In a hospital room at the Stanford Medical Center, Paul Kalanithi flips through his CT scan images, which show that his lungs are filled with tumors. His wife Lucy is by his side. Paul is a neurosurgical resident in his last year of training at Stanford. He had earned the respect of his professors and had won prestigious national awards, which had led to job offers from major universities. He is looking forward to finishing the grueling demands of residency, having children, and spending more time with Lucy. But the scans, which show advanced cancer, put that future in jeopardy.
Before getting the CT scan, Paul had been experiencing back pain. X-rays of Paul's back had shown no issues, but as the condition worsens, he gets X-rays of his chest. Lucy, meanwhile, has been feeling that Paul has not been confiding his worries to her, and has decided to move out for a week. After the scans come back and Paul tells Lucy that he has stage IV lung cancer, though, she vows never to leave him. Paul is admitted to the hospital, and he feels his future evaporate.
In Part I of the memoir, Paul jumps back to his early life spent in Kingman, Arizona. Though his father is a doctor, as Paul prepares to go to college, he doesn't see himself as ever being a doctor. Instead, he wants to be a writer. His mother had instilled in him a love of literature, while his father, a cardiologist, had often been absent. Paul does admire the way his father earns his patients' trust and give them comfort.
As an undergraduate at Stanford, Paul pursues degrees in both English literature and human biology. He is driven by the question of what makes life meaningful, and feels that both of these fields provide different perspectives on human experience and consciousness.
Paul applies for a master’s in English literature at Stanford and studies Walt Whitman for his thesis. But he realizes that he doesn’t quite fit into the English department because of his interest in science and his desire for practical experience. He then decides to apply to medical school, and is accepted to the Yale School of Medicine, where he meets Lucy. Paul also describes how, at medical school, he comes to experience death. He dissects cadavers. Lucy discovers that a patient she saw as she practiced doing an EKG had later died. They med students also read Shep Nuland’s book How We Die, a book that is unflinching in its description of death.
After two years of studying, Paul’s final two years of med school are spent n the hospital and the clinic, where Paul comes to understand that practical experience, not just theoretical knowledge, is imperative for doctors, whether delivering babies or performing surgery. Paul also discovers how much mental fortitude is required of doctors because they are responsible for their patients’ well-being.
After graduating from medical school, Paul decides to specialize in neurosurgery because he is interested in the brain’s relationship to a person’s sense of identity. Paul returns to Stanford for his residency. At first his paperwork seems very dry, but he quickly realizes that people’s lives lie behind that paperwork. His schedule is intense, which only grows worse during his second year when Paul is on call for emergencies. He begins to worry that being so close to death only blinds him to it, as he and a fellow doctor named Jeff develop inside jokes about patients’ prognoses. After learning that a friend of his has died in a car accident, Paul resolves to take care of his patients emotionally as well as physically. He helps one of his patients decide to undergo surgery by gathering her family and talking calmly through the options with her. The surgery goes successfully.
Paul realizes that there is also a price to the empathy he offers, because it makes him open and vulnerable and in the field of medicine he has chosen so many patients die regardless of his best efforts. Still, he never questions whether his work is worthwhile. In the middle of residency, doctors train in additional fields, and Paul opts to study neuroscience. The head of the neuroscience lab is a man nicknamed V, whom Paul views as a mentor. While Paul works at the lab, V is diagnosed with pancreatic cancer, but after treatment he is able to return to work. Paul completes his work with the lab and enters his sixth year of residency.
Paul’s describes his sixth year as a black hole time-wise because he spends so many hours in the operating room. He never feels like time is passing when he operates because he is so intensely focused on the task at hand. Being technically precise, he says, is crucial because a mistake with a scalpel in brain surgery can be catastrophic for a patient. Some areas of the brain—primarily the areas that control language—are even off-limits to surgery most of the time because the risk of harming them is too great.
As Paul nears the end of his residency, he once more becomes acutely aware of the weight of responsibility doctors bear, when he learns that his friend from medical school, Jeff, had a patient die from a difficult complication. That evening, Jeff committed suicide. Paul wishes he could have shared with Jeff what he had learned thus far in his career: that death will always win, but it is still valuable to strive for one’s patients.
In the second part of the memoir, Paul returns to the day he is diagnosed with cancer. The tumors have invaded multiple organ systems, and he believes that his death is imminent. He meets with his oncologist, Emma, who steps him through his treatment plan but refuses to tell him the statistical probability of his death in order to allow him to remain optimistic.
Paul had grown weak leading up to his diagnosis, making basic functions difficult. His family works to help Paul adjust to a new life. When tests conclude that Paul’s cancer is treatable because of a mutation in his tumors, he grows more hopeful for his future. Emma explains that she hopes to help him return to neurosurgery, if that’s what he would like to do.
Paul begins physical therapy and gradually regains strength and stamina. He and Lucy contemplate whether they should have a child, which they had planned to do when Paul had finished residency. Lucy wants the choice to be Paul’s because he would likely be spending the majority of his remaining time as a new father and would not get to watch that child grow up. Paul feels that the decision should be Lucy’s because she would likely have to raise the child alone. They agree to have a child, knowing that it would bring them and their family much-needed happiness in a trying time.
Six weeks after starting treatment, Paul has another CT scan and discovers that his lungs are almost completely clear of tumors. His cancer is stable, and he is relieved. He pushes himself to return to the operating room, refusing to give up his career until he has to. He alters his physical therapy program to build the kind of strength required of a surgeon, such as being able to stand for long hours.
His first day back in the operating room, Paul’s muscle memory kicks in and the surgery is going smoothly, until he gets nervous and feels faint. He has a junior resident finish the surgery for him. Each day, he remembers more and more skills and takes on more and more of a workload, until he is not only operating but is also working with patients again, which also returns some of the joy of the work to him.
Seven months after Paul returns to surgery, he takes another CT scan—his last before graduating and becoming a father. Paul’s scan reveals a new tumor growing in his lungs. It is Thursday, and his next oncology appointment isn’t until Monday. Paul goes to the hospital the next day for his final day of work. His last surgery goes smoothly, until the attending doctor accidentally opens up the patient’s spine and spills fluid. Paul finishes the case, gathers his things, and leaves. Sitting in his car, he begins to cry.
Paul begins chemotherapy every three weeks, which wears him down. Various complications prevent him from returning to work. On the day of his graduation, he begins vomiting uncontrollably and spends a week in the hospital, severely dehydrated and deteriorating. He eventually stabilizes and is released from the hospital.
Two days after he is released, his daughter Cady is born on July fourth. She brings Paul and the rest of the family a lot of joy, and he is happy to have created something that will last beyond his own lifetime and will affirm his existence in the future. He ends the book with a message to her, saying that she has given him the greatest joy of his life.
Lucy finishes the memoir with an epilogue, describing the circumstances of Paul’s death. Around Christmas, Paul’s third treatment option stops working, and the cancer spreads to his brain. He becomes completely focused on writing this book, something he had always imagined doing later in his career.
Spring rolls in, and Paul needs supplemental oxygen to make his breathing comfortable. In the last few days of his life, Paul struggles to breathe and is taken to the hospital. They give him a BiPAP machine as a temporary solution, but the next step is being put on a ventilator. Paul, worried that he would remain too sick to come off of the ventilator, instead chooses “comfort care.” He tells Lucy he is ready to die, and says goodbye to his family, wife and daughter. They remove the breathing mask, and Paul slips into unconsciousness. That evening, Paul takes his last breath.
Lucy explains that When Breath Becomes Air is in a sense unfinished, even though Paul worked on it tirelessly. With the book, Paul wanted to help people understand death and face their mortality. She expresses how grateful she was to have been a part of what gave Paul’s life meaning, and to have witnessed him face death with integrity.
