In this retrospective study the authors initiated a series of discussions with the medical team members who cared for these patients and participated in condolence visits. These were unstructured open discussions during which the researchers attempted to understand the underlying reasons for the occurrence of the spontaneous condolence visits and ensuing issues and questions. The main recurring themes are presented and discussed.
Do these visits invade the privacy of the families during the initial mourning periods?
In some cultures condolence visits could be interpreted as infringing upon the privacy of the family. In Judaism, as well as in other religions and cultures, it is customary to pay a condolence visit during the first week following the death. The bereaved - the closest family members - are all together, sitting on a low chair which indicates they are in mourning. The visitors which include relatives, friends and neighbors, come and give support and strength. The Shiva condolence consists of one week (Shiva in Hebrew means Seven) and is meant to process the condolence intensity, and is certainly an accepted cultural and religious tradition [10
Are the home visits really a part of the professional treatment?
The underlying supposition is that the condolence visits are part of the continuity of the medical staff treatment process. Ferris, et al. [11
] reported a survey at two academic medical centers that the house staff task of care after a death including follow up with the family [11
]. Chau, et al. [6
] presented a study at the annual meeting of the American Society of Clinical Oncology pertaining to condolence practices among Canadian cancer physicians. The study groups were divided into medical oncologists (MO), radiation oncologists (RO) and palliative care (PC) professionals. The frequency of the physician consistently sending cards were (in percent): 18.2 (MO): 7.1 (RO): 29.5 (PC) respectively. Telephoning to the family achieved a higher level of participation by all physicians: 21.1 (MO), 13.5 (RO), 34.8 (PC). Attending the funeral had the lowest level of attendance: 6.4 (MO), 3.3 (RO), 13.4 (PC). Referring family to condolence support programs had mixed priorities: 6.5 (MO), 3.9 (RO), 19.1 (PC) as did post-terminal death family meetings: 6.4 (MO), 3.3 (RO), 13.4 (PC) respectively. It is significant that these condolence practices are considered and undertaken more frequently with palliative care physicians. Participation notably is beginning to be initiated with medical oncologists and radiation oncologists. Thus it is important to recognize that the treatment process does not end with the death of the deceased, and continues through the condolence visit of the medical staff during the first week of the formal mourning period [5
Are these visits confusing the professional and personal boundaries?
In coping with the loved one's illness, the patient's family depends in many ways upon the support and intervention from the treating physician and medical staff [12
]. Treatment questions are addressed to the nursing staff and difficulties related to emotional concern are directed to the social worker. The medical conditions relating to specific acute problems (fever, vomiting, infection, convulsion etc.) are discussed with the physician. All these efforts reinforce the family affinity and attachment with the staff.
Issues surrounding death (DNR decisions, intubation and tube feeding), and personal preference frequently arise in discussion between the staff and families of the patients [13
]. After the patient's death, it is often overlooked that the family still looks to the medical team for comfort, insight and guidance. A condolence visit consisting of the combined team approach by the physician, nurse and social worker to the family's home has significantly greater impact than a visit by only one staff member. The medical staff appears at the family home condolence visit in uniform, directly from work and during working hours. Such a visit is not a social call, nor is it private in nature but serves to represent the department or even the hospital in its entirety.
What purposes do these visits serve?
The main purpose of visiting the bereaved family is to transfer an awareness of empathy, recognition and contribution. Additionally, the staff attempts to relieve the family of emotions of guilt or anger that may exist by reinforcing the validity of the medical decisions that were made by the family as well as respecting the devotion and dedication of the spouse, children and family [7
The visits express caring and concern, and help diffuse the family's closeness towards the medical team. It is important to recognize that the primary goal of the condolence visit to the home of the bereaved families is to meet the needs of the family, even though there may be personal reactions and requirements by part of the staff concerning the patient and the family [14
A face-to-face visit with the family facilitates: 1. Non-verbal expressions of sympathy which are impossible to communicate by any other means. 2. Allowing the family to speak amiably, with additional detail, and in a non-threatening environment. 3. Providing guidance for condolence support programs.
Do these visits benefit the family and/or the staff?
The medical staff believes that these visits constitute an integral part of the caring process for the patient's family. A visit to the grieving family thus gives closure to the care and concludes the responsibility of the staff to the patient and the family [16
]. The sense of loss and failure for physicians and staff does occur as a result of the patient's death and the family lack of contact. This is experienced less keenly by geriatric physicians and specialized staffs recognizing death as a natural process and thus these professionals continue to be involved during the condolence period [17
The home visit sets an example for a comprehensive approach by the entire medical team, emphasizing humanistic and holistic treatment and does not focus solely on technical clinical duties with the patient and family [18
]. In an era of technological life supports, the entire dying process is prolonged, and places a greater emotional burden and requirements upon the family. Therefore, humanistic and comprehensive treatment who met the needs of the family and focus on the family is optimal.
In the past, the departmental policy following the demise of a patient consisted of the social worker and/or the head physician of the department communicating sympathy by telephone to the family of the deceased. Acknowledgement emerged for the necessity to change this procedure as a visit in person is substantially greater in impact than a mere phone call.
In a telephone call conducted among two third of the bereaved families a month after the patient's demise, the families expressed profound appreciation for the deceased treatment and for the condolence visit by the medical team.
What criteria should be applied to decide which families to visit?
Primary and secondary criteria for condolence visits have now been established. Although visiting the families of all deceased patients would be ideal, it is unrealistic (time, absence of staff and distance) to expect staff to make condolence visits for all deceased patients [19
1. The primary criteria chosen established the acceptance and awareness of a significant and close-knit relationship developed between the family and the staff, and thus it is deemed appropriate for continuity and closure to make the home visit. The nature of a deeper relationship with the family includes open expression of feelings during the hospitalization of the patient, and frequent, lengthy conversations conducted with the staff. Furthermore, the probability of a close relationship between the medical team and the family is abundantly greater when the dying process has extended over a long period.
2. The secondary criteria utilized were to clarify the cause of unexpected death, respond to complaints, anger and/or dissatisfaction expressed by the family.
For example, the patient may have died suddenly and unexpectedly, the family may not have been prepared and perhaps they may suspect that there were influencing factors, including neglect or lack of attention pertaining to the sudden death. A home visit during the first week after the patient's death gives the family a chance to inquire and clarify the cause of the death and to vent suspicions or anger on a face-to-face basis with the staff.