When Breath Becomes Air

by

Paul Kalanithi

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When Breath Becomes Air: Epilogue Summary & Analysis

Summary
Analysis
Lucy takes over the narration, opening with the circumstances of Paul’s death: surrounded by family, in a bed a short distance away from the labor and delivery ward where Cady had been born eight months earlier.
Taking over the narration, Lucy reveals what readers knew all along: that Paul’s death was imminent. But she emphasizes that in the end, time with family became one of Paul’s most important values.
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Lucy jumps back in time to describe Paul’s deterioration. Around Cady’s first Christmas, when she is five months old, Paul’s third treatment option stops working. His strength begins to wane, and Lucy describes the joyful moments they experience even under the circumstances: they host cozy dinner parties, hold each other, and enjoy watching Cady grow. Lucy writes that Paul becomes singularly focused on finishing his book.
Lucy’s description of Paul’s final months reveals how Paul takes advantage of his present and searches for a purpose after he can no longer perform surgery. He becomes focused on the two things that preserve his legacy: caring for his daughter and watching her grow, and ensuring that he will become a writer, as he had always hoped.
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By the spring, Paul needs supplemental oxygen to make his breathing comfortable. The cancer infiltrates Paul’s brain. The prospect of neurological decline hits him hard, as he fears losing agency and meaning. Lucy and Paul strategize with Emma about how to preserve his mental acuity as long as possible. Looking back, Lucy comments that she had envisioned his funeral in a few weeks, not knowing that he actually had days to live.
Paul faces more and more limited time and he continues to focus on present experiences. At the same time, he becomes more and more ready to die, particularly in the event that he loses mental acuity and his time no longer becomes meaningful. He relies on Lucy and Emma to support him but also to show their judgment in the event that death is preferable to an existence tied to life support.
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Lucy describes Paul’s final Saturday. The family sits in their living room, holding Cady on his lap, Paul’s mother and father sitting nearby. Paul asks not to see nonfamily visitors, and isn’t able to work on the book, knowing that he would be unlikely to finish the manuscript.
In his final days, Paul even relinquishes his efforts to work on his book because he knows that it is likely someone else will have to carry on that task anyway. Instead, he makes the most of the present with his family and his daughter.
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To prepare for his clinical trial, Lucy must videotape Paul doing the same task every day to track any decline in his speech. Paul opts to read The Waste Land. His family laughs when Paul puts the book on his lap and recites the poem from memory.
Even just before death, Paul still clings to reading literature as a cherished pastime, choosing to read from The Waste Land as the task by which he will track his illness.
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The next day, Paul has a severe 104-degree fever. Paul, Lucy, Paul’s father, and Paul’s brother Suman return from the emergency room within a few hours. Lucy watches him sleep and begins to cry, knowing that she does not have much time with him left.
Over the two years of Paul’s diagnosis, Lucy also comes to realize that she must take advantage of the present with Paul, and she works hard to keep his spirits up during the time she has with him.
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That evening, Paul’s condition worsens abruptly, and he struggles to breathe. Lucy calls an ambulance, and Paul tells her that this may be how his life ends. They place a mask on his nose to help his breathing with a BiPAP machine. Paul’s blood carbon dioxide level is critically high, indicating that the work of breathing is overwhelming his lungs, which have been weakened by the cancer.
Paul continues to try and fight for his life, but knows that his time is limited and starts to see that machines are doing much of the work of breathing for him. He knows that he has receives a lot of support in the past, and begins to come to a place of acceptance with his death.
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That evening, Paul consults with physicians about the steps forward. The critical-care attending doctor tells Paul that BiPAP is only a temporary solution; the only remaining intervention is for Paul to be put on a ventilator. Paul is concerned that he would remain too sick to ever come off of the ventilator, and that he would be lost to delirium, then organ failure.
Just as Paul had made judgment calls with his own patients throughout his neurosurgery career, he begins to come to a judgment call about the remainder of his life, believing that a life confined to a ventilator before slowly dying is not one worth living.
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Paul thinks about the alternative: choosing “comfort care,” even though death would be more certain and would come more quickly. His mother asks him not to make any decisions until everyone has had a night to sleep on it. In the morning Paul reiterates that comfort care may be the best option. He expresses a desire to go home, but Lucy worries that he might die while being driven home. Paul then asks for Cady to be brought to his room.
Before Paul makes the final decision to die, Paul chooses to spend one more day with family in the comfort of his own home, which Lucy tries to recreate by bringing Cady to him. As Paul had written in his section of the memoir, the joy that his daughter brings him is enough to make his time feel meaningful.
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Cady arrives and is nestled next to Paul. Paul’s medical team discusses his respiratory failure with Lucy outside. Paul’s condition is declining, and he must be intubated quickly in order to prevent death. Lucy tells them that if he doesn’t have a chance of meaningful time, he wants to take the BiPAP mask off and hold his daughter.
Lucy also understands Paul’s priorities, and knows that if he loses consciousness, she will have to make a judgment call for Paul as well, understanding his priorities and knowing that if there is no hope of “meaningful time,” he would rather die.
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Lucy returns to Paul’s bedside. He tells her “I’m ready,”—to take the mask off, to start morphine, and to die, she explains. The family gathers to express their love and respect. Paul conveys his gratitude to his mother and father. He asks that his manuscript be published in some form. He tells Lucy he loves her for a final time. The attending physician affirms Paul’s bravery. Lucy climbs into Paul’s hospital bed and thinks of other beds they had shared.
Paul’s final hours are spent with the things he most values: his family, his wife, and his daughter. He reaffirms his desire for his words to carry on his legacy by asking Lucy to make sure his book is published. And finally, the attending doctor provides one more instance of emotional support, in telling Paul that in his death lies bravery, and that his family will be able to go on.
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An hour later, Paul’s BiPAP machine and monitors are turned off, and morphine drips steadily through his IV. His breath is shallow, and he slips into unconsciousness. For nine hours, Paul’s family—his mother, father, Suman, Jeevan, Cady, and Lucy—sit vigil as Paul’s breathing becomes increasingly effortful. More family arrives, and then their pastor.
Lucy and Paul’s family continue to support him, even in the final hours of his life. Their pastor’s arrival also confirms that Paul’s family had been crucial in giving him his Christian values, but that spending time with his family had also become one of his most important values.
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As the day comes to a close, a family friend arrives to take Cady home for the night. Lucy holds Cady against Paul, knowing that Cady doesn’t understand that this moment is a farewell. As the room darkens, Paul’s breathing becomes faltering and irregular. Just before nine o’clock, he inhales and exhales “one last, deep, final breath.”
As Lucy says later, Paul’s death is tragic, but he was not a tragedy: his life was spent helping patients as they faced life-altering and life-shattering diseases, building a family, and giving others comfort in his words as he faced death with grace.
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Lucy tells the reader that When Breath Becomes Air is in a sense, unfinished, because Paul was not able to complete the manuscript. But she also recounts how tirelessly Paul wrote in the final months of his life, starting from when he was still a neurosurgery chief. She describes how when Paul’s fingertips developed painful fissures, he acquired gloves that allowed him to continue, and how retaining mental focus was Paul’s top priority. Lucy says that Paul’s main motivation in writing the book was to help people understand death and face their mortality.
Lucy’s explanation of the book makes it clear that there is a lot about Paul’s life and experiences that went unwritten because he ran out of time, but that Paul spent so much of his remaining time working on it because he wanted to make sure not only that he relayed his life story but also gave advice to those who might be going through a similar experience. Thus he would still comfort many patients even after his death.
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Related Quotes
Lucy confesses that many of their friends and family will have been unaware of her and Paul’s marital trouble before reading the book. She is glad he included it, however, because it shows the strength they had in overcoming this strain and in facing Paul’s cancer together.
Just as Paul does not gloss over his faults and mistakes, Lucy refuses to cut out the tense part of their relationship. She knows that in the end, both she and Paul were able to overcome hardships to reaffirm their commitment to each other and their family.
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Lucy explains that Paul was committed to ensuring a meaningful future for her, and that she in turn worked to ensure that Paul’s remaining time was worthwhile, managing his medical care, listening to his fears, and ensuring he never felt alone. A few weeks before his death, Lucy asked whether Paul could breathe okay with her head on his chest, to which he responded that it is the only way he knows how to breathe.
Lucy also demonstrates the ways in which she supported Paul as much as any doctor (especially as a doctor herself). She knew that as much as she could take care of him physically and mentally at home would have just as great a benefit to his overall health.
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Lucy writes that Paul’s voice in When Breath Becomes Air seems somewhat solitary. She feels the book misses the love and warmth around him, and the humor he possessed. But she admits that the Paul she misses the most is the man he was in his last year, writing this book: “frail but never weak.”
Lucy’s description of Paul and her epilogue express how loved and supported Paul really was. In many ways, his strength in the face of death can be attributed to the many sources of support he received from friends, family, and doctors.
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Lucy knows that Paul was and would have been proud of the book, which was a culmination of his love for literature and a way of weaving a powerful story about living with death from his own life.
Lucy affirms once again Paul’s love of literature, particularly in the final stage of his life, and his desire to give his own words a longevity he did not have.
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Paul is buried in a willow casket at the edge of a field in the Santa Cruz Mountains. He had been unattached to the fate of his body after death, and left it to Lucy to make those decisions. Lucy says that she chose his grave site because of its ruggedness and honor, its attachment to nature, and its beauty.
Paul’s burial site ties back into his experience at the camp he attended his sophomore year of college. The real-life experience of nature reaffirmed his own presence in the world, and Lucy chooses a burial site to give him that experience again.
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Lucy visits Paul’s grave often, pouring wine out on the grass for Paul, and rubbing the grass as if it were his hair. She describes how surprised she has been that she continues to feel the same love and gratitude towards Paul even alongside her sorrow. Her love for him continues in publishing his book and in caring for Cady.
Lucy describes her efforts to carry on Paul’s in shepherding his manuscript and in raising their daughter. Describing the grass as Paul’s hair may be another homage to Walt Whitman, who wrote that grass seemed to him to be “the uncut hair of graves.”
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Lucy knows that had Paul lived, he would have made great contributions to the fields of neurosurgery and neuroscience. Instead, she explains, this book is a new way for him to help others, a contribution only he could make.
Lucy describes a final time how in the absence of a legacy Paul could leave in the field of neurosurgery, he instead left a legacy of words through this memoir, to allow others some comfort in facing their own deaths.
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Two days after Paul’s death, Lucy writes a journal entry addressed to Cady. She writes that “When someone dies, people tend to say great things about him.” She knows that the things others are saying about Paul are true—that he was that good and that brave. He wondered about death and whether he could face it with integrity. She confirms, as his wife and his witness, that he did face death with integrity.
After Paul’s death, Lucy continues to show her support for him. Without her, Paul’s legacy would be virtually nonexistent, as she shepherded his manuscript into fruition and raised his daughter. Even though their story began from a place of strain, it ends with the confirmation of the value of family, and how it allowed Paul to accomplish some of his goals and face death knowing that his life had had meaning.
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