We surveyed a US population of cancer care physicians regarding their participation in common bereavement activities after the death of a patient. An important distinction in these activities is that although bereavement counseling has the potential to intervene and affect complicated grief,26
a majority of surveyed activities represent expressions of condolence. The extent to which condolence expressions have an impact on health outcomes is unknown, although we propose it affords potential contact to identify those who may benefit from counseling. Seventy percent of our respondents referred to a bereavement program at least sometimes; however, the circumstances surrounding this referral and any possible impact on the bereaved are beyond the scope of our study.
Interpretation of the high bereavement follow-up rates seen in our study is significantly limited by its disappointing 22% response rate. Originally, we suspected that e-mail solicitation may have either been overlooked or blocked by e-mail filtering programs, but additional contact by US mail showed only small recruitment benefit. Two similar studies of physician bereavement practices have been performed in Canada and Israel, each demonstrating an approximately 70% response rate.23,25
Similar recruitment methods were used, although one study did provide a small incentive for participation.23
Because physician bereavement practices remain a relatively understudied area, to place our findings within the proper context, we offer comparisons to these two similar studies while acknowledging that the substantial differences in participation rates and presence of biases challenge the validity of direct comparison.
In a similar population of Canadian physicians, Chau et al23
found that one third of respondents usually or always performed the active practices of sending a condolence card, attending a funeral, or, most commonly, placing a telephone call to families. More than two thirds of respondents in our regional domestic survey reported regularly participating in at least one of these activities. Canadian physicians with access to a palliative care program were less likely to perform bereavement follow-up, which the authors suggested may have represented delegation of bereavement follow-up to palliative care services, a finding absent in our study. Finally, survey of the Canadian physician group found that palliative care physicians were the most likely group to perform active bereavement follow-up. In contrast, we found that medical oncologists were most likely to engage in active bereavement follow-up. It has been demonstrated that often, referral to palliative care physicians occurs relatively late in the course of disease.27–29
It is possible that delay in palliative care referral may result in a shorter timeframe in which to develop the physician-patient bond that makes follow-up more likely.25
Seventy-four percent of Israeli oncologists surveyed by Corn et al25
reported frequently or occasionally participating in bereavement rituals, with 26% reporting that they never engaged in any sort of bereavement rituals. The likelihood of bereavement activity participation was significantly associated with the presence of a special bond with patients. Grouping the practices of attendance at funerals, visitations, and memorial services together, they found that 29% of respondents frequently or occasionally attended these events. In comparison, 16% of our respondents reported always, usually, or sometimes attending a funeral or memorial service. This discrepancy in ritual attendance rates may be explained by differences in culture, practice of medicine, or perceived expectations and responsibilities. A consistent barrier reported in these studies as well as ours was lack of time.
From a historical perspective, the physician's letter of condolence is one of the oldest enduring forms of grief expression in medicine.12,30–32
As the most common active practice in our study, it is not surprising that the belief that this form of communication was a physician's responsibility was positively associated with active follow-up. Taking into consideration the self-reported lack of training as well as feelings of uncertainty about what to say, perhaps a good starting point is to revisit training in this dying art. Various authors have suggested the essential components of a condolence letter include acknowledgment of loss, recognition of one's role in care, mention of a personal quality or memory of the deceased, an offer to remain available for support or questions, and expression of sympathy.31,33
Identification of the appropriate family contact is also key for such communication.
The perceived lack of adequate training regarding bereavement activities during residency or fellowship has been demonstrated in other studies of physicians dealing with end-of-life issues.34–38
Additionally, barriers that were negatively associated with active bereavement follow-up included lack of bereavement support resources and feeling uncomfortable about what to say. Since ASCO developed recommendations a decade ago,11
there has been an expansion of palliative care rotations as well as improvements in educational resources to specifically address the need for education in end-of-life care.16,39
Palliative care programs have also greatly expanded, perhaps causing some to assume embedded bereavement follow-up mechanisms. In practice, bereavement follow-up is often performed by various members of the health care team.24,40
It is important to consider that although follow-up in general is welcomed, studies have demonstrated that family members feel it is important to have contact with a patient's physician.20,41
Determining the direct impact of these efforts on the bereaved will require longitudinal study.
We do not presume that lack of participation in bereavement follow-up is the result of avoidance. There are countless factors that influence an individual's decision to reach out to a patient's family. Although the individual needs of the bereaved can be highly variable,42
a significant proportion of families express the desire for and satisfaction with such activities.19,40,43–45
As mentioned, the extent to which direct contact through offerings of condolence ultimately leads to referral for support or counseling would be a point of interest for future study.
We acknowledge the low response rate to our survey significantly limits its generalizability, and the high rates of participation in bereavement follow-up likely reflect contribution from both response and social desirability biases. Because of the design of our study, it was not possible to determine difference in demographics from respondents and nonrespondents. To aid in comparison, the methods selected for this study mirror those of a similar study of bereavement practices among cancer care physicians.23
However, given our smaller sample size, such methods may lack sufficient statistical power. Finally, although we expected membership in the surveyed professional organizations to represent the majority of physicians we were interested in targeting, there likely remains a substantial unsurveyed population.
In conclusion, a large proportion of our study respondents reported engaging in bereavement follow-up, with a concurrent perceived lack of training in these activities. Although the role of the physician in bereavement follow-up is not clearly defined, efforts to improve communication, identify available resources, and address bereavement activities in postgraduate training and maintenance of certification may, in part, lead to improved multidisciplinary treatment of patients with cancer, their families, and caregivers. Future studies linking physician training and practices with the longitudinal family and caregiver adjustment to loss are needed.