By Sonia Singh MD

Pronouncing Death, Eating a Sandwich

I vividly remember the first time I pronounced a patient dead. It was a few months into my intern year on the inpatient hematology service. In retrospect, I’m surprised I had escaped it that long. I was sitting at my desk in the resident workroom eating a turkey sandwich. A nurse knocked on the door and told me that Mrs. P had stopped breathing. It was an expected death – she had recurrent leukemia and had not responded to the last line of chemotherapy. After many long discussions we had shifted our focus to comfort rather than survival. She was 34 with two small children – one of the many cases that reminded me that life isn’t fair.

I walked calmly to her room, asked her sobbing family to step out, performed the death exam, gave my condolences to her husband and the time of death to her nurse, and returned to the workroom. The fellow asked me how it had gone.

“Terrible,” I wanted to say. It was one of the saddest things I had ever had to do in my life. But I didn’t say that. I thought if I said more than a few words I might start to cry, and besides, he had probably done this a hundred times. I didn’t want to be perceived as melodramatic.

“It went okay,” I responded. We looked at each other and both let out a heavy sigh. I sat down in front of my half-eaten sandwich and despite the fact that it felt like a denial of my own humanity, I decided to keep eating. Part of me felt like a monster at the time, but most of me felt like it was an act of self-preservation. I could not afford to do anything in that moment but bury it and keep going.

I can think of countless times over the course of residency that I did this – walking away from an unsuccessful code, sitting in the ICU filling out a “death packet,” returning to the call room after a terminal extubation – situations in which I felt that humanity bubbling up in me and I diligently pushed it back down. I became alarmingly good at this, as did my colleagues, and it wasn’t until the loss of my first patient outside of residency that it occurred to me how absurd this was.

By the way, Mr. D is Dead

Almost four years to the day after I pronounced my first patient dead, I lost my first patient as a primary care attending. He had avoided doctors for 30 years but couldn’t ignore his daily fevers and night sweats any longer. Shortly after our first visit he was diagnosed with lymphoma and subsequently underwent chemotherapy and achieved complete remission. Several months later he messaged me requesting a refill on his albuterol. I wonder now if that was a sign. I messaged him back asking how he was doing and encouraging him to come see me in clinic and get his flu shot. He never responded. A few weeks later he presented to the ER in septic shock and died within days. I was left with the familiar feeling of helplessness that I had throughout residency when patients passed away. It was a sunny Sunday morning when I logged into Epic and saw the death note. Although it hurt and I wondered for a few moments what I could have done differently, I eventually went out and forced myself to enjoy the day. Something I had trained myself to do in residency when there was simply no time to grieve.

On Monday morning I broke the news to my medical assistant. In our clinic, doctors and their medical assistants work as a close team in caring for a panel. I consider the patients we see to be “ours” – we both know their stories and quirks in addition to their medical needs.

“I don’t know if you saw this already… but Mr. D passed away over the weekend,” I said as I was robotically signing prescription refills and home health orders.

She was quiet. As soon as I looked up and saw the expression on her face I realized that I had been far too casual in my delivery. I had said the words in the way that I had grown accustomed to saying and hearing them in the hospital, where deaths happened relatively often. But this was a primary care office with a generally healthy, young population, and this was the first death we had had together, possibly her first patient death ever. She had a completely natural human reaction to the situation – a mixture of sadness and shock. I felt my own heart sink to my feet as she sat next to me speechless – not only at the thought of the death itself and my assistant’s response, but at my own callousness until that point. How could I reclaim my humanity? How could I have avoided losing a part of it in the first place?

Red Blanket, Red Paper Crane

The answer to these questions arrived in my mind in the form of a paper crane. As a resident I had cared for a patient on the inpatient oncology service whom every member of the team adored. He had been in the hospital for months and we had gotten to know him exceptionally well. Patients have every right to be miserable in the hospital, but Mr. A’s overwhelming kindness, gratitude and patience under the worst of circumstances touched us on a daily basis. We had even smuggled him a red blanket, a gift often given to hospital donors, board members and other VIPs upon admission to our hospital. It was a symbol of how he had affected us. A few days later, he had made each member of the team a red paper crane.

Even though it took him mere minutes to make and he handed one to every white coat that entered the room, I found it deeply meaningful. He had channeled his hope and fear and suffering into this elegantly folded piece of paper and given it to each of us. It was an acknowledgement of our humanity as well as his. I placed mine next to my computer in the workroom and found myself looking at it in moments I needed to remember why we were all there.

Less then a week later my red paper crane disappeared, presumably discarded by housekeeping during a deep clean. I was crushed. I thought about making another one, but I wasn’t sure how and it felt futile at the time. However, in retrospect I see both the significance and the potential that paper crane had. It was exactly what I had been wanting and needing throughout my training – some small way to acknowledge and honor the patients who I lost – something between pronouncing death and eating a sandwich, some time or space or object in which to briefly channel those difficult emotions, an opportunity to reflect and create something tangible to honor and acknowledge the loss of a patient and to ultimately let it go.

The creation of The Paper Cranes Project represents the culmination of these experiences. The Project was initially piloted at my own clinic, Stanford Collaborative Primary Care in December 2017.

IMG_2012.jpgSonia Singh is an aspiring writer and primary care physician at Stanford Health Care. She shares her thoughts on the often uncharted yet remarkable aspects of medicine and life in general at