Paul Kalanithi - When Breath Becomes Air

Copyright 2016 by Corcovado, Inc.

Foreword copyright 2016 by Abraham Verghese

All rights reserved.

Published in the United States by Random House, an imprint and division of Penguin Random House LLC, New York.

RANDOM HOUSE and the HOUSE colophon are registered trademarks of Penguin Random House LLC.

Library of Congress Cataloging-in-Publication Data

Names: Kalanithi, Paul, author.

Title: When breath becomes air / Paul Kalanithi ; foreword by Abraham Verghese.

Description: New York : Random House, 2016.

Identifiers: LCCN 2015023815 | ISBN 9780812988406 (hardback) | ISBN 9780812988413 (ebook)

Subjects: LCSH: Kalanithi, PaulHealth. | LungsCancerPatientsUnited StatesBiography. | NeurosurgeonsBiography. | Husband and wife. | BISAC: BIOGRAPHY & AUTOBIOGRAPHY / Personal Memoirs. | MEDICAL / General. | SOCIAL SCIENCE / Death & Dying.

Classification: LCC RC280.L8 K35 2016 | DDC 616.99/424dc23 LC record available at http://lccn.loc.gov/2015023815

eBook ISBN9780812988413

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Book design by Liz Cosgrove, adapted for eBook

Cover design: Rachel Ake

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Contents

E VENTS DESCRIBED ARE BASED on Dr. Kalanithis memory of real-world situations. However, the names of all patients discussed in this bookif given at allhave been changed. In addition, in each of the medical cases described, identifying detailssuch as patients ages, genders, ethnicities, professions, familial relationships, places of residence, medical histories, and/or diagnoseshave been changed. With one exception, the names of Dr. Kalanithis colleagues, friends, and treating physicians have also been changed. Any resemblance to persons living or dead resulting from changes to names or identifying details is entirely coincidental and unintentional.

FOREWORD

Abraham Verghese

I T OCCURS TO ME, as I write this, that the foreword to this book might be better thought of as an afterword. Because when it comes to Paul Kalanithi, all sense of time is turned on its head. To begin withor, maybe, to end withI got to know Paul only after his death. (Bear with me.) I came to know him most intimately when hed ceased to be.

I met him one memorable afternoon at Stanford in early February 2014. Hed just published an op-ed titled How Long Have I Got Left? in The New York Times, an essay that would elicit an overwhelming response, an outpouring from readers. In the ensuing days, it spread exponentially. (Im an infectious diseases specialist, so please forgive me for not using the word viral as a metaphor.) In the aftermath of that, hed asked to come see me, to chat, to get advice about literary agents, editors, the publishing processhe had a desire to write a book, this book, the one you are now holding in your hands. I recall the sun filtering through the magnolia tree outside my office and lighting this scene: Paul seated before me, his beautiful hands exceedingly still, his prophets beard full, those dark eyes taking the measure of me. In my memory, the picture has a Vermeer-like quality, a camera obscura sharpness. I remember thinking, You must remember this, because what was falling on my retina was precious. And because, in the context of Pauls diagnosis, I became aware of not just his mortality but my own.

We talked about a lot of things that afternoon. He was a neurosurgical chief resident. We had probably crossed paths at some point, but we hadnt shared a patient that we could recall. He told me he had been an English and biology major as an undergraduate at Stanford, and then stayed on for a masters in English literature. We talked about his lifelong love of writing and reading. I was struck by how easily he could have been an English professorand, indeed, he had seemed to be headed down that path at one point in his life. But then, just like his namesake on the road to Damascus, he felt the calling. He became a physician instead, but one who always dreamed of coming back to literature in some form. A book, perhaps. One day. He thought he had time, and why not? And yet now time was the very thing he had so little of.

I remember his wry, gentle smile, a hint of mischief there, even though his face was gaunt and haggard. Hed been through the wringer with this cancer but a new biological therapy had produced a good response, allowing him to look ahead a bit. He said during medical school hed assumed that he would become a psychiatrist, only to fall in love with neurosurgery. It was much more than a falling in love with the intricacies of the brain, much more than the satisfaction of training his hands to accomplish amazing featsit was a love and empathy for those who suffered, for what they endured and what he might bring to bear. I dont think he told me this as much as I had heard about this quality of his from students of mine who were his acolytes: his fierce belief in the moral dimension of his job. And then we talked about his dying.

After that meeting, we kept in touch by email, but never saw each other again. It was not just that I disappeared into my own world of deadlines and responsibilities but also my strong sense that the burden was on me to be respectful of his time. It was up to Paul if he wanted to see me. I felt that the last thing he needed was the obligation to service a new friendship. I thought about him a lot, though, and about his wife. I wanted to ask him if he was writing. Was he finding the time? For years, as a busy physician, Id struggled to find the time to write. I wanted to tell him that a famous writer, commiserating about this eternal problem, once said to me, If I were a neurosurgeon and I announced that I had to leave my guests to go in for an emergency craniotomy, no one would say a word. But if I said I needed to leave the guests in the living room to go upstairs to write I wondered if Paul would have found this funny. After all, he could actually say he was going to do a craniotomy! It was plausible! And then he could go write instead.

While Paul was writing this book, he published a short, remarkable essay in Stanford Medicine, in an issue that was devoted to the idea of time. I had an essay in the same issue, my piece juxtaposed to his, though I learned of his contribution only when the magazine was in my hands. In reading his words, I had a second, deeper glimpse of something of which there had been a hint in the New York Times essay: Pauls writing was simply stunning. He could have been writing about anything, and it would have been just as powerful. But he wasnt writing about anythinghe was writing about time and what it meant to him now, in the context of his illness. Which made it all so incredibly poignant.

But heres the thing I must come back to : the prose was unforgettable. Out of his pen he was spinning gold.

I reread Paul's piece again and again, trying to understand what he had brought about. First, it was musical. It had echoes of Galway Kinnell, almost a prose poem. (If one day it happens / you find yourself with someone you love / in a caf at one end /of the Pont Mirabeau, at the zinc bar / where wine stands in upward opening glasses to quote a Kinnell line, from a poem I once heard him recite in a bookstore in Iowa City, never looking down at the paper.) But it also had a taste of something else, something from an antique land, from a time before zinc bars. It finally came to me a few days later when I picked up his essay yet again: Pauls writing was reminiscent of Thomas Brownes. Browne had written Religio Medici in the prose of 1642, with all its archaic spellings and speech. As a young physician, I was obsessed with that book, kept at it like a farmer trying to drain a bog that his father before him had failed to drain. It was a futile task, and yet I was desperate to learn its secrets, tossing it aside in frustration, then picking it up again, unsure that it had anything for me but, in sounding the words, sensing that it did. I felt that I lacked some critical receptor for the letters to sing, to impart their meaning. It remained opaque, no matter how hard I tried.