When Breath Becomes Air

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 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.

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.

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.

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.

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 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.

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.

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 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.

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.

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.

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 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.

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.

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 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.

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.

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 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 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.

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.

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.

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.

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.

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.

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 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.

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 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 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.

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.

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. 

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.

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.”

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 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.

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.

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 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.

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.

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 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.

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 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 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 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.

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.

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.

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 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.

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.

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.

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.

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.”

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.

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 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.