The Letter of Condolence
By Cecilia Runkle, PhD
Reprinted and adapted from Ethics ship between the physician and the Patient Communication,2 Dr Scott
Rounds, Fall 2002. patient’s family … Whether inten- Abramson, Neurology, Hayward,
“A physician’s responsibility for tional or not, the failure to commu- CA, tells the story of a young woman
the care of a patient does not end nicate with family members conveys he talked with whose father died
when the patient dies. There is one a lack of concern about their loss.”1 the month before, under the care
final responsibility—to help the It has been said that we are more of KP clinicians. She said, “After he
bereaved family members. A letter likely to receive a condolence card died, I heard not one word from
of condolence can contribute to from our veterinarian than we are Kaiser. Not one phone call; not one
healing a bereaved family and can from our personal physician. condolence card. Doctors and
help achieve closure in the relation- In a recent column for Clinician- 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.”
Doctors and Sympathy Cards In a noteworthy article extolling the A letter of
By Mark Geliebter, MD value of writing letters of condo- condolence can
lence, Bedell, Cadenhead, and contribute to
As soon as the Code Blue ends in the emergency department all of Graboys1 outlined why doctors do healing a
the housestaff scatter. During my training, I was always struck by not regularly write letters of condo- bereaved
how quickly the doctors would leave the scene as soon as the pa- lence. Reasons included a lack of family and can
tient was pronounced dead. There was no lingering—as if no one time, a feeling that they did not know help achieve
wanted to stay in the room with the dead person. The strategy seemed the patient well enough, no specific closure in the
to be to create physical distance from any associated feelings of fail- team member was responsible for relationship
ure as a doctor. There was no ritual to follow at the end of an unsuc- writing the letter, a loss for words, between the
cessful resuscitation effort. There was never any discussion about the and difficulty with their own experi- physician and
ritual of death. We would spend weeks and weeks discussing the ence of the loss as a sense of failure. the patient’s
Krebs molecular “life cycle” in medical school. However, discussions Generally, in the larger context of family …
about the natural cycle of life and death were rare. After practicing medicine, the focus is on cure—not
internal medicine for many years at Martinez, CA, I was struck by my on what to do if a disease cannot
own lack of closure when my patients died. I too would not hover at be cured. Slow integration of pal-
the bedside when a patient of mine had died. I would not routinely liative care, relatively few discus-
connect with family members after a death. Many years ago, I became sions about advanced care planning,
involved in physician wellness efforts at my facility and regionally. I delayed referrals to hospice, and re-
realized that exploring our own relationship with death and dying was luctance to follow up with family
a key element in physician well-being. members when our patient dies are
One of the outcomes of that exploration was the decision to start a all behaviors that show how diffi-
new practice for myself in 1995. I began to list the name of every cult it is for those of us in health
patient of mine who died. I generally would include a diagnosis, care to focus on dying and death.
medical record number, date and place of death. I started a folder That is not to say that the will to do
labeled “Death and Dying.” I also began to send a sympathy card to more is not there—culture and lack
Continued on next page. of training may be the culprits.
Cecilia Runkle, PhD, is a Training and Development Consultant with The Permanente Medical Group Inc in Physician
Education and Development where she specializes in clinician-patient communication. E-mail: firstname.lastname@example.org.
Mark Geliebter, MD, has been an internist at the Martinez, CA facility since 1979. He serves as lead physician for
Medical Advance Planning for the Diablo Service Area, as well as a Communication Consultant. He also has a long-
term interest in physician wellness. E-mail: email@example.com.
The Permanente Journal/ Summer 2003/ Volume 7 No. 3 69
The Letter of Condolence
In one small way, you would like to begin incorporating deceased. It seems like only yes-
can make a difference: into your medical practice, the fol- terday that Ruth talked about
to others and to lowing guidelines, adapted from her love of card playing. I ad-
yourself Wolfson and Menkin’s “Writing a mired her energy and quick wit.
Bedell et al1 highlight the benefit condolence letter,”3 may be helpful. • Note special qualities of the
of writing a letter of condolence as • Address the family member. family member. I was deeply
twofold: to be a source of comfort Dear Mrs Wagner, … moved by the devotion you and
to the survivors and to help clini- • Acknowledge the loss and your family showed during the
cians achieve a sense of closure name the deceased. Dr Murphy period of Ruth’s final illness.
about the death of their patient. In and I were deeply saddened Your concern was one indica-
the sidebar on the previous page, today when we learned from tion of your love for her. Al-
Dr Mark Geliebter, Martinez, CA, your hospice nurse Lois that though she was a fiercely in-
describes how he began writing let- your mother, Ruth Smith, had dependent woman, I know she
ters of condolence to his patients died. appreciated your involvement
and the value this practice has had • Express your sympathy. We are and help.
for him. thinking of you and send our • End with a word or phrase of
If you decide that writing a letter heartfelt condolences. sympathy. With affection and
of condolence is a practice you • Note special qualities of the deep sympathy, we hope that
your fond memories of Ruth
will give you comfort.
Doctors and Sympathy Cards Throughout KP Northern Califor-
nia, some departments, team mem-
Continued from previous page.
bers, and individual clinicians have
each family (I later found these cards available as a KP stock item!). chosen to routinely send letters or
Initially, I began with brief statements of sympathy. More recently, cards of condolence to family mem-
I’ve been writing more personal comments, especially when I’ve had bers when a patient dies. Clinicians
a longer relationship with the person or their family. I frequently report the deep satisfaction they
mention that I felt privileged to have been their physician. I also try to feel in this act of follow-up; family
call the families that I feel connected to. I have received frequent members report their heartfelt
positive feedback from families for my personal note or call. They are thanks that KP clinicians took the
most appreciative of my thoughtful acknowledgments. time to recognize the family’s grief
This has created a ritual practice for myself at the time of a patient’s and their role in the care of the pa-
death. It also gives me a way to remember my patients. When I re- tient. Letters of condolence can
view my list, I can usually remember something about them, their make all the difference—to our
faces, their personalities, or some ethical or medical issues that may members and to us as clinicians. ❖
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 References
on some synagogue or other walls that list names of members or their 1. Bedell SE, Cadenhead K, Graboys
TB. The doctor’s letter of condo-
families who have died. Sending the sympathy card and making the
lence. N Engl J Med 2001 Apr
follow-up phone calls have become part of my own sense of respon- 12;344(15):1162-4.
sibility as a physician. It helps obviate the need to run out of the room 2. Abramson S. Full and meaningful
after an unsuccessful Code Blue, as I did when a medical student. care to patients: communication
Integrating the reality of death; embracing it as a natural process; devel- consultant corner [letter]. Available
oping coping strategies; not labeling death as failure; finding rituals; from: http://kpnet.kp.org.cpc/quick/
care.html (accessed July 23, 2003).
doing outreach during and after the dying process are all part of our
2. Wolfson R, Menkin E. Writing a
role as physicians. All of these insights and rituals will add to our own condolence letter. Fast Facts and
personal wisdom of dealing with the inevitability of our patients’ and Concept #22, Internal Medicine
our own deaths. ❖ End-of-Life Education Project.
Available from: www.wshmc.org/
(accessed July 23, 2003).
70 The Permanente Journal/ Summer 2003/ Volume 7 No. 3