hospital, Lucy begins to experience contractions. By this point, Paul is gaunt, losing hair, and unable to read. During his next visit with Emma, he is told that his chemotherapy will be put on hiatus until he grows stronger. Emma claims that he has “five good years left,” but her tone is uncertain.

Returning from his appointment, Paul learns that Lucy has gone into labor. From a cot, he watches Lucy give birth to their daughter. They name the child Elizabeth Acadia and plan to call her Cady. In the following months, Paul spends time writing and being with his daughter. He closes his manuscript with a message to Cady: that she has filled his last days with joy and contentment.


Part 2, Section 1 Summary


Epilogue by Lucy Kalanithi Summary