Locating Five Stages of Grief of Dr. Kalanithi: A Textual Analysis of When Air Becomes Breath

– This study takes place in the realm of psychological literature. It analyzes the autobiography of American Dr. Paul Kalanithi, When Air Biomes Breath. The story revolves around Dr. Kalanithi’s life being a patient of lung cancer at the last stage, IV. The book is marvelous and incredible, life-affirming meditation from this remarkable man, on the subject of difficulty of confronting mortality and the bond between doctor and patient. This is a memoir about his life and disease, combating metastatic lung cancer. He shares grief, suffering, turmoil and psychological trauma and its balance point in the book. Similarly, the researchers have inspected the stages of grief Dr. suffered from. For this, Textual Analysis of the book is conducted through Kubler-Ross Model of grief as a theoretical framework. The study is designed descriptively. The selected excerpts from the story are analyzed to reach the research question. The findings of the study reveal that Dr. Kalanithi had deeply suffered from five stages of grief as proposed by Ross, but his circle of grief goes in contrast. He randomly accepted, rejected, became angry and denied, and again accepted this turmoil. Relatively, this study is helpful for understanding the model and the storyline of Dr. Kalanithi in the realm of psychological literature.


I. Introduction
When Breath Becomes Air (2016) completely retains the elements of an autobiography and non-fiction work.It is written by Dr. Paul Kalanithi (2015), who hailed from America and was a student of English literature, medicine and was a Neurosurgeon.The book is marvelous and incredible, life-affirming meditation from this remarkable man, on the subject of difficulty of confronting mortality and the bond between doctor and patient.This is a memoir about his life and disease, combating metastatic lung cancer in stage IV.He shares grief, suffering, turmoil and psychological trauma and its balance point in the book.The whole book revolves around his own life experiences which sound grieving and painful for him.Hence, the elements of Kubler-Ross's (2004) model of grief also prevail in the autobiography of Dr. (2015).Therefore this model of grief is taken as theoretical framework in order to conduct this research.
Additionally, Kubler-Ross, Elisabeth (1926-2004) was a Swiss-born American psychiatrist whose study and work on people with terminal illnesses tended to shift perceptions towards death and the consideration of the dying.She resisted the stigma against publicly discussing and examining death, and was a catalyst in the US to establish hospices where the dying ones are equipped with preventative assistance, treatment and care.The model of five stages of grief (The Kubler-Ross Model) is also purposed by Kubler-Ross in her book On Death and Dying (1969).She posits that a person who suffers from turmoil usually comes through the five stages of grief which are: denial, anger, bargaining, depression, and acceptance (Shiel, 2005).

A. Background
According to Psychology, for people, grief is an intense, often emotional trauma, irrespective of whether their distress derives from a deceased relative or from a fatal illness they have obtained or someone they love.They can feel depressed and detached from regular activities, unable to continue with basic duties while lumbered with their feeling of disappointment.The natural response to loss is sorrow.Grief is a common phenomenon as well as a particular one.Specific grief paths diverge and are shaped by the essence of the impairment: the death of a close one, the termination of a close person, work loss, deprivation by theft or the loss of sovereignty through inability are some examples of damage (Mayoclinic, 2016).The intense inflammation that follows loss is grieving.It can feel all-encompassing because it is a representation of what people love.Grief is not restricted to the losing of individuals, but it can be exacerbated by feelings of remorse and uncertainty as it follows the death of a loved one, particularly if the connection was a strong one (see psychologytoday.com).

B. Problem Statement
The human mind has faced turmoil and grief throughout human history.Dr. Paul Kalanithi (2015) has also been the victim of this turmoil during his life.His book When Breathe Becomes Air (2016) which is an autobiography in nature, sheds light on Dr.'s life full of turmoil and grief.As this book has been given touch through other perspectives by other researchers, this study highlights the elements of Kubler-Ross Model in the story of Dr. Kalanithi in order to find grief that how Dr. has suffered from grief.It evaluates the stages of grief Dr. Kalanithi suffers from.

II. Literature Review
The researchers bring some related literature here.The literature is reviewed on understanding grief and previous studies on the selected book.Netw (2017) conducted a study on the topic of "When Breath Becomes Air-As Physician Becomes Patient".The study is basically on a conference held about Dr. Paul Kalanithi, the writer of the book selected for this research.The writer has analyzed the speech by Dr.'s wife Lucy Kalanithi MD, Paul's oncologist, Wakelee MD and answer question in the conference.The evaluator explains the situation of the Dr. explained by Dr. Wakelee as physician-turned-patient.The writer also writes about the balance between the professional and personal life explained by Dr. Wakelee.The researcher evaluates those questions which provide information about the relationship between doctor and patient who are actually wife and husband.Dr. Kalanithi explains the circumstances about the situation when Dr. Paul was diagnosed with lung cancer at stage IV.The situation after diagnosis is evaluated through Dr. Carlson who was also in the conference.He says that Dr. Paul also used to work after diagnosis.Lastly, the study meets at the end describing the death scene comparatively at home vs hospital.Before that he was at home without medication, and suddenly felt respiratory failure which caused her bring him to hospital.She prefers his death at hospital, because it was not emotionally easy for her to see him dying home helplessly.Granek (2010) conducted the research on Grief as Pathology.It is a comprehensible article with apparent purpose which is to indicate the evolution of grief.It comprehensively evolves from the theories of Sigmund Freud to the contemporary psychology.The whole formula of grief is generated through historical theories and expenses of psychology.It does not only demonstrate the introduction of grief but also uncovers the source of grief and impacts of grief on individual.In brief, it signifies the grief from inception to conclusion.The other thing is that it unveils the progress of psychology with the extend of grief theory as it takes the example of a person if he/she is in depressed condition because of any issue which makes a person totally sad, then that thing will influence not only person's feeling but also have a bad influence over brain and it automatically causes health issues.Therefore, grief causes a great impact on psychology and this article emphasizes the grief over death of a close person.The researcher concludes that it also manifests that in a society the proficient of mental health not only prescribes medicine but also trained people especially for pathology.Read, Adiibokah & Nyme (2009) have conducted the research on the topic "Local suffering and the global discourse of mental health and human rights: An ethnographic study of responses to mental illness in rural Ghana" The study talks about the background of the study that The Global Movement for Mental Health has come to aware the people about mental illness who neglect it.This involves that human rights have promoted the idea about the treatment for the people who have been living with it with their families.This study form the method of ethnographic research dealing with the mental illness in rural Ghana.The researchers have found the findings that in rural Ghana mentally ill people were beaded brutally in their homes.They were neglected with respect to treatment.This is why some mental institutions were generated to put them there as it was difficult for the psychiatrist to deal with them in their homes.The researcher concludes the study that people should be engaged with the mental preparation for this restraint.Corr. (2007) has conducted the research related to the theoretical framework of the study.The research is subjected as, "Copying with dying: Lessons that we should and should not learn from the work of Elisabeth Kubler-Ross" Mostly, people read articles to gain clear ideas about a specific thing which is blurred in their mind but this research has opposite discussion about it.This article is like full of jumbled ideas because on one side it talks about the things people should learn and on the other side it says people shouldn't follow them.In short, the author of article himself is confused whether he should support this idea or not.Firstly, article gives the idea that Kubler-Ross Model is not applicable yet on the next side, it recommend to comprehend few points of it.Charles argues that there are some reasons for one should not follow this model.Relatively, he provides major reasons that why people should contemplate about them while dealing and coping with dying.He provides that Ross's model is not practically dealing with the psychology, rather it deals with the teaching or schooling of psychiatry.In short, the whole www.researth.iars.info/index.php/curiediscussion is basically a piece of criticism which provides the both aspects of her model of grief and its stages.
The aforementioned reviews have mainly a touch with the subject of this research.The study is psychological, yet in literature: an autobiographical nature.The reviewed researches retain the same subjects of psychology.Specifically, the whole review is across the study's genre.It discloses that Dr. Paul Kalanithi's story has been deprived by the researchers.For this, this research aims at manifesting elements of Kubler-Ross Model of grief reflected by in Dr. Kalanithi's autobiographical book.

III. Research Methodology
The researchers here discuss research method and theoretical framework.

A. Theoretical Framework: Kubler-Ross's Model of Grief
Everybody faces grief in their life.For children divorce is a grief, for parents the death of their offspring causes grief.Grief can be caused by accident, death, break-up and heartbreaking, etc. Elisabeth Kubler-Ross identified five common phases of grief discussed in his book of personal experiments and experiences, On Death and Dying.The five stages are popularly known as: Denial, Anger, Bargaining, Depression and Acceptance (Kubler-Ross Model of Grief).

B. Denial
Denial causes the neglecting attitudes towards life.This attitudes provides fake satisfaction, and does not lead to the actual reality.The bad news is usually defied in this attitude.For Example, Ross writes that, if a diseased person knows about his positive reports, he suddenly denies them, and provides logic that, it may have been mixed up or they are wrong.There may have been a systematic error (Ross, 1969, p.25).It provides assistance with coping with issue and not overwhelmingly contemplating over grief.According to Ross every patient has this attitude of denial.Denial is not permanent it fades away (Ross, 1969, p. 26).

C. Anger
According to Ross, once Denial has faded away, another stage of grief takes place, which is anger, rage, envy and resentment (Ross, 1969, p.32).The patients at this stage usually come out of the satisfactory reality, and accept the fact of their grief.For example, they get hyper, they ask questions from God that why this happened to them only.They feel inferiority complex, and get angry over everything.Ross purposes that it is also a stage of grief, when someone is angry in the condition of sadness or grief.Unlike denial, this stage is not easy to be copped with.Only few patients understand this and think about where this anger comes from.

D. Bargaining
The third stage of Grief is bargaining.This brings a hope for people.It is normally fake in the case of patients.Ross discusses that patient usually after hearing about their bad news, denial and anger, they tart bargaining.For Example, they prays that if they get well soon, they will sacrifice something.According to Ross this is also stage of fear in the mind, which causes them to overwhelm their grief by getting approved it, by sacrificing them (Ross, 1969, p. 52).This also involves guilt, which stands as a common wing of men.They bargain to save themselves, because they are in fear.

E. Depression
Depression is a present emotion in human life.It is most acceptable and displaying form of grief.People associate grief with depression.According to Kubler-Ross, grief is common in depressed people, and they themselves highlight it.The patient's guilt, anger and denial go away in this stage.He forgets his smile, and finds no way to pace.People withdraw from life, and go numb at this stage (Ross, 1969, p.54).

F. Acceptance
The last stage of grief according to Kubler-Ross model is acceptance.According to the model, at this stage patients usually accept everything.They seem to bid farewell by accepting their grief, trouble and disease (Ross, 1969, p.75).Kubler-Ross also calls this acceptance a stage of grief.This is acceptance of reality.If someone died, it is not fine, but the person is going to be fine at the death of his/her.This acceptance is also a grief.This is, on a ground, readjusting, and adjusting the whole circumstance.
Similarly.Such identical elements of grief prevail in the autobiography of Dr. Paul Kalanithi.He suffered from grief in his life when he was diagnosed with cancer.Therefore, the researchers attempt to diagnose the stages of grief Dr. Kalanithi suffered from through this theoretical framework.

IV. Analysis
The study here provides the complete textual analysis.This section deals with some selected quotes from the subject-text of the study.The quotations are analyzed with the optic of subjective interpretation.The researchers share theoretical subjectivity-based interpretive answers to the research questions and objects.The chapter aims at displaying and justifying the research objectives and finds the research problem.The analysis is done in the light of aforementioned theoretical framework of Kubler-Ross Model of Greif.www.researth.iars.info/index.php/curie

A. Model of Grief
The model was introduced by Kubler Ross and it deals with the grief in human psychology.It has majorly five assumptions: Denial, Anger, Bargaining, Depression and Acceptance.Principally, these assumptions are stages a person comes across when he or she suffers from grief.Hence, the character of Paul Kalanithi also faces these stages in the story of his life shaped by him.He suffered from lung cancer stageiv.While suffering from this illuminating disease he also came across the stage of grief and he himself accepts in his autobiography.Therefore, this model is taken as theoretical framework to locate Paul's grief and the stages.

B. Textual Analysis
Every human being normally comes across some saddest chapter of life.He or she faces some biological, medical, social, economic, political and relational, etc grief and pain.This sometimes brings hope, sometimes despair.Some people accept their miserable atmosphere.Some people deny it.Some people also get angry because of their pain.Other also bargain for the eradication of their grief with religious affiliations, etc.A good number of these grieved person gets depressed because of that.It sometimes causes their suicide, etc.Therefore, the masters of psychology have studied this grief study, and many a writers have depicted and portrayed such grieved characters in their literature too.
The real life character of Paul Kalanithi also suffered from the stages of grief.Later, he wrote his autobiographical story, in which he has narrated the whole suffering from being healthy to being ill-diagnosed with lung cancer.Hence, the following discussion deals with justifying the grief stages through the textual references from the autobiography.

C. Paul Kalanithi as Patient
"I'd examined scores of such scans, on the off chance that some procedure might benefit the patient.But this scan was different: it was my own."(Kalanithi, 2016) Paul Kalanithi was basically as student of English literature and medicine.He was neurosurgeon.It is strange and coincident to know that being a doctor he became the patient of same suffering.It is considered normal in the daily routine, but for the world of medicine, it is really a coincidence.Paul Kalanithi shifted from a healthy life towards the life of grief and suffering.For justifying his disease, before justifying his grief, the aforementioned quote is taken from his autobiographical work.This line is firstly chosen to prove Paul as a patient.The line displays that Paul has some sort of medical problem.The line shows that he was healthy in his early life and was doing well in his life professionally and socially.But suddenly, there was a scan he talks about in the line.The scan was different from the normal scans.For the scan he had, was his own.He admits it.The scan later, shows his lung cancer at the stage of IV.The above line, therefore, describes him as a patient of some disease, which later creates grief for him.The furtherer references, for justifying his grief with respect to the research question and objective, are taken below.

D. Denial as Grief
According to the model of grief, the first stage of grief is denial.When a person or any patient denies the reality of life he or she is actually in grief.The person pays the neglecting attitude towards life.The neglect is basically the denial, and that denial is psychologically grief.Similarly, in the story of Paul Kalanithi, it sounds very apparent the element of denial.
When, Paul was diagnosed with cancer, he started admitting and finding the alternative ways to deny it.This was actually his grief which let him to find the alternatives in order to neglect the truth of life and provide him a fake satisfaction.

"As if I might find something that would change the diagnosis" (Kalanithi, 2016)
The aforementioned line also describes Paul Kalanithi in grief.
He is suffering from it, and he unconsciously wants to deny it.
In the hospital, Paul is with his wife.At the place, he asks his wife if he finds something that may shift his diagnosis.He seems in fear, and wants to find the alternative way to escape from his disease, his diagnosis.Generally, he appears to be escaping from his initial diagnosis.The line obviously supports and justifies the argument of the model that grief causes the denial in patient or any other person in social life.This same happens with Dr. Paul who is in fear and denies his diagnosis by indirect pray that his diagnosis might be change, unreal or mistaken.
"In the past year we'd both suspected, but refused to believe, or even discuss, that a cancer was growing inside me." (Kalanithi, 2016) Another example from the text is brought here to justify his grief the denial of it.In the story, he mentions his lying, in a tight hug like a young couple, on bed, and he himself admits that both his wife and he had denied his disease when he was firstly diagnosed with it.Despite knowing the fact that cancer was breathing inside his body, he refused to believe this.This refusal is basically also a grief, a fear and a misery a person's come across in his life.According to the model, the person denies such facts of life because he or she does not want to face that grief, or he or she does not have nerve to stand against such grieved chapter of life.In that case, people deny the fact.Paul also does same in the story.He at many places denies the face of his cancer, and in the mentioned he himself admits that he refused the suffering from cancer.According to psychological theoretical framework, this denial is a proper sign of psychology that help to escape the patient from reality.
The same happens to Dr. Paul.
I turned off my phone."Let's get some ice cream," I said."(Kalanithi, 2016) The above mentioned line is third example of Paul's denial of his disease.In the story, he is lying on bed with wife Lucy, where she somehow looks at his phone, which shows the display of his search list about cancer.The wife throws the bundle of question over his face, but he denies to answer, and asks her about getting ice cream.This portrays his denial because he does not want to be grieved while sharing this all with his wife.This his denial of grief.He escapes from grief by not sharing the disease with his wife at temporary level.The denial is proven as grief, this suggests the theoretical framework of the study, too.

E. Acceptance as Grief
According to the model of grief, acceptance is also a stage of grief, where the patient or a person accepts the situation as it is.The person cannot find a way to escape from the fact, and let himself be habitual of it.This situation of acceptance makes the patient somehow more grieved.The person becomes pessimistic and feels inferior to the opportunities of life for his grief.This helps him to understand the pain of life, and he sees no alternative way to his grief, but its acceptance and want to become used to it.This also sometimes help him to understand that this is what reality is.This amalgam of acceptance, grief, and having no other way in life, psychologically causes more pain, because this situation makes the patient helpless.
In the story of Paul, this stage of grief is his character can also be located in his autobiography."Of course," I said, "if this were a board's exam question-thirty-five-year-old with unexplained weight loss and new onset back pain-the obvious answer would be (C) cancer" (Kalanithi, 2016).The mentioned dialogue reflects the acceptance of Paul about his diagnosis.He seems equal to understand the fact that this is his diagnosis, this is the fact: and it is cancer.He understands that he should admit this fact.The dialogue is uttered to doctor he meets in the hospital where he seems accepting his diagnosis in very interesting words.He relates his report and condition to the academic procedure of judging a student.He says to doctor that even if this question of his condition was given in the board exam, the answer would be C option: Cancer.Simply, Paul accepts his cancer to his doctor.His acceptance shows that he is grieved.He psychologically suffers from an ill-condition.

F. Acceptance & Depression as Grief
"I'm sorry, but I'm dying from cancer."(Kalanithi, 2016) The above line from the story of Paul basically depicts 2 stages of grief: depression and acceptance.On one hand, Dr. is accepting his disease, and says that he is going to die.This show his hopelessness and anxiety.He admits his grief of disease and finds no alternative way to escape from it.Therefore, he remains in depression.When a person finds no way to do anything, he or she indulges in depression.And, according to the model of grief, depression is the constant stage in human life.Paul also suffers from depression when he finds no other way to escape from disease and accepts it as a fact.His acceptance is here is depression.The unresolved condition of his disease causes depression for him, and he accepts his fate.

G. Bargaining as Grief
The model proposes the stage of bargaining.It is basically the fake hope of for the patients.It provides fake satisfaction to them.It is sometimes religious too.Patients usually pray from God and convinces themselves that if it is to be alright, they will sacrifice something for this.This, according to Psychology is fake.This bargaining with God and with anyone else is also a stage of grief, where the person wants to escape from it.
Similarly, this happens to be same in the story of Paul.
"Things are going to be okay," I said."It's just residency."... "The sun was setting.I would be discharged the next morning."(Kalanithi, 2016).Paul normally appears to be bargaining with his wife Lucy, and tries to convince her and himself that the condition is to be fine.He will be alright with passage of time.The aforementioned line form the story justifies this argument.The line in the story is uttered to Lucy by Dr. Paul.The other line describes his hope which is usually gained by bargaining.Therefore, according to the model, Paul actually defies his grief of suffering from cancer, and he provides fake and self-satisfaction to his wife and himself by bargaining socially not religiously.This displays his peak of grief, misery and sadness.There are no words to express the secret agony of his soul, but to bargaining, faking himself, his mind by creating fake satisfaction for his family and himself.

H. Anger as Grief
"Fine, I said.If she decided to leave, then I would assume the relationship was over."(Kalanithi, 2016) This line clearly depicts Paul's another stage of grief as discussed in the Greif Model.This puts the clear image of anger in the mind of the readers.The Model discusses that after denial there is anger in one's personality.The patient or the person shows anger at things.According to the study of model, this anger normally becomes the source of escape from the lexical grief.People try to run away from grief by showing grief.Therefore, in the story, Paul does the same.He shows anger over his wife for leaving him alone.He in anger breaks his relationship, if she goes to the trip alone.Actually, her leaving for trip causes grief for Paul.He becomes sad.But, he shows anger over it, and displays that he will end the relationship if she leaves him.So, this is not basically about ending relationship, rather it his anger, which helps him escape from the grief.Hence, in the light of the model, this anger is not anger, but his grief.

I. Acceptance of the Model
"It struck me that I had traversed the five stages of grief-the "Denial → Anger → bargaining → Depression → Acceptance" cliché-but I had done it all backward."(Kalanithi, 2016) The line quoted above retains a great significance in the whole discussion.The whole study attempts at proving five stages of grief proposed by Kubler Ross in the story of Dr. Paul.The researcher has brought some quotations from the text and has interpreted them in the light of model.But, this line does not need any interpretative worth.The line itself displays the Ross' concept of Grief.The stages proposed by Kubler Ross are accepted by the character, Paul himself in the story.He himself admits that he has suffered from five stages of grief.He, staring from a healthy life and ending at a diseased life, sees his life revolving around the five stage of grief.And in the field of Psychology, these five stages of grief are initiated by Kubler Ross, known as Kubler-Ross Model of Grief.The aim of this study also ends here by locating the exact acceptance of the character about his journey of five stages, and he argues that he has gone opposite to the order of stages.Like model proposes first stage of grief as denial, but in the story one finds that firstly he accepts this, but at the end, he denies it.He does not want to die, and deems himself fine, and goes to his hospital and does treatment of other patients, which shows his denial of the fact of being affected with cancerlung cancer -IV.

V. Conclusion
This section deals with concluding the whole study.The researcher here provides the conclusion of the study.The study mainly focuses on locating the Kubler-Ross Model of Grief.The model shares five stages of grief, and the complete stage are located in the in story of Dr. Paul too.Dr. Paul Kalanithi was a neurosurgeon and the student of English literature.The main focus of his life went on the medical field.He was a successful doctor who himself later turned to a patient.The story is tragic in nature as it deals with grief method in human psyche and life.The stages of grief replete in the Paul's life in very obvious form.When Paul is diagnosed with diseases he accepts as well as defies it.Later, he accepts it, he does bargaining for being happy in his life by curing the disease.Later, he also takes side of anger by replacing his grief with escape from its reality of leaving his wife on trip leaving him behind.Additionally, he appears to be in depression too while he is unable to find any alternative way to escape from the disease, and accepts it in depression.
At the end, it comes to a shocking point, when he himself accepts that he has suffered from the five stage of grief.This is a direct confession by the character in the story.Moreover, he pays argument that he has gone through the stages in opposite direction.First, stage of grief is denial, but in the beginning he along with denying, also accepts it, whereas, acceptance is the last stage of grief where the patient is remained with alternative source of way.And in the end of story, he denies his disease, and serves in his hospital.Where he should accept his grief, he denies it.This is uniqueness in him accordingly in the light of the model.In a nutshell, in any case, Dr. Paul suffers from lung cancer, and he also, though unorderly, comes across the five stages of grief as proposed by Ross (1969).