Aligning Intention and Effect: What Can We Learn From Family Members’ Responses to Condolence Letters?*

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Even when bolstered by good intentions, unforeseen and occasionally harmful consequences may arise from our actions as healthcare providers. An example of this phenomenon was recently provided by a randomized trial assessing the effect of a condolence letter on grief symptoms among relatives of patients who died in the ICU (1). It is surprising that a condolence letter, a gesture which seems intuitively helpful, was linked to increased symptoms of psychological distress among bereaved family members (1). This left many of us asking questions about our own practice of sending condolence letters, while also wondering how we might better understand these findings. In this issue of Critical Care Medicine, Kentish-Barnes et al (2) use rigorous qualitative methods to explore the experiences of family members receiving condolence letters as part of their randomized trial. By allowing us to understand more about the impact of the intervention, this study highlights one of the important ways qualitative research can be used to improve the conduct of randomized trials. Qualitative research is frequently used to develop and implement interventions before a trial (3), but this study shows how qualitative methods can also provide key insights after the trial is complete.
In this qualitative analysis, the authors evaluated transcribed statements obtained during follow-up interviews with bereaved relatives (2). During the randomized trial, interviewers were appropriately blinded to group allocation, so statements about condolence letters had to come spontaneously from family members and could then be followed by an in-depth interview. In addition to transcribed statements from interviews, the authors also analyzed written feedback sent from relatives to clinicians during a four-month period following the patient’s death. Using thematic analysis, the investigators identified six themes related to the receipt of condolence letters: 1) a feeling of support; 2) humanization of the medical system; 3) an opportunity for reflection; 4) an opportunity to describe their loved-one; 5) continuity and closure; and 6) doubts and ambivalence. Although several of these themes suggest the potential for condolence letters to foster positive experiences among relatives of patients who died in the ICU, there were negative reactions that cannot be ignored.
Several of the identified themes have direct appeal to critical care clinicians striving to provide family-centered care. The goals of supporting family members during a difficult time, acknowledging the humanity of their loved one, and ensuring family members that the medical team provided high-quality care, are all important (4). In many instances, statements from family members demonstrate the ability of the condolence letter to help achieve these goals even after the patient’s death. However, for some, the statements reveal a mixture of emotions. In addition to feelings of support and gratitude, family members note sadness as they relive the death of their loved one, grapple with grief, or express regret related to the patient’s hospital stay. The bereavement process differs for each individual (5–7), so it is possible that for some, feelings of support associated with the letter may be overshadowed by a renewed sense of loss. It is also possible that an intervention providing psychological support could cause a temporary increase in symptoms associated with remembering the death and yet enhance long-term recovery from grief. Since this study followed family members for 6 months, a temporary increase in symptoms followed by a later reduction would require following family members well beyond 6 months; future studies should consider following family members for 1 or 2 years (1). Other reactions to the letter highlight unintended consequences that may have resulted from the format of the letter.
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