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     Schwartz Center Rounds
          When Does the Responsibility of Our Care End:
                         Bereavement
    RICHARD T. PENSON, KARA M. GREEN, BRUCE A. CHABNER, THOMAS J. LYNCH, JR.
         Department of Medicine, Division of Hematology-Oncology, Massachusetts General Hospital,
                                        Boston, Massachusetts, USA


                                  Key Words. Psychosocial · Oncology · Hospice · Abandonment · Support




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L EARNING O BJECTIVES
After completing this course, the reader will be able to:
   1. Understand the effect of grief on the bereaved and on staff.
   2. Understand the responsibilities of compassionate cancer care.
   3. Recognize the resources available for uncomplicated and complicated grief.

          CME       Access and take the CME test online and receive one hour of AMA PRA category 1 credit in Risk
                                              Management at CME.TheOncologist.com


A BSTRACT
    Shortly before his death in 1995, Kenneth B. Schwartz,            of involved compassion for the family and fractured
a cancer patient at Massachusetts General Hospital,                   relationships. Grief for loss is an inevitable part of life
founded the Kenneth B. Schwartz Center. The Schwartz                  and a common part of cancer care. Support of the
Center is a non-profit organization dedicated to supporting           bereaved may be one of the hardest tasks for cancer
and advancing compassionate health care delivery, which               care professionals, who are confronted with the limits
provides hope to the patient, support to caregivers, and sus-         of modern medicine. There is a responsibility to pro-
tenance to the healing process. The center sponsors the               vide grieving families with support and care; care that
Schwartz Center Rounds, a monthly multidisciplinary                   goes beyond the death. A compassionate response
forum where caregivers reflect on important psychosocial              helps both those who suffer and those who care.
issues faced by patients, their families, and their caregivers,       Complicated and uncomplicated bereavement, grief
and gain insight and support from fellow staff members.               reactions, resources for bereavement counseling, and
    Two vignettes are presented of a caregiver’s response             the role of condolence letters are reviewed. The
to the death of a patient, contrasting the extremes                   Oncologist 2002;7:251-258


PRESENTATION                                                               of a boy. He came in a little stroller with his baby sister
                                                                           and once in a while with his older sister who was 9 at the
Vignette #1
                                                                           time. Everybody cared a great deal about him. He devel-
Social Worker: I wanted to talk about Joey who was a three-                oped strong relationships, both in Radiation Oncology
   year old very bouncy little Mexican jumping bean kind                   and on the Pediatric floor where he got his chemotherapy.

Correspondence: Richard T. Penson, M.R.C.P., M.D., Instructor in Medicine, Hematology-Oncology, Cox 548, 100 Blossom
Street, Boston, Massachusetts 02114-2617, USA. Telephone: 617-726-5867; Fax: 617-724-6898; e-mail: rpenson@partners.org
Received May 6, 2002; accepted for publication May 6, 2002. ©AlphaMed Press 1083-7159/2002/$5.00/0

The Oncologist 2002;7:251-258 www.TheOncologist.com
Penson, Green, Chabner et al.                                                                                                    252


          As time went on, he became more and more ill.                 different chemotherapy regimens, most recently having
     There were some difficult issues. As he came closer to             a beautiful response to Iressa™. Many of the fellows
     death, he was transferred to a local hospital and then             have seen pictures of Mr A’s tumor response. He really
     went home and he died at home. The parents came                    had a wonderful response to Iressa. The reason to pre-
     from two different religious background and the ques-              sent him in this venue, is that he was someone who
     tion arose, “Where was Joey going to be buried?” The               became very close with me, with his nurse, his infusion
     father wanted one place and the mom wanted another.                room nurse, with the clinic coordinator, and with many
     Because it was very important to the mom that Joey be              others on the floor. He had a very rough clinical course,
     buried where she was going to be buried, they found a              and toward the end was coming in very, very frequently.
     rabbi and he was buried in a Jewish cemetery. It was a             There were lots of phone calls. He talked to us probably
     huge loss for the family, for the parents, for the grand-          once every day or two and was seeing me at least
     parents, and for staff as well. I am still close to the mom        weekly for the last 3 months of his life (pause); and then
     and a few months ago, after Joey died, she came in with            he died two months ago. I called his wife to offer my
     her older daughter who said, “Tell her, tell her.” Mom             condolences and we really haven’t talked since, nor
     was pregnant and it was very exciting for everyone.                have other people from the team talked to the family.
     She has subsequently had a healthy baby boy. Ms. S                 We were talking yesterday about how hollow that feels.




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     says he is a lot like                                                                             An intense personal rela-
     Joey. Mom did a                  … there is also a personal                                       tionship suddenly ends
     number of things                                                                                  when the patient dies. We
     with dad to help her         comfort level. Some of us are more                                   talked about what role
     move on and to say                                                                                bereavement care has, not
     goodbye to Joey. In           comfortable than others making                                      just for the patient and
     fact, she was close to                                                                            family, but also for the
     Mike Gollivan of the        that connection. These are personal                                   staff themselves; and if
     television program                                                                                we made a better commit-
     Chronicles. He was               and professional decisions.                                      ment, what a difference
     a good friend and                                                                                 that would make to our
     asked permission from the parents to put Joey’s story              care. Yet we understand the need to balance that com-
     on television, and it aired on Channel 5. The parents were         mitment with the extraordinary responsibilities we
     very open. The father especially wept copiously. They              face, making the time to take care of our current
     were very honest about how hard it is to live with the loss        patients.
     of such a special kid. Joey loved the play corner up on the
     pediatric floor, so they donated this really beautiful, well-   DIALOGUE
     constructed wooden kitchen with a sink and a fridge and
     a stove. There is a little plaque that has Joey’s name on it.   Bereavement
     I continued to talk with Ms. S. They came to the pediatric
     memorial service that is held annually. Everyone is             Palliative Care Nurse: In the palliative care service, we
     invited. People come, they write poems, they speak, they           have a built-in follow-up for patients and families fol-
     draw pictures, and they put up photos. It’s a wonderfully          lowing a death. However, we still struggle with what
     healing ceremony. Ms. S. and I have an appointment for             the right kind of follow-up should be. How much? How
     coffee very soon. They are going to be okay, but I think           often? What should we be doing? How much can we
     it’s a loss that they will always have. There is a gap that        help? We did a survey of caregivers’ bereavement care at
     is always going to be there. There have been letters and           MGH. It was wonderful to see that across the board indi-
     phone calls from the doctors and nurses and all of this has        vidual caregivers are doing a tremendous amount; cards,
     been enormously meaningful.                                        letters, phone calls [1]. Everybody who answered felt they
                                                                        should be doing more, and felt that MGH should be doing
Vignette #2                                                             more. I think that each one of us struggles with what we
                                                                        should do and how we make ourselves available. We’re
 Oncologist: Mr. A is a 47-year-old man whom we took care               always telling people, “Please call at any time, please let us
   of for approximately 4 years with non-small cell lung                know how you’re doing,” and if they actually take us up
   cancer and who participated in approximately seven                   on it and call us, then what do we do? It’s important to
253                                                                              When Does the Responsibility of Our Care End: Bereavement

      know who is at risk of serious depression, who needs more            with. I know we all feel that we want to be there and
      support than others, and what a caregiver can do. I think            reach out to our families, we don’t want to be seen as
      there is also a personal comfort level. Some of us are more          not caring, and people are truly at risk for significant
      comfortable than others making that connection. These are            dysfunction. But what I struggle with is where do you
      personal and professional decisions. I got a phone call              draw the line? It has been a personal struggle for me
      from a patient’s son recently. Apparently, we had sent a lot         trying to balance my clinical care with my own sanity.
      of cards and letters. I had probably sent a letter to this fam-
      ily at about the 2 or 3 month mark. He called up to thank         Condolence and Counseling
      me for that letter. I couldn’t place the person I was talking
      to. I think that it was the patient’s father who had died. To     Social Worker: I think you can ask the question, “Who
      be honest, I couldn’t remember the patient. He said to me,           else is there for you?” and take more initiative. I have
      “I just wanted to call and thank you and I wanted you all            felt pretty comfortable reviewing that with the family,
      to know that our family will hold on to this letter forever.”        “What would be most helpful to you” or “What would
      The importance of these gestures really hit me.                      you like right now?” Not to focus on their neediness,
                                                                           but to see this contact as part of the ongoing care.
Social Worker: The kind of closeness that the staff has with               We’re not through just because the patient died. They




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   the person when he or                                                                                 need to know that.
   she is terminally ill             You’re acknowledging that you                                       Certainly, they want to
   and going through                                                                                     know we’re doing it out
   treatment, is some-             connected with the patient and the                                    of our care for this partic-
   thing that few others                                                                                 ular person, but it also
   in the community                  family in the struggle, and that                                    helps to know that’s the
   really share with the                                                                                 way the hospital feels. I
   family. Then the                    the relationship still holds                                      think it makes them feel
   emptiness that’s left                                                                                 less needy.
   after a death is one of                  meaning for you.
   the toughest things to                                                                                 Oncologist: The culture
   deal with. I think part of what makes continued contact so              has changed radically. Ten years ago as a practicing
   meaningful is the knowledge that you weren’t just doing                 oncologist I had never made a single hospice visit to a
   your job. You’re acknowledging that you connected with                  patient at home. There are a number of indications for
   the patient and the family in the struggle, and that the                referral to hospice, and while the care of your patients
   relationship still holds meaning for you. The medical                   is obviously the priority, when the patient dies there are
   team can become an extended family. The family or                       a greater number of suffering individuals. Hospice
   relative can feel very isolated.                                        gives 1 year of bereavement counseling. I see counsel-
                                                                           ing for the survivors as an indication for hospice much
Infusion Nurse: I find that there are a lot of patients who                like symptom management or VNA (nursing) services
   want to do everything they can to treat their cancer and                for the patient.
   so their referral to hospice is very late, often in the last
   2 weeks of their lives. Family and friends of a patient              Social Worker: Something that I’ve done when I’ve worked
   that we form closer relationships with often come back                  very closely with a family and I knew I couldn’t keep up
   to update us, but many fall through the cracks.                         with forever is to bring a community person or a
                                                                           bereavement counselor to a meeting with me to enable
Social Worker: It worries me that the cranky patient doesn’t               the transition. They could hear about our relationship,
   get the same follow-up.                                                 and our memories, and then they can go on from there,
                                                                           having already connected, via me, to the family.
Oncologist: Hospice programs have wonderful bereave-
  ment programs but their bereavement staff, for the most               Pediatric Oncologist: In pediatrics, the relatives often say
  part, is not the staff that cared for the patient prior to the           staff had a better understanding of what the patient was
  death. They are separate and they are separate for a lot                 really going through, compared to other members of
  of pretty good reasons. You can burnout caring too                       the extended family or friends. We developed a prac-
  much. I would like to ask a question that I struggle                     tice where we sent cards at the crucial times that are the
Penson, Green, Chabner et al.                                                                                            254


     hardest on the family, such as Christmas and birthdays        card were tremendously powerful and very important
     and anniversaries, as well as the memorial service. The       to the families.
     service is very hard for parents because they have to
     say their child’s name and acknowledge that the child      Social Worker: Bereavement care is also painful because
     really died.                                                  it brings up the difficult issue that what we were trying
                                                                   to do for a patient didn’t work.
 Pediatric Nurse: We’ve recently started bereavement
    rounds for staff once a month and discuss every child       Oncologist: I guess it also comes down to how much do
    who has died over the past month. We invite everyone          we embrace the concept that most of oncology is pal-
    involved in the patient’s care. We’re also starting to        liative care to some degree. We should therefore look at
    ask families to come back in if they wish. Not all fam-       death not as failure, but natural.
    ilies are interested in doing this, but we believe it is
    helpful to actually formalize the invitation so that        Palliative Care Physician: I always feel guilty when
    every family is given the invitation to come back in           somebody dies and I think of all the things that could
    and meet with staff                                                                       have been done better.
    and talk about the          What I struggle with is where do                              Although calling a widow




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    loss of their child. In                                                                   is terribly sad, it is also
    pediatrics, many of          you draw the line? It has been a                             incredibly gratifying for us
    us go to the wakes                                                                        to see that we have made a
    and funerals of our         personal struggle for me trying to                            difference in people’s
    patients. There are                                                                       lives. Maybe we judge
    some families we are          balance my clinical care with                               ourselves too harshly.
    really close to and we
    talk to them very fre-               my own sanity.                                           Oncologist: I’ve found
    quently. But there are                                                                           that it’s very helpful to
    other families that no one has contact with at all. What       reinforce three things in phone calls to people who’ve
    we’re trying to develop is a program where everybody           recently been bereaved. First, that we’ve valued their
    gets at least some minimum level of contact.                   loved one. Second, that we did everything we could do
                                                                   and equally important, is, third, to state that they did
 Palliative Care Physician: Following people through               everything that one could do. I’ve been impressed at
    bereavement is very important. Isaac Bashevis Singer           how often the family member is initially surprised when
    said in one of his short stories, “Grief is silent and         you say that, then clearly reassured that they did do
    therein lies its uncanny power.” They just aren’t reach-       everything that they could do to help their loved one.
    ing out for help. When we did our bereavement survey,
    the interviewers didn’t really like it. They were calling   Psychologist: Both cure and healing fall within the respon-
    the family at 3, 6, and 9 months. Families weren’t talk-       sibility of the health care profession. I think doctors and
    ing about things and they weren’t in bereavement pro-          nurses offer the most powerful kind of healing possible
    grams. They were not getting services and were just            when they really care about someone. You weren’t just
    suffering quietly in all of the terrible sadness they are      a pro doing what you had to do. You went beyond
    living with on their own. There is real morbidity asso-        being technically competent.
    ciated with it and intervention is helpful. Bereavement
    care always ends up on the bottom of the list of things     Closure
    to do. It can always be put off until tomorrow. If you
    want to get it done, there needs to be someone assigned     Psychologist: I think we should separate the needs of
    to take care of these people.                                  families to grieve from our need to say goodbye to
                                                                   these people when the patient dies. Many times, I
 Psychologist: Doing focus group research on bereave-              think staff reach out to families because they just felt
    ment was incredibly painful for the staff because of the       connected to them while the patient was alive and
    stories that we heard. At the same time it was also a          they need some closure for themselves, acknowledg-
    wonderful example of God being in the details,                 ing the personal contact. That is to be respected. We
    because very small gestures like receiving a sympathy          should honor the personal relationship by saying
255                                                                        When Does the Responsibility of Our Care End: Bereavement

      goodbye before the patient dies and then to the fam-       by their own, or the deceased’s, physician [6]. Larger stud-
      ily or friends afterward. A phone call or condolence       ies corroborate these findings [7]. Even in areas well served
      note isn’t quite the same as doing bereavement work        by palliative care, family’s needs for additional information
      for the family. To an extent it’s part of “finishing up”   and emotional support continue to be great [8].
      for us and I think there are two needs here and that
      we sometimes only think in terms of the patient’s          Definitions
      needs as survivors; we also need to realize we have to          Grief is the psychological, behavioral, social, and phys-
      sacrifice.                                                 ical reaction to the loss of someone or something that is
                                                                 closely tied to a person’s identity. Grief is a natural but
Oncologist: In response to that, I very often ask myself the     intensely individual aspect of human experience. Mourning
  question, “Am I doing this for me or am I doing this for       represents the process by which people adapt to loss.
  them?” I have sometimes been reluctant to do that fol-         Bereavement is the period after a loss during which grief is
  low-up because I did not want to put the family in the         experienced and mourning occurs [9-12].
  situation where they were consoling me for my loss.                 There are a number of constructs that attempt to explain
                                                                                                     how individuals cope
Social Worker: For me              We’re not through just because                                    with grief. The task-




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   one of the most                                                                                   based approach is the
   powerful Schwartz               the patient died. They need to                                    model most commonly
   Rounds was when                                                                                   used [13]. Kubler-Ross’
   the mother of a                           know that.                                              seminal model, with the
   young man who died                                                                                stages of denial, anger,
   said, (I can’t say this without weeping. I was so moved)      bargaining, depression, and acceptance, has been criticized
   “It means so much to me to know what my son meant             as inflexible [14]. While all these behaviors are common in
   to you. My mother died 35 years ago. The doctor never         bereavement, not all individuals experience all stages, some
   spoke to me after her death. You have just healed 35          skip stages, while others regress through stages or experience
   years of suffering” [2]. So I think when we can sin-          different reactions concurrently. Increasingly, the phases of
   cerely say how we feel, that really does make a huge          grief are seen in relation to the conceptual framework of
   impact on the family, even if we think that it’s coming       attachment theory (which describes the bonds that are
   from our own need.                                            formed early in life with parental figures and derived from
                                                                 the need to feel secure) and human information processing
DISCUSSION                                                       (the filtering of unwanted information). This then divides the
                                                                 bereavement process into four phases: A) shock and numb-
Introduction                                                     ness: survivors have difficulty processing the loss and are
    More than 2 million people die each year in the U.S.         stunned and numb; B) yearning and searching, intense sepa-
The death of a loved one is widely acknowledged to be one        ration anxiety and denial of the reality of the loss; C) disor-
of the most traumatic of life events [3]. Bereavement is         ganization and despair, depression and distraction lead to
associated with declines in health, inappropriate health ser-    difficulty planning future activities, and D) reorganization
vice use, increased risk of depression, sleep disruption,        and positive readjustment [15]. Though sorrow is intensely
increased consumption of tobacco, alcohol, and tranquil-         painful and psychologically draining, grief is a normal
izers, increased suicide and death [4, 5]. Yet many individ-     emotional response for all that experience a loss [16, 17].
uals receive little or no support from health care
professionals during the bereavement period. A telephone         Optimal End-of-Life Care: Anticipating Bereavement
interview study of 53 English speaking relatives or close            The quality of care at the end of a patient’s life is very
companions of adults who had died in the proceeding year         important to the family of the patient and can directly affect
at MGH reported high satisfaction. However, there were           the way the family deals with the death of their loved one.
complaints about the lack of privacy, dignity, and comfort,      In order to truly be effective in end-of-life care, the physi-
poor communication, excessive waiting for care, little           cian needs to be sure he or she addresses the pressing issues
attention to advanced directives, and little bereavement         of the impending grief of the patient as well as that of the
support. Over one-third of relatives reported no contact         family and the caregivers [17].
with hospital health professionals after the death and of the        Patients and family members define a “good” death based
19% who sought professional help, none had been referred         on physical comfort, the quality of personal relationships,
Penson, Green, Chabner et al.                                                                                               256


finding meaning in their life and death, feeling some sense of     is known, negotiate how information should be handled,
control in the situation, and active preparations for death [7].   share bad news clearly and compassionately, respond to
                                                                   emotions, set goals, and agree to a plan [17]. A comprehen-
Counseling                                                         sive assessment should include a screen of the psychosocial
     Grief counseling guides uncomplicated “normal” grief          domains, with a view to optimizing control of symptoms,
to healthy completion with insight and adjustment. The             maintaining psychological integrity and finding meaning in
positive impact of counseling the bereaved was pioneered           the chaos [16]. What did the illness mean to them [23]?
by Colin Murray Parkes with a study of the effects of a            What are their coping styles [24-26]? What is the extent of
comprehensive bereavement program. Twenty close rela-              the social network [27]? What are the strengths and weak-
tives of patients who had died in a palliative care unit were      nesses of major relationships with health care providers
compared with a matched group of 20 relatives of patients          [28]? What are the major stressors [29]? What spiritual
who had died of cancer in other wards of the same hospi-           resources are available [30]? Are there psychiatric vulnera-
tal [18]. Interviewed by telephone 2 weeks and 1 year              bilities (depression, anxiety, or drug dependence) [25, 31]?
after bereavement, relatives of the palliative care unit           Are there financial issues [32]?
patients reported signifi-
cantly fewer psycholog-             Bereavement care always ends                                       Complicated Grief




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ical symptoms and less                                                                                     In 1944, Lindemann
lasting grief and anger.            up on the bottom of the list of                                    described “morbid grief
Factors thought to have                                                                                reactions” [33]. Compli-
contributed to the better             things to do … If you want                                       cated or pathological
outcomes were success-                                                                                 grief occurs when normal
ful relief of pain, aware-         to get it done, there needs to be                                   bereavement is associ-
ness of the coming death                                                                               ated with psychiatric
of the patient, and sup-            someone assigned to take care                                      sequelae and overlaps
port given to relatives                                                                                with an adjustment disor-
after bereavement. A                        of these people.                                           der, major depression,
larger study also reported                                                                             substance abuse, or post-
better outcomes for the bereaved of those who died in hos-         traumatic stress disorder. There is no clear definition and
pice [19]. However, other studies have reported few or no          the cultural context has a profound influence on the inter-
significant differences [20]. Notably Kane’s study used a          pretation of the intensity of loss and disruption caused by
longitudinal design and randomized participants to either          “excessive” grief. There is greater consensus about absent,
hospice or traditional care [20].                                  inhibited, delayed, conflicted, or chronic grief [9, 34].
     Whatever the setting, proactively providing indicated         Identifying compounding grief from earlier losses, unfin-
counseling around the time of death appears to help shorten        ished business, and secondary gain may be necessary to
the period of distress after bereavement [21].                     enable the grief to be working through. While some argue
     Immediately after the death, the bereaved need compas-        for early intervention for major depressive disorders irre-
sionate attention and validation of their loss, with time and      spective of bereavement status [35], others advocate treat-
permission to grieve. Over the first month, expression of          ment be instituted only if symptoms persist beyond 1 year
grief should be encouraged and the person reassured that it is     after the loss [36], yet other diagnostic algorithms for diag-
a normal human reaction. Assessment of the social support          nosing complicated grief mandate significant “separation
and coping strategies should identify practical or financial       distress,” “traumatic distress,” and disrupted functioning
problems. Beyond a month, a physician should screen for            extending beyond 6 months [37]. Obviously suicidal
depression, consider referral for counseling, or should con-       ideation should prompt urgent assessment.
sider pharmacologic intervention. A recent review helpfully
summarized the assessment, recommendations for interven-           Grieving Children
tions, and indications for referral [10]. Data suggest that a          The National Cancer Institute estimates that 24% of
variety of interventions, including individualized counsel-        adults with cancer are parenting children under 18 years
ing by a trained volunteer, professional counseling, or            [38]. Children are helped by a simple and age appropriate
group therapy may offer benefit [18, 22]. Physician compe-         explanation of death. Questions should be addressed hon-
tence in end-of-life care requires skill and relationship          estly and directly. Euphemisms that are open to misinter-
building. The carer needs to be prepared to establish what         pretation should be avoided. Children benefit from being
257                                                                                 When Does the Responsibility of Our Care End: Bereavement

involved in the planning of and participation in mourning                the relationship between physician and patient; C) A specific
rituals. Common concerns of bereaved children are: was it                personal memory; D) Reference to the patient’s work,
my fault, is it going to happen to me, and who is going to               courage, or character, and E) A statement that it was a privi-
take care of me? These should be explicitly addressed. If                lege to have taken part in the patient’s care [43]. Superficial
the remaining parent is too distressed to be a support, other            attempts to assuage grief, such as, “It was meant to be,” or
support should be mobilized [39]. Perhaps what children                  “I know how you feel,” should be avoided.
and adults most need is that we be “real” with them, as out-
lined in the Velveteen Rabbit by Marjorie Williams in                    Resources
which the new toy learns the rocking horse’s wisdom,                         www.cancer.gov/cancer_information has helpful informa-
earned in his dedication to love [40]. The MGH has a                     tion on loss, grief, and bereavement for both patients and
tremendous liaison psychiatric support service for families              health professionals. There is a list of bereavement services
of patients with cancer, a review of which is to be published            and support groups available in the U.S. at www.hospice
in the Journal of Clinical                                                                                   foundation.org. THEOS
Oncology later this year           Medical staff have a responsibility                                       (They Help Each Other
[Paula K. Rauch; personal                                                                                    Spiritually) is an organiza-
communication] [41].                  to provide grieving families                                           tion that helps widowed




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                                                                                                             men and women cope with
The Condolence Letter               with support and care; care that                                         losing their spouse through
     It is true. We are too                                                                                  monthly meetings (tele-
busy. We may feel that                   goes beyond the death.                                              phone: 412-471-7779).
we did not know the                                                                                          There are also a number
patient well enough to write a genuine letter of condolence,             of “local” grief support websites such as www.counseling
the responsibility for writing the letter may not be clearly             forloss.com with excellent information and specific national
assigned to one member of the team, or there may be no                   organizations such as www.aarp.org/griefand loss or
mechanism to collate information about recent deaths.                    CRUSE (http://www.crusebereavementcare.org.uk) in the
Writing condolence letters requires that we overcome our                 UK (telephone: 0870 1671677).
own sense of loss, our sense of failure, and it is hard to know
what to say when someone dies. Physicians rarely write                   CONCLUSION
letters of condolence [42].
                                                                         “Never does one feel oneself so utterly helpless as in trying
     A flurry of very positive correspondence followed a
                                                                         to speak comfort for great bereavement.”
recent New England Journal of Medicine sounding board arti-
cle “The doctor’s letter of condolence” [43]. A number of
                                                                                                                      Jane Welsh Carlyle
institutions have successfully instituted “task forces” or
“bereavement coordinators” who coordinate letters, bereave-                   Grief for loss is an inevitable part of everyone’s life.
ment counseling, and have information about community                    People cope, or fail to cope, in diverse ways. Bereavement
resources, support groups, and the services of the hospital              may be one of the hardest tasks for health care profession-
chaplains [44]. However, a personal letter communicates                  als confronted with the limitations of our endeavors.
compassionate care. The article helpfully listed suggested ele-          Medical staff have a responsibility to provide grieving fam-
ments to a letter of condolence: A) A direct expression of sor-          ilies with support and care; care that goes beyond the death.
row. This should not revisit clinical issues in order to avoid           A compassionate response helps both those who suffer and
issues of legal liability; B) Detail of the extent and depth of          those who care.


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  Richard T. Penson, Kara M. Green, Bruce A. Chabner and Thomas J. Lynch, Jr.
                          Oncologist 2002;7;251-258
                  This information is current as of April 2, 2010

Updated Information          including high-resolution figures, can be found at:
& Services                   http://www.TheOncologist.com/cgi/content/full/7/3/251
Errata                       An erratum has been published regarding this article. Please see
                             next page or:
                             http://www.TheOncologist.com/cgi/content/full/7/4/388




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       The
Oncologist                          ®




                                                       Erratum

                      WHEN DOES THE RESPONSIBILITY OF OUR CARE END: BEREAVEMENT
                                            The Oncologist 2002;7:251-258

   On page 252, in the first paragraph, the anchorman was misidentified for the television program Chronicles: the correct
anchor was Ron Gollobin.




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