The Letter of Condolence

"A physician's responsibility for the care of a patient does not end when the patient dies. There is one final responsibility--to help the bereaved family members. A letter of condolence can contribute to healing a bereaved family and can help achieve closure in the relationship between the physician and the patient's family ... Whether intentional or not, the failure to communicate with family members conveys a lack of concern about their loss."¹

It has been said that we are more likely to receive a condolence card from our veterinarian than we are from our personal physician.

In a recent column for Clinician-Patient Communication,² Dr Scott Abramson, Neurology, Hayward, CA, tells the story of a young woman he talked with whose father died the month before, under the care of KP clinicians. She said, "After he died, I heard not one word from Kaiser. Not one phone call; not one condolence card. Doctors and nurses showed such great concern while he was dying; yet after his death, it was as if he never existed! I felt hurt. I felt abandoned."

In a noteworthy article extolling the value of writing letters of condolence, Bedell, Cadenhead, and Graboys¹ outlined why doctors do not regularly write letters of condolence. Reasons included a lack of time, a feeling that they did not know the patient well enough, no specific team member was responsible for writing the letter, a loss for words, and difficulty with their own experience of the loss as a sense of failure.

Generally, in the larger context of medicine, the focus is on cure--not on what to do if a disease cannot be cured. Slow integration of palliative care, relatively few discussions about advanced care planning, delayed referrals to hospice, and reluctance to follow up with family members when our patient dies are all behaviors that show how difficult it is for those of us in health care to focus on dying and death. That is not to say that the will to do more is not there--culture and lack of training may be the culprits.

Bedell et al¹ highlight the benefit of writing a letter of condolence as twofold: to be a source of comfort to the survivors and to help clinicians achieve a sense of closure about the death of their patient. In the sidebar on the previous page, Dr Mark Geliebter, Martinez, CA, describes how he began writing letters of condolence to his patients and the value this practice has had for him.

If you decide that writing a letter of condolence is a practice you would like to begin incorporating into your medical practice, the following guidelines, adapted from Wolfson and Menkin's "Writing a condolence letter,"³ may be helpful.

Throughout KP Northern California, some departments, team members, and individual clinicians have chosen to routinely send letters or cards of condolence to family members when a patient dies. Clinicians report the deep satisfaction they feel in this act of follow-up; family members report their heartfelt thanks that KP clinicians took the time to recognize the family's grief and their role in the care of the patient. Letters of condolence can make all the difference--to our members and to us as clinicians.

Doctors and Sympathy Cards
By Mark Geliebter, MD

As soon as the Code Blue ends in the emergency department all of the housestaff scatter. During my training, I was always struck by how quickly the doctors would leave the scene as soon as the patient was pronounced dead. There was no lingering--as if no one wanted to stay in the room with the dead person. The strategy seemed to be to create physical distance from any associated feelings of failure as a doctor. There was no ritual to follow at the end of an unsuccessful resuscitation effort. There was never any discussion about the ritual of death. We would spend weeks and weeks discussing the Krebs molecular "life cycle" in medical school. However, discussions about the natural cycle of life and death were rare. After practicing internal medicine for many years at Martinez, CA, I was struck by my own lack of closure when my patients died. I too would not hover at the bedside when a patient of mine had died. I would not routinely connect with family members after a death. Many years ago, I became involved in physician wellness efforts at my facility and regionally. I realized that exploring our own relationship with death and dying was a key element in physician well-being.

One of the outcomes of that exploration was the decision to start a new practice for myself in 1995. I began to list the name of every patient of mine who died. I generally would include a diagnosis, medical record number, date and place of death. I started a folder labeled "Death and Dying." I also began to send a sympathy card to each family (I later found these cards available as a KP stock item!).

Initially, I began with brief statements of sympathy. More recently, I've been writing more personal comments, especially when I've had a longer relationship with the person or their family. I frequently mention that I felt privileged to have been their physician. I also try to call the families that I feel connected to. I have received frequent positive feedback from families for my personal note or call. They are most appreciative of my thoughtful acknowledgments.

This has created a ritual practice for myself at the time of a patient's death. It also gives me a way to remember my patients. When I review my list, I can usually remember something about them, their faces, their personalities, or some ethical or medical issues that may have been challenging. Even after many years, the list elicits those memories. I would have totally forgotten many patients that had died if it weren't for my list. At times, it reminds me of memorial plaques on some synagogue or other walls that list names of members or their families who have died. Sending the sympathy card and making the follow-up phone calls have become part of my own sense of responsibility as a physician. It helps obviate the need to run out of the room after an unsuccessful Code Blue, as I did when a medical student. Integrating the reality of death; embracing it as a natural process; developing coping strategies; not labeling death as failure; finding rituals; doing outreach during and after the dying process are all part of our role as physicians. All of these insights and rituals will add to our own personal wisdom of dealing with the inevitability of our patients' and our own deaths.


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