‘When Breath Becomes Air’: A Neurosurgeon’s Cancer Opus

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More than two and a half million Americans died last year, and one of them was Paul Kalanithi. He died on Monday March 9, 2015, just before 9 pm.

Paul was an exceptional person–an English and biology major who did post-graduate work at Cambridge and the Yale School of Medicine, and completed a neurosurgery residency at Stanford–but the lung cancer that consumed him wasn’t aware of his accomplishments. Cancer works that way. It’s an equal opportunity destroyer.

The cut-off for dying “tragically young” is subjective; at 51 years of age, I feel like I’m somewhere past that mark. But Paul was diagnosed at age 36, just as he was preparing to finish the final year of his neurosurgical training, so ‘tragic’ more than fits. Worse than the diagnosis was the prognosis: the widespread lung cancer he saw on his initial CT scan was not the kind that could be cured.

As Dr. Kalanithi wrote in his beautiful book, When Breath Becomes Air, after the diagnosis of advanced lung cancer was confirmed, “My carefully planned and hard-won future no longer existed. Death, so familiar to me in my work, was now paying a personal visit.”

An insightful and widely circulated essay by USC physician Ken Murray titled, “How Doctors Die: It’s not like the rest of us, but it should be” begins with the story of a physician colleague diagnosed with incurable pancreatic cancer. The colleague refused any treatments that might have “knocked back” the cancer and bought him some time. Instead he opted for the sanctity of his home and an autonomy unencumbered by doctors’ appointments and treatment side effects.

If readers didn’t get any further than Murray’s opening paragraph, they might get the idea that physicians belong to some special club, where we know Death’s secret handshake, and when we feel its grip we routinely opt out of all treatments.

Most of us don’t do that. Kalanithi didn’t. Even though his cancer was incurable, he didn’t see treatment as “futile,” and he used the time it bought him to complete his residency, rekindle his relationship with his internist wife (residency training can be a deep matrimonial strain), have a daughter, and write a book.

But as Murray carefully points out, physicians (and nurses, and others who work in health care) can make more informed decisions about end-of-life care because we are more informed. Our experience affords us a better sense of the perils of excessive treatment, the kind that buys suffering but very little time. (Granted, we may not work hard enough to convey that experience to our patients.)

I can tell you this: physicians are human through and through, and our struggles with our own health problems and our own mortality are very pedestrian. We do grief. We do despair. We lunge for any hope. Like Kalanithi, we do dumbstruck.

“Here we were, finally face-to-face, and yet nothing about it seemed recognizable,” Kalanithi wrote of his cancer diagnosis. “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.”

Although his death was not unique, Kalanithi’s perspective on his illness certainly was, and his keen intellect and writing skills make When Breath Becomes Air a compelling read. Reading about death is not macabre. We need to consider it so that we can get on with our life, and live it fully.

Paul certainly did. From the book’s powerful epilogue, written by Lucy Kalanithi, Paul’s wife:

Relying on his own strength and the support of his family and community, Paul faced each stage of his illness with grace–not with bravado or a misguided faith that he would ‘overcome’ or ‘beat’ cancer but with an authenticity that allowed him to grieve the loss of the future he had planned and forge a new one…. He let himself be open and vulnerable, let himself be comforted. 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.

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