Effect of a condolence letter on grief symptoms among relatives of patients who died in the ICU: a randomized clinical trial

Abstract

Purpose

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.

Methods

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.

Results

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).

Conclusions

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.

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Acknowledgments

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.

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Corresponding author

Correspondence to Elie Azoulay.

Ethics declarations

Funding

Grant from the Fondation de France, a non-profit institution.

Additional information

This study was performed on behalf of the Famirea Study Group.

All contributors are listed in the Electronic supplementary material 1.

Electronic supplementary material

Appendices

Appendix 1: Participating ICUs

  Investigator name City Hospital Type of intensive care
1 Marion Venot Paris Saint Louis Medical intensive care
2 Benoît Champigneulle Paris Cochin Medical intensive care
3 Maité Garrouste Paris Saint Joseph General intensive care
4 Gilles Troche Le Chesnay-Versailles André Mignot General intensive care
5 Olivier Guisset Bordeaux Saint André Medical intensive care
6 Anne Renault Brest Cavale Blanche Medical intensive care
7 Laurent Argaud Lyon Edouard Herriot Medical intensive care
8 Mélanie Adda Marseille Hôpital Nord Medical intensive care
9 Jean-Philippe Rigaud Dieppe CH de Dieppe General intensive care
10 Isabelle Vinatier La Roche-sur-Yon Les Oudairies General intensive care
11 Samir Jaber Montpellier Saint Eloi General intensive care
12 Marina Thirion Argenteuil CH Victor Dupouy General intensive care
13 Olivier Lesieur La Rochelle CH de la Rochelle General intensive care
14 René Robert Poitiers CHU de Poitiers Medical intensive care
15 Raphaël Cinotti Nantes CHU de Nantes Surgical intensive care
16 Laure Calvet Clermont Ferrand CHU Gabriel Montpied General intensive care
17 Caroline Bornstain Montfermeil CHI Le Raincy General intensive care
18 Marion Gilbert Corbeil-Essones CH Sud-Francilien General intensive care
19 Véronique Gaday Pontoise CH René Dubos General intensive care
20 Alexandre Demoule Paris La Pitié-Salpêtrière Medical intensive care
21 François Thomas Amiens CHU Amiens-Picardie Hôpital Sud Nephrology intensive care
22 Julien Massot Paris HEGP Anesthesia-surgical intensive care

Appendix 2

Recommendations for writing a condolence letter and examples

Why write a condolence letter?

  • To help family members in the bereavement process: the letter helps relatives feel recognized in their pain and not abandoned by the hospital team,

  • to help family members manage potential feelings of anger or lack of understanding following an unexpected death,

  • to help the physician take stock of the patient’s death,

  • to bring closure to the relationship between caregivers and the families of the deceased patient.

Recommendations for writing a condolence letter

The condolence letter must be handwritten

  • Avoid superficial expressions like “I know what you’re feeling”.

  • Don’t write too formal a letter!

  • Please be sure to integrate the following five domains.

Five domains to include in the letter:

  1. 1.

    Recognize the death—name the deceased

    • The importance of naming the deceased.

    • Reduces the feeling of loneliness of the family member.

  2. 2.

    Talk about the deceased

    • If possible, personality, age, interests (sports, religion…).

    • If possible, mention a specific memory of the deceased.

    • If possible, mention the relationship of the deceased with the family member.

  3. 3.

    Recognize the family member

    • Personality, strengths (to recognize a potential for coping effectively).

    • Mention what the family member did for or with the patient in ICU (frequent visits, participating in care, etc.).

    • Or even the relationship of the family member with the ICU team.

  4. 4.

    Offer help: the possibility of contacting you

    • Be specific (phone number of the ICU).

  5. 5.

    Express your sympathy (conclusion)

    • Symbolize a shared emotion.

Examples

  1. 1.

    Recognize the death and name the deceased

I send you my sincere condolences on the death of your sister, Alison Smith. Natalie, who was your sister’s nurse, joins me in expressing our sympathy.

  1. 2.

    Mention the deceased

    1. (a)

      Patient who was conscious and able to communicate:

We had the opportunity to get to know your brother during his stay in our unit. He was very brave. His smile and his words touched us often. His caregivers were always happy to go into his room.

Or

We had the opportunity to get to know your mother during her stay in our unit. She was very brave. We understood her need to be cared for and reassured and we hope we were able to comfort her in the difficult moments.

  1. (b)

    Patient who was conscious but had difficulty communicating:

We had the opportunity to get to know your brother during his stay in our unit. He seemed very brave. He tried to communicate with us in different ways, for example using the whiteboard we gave him, even though we know it was sometimes difficult for him.

  1. (c)

    Patient who was never conscious in the ICU.

We did not have the opportunity to really get to know your aunt and we regret that. However, thanks to her family members, we could see that she was a kind and brave woman and we did our best to care for her and help her with kindness and respect.

  1. 3.

    Recognize the family member.

You were very present during his stay, ready to assist and be present for your brother. In my experience as a physician, I believe that the presence and support of a family member brings peace and serenity to those who are at the end of life.

  1. 4.

    Offer help.

I remain at your service if you wish to ask any questions or simply discuss your brother’s stay in intensive care. Please feel free to call us at [telephone number].

  1. 5.

    Express your sympathy (conclusion).

We send you our warmest thoughts,

Dr. Doe.

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Kentish-Barnes, N., Chevret, S., Champigneulle, B. et al. Effect of a condolence letter on grief symptoms among relatives of patients who died in the ICU: a randomized clinical trial. Intensive Care Med 43, 473–484 (2017). https://doi.org/10.1007/s00134-016-4669-9

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Keywords

  • Letter of condolence
  • Bereaved relatives
  • Grief symptoms