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

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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.

Author information

Authors and Affiliations

  1. Assistance Publique, Hôpitaux de Paris, Saint-Louis University Hospital, Famiréa Research Group, Paris, France

    Nancy Kentish-Barnes, Virginie Souppart, Marion Galon, Zoé Cohen-Solal & Elie Azoulay

  2. ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153, INSERM, Paris Diderot Sorbonne University and Service de Biostatistique et Information Médicale AP-HP, Hôpital Saint-Louis, Paris, France

    Sylvie Chevret

  3. Assistance Publique, Hôpitaux de Paris, Cochin University Hospital, Paris, France

    Benoît Champigneulle

  4. Victor Dupouy Hospital, Argenteuil, France

    Marina Thirion

  5. Sud Francilien Hospital, Corbeil-Essonnes, France

    Marion Gilbert

  6. La Rochelle Hospital, La Rochelle, France

    Olivier Lesieur

  7. Cavale Blanche University Hospital, Brest, France

    Anne Renault

  8. Saint Joseph Hospital, Paris, France

    Maïté Garrouste-Orgeas

  9. Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon Est University, Lyon, France

    Laurent Argaud

  10. Assistance Publique, Hôpitaux de Paris, Saint-Louis University Hospital, Paris, France

    Marion Venot

  11. Assistance Publique, Hôpitaux de Paris, La Pitié-Salpêtrière University Hospital, Paris, France

    Alexandre Demoule

  12. Saint André University Hospital, Bordeaux, France

    Olivier Guisset

  13. Les Oudairies Hospital, La Roche sur Yon, France

    Isabelle Vinatier

  14. Versailles Hospital, Versailles, France

    Gilles Troché

  15. Assistance Publique, Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France

    Julien Massot

  16. Saint Eloi University Hospital, and Inserm U-1046, Montpellier, France

    Samir Jaber

  17. Le Raincy-Montfermeil Hospital, Montfermeil, France

    Caroline Bornstain

  18. René-Dubos Hospital, Pontoise, France

    Véronique Gaday

  19. Poitiers University Hospital and Poitiers University and Inserm CIC 1402, Poitiers, France

    René Robert

  20. Dieppe Hospital, Dieppe, France

    Jean-Philippe Rigaud

  21. Hôtel Dieu University Hospital, Nantes, France

    Raphaël Cinotti

  22. Assistance Publique, Hôpitaux de Marseille, Hôpital Nord University Hospital, Marseille, France

    Mélanie Adda

  23. Sud Amiens University Hospital, Amiens, France

    François Thomas

  24. Gabriel Montpied University Hospital, Clermont-Ferrand, France

    Laure Calvet

  25. Assistance Publique, Hôpitaux de Paris, Cochin University Hospital, Paris Descartes University, Paris, France

    Alain Cariou

  26. Medical Intensive Care Unit, Hôpital Saint-Louis, ECSTRA Team, and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University , 1 rue Claude Vellefaux, 75010, Paris, France

    Elie Azoulay

Authors
  1. Nancy Kentish-Barnes
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  2. Sylvie Chevret
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  3. Benoît Champigneulle
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  4. Marina Thirion
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  5. Virginie Souppart
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  6. Marion Gilbert
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  7. Olivier Lesieur
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  8. Anne Renault
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  9. Maïté Garrouste-Orgeas
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  10. Laurent Argaud
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  11. Marion Venot
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  12. Alexandre Demoule
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  13. Olivier Guisset
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  14. Isabelle Vinatier
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  15. Gilles Troché
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  16. Julien Massot
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  17. Samir Jaber
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  18. Caroline Bornstain
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  19. Véronique Gaday
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  20. René Robert
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  21. Jean-Philippe Rigaud
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  22. Raphaël Cinotti
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  23. Mélanie Adda
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  24. François Thomas
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  25. Laure Calvet
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  26. Marion Galon
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  27. Zoé Cohen-Solal
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  28. Alain Cariou
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  29. Elie Azoulay
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Consortia

Famirea Study Group

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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