Reader question

Condolences are fine, but be careful what you say

Reader question: What is the risk of having physicians express their condolences to the family after a patient dies? I know that the doctor shouldn’t blurt out a confession that it’s all our fault, but other than that, does it matter much what he or she says? Is it OK to actually send a written letter of condolence?

Answer: Expressions of condolence can be entirely appropriate, and the risk manager should avoid any tendency to be overprotective in this situation, says Peggy Nakamura, RN, MBA, JD, DFASHRM, executive director of risk management and associate counsel at Adventist Health in Roseville, CA. Nakamura also is a past president of the American Society for Healthcare Risk Management in Chicago.

While it is correct that the risk manager should help physicians and staff express their condolences appropriately, Nakamura says this is a situation in which you should think as a caring human being first and a risk manager second. The situation gets a little dicier when it is apparent that a medical error contributed to the death, or may have contributed, but even then Nakamura says an expression of condolence is appropriate.

"If you have had a physician/patient relationship up to the point that the patient dies, expressions of condolence will be welcome and appropriate," she says. "If it’s a physician who has consulted in the last part of the patient’s life, I don’t think it means as much to the family. And above all else, whatever is expressed should be genuine and heartfelt."

New research suggests that a condolence letter could greatly improve relations between health care providers and the public, but it also says condolence letters are rare. (NEJM 2001; 342:1,163-1,165). While the authors of the study say any expression of condolence from the physician can help the patient’s family cope with their grief, they say a written condolence letter is "a concrete gift that the recipient can read over and over." The researchers suggest that the doctor avoid shallow cliches like "it was meant to be" or "I know how you feel." And they also suggest that the doctor avoid discussing the patient’s illness in detail because that may invite legal liability.

That, of course, is why many physicians and staff avoid contacting the deceased patient’s family. They fear they may be opening the door to a lawsuit by an angry family. They think their risk manager wouldn’t want them to say anything, that they are doing what the risk manager would suggest. Maybe, but not necessarily.

Nakamura says the risk of liability from expressions of condolence is not great unless medical errors were involved. When there is no suspicion that medical errors played a role, then physicians and staff should be free — even encouraged — to express their condolence to the family, she says. They should be cautioned not to state anything that implies that they or the facility is at fault, but a sincere expression of sympathy should not be discouraged, she says.

When a medical error is suspected, Nakamura says everyone must be more careful. But still, she says she would not suggest a physician or staff member refrain from expressing sympathy. The timing of the condolence is important, she says. It might be good to wait a few days so that the family has had time to absorb the loss, but she cautions that waiting too long can backfire. A condolence letter that comes too late can look like a defense strategy, rather than a sincere expression of concern.

Written expressions of condolence are more of a concern in this situation, because it could be used against the provider in a malpractice suit if it is not carefully worded. Nakamura urges all of her staff and physicians to consult with her before sending a letter of condolence.

"I’ve reviewed a number of letters for our medical staff. I’ve suggested wording changes, and I’ve suggested they not go too far and take responsibility for everything that happened," she says. "But I try not to go too far into a defensive mode, and I encourage them to focus on the sympathy, the human experience. Everyone wants to have the clinicians acknowledge that someone’s death was noticed by them, that it wasn’t just a normal day’s work. They want to know that their loved one mattered."

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