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* From the Department of Medicine, Jefferson Medical College, Philadelphia, PA.
Correspondence to: Gregory C. Kane, MD, FCCP, Jefferson Medical College, Division of Pulmonary and Critical Care Medicine, Jefferson University Hospital, 1025 Walnut St, No. 805, Philadelphia, PA 19107-5083; e-mail: gregory.kane{at}jefferson.edu
In this era of instant communication through text messaging, e-mail, instant messaging, and cellular phones, personal communications, particularly handwritten notes or personal letters, are becoming quite rare. These technological advances in communications may, ironically, be contributing to the demise of various forms of communication, including the doctor’s letter of condolence.1 Writing a letter of condolence rarely occurs when a patient dies. This is unfortunate, as we are losing an opportunity to enhance our contact with the loved ones of the recently deceased, and as a result we are distancing ourselves further from those whom we serve. Surprisingly, medical textbooks or journals rarely devote pages to this final act of kindness, and may be contributing to the demise of such letters.2 In this article, I will review the literature on the doctor’s letter of condolence as well as calls from those who have proposed that we not abandon this practice. While some physicians have sent letters of condolence, many have not, yet it can be argued that this simple gesture may afford the bereaved great consolation.
In the end, it is my intent to sound a call to arms to the community of pulmonary/critical care physicians who have taken leadership on so many other clinical issues to regularly adopt this practice. Such final communications can serve as a mechanism of conveying respect for the departed and reminding families of the importance of the relationship between physician and patient. Promoting a dying art for physicians who may not have been introduced to this final communication, and reinforcing the practice among those practitioners already choosing to write such letters are the goals of this article. An approach to such a letter is provided so that readers might be able to craft a suitable letter of condolence.
The Problem
Historically, physicians were more often personally present at the time of death and thus could offer condolences directly and verbally, mitigating the need for a letter. Nonetheless, the doctor’s letter of condolence was an accepted responsibility and an important part of the support offered to the bereaved. This may have also been consistent with the era 2 centuries ago, when mourning was prolonged, involved, and elaborate.34
Fast-forward to the current era with housestaff, busy office schedules, and coverage arrangements in multispecialty groups; we have lost personal contact at the time of death. Unfortunately, we have not allowed letters of condolence to routinely fill the gap and express our feelings at the end of life.
In their commentary on writing letters of condolence, Bedell et al5 outlined why doctors do not regularly write letters of condolence. Potential explanations included a lack of time, a loss for the appropriate expression of sympathy, a feeling that they did not know the patient well enough, lack of a specific team member responsible for writing the letter, or a sense of failure over the death. No doubt, this has been fostered by a lack of role modeling or broader discussion of such practices.
In a personal and memorable patient encounter, I sat and listened while a tearful patient cried at having received no contact from the physician who treated her husband for metastatic lung cancer for a treatment duration of 9 months. As I struggled to comprehend her sense of pain and abandonment, I considered offering as possible explanation that the physician may not have been "on call" at the time of the death and may have mistakenly believed that his partner had offered such a gesture verbally. Before I could respond, however, my patient added that her veterinarian had sent a card when the family dog died. I was speechless.
Other physicians have shared similar experiences, sometimes involving family members, friends, or mutual patients. In his convocation speech on becoming President of the American College of Chest Physicians in 2003, Dr. Richard Irwin described a vision for patient-centered care. His vision was comprehensive but also included a discussion of sympathy cards after the death of a patient. He noted, "when physicians do not acknowledge the deaths of their patients, it is perceived that physicians are silently saying that the deceased patient was not important."6
Style
The style of the letter of condolence has been the source of much commentary. Many insist that the note must be handwritten on a card or personal stationary. Others have pointed out that whether crafted by hand or typewritten, there are a few important guidelines.57 The letter must be respectful and specially constructed. Automated signatures or hurried dictations simply will not suffice and may even demean the gesture. I suggest adopting a style that works for the reader and sticking with this (Table 1 ).
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Letters of condolence need not be long and are often best written by hand. Several authors57 have suggested the content to be considered in a condolence letter. First, acknowledge the loss and provide some comfort to the bereaved. Words should be direct. For example, "I was saddened by your wife’s death." In the body of the note, the specific content will depend on the exact nature of the relationship with the family or support person. Many experts suggest recalling a special memory of the deceased, such as a special hobby or interest. Remember that the letter is for the survivors. Consider noting the loving qualities of the survivors, particularly those things that they did to support the care of the deceased. Such expressions may assuage their anguish and commend the role they played in helping the deceased while alive. You will also assist them in coping with an overwhelming loss so that they can go forward without guilt or anxiety about whether they did enough. An offer to help or invitation to contact you should be genuine and specific. This may often be important if the bereaved have questions about the medical events or disease process. Finally, end with a special closing, as a routine "sincerely yours" may lack the full expression of respect intended (Table 2 ).
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It is with deep grief that I learn of the death of your kind and brave Father; and especially that it is affecting your young heart beyond what is common in such cases. In this sad world of ours, sorrow comes to all; and, to the young it comes with bitterest agony, because it takes them unawares. The older have learned ever to expect it.
Note that Lincoln uses the word death directly and describes her father as kind and brave. Years later, one can only imagine how this woman might cherish such kind and comforting words from our sixteenth President.
Outcome
Most importantly, the letter of condolence allows the physician to bring a significant relationship to completion and remind the family of the special bond between physician and the patient.9 It can remind the bereaved of their special strength at a time when they vitally need such support. Occasionally, the family or loved one may reply, but such replies should not be sought or expected.
Other Considerations
If you work in an office with an automated patient reminder system, be sure staff removes the patient from the system. Families may resent a call to remind them of an appointment for their deceased loved one. While these miscues can occur in large office systems, attention to such small details will be appreciated by the family.
Concluding Thoughts
The doctor’s letter of condolence can serve as final act of kindness for a mourner and stand as a fitting and meaningful conclusion to the physician/patient/family relationship, providing comfort to the bereaved and communicating the impact of therapeutic relationship that has come to a close. To comfortably meet this responsibility, it is necessary for the physician to be comfortable with their role as death approaches.1011 It may also be necessary for educators to act as role models teaching these communications in order for the practice to be adopted by younger physicians.12
Years from now, in another age, archaeologists may survey the remains of our society and marvel at medical technologies evidenced by the collection of joint replacements, cardiac stents, valvular implants, and titanium plates among the remains in our places of burial. It would be my hope that they would also identify in the written archives a condolence letter to note the personal connections that bound the physicians of the age to their patients and the surviving loved ones, providing evidence that we are truly human.
Footnotes
The author has no conflict of interest to disclose.
Received for publication December 7, 2006. Accepted for publication December 7, 2006.
References
This article has been cited by other articles:
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  A. Musani A Dying Art?: The Doctor's Letter of Condolence Chest, November 1, 2007; 132(5): 1718 - 1719. [Full Text] [PDF]
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