June 27th, 2017

Bring Back the Letter of Condolence

Harrison Reed, PA-C, practices critical care medicine in Baltimore, MD.

I don’t remember the first time I watched someone die. I don’t remember the second or third time either. But I know it happened when I was 24 years old, and I know that, afterward, I went home, ate dinner, and went to sleep. The next morning I woke up, put on a clean pair of scrubs, and did it all over again.

Before I could even grow the scruffy hint of a beard, death had become a constant companion. But that didn’t mean participating in someone’s death ever felt routine, or that I grew numb to its significance. If anything, the effect was the opposite.

The more I encountered death, the more I saw it as an important chapter of life. And I made it my duty to ensure that my patients and their families navigated this often-saddening event surrounded by as many positive experiences as possible.

But as a brand new physician assistant in the intensive care unit of a mega-hospital, that desire was no easy accomplishment. A medical ICU at an academic center invites the intersection of two conflicting concepts: the close bonds that can form between clinicians and patients (or their families) over a prolonged hospitalization, and the factory-style shift work that keeps the entire process functioning.

That concoction produces the same scenario time and time again: we meet people with their every vulnerability flayed open to the world, guide them through their personal hells, and tear ourselves away at the end of their lifespans or the end of our work week, whichever comes first.

For patients and families, it must feel cruel. On the other side of that hospital bed, they may have found a friend in the most unexpected way, only to have that person vanish at the worst time. Then a new stranger appears, ready to restart the process.

That level of interchangeability clashes with the intimacy of death. At this most significant time in their lives, we pummel our patients’ families with a barrage of white coats.

The idea of dehumanizing medicine, especially at the end of life, began to bother me so much that I wondered if critical care was the right field for me. In my search for consolation, I found an article written by Dr. Gregory Kane. In it, he described a bygone tradition once commonplace in medicine: the letter of condolence.

By writing a letter to deceased patients’ next of kin, Dr. Kane argued, clinicians can offer families an irreplaceable level of support. We can reassure them that their loved one’s life was significant and that he or she mattered to the medical team not just as a patient, but also as a person.

Soon after I read Dr. Kane’s article, I faced a particularly difficult experience saying goodbye to a patient and her family. It was the first time I had considered writing a letter of condolence, but it seemed more appropriate than ever. I later detailed the entire experience in my essay “The Letter.”

To many people, this act probably sounds overly sentimental. Any kind of attachment might be unwise, or it might be seen as a sign of weakness. Despite the occasional lip service, our medical culture doesn’t place a premium on emotional sensitivity. Besides, isn’t letter writing out of fashion?

As those doubts grew, I decided to write a second letter. This one was to Dr. Kane. I told him how much I appreciated his advocacy for the letter of condolence and how writing one myself had convinced me of its value. I also said that I hoped the idea would see a resurgence, that it might catch on with a new generation of medical providers, but I worried I couldn’t convince others to spend precious time and energy on such a task.

His response was, unsurprisingly, wise.

Just share your experience with anyone who will listen, he said. “That will say it all.”

And now I have.


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9 Responses to “Bring Back the Letter of Condolence”

  1. James Thompson says:

    Thanks for posting. It seems providers may shield themselves from the dying process and thereby become somewhat callous to the hearts of patients. Might even carry the same over to our own family and friends.

    I will go get some beautiful cards from a local artist to use for my letters.

  2. Dave Mittman, PA, DFAAPA says:

    Excellent idea. Beautiful way to end a relationship with a patient and their family.

  3. Max Voysey says:

    Any attempt at humanization of a dehumanizing system is positive. There are many opportunities. Thanks for pointing out another one.

  4. John Thompson says:

    Thanks, Harrison. I’m retired now — formerly a rheumatologist whose specialty implies long-term relationships with many patients. I learned the importance of a letter of condolence, as well as attendance at the funerals of former patients. Many families were surprised that I did so, but my patients were my friends and their lives were important to me.

  5. Gabriela Carrillo-Núñez says:

    I am medicine teacher and I’m going to share with my studentd this extraordinary way to be better doctors. Nobody teach us what to do with the relatives when a patient die and how express our own pain.

  6. My father was a frequent patient at the University of Kansas Medical Center due to complications of his diabetes. He died when he was only 70 despite the outstanding care of his nephrologists. My mother received a letter of condolence from Dr. Arnold Chonko. It was the kindest letter I have ever read. I had been a nurse anesthetist at the Children’s Mercy Hospital in Kansas City, MO for many years before that and had never heard of a physician writing to the deceased patient’s family. My mother is gone now but we cherish the kindness of Dr. Chonko.

  7. Francis J Gilroy, MD says:

    As an ophthalmologist, I was not often involved in the terminal illness of my patients of longs standing, however, l always had my assistants place the charts of former patients on my desk when we became aware of their death, usually in the local newspaper. I would then send a simple hand written note to the next of kin on my personal stationary.

    It doesn’t have to be long. Usually “My staff and I were saddened to learn of the death of (your spouse or parent), it had always been our pleSure to have cared for them. (Occasionally I added a short anecdote for those more memorable.) it only took a few minutes several times a month, even in a large practice that was mostly geriatric, but feed back was always very positive even several years after, on a subsequent visit by the relative and often I received a note of thanks for the thought.

    Even now that I am retired, I write a condolence note to the obituary when I see the notice of one for whom I followed for years. We do become a trusted member of the family over time.

    I commend Mr HARRISON for bringing the subject to our attention.

  8. Tiffany varchetto says:

    Love this! This is wonderful for patients and their families. Also some emotion to ourselves. We are not robots, this shows why we are human and why we chose to be in this field and help ithers.

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