My Condolences: Making Bereavement Contact Part of Our Standard Operating Procedures

When I was a new hospice and palliative medicine fellow, I remember being surprised at the close of a two week stretch working with one attending physician when she said, “let's break for lunch and make some bereavement calls for our patients who've died these past weeks.” I recall stammering a bit and feeling unprepared. I do not know whether I expected to have soft music playing and incense burning when I sat down to call my patients' loved ones, but making these calls together in the cramped fellows' office right after polishing off a turkey sandwich felt quite jarring. However, as we called caregiver after caregiver, some of whom we had gotten to know well over many intensive hospitalizations, and some we had only met during the last moments of their loved ones' lives, the awkwardness faded away and I was glad that early on in my fellowship, my hand had been forced to make this a routine part of my practice.

It would have been much easier to put off these calls to the end of the day or when I had some quieter off-service time, but I would have been less likely to follow through, as life has a habit of getting in the way. It is also easy to rationalize. “I didn't know the patient for that long—I'm sure the family would rather hear from the oncologist.” Or, “I don't know what to say, and I'm worried that calling the family may just make things worse.” “They're probably exhausted and busy making arrangements.” Through being coached that reaching out to our patients' loved ones after death is part of our standard operating procedures, I could not give myself that out.

An article in this issue of the Journal of Palliative Medicine by Makarem et al. reports on the experiences of bereavement contact among caregivers of patients with advanced cancer. Their reported percentage of caregivers who received bereavement contact (50%) was consistent with that found in the literature. A number of barriers have been proposed, including a lack of time, a loss for the appropriate expression of condolence, inadequate bereavement training, and uncertainty about which family member to contact.^1,2

Bereavement follow-up has long been considered a cornerstone of palliative care best practices. ³ Although palliative care physicians were most frequently identified as the provider making bereavement contact in this study, their contact still only occurred in a minority. Clearly there is still room for improvement.

Throughout my career, I have had periods of time when I have been better or worse at reaching out to bereaved family members. There was a stretch when it seemed I had an odd knack for calling during the funeral (and was once chagrined when my patient's wife actually answered during the funeral service, until she said, “It's like my husband was letting you know I needed you right in this moment!”).

In a day and age where the last time I can remember writing a hand-written card was for my wedding thank you notes, this practice can often feel outdated and outside of a busy clinician's wheelhouse. “Thanks for the lovely dishes from our registry” feels very different than, “I'm so sorry to hear of David's passing and I'm thinking of you…” In the age of e-mails and texts and Facebook, putting pen to paper or even making a phone call may seem archaic, but I have also found it to be a rewarding ritual, even when it can be difficult to know how our calls or notes are perceived.

Thus, it was reassuring to read that in this study, contact was appreciated and considered beneficial by all who received it, with no caregivers reporting a negative impact from bereavement contact. Even more interesting to me, for caregivers who had not received contact, common reactions included rationalization, ambivalence, and regret. Prominent themes emerging from those who were contacted included “contact reflects caring,” “contact offers support,” and “contact facilitates closure.”

One of the reasons I enjoy being co-editor for the Books and Media section of the Journal of Palliative Medicine is that I love stories. I love reading them, writing them, and sharing them. I deeply believe in the power of storytelling, and have found that some of the most powerful stories can be those we tell ourselves. In these bereavement contacts, we have the opportunity to shape our patients' stories and, in the case of grief, to help guide the narrative that loved ones may have even after our patients' deaths.

Although condolences are now a routine part of my practice, every once in a while, the death of a patient will strike me particularly hard, and I am at a loss for words when calling or writing a letter. In those moments, I am grateful for published guidelines about expressing condolences, such as Wolfson and Menkin's “Fast Facts and Concepts #22: Writing a Condolence Letter” ⁴ or the concrete examples found in Bedell et al.'s article “The Doctor's Letter of Condolence.” ⁵ When battling with my own grief and loss over a patient's death, I find it helpful to return to these articles for guidance. Even when it may initially feel rote or impersonal, I can find my own truth and sincerity in the examples provided.

As I am writing this, an Outlook notification pops up in the corner of my screen. It is an e-mail from my division's bereavement coordinator, reminding us about the opportunity to sign cards for loved ones of patients we have cared for who died this past week. I am grateful that years after that first reminder in fellowship, I still have colleagues who are willing to stand in the gap for bereaved caregivers, advocating that I participate in their bereavement support as a routine part of my job as a palliative care clinician. And I am grateful for Makarem et al.'s article highlighted in this issue, advocating for integration of bereavement contact into routine supportive care for caregivers.