Effect of a condolence letter on grief symptoms among relatives of patients who died in the ICU: a randomized clinical trial
Family members of patients who die in the intensive care unit (ICU) may experience symptoms of stress, anxiety, depression, posttraumatic stress disorder (PTSD), and/or prolonged grief. We evaluated whether grief symptoms were alleviated if the physician and the nurse in charge at the time of death sent the closest relative a handwritten condolence letter.
Multicenter randomized trial conducted among 242 relatives of patients who died at 22 ICUs in France between December 2014 and October 2015. Relatives were randomly assigned to receiving (n = 123) or not receiving (n = 119) a condolence letter. The primary endpoint was the Hospital Anxiety and Depression Score (HADS) at 1 month. Secondary endpoints included HADS, complicated grief (ICG), and PTSD-related symptoms (IES-R) at 6 months. Observers were blinded to group allocation.
At 1 month, 208 (85.9%) relatives completed the HADS; median score was 16 [IQR, 10–22] with and 14 [8–21.5] without the letter (P = 0.36). Although scores were higher in the intervention group, there were no significant differences regarding the HADS-depression subscale (8 [4–12] vs. 6 [2–12], mean difference 1.1 [−0.5 to 2.6]; P = 0.09) and prevalence of depression symptoms (56.0 vs. 42.4%, RR 0.76 [0.57–1.00]; P = 0.05). At 6 months, 190 (78.5%) relatives were interviewed. The intervention significantly increased the HADS (13 [7–19] vs. 10 [4–17.5], P = 0.04), HADS-depression subscale (6 [2–10] vs. 3 [1–9], P = 0.02), prevalence of depression symptoms (36.6 vs. 24.7%, P = 0.05) and PTSD-related symptoms (52.4 vs. 37.1%, P = 0.03).
In relatives of patients who died in the ICU, a condolence letter failed to alleviate grief symptoms and may have worsened depression and PTSD-related symptoms.
Trial registration Clinicaltrials.gov Identifier: NCT02325297.
KeywordsLetter of condolence Bereaved relatives Grief symptoms
We would like to thank Marine Chaize and Frédéric Pochard for their advice and thoughtful comments regarding the study.
Contributors: Virginie Lemiale MD, Sandrine Vallade MD from Assistance Publique, Hôpitaux de Paris, Saint-Louis University Hospital, Paris, France. Guillaume Géri MD, Wulfran Bougouin MD, Michel Arnaout MD, Lara Zafrani MD, Shirley Spagnolo MD, and Olivier Passouant MD from Assistance Publique, Hôpitaux de Paris, Cochin University Hospital, Paris, France. Gérald Choukroun MD and Laura Federicci MD from Sud Francilien Hospital, Corbeil-Essonnes, France. Alexandre Herbland MD and Maxime Leloup MD from La Rochelle Hospital, La Rochelle, France. Amelie Bazire MD and Pierre Bailly MD from Cavale Blanche University Hospital, Brest, France. Thomas Baudry MD, Romain Hernu MD, and Sylvie de la Salle RN from Hospices Civils de Lyon, Edouard Herriot Hospital and Lyon Est University, Lyon, France. Alexandre Demoule MD, PhD; Julien Mayaux MD from Assistance Publique, Hôpitaux de Paris, La Pitié-Salpêtrière University Hospital, Paris, France. Sébastien Cavelot (CRA) and Sybille Merceron MD from Versailles Hospital, Versailles, France. Arnaud Follin MD, Gersande Fave MD, Anne-Laure Constant MD, and Vibol Chhor MD from Assistance Publique, Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France. Julie Carr MD, Audrey De Jong MD, and Albert Prades RN from Saint Eloi University Hospital, Montpellier, France. Vincent Francois MD from Le Raincy-Montfermeil Hospital, Montfermeil, France. Marie Thuong MD from René-Dubos Hospital, Pontoise, France. Séverin Cabason MD from Poitiers University Hospital and Poitiers University, Poitiers, France. Stéphanie Gelinotte MD from Dieppe Hospital, Dieppe, France. Laurent Papazian MD PhD, Jean-Marie Forel MD, Christophe Guervilly MD, Sami Hraiech MD, PhD, Samuel Lehingue MD, Romain Rambaud MD, Elisa Marchi MD, and Pierre Esnault MD from Hôpital Nord University Hospital, Marseille, France. Michel Slama MD, PhD, Julien Maizel MD, and Thierry Soupison MD from Sud Amiens University Hospital, Amiens, France. Bertrand Souweine MD, PhD from Gabriel Montpied University Hospital, Clermont-Ferrand, France.
Compliance with ethical standards
Grant from the Fondation de France, a non-profit institution.
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