What a Difference a Letter Can Make
Authors: Steven F. Duane
Journal: Journal of Clinical Oncology (2012)

DOI: 10.1200/JCO.2012.43.6162 I learned an important life lesson recently from a sixth-grade student: a letter from your mom can make all the difference. All too often, oncologists find themselves in the difficult position of sitting across from a dying patient who is also the mother or father of young children, discussing end-of-life care. In my practice, such conversations usually involved young women with metastatic breast cancer. When the delicate topic of the patient’s children was broached, tears were inevitable. There is perhaps no greater sadness than that of a mother who is about to leave her children behind forever. After allowing time for the patient to cry and to say whatever she felt up to saying, I often talked gently about ways that I hoped might help my patient and her children cope a little bit better with such an unthinkable loss. One idea that I sometimes suggested was for the patient to write letters to each of her children to open on special occasions in the future, after the patient was gone—letters for certain birthdays, graduation, or a wedding day. Despite making this recommendation, to me the act of writing such letters had always seemed impossible. And I also often wondered how these letters would be received by the child—would the communications from a long-gone parent be eagerly anticipated and prized, or would they instead be dreaded, summoning ghosts and painful memories of a desperately sad time? Whenever I imagined that future birthday or wedding day, I could see an image of the letter being opened and read, but my thoughts were unable to go any further. Enter the sixth grader who taught me just how important those letters can be to the recipient. I was asked to attend a support group for kids who had lost a loved one. This group is open to sixth through eighth graders and meets weekly in a local junior high school. The two group facilitators had been inundated with medical questions from the students, and the counselors asked me to attend one of the group meetings to help answer some of these queries. I accepted, but I had some reservations about talking with junior high school students, especially as it has been almost half a century since I was that age myself. I arrived at the meeting early and was led to a room that was near the school principal’s office. The room was large and stark, making it seem more suited for detention than for baring one’s heart. The kids filed in slowly; eventually, six students comprised the group. They looked so young as they talked about band practice, compared homerooms, and speculated about this evening’s basketball game. “So, are you the doctor?” one boy eagerly asked. “Yes,” I said, knowing that my gray hair and necktie had likely already answered his question. The facilitators began by asking each student to introduce themselves and briefly recount the story of their loved one’s death. Cancer was the common theme. Questions quickly followed. Initially, these questions were easy, straightforward ones that I had answered many times before. How did the cancer get to my mom’s brain? Why does chemotherapy make a person so sick? But soon the questions began to cover more uncomfortable matters. What does it mean that I dream about my dad? Is it OK that I am mad at God for taking my mom? It quickly became clear to me that these kids had been forced to grow up faster than children should, and they were demonstrating maturity and wisdom well beyond their years. One young boy grew quiet, and the counselor noted his bowed head looking down. “Are you OK?” she asked. His soft response was, “It’s just not fair. Sometimes it makes me so angry that my mom had to die.” The counselor repositioned herself, now sitting next to the boy with her arm around him. (There are uncelebrated heroes on this earth, and I realized that I was witnessing one of them in action). “What do you do when you feel this way?” she asked him. He looked up, paused briefly and said, “I read my mom’s letter. I was reading it just now.” He volunteered, “Would you like to see it?” After a few questions from the group leaders probing whether it would be OK, we collectively asked the boy to share the letter. He explained that his mom died of cancer when he was 5 years old and she had written this letter just before her death. He had not been given the letter until he was 8. Now, he keeps a copy of his mother’s letter on his smart phone, along with her picture. JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 30 NUMBER 33 NOVEMBER 2