Always Well Within

Calm Your Mind, Ease Your Heart, Embrace Your Inner Wisdom

Critical Choices on the Border of Life

What choices will you make due to life-threatening illness?

The common man whose identity is based on ego will do everything to live, but the spiritual man who is searching for truth, will take every opportunity to die. What does it mean to die? To die to one’s ignorance, to die to the ego, to die to fear, to die to suffering, to die to misconception, to die to judgements so they can really wake up to their timeless reality. – Mooji

Raw.  Vulnerable.  Honest.  Those words jump immediately into my mind when I attempt to describe the New York Times Bestseller, When Breath Becomes Air by Paul Kalanithi.

I rarely read books these days.  But this one traveled around my circle so I couldn’t miss it.  And, to be honest, I’m fascinated by death at the moment.

I want to know death in its stark reality so I can face it truthfully.  I want to know the myriad emotions that might arrive when death says hello – from fear to denial to great compassion to release from worldly concerns.  I want to know the gifts a prospective death promises to bring, at least to those who are willing to acknowledge and embrace it:  For example, the ability to embrace each moment fully with loving awareness.

What Then Is the Meaning of Life?

When Breath Becomes Air beautifully stirs up and addresses many existential questions, especially those related to identity.  It looks at the life-shattering, disorienting, and dislocating experience of a potentially fatal diagnosis, which makes every new moment uncertain.

Two questions remained with me as I concluded reading and continued to reflect on the essence of this book.

  1. As much as we say we want to live, why don’t we take care of ourselves fully so that might be the outcome – me included?
  2. On the other hand, is the true purpose of a human life simply to preserve one’s own existence at all costs?

As background information, here’s a short summary of the book:

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. One day he was a doctor making a living treating the dying, and the next he was a patient struggling to live. Just like that, the future he and his wife had imagined evaporated. When Breath Becomes Air, which features a Foreword by Dr. Abraham Verghese and an Epilogue by Kalanithi’s wife, Lucy, chronicles Kalanithi’s transformation from a naïve medical student ‘possessed,’ as he wrote, ‘by the question of what, given that all organisms die, makes a virtuous and meaningful life’ into a young neurosurgeon at Stanford, guiding patients toward a deeper understanding of death and illness, and finally into a patient and a new father to a baby girl, confronting his own mortality.

Reflections on the meaning of life

These questions arose for me because Kalanithi returned to his ultra-demanding neurosurgery at the conclusion of his first round of cancer treatment.  Yes, the scans showed his lung tumors dissolving, but physical discomfort continued as his constant companion.

Kalanithi himself feels he went through Kubler-Ross’s five stages of grief in reverse, with acceptance coming first and denial last, the latter influencing his decision to return to neurosurgery.  He claimed that denial might be the only viable way forward, not knowing if you have minutes, months, or years to live.

The monolithic uncertainty of my future was deadening; everywhere I turned, the shadow of death obscured the meaning of any action.

But finally, clarity revealed what he considered to be the best course of action.

Self-Care Or Compassion?

When Breath Becomes Air

Paul Kalanithi, author of When Breath Becomes Air

One morning, Kalanithi felt he couldn’t face another day in pain without a project beyond breakfast.  The seas of uncertainty parted, he says.  He decided to push himself to return to the operating room.  Why?

Because I could.  Because that’s who I was.  Because I would have to learn to live in a different way, seeing death as an imposing itinerant visitor but knowing that even if I’m dying, until I actually die, I am still living.

…Eventually, though, the itch to hold a surgical drill again had become too compelling.  Moral duty has weight, things that have weight have gravity, and so the duty to bear mortal responsibility pulled me back into the operating room.

At first he returned at a slower pace.  But then the ante increased, when medical authorities required him to take on full duties in order to complete his residency and graduate.   Nausea, pain, and fatigue plagued Kalanithi, but he expanded his hours and his duties, nevertheless.  He upped his doses of Tylenol, NSAIDS and antiemetics to keep going.

Half a year later, while he was interviewing for a job in Wisconsin, he realized:

For the last several months, I had striven with every ounce to restore my life to its pre-cancer trajectory, trying to deny cancer any purchase on my life.  As desperately as I now wanted to feel triumphant, instead I felt like the claws of the crab holding me back.  The curse of cancer created a strange and strained existence, challenging me to be neither blind to, nor bound by, death’s approach.  Even when the cancer was in retreat, it cast long shadows.

Seven months after Kalanithi returned to the operating room as a neurosurgeon, a new tumor – a large one – appeared in the middle of his right lobe.  With a new round of cancer treatment, came his consequent divorce from neurosurgery.  Kalanithi died about 9 months later, less than a year after the birth of his daughter, who brought joy and sparkle into his dissolving life.

Action Or Retreat?

I don’t think any of us can possibly know what the right decision might be when it comes to another person’s treatment for a life-threatening illness.

At first, I wondered:  Why did Kalanithi return to the operating room and expose himself to high levels of stress, strain, and fatigue, which could only be an overwhelming burden on his barely recovered system?  Was it the inability to live with uncertainty, to live without a solid identity, or to live without an obvious purpose that drove him to do so?

At the same time, Kalanithi considered neurosurgery to be sacred work.  He speaks of moral gravity as the impetus which drew him back to the operating room.  Perhaps such compassionate motivation serves as the only true purpose and real reason for a human life.  Perhaps our life holds the most meaning when we’re willing to sacrifice it for others.

Is there an alternative?  In Tibet – before the invasion of the Chinese – a person struck by a potentially fatal illness would often retreat from the world into spiritual practice.   Tibetan Buddhism offers a complete roadmap to help you prepare for death and what occurs both at the moment of death and during the in-between states afterward.  Interestingly, instead of dying, some would actually recover their health due to the power of the practice.

A spiritual spark touched Kalinithi as well.  He returned to his childhood Christian faith during his later rounds of treatment.  Literature also strongly influence his views and his choices.

Western theology, from the little I understand, does not provide a charted course for one’s travel from the onset of illness to the entrance door of another world.  I image it can feel like a solitary journey.  Understandably, one might feel at a loss for what to do in the state of uncertainty, and thus feel the impetus to choose action over being.

What Choices Will You Make at the Border of Life?

An inquisitive man, Kalanthini grappled with the questions of life and death from an early age.  In fact, his own fascination with the meaning of life and his desire to help the dying and their families set off his journey into neurosurgery.

Because no single answer exists when it comes to your choices at the border of life, it seems appropriate to raise questions for contemplation, just as Kalanithi has done in When Breath Becomes Air.  Perhaps, these reflections might bring you closer to knowing how you would like to be, to feel, and to act, when faced with the distinct knowledge that death might be near, but the exact timing uncertain.

  • Would it help to learn to hold your identity lightly?
  • How would you begin to let go of your attachments to this life?
  • How would you accept that it’s truly okay to die?
  • Will you create a transition period to be still with your true self until death arrives?
  • What is your moral duty?
  • Does your value depend on doing?
  • Is there merit in simply being?
  • What would be the best balance of doing and being if you were give a limited time to live?
  • Will you keep working until the last possible minute?
  • What lessons do you take away from Kalinithi’s story?

We know one thing for certain:  Life is fatal.  You don’t have to be diagnosed with a life-threatening illness to die.  Death could come at any moment.

So how do you live fully now, filling each moment with meaning, while balancing that dedication and determination with an equally constant willingness to let go?

P. S. You might also like A Simple Formula for a Sweet Life, another end-of-life story.

Thank you for reading!  I appreciate your presence.  Have you signed up for my monthly note – Wild Arisings – yet?  Learn more and join here – you’ll get some goodies too.  May you be well, happy, and safe – always.  With love, Sandra

Photo:  Norbert von der Groeben- Stanford Health Care

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26 Comments

  1. What a beautiful article and review, Sandra! Gosh, this is the gazillionth time in a few days that this book has come across my path, so I must ‘need’ to read it.

    In my younger years, I did lots of research on the psychology of death. I wanted to understand it so I wouldn’t fear it. From there grew this unwavering trust in the unfolding of life and a desire and ability to be fully present to honoring natural cycles within it.

    In my recent years, I’m learning to understand the energy of death. Several years ago, I was diagnosed with cancer and told I would die in a few months. My children were quite young, so we had open (age-appropriate) conversations about death. I wanted to make sure if I did pass they would keep their faith, trust flow and keep living infinite possibility (along with whatever their grieving process entailed). We celebrated the heck out of every day, around their school schedule. I didn’t die (yay!) but we all three learned the power of being present to even that which we don’t understand and may fear, with love and of celebrating the moment we are in instead of worrying about the moments one of us might not be in.

    I also taught them to look to the sun (and moon) because I love both and we are out at the beach often at sunset and moon-rise together, and to know that we can feel each other’s presence (and that of everyone we love) through light, regardless of where our (or their) physical form may be.

    I love the title of “When Breath Becomes Air” – I think feeling into that alone, even without the full story, can be expansive and freeing. What a beautiful gift you’ve given us through your choice to read, then write about, this book!

    • Thank you, Joy! I felt the same way, that this book kept crossing my path so it was time to read it.

      This is so unique for a young person and very special > “From there grew this unwavering trust in the unfolding of life and a desire and ability to be fully present to honoring natural cycles within it.”

      This is so amazing: “We celebrated the heck out of every day, around their school schedule. I didn’t die (yay!) but we all three learned the power of being present to even that which we don’t understand and may fear, with love and of celebrating the moment we are in instead of worrying about the moments one of us might not be in.”

      I thought the title was very special too.

      Thanks for sharing your experiences, Joy. They contain profound lessons for us and will surely inspire us to live well now and in those moments when death draws closer.

  2. Beautiful, Sandra. I can completely relate to this since I have been through the same. The biggest question for me was: Did I make a difference? I realized at a very deep level that all that I thought to be important until then, was no longer relevant (career, material things). Cultivating kindness, raising my awareness, questioning my beliefs, … became more and more important. And this goes with ups and downs, it is like ebb and flow, some days this goes better than others. Embracing my flaws, accepting myself completely has been a big part of the journey too. Thank you for the beautiful article and reminding us to never ask ourselves the existential questions.

    • Thank you, Barbara! What an important realization. It’s interesting to see how all the “normal” things drop away and you centered in love, kindness, and awareness. I understand the ebb and flow nature of this. We’re still working through our patterns so some days we’ll have more clarity than others. Thanks for sharing your story. I’m sure it will inspire others!

  3. I must read this book Sandra. It sounds amazing.

    Your opening quote by Mooji reminded me of something I read in a Neville Goddard lecture quoting from a William Blake poem – that death is to be lived daily. Not death as we think of it here on earth but as Mooji speaks of it. Death to old ways of being, death in order to outgrow where we are. Which seems to be part of the questioning we have.

    Ever since I read this I’ve viewed death as another step along the journey. Clearly something visited upon us all, but not the thing I used to be so afraid of.

    I’ve seen and felt the incredible love that exists at no level on this planet, as I’ve held the hands of many loved ones as they slipped away. So I intend to view it as beautiful when my time comes.

    We’ll see!!!

    • What you’ve shared is so inspiring, Elle. I love these words:

      “Ever since I read this I’ve viewed death as another step along the journey. Clearly something visited upon us all, but not the thing I used to be so afraid of.

      I’ve seen and felt the incredible love that exists at no level on this planet, as I’ve held the hands of many loved ones as they slipped away. So I intend to view it as beautiful when my time comes.”

      If we can all gently hold to this, our transition will be in peace. Thanks for this beautiful encouragement.

  4. I was in a meditation retreat this weekend and the Teacher asked a lady new to the practice, “Are you afraid of dying?” and she answered, “Funny you should ask that since I have terminal cancer.” And a timely conversation ensued from which we all learned. Then I see this article… Perfect timing as I have continued to ponder this. For me having faced some rather serious health challenges myself, I believe it is a balance of spiritual retreat and making the very most of every day in life… actively loving my family, friends… seeking opportunities to help and touch other lives… celebrating the simple beauty and joy of a flower, a song, the sky… having fun… I hope when my day comes to leave this Earth I will feel no regrets. I believe ultimately our purpose here on Earth is to cultivate spiritually for the spiritual essence of who we are in what animates the physical body and is what will travel on when the body expires. I believe spiritual cultivation is bolstered by pockets of retreat but just as important by action in daily life in the world. But then, I am a middle-path-walker rather than a monk or a nun so that is just my view… Thank you for a timely and beautiful article.

    • Lynn,

      Doesn’t that give you goosebumps that the teacher could have such a clear hunch about that, maybe without fully knowing it herself. I’m glad you’ve found the right way for yourself, balancing spiritual retreat and making the very most of every day in life.

      I have the same feeling about the purpose of life. We’re all different though and as you beautifully point out, called to different paths. I’ve been on a long retreat and I know they are not necessarily easy because you are face to face with your own mind, emotions, and patterns. It’s all good and an opportunity to uncover our spiritual essence.

      Thanks for sharing your thoughts, Lynn. I feel this depth in many of the blog posts you’ve written of late. Be well!

  5. I don’t fear death (I think it will be an incredibly beautiful new experience filled with love and light and color) but the process of dying is indeed frightening to me. I do trust that when the time comes, I will be able to find purpose and gratitude in whatever I am called upon to experience in the body. I have such a strange view of death ——I think everyone who has died is still with me and I can communicate with them and they with me. I still ask my mentor/art teacher for his help in teaching and in painting and know that I receive it. A poet friend of mine just died and I am asking for her help in writing —-she used to be my main critic —in a good way. Would not let me get by with ANY triteness or ordinary images! I am asking for her “poet brain” to help me write the kinds of poems she used to help me write when she was in a body. I hope I am helping people now and will be able to continue after I do not have this particular body. Getting older really makes me aware of how much time I have to do what I would like to do in this lifetime. And the truth is, that is probably not really very important in the over-all scheme of things 🙂 :).

    • This is such an interesting point, Jean – to not fear what’s beyond death but to feel discomfort with the process of dying. I understand. It can often be uncomfortable and a takes a bit of doing to wrap our head around that. What a beautiful view you have. How amazing that you still feel connected with everyone you know who has died! I love your aspiration to be able continue to help people after death. I’m sure that will manifest for you.

  6. Sounds like a fascinating book that I want to read. Thank you for such a thoughtful and caring glimpse of it and for sharing your thought provoking observations.

    • I’m glad you enjoyed this short review, Debbie I only touched on parts of the book, of course. I think you would find it interesting. Love to you, Debbie.

  7. Catherine Sommer

    Hi Sandra — Interesting synchronicity: Last night I read a review of When Breath Becomes Air in the New York Times book review (from February 14, the book review theme titled “Love & Death.”) and wanted to start a conversation about it, then read your blog entry in my email just now. Thank you for starting the conversation! Adding to the synchronicity, in a few days the Rigpa course “In the Mirror of Death” that I joined will begin.

    While reading the NYT review, what struck me was the following quote from the book: “But now time feels less like a ticking clock and more like a state of being . . . 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.” Though I haven’t read the book, the review had many quotes from it, and the reviewer noted some of the transformations that Kalanithi wrote about going through while coming to terms with death. I can only imagine how I might react to a diagnosis of imminently terminal cancer. However, in my experience of being “jarred” awake (from sudden loss, change, and other events that disrupt our tendency to sleep-walk/-stumble/-run through life), the future and past fall away, “opening up –” rather than “flattening out –” to unveil the eternal present.

    In the past 5 years, I have experienced a lot of loss, change, trauma and upheaval, which naturally has prompted reflection and contemplation on death; that it arrives for everybody and we (mostly) don’t know how or when. One of the main motivations for why I meditate is to prepare for death. When we are present/non-distracted, we live most fully — wherever we are, whoever we are. In this way, with practice, I will be ready to meet death whenever and however it arrives, hopefully with the strength and grace I am currently cultivating.

    The events of the past few years have supported the process of coming to know myself, and the nature of being. Severe loss and anguish gifted me with the willingness to confront the habits of attachment and aversion; I’m beginning to learn the truth of impermanence. With the dawning realization of how fragile life is, I’m beginning to embrace the truth of interdependence. These truths are setting me free — to be authentic, to love more fully, to give & receive more appropriately, to be more effective as a human being friend, lover, family member, neighbor, artist, healer, chef, musician, world citizen — all the various elements that this composition called Catherine is comprised of.

    Thank you, Sandra, for your blog. Your generosity of time and energy spent on reflection and composition, and wisdom, love, compassion, courage, honesty and encouragement shine forth in your entries.

    Love,
    Catherine

    • Hi Catherine, I so appreciate how you’ve articulated how you view death and preparing for it so beautifully. It’s interest that I didn’t catch that particular quote from the book. It’s probably because of this key difference you underline – “flattening” as opposed to “opening.” But I do sense a quality of letting go in the quote you shared.

      While loss can be painful and uncomfortable, you also show how it can open us so perfectly to each moment in life: “However, in my experience of being “jarred” awake (from sudden loss, change, and other events that disrupt our tendency to sleep-walk/-stumble/-run through life), the future and past fall away, “opening up –” rather than “flattening out –” to unveil the eternal present.”

      This is why I meditation too, in addition to the benefits it has for my life right now and my ability to relate with others with more kindness. “One of the main motivations for why I meditate is to prepare for death. When we are present/non-distracted, we live most fully — wherever we are, whoever we are. In this way, with practice, I will be ready to meet death whenever and however it arrives, hopefully with the strength and grace I am currently cultivating.”

      This is so beautiful and exactly the place we can reach when we reflect on and face death honestly. “These truths are setting me free — to be authentic, to love more fully, to give & receive more appropriately, to be more effective as a human being friend, lover, family member, neighbor, artist, healer, chef, musician, world citizen — all the various elements that this composition called Catherine is comprised of.”

      Thanks for sharing your experience, Catherine. The way you are embracing meditation and the possibility of death are so inspiring. Sending you lots of love.

  8. I had the privilege of being in the room when my step-grandfather passed. It surprised me to discover that even though I had never seen a person die before, I was familiar with the feeling that was in the room. I had felt it giving birth. A life coming, and a life leaving, surrounded by people ushering in and ushering out. To me, there really isn’t much difference.

    When I was waiting to go into labor with my oldest daughter, I wasn’t afraid, just curious. When my water broke it was an interesting sensation. When the contractions started my first thought was “Oh THAT’S what it feels like!” and I was curious the entire time from start to finish and it was an amazing experience despite the pain. I’m hoping that I can approach death with that same awareness and curiosity. My own belief that we continue to exist after death certainly helps.

    • Dear Joelle, These are such special experiences. I’m deeply moved by the confidence you have found through these moments of “coming and going” and your faith in the idea that we continue to exist after death. I wish every could come to this same sense of peace with death. There’s also an important lesson here in the power of curiosity and how it can take our focus away from pain in the moment. Thank you for uplifting us and giving us such a positive view of death.

  9. Hi Sandra,

    If the review of this book is so heartbreaking, I can’t even imagine how touching this book would be! I can feel a surge of emotions in my heart at the journey of this neurosurgeon, his grit and fortitude to return to his work, which must be his life…I am overwhelmed by the choice of words and the poignancy of the quotes from this book.

    Such an accomplished doctor who was just starting his life being consumed by cancer! My thoughts are getting distracted…many questions are criss crossing my mind…Why does He give if He has to take away all in this manner? Is He even there?

    I think Kalanithi returned to his work because he wanted to live a full life, a life he had aspired to live, a life that gave him utmost contentment and he wanted to touch it wholly before going.

    Yes! Death could come at any moment but it is certainly not expected at the prime of life, when you are just embarking on your life, when your dreams are glowing before you, promising a rewarding life…I wish God could be more kind and loving.
    Love you dear friend.
    Balroop.

    • Dear Balroop,

      Your first paragraph so beautifully captures the essence of this book. As you point out though, it’s not just about heartbreak, but it’s also about living fully and even bringing a new being into life as your own dissolves. Yes, it doesn’t seem fair that such a brilliant and young neurosurgeon, who had an amazing heart and wish to help, would leave us so soon. But maybe his leaving is as much his message as staying would have been. I think of all the people he’s touched now with this words and how he’s made a difference in their lives. What comes to mind is the saying that, “God works in mysterious ways.” Thanks for sharing your perspectives on this. All my love to you, dear Balroop.

  10. Wow, Sandra. This is a topic that intrigues me as well. A friend of mine leads “death cafes.” Have you heard of this? (You can google “death cafe” or if you want to know more about what is happening here, “death cafe portland.” ) Anyway, it is, as the name suggests, a place to visit, have some tea or coffee, and talk about death. There was quite a big event here last year with hundreds of people, but most are smaller.

    When I used to have a word of the year, my word one year was “prepare.” Although I didn’t have a sense that my physical death was imminent, I did get a strong message that I should prepare to die. Once I could make friends with my death and see death as a friend or advisor, then death was not something to fear.

    I believe you (or was it someone else?) said once that there was a concept about a “death twin” born at the same time we are, who accompanies us as a friend through life. I loved the image.

    Like others, I think this book is going to be at the top of my reading list. I love the title. It reminds me of the Hebrew name for God sounding like the breath. The breath becomes not just air, but sacred air.

    Hmm, this comment has meandered all over the place, but your post, as well as all the comments and your responses, definitely got my attention.

    Again, wow.

    • Hi Galen! How interesting, we’re going to have our first Death Cafe here this month! I’m looking forward to it. This is really the key, isn’t it: “Once I could make friends with my death and see death as a friend or advisor, then death was not something to fear.” We might go through some ups and downs going through this process, but I think it’s possible to feel more peace and more acceptance of whatever emotions arise around impermanence and death.

      I’ve never heard of a “death twin” before, that’s fascinating! I’ve heard we’re born with our own angel and our own demon. Similar.

      I hope you enjoy the book. It’s such a pleasure to see you here.

  11. Thank you for sharing this, I will read the book, just put a reservation in at the Library.
    I don’t fear death, maybe after having 2 NDE and being with my parents when they passed. For this young man, it seems he fulfilled his calling in part.

    I was interested that he returned to his Christian faith. The Dali Lama I know encourages people to explore their traditional religons xxoo

    • I’m so glad you don’t fear death, Suzie! The ability to let go with ease is an amazing accomplishment, I feel. Yes, it was interesting that Dr. Kalanithi returned to his Christian faith, since he was so rooted in science. But something spoke to him there and so I see his heart followed.

  12. This is a beautifully written piece, Sandra. Thank you so much for sharing the book and the story of Dr. Kalanithi. It is so heartbreaking to read about younger people living vital lives to have their gifts cut short. Yet, the book feels like one that will encourage all of us to consider our own death and prepare for it by putting more meaning and focus into our lives.

    • I think you’ve captured the essence of the book beautifully, Cathy. I think this would be Dr. Kalanithi’s wish for us as well!

  13. James Salls

    I feel as if this article helps us to realize what things are important in life. The statement of how to find the balance between, “doing and being,” left me pondering. When faced with lifes challenges, or the challenge of death we often try to focus so much on a task and lose ourselves in that task rather then living. However, as the article states we alone must decide how we are comfortable in going, how we will embrace death, and how we will live. The article was insightful and helped me to self-reflect on what decisions I am making in the present so thank you

    • You’re very welcome, James. I feel like you’ve truly embraced the message in my article and in this book. You’re so right that we tend to be task oriented, but that’s not always optimal. I wish you the very best with your reflections and may you enjoy each moment of your life. Thank for taking the time to let me know how this article touched you. That means so much to me.

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