When Breath Becomes Air: Epilogue 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.

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.

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.

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.

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.

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.

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.

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.

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.

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 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.

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.

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.”

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 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.

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 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 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.

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.

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 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.

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.