Sounding Board
The Doctor's Letter of Condolence
N Engl J Med 2001; 344:1162-1164April 12, 2001DOI: 10.1056/NEJM200104123441510
- Article
In response to an article on grief, one of us received the following letter (the names have been changed):
Dear Doctor,
On August 3, my mother, Jean Smith, died. She had been a patient at the Medical Center with Dr. Roberts. Until her death, at 90, she was an active person, involved with her family and the world — driving, going to yoga class. She died suddenly, in her sleep. We are all bereft.
Several weeks after her death, I wrote to Dr. Roberts to tell him that she had died. I told him how very much I appreciated his care — his conscientious medical attention as well as his reassurance when she was anxious and worried about her health.
I have never gotten a response from him or from anyone else at the Medical Center. I find this very disappointing, and it has troubled me a great deal. I thought you should know this.
Sincerely,
Margaret SmithA 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 the healing of a bereaved family and help achieve closure in the relationship between the physician and the patient's family.
Most doctors do not write a letter of condolence after a patient dies,1 even though they know such a letter can help both the family and the doctor deal with the loss. There are many reasons for the failure to write letters of condolence. As one colleague commented, “Doctors are just too busy.” The physician may feel that he or she did not know the patient well enough to write a genuine letter of condolence, or the physician may be part of a clinical team, and the responsibility for writing the letter may not be clearly assigned to one member of the team. A doctor who has not seen a patient for some time may hesitate to write to the family. In addition, writing condolence letters requires that doctors overcome their own sense of loss or failure.2,3 Finally, it is hard to know what to say when someone dies.
Cultural Changes in Mourning
In 19th century America, the process of grieving was detailed and elaborate.4-6 The doctor's letter of condolence was an accepted responsibility and an important part of the support offered to the bereaved. Dr. James Jackson's letter of 1892 to Mrs. Louisa Higginson shows the level of detail that was characteristic of physicians' condolence letters in the 19th century.7
My Dear Friend,
I need not tell you how much I have sympathized with you. I think I realize in some measure how much you will miss dear Aunt Nancy for a long time — for the rest of your life. I know that she has been a part of you. . . . Mind as well as body was duly exercised, and she always had stock from which she poured out stores for the delight of her friends, — stores of wit and wisdom, affording pleasure with profit to all around her.
How constantly will the events of life recall her to our minds — realizing what she said or did under interesting and important circumstances — or perhaps suggesting imperfectly what she would have said under new and unexpected occurrences.
For you my dear friend I implore God's blessing.
Your old friend,
J. JacksonToday, the pattern of mourning has changed. Despite a resurgence of interest in achieving “the good death,”8 we often neglect those who are bereft after the death of a relative or friend. In fact, over the past century, the accepted process and rituals of mourning have become much abbreviated. As Margaret Mead wrote, “Mourning has become unfashionable in the United States. The bereaved are supposed to pull themselves together as quickly as possible and to reweave the torn fabric of life. We do not allow for the weeks and months during which a loss is realized.”9 With less support offered to the family, grief may become more complicated and prolonged.10
The doctor's role at the time of mourning has also become more distant and less supportive. Physicians are not trained to support a bereaved family. A recent review of the 50 top-selling medical textbooks showed that there was “a paucity of attention . . . to the domain of physician responsibilities after death.”11 As Therese Rando notes, “Professionals tend, as does the general public, to have inappropriate expectations and unrealistic attitudes about grief and mourning.”12 For a variety of reasons, doctors infrequently attend the funerals of their patients.1,13 Writing a letter of condolence after a patient's death, once an accepted practice among clinicians, is now often omitted as well.
The Letter of Condolence
The family of a seriously ill patient depends on the doctor's experience and judgment in dealing with the illness. After the patient has died, the family may depend on the doctor's experience with grief and on his or her words of comfort. A letter of condolence from the doctor may thus have special meaning for a family in mourning.
A letter of condolence allows the doctor to express his or her sympathy for a family's loss, and it helps the family as they move through the natural phases of grief. A letter that addresses the reality of death aids the family in accepting “the discomfort of bereavement”14 and affirms the importance of the relationship between the deceased person and the doctor.
Especially in the case of a death that is unexpected or comes after complications from hospitalization or a procedure, the letter of condolence helps the family members manage the anger that accompanies their loss. The emergency department at one hospital initiated a program in which the staff member who had been responsible for the care of a deceased patient sent a sympathy card to the family. The response from the families was very positive.15 The absence of a letter of condolence may arouse disappointment, as expressed by Margaret Smith, or even suspicion, as in the case of a bereaved daughter who said, “After my mom died, the doctor never even wrote me. He ran and hid.”
Although not often discussed openly, writing a letter of condolence may, according to Susan Block, help relieve the physician's burden of “grief and distress about the loss”16 of a patient. The physician, like the patient's family, needs to have a sense of closure about the death.
In addition to the benefits for the family and the physician, writing a letter of condolence provides a model of “humanistic behavior”17 for nurses, office staff, and residents. Throughout George Thorn's tenure as physician-in-chief at Peter Bent Brigham Hospital in Boston, it was the responsibility of residents to write letters of condolence. Although this practice has not continued, some physicians still use teaching rounds to emphasize the importance of the condolence letter. In our practice, we discuss the letter of condolence during mortality conferences. We encourage all physicians, house staff, and fellows who have had personal contact with the deceased patient to write the family. Unlike expressions of condolence made by telephone or in person, a letter of condolence is a concrete gift that the recipient can and will review over and over.
Suggestions for Writing a Condolence Letter
There are ways to make the difficult task of writing a condolence letter easier. The letter may describe in detail the extent and depth of the relationship between the physician and the patient, or it may be a much shorter expression of sympathy. Whatever one writes, it is important to avoid superficial attempts to assuage grief, such as, “It was meant to be” or “I know how you feel.” In order to avoid issues of legal liability, the letter should focus on the sadness of death rather than revisit the clinical details of the illness.18
One can begin the letter with a direct expression of sorrow about the death, such as “I am writing to send you my condolences on the death of your husband.” In our condolence letters, we try to include a personal memory of the patient and something about the patient's family or work. Specific references to achievement at work, devotion to family, courage during the illness, or the patient's character can bring life to the letter. We also state that it was a privilege to have participated in the patient's care. We point out the comfort the patient received from the family's love. We conclude the letter with a few words of support to let the family know our thoughts are with them. These suggestions are intended not as a substitute for the expression of genuine thoughts and feelings but as an aid in approaching the task.
Conclusions
The letter of condolence is a professional responsibility of the past that is worth reviving. It can have a positive effect on the grief that family members experience and can help them face the future. The letter may be of considerable importance, as one family member suggested: “If the physician does reach out to the bereaved family, not only is comfort felt in sharing the enormous loss, but there is a positive feeling generated toward the physician. This influences all future contacts, not only with that doctor, but all doctors.”
Failure to write a letter of condolence is more than a simple omission. Whether intentional or not, the failure to communicate with family members conveys a lack of concern about their loss.19 In a medical world shaped by technological advances in the care of patients, we must maintain our humanity in our interactions with patients and their families, particularly when we share with them some of the most profound moments of life and death. After a patient dies, when we all feel helpless, the best care we can provide is our expression of concern and sympathy in a letter of condolence.
Susanna E. Bedell, M.D.
Lown Cardiovascular Center, Brookline, MA 02446Karen Cadenhead, Ed.D.
Concord, MA 01742Thomas B. Graboys, M.D.
Lown Cardiovascular Center, Brookline, MA 02446Supported by a grant from the Lown Cardiovascular Research Foundation.
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Javier Barbero Gutiérrez, Helena García-Llana, Rocío Rodríguez Rey, Mirian Prado Redondo, Valeria Marongiu, Miguel Ángel Canales Albendea, Rafael Selgas Gutiérrez. (2013) Evaluación del impacto de cartas de condolencia en familiares en duelo. Medicina Paliativa
2
Javier Barbero Gutiérrez, Alicia Alameda Angulo, Laura Díaz Sayas, Mari Carmen Jiménez Ávalos, Helena García Llana. (2013) Las cartas de condolencia: marco conceptual y protocolo. Medicina Paliativa
3
Santiago Borasino, Wynne E. Morrison, Jordan Silberman, Chris Feudtner. (2011) Factors associated with pediatric critical care attending follow-up with families after the death of a patient: A national survey with an experimental design*. Pediatric Critical Care Medicine 12:6, 622-627
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Joanne Wolfe. Easing Distress When Death is Near. In: Textbook of Interdisciplinary Pediatric Palliative Care. Elsevier, 2011:368-384.
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Silke Collins-Tracey, Josephine M. Clayton, Laura Kirsten, Phyllis N. Butow, Martin H.N. Tattersall, Richard Chye. (2009) Contacting Bereaved Relatives: The Views and Practices of Palliative Care and Oncology Health Care Professionals. Journal of Pain and Symptom Management 37:5, 807-822
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