When Tomorrow Feels Impossible

Paul Kalanithi was born in New York, moving at age 10 with his family to Kingman, Arizona. Kingman was a desert town. The wild, windy desert proved alien and alluring. His mother, concerned his education might suffer, read to him from the ‘college prep reading list.’ He developed a love of books – T. S. Eliot, Nabokov, Conrad, Tolstoy… He said,

“Books became my closest confidants, finely ground lenses providing new views of the world.”

He found literature provided the richest material for moral reflection.

At the age of thirty-six, on the verge of completing a decade’s worth of training as a neurosurgeon, Paul Kalanithi was diagnosed with stage IV lung cancer. He was a non-smoker. The cancer was the result of a genetic mutation. One day he was a doctor making a living treating the dying, and the next he was a patient struggling to live.

The CT scan results revealed multiple tumours. In that single moment, he writes, “the future I had imagined, the one just about to be realised, the culmination of decades of striving, evaporated.” Now, he’d wear a light blue hospital gown instead of a surgical one. The diagnosis stole not only his future but also his identity.

As a medical student, he was absorbed, as he wrote, ‘by the question of what, given that all organisms die, makes a virtuous and meaningful life.’

When Breath Becomes Air

This was the question he would engage with during the final months of his life. This was the question he would write about in his book When Breath Becomes Air.

“What makes human life meaningful, even in the face of death and decay?”

It is not uncommon for a person with a terminal illness to want to know how long they have to live. Paul Kalanithi wrestled with this issue. He noted that even more difficult than facing the certainty of death was facing an uncertain life.

“The path forward would seem obvious, if only I knew how many months or years I had left,” he wrote. “Tell me 3 months, I’d just spend time with my family. Tell me 1 year, I’d have a plan…. 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 only say, ‘I can’t tell you a time. You’ve got to find what matters to you most.’”

He could see it wasn’t helpful to agonise over how long you have. He says,

“The reason doctors don’t give patients specific prognoses is not merely because they cannot… What patients seek is not scientific knowledge that doctors hide but existential authenticity each person must find on their own. Getting too deeply into statistics is like trying to quench a thirst with salty water. The angst of facing mortality has no remedy in probability.”

How We Die: Reflections of Life's Final Chapter, New Edition

In his book How We Die: Reflections of Life’s Final Chapter, New Edition, Sherwin Nuland explores ways in which physicians may nurture hope among the dying. Though he recognised the diverse manifestations of hope, Nuland noted,

“Of the many kinds of hope a doctor can help his patient find at the very end of life, the one that encompasses all the rest is the belief that one final success may yet be achieved whose promise vanquishes the immediacy of suffering and sorrow.”

Aware of the precariousness of his illness, Paul Kalanithi was determined to proceed with his life. Some things ceased to be a priority. With the cancer metastasizing in his lungs he writes,

“Everyone succumbs to finitude. Most ambitions are either achieved or abandoned, either way, they belong to the past. The future, instead of the ladder towards the goals of life, flattens out into a perpetual present. Money, status, all the vanities the preacher of Ecclesiastes described hold so little interest: a chasing after wind, indeed.”

Facing mortality brings about a compression of priorities. Paul and his wife Lucy decided they wanted to have a child. Paul knew a child would bring joy to the whole family. He couldn’t bear to picture Lucy husbandless and childless after he died. Lucy wondered whether having to say goodbye to your child would make death more painful. Paul didn’t see this as a negative. He and Lucy both felt that life wasn’t about avoiding suffering.

He wrote these heartfelt words for his daughter Cady. He says,

“When you come to one of the many moments in life when you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more, but rests, satisfied. In this time, right now, that is an enormous thing.”

Paul Kalanithi was a ‘dual citizen,’ a doctor and a seriously ill patient. The experience of being a patient gave him a much deeper appreciation of how difficult it is for patients to navigate their way through a serious illness. He discovered anew ‘care for the dying involves empathy and respect.’ He says,

“To empathise with a dying person is to feel a pain that we can’t fix.”

Paul Kalanithi died on March 19th, 2015. He had been working on his book “When Breath Becomes Air.” One of his final requests was that his manuscript is published in some form.

Writing about Paul Kalanithi’s call to neurosurgery, Abraham Verghese says,

“It was much more than falling in love with the intricacies of the brain, much more than the satisfaction of training his hand to accomplish amazing feats – it was a love and empathy for those who suffered, for what they endured and what he might bring to bear.”

When tomorrow feels impossible, remember Paul Kalanithi and the words that empowered him to go on. Here is the context:

“I woke up in pain, facing another day – no project beyond breakfast seemed tenable. I can’t go on, I thought, and immediately, its antiphon responded, completing Samuel Beckett’s seven words, words I had learned long ago as an undergraduate: I’ll go on. 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.”

Author: Bruce Rickard

Reflections on Suicide and Staying Alive: My son's suicide changed everything. I felt an obligation to understand why anyone would want to end their life. My regular blog posts explore the causes and prevalence of suicide and what is needed to sustain a healthy mind and a hope-filled future.

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