Paul relays his and others’ struggles with confronting premature death. While facing mortality is a one-time occurrence for most patients, doctors encounter death constantly. Beyond providing physical care for their patients, Paul argues that two of the most crucial responsibilities of a doctor lie in having mental fortitude and being able to provide emotional support. These two types of strength allow doctors to alleviate suffering and distress, even when people are facing the inevitability of death.
When doctors reach the limits of the physical care they can provide, Paul feels that it is their duty to also provide emotional support. For example, Paul listens in as a pediatric neurosurgeon explains to a mother that her child has a large brain tumor. The doctor proceeds gently, acknowledging the tragedy of the situation, and counselling her on the possible operations and outcomes for her son. With this emotional comfort, the mother is able to make decisions about her son’s medical care rather than succumbing to despair. One of Paul’s own patients is a woman who experiences a seizure. A scan shows that she has a benign brain tumor pressing on her right frontal lobe, and Paul knows that an operation would have minimal risks and almost certainly eliminate her seizures. However, when he realizes that she is terrified of the idea of brain surgery, he gathers her family to calmly talk through the options rather than detailing all of the possible risks and complications. With his informed guidance, she chooses surgery, which goes successfully. Thus, in providing his patient with a network of support including himself, Paul ensures that she lives a healthier and longer life.
Another example Paul gives of his own patients is a woman named Mrs. Lee. He realizes that her local ER had sent her to him so that he would break the news to her that she had brain cancer. Paul refuses to dodge questions and is both direct and caring with her, taking her step by step through surgery, and then through what chemotherapy and radiation treatment will entail. He understands that in cases like this, the first conversation with a neurosurgeon will forever color how a patient chooses to proceed, and that “when there’s no place for the scalpel, words are the surgeon’s only tool.” Emotional support, then, can be just almost as vital as medical care to a dying person. Paul’s own oncologist, Emma, provides mental support for him, as well. Initially, Paul tries to do as much research as he can and become an expert in his own treatment. Emma allows him to do this, but when his first treatment eventually becomes unsuccessful, she tells him that he can just be the patient, and that she can be solely responsible for his care. Paul is shocked, but he is eventually grateful to be relieved of the burden of being his own doctor, allowing him to put his energy back into recovering.
Yet at the same time, doctors also struggle with the human frailty of their patients, and they require mental and emotional fortitude in order to continue to work in a field in which the patients they treat often die. Patients quickly become more than paperwork, such as in an early example that Paul gives about his wife Lucy’s experience. While in medical school, Lucy studies EKGs and identifies one example that shows a fatal arrhythmia. She begins to cry as she realizes that wherever the example had come from, the patient had not survived. In order to perform even everyday tasks, doctors need to develop an ability to cope with fear and death. Paul describes a med school professor, Shep Nuland, who wrote about being a young medical student and cutting open a patient whose heart had stopped in order to squeeze the life back into the person. Though he is ultimately unsuccessful and Nuland’s patient dies, Paul calls his actions heroic. Despite the gruesomeness of the situation, Nuland is willing to go above and beyond what is normally expected of medical students in order to save his patients.
One of Paul’s doctor friends, Jeff, fails to keep up this emotional strength in the course of dealing constantly with death in his job. During residency, one of Jeff’s patients has a particularly difficult complication and dies. Jeff commits suicide that night, unable to bear the responsibility for the deaths of others. Paul experiences his own struggle in maintaining resilience in the face of constant death around him. He describes how in a single day, he had failed to save a child who had been shot in the head for wearing the wrong color shoes, and then had to explain to a mother that her newborn child, who was born without a brain, would not live much longer. Even though these experiences bring him to tears, Paul understands that the work he does is important.
Initially, Paul feels somewhat inured to the death around him, trying to protect himself from his work’s tragedies. Along the path of this career, however, Paul becomes impressed by those around him who are able to withstand the grief and provide emotional comfort for their patients, viewing these qualities as being equally important as a surgeon’s technical skills. Even though his failures are emotionally taxing and fighting against death is a losing battle, Paul understands that it is vital to keep striving for his patients.
Human Mortality, Strength, and Support ThemeTracker
Human Mortality, Strength, and Support Quotes in When Breath Becomes Air
When there’s no place for the scalpel, words are the surgeon’s only tool.
Being with patients in these moments certainly had its emotional cost, but it also had its rewards. I don't think I ever spent a minute of any day wondering why I did this work, or whether it was worth it.
Good intentions were not enough, not when so much depended on my skills, when the difference between tragedy and triumph was defined by one or two millimeters.
The secret is to know that the deck is stacked […] and yet still struggle to win for your patients. You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.
The angst of facing mortality has no remedy in probability.
I got out of bed and took a step forward, repeating the phrase over and over: “I can’t go on. I’ll go on.”
The physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.
This book carries the urgency of racing against time, of having important things to say. Paul confronted death—examined it, wrestled with it, accepted it—as a physician and a patient. He wanted to help people understand death and face their mortality.
Caring for our daughter, nurturing relationships with family, publishing this book, pursuing meaningful work, visiting Paul’s grave, grieving and honoring him, persisting…my love goes on—lives on—in a way I’d never expected.