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Bereavement Support on the Frontline of COVID-19: Recommendations for Hospital Clinicians

      Abstract

      Deaths due to COVID-19 are associated with risk factors which can lead to prolonged grief disorder, post-traumatic stress, and other poor bereavement outcomes among relatives, as well as moral injury and distress in frontline staff. Here we review relevant research evidence and provide evidence-based recommendations and resources for hospital clinicians to mitigate poor bereavement outcomes and support staff. For relatives, bereavement risk factors include dying in an intensive care unit, severe breathlessness, patient isolation or restricted access, significant patient and family emotional distress, and disruption to relatives' social support networks. Recommendations include advance care planning; proactive, sensitive, and regular communication with family members alongside accurate information provision; enabling family members to say goodbye in person where possible; supporting virtual communication; providing excellent symptom management and emotional and spiritual support; and providing and/or sign-posting to bereavement services. To mitigate effects of this emotionally challenging work on staff, we recommend an organizational and systemic approach which includes access to informal and professional support.

      Key Words

      Introduction

      At the time of writing, there have been over 190,000 deaths globally from COVID-19, with an estimated 0.95 million people bereaved. Although the true impact of COVID-19 is as yet unknown, considerable levels of grief and bereavement will follow.
      Bereavement is a natural part of the human experience but can be intensely painful and negatively impact physical and mental health. Approximately one in 10 bereaved adults develop prolonged grief disorder (PGD),
      • Lundorff M.
      • Holmgren H.
      • Zachariae R.
      • Farver-Vestergaard I.
      • O'Connor M.
      Prevalence of prolonged grief disorder in adult bereavement: a systematic review and meta-analysis.
      which involves intense symptoms of grief that endure for more than six months after loss, separation distress, intrusive thoughts, and feelings of emptiness or meaninglessness.
      Wallace et al. describe the types of grief associated with the COVID-19 pandemic and provide useful general guidance for its mitigation.
      • Wallace C.
      • Wladkowski S.P.
      • Gibson A.
      • White P.
      Grief during the COVID-19 pandemic: considerations for palliative care providers.
      Here, we review bereavement risk factors in COVID-19, provide evidence-based recommendations for how to support bereaved relatives (Table 1), and highlight additional resources (Table 2).
      Table 1Evidence-Based Recommendations for Mitigating Poor Bereavement Outcomes in Relatives
      Before a Patient's Death
      • Early advance care planning discussions and parallel planning with patients and families
      • Timely, proactive, and sensitive information provision and communication with families, guided by the VALUE mnemonic: value and appreciate what family members say; acknowledge family members' emotions; listen to their concerns; understand who the patient was in active life by asking questions; elicit questions from family members
      • Where possible, assign a specific contact person for each patient to help ensure continuity of care and timely communication with families before and after death
      • Follow expert guidance on tele-communication and communication with PPE (see Table 2)
      • Specialist palliative care collaboration, referral, and advice; use triage and remote communication where needed
      • Optimize symptom management
      • Where possible, allow and facilitate a family member to visit a deteriorating patient
      • Facilitate virtual communication using smartphones, tablet computers, and other technology. Enlist donations to source tablets, smartphones, and charging devices (patients are often admitted to hospital with their phones but not chargers). Dedicated equipment with appropriate applications can then be loaned to patients and families in COVID-19 areas.
      • To avoid distress, be cautious about virtual communication when a patient is actively dying
      • Ensure patients and families have access to emotional, psychological, and spiritual support, including access to chaplaincy
      After a Patient's Death
      • Some families may want mementoes or keepsakes (e.g., locks of hair, handprints, etc.). Local practice may vary; in the U.K., these can be taken at the time of care after death, but not at a later date, placed in a sealed bag and not opened before seven days.
        • Lawrie I.
        • Murphy F.
        COVID-19 and Palliative, End of Life and Bereavement Care in Secondary Care: Role of the specialty and guidance to aid care.
      • Ensure an involved clinician is available postmortem to speak and listen to family members, discuss what happened, and answer questions via telephone.
      • Identify relatives who may be at particular risk of poor bereavement outcomes (e.g., due to social isolation) for enhanced follow-up and support.
      • Enlist the support of allied health professionals from other specialties within the hospital, whose workload may have decreased during the pandemic, to help provide psychosocial support to bereaved families.
      • Create a COVID-19 bereavement leaflet which signposts relatives to local bereavement support available via e-mail, telephone, mobile apps, Web forums, Web chats, and virtual peer support, and where to get faith-specific advice. These should be given to the family as soon as possible after the patient's death.
      • Send a personalized condolence letter. The best timing of a condolence letter is not currently known; however, it should be personalized, not make commitments that cannot be met and include information regarding further support.
      • If needed, provide a list of local support services which may be able to provide practical help and support to people who are suddenly vulnerable due to a bereavement and may be self-isolating.
      • Provide up-to-date information and guidance on arranging a funeral or other religious ceremony and registering a death, with suggestions and resources for future ceremonies. Funeral poverty may be a concern for many relatives, so signposting toward organizations who can advise on this issue may be helpful.
      • Consider providing bereavement support evenings and/or culturally sensitive bereavement services for relatives after the immediate crisis.
      Table 2Resources
      Advance care planning in COVID-19Respecting Choices (US): https://respectingchoices.org/covid-19-resources/#planning-conversations

      Compassion in Dying (UK): https://coronavirus.compassionindying.org.uk/making-decisions-about-treatment/
      COVID-19 communicationCenter to Advance Palliative Care (CAPC) COVID-19 Response Resources—includes communication guidance from VitalTalk, the Serious Illness Program and others (US): https://www.capc.org/toolkits/covid-19-response-resources/

      Discussion of unwelcome news during COVID-19 pandemic: A framework for health and social care professionals, E-learning for Health (UK) https://portal.e-lfh.org.uk/LearningContent/LaunchFileForGuestAccess/611123
      Telephone communicationPatient Safety Learning (UK). Talking to relatives: A guide to compassionate phone communication during COVID-19. 2020. https://www.pslhub.org/learn/coronavirus-covid19/tips/talking-to-relatives-a-guide-to-compassionate-phone-communication-during-covid-19-r2009/
      Communication via PPECARDMEDIC – Flashcards for communicating with patients in the ICU during the COVID-19 pandemic. 2020. https://www.cardmedic.com/
      Information leaflets for hospital admissionEditable leaflets to provide to patients and families (Europe): https://erj.ersjournals.com/content/early/2020/04/07/13993003.00815-2020
      Supporting staffStrategies for Public Service Personnel Leadership (Canada): https://www.cipsrt-icrtsp.ca/covid-19/strategies-for-psp-leadership/

      King's Fund (UK): Responding to stress experienced by hospital staff working with COVID-19 https://www.kingsfund.org.uk/audio-video/stress-hospital-staff-covid-19

      Dying in Hospital, Advance Care Planning, and Communication

      Most deaths from COVID-19 currently occur in hospital. Advance care planning (ACP) discussions would ideally have been documented before admission and revisited in hospital.
      • Billings J.A.
      • Bernacki R.
      Strategic targeting of advance care planning interventions: the goldilocks phenomenon.
      However, if ACP has not yet occurred, where possible these discussions should be initiated with patients and families to assist with parallel planning (preparing for the worst while hoping for the best)
      • Wallace C.
      • Wladkowski S.P.
      • Gibson A.
      • White P.
      Grief during the COVID-19 pandemic: considerations for palliative care providers.
      ,
      • Bajwah S.
      • Wilcock A.
      • Towers R.
      • et al.
      Managing the supportive care needs of those affected by COVID-19.
      (Table 1). ACP aims to understand patients' unique perspectives on what gives life meaning and helps ensure care is consistent with their values. This includes helping patients avoid unwanted or nonbeneficial high-intensity treatments.
      • Khandelwal N.
      • Long A.C.
      • Lee R.Y.
      • McDermott C.L.
      • Engelberg R.A.
      • Curtis J.R.
      Pragmatic methods to avoid intensive care unit admission when it does not align with patient and family goals.
      Planning for future care also prepares family members for the death of their relative and leads to better outcomes after death.
      • Heyland D.K.
      • Rocker G.M.
      • O'Callaghan C.J.
      • Dodek P.M.
      • Cook D.J.
      Dying in the ICU: perspectives of family members.
      Some of the most critically ill patients with COVID-19 are admitted to and may die in intensive care units (ICUs). While for some patients this will be clinically appropriate and in line with their preferences, among surviving relatives, ICU bereavement is associated with poor mental health outcomes including PGD (5%–52%), post-traumatic stress disorder (PTSD) (14%–50%), and depression (18%–27%).
      • Kentish-Barnes N.
      • Chaize M.
      • Seegers V.
      • et al.
      Complicated grief after death of a relative in the intensive care unit.
      • Kross E.K.
      • Engelberg R.A.
      • Gries C.J.
      • Nielsen E.L.
      • Zatzick D.
      • Curtis J.R.
      ICU care associated with symptoms of depression and posttraumatic stress disorder among family members of patients who die in the ICU.
      • Probst D.R.
      • Gustin J.L.
      • Goodman L.F.
      • Lorenz A.
      • Wells-Di Gregorio S.M.
      ICU versus non-ICU hospital death: family member complicated grief, posttraumatic stress, and depressive symptoms.
      Whether or not a patient dies in ICU, we know that clear, complete communication by health care providers improves bereaved relatives' satisfaction with end-of-life care,
      • Heyland D.K.
      • Rocker G.M.
      • O'Callaghan C.J.
      • Dodek P.M.
      • Cook D.J.
      Dying in the ICU: perspectives of family members.
      and that families appreciate proactive, regular, and sensitive communication and accurate information.
      • Heyland D.K.
      • Rocker G.M.
      • O'Callaghan C.J.
      • Dodek P.M.
      • Cook D.J.
      Dying in the ICU: perspectives of family members.
      ,
      • Lautrette A.
      • Darmon M.
      • Megarbane B.
      • et al.
      A communication strategy and brochure for relatives of patients dying in the ICU.
      ,
      • Ó Coimín D.
      • Prizeman G.
      • Korn B.
      • Donnelly S.
      • Hynes G.
      Dying in acute hospitals: voices of bereaved relatives.
      Conversely, poor communication with relatives is associated with PGD.
      • Kentish-Barnes N.
      • Chaize M.
      • Seegers V.
      • et al.
      Complicated grief after death of a relative in the intensive care unit.
      Specific communication strategies that increase family satisfaction include the following: empathic statements assuring nonabandonment, assurances of comfort, and provision of written information.
      • Hinkle L.J.
      • Bosslet G.T.
      • Torke A.M.
      Factors associated with family satisfaction with end-of-life care in the ICU: a systematic review.
      Conversation analytic research has identified communication practices useful in end-of-life care
      • Parry R.
      • Land V.
      • Seymour J.
      How to communicate with patients about future illness progression and end of life: a systematic review.
      and has been incorporated in COVID-19 training (Table 2). Family conferences informed by the “VALUE” mnemonic have been found to lessen bereavement burden.
      • Lautrette A.
      • Darmon M.
      • Megarbane B.
      • et al.
      A communication strategy and brochure for relatives of patients dying in the ICU.
      In COVID-19, communication at the bedside is challenging, as health professionals need to wear personal protective equipment (PPE). The depersonalization of protective clothing and communication through a mask and visor is testing, particularly when a patient is frail or hearing impaired; however, guidelines and flashcards are now available (Table 2). Regular telephone communication is vital, with Swiss guidance recommending twice-daily calls to family members when a patient is seriously ill or dying, and families being told when a patient is “sick enough to die.”
      • Tanja F.-S.
      • Nancy P.
      • Keller N.
      • Claudia G.
      Conservative management of Covid-19 patients – emergency palliative care in action.
      Telephone communication is understandably difficult, particularly when breaking news of a death, but there are resources to support staff (Table 2).
      Palliative care, whether generalist or specialist, plays a central role in responding to COVID-19. Specialist palliative care involvement in the emergency department reduces hospital length of stay and ICU admission,
      • Grudzen C.
      • Richardson L.D.
      • Baumlin K.M.
      • et al.
      Redesigned geriatric emergency care may have helped reduce admissions of older adults to intensive care units.
      whereas in the ICU, it decreases hospital and ICU stays.
      • Aslakson R.
      • Cheng J.
      • Vollenweider D.
      • Galusca D.
      • Smith T.J.
      • Pronovost P.J.
      Evidence-based palliative care in the intensive care unit: a systematic review of interventions.
      Early palliative care consultations also improve bereaved relatives' perception of the quality of end-of-life care.
      • Kaufer M.
      • Murphy P.
      • Barker K.
      • Mosenthal A.
      Family satisfaction following the death of a loved one in an inner city MICU.
      However, as specialist palliative care is a limited resource, consultation and referral will need to be triaged,
      • Powell V.D.
      • Silveira M.J.
      What should palliative care's response be to the COVID-19 pandemic?.
      with input focused on supporting and coaching primary teams, often digitally or via telephone.
      • Fausto J.
      • Hirano L.
      • Lam D.
      • et al.
      Creating a palliative care Inpatient Response plan for COVID19 – the UW medicine experience.

      Patient Isolation, Family Access, and Virtual Communication

      An additional risk factor for poor bereavement is the need to isolate patients to control the spread of COVID-19. Restricted access to a patient and not being able to say “goodbye” are distressing to relatives
      • Probst D.R.
      • Gustin J.L.
      • Goodman L.F.
      • Lorenz A.
      • Wells-Di Gregorio S.M.
      ICU versus non-ICU hospital death: family member complicated grief, posttraumatic stress, and depressive symptoms.
      and associated with PGD and PTSD in bereavement.
      • Kentish-Barnes N.
      • Chaize M.
      • Seegers V.
      • et al.
      Complicated grief after death of a relative in the intensive care unit.
      If relatives are not in a high-risk category, in quarantine or unwell themselves, it is therefore recommended that access be granted for short periods.
      • Tanja F.-S.
      • Nancy P.
      • Keller N.
      • Claudia G.
      Conservative management of Covid-19 patients – emergency palliative care in action.
      Ideally, patients will have single-occupancy rooms to allow quiet and privacy to spend time with relatives.
      • Ó Coimín D.
      • Prizeman G.
      • Korn B.
      • Donnelly S.
      • Hynes G.
      Dying in acute hospitals: voices of bereaved relatives.
      However, for many relatives, visiting may pose a significant health risk. There may also be shortages of PPE for relatives or a lack of staff to assist relatives with donning PPE, particularly where testing of health care staff is insufficient.
      It is therefore also recommended that clinical teams help enable patient-family communication via virtual means, following infection control guidelines for devices—particularly if an in-person visit is not possible (Table 1). However, Swiss guidance does not recommend virtual contact between patients with COVID-19 and their families when a patient is actively dying
      • Tanja F.-S.
      • Nancy P.
      • Keller N.
      • Claudia G.
      Conservative management of Covid-19 patients – emergency palliative care in action.
      ; previous studies have found an association between relatives witnessing death in ICU and higher rates of both PGD and PTSD.
      • Kentish-Barnes N.
      • Chaize M.
      • Seegers V.
      • et al.
      Complicated grief after death of a relative in the intensive care unit.
      ,
      • Kross E.K.
      • Engelberg R.A.
      • Gries C.J.
      • Nielsen E.L.
      • Zatzick D.
      • Curtis J.R.
      ICU care associated with symptoms of depression and posttraumatic stress disorder among family members of patients who die in the ICU.

      Symptom Management

      The breathlessness
      • Bajwah S.
      • Wilcock A.
      • Towers R.
      • et al.
      Managing the supportive care needs of those affected by COVID-19.
      associated with COVID-19 may also be problematic for bereavement. Severe shortness of breath in patients can be highly distressing to relatives.
      • Probst D.R.
      • Gustin J.L.
      • Goodman L.F.
      • Lorenz A.
      • Wells-Di Gregorio S.M.
      ICU versus non-ICU hospital death: family member complicated grief, posttraumatic stress, and depressive symptoms.
      Among bereaved caregivers, the perception that a patient could not breathe peacefully is associated with a higher risk of PTSD, and a patient dying while intubated is associated with both PGD and PTSD.
      • Kentish-Barnes N.
      • Chaize M.
      • Seegers V.
      • et al.
      Complicated grief after death of a relative in the intensive care unit.
      Conversely, there is evidence that withdrawal of life-prolonging interventions and extubation before death increase satisfaction among bereaved family members
      • Hinkle L.J.
      • Bosslet G.T.
      • Torke A.M.
      Factors associated with family satisfaction with end-of-life care in the ICU: a systematic review.
      ; withdrawal should be clearly explained and in the context of good symptom control.
      • Keenan S.P.
      • Mawdsley C.
      • Plotkin D.
      • Webster G.K.
      • Priestap F.
      Withdrawal of life support: how the family feels, and why.

      Emotional and Spiritual Distress

      Patients who are seriously ill with COVID-19 and their families are inevitably anxious, afraid, alone, and in need emotional support, yet this is an area in which hospital care has been found lacking.
      • Ó Coimín D.
      • Prizeman G.
      • Korn B.
      • Donnelly S.
      • Hynes G.
      Dying in acute hospitals: voices of bereaved relatives.
      ,
      • Teno J.M.
      • Clarridge B.R.
      • Casey V.
      • et al.
      Family perspectives on end-of-life care at the last place of care.
      In addition to considering pharmacological and nonpharmacological interventions,
      • Bajwah S.
      • Wilcock A.
      • Towers R.
      • et al.
      Managing the supportive care needs of those affected by COVID-19.
      attending to the tenor of care is key. Care for the patient and family should provide for physical comfort, autonomy, meaningfulness, preparedness, and interpersonal connection
      • Proulx K.
      • Jacelon C.
      Dying with dignity: the good patient versus the good death.
      and be mindful of the “ABCDs” of dignity-conserving care (attitudes, behaviors, compassion, and dialogue).
      • Chochinov H.M.
      Dignity and the essence of medicine: the A, B, C, and D of dignity conserving care.
      Care must also respect cultural and religious diversity, and staff require cultural competence to provide appropriate support to families whose cultural and faith background is different from their own.
      Bereaved family members may question why they have survived when their loved one did not, feel guilt over possibly transmitting the disease and a loss of coherence or meaning, and mourn the loss of future dreams and hopes.
      • Bajwah S.
      • Wilcock A.
      • Towers R.
      • et al.
      Managing the supportive care needs of those affected by COVID-19.
      ,
      • Yuichi Clark P.
      • Joseph D.M.
      • Humphreys J.
      Cultural, psychological, and spiritual dimensions of palliative care in humanitarian crises.
      Relatives' perception of whether a patient received emotional support at the end of life is a determinant of their experience of bereavement.
      • Teno J.M.
      • Clarridge B.R.
      • Casey V.
      • et al.
      Family perspectives on end-of-life care at the last place of care.
      Greater attention to the dying patient's emotional well-being helps limit relatives' distress.
      • Probst D.R.
      • Gustin J.L.
      • Goodman L.F.
      • Lorenz A.
      • Wells-Di Gregorio S.M.
      ICU versus non-ICU hospital death: family member complicated grief, posttraumatic stress, and depressive symptoms.
      Showing respect and compassion and comforting bereaved relatives mitigate poor outcomes and dissatisfaction.
      • Heyland D.K.
      • Rocker G.M.
      • O'Callaghan C.J.
      • Dodek P.M.
      • Cook D.J.
      Dying in the ICU: perspectives of family members.
      All frontline staff should be able to provide the basics of culturally sensitive bereavement support and signpost to specialist services.
      • Leong I.Y.
      • Lee A.O.
      • Ng T.W.
      • et al.
      The challenge of providing holistic care in a viral epidemic: opportunities for palliative care.
      Access to spiritual support at the end of life is important for many patients and families, whether or not they are religious, but this is an aspect of care somewhat neglected in acute hospitals.
      Physicians. RCo
      End of life care audit-dying in hospital: National Report for England.
      As in humanitarian crises, spiritual care during COVID-19 will include helping individuals face and overcome fears and find hope and meaning; attending to existential suffering; addressing feelings of punishment, guilt, unfairness, and remorse; assisting when people need to confess or reconcile; and offering grief support and death preparation assistance.
      • Yuichi Clark P.
      • Joseph D.M.
      • Humphreys J.
      Cultural, psychological, and spiritual dimensions of palliative care in humanitarian crises.
      While chaplains play a crucial role in the team and have specialist skills, “spiritual first-aid,” based on skilled listening and expressing kindness and compassion, can also be provided by other staff.
      • Yuichi Clark P.
      • Joseph D.M.
      • Humphreys J.
      Cultural, psychological, and spiritual dimensions of palliative care in humanitarian crises.

      Grieving in Isolation and Bereavement Support

      A common impulse for those experiencing grief is to seek comfort in the arms of family, friends, and community. Yet in the context of COVID-19, bereaved family members may have limited social support due to physical distancing requirements and be forced to grieve alone. Loss of social and community networks, living alone, and loss of income are known to exacerbate psychological morbidity in bereavement.
      • Kentish-Barnes N.
      • Chaize M.
      • Seegers V.
      • et al.
      Complicated grief after death of a relative in the intensive care unit.
      ,
      • Kun P.
      • Han S.
      • Chen X.
      • Yao L.
      Prevalence and risk factors for posttraumatic stress disorder: a cross-sectional study among survivors of the Wenchuan 2008 earthquake in China.
      Health and social care professionals, and those supporting the bereaved informally, can encourage those who are grieving to express their grief and reach out to others, online or via telephone, letters, or videos. Although these methods cannot replace face-to-face conversation and physical affection, they nevertheless enable connection in the interim.
      While family, friends, and existing networks are the foundation of bereavement support, and for many people the only support needed, formal bereavement services play a central role in supporting individuals and families. Poor bereavement outcomes are associated with being a female relative, a spouse, older age, trauma, and lower educational attainment, socioeconomic status, and social support.
      • Milic J.
      • Muka T.
      • Ikram M.A.
      • Franco O.H.
      • Tiemeier H.
      Determinants and predictors of grief severity and persistence: the Rotterdam study.
      • Thomas K.
      • Hudson P.
      • Trauer T.
      • Remedios C.
      • Clarke D.
      Risk factors for developing prolonged grief during bereavement in family carers of cancer patients in palliative care: a longitudinal study.
      • Lobb E.A.
      • Kristjanson L.J.
      • Aoun S.M.
      • Monterosso L.
      • Halkett G.K.
      • Davies A.
      Predictors of complicated grief: a systematic review of empirical studies.
      Awareness of these risk factors can guide information provision and support.
      A systematic review of bereavement support in adult ICU identified several interventions: a personal memento, a handwritten condolence letter, a post-death meeting, storytelling, research participation, use of a diary, and a bereavement follow-up program. Although evidence for effectiveness was weak, all interventions were well accepted by families.
      • Efstathiou N.
      • Walker W.
      • Metcalfe A.
      • Vanderspank-Wright B.
      The state of bereavement support in adult intensive care: a systematic review and narrative synthesis.
      Bereaved relatives report that they prefer hospital staff make contact with them after the death of their family member.
      • Ó Coimín D.
      • Prizeman G.
      • Korn B.
      • Donnelly S.
      • Hynes G.
      Dying in acute hospitals: voices of bereaved relatives.
      A personalized condolence letter can help to humanize the medical institution but might also highlight the absence of further support
      • Kentish-Barnes N.
      • Cohen-Solal Z.
      • Souppart V.
      • et al.
      “It was the only thing I could hold onto, but…”: receiving a letter of condolence after loss of a loved one in the ICU: a qualitative study of bereaved relatives' experience.
      ; hence bereavement leaflets sign-posting to services are also important.
      • Ó Coimín D.
      • Prizeman G.
      • Korn B.
      • Donnelly S.
      • Hynes G.
      Dying in acute hospitals: voices of bereaved relatives.
      While the best timing of a condolence letter is unclear, it is crucial that letters avoid making commitments (e.g., to provide further information) which cannot be met.
      • Kentish-Barnes N.
      • Chevret S.
      • Champigneulle B.
      • et al.
      Effect of a condolence letter on grief symptoms among relatives of patients who died in the ICU: a randomized clinical trial.
      Organized bereavement support evenings can be a form of comfort and have a positive impact on relatives' grieving process.
      • Walsh T.
      • Foreman M.
      • Curry P.
      • O'Driscoll S.
      • McCormack M.
      Bereavement support in an acute hospital: an Irish model.
      Another way a pandemic such as COVID-19 disrupts the process of bereavement is by impacting families' ability to hold funerals and other ceremonies.
      • Wallace C.
      • Wladkowski S.P.
      • Gibson A.
      • White P.
      Grief during the COVID-19 pandemic: considerations for palliative care providers.
      ,
      • Leong I.Y.
      • Lee A.O.
      • Ng T.W.
      • et al.
      The challenge of providing holistic care in a viral epidemic: opportunities for palliative care.
      Funerals play a key role in mourning, bringing together those who remember the deceased to celebrate their life, and creating a supportive network for the bereaved family. Restrictions during the pandemic mean that funerals carried out in this time are unlikely to match the wishes of the bereaved or the deceased. However, it is possible to adapt funeral services using online methods to ensure important people are included, even if attendance is not possible (Table 2). After the crisis, relatives can hold ceremonies to remember their loved one, and culturally sensitive bereavement services held in hospitals may be helpful for closure and to show respect for the dead.
      • Ó Coimín D.
      • Prizeman G.
      • Korn B.
      • Donnelly S.
      • Hynes G.
      Dying in acute hospitals: voices of bereaved relatives.

      The Impact of Deaths From COVID-19 Among Staff

      In the COVID-19 pandemic, the ICU has been described as the “frontline of a war” against the disease, with clinicians the “soldiers in the trenches.” While war metaphors have limitations, we know from the experiences of clinicians in China, Italy, and Switzerland that care of patients with COVID-19 results in major ethical dilemmas and a psychological toll on the health care teams caring for them, in part due to limited resources.
      • Tanja F.-S.
      • Nancy P.
      • Keller N.
      • Claudia G.
      Conservative management of Covid-19 patients – emergency palliative care in action.
      ,
      • Lai J.
      • Ma S.
      • Wang Y.
      • et al.
      Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019.
      Frontline staff are at risk of secondary or vicarious trauma, as a result of repeated empathic engagement with sadness and loss,
      • Cook D.
      • Rocker G.
      Dying with dignity in the intensive care unit.
      as well as moral injury,
      • Williamson V.
      • Murphy D.
      • Greenberg N.
      COVID-19 and experiences of moral injury in front-line key workers.
      resulting from actions, or the lack of them, which violate one's moral or ethical code. This can lead to depression, anxiety, and post-traumatic distress.
      • Williamson V.
      • Stevelink S.A.M.
      • Greenberg N.
      Occupational moral injury and mental health: systematic review and meta-analysis.
      We recommend that health care leaders and organizations take responsibility and ensure staff are prepared for the emotional consequences of their work and that resources, guidance, and training are in place to safeguard health care providers' health.
      • Williamson V.
      • Murphy D.
      • Greenberg N.
      COVID-19 and experiences of moral injury in front-line key workers.
      Self-care strategies and individual “resilience tools” such as mindfulness and reflective practice are insufficient; resilience should not become another responsibility of staff working in traumatic conditions but requires an organizational and systemic response.
      • Humphreys J.
      • Joseph D.M.
      A trauma-informed response to working in humanitarian crises: focus on provider.
      Organizations should actively monitor frontline staff, facilitate effective team cohesion, and implement strategies to support teams' day-to-day work, including informal debriefing and peer support. Single-session psychological debriefing approaches should be avoided as they may cause additional harm.
      • Brooks S.K.
      • Rubin G.J.
      • Greenberg N.
      Traumatic stress within disaster-exposed occupations: overview of the literature and suggestions for the management of traumatic stress in the workplace.
      Leaders and organizations should also make professional sources of support readily available; this includes formal bereavement counseling, which can enhance awareness about vicarious traumatization and encourage adaptive coping strategies.
      • Cook D.
      • Rocker G.
      Dying with dignity in the intensive care unit.

      Conclusions

      COVID-19 brings new challenges and difficulties in caring for patients and their loved ones, and supporting staff. Evidence suggests several risk factors for poor bereavement outcomes in COVID-19, including severe breathlessness, patient isolation, and disruption to relatives' social support networks. Understanding the risk of trauma and moral injury to staff in the current pandemic is essential for the early identification and prevention of harm. Drawing on best available evidence, we have made recommendations for mitigating negative effects on bereaved relatives and health care professionals. These include proactive, sensitive, and regular communication with family members alongside accurate information provision; enabling family members to say goodbye in person and supporting virtual communication; providing excellent symptom management and emotional and spiritual support; sign-posting to bereavement services; and supporting bereaved relatives to adapt funerals and seek appropriate bereavement support, as well as consistent leadership and support for health professionals in the frontline.

      Disclosures and Acknowledgments

      The authors state that they have no conflicts of interest to disclose.
      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Selman is funded by a Career Development Fellowship from the National Institute for Health Research (UK).

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