1. Harpham, Wendy S. MD, FACP

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Remember the last time you returned to work after a nice holiday and learned a longtime patient had died? What did you do? Years ago, physicians routinely sent condolence cards. Times have changed. Handwritten notes of sympathy are going the way of the complete exam. Is that okay? Or should we resurrect the practice as the standard of care, especially for physicians off-call at the time of the patient's death? To consider the pros and cons, let's begin with a case.

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Wendy S. Harpham, MD... - Click to enlarge in new windowWendy S. Harpham, MD, FACP. WENDY S. HARPHAM, MD, FACP, is an internist, cancer survivor, and author. Her books include

A couple's only child, a son, was diagnosed with a serious disease at 4 years old. For 2 decades, the mother calmed her anxieties with realistic hope he'd survive long enough to be rescued by the cure allegedly just around the corner. Then, that mother was nearly blinded by a sparkling new hope on the left ring finger of the young woman soon to join the family. A few months later, her son developed another routine infection, which triggered another routine hospitalization. He died. A cross-covering doctor pronounced him. And that was that.


Day after day, with little letup for weeks, hundreds of cards and notes crowded out the flowers, food, and gifts delivered by people whose lives were touched in some way by her son. The resilient mom began to accept her boy would be 24 years old forever, his hugs replaced with photographs, videos, and pictures painted in words. Each image blew breath into her son's spirit that lived on in her world where medical advances had not come soon enough.


It's now 4 months since her son's death. She told me how walking to her mailbox or pushing the button of her answering machine still triggered a wave of emotion. Except the yearning for a message from her son's physicians has given way to despair of finding that comfort.


The bereaved mother asked me, "How could it be not one of the specialists who cared for my son for over 20 years offered any condolence?" I learned her son joked with his doctors at many of the hundreds of office visits and hospitalizations, and he trusted them with his life. "It can mean only one thing...," she sputtered, her lips tightening. "He was just another patient, a disease needing treatment. Our son never mattered to them."


I took her hands in mine. Sympathizing with her hurt and anger, I wanted her to understand, "It's not that simple." The urge to defend doctors was subdued by my uncertainty about the place of condolence notes in modern medicine. Before rattling off legitimate explanations, I had to ask myself: Do any explanations justify not sending a note of condolence?


Let's look. Given the pace of oncology practice and how often cancer patients die, the time and energy required for even brief notes may feel burdensome. Unlike with charting or coding, clinicians have the option of not starting their day earlier-than-early or ending it later-than-late in an emotional space defined by death.


It takes guts to enter that space where prescription pads sit untouched, reminding clinicians of the uselessness of the expertise that differentiates them from other clinicians, let alone from ordinary folks. It takes discipline to take pen in hand, a posture that awakens memories of past medical decisions and interpersonal interactions. Even if they did everything right, some memories may trigger second-guessing or regret. Not surprisingly, instincts may push clinicians to avoid that place where feelings of loss, failure, and powerlessness can eat away at confidence and hope, like water dripping on limestone.


Of all the notes you write at work, those of condolence can be the thorniest. Some oncologists get hamstrung trying to find proper phrases, especially if harboring a twinge of concern about others misconstruing their meaning. It's rational, not paranoid, to fear saying something that unwittingly causes pain or, worse, ricochets back to hurt you. Just ask any clinician who reached out with heartfelt condolences-such as, "I'm so sorry for your loss" or "I wish we could have done more"-and was rewarded months or years later with a malpractice suit.


My conviction that clinicians need to send condolence notes to the families of longtime patients is based on the ancient adages to "comfort always" and "first, do no harm." Those notes comfort bereaved family members and prevent them from the pain of thinking their loved ones didn't matter to their longtime physicians.


Writing condolence notes can be healing for clinicians, too. Performing that last act of kindness for longtime patients can provide a sense of closure that helps clinicians process the loss and move on. Knowing they can help the bereaved in a uniquely meaningful way reminds them of the healing power of their words. Taking a moment to reflect on their relationship from beginning to end can renew the sense of honor and privilege of caring for patients.


To make the task a bit easier, here are a few tips for writing a brief note of condolence. (I've suggested language that may avoid the risk of family members misreading your note as evidence of fault.)


* Keep a supply of blank notes, well-worded store-bought cards, or custom cards.


* Acknowledge the death ("I was saddened by the death of...." or "It was an honor and privilege to care for....").


* Recall a special memory; mention a trait you admired.


* If appropriate, applaud the family's care of the patient.


* Avoid hurried notes and automated signatures.



Written notes offer advantages over phone calls. You benefit from being able to control the time investment and having the option of abandoning the effort mid-sentence if suddenly not in the right frame of mind. By crafting an exact message, you eliminate the risk of an unfortunate choice of words popping out. Bereaved family members benefit from a note, too. A phone call may catch them when they can't listen to, let alone process and remember, what you say. With a condolence note, they control when and where they read it. They can treasure the card as a keepsake, reading and sharing your words over and over as they heal.


In our world of high-tech medicine and instant messaging, condolence notes are not passe. They help preserve the humanity of our calling.