The Butterfly Effect: Supporting Pediatric Trainee Bereavement Through a Condolence Card Project Free

As medical students and residents, we have all grappled with patient death and dying at some point in our training. These experiences often remain with us, informing our clinical practice, our personal wellbeing, and the ways in which we build relationships with patients and families. One memory, among many, inspired our work to bolster and reform trainee bereavement practices.

On Monday, I walked into the hospital apprehensively. I was nearing the end of a month-long rotation in the medical-surgical ICU, my first experience caring for critically ill children during residency. I heard the news from my coresident: my patient had died on Sunday. Although it was not unexpected, it still hurt all the same.

It was 5:50 am when I rounded the hospital corner and approached his old room. As I peeked inside, my heart sank. Just 3 days ago, this room was full of people and things and sounds; everything was in color. There were Paw Patrol stickers and family photos covering the walls, and stuffed animals spilling onto the floor. Today, however, aside from the paper cut-out of a butterfly hanging gently over the entryway, his room was completely bare.

Before the weekend, when death inched closer, the ICU team taught me the meaning of the hospital butterfly. As a patient is nearing the end of life, a paper butterfly is placed at the entrance to their room, an indicator to providers of the circumstances inside. This makes the butterfly sign both a harbinger of death as well as a symbol of hope, transformation, and metamorphosis. This was my first time seeing a butterfly, and I felt its presence deeply.

I pressed my palms into my eyes, a hopeful gesture to stop the tears, and walked into our workroom. My coresident and I exchanged knowing glances, and I knew they felt it too. We both sighed and then started the sign-out process. There were many sick patients on our service who needed our attention. The day had to go on.

It has now been 2 years since this patient’s death, but I still think about him and his family. I reflect on his dying process and question whether I did too little or too much. I worry that his family will never really know how deeply I cared or how profoundly he impacted me as a training pediatrician. I wonder whether other residents have experienced this same confusion and doubt around patient death. I ask myself the question: how do we, as providers, bereave dying patients?

Provider bereavement practices, although exceptionally important, are far from standardized. Provider grief is largely underacknowledged and undersupported at an institutional level.¹  Despite the known negative implications, there is a lack of opportunities for medical providers to achieve closure after patient death. This can contribute to professional loneliness, loss of meaning in work, feelings of frustration and anger toward the health care system, loss of humanism, and increased burnout and depression.²  Pediatric trainees are particularly vulnerable to these impacts, given their high baseline levels of burnout and depression in the midst of training.³  In addition, these perspectives may be exacerbated by the fact that pediatric trainees are generally unprepared for interactions with dying patients and their families, with only 32% of resident physicians in a cross-sectional survey expressing comfort approaching end-of-life scenarios.⁴  Another survey found that even fewer trainees, only 10%, had experience with condolence expression.⁵  This may be influenced by the lack of requirement for an end-of-life care curriculum for pediatric residents within the Accreditation Council for Graduate Medical Education.⁶ 

One approach to grief processing is through bereaved family outreach in the medical setting. Various studies have outlined the positive benefits of continued correspondence between bereaved families and health care providers after a child’s death. For families, bereavement outreach has been shown to minimize feelings of abandonment and ameliorate what is often perceived as an abrupt end to contact with the medical team.⁷  In turn, provider communication has been cited to improve coping and lead families to feel cared for and supported.⁸  For providers, such connection with families serves as a platform for reflection and emotional catharsis.⁹ 

Although bereavement outreach can occur in several ways, through phone calls, in-person meetings, attendance at services or funerals, or through written means, condolence card writing has been particularly well-evaluated in the literature. In a randomized control trial among bereaved families and health care providers, families who received condolence cards noted that these personalized letters revealed compassion and represented an important continuation of care after the death of their loved ones. In conjunction, clinicians who participated in card-writing reported feeling grateful to have had the “opportunity to express shared humanity,” and to have a meaningful space to reflect on the personal and professional impact of these patients.¹⁰ 

In light of the known gaps in trainee bereavement education, coupled with the known existing benefits of condolence expression for both families and health care providers, we sought to create a bereavement program for residents in our pediatric residency. In partnership with trainees in our pediatric palliative care department, we designed and implemented a residency-wide bereavement expression program. This trainee-led project was aimed to provide both education on and means of bereavement expression to deceased patients’ families who were previously cared for on various medical services. We approached this by placing a basket in our house staff lounge with blank cards addressed to bereaved families. We included printed education on best practices for condolence card writing in the basket. These materials offered various examples of written bereavement expressions, such as “thinking of you and your family” and “with my deepest sympathy,” and proposed strategies for letter formulation after the sequence of acknowledging the loss, sharing a meaningful memory, and offering a wish for comfort. We selected the house staff lounge as the home for our basket, given that this location offered the best physical space for on-campus participation away from the work environment. The palliative care department provided an updated list of patient names on a monthly basis, and we exchanged cards labeled with these names in the basket at regular intervals. In tandem, we collaborated with the chief residents to distribute emails to the residents every week listing the names of the patients who had recently passed and encouraging engagement in the card-writing project as one possible method of bereavement expression. We also performed key outreach to the leadership of subspecialty rotations with a higher proportion of critically ill children (including the medical and surgical ICUs and oncology) to better support those residents who might be on service at the time of a patient’s passing.

In discussion with residents, those who participated in the bereavement card project expressed appreciation for the program. Trainees commented that “this project is so important,” “I can’t thank you all enough for putting this together,” and “thank you for organizing.” Specific gratitude was noted for the project’s role in “creating space,” “providing an outlet for processing…these challenging situations,” and allowing for “meaningful reflection on patient death.” Through various conversations with trainees, we identified potential barriers to completing condolence cards, such as finding time in the busy trainee schedule and infrequent access to the condolence cards. On the basis of these findings, we adapted our approach each month, adding an option to e-mail a message to be added to a card and considering additional locations for physical cards to be available. Since project implementation, larger numbers of residents have participated in condolence card writing over time, and adaptations are ongoing to minimize barriers to involvement to ensure the broadest reach.

Our collaboration between pediatric residents and pediatric palliative care fellows was well-suited to design a trainee-led bereavement program that increased trainee condolence expression. Providing opportunities for trainees to process grief around patient loss, even the simple act of writing a card to families, is impactful for providers early in their careers. The hope is that projects like these will infuse new meaning into the symbol of the butterfly and inspire a butterfly effect: a time when provider grief, especially among trainees, is consistently recognized, and there are well-established institutional supports to promote healing for those that have dedicated their lives to healing others.