Review: ‘When breath becomes air,’ Dr. Kalanithi a Præmaturi death

What makes life worth living in the face of death?

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“Proof that the dying have the most to teach us about living.” Atul Gawande, Being Mortal

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There aren’t many words I can conjure to describe the anguish and empathy for – a 36-year old – neurosurgeon – diagnosed with metastatic lung cancer – faced with the grave reality of dying.

This book, the lifetime of experiences shared in it and the brilliance and passionate style of writing by the author prompted an overwhelming response in me.

Since reading Paul’s book, When breath becomes air, his full name has involuntarily crept into my mind. Whilst at Amsterdam airport this past week, I caught sight of a family sorely saying their goodbyes, taking last pictures before separation, exhales, tears, ‘call us when you get there’ shouts over heaps of departure gate announcements. In that moment oddly, Paul’s story took hold of me again.

I immediately thought of the Monday, March 9, 2015, when Paul died surrounded by his family. I sorely wondered of his wife, Lucy Goddard Kalanithi, his daughter, Cady who was only 8 months at the time. The image of his father Sujatha (described in the book) appeared to me – Paul leaning against his father’s stomach while he stroked his hair. The memory of his strict mother formed: how she “intoxicating… (them) with volumes of romantic poetry” during their home schooling years. Flash back: how she ensured that Paul and his brothers Suman and Jeevan methodically followed a ‘college reading prep list’ so their secondary education would not hobble their prospects of university.

These images linger(d) in the air, as though I knew Paul and his family intimately. All at once I became saddened by the vacant hole he left behind in their lives. Perturbed by how death can easily knock and smash years of work and preparation. Paul had an incessant hunger and restlessness. This led him to complete two B.A.s and an M.A. in literature at Stanford, soon afterward a Master of Philosophy at Cambridge, before graduating cum laude from the Yale School of Medicine. He returned to Stanford for a residency in neurosurgical surgery and a postdoctoral fellowship in neuroscience. He was at the tail end of his training when his unimaginable diagnosis hit. To describe this shattering moment Dr. Kalanithi writes:

“I flipped through the CT scan images, the diagnosis obvious: the lungs were matted with innumerable tumors, the spine deformed, a full lobe of the liver obliterated. Cancer, widely disseminated. I was a neurosurgical resident entering my final year of training. Over the last six years, I’d examined scores of such scans, on the off chance that some procedure might benefit the patient. But this scan was different: it was my own.”

How Long Have I Got Left? This is the question Paul asked whilst grappling with mortality during his illness. It is true, that whilst we all know that someday we will die, we do not know when that someday will be. For Paul, however, this knowledge… the fact of dying became acutely known upon his diagnosis. Unsettling to say the least. Think about it for a moment, can you imagine the overwhelming unease that must yield to have you looking at your doctor, asking:

How Long Have I Got Left?

How Long Have I Got Left?

How Long Have I Got Left?

He would choose how to spend his time depending on the answer to this question. If a few months, he would solely spend time with family. A year, he would write a book. A decade he would “return to treating diseases.” The idea that you take it one day at a time became overwhelmingly disempowering for Paul, “What am I supposed to do with that day” he asked, “when I do not know how many remain?”   To which his oncologist would say: “I can’t tell you a time. You’ve got to find what matters most to you.” In Pauls view, when a patient asks with angst questions on the probable number of days left to their lives, it is not scientific knowledge or mere statistics that they seek, but existential authenticity. An existential authenticity that each must find on their own.

Interestingly, Paul had spent years questioning the “meaning of life” seeking to “find answers that are not in books” as his wife Lucy puts it. It may be fair to suggest that these answers came to Paul in the culmination of sadness and seeming cruelty: In the face of death and decay. When chemotherapy ravaged his skin, altering its former smoothness, perhaps in the moments of having no time and being too weak to frantically cross off a bucket list, or in the moments where he wished to write but his energy too reduced; this compounded by cracked fingertips which made the simple act of typing too painful.

What makes life worth living in the face of death?

The future he had imagined and worked hard towards suddenly evaporated.

paul & cady .jpgThink about it, when you are dying should you still try to have a child, or will having a child make it even harder to die?

These are the questions Lucy and Paul grappled with (They decided to have a child, the book is dedicated to Cady). What long term plans could they (really)  make – what did long term even mean for them? Pauls very identity had been ‘catastrophically interrupted’. “Which is correct,” he asks? muddling through his identity as a patient.

“I am a neurosurgeon,” “I was a neurosurgeon,” “I had been a neurosurgeon before and will be again”?

The will to live when Cady, his daughter was born became two-edged: Every day brought Paul the satiating joy of experiencing the life of his baby girl- “a first grasp, a first smile, a first laugh,” but every day came sooner than he desired as it “brought him closer to the next cancer recurrence – and eventually, death.”

Sadly that day came. Cady’s life, on the other hand, has just begun.

The most heart-wrenching words in the book (for me) came in the final paragraph of the book. Quoted here is a beautiful message Paul writes to his daughter:

To Cady: “When you come to one of the many moments in life when 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 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.”

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