When written words are not helpful…

Randomised trial on Condolence Letters for grief symptoms among ICU patients’ relatives

Relatives of patients in an intensive care unit (ICU) are not simple hospital visitors. This special group of visitors are physically, emotionally and spiritually involved in every aspect of patients’ care, especially in the end-of-life [1]. In more than half of the cases, bereaved relatives experience symptoms such as anxiety, depression, fatigue, fear, traumatic stress and complicated grief [2]. Some of these symptoms commonly persist up to one year after a beloved’s death and, sometimes, longer [3]. Studies have demonstrated that valuable communication with clinicians might be beneficial in terms of lessening grief symptoms experienced by relatives and caregivers of patients who die in ICU [1]. For relatives of patients who have remained in ICU for a long, intensely emotional period of time, a patient’s death also abruptly interrupts a significant relationship with clinicians. A condolence letter may be an effective, simple and inexpensive way to facilitate the grieving process in the relatives. 

In this multicentre randomised controlled trial, the authors investigated the effect of a handwritten condolence letter sent to the closest relative by the physician and nurse who was in charge at the time of death [4]. The primary outcome was the Hospital Anxiety and Depression Score (HADS) at 1 month. Secondary outcomes were HADS, complicated grief, and post-traumatic stress disorder (PTSD) symptoms at 6 months.

Twenty-two centres in France participated in the study from December 2014 to December 2015. A single relative per patient was included based on healthcare proxies or involvement in ICU care. The condolence letters were handmade within 3 days after patients’ death and sent by standard mail after 15 days. All the letters included 5 domains:

1) recognise the death
2) talk about the deceased
3) recognise the family member
4) offer help
5) express sympathy.

Investigators blind to the study group did the follow-up telephone interview at 1 and 6 months.

From 356 patients assessed for eligibility, 242 were randomised: 121 to condolence letter and 119 to standard of care (without condolence letter). Lost to follow-up at 1 and 6 months were balanced among groups. Patients’ and family members’ characteristics were also similar between groups.

Regarding the primary outcome, the HADS score at 1 month was 16 (IQR 10-22) in the intervention group and 14 (8-21.5) in the control group (P=0.36). No significant difference was found in the HADS depression subscale, prevalence of depression symptoms, HADS anxiety subscale and prevalence of anxiety symptoms at 1 month. At 6 months, HADS score HADS depression subscale, prevalence of depression symptoms, prevalence of PTSD-related disorders were higher in the intervention group. In a multivariate analysis model, condolence letter, lower relative’s age, spouse or partner status, female gender of relative, and family educational level were significantly associated with a high (≥ 13) 6-month HADS score.

Strengths of the study include the multicenter design, low rate of lost-to-follow up, blinding of outcome assessors, well-validated scores used as outcomes and good statistical power for the primary outcome. On the other hand, all the involved centers were in France and had a large experience in end-of-life management and family-centered care, potentially limiting the general applicability of results. Moreover, although there were recommended domains and guidelines to follow, clinicians were free to write what they want in the letters limiting the standardisation of the intervention.

Concerning explanations for these findings, it may be argued that the letter may have been seen by the relatives as an unwelcome reminder of the painful period related to the beloved’s ICU stay and death with potential negative effects on physiological status. Moreover, it may have counteracted the psychological protection afforded by denial leading to depression and PTSD symptoms exacerbation.

In conclusion, this trial demonstrated that a condolence letter, as a sole post-ICU intervention, was not effective in alleviating grief symptoms in bereaved relatives and may have worsened depression and PTDS symptoms.

Article review prepared and submitted by Andrea Cortegiani, member of the ESICM Journal Review Club.

References

1. Azoulay E, Chaize M, Kentish-Barnes N (2014) Involvement of ICU families in decisions: fine-tuning the partnership. Ann Intensive Care 4:37.
2. Schmidt M, Azoulay E (2012) Having a loved one in the ICU: the forgotten family. Curr Opin Crit Care 18:540–547. doi: 10.1097/MCC.0b013e328357f141
3. Cameron JI, Chu LM, Matte A, et al. (2016) One-Year Outcomes in Caregivers of Critically Ill Patients. N Engl J Med 374:1831–1841. doi: 10.1056/NEJMoa1511160
4. Kentish-Barnes N, Chevret S, Champigneulle B, et al. (2017) Effect of a condolence letter on grief symptoms among relatives of patients who died in the ICU: a randomised clinical trial. Intensive Care Med. doi: 10.1007/s00134-016-4669-9. [Epub ahead of print]