BOOK REVIEW: 'When breath becomes air' tells story of doctor becoming patient with terminal illness

What happens when you work so hard to build a dream and get so close to achieving it, only for an illness to take a piss at everything you’ve built and forever change the trajectory of your life?

For Paul Kalanithi, the author of the book, “When breath becomes air”, that is what happened.

Kalanithi, a brilliant man, trained in neurosurgery, was close to getting the enviable role of neurosurgeon-neuroscientist at a prestigious university, when a lung cancer diagnosis changed the trajectory of his life.

In his poignant book written in the final year of his life, Kalanithi shares his experiences on the operating table and the field of medicine in general, and in the process exposing the reality of how flawed humans are. He shares what it was like moving from doctor to patient after being diagnosed with terminal lung cancer, how his priorities changed and he decided to pursue one of his other loves - literature - and writing a book, and he explores what life is worth living - is all life worth living or is some life not worth living - due to a grave illness for example?

The turn of events in Kalanithi’s life bring to mind the lyrics of Alanis Morissette’s song ‘Ironic’: “An old man turned 98, won the lottery… and died the next day…. A man who had never been on a flight, had waited his whole damn life to take that flight, and as the plane crushed down…. Isn’t it ironic…”

On the subject of the flawed nature of doctors - just like any other mortal - Kalanithi paints a shocking, yet not shocking picture of how convenience can at times take precedence for  some medics, rather than sovereignty of life. Doctors are sometimes looked at as heroes - Demi gods of sorts, who hold the key to life - but Kalanithi shows how naïve this line of thinking is.

Being a doctor is a calling, it is often said, because despite the good pay, there are long hours, burnout and many other challenges. Woe unto you if you are in the care of a doctor who is burnt out and that doctor is supposed to perform surgery on you or make a life and death call.

Kalanithi gave the example of his time as a medical student and how his colleague was tired and was supposed to be in the operating room for what would be a nine-hour surgery, but the procedure does not happen if a patient has metastases - meaning cancer has spread and the operation is useless. Kalanithi remembers how his colleague actually prayed for there to be metastases so that she wouldn’t have to be there for the long surgery. “Mari had a whisper of a thought - please God, let there be mets (metastases). There were. The patient was sewn back up, the procedure cancelled. First came relief, then a gnawing, deepening shame.”

Kalanithi also tackled how illness affects a relationship. His marriage had gone through a rough patch as he spent more on more time at work, but with his diagnosis, he and his wife, Lucy, also a medic, rekindled their love, albeit in the face of adversity of managing a terminal illness. The hard questions of whether to have a child when the reality that he would not be there to raise the child was something the couple tackled. Kalanithi talks of not wanting to burden Lucy with being a widowed mother, but at the same time not wanting to have her not experience motherhood - something she wanted. The couple settled on having a child, and Kalanithi was there for the first couple of months of their daughter’s life, though his experiences were severely affected because his condition had deteriorated fast in the last months of his life.

Another subject tackled in the book is whether all life is worth living.

“Learning to judge whose lives could be saved, whose couldn’t be and whose shouldn’t be requires an unattainable prognostic ability. I made mistakes. Rushing a patient to the OR (operating room) to save only enough brain that his hear beats but he can never speak, he eats through a tube, and he is condemned to an existence he would never want… I came to see this as a more egregious failure than the patient dying.”

On almost reaching the peak of his career, only to be shattered by disease, Kalanithi spoke about being sure about getting an enviable position of surgeon-scientist, only for illness to change his trajectory and later learning the job was given to someone else after his diagnosis. He spoke of going through the five stages of grief. “… after the bargaining came flashes of anger: “I work my whole life to get to this point, and then you give me cancer?” He wrote.

Kalanithi also addressed the thin line between faith and reality. He wrote about how his father had declared that he was going to “beat this thing and somehow be cured” and not knowing how to react, being a doctor and knowing the facts. He said, “How many times had I heard a patient’s family member make similar declarations?I never knew what to say to them then, and I didn’t know what to say to my father now.”

From the examples Kalanithi gives in the early chapters of his book, his stand on what life is worth living is clear and you can almost predict what choices he made towards the end of his life as the disease progressed - to keep holding on despite severe side effects, or die peacefully on his own terms. He chose the latter.

Kalanithi chose comfort care, rather than to be intubated during the final days leading to his death. He was surrounded by his family during his last hours. 

Lucy writes the epilogue of the book, saying that although Kalanithi did not quite get to finish writing the book before his death, it was perfect as it was. She said that the parts of Kalanithi the reader experiences reading the book are just a small piece of who he was and were determined by where he was at the time of writing - battling terminal illness. She pointed out that the book did not bring out the humorous side of her husband and other traits.

She writes, “Paul’s decision to look death in the eye was a testament not just to who he was in the final hours of his life, but who he had always been.” 

In conclusion , the book articulately brings out the realities of life and death and how thin the line between the two can be.

Rating: 4/5