As Paul Kalanithi neared his graduation from Stanford Medical School, he knew he was physically ill. Subsequent testing confirmed that he had stage IV lung cancer. This book became his final project, an attempt to convey what dying means to a person who is still living. Paul chronicles those things that brought him a sense of significance throughout his life and especially in his last days. 

When Paul was ten years old, his family moved from the affluent village of Bronxville, New York, to the tiny town of Kingman, Arizona. His father, a cardiologist, wanted to establish his own practice in a less expensive area. With three sons, each of whom was expected to go to college, he needed more room in the budget for education.

Paul was the middle son, with a brother two years younger and the other two years his senior. What Paul remembers most about this time in his life was how little he saw of his dad and how infrequent their interactions were. The practice consumed most of his father’s time. A largely absent father convinced Paul that medicine was not the career for him.

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While Paul’s dad was finding success with his practice, his mom was investing time and energy in the education system of Kingman. She joined the local school board with the aim of forging a path that her sons could follow to prestigious universities; she did not want to see them end up at Kingman Community College.

She had trained in India as a physiologist, a career she had put aside to care for her three boys when she and her husband moved to America. Their inter-religious marriage—he was Catholic and she was Hindu—was met with such outrage by both families that they emigrated to escape the fury. And though Kingman was a tiny, impoverished school district, Paul’s mom vowed that her children would never be deprived of a good education.

So, at the age of ten, his mom had Paul reading all the classics of English literature that he could possibly comprehend. A couple of years later, his older brother, now at the university, began sending home books he had finished so Paul could read them, too. Later in life, Paul attributed his love of literature to these early influences.

With his family's guidance, Paul decided to go to Stanford and major in English Literature. Casually reading a horror story that summer before university caused him to rethink things a bit. While his mom had only exposed him to the classics, this mundane novel held his attention and entertained him. He wondered about the relationship between the brain and the mind: what were the differences, and how did they affect one another? That night, Paul pored through the Stanford course catalog and added classes in biology and neuroscience.

As he neared graduation, Paul found himself searching for a deeper understanding of life’s meaning. Literature seemed to provide an account of the mind, while neuroscience concerned itself with an explanation of how the brain functioned. As to the question of meaning, Paul decided that the answer was inextricably bound up in human relationships and morality. Through his course work in literature, biology, philosophy, and neuroscience, Paul sought to grasp how the brain could allow an organism to define meaning for itself in this world.

During his senior year, Paul's neuroscience class visited an institution for people who had suffered severe brain injuries. Aside from the ever-present wailing and violent rocking exhibited by so many patients, what struck Paul as odd was that there were no other visitors. He asked the guide if this was common. She confirmed that it was: family visits tend to taper off after a couple months. Eventually, most families come for birthdays and Christmases, and then stop visiting altogether. This response angered Paul, but it reinforced his understanding that the brain gives us the ability to forge relationships with other humans and thus add meaning to life. If the mind becomes broken, relationships are all but impossible to maintain.

Paul's college thesis, Whitman and the Medicalization of Personality, dealt with elements of psychiatry and neuroscience, as well as literary criticism. After completing it, he realized that the next step for him would be the pursuit of medicine, for, as Whitman had concluded, it was the physician who could truly understand "the Physiological-Spiritual Man."

After a year at Cambridge studying the philosophy and history of medicine, Paul was accepted at Yale and returned to the United States to begin medical school. Early on, he came to understand that the body is matter and mechanism. By manipulating that matter and mechanism, medicine can ease profound pain and even correct abnormalities. 

As Paul began to rotate shifts through various departments of the hospital and was called upon to make decisions regarding the wellbeing of patients, the field of medicine assumed a more complex and metaphysical nature. Life and death were no longer abstract concepts to be debated in the classroom; rather, they were realities that surgeons had to deal with every day. A surgeon needed training and intelligence, surely, but moral clarity was essential, too. And as if the mental rigors weren’t challenging enough, the physical demand—being on one’s feet for lengthy shifts—was grueling. One unexpected benefit of attending Yale was that Lucy, his future wife, was also enrolled there. 

Four years into medical school, Paul watched as fellow classmates began to specialize in less demanding areas of medicine, such as dermatology. The medical community had termed these areas of medicine “lifestyle” specialties, as they tended to produce high salaries without high stress. For Paul, though, neurosurgery would be his choice since medicine was more of a calling for him than a job.

One night, while listening to another pediatric neurosurgeon speak to the parents of a young child with a large brain tumor, Paul was struck by the need for a surgeon not only to provide the clinical facts, but also to give caring guidance. While he had not fully considered it before, Paul now saw that the issues of life, death, and meaning usually arise in a medical context.

One issue in particular that the neurosurgeon must confront is the major impact brain surgery might well have on a patient’s quality of life. The question isn’t simply whether a patient will live or die, but whether life post-surgery will be worth living. What would one be willing to sacrifice to stop epileptic seizures? The loss of the right hand’s functions? Might the patient accept a visual blind spot to eliminate the slight chance of a brain hemorrhage? How much neurological pain would a parent allow his or her child to suffer before death becomes preferable?

Paul had found the confluence of life, death, and meaning in the field of neurosurgery. “They are not only the best surgeons, but the best doctors in a hospital,” his chief resident told him. Here in med school, Paul had truly hit his stride.

On breaks and holidays, Paul and Lucy would travel from New Haven to Kingman to visit Paul's family. Often, the three of them would do medical rounds together at his dad's clinic. What Paul was discovering at Yale was being modeled by his dad in his interactions with patients. Technical procedures were first rate, and patient care was always well-informed, deeply empathetic, and leavened with kindness. 

Because Paul’s father had been largely absent in his youth, he never held his dad up as a role model. But now he was inspired by the way his father handled patients, laughing with them and gaining their trust. Paul was beginning to look on his dad with admiration for the first time.          

"Excellence in all things" is the mantra of neurosurgeons. Paul took this to heart and put it into practice. By the last year of his residency, he had become the chief resident at the Stanford Hospital. Every responsibility, every decision, rested on his shoulders. His experience over the past nine years had taught him that technical excellence was a moral obligation, that even after an exhausting operation, it wasn't over until the paperwork was properly completed and filed. Even the smallest detail couldn't wait until tomorrow. And yet, with all the care, planning, and knowledge, mistakes did occur in the operating room, a reality he had witnessed over the years when fellow surgeons had missed the mark by one or two millimeters. Such mistakes left patients mute, paralyzed, or emotionally depressed.

With his time as chief resident drawing to a close, Paul knew he had mastered all the core cranial procedures. His research in generating signals into the brain was drawing much praise and attention. Not a day went by that he didn’t receive a job offer. And it was an open secret that Stanford was creating a new position for a neurosurgeon-neuroscientist that was Paul's for the asking.

He knew well that a human being can never reach perfection, but one should always strive to come as close as possible. 

Lying in a hospital bed next to Lucy, Paul reviewed the CT scan images showing that a number of his organs had been invaded. Despite the fact that Paul had never smoked, the diagnosis was lung cancer. His first thought was about all the potential within himself that would go unrealized. Death, an enemy he had helped so many others confront, was now visiting him. Statistically, only 0.0012 percent of thirty-six-year-olds get lung cancer.

When Paul's oncologist first visited him, he asked her to review the Kaplan-Meier estimator. This is a collection of data that describes the survival characteristics associated with various diseases. In short, it predicts life expectancy after treatment. His doctor minced no words. "No," she said. "Absolutely not."

This stunned Paul. Life on the other side of the white coat was different. He was no longer in control. While laid up in the hospital, he took some time to research the various treatment approaches, but the pain in his back had become excruciating and the medication kept him groggy.

As his oncologist discussed the medical options, she asked if returning to surgery was important to him. As Paul had spent almost a third of his life preparing for it, the simple answer was ‘yes.’ But there was every chance that he would not defeat this enemy. As the tests came back, they showed that Paul had stage IV lung cancer. There was very little hope of survival.

One topic Paul and Lucy had been discussing was having a baby. They decided to wait until Paul finished his residency. That discussion now rose to the top of the list. Unsure of exactly how long he had to live, Paul was averse to Lucy raising a baby alone. And yet, not having a child seemed unthinkable. Since the effects of the cancer drugs on Paul's body were not fully known, they decided to visit a sperm bank and make the arrangements before his treatment began. When the woman helping them asked who would legally own the sperm if one of them was to die, Lucy burst into tears.

Paul's initial test results ruled out chemotherapy as the primary treatment. He was able to start taking an oral medication called Tarceva, which had far less drastic side effects than chemo. As the months passed, Paul began to feel stronger. He attended physical therapy every day. The idea of returning to work as a surgeon was looking like a real possibility. The future Paul had envisioned came back into focus as death seemed to be retreating into the shadows.

The positive response to treatment also bolstered his and Lucy's desire to have a child. It was something they had both wanted and now it seemed that it would further cement their love for one another, despite Lucy likely being the sole parent. A child would bring joy to the entire family. Saying goodbye to a baby would surely be painful, but the blessings far outweighed the drawbacks in both their minds. The decision made, they advised the clinic and began the process of impregnating Lucy through in vitro fertilization.

During his recuperation, Paul started to read everything he could that dealt with mortality. His hope was to learn a new vocabulary that would define and make sense of death. He found that he very much needed inspirational language to help him move forward. Seven words from Samuel Beckett became his motto: “I can’t go on. I’ll go on.”

Paul continued to grow stronger. Since he was still alive, he wanted to add worth and value to his life.  He decided a return to the operating room would accomplish that. This meant he needed to refocus his physical therapy to concentrate on micro-manipulation of small objects, pronation exercises, and rebuilding the leg strength needed to stand for hours at a time.

During this time, Paul’s tumors had begun to shrink. In a meeting with his oncologist, she said that based on these recent results, a life expectancy of another seven to ten years was not out of the question. Lucy was also supportive of his choice to get back to the OR. The program director gave his blessing, and Paul was on the rotation schedule again. Before his first operation, he reviewed all the necessary textbooks, the relevant anatomy, and each step of the process just to be certain. 

As he began the procedure the next day, all the muscle memory came flooding back. He drilled three perfect holes in the patient’s skull, keeping the drill cool as he worked. He sliced through the dura with a sharp knife, exposing the brain. But suddenly his field of vision darkened and his legs felt weak. He told the attending resident that he felt faint and had the junior resident finish the procedure. After resting for twenty minutes in the lounge, Paul decided it was just a case of his nerves getting the better of him. He vowed tomorrow would be better.

And it was better. His strength improved, as did his technique and procedural memory. Within a month he was working at three-quarter capacity. By the end of the day, though, his muscles were on fire and he was exhausted. Worse, the work that had once brought so much joy and satisfaction was now drudgery; his focus was solely on fighting off the effects of nausea, fatigue, and searing pain.

With Lucy now in her first trimester of pregnancy, a steady income assumed a new importance. Furthermore, in order to graduate, Paul needed to take on the full load of a chief resident to satisfy the demands of the medical faculty. Paul admitted to his fellow surgeons that he had slacked off due to the intense physical demands of the OR. He decided to return to his full-time schedule to ensure his graduation and to prove to himself he could do it.

Seven months after returning to work, Paul reviewed the latest results of his CT scan and saw the faintest trace of a new, large tumor filling his right lung. That night, he and Lucy began mapping out the next steps of his treatment, as he wouldn't see his oncologist until the following week. It became clear now that chemotherapy would be necessary.

The enormity of the moment weighed on him as he prepped for what would likely be his final operation. Chemotherapy, and the attendant decline in bodily strength, would prohibit him from working as a surgeon. He wanted this final procedure to go perfectly, and it did. He even sewed up the patient with a nylon stitch, which is more difficult than using staples.

Chemo began the next Monday. By Tuesday, Paul started to feel all the effects he had read about and seen over the years working in a hospital. Why should he be different? He experienced deep fatigue, constant weariness, an inability to eat, the ever-present taste of salt in his mouth, piercing nausea, and uncontrollable vomiting. Paul was so ill he could not attend his own graduation. And Lucy was due in two short weeks.

The symptoms worsened and Paul had to be admitted to the ICU. The diarrhea and vomiting worsened and his kidneys began to fail. It was here in the ICU that Paul turned over complete control of his recovery to his oncologist. He was willing to play the role of the patient now, no longer second-guessing her suggestions. 

After two weeks, Paul was finally released from the hospital. He had lost more than forty pounds. His skin was paper thin and any physical activity tired him immediately. A couple days after discharge, Lucy's contractions began. Paul returned to the hospital in a wheelchair to be with her. On July 4, at 2:11 a.m., Elizabeth Acadia (Cady) made her way into the world. The nurse wrapped her in blankets and laid her in Paul's arms.

A new energy entered the Kalanithi household that July, as did an appreciation of the double-edged nature of time: as Paul's days grew appreciably shorter, Cady's lengthened and grew fuller. Cady was all about the future; Paul's end was imminent. He wondered if the beautiful baby girl nestled in the crook of his arm would have any memory of him. His fondest wish for her was that one day she’d realize that she brought joy beyond measure to a dying man's final days.

Paul died on Monday, March 9, 2015, with his family at his side. Besides caring for his wife, Lucy,  and his newborn daughter, he worked as much as possible on this book during his final months. While the decline of his body was devastating, he did retain mental acuity up until the last few weeks.

This book was his last project, a bridge to reach those who were suffering from states similar to his, but also to relate what living with death felt like. A surgeon, a scientist, a writer, a husband, a father, a son, a brother, and, at the last, a terminal patient—he explains how he views mortality from each of those perspectives.

In Lucy’s words, “I will tell Cady, when she is ready, that all the wonderful things people said about her dad were really true. He was that good and that brave.”

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