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book review

Paul Kalanithi, M.D. Resident in Neurological Surgery, at the Stanford Hospital is survived by his wife Lucy and their daughter Cady.

Paul Kalanithi’s memoir, When Breath Becomes Air, begins with a wallop. A neurosurgical resident in his final year of training, he’s examining the CT scans of a patient with Stage 4 lung cancer. He’s seen many such scans. This time, though, he is the patient, not the doctor. Wearing a hospital gown, tethered to an IV pole, Kalanithi reads his own death sentence by scrolling through the images on the computer screen a nurse has left in his room.

Only 0.0012 per cent of 36-year-olds get lung cancer, Kalanithi tells us. "Yes, all cancer patients are unlucky," he writes, "but there's cancer, and then there's CANCER, and you have to be really unlucky to have the latter." Many of us have read heart-rending tales of young lives cut short. Kalanithi's memoir could be another such piteous account, with the added fillip that he is a doctor.

An insider in the mysterious and bewildering realm of hope and fear that represents modern health care, Kalanithi is in a position to enlighten us about how doctors die. Do they know something we don't? Do they get access to earlier treatment, experimental drugs, better pain medication than the rest of us? Spoiler alert. Kalanithi expires the way most people do: reluctantly, after several debilitating rounds of failed treatment, in a hospital bed, monitors turned off, drugged into unconsciousness until the morphine mercifully suppresses his compromised breathing. At the time, California didn't allow physician-assisted dying, which may be why he never raises the issue of a hastened death.

I first learned of Kalanithi and his fate in January, 2014, when he wrote an opinion piece in The New York Times under the provocative headline, "How Long Have I Got Left?"

Here's how he described his dilemma:

"The path forward would seem obvious, if only I knew how many months or years I had left. Tell me three months, I'd just spend time with family. Tell me one year, I'd have a plan (write that book). Give me 10 years, I'd get back to treating diseases. The pedestrian truth that you live one day at a time didn't help: What was I supposed to do with that day? My oncologist would say only: 'I can't tell you a time. You've got to find what matters most to you.'"

When Breath Becomes Air is the story of how Kalanithi learned to stop planning his future and to live in the present until he died, in March, 2015, surrounded by his family. He was 37 years old. Afterward, his wife, Lucy Kalanithi, picked up the keyboard and wrote an epilogue about her husband's illness, the birth of their daughter Cady and her own grief as she reassembled the shattered kaleidoscopic pieces of their life together and attempted to move on by herself. All of this is exquisitely moving and you are a more stoic person than I if you can read it without splashing a few tears as you turn the pages. But that is not why I am urging you to read this book.

Kalanithi was born into a South Asian immigrant family. Many of them were doctors – his father, his mother, an uncle – but he never intended to be one himself. He knew medicine only by its deficits. He writes about "the absence of a father growing up, one who went to work before dawn and returned in the dark to a plate of reheated dinner."

When Kalanithi was 10, his father, who was anxious about the cost of living and the price of educating his three sons at elite colleges, moved the family from an affluent suburb north of Manhattan, N.Y., to Kingman, Ariz. Kalanithi describes it as a small town "in a desert valley ringed by two mountain ranges, known primarily to the outside world as a place to get gas en route to somewhere else."

Kalanithi grew up hiking and reading because his stay-at-home mother, devastated to learn that the family had settled in "the least educated district in America" with a high-school dropout rate "somewhere north of 30 per cent," imposed her own curriculum on her sons based on a "college prep reading list" that she had acquired somehow, somewhere.

An excellent student, Paul Kalanithi, the middle son, intended to be a writer. Along the way, he became fascinated by human biology, after reading a junk novel given to him by an older girlfriend. It impressed upon him the notion that the brain was a biological organ that enabled the mind to make sense of the world and, among other things, appreciate the meaning of literature, his first love.

Consequently, he studied both literature and biology at Stanford University, before earning a graduate degree in history and philosophy of science and medicine at Cambridge and then going to medical school at Yale. He graduated cum laude with a stack of prizes, went back across the country to do a residency in neurological surgery at Stanford, published a series of heralded research papers as a postdoctoral fellow and was weighing exciting and lucrative job offers when the fickle finger of fate picked him out as its next victim.

Kalanithi's achievement is to marry the art and science of medicine in a very personal story about how he learned to live until he died. Cancer allowed – forced? – Kalanithi to put down the scalpel and confront his own credo as a healer, enhanced by his experience as a patient. Turning off his medical research brain and concentrating instead on figuring out what matters to him as a husband, an expectant father and a human being is transformative. In the process, he becomes a much more humane and caring doctor. That is one of the saddest parts of this book: what we have all lost with Kalanithi's death.

I've been thinking about life and death and the choices we make for a few years now because I have been writing a book about end-of-life, palliative care and physician-assisted dying. I'm perfectly healthy, so far as I know, but what do we ever really know about what is happening in our bodies and our brains at the cellular level, until it is too late, or almost too late? Given those realities, I have a basic message: If we want choices, we need to think about what matters to us and discuss our wishes and our fears with family, loved ones and the doctors and lawyers who are entrusted with our lives and our affairs. This memoir provides a good entry into such thoughts and conversations.

When Breath Becomes Air is Kalanithi's first and last book. As readers, we have been deprived of the chance to add his name to the ranks of doctor writers, including Sherwin Nuland, Oliver Sacks, Abraham Verghese (who contributes an eloquent foreword) and Atul Gawande. These physicians – surprisingly all male – have the ambition, the scientific knowledge and the literary talent to invite us into their clinical world, reveal its secrets and, in so doing, enlarge our understanding and enhance our perceptions of what it is to be human.

Sandra Martin writes The Long Goodbye column for The Globe and Mail. Her book A Good Death: Making the Most of Our Final Choices will be published in April by HarperCollins.

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