PEDIATRIC FAST FACTS AND CONCEPTS #P11.2*

Background   The origins of the word condolence stem from Latin roots: com ‘together,” and dolere, “to grieve”. Parents grieving the death of their child benefit from condoling words and actions of those around them. Grieving the death of a child differs from other types of bereavement, as children are not meant to precede their parents in death, particularly in modern times. Thus, words of condolence should account for the ground-shattering change experienced within the family’s life. Meaningful, personal, and compassionate letters of condolence can be both a tribute to the child who died and a source of comfort to the parents. Fast Fact #22 discusses condolence letters for the general population.

Writing a Note of Condolence

1. Timing: Don’t rush to send out a card. Your words are very important to the family. They may go back and read your note many times over the years, so take your time. A hand-written note was historically considered most meaningful, but email, text, and social media posts/messages may also be appreciated by many families. 
2. Opening the note: Consider identifying yourself and expressing something personal about the impact of the loss (e.g., “I was devastated to learn about _____’s death”), followed by an expression of genuine sympathy (e.g., “I am thinking of you and the rest of the family”). Use the child’s first name.
3. Sharing a concrete memory & honoring the child: Parents want their child to be remembered for who they were in life. Share a story, memory, accomplishment, or experience you had with the child. A personalized note is much more meaningful than clichés like, “I will always remember their sense of humor.” Parents find comfort in reading about their child’s special qualities and the impact they had on others. Feel free to include pictures you may have of the child.
4. Offering strength: Praise or compliment the family for how they supported or parented their child and, if appropriate, their other children as well (e.g., “I witnessed what wonderful parents you were to _____ and the support you gave one another. I hope you continue to take such good care of each other”). Such praise can bolster long-term coping.  
5. Close with words of sympathy and support: “Sending you peace” or “Thinking of you and your family”.

Additional Considerations

• Reaching out to the child’s parents by phone, in accordance with their communication and timing preferences, is a wonderful option. Considerations #2-5 remain the same. You may open with a message of solidarity and state that the family has been in your thoughts. Consider inquiring about how the family is coping. In merely listening, you are providing an empathic presence, a key ingredient of compassionate communication (1).
• If there are siblings and/or grandparents, a personalized note to them will be tremendously appreciated. For younger siblings, such letters will mean a lot to them when they get older. 
• Within a letter or conversations of condolence, it is best to avoid assumptions including words that express a belief system (e.g., “I know he is in a better place” or, “God doesn’t give you more than you can handle”) that may be different than the family’s belief system. Families may also find efforts to make sense of the loss or to minimize their pain to be hurtful (e.g., “Everything happens for a reason” / “You have other children” or “Time will make it better”). Unless the writer has also lost a child, words such as, “I know how you feel” can amplify loneliness and suffering. 
• Ongoing contact is most helpful. Parents benefit from having their grief recognized over time, such as on the child’s birthday, the anniversary of the child’s death, and on certain holidays, Mother’s/Father’s Day, or the first day of school. Parents may appreciate when something is done in honor of or in the child’s memory on one of these difficult days.
• Many parents search for meaning after a child’s death is a long and painful process (2, 3). Creating a legacy—something that positively represents the child who died—can be a source of meaning. In future correspondence, consider discussing legacies the family can help to create, such as a school award in the child’s name, a fund to support an interest that others with the same condition can enjoy (e.g., art therapy), or funding related scientific research. Legacy building should be communicated gently to avoid inadvertently inducing guilt around not pursuing it. Sharing what some parents have found helpful while also acknowledging it is not for everyone (and that grief can be exhausting and overwhelming) is a nice way to communicate your support.
• Sharing condolences through real-time conversation can feel challenging for complex reasons, including time pressure, compassion fatigue, and struggling to find “the right words in the moment”. Helpful scripts exist to support and encourage clinicians in this impactful interaction (4).
• When possible, use correspondence as an opportunity to normalize the need for support after the death of a child; let parents know about bereavement support services available through your institution, a local hospice, or within the community to support continuity of care.

Teaching Points Condoling actions are often deeply appreciated by families who have lost a child. It is common for the profound pain that bereaved parents face to persist, and all members of the family will need ongoing support for a very long time. Families are comforted when people take the time to write personal letters, listen to them, and communicate with them, especially about their child and their grief. Writing about and talking about the child shows families that their child has not been forgotten, which is extremely meaningful and critically important for bereaved parents (5,6). 

Acknowledgements The authors wish to thank members of the Children’s National Health Systems Palliative Care Special Interest Group for their thoughtful feedback. 

References

1. Denhup, C. Grief. In: Pediatric Palliative Care. Hoffman, R & Smith, S (Eds), The American Childhood Cancer Organization (ACCO), Kensington, Maryland, 2015, pp. 205-215. 
2. Zunin, LM, Zunin, HS. The Art of Condolence. Harper Collins, New York, New York, 1991.
3. Kelly-Langen, C, Carst, N, Friebert, S. The child’s legacy. In: Pediatric Palliative Care. Hoffman, R & Smith, S (Eds), The American Childhood Cancer Organization (ACCO), Kensington, Maryland, 2015, pp. 221-235. 
4. Lichtenthal, W.G., Roberts, K.E., Prigerson, H.G. Bereavement Care in the Wake of COVID-19: Offering Condolences and Referrals. Annals of Internal Medicine, November, 2020.
5. Weaver, M., Lichtenthal, W.G., Larson, K., and Wiener, L., How I approach expressing condolences and longitudinal remembering to a family after the death of a child. Pediatric Blood & Cancer 66: e27489, 2019.
6. Henderson, C. The Art of the Condolence Note workshop. www.carolhenderson.com.

**Connotes Pediatric Fast Fact Topic #11 – Grief and Bereavement; 2^nd article on this topic.

Conflict of Interest: None to report

Version History:  first electronically published in May 2022; originally edited by Julie SW Childers MD

Authors’ Affiliations: MW — University of Nebraska, Omaha, NE and the VA National Center for Ethics in Health Care, Washington, DC; WGL — Memorial Sloan Kettering Cancer Center New York, NY; LW – National Cancer Institute, Bethesda, MD

Authors’ Disclaimer:  The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the U.S. Department of Veterans Affairs, the U.S. Government, or the VA National Center for Ethics in Health Care