When Breath Becomes Air: Lessons Learned

13 Mar 2016

By Jane Zhao

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        It is only when confronted with our own mortality that some start to embrace life.  In part two of his memoir, Dr. Paul Kalanithi takes us on a journey from the time of his diagnosis of terminal lung cancer to his last few days and shows us just how alive he is throughout the time he is actively dying. Rather than summing up his narrative, I have highlighted certain passages from Part Two in chronological order to give an accurate depiction of his transformation from doctor to patient back to doctor, all the while juggling various roles as husband, son, and finally as a new father.

Warning: There are spoilers ahead!

~~~Excerpts from “Part Two: Cease Not till Death”~~~

“’I’m never coming back to this hospital as a doctor.’”

        Kalanithi tells his coresident this immediately after he is diagnosed with stage four lung cancer. He later reneges and returns to work, but initially, it was inconceivable to think any other way. Surgery, particularly neurosurgery, as he states “is really hard work, and no one would have faulted me for not going back.” It is not only physically taxing but it can be emotionally and mentally draining. Kalanithi always describes neurosurgery as a calling because there is absolutely no incentive to pursue neurosurgery as a job. As a job, “it is one of the absolute worst.”

“Death, so familiar to me in my work, was now paying a personal visit. Here we were, finally face-to-face, and yet nothing about it seemed recognizable. Standing at the crossroads where I should have been able to see and follow the footprints of the countless patients I had treated over the years, I saw instead only a blank, a harsh, vacant, gleaming white desert, as if a sandstorm had erased all trace of familiarity.”

        It does not matter how many patients we treat or how many times we walk through the process of death and dying. At most, we can be there for our patients, as they come to terms with their own mortality, but the experience is otherwise a solitary one. As a neurosurgery chief resident, Kalanithi is a seasoned veteran when it comes to the topic of broaching poor prognoses, but he only truly began to understand the scope of loneliness that comes with terminal diagnoses after his own experiences with lung cancer.

“…without that duty to care for the ill pushing me forward, I became an invalid.”

        How do any of us identify ourselves? Our profession shapes the way we are viewed by those around us. When we find ourselves stripped of the ability to perform our sense of duty, our world turns upside down. We face an existential crisis. Who am I now?  

What defines you beyond surgery? Did Kalanithi’s memoir create a sense of gratefulness because you can still do the job you are passionate about?

“Grand illnesses are supposed to be life-clarifying. Instead… my ability to make lunch plans had been shot to hell.”

There is no science to knowing when death will happen, even when it is certain. What are you supposed to do when you do not know how much time you have left? This is the struggle Kalanithi faces, when his chemotherapy regimen stalls his cancer just enough for him to perform full speed at back at work.  

He was in his final year of training,  when everyone else was actively job hunting.  He knew his time was limited. He knew his values. Given one year, he could write a book. Given ten years, he could return full force to his clinical practice. The trouble, though, is he has no idea where he falls in that spectrum.

“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.”

Kalanithi discovered the power of having faith, whether it was in God, people, or some higher force controlling destiny and fate. When the answers to why and how were not found in science, he found his comfort in God, returning to the faith of his childhood. Where do you find the answers to why and how? Where do you seek comfort in the journeys your patients and loved ones travel?  

“There we were, doctor and patient, in a relationship that sometimes carries a magisterial air and other times, like now, was no more, and no less, than two people huddled together, as one faces the abyss.”

        The patient-physician relationship is a two way street. When patients die, physicians are not immune to mourning. We grieve.  We need hope. In the care of our other patients, we bury this vulnerability. However, even as a patient, Kalanithi recognized when the end is near, by the sadness his oncologist cannot hide.   

“’I can’t go on. I’ll go on.’”

This is a message to all of us. We keep moving even when we cannot. In life we have no other option. Time does not stand still for anyone. In our darkest moments, Kalanithi is encouraging us all to go on.


Part Two of Kalanithi’s work ends relatively abruptly, with him describing the joy his new daughter brings to his life. His health deteriorates before he has a chance to finish the great work he began. His wife, Lucy, helps us follow him to the end of his journey in the epilogue. My eyes stayed surprisingly dry throughout Part One and Part Two, but tears started flowing once I reached the epilogue. The love between both of them was—is—obvious. His dream of becoming published was fulfilled  by her, and together they show us the best way to live is to “cease not till death.”

Previous posts about When Breath Becomes Air can be found by Minerva Romero Arenas and Shree Agrawal.


Jane Zhao is a general surgery resident at the University at Buffalo, State University of New York. She obtained her medical degree with a scholarly concentration in Clinical Quality, Safety, and Evidence-based Medicine from McGovern Medical School, University of Texas Health Science Center at Houston and completed her undergraduate studies in Medicine, Health, & Society at Vanderbilt University. She was the 2012 recipient of the Shohrae Hajibashi Memorial Leadership Award and chaired the AWS Blog Subcommittee from 2013 to 2014.

Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author, and are not necessarily the opinion of the Association of Women Surgeons.

One Reply to “When Breath Becomes Air: Lessons Learned”

  1. You took some wonderful lessons from a very sad book and did a great job in the writing of it. Thanks for your good article.

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