You know you're sorry when a patient dies under your care, but do you convey that to the family?
Researchers at the University of Washington recently surveyed more than 400 of their colleagues about expressing condolences to deceased patients' families. The survey asked physicians, nurse practitioners, and physician assistants whether they offer condolences, other than while notifying someone of a death, and why or why not.
More than a quarter of hospitalists said that they never or rarely do something to convey their condolences, and about half said they do it always or often. That's not enough, according to study author Susan Merel, MD, ACP Member, an assistant professor at the University of Washington Medical Center in Seattle.
She recently spoke to ACP Hospitalist about how she'd like hospitalists to respond to her study results, which were published online by the Journal of Palliative Medicine on Dec. 10, 2014.
Q: What interested you in expression of condolences?
A: I'm an internal medicine hospitalist trained in geriatrics and also with some experience in palliative care. This topic wasn't really discussed with me or taught [to me] until probably my first year of practice, when a colleague who is also a coauthor on this paper [Melissa Hagman, MD, FACP] did some teaching on this and said this may be something that families expect and something that can be really positive, to express condolences either verbally—not just at the time of telling somebody that their loved one has died, but to specifically make a phone call—or by sending a condolence card.
Q: Before the study, what had you observed about physicians' expressions of condolences?
A: One of the coauthors [Corinne L. Fligner, MD] is a pathologist, and she had become interested in this because when she calls to talk to families about autopsies, she will express condolences over the phone, which of course makes sense—you're calling somebody whose loved one just died. But she occasionally would get a response from families that “Nobody from the hospital expressed condolences to me before, Dr. Fligner. I'm glad that you're doing that. I kind of expected a letter from my doctors.”
If I had shared a patient with a colleague and [the patient] died while they were in the hospital or shortly after, I would send a card and I would have other folks sign it. I often was met with “Gee, that's a great idea, I wasn't sure if that was something that was OK. I wasn't sure if that would be appropriate or would upset the family.”
Q: What responses have you gotten to your condolences?
A: I have a file of communication that I've gotten in response. I certainly don't write a condolence card expecting a card back, but there are people who make up a card with a photo of the deceased that they send…. I also have a copy of a beautiful letter that a patient's husband sent to a medical student of mine after she had sent a letter expressing condolences. His letter was all about things that he remembered about the hospitalization and how great the medical student was, and telling her about what his life has been like, and wishing her all the best in her future career.
I found it to also be a helpful ritual to me. Like many of us, I don't have much handwritten communication in my life. I send e-mails and I text and I Facebook, but … I send a handwritten card if I'm expressing condolences, just as you would with somebody who is not your patient. I find that to be a rewarding ritual.
Q: What did the study find that your colleagues do regarding condolences?
A: The practice of expressing condolences to a family when a patient dies in our study was more common than in previous studies. The percentage was about 55%, which is encouraging in some ways. I think it should be more than that, but it was a majority. The other main findings that I think are relevant are that hospitalists—as we defined them, people who said they provide just inpatient care—were less likely to express condolences than those who provide some outpatient care. And younger folks, in practice for less than 20 years, were less likely to express condolences. This tells me that this may be a practice that is waning over time, and perhaps waning with the advent of our fragmented care system and the hospitalist movement.
Q: What would you like to see hospitalists do?
A: I think hospitalists should get in the practice of expressing condolences when they've had significant contact and involvement with a patient. That could be a phone call or a letter or a card. I'm not saying that you need to do this for every patient that you met once. This is a human interaction that you should only do if it feels right to you. From my experience with colleagues, I think some people want to do it …but they're just not sure that it's appropriate, so I want to say that it is.
Q: Should condolences be mandatory or organized by the hospital?
A: There'd been some discussion on and off about whether there should be policies in our medical center about expressing condolences, whether there should be some kind of formal letter from the medical center…. Our [survey] respondents didn't want policies or mandates. They didn't want a form letter from the hospital …but they wanted it to be easier to do it. They wanted guidance in what to say in the letter. They wanted stamps and cards. They wanted social work help in finding the right person to write the letter to if they didn't happen to meet the family.
Q: What guidance would you offer on what to say in the letter?
A: There are some very good published guidelines for what to say in a condolence letter [by Gregory C. Kane, MD, published in CHEST in April 2007]. Those are the guidelines that I used to teach trainees about what to say in a letter. It would go something like this: “I'm writing to express my condolences on the death of your wife. I remember her well. (I would then share a remembrance from the hospitalization if I had one.) It was clear how much you loved each other. I liked her stories about growing up in x place. My thoughts are with you during this difficult time.”
Q: What's happening at your hospital on this issue now?
A: We are partnering with our patient and family resource council, and I talked to the medical director about what resources they could provide. We do have some cards for our hospitalist group that we had printed and our ICU colleagues also have cards available. We don't have a systemic response yet, but we're trying to have one.