When Breath Becomes Air by Paul Kalanithi

Why I Recommend This Book

When Breath Becomes Air is a thought-provoking book and will definitely open up an interesting dialogue in your book club. Death is something most of us don’t want to think about, but Paul Kalanithi faces the end with integrity and a realistic, yet hopeful view, that you will leave with nothing but respect for him and his wife Lucy.

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Summary

Paul Kalanithi, in his last year of residency as a neurosurgeon, is diagnosed with lung cancer and his plan for life is derailed. What comes from it is this beautiful insight of one who is faced with a terminal illness and his views on life and death.

Quotes and Info About the Author

• Paul Kalanithi was neurosurgeon and writer. 
• Paul Kalanithi grew up in Kingman, Arizona. 
• While completing his residency training in neurological surgery and a postdoctoral fellowship in neuroscience, he was diagnosed with lung cancer at the age of 35, which spurred his desire to write this book.
• He was married to Lucy Kalanithi and dedicated the book to his daughter Cady.
• He died March 9, 2015

“In a way, though, the certainty of death was easier than this uncertain life. Didn’t those in purgatory prefer to go to hell, and just be done with it? Was I supposed to be making funeral arrangements? Devoting myself to my wife, my parents, my brothers, my friends, my adorable niece? Writing the book I had always wanted to write? Or was I supposed to go back to negotiating my multiyear job offers?

The path forward would seem obvious, if only I knew how many months or years I had left. Tell me three months, I’d just spend time with family. Tell me one year, I’d have a plan (write that book). Give me 10 years, I’d get back to treating diseases. The pedestrian truth that you live one day at a time didn’t help: What was I supposed to do with that day? My oncologist would say only: ‘I can’t tell you a time. You’ve got to find what matters most to you.’” -Paul Kalanithi (New York Times article, “How Long Have I Got To Live”)

“I remember the moment when my overwhelming uneasiness yielded. Seven words from Samuel Beckett, a writer I’ve not even read that well, learned long ago as an undergraduate, began to repeat in my head, and the seemingly impassable sea of uncertainty parted: ‘I can’t go on. I’ll go on.’ I took a step forward, repeating the phrase over and over: “I can’t go on. I’ll go on.” And then, at some point, I was through.

I am now almost exactly eight months from my diagnosis. My strength has recovered substantially. In treatment, the cancer is retreating. I have gradually returned to work. I’m knocking the dust off scientific manuscripts. I’m writing more, seeing more, feeling more. Every morning at 5:30, as the alarm clock goes off, and my dead body awakes, my wife asleep next to me, I think again to myself: ‘I can’t go on.’ And a minute later, I am in my scrubs, heading to the operating room, alive: ‘I’ll go on.’” -Paul Kalanithi (New York Times article, “How Long Have I Got To Live”)

Book Club Discussion

Question 1: In an email to a friend, Paul Kalanithi said his goal for the book: “It’s just tragic enough and just imaginable enough. [The reader] can get into these shoes, walk a bit, and say, ‘So that’s what it looks like from here…sooner or later I’ll be back here in my own shoes.’ That’s what I’m aiming for, I think. Not the sensationalism of dying, and not exhortations to gather rosebuds, but: Here’s what lies up ahead on the road.” As the reader, did he fulfill his goal for this book for you?

Question 2: His wife said, “He spent much of his life wrestling with the question of how to live a meaningful life, and his book explores that essential territory.” What do you feel Paul’s conclusions were in his search for a meaningful life? What are your thoughts on what a meaningful life looks like? (Also, refer to Quote 4 under Quotes From The Book)

Question 3: Referring to Quote 11 under Quotes From The Book, what are your thoughts on Paul’s exploration and conclusion on the relationship between faith and science? Do you agree with his conclusion?

Question 4: How do you think Paul’s training in medicine affected his outlook and experience as he faced his own illness? Do you think his knowledge in medicine helped with facing his illness or in some ways did it make it harder?

Question 5: What did you think about Lucy and Paul’s decision to have a child, even though he was terminally ill? What do you think you would do in their situation?

Question 6: Referring to Quote 12 and Quote 13 under Quotes From The Book, Paul mentions choosing to continue living instead of dying even though he was very ill. In what ways did he do this? Do you think this would be a difficult perspective to hold onto when terminally ill?

Question 7: Did this book impact your thoughts on medicine, medical care, and the patient/physician relationship? If so, how?

Question 8: Paul passed away before completing this book. What other thoughts would you have wanted to hear from him if he were still alive?

Question 9: Were there any quotes from the book or life experiences that Paul shared that stuck out to you? 

Question 10: Referring to Quote 16, both Lucy and Paul mention they were having marital problems before Paul’s diagnosis. In what ways can difficult trials bring relationships closer and heal past hurts? In what ways can it do the opposite? What do you think makes the difference?

Question 11: Referring to Quote 19, Lucy said, “What happened to Paul was tragic, but he was not a tragedy.” Did you feel the same way after reading this book?

Question 12: Also referring to Quote 20, Lucy shares her experience with the loss of her husband and what she expected and what surprised her. If you have lost someone close, could you relate to her feelings? If so, how? If you haven’t lost anyone close, how did you feel reading about her experience?

Quotes From The Book

Quote 1: “Literature not only illuminated another’s experience, it provided, I believed, the richest material for moral reflection.”

Quote 2: “I was pursuing medicine to bear witness to the twinned mysteries of death, its experiential and biological manifestations: at once deeply personal and utterly impersonal.”

Quote 3: “Putting lifestyle first is how you find a job — not a calling.”

Quote 4: “Because the brain mediates our experience of the world, any neurosurgical problem forces a patient and family, ideally with a doctor as a guide, to answer this question: What makes life meaningful enough to go on living?”

Quote 5: “When there’s no place for the scalpel, words are the surgeon’s only tool.”

Quote 6: “How little do doctors understand the hells through which we put patients.”

Quote 7: “Neurosurgery requires a commitment to one’s own excellence and a commitment to another’s identity.”

Quote 8: “We had assumed an onerous yoke, that of mortal responsibility. Our patients’ lives and identities may be in our hands, yet death always wins. Even if you are perfect, the world isn’t. The secret is to know that the deck is stacked, that you will lose, that your hands or judgment will slip, and yet still struggle to win for your patients. You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.”

Quote 9: “One chapter of my life seemed to have ended; perhaps the whole book was closing. Instead of being the pastoral figure aiding a life transition, I found myself the sheep, lost and confused. Severe illness wasn’t life-altering, it was life-shattering.”

Quote 10: “My carefully planned and hard-won future no longer existed. Death, so familiar to me in my work, was now paying to personal visit. Here we were, finally face-to-face, and yet nothing about it seemed recognizable.”

Quote 11: “Science may provide the most useful way to organize empirical, reproducible data, but its power to do so is predicated on its inability to grasp the most central aspects of human life: hope, fear, love, hate, beauty, envy, honor, weakness, striving, suffering, virtue. Between these core passions and scientific theory, there will always be a gap. No system of thought can contain the fullness of human experience.”

Quote 12: “We decided to have a child. We would carry on living, instead of dying.”

Quote 13: “That morning, I made a decision: I would push myself to return to the OR. Why? Because I could. Because that’s who I was. Because I would have to learn to live in a different way, seeing death as an imposing itinerant visitor by knowing that even if I’m dying, until I actually die, I am still living.”

Quote 14: “Human knowledge is never contained in one person. It grows from the relationships we create between each other and the world, and still it is never complete.”

Quote 15: “When you come to one of the many moments in life where you must give an account of 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 you, 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.”

Quote 16: “His cancer diagnosis was like a nutcracker, getting us back into the soft, nourishing meat of our marriage.” -Lucy Kalanithi (Paul’s wife)

Quote 17: “That Paul and I formed part of the deep meaning of each other’s lives is one of the greatest blessings that has ever come to me.” -Lucy Kalanithi (Paul’s wife)

Quote 18: “Even while terminally ill, Paul was fully alive; despite physical collapse, he remained vigorous, open, full of hope not for an unlikely cure but for days that were full of purpose and meaning.” -Lucy Kalanithi (Paul’s wife)

Quote 19: “What happened to Paul was tragic, but he was not a tragedy.  I expected to feel only empty and heartbroken after Paul died. It never occurred to me that you could love someone the same way after he was gone, that I would continue to feel such love and gratitude alongside the terrible sorrow.” -Lucy Kalanithi (Paul’s wife)

Additional Activities

Before Paul’s death, he wrote an opinion article published in The New York Times.

Lucy Kalanithi also wrote an article for The New York Times about her experience with the death of her husband, Paul.

A New York Times Q&A session with Lucy Kalanithi about publishing her husband’s work after his death.

An interview with Katie Couric and Lucy Kalanithi.

An article and interview with Paul Kalanithi during his struggle with cancer, including pictures of his work and daughter.

Stanford Medicine’s Obituary for Paul Kalanithi.

An article about Lucy Kalanithi and her remarriage.

Refreshments

With more serious and somber books, sometimes I fear posting refreshments feels too light-hearted with the topic. However, I feel food is one way to remember and even honor someone. After reading “When Breath Becomes Air” Paul Kalanithi is a person who deserves honor and remembrance. Here are a few foods that Paul liked, mentioned by his wife, Lucy, in the book.

Paul’s mother made him Indian dosa with coconut chutney (a comfort food for him) while he was sick.

Lucy Kalanithi also mentioned breakfast sandwiches mad egg, sausage, and cheese on a roll and smoothies as other foods Paul liked eating.