When Breath Becomes Air

by

Paul Kalanithi

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When Breath Becomes Air: Part 2 Summary & Analysis

Summary
Analysis
Paul’s narration jumps forward to the day he is diagnosed with cancer, where the prologue left off. He and Lucy look at the CT scan images, which show that the tumors have invaded multiple organ systems. The prognosis is grim, and the two of them begin to cry. Lucy tells Paul she loves him; Paul tells her that he is afraid to die. He then begins to think of Lucy’s future, and tells her to remarry.
Paul’s first thoughts after his diagnosis immediately jump to what will be most valuable for him going forward: his remaining time (and lack of it), and ensuring that his wife has a good future. Lucy, for her own part, begins to take on her own role in providing Paul with the support that he showed so many others.
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Paul’s friend Victoria stops by his room, and the two discuss the scans and his treatments. She begins to talk about the logistics of Paul returning to residency, but Paul stops her, believing that he will never return to the hospital as a doctor.
Again, Paul has little hope in his future, believing he has very little time left. However, with the help of his oncologist, he is eventually able to return to residency in order to keep his life and his career going.
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Paul’s brother Jeevan arrives and tries to comfort Paul by telling him that he has already accomplished so much. Paul is upset by his words, knowing that so much of his life has been spent “building potential,” and now that potential will be unfulfilled because his future has been taken from him.
The fact that Jeevan arrives so soon again identifies another value: family. In the absence of time, family itself becomes a value. Jeevan’s statement, however, is less than comforting to Paul because so much of his life thus far had been building up to a future that would no longer exist.
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That night, Paul briefly meets his oncologist, Emma Hayward, prior to a more official appointment the following week. Emma begins to step Paul through his treatment plan, which will depend on the results of certain lab results from Paul’s tumor sample. Paul asks to know about the Kaplan-Meier survival curves for his type of cancer. Emma refuses to share the statistical details.
Paul is initially frustrated with Emma’s treatment of him. Yet many of the things she does echo Paul’s own thoughts on what makes a good physician, particularly refusing to give patients detailed statistical data. At this moment, however, Paul has not yet become accustomed to being a patient, and being taken care of.
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Emma continues stepping through what Paul’s treatment might look like and offers to discuss how Paul might be able to return to work. Paul is baffled by this offer, believing that returning to work was an impossibility given the severity of the tumors. He begins to wonder if he is wrong about his prognosis.
Even in their first conversation, Emma offers Paul hope and confidence in the idea of having a future, and she follows through in her work to set him back on his feet and forge a new chapter of his life.
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Emma leaves, and Paul, Lucy and his family begin to search their network of medical colleagues for the best lung cancer oncologists. They quickly discover that Emma is not only one of the best oncologists for lung cancer but is also is known for her deep compassion.
Paul at first does not trust Emma, but hearing confirmation that she not only has technical excellence but also immense empathy reassures him, demonstrating his own priorities in finding a doctor with these qualities.
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Paul had grown noticeably weaker over the previous week, and basic functions like going to the bathroom become difficult for him. Paul marvels how less than a week earlier he had spent nearly thirty-six straight hours in the operating room. He worries that being released from work, and no longer bearing a sense of duty to his patients, will cause him to grow even weaker.
Prior to treatment, Paul’s condition quickly deteriorates. This weakening also demonstrates that without a clear sense of one’s values and future goals, life can quickly slip away. Paul, unsure of his identity because he can no longer practice medicine, worries that without motivation, he will quickly die. 
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Paul begins to do research on his cancer, but the sheer amount of information overwhelms him, and he feels he is unable to find information and statistics that are specific to himself.
The incomprehensibility of cancer statistics demonstrates that dry knowledge is not always helpful information. What he really seeks is nuanced language about his survival prospects.
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Paul’s family works to help Paul adjust to a new life, creating an account with a mail-order pharmacy, buying a new mattress for his back pain, and setting up financial safety nets for himself and Lucy. Paul’s father believes that these modifications represent Paul’s resignation to his disease. He believes that Paul will beat his cancer. Paul doesn’t know what to say to his father.
Paul’s family provides emotional and physical support for him as well; however, his father’s confidence about the future also worries Paul because he isn’t as certain about his survival. Facing death, Emma’s ability to provide both treatment and hope becomes more valuable than false optimism and denial. 
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Paul and Lucy return to the hospital for his first official appointment with Emma. Emma explains the two likely treatment options: the first is chemotherapy, which targets rapidly dividing cells—not only cancer cells but also hair cells, intestines, and bone marrow. The second option involves newer therapies, targeting specific mutations in cancer cells, which can lead to long-term survival in some patients.
Like Paul had done with his own patients, Emma meets with Paul and his family to calmly discuss the different options. Like Paul’s own patients, this allows him to see the way forward and make informed decisions about his treatment.
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Emma explains that the results of the tests for a common mutation, EGFR, will come back the next day. If Paul has this mutation, he can take a pill called Tarceva instead of chemotherapy. If not, Emma sets up an appointment for chemotherapy on Monday just in case. Paul feels a kinship with Emma, saying that he also liked to have contingency plans during surgery.
It is only when Paul understands Emma’s different strategies to fight his lung cancer that he realizes how similar he and Emma are in their desire to provide both physical and emotional support in as many ways as possible.
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Emma tells Paul that if he has to have chemotherapy, she will swap out one of the drugs because it is more toxic, and she wants to protect the nerves in his hands if he aims to return to neurosurgery. Paul begins to hope for the possibility of returning to work. He again asks about the Kaplan-Meier statistics, and she again refuses to tell him.
Again, this highlights other similarities between Paul and Emma. Emma seeks to understand his priorities and chooses treatments accordingly. Paul still doesn’t understand her withholding of statistical information, but she does so because (as he points out earlier) it can be potentially harmful to be specific rather than leaving room for hope.
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Paul explains one of the paradoxes of coming so close to death: before he was diagnosed, he knew that he would die, just not when—a circumstance that had not changed after his diagnosis. The difference is that Paul feels his impending death more acutely, but he says that there is no other way to live than having hope in the future.
Paul’s situation has not only changed in that he knows “acutely” that he will die, but he also knows that he likely has less time than he did. Without specific information, however, he struggles with how to move forward, knowing that he must identify specific values and goals to pursue in what little time he has left.
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Paul does a bit more research and discovers that having an EGFR mutation seems to add a year of life on average, with the potential for long-term survival. Not having this mutation suggests an 80 percent chance of death within two years.
Paul’s own research, with its nuance (“adding a year of life on average”) and its room for hope (“potential for long-term survival”) becomes much more helpful than had Emma told him the detailed statistics, as Paul explained in the first section of the book.
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The next day, Paul and Lucy visit the sperm bank to preserve options because the cancer drugs might affect Paul’s sperm. The two had planned on having kids at the end of Paul’s residency, but the uncertainty of Paul’s future also creates uncertainty about whether they should have children.
With their visit to the sperm bank, Paul begins to identifies one of his core values and one of the things that becomes most important to him in his last two years: having a daughter to carry on his life.
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Paul contemplates the idea of hope in a statistical context. He questions whether hope is merely represented by a section of the probability curve that is above average—leaving room for the possibility of a better than normal survival rate. He explains how difficult it is to give patients specific prognoses because what they’re really looking for is existential comfort, which cannot be remedied by probability and statistics.
Paul comes to realize what Emma had known—and what he himself had known earlier in the memoir: that specific statistics are not actually helpful to patients. What is helpful instead is providing a frame of reference for patients’ prognoses but still leaving room for hope—a compromise between science and language.
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Paul and Lucy return home from the sperm bank and learn that he does have the treatable EGFR mutation. Chemotherapy is off, and Paul instead begins to take the Tarceva pill. He quickly begins to feel stronger and puts on weight.
As Paul had researched, taking Tarceva is a much better initial option than chemotherapy. Now armed with the idea that Tarceva adds time to his life, he begins to have confidence in the potential of a future.
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At Paul and Emma’s first appointment after his treatment begins, the two discuss Paul’s future. Emma tells him that if he wants to return to surgery, he should be able to work back up to it. Paul says that it is hard to identify his values without knowing how much time he has left, saying that if he had two years, he would write. If he had ten, he’d return to surgery.
With this confidence in a potential future, Paul begins to hope for the ability to return to work with Emma’s help. As before, working is a long-term value, predicated on the idea of a future. However, he is still unsure whether he has much of a future, and wonders whether he should focus on creating something—like this book—instead.
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Paul becomes slightly frustrated that Emma is not giving him more of a sense of how long he might survive. But Paul also remembers instances in which his own predictions had been wrong, such as when he had counseled a family to withdraw life support for their son, only for them to return two years later with a video of him playing the piano and thanking Paul for saving his life.
Paul’s frustration in Emma’s lack of specifics continues, but each time he mentions it he seems to temper his annoyance by remembering that he would offer the same kind of advice and support, and had made mistakes of his own in his counsel. He is still becoming accustomed to the idea of being the patient rather than the doctor.
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Paul and Lucy also start seeing a couple’s therapist who specializes in cancer patients. The therapist tells them that they are doing better than any couple she’s seen. Paul is pleased by this, but Lucy is not. She worries that if they are the best at handling their situation, their current state won’t improve.
Paul and Lucy’s visit demonstrates their commitment to each other and to being a family, and her commitment to support him through his cancer treatment. These factors give Paul the energy to continue treatment and give his life meaning.
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Paul realizes that he is starting to see death as both a doctor and a patient. He uses his medical background to learn detailed information about stage IV lung cancer, which has emerging therapies that are providing years of life for the first time. At the same time, as a patient, he sees that he must understand what gives his own life meaning to be able to rebuild his life, or to forge a new path forward.
Paul’s interest in science and wanting to find out how biology and identity allow him to understand his treatments and provide a roadmap for him in how to face his mortality. There is a tragic irony in the fact that someone so familiar with death and cancer falls victim to it himself, but Paul works just as hard to recover as he does to treat his patients.
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The bulk of Paul’s time is now spent in physical therapy. Paul’s body at this point is frail, but he is determined to regain strength and stamina. Gradually, he works up to being able to go to restaurants with friends, and then to biking again.
With the love and support of his family, and with the dedication and treatment from Emma, Paul begins to regain some of his old abilities and strength.
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The largest decision that looms over Paul is whether he and Lucy should have a child. Lucy feels that the choice should be Paul’s, because he would be spending a majority of his remaining time as a new father. Paul worries about leaving Lucy both husbandless and childless, but he believes the choice should be hers because she would likely have to raise the child on her own. Lucy asks if having to say goodbye to a child would make Paul’s death more painful, and Paul argues that life isn’t about avoiding suffering.
Lucy’s primary concern in having a child is time: how much time it would take of Paul’s last few years? Paul’s primary concern is the future: without him, how would motherhood work for Lucy? Ultimately, however, the choice comes down to the fact that a child would be a wonderful addition to the family, and would in a way allow Paul’s life to go on after his death.
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Paul and Lucy agree to have a child. Because of the medications Paul is on, they decide to visit a specialist at a reproductive clinic. They create a few embryos using in vitro fertilization and implant the healthiest.
Even in the creation of a new life, death plays its part in the embryos that are not implanted—another way in which science has both costs and benefits.
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Six weeks after starting treatment, Paul has his first CT scan to measure any improvement against the cancer. The CT tech lets Paul glance at his images. Paul’s lungs are almost completely clear of tumors. His cancer is stable, and he is relieved.
The success of Paul’s first treatment is a relief because it gives him more of his most valuable resource: time. This in turn allows him to spend more of that time on the things he values.
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Emma concludes that Paul is well enough to meet every six weeks. That weekend, Paul looks forward to reconnecting with a few former Stanford neurosurgery graduates. Seeing his friend Victoria receive job offers, grants, and publications, however, only heightens the contrast between the success of his old life and the hardships of his new one.
Once again, Paul realizes the cost of his disease on his life. Even without knowing how much time he has left, the inability to know whether he has a future career forces him to prioritize other pressing things, like having a family.
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Paul returns to reading literature. He reads works on mortality and memoirs of cancer patients in order to gain “a vocabulary with which to make sense of death.” Struck by immense pain one morning, he begins to use the last seven words of Samuel Beckett’s The Unnamable as a mantra: “I can’t go on. I’ll go on.”
Paul turns away from science in this moment because he realizes that research can only get him so far. He wants to understand his disease through the experiences of others and make sense of his life and death through works that speak to mortality.
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Paul pushes himself to return to the OR, refusing to give up his life and his career until he absolutely has to. He alters his physical therapy program to focus on building strength necessary for operating. Paul’s next CT scan shows that his tumor has shrunk even more. Emma tells him that it is not out of the realm of possibility for Paul to live another ten years.
Even with more limited time, Paul understands that returning to surgery is something that is important to him—as he had said earlier, he had been working his whole life to pursue a career in neurosurgery.
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Paul is both excited at the prospect of another ten years, but also nervous about returning to the burden of neurosurgery. Yet Paul feels the weight of moral duty pushing him back to the operating room. He calls his program director to tell him he is ready to return.
Paul worries about the toll that surgery might take on his body, but feels compelled by alleviating the suffering of others, now armed with similar experiences as his patients as well.
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Paul and Victoria discuss how best to reintroduce Paul to the daily routine. He would only do one case per day, and wouldn’t manage patients outside the OR or be on call. Paul’s first surgery back is a temporal lobectomy (an operation used to cure epilepsy), one of his favorite operations.
Paul initially takes on a light load out of caution, but even returning for a single surgery is a major achievement for him. He is still helping patients, but without the added burden of taking care of them emotionally as well as physically.
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Paul pores over his textbooks the night before, reviewing the steps of the operation. He arrives at the hospital for the first time in five months. He begins the operation, feeling his muscle memory kicking in. After the first few steps of the surgery, Paul begins to feel faint. He goes to lie down, letting his junior resident finish the case. After lying down for twenty minutes, he realizes he was simply nervous.
Paul returns to his textbooks to go over the basics, but no textbook is a replacement for the years of experience that Paul has had in the operating room. However, remembering his responsibility and that his mistakes can be detrimental, his nerves overwhelm him.
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Each successive day, Paul remembers more and more of his training. His strength improves, as does his fluidity and technique. After a month, he is taking on nearly a full load of operating. He admits, however, that operating has become joyless; he merely wants to restore his life to its prior trajectory. He comes home each night exhausted, sneaking into bed next to Lucy, who is now in the first trimester of her pregnancy.
Paul’s experience allows him to return to full speed in surgery. However, his joylessness at regaining his prior path could be due to the fact that he has returned to an automatic way of life, instead of living in the present and appreciating time with his family and making an impact on patients by working with them directly.
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At his next appointment with Emma, Paul confesses that he is disappointed that a surgeon-scientist position at Stanford had been filled when he was sick. He realizes he might have to give up on his interest in becoming a scientist because he lacks a long timeframe to complete projects. Emma reassures him that he is doing well given his circumstances. 
Paul provides one of the other reasons why he begins to move away from science. Technology is moving at a rapid pace, but it is unlikely that he will have the time to complete long-term projects. He must still identify a path for himself within the time that he has.
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Later that day, one of the professors at Stanford stops Paul in the hospital hallway. She tells him that some of the other professors are concerned about Paul graduating, because he is not performing the full load of a chief resident. In response, Paul starts to care for patients again and gets back to full speed. Though he still battles nausea, pain, and fatigue, he rediscovers meaning in his job by working with patients directly again.
Not only does caring for patients put Paul back on his prior path to graduating, but it also restores some of the joy that he had found in his job, as he had previously confirmed that caring for patients mentally as well as physically is a part of the job he considers equally as vital. Additionally, because of his cancer, he is uniquely equipped to speak to patients about their fears.
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It strikes Paul that he has gone through the five stages of grief (Denial, Anger, Bargaining, Depression, and Acceptance)—only he has done it backwards. He had been ready to die, then depressed because of his lack of understanding when he might die. He begins to ask God why he couldn’t have had an easier test of faith (somewhat in jest), but also has flashes of anger that he has worked his whole life to become a neurosurgeon, only to get cancer. Finally, he arrives at denial, considering, “Maybe, in the absence of any certainty. We should just assume that we’re going to live a long time. Maybe that’s the only way forward.”
This is the first time in which Paul directly expresses anger and frustration with getting cancer. But as Lucy says in the epilogue, even though Paul wasn’t able to make more of a contribution to neurosurgery and neuroscience, this book became a different way for him to help others. Additionally here, Paul acknowledges the paradox of time—that though the most meaningful moments occur in the present, one must always have faith in a future.
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Paul continues to work towards graduation, only a few months away. His body is wearing out, and he takes daily doses of Tylenol and anti-inflammatory drugs called NSAIDs. He flies to Wisconsin for a job interview, but fears scenarios in which his cancer relapses two years down the line, forcing Lucy to care for a newborn and a dying husband away from family and friends.
Paul reiterates his concern for Lucy in the event of a relapse of his illness and his death: he wants his family to be able to have a future, even if it will be without him. Even when his treatment is working, Paul’s mortality and lack of time loom on the horizon.
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Paul also worries that if he were to move to Wisconsin, he would be far from Emma, who has earned his deep trust and respect. He realizes one of the most important duties of a physician is not to delay death or to return patients to their old lives, but to make sure a patient (or their family) can work to forge a new life, as Emma has done for him.
Paul also reveals his concern about being away from Emma, who has at this point earned his admiration. Like he does with his own patients, Emma provided him both physical and emotional comfort, allowing him to identify his values and (literally) open a new chapter of his life.
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A few weeks later, during Lent, Paul, Lucy, and his mother and father attend church together. Paul interprets the reading that day as a mocking of literalist readings of Scripture. This and other passages like it, Paul says, had brought him back to Christianity after he had become an “ironclad” atheist following college. Paul’s primary argument against Christianity had been its lack of proof.
Even though Paul at times had felt removed from Christianity, his family’s deep faith had initiated his relationship with God and religion and given him those values. Now, in his final months of life, he finds those values and the various interpretations of the readings comforting.
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Paul had come to hope for a scientific framework to explain life, but Paul reasons that exclusively scientific structures do not allow for clear accounts of love, hate, or meaning. Paul believes these concepts are undeniably woven into the world as humans know it but are relatively inexplicable by science. Paul also explains that science is ultimately a human construct, and therefore cannot reach some permanent truth, nor can it account for the fullness of human experience.
Paul does not necessarily posit religion against science; instead, he sees these two ideas as means of understanding different aspects of the world. Certain concepts can be explained by textbook scientific principles, but human emotions and networks are largely understood only through experiencing them.
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Paul had thus returned to what he believes are the central values of Christianity (sacrifice, redemption, forgiveness) because he found them compelling. The Old Testament argues for justice; the New Testament argues for mercy. Paul believes Jesus’s message is that mercy wins out over justice, and that the meaning of original sin is that humans know how to be good, but they can’t always live up to that standard.
This interpretation rings true for Paul as well as his father in different ways: his father knew how to be a good father, but sometimes sacrificed his time to his patients instead of his family. Before Paul’s diagnosis, he did the same thing. Paul also knew how to be an emotionally invested doctor, but initially separated himself from patient’s lives to avoid their sadness and suffering before realizing how important it was to connect with them personally.
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Paul’s musings ultimately come to these conclusions: no one person can say anything definitive about God, and no one person can find Truth. Human knowledge grows from the relationships humans create with one another and the world, and even then, it is still never complete.
Here Paul offers his own argument as to why experience is often more valuable than textbook knowledge: it arises from humans’ relationships with each other and the world, rather than simply constituting dry facts.
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Seven months after Paul returns to surgery, he takes another CT scan—his last before finishing residency and becoming a father. The CT tech once again offers Paul a look at his scan, but he declines, as he has a lot of work to do at the hospital. Two hours later Paul sits down in the neurosurgery office and looks at patients’ scans for the next day. Finally, he types his own name into the database. His scans show a new tumor growing in his lungs.
Paul’s relapse comes at a particularly unexpected time—just as he is about to graduate and has returned to his full neurosurgery load at the hospital. Presenting the narrative in this way allows Paul to craft an argument that as soon as he feels comfortable in his future, it is taken away from him yet again.
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Paul returns home to tell Lucy about the cancer growth. It is Thursday night, and he wouldn’t have another appointment with Emma until Monday, so the two of them map out the next steps of his treatment. It is likely he will have to undergo chemotherapy.
Once again, Lucy becomes just as important in providing Paul with support, whether through research about his next steps or simply through comfort as he faces his mortality for a second time.
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Paul sets his worry aside for one more day—his last day as a neurosurgeon. He arrives at the hospital and makes his usual rounds. He spends a few minutes with a patient, Mr. R, who has a rare syndrome called Gerstmann’s that alters his ability to write, to do arithmetic, and to tell left from right. Mr. R is getting better, Paul says, and will likely make a full recovery.
Paul’s last day as a neurosurgeon is full of reminders of what drew him to the practice in the first place. Mr. R represents a case of intersection between biology, language, and identity, as he has specific deficits from a brain irregularity.
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Paul prepares for his last surgery case, in which he will remove bony overgrowths from a patient’s spine. He wants the case to be perfect. At first everything goes smoothly, but the attending doctor accidently tears a hole in the patient’s dura, which contains spinal fluid. The fluid fills the wound and the surgery takes another hour to complete. Paul sews up the wound, frustrated, but he finds some solace in the fact that the stitches come together so well at the end. A nurse with whom Paul has not worked before asks him if he has any more cases that day. He says no, and she comments that it’s a happy ending.
Paul finishes his time as a neurosurgeon in the operating room. In the first part of the memoir, Paul mentions that being in the operating room makes the clock feel irrelevant, and during this surgery Paul knows that he must take advantage of the experience, as he may never operate again. Even though the surgery doesn’t go smoothly, it allows Paul one final chance to treat a patient—something he had worked nearly his entire life to do. 
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Paul gathers his things from the hospital but leaves his textbooks behind. He gets into his car and begins to cry. He drives home, and later that night he calls Victoria to tell her that he wouldn’t be coming in to the hospital on Monday, or possibly ever again.
Paul’s textbooks here represent two things: that his experience has surpassed his need for those textbooks, but also that he has a desire to leave something behind to improve the lives of others.
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Paul and Lucy go to Emma’s office on Monday. She says that they will look for more mutations in the tumor, otherwise Paul will have to go to chemotherapy. Paul tells her he is taking leave from neurosurgery. She accepts this decision but assures him that this tumor is only a bump in the road.
Once again, Paul begins to lose hope in his future, while Emma maintains that this is not the end for Paul. She will continue to support him through either immunotherapy or chemotherapy treatments.
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No targetable mutations are found, and so chemotherapy becomes Paul’s only option. Paul asks Emma about the different chemotherapy agents and their side effects, asking to include a particular agent called Avastin. Emma agrees with his request, but she also tells him that while she’s happy to make his medical plan together, he can also just let her be the doctor and release himself from the responsibility of his own medical care.
There is still one element of Paul’s treatment that he has not completely left to Emma: Paul still does immense amounts of research to try to become an expert in his own care, demonstrating the mental burden that he is placing on himself. Emma recognizes this burden and tells him that he can simply let her be the doctor.
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Paul, Lucy, and Paul’s mother go to the infusion center together for Paul’s chemotherapy, to which he would return every three weeks. The next day, he feels its effects. He becomes extremely tired, and all food begins to taste like pure salt. Over the next few weeks, he goes in and out of the hospital due to minor complications, which are just enough to prevent him from returning to work.
Paul’s family works to care for him through his second round of treatments. Lucy and his mother demonstrate how family becomes not only one of the most important values for Paul but also his support system. Chemotherapy is also another example of science necessitating cures that have both costs and benefits to health.
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This cycle continues until the day of Paul’s graduation. As he is dressing, he is struck by a wave of nausea, and he begins vomiting green bile uncontrollably. He is rushed to the hospital.
Paul’s cancer robs him not only of time in the future, but also experiences in the present for which he has worked years to achieve.
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Paul and the resident, Brad, discuss his medical history and medications. That evening, the nurse reviews his medication list, and he is confused to discover that Tarceva, which he had continued to take, is not on it. Brad returns later that night, saying that he is taking Paul off of Tarceva. After arguing about why he needs Tarceva, Paul realizes that Brad doesn’t want to give him the medication because it would involve revealing his error to Emma. Paul demands that he order the medication. When morning arrives, Paul discovers that the medication had not been ordered. Emma stops by his room and apologizes for the mix-up, and tells Paul that she will be heading out of town for a week.
This experience with the resident echoes one of Paul’s earlier experiences in his second year of residency with a fellow resident who is unable to admit his mistakes. Whereas before Paul had seen how the person would not have a long career as a resident, as a patient Paul feels the effects firsthand of a doctor who cares less about the patient’s condition than he does about his own reputation. This is in contrast with Emma, who works diligently to make sure that Paul receives the medication that he needs.
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Over the course of the day, Paul’s condition rapidly deteriorates. He becomes severely dehydrated and is transferred to the intensive care unit. Part of his soft palate and pharynx dies and peels out of his mouth. He is in severe pain and comes in and out of consciousness. Lucy, thirty-eight weeks pregnant, moves into his old call room to be close to him at night. Many different types of doctors are involved in Paul’s care, but they often disagree on what should be done to treat him. He tries to advise them as best he can, but he begins losing track of events and time.
Particularly after Brad refuses to admit his mistakes, Paul feels the need to make sure that he gets the proper care in Emma’s absence. This puts a huge burden on himself and on Lucy as they try to sort out the best way forward. Paul does not make it clear whether the lack of Tarceva causes this rapid deterioration, but if that were the case, the lack of empathy from this particular resident had near-fatal consequences.
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Emma returns and informs Paul that he’s been in the intensive care unit for over a week, but that he’s getting better. Paul expresses that it might be a good idea for him to just be the patient, and for her to be the doctor, as she had offered before he started chemotherapy. He finds comfort in relinquishing this responsibility and quotes a passage from The Waste Land that describes a boat being controlled by an expert hand.
When Emma returns, Paul agrees that he shouldn’t try to be responsible for his own care. In taking charge, Emma relieves him of a huge mental weight. Additionally, Paul’s quotation of The Waste Land reinforces his ties to literature as a means of making sense of his disease and his situation.
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Paul is discharged from the hospital, and two days later, Lucy has her first contractions. She stays home while Paul’s mother drives him to a follow-up appointment with Emma. Emma comments that his disease looks stable, and says that Paul can’t restart any treatment until he regained some strength. Paul worries about his future treatments because Tarceva and chemotherapy had both failed him. Emma tells him he has five good years left.
Emma finally gives him a more definitive answer on how much time Paul has left (though Paul’s actual remaining time is about one year, not five). This conclusive statement prompts Paul to really focus on the things that matter in the final months of his life: his family, his daughter (who is about to be born), and his book.
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On the way home from the hospital, Lucy’s mom calls to say that Lucy has gone into labor. Paul and his mother turn back. Paul lies down on a cot in the delivery room as their daughter, Cady, is born. Paul holds her, and in this newborn he sees the possibility of new life, which he describes as “a blank page on which I would go on.”
Though Paul never talks about his legacy explicitly, the reference to “a blank page” shows the value he places on having something that will carry him into the future in some way. Here he is referring to his daughter, but the reader can also see a metaphorical reference to his book as well.
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Over the next few days and weeks, Cady experiences a series of firsts: a first grasp, smile, and laugh. Paul, on the other hand, has less and less energy, and he feels the days are very short because he moves so slowly through them.
Underscored by the knowledge that Paul doesn’t have very much time left with his daughter, the days begin to feel very short as Paul loses more and more energy because of his disease.
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Paul struggles with how to think about the future, because he had always been so future-oriented. Now, he says, he doesn’t even know what verb tense to use when describing himself.
Paul’s uncertainty about language in this moment echoes his uncertainty about his life, because he is even unable to know what verb tense most accurately describes himself.
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Paul’s final words in the memoir express hope that Cady will have some memory of him. She is all future, he says, while his life essentially belongs to the past. He relays one final message for her: when she must evaluate her own meaning to the world, she should not discount the fact that she has given him the greatest joy of his life.
The last passage Paul writes highlights what Paul has found most meaningful in his final days: the joy given to him by his newborn daughter, and knowing that she will continue on into the future long after he is gone.
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