Gratitude letters from patients in palliative care and their caregivers: A qualitative analysis

E. Poncin1, E. Bovet1, R. A. Foley1, G. D. Borasio1, M. Bernard1 (1Lausanne)


We conducted a pilot gratitude intervention, namely writing and sharing a gratitude letter, with palliative patients and their caregivers.


This paper investigates what people wrote in their letters, shedding light on the themes characterising them and on how their discourse is articulated.


We asked participants to reflect on the past few years, remember when they felt grateful towards the other, think about the impact she/he had on their life and put these thoughts in writing. 22 patients and 12 caregivers gave us access to their letters.

Using an inductive method, two researchers independently devised a list of codes and coded two randomly selected letters. After agreeing on an initial codebook, they coded and crosschecked four additional letters and updated the codebook. As their level of agreement was over 90%, one researcher pursued the analysis independently. The other performed a final crosscheck.


The letters are heterogeneous, touching upon a wide array of themes that are fluid and interconnected. To capture their nuances, we created a layered system based on four core concepts:

  1. temporality – autobiographical history, illness, future and end of life
  2. people and actions – how people describe themselves and the other, and support to/from the other
  3. emotions and their expressions
  4. writing – letters’ structures and rhetorical devices

The most prevalent themes are support from the other, with people evoking how the other is “entirely present” or does “everything” throughout the illness; the other person, described in terms of “kindness” or “generosity”; and positive emotions such as “vivid joy” and “happiness of having you”. Many evoked living with the illness, in terms of suffering or as a brave fight. A few people wrote about the end of life, as something “difficult” which they “can’t imagine”, or as a departure “towards the stars”. Focusing on direct expressions of gratitude, people were thankful for the other “having been in my life”, “for who you are”, “your kindness” and “for loving me”. Several participants noted that writing helped them express their feelings towards the other. 


In their letters, palliative care patients and their caregivers express gratitude for the other’s presence, love and support. Post-intervention interviews with participants further revealed that writing and sharing these letters had positive effects for most, promoting positive emotions and improving relationships.