Abstract
Key Words
Key Message
Your absence has gone through me
Like thread through a needle.
Everything I do is stitched with its color.W.S. Merwin
John Hopkins Coronavirus Resource Center. Available at: https://coronavirus.jhu.edu/map.html. Accessed March 12, 2021.
CDC COVID Data Tracker. Available at:https://covid.cdc.gov/covid-data-tracker/#health-care-personnel. Accessed March 12, 2021.
Guardian database “lost on the frontline.” Available at:https://www.theguardian.com/us-news/ng-interactive/2020/aug/11/lost-on-the-frontline-covid-19-coronavirus-us-healthcare-workers-deaths-database. Accessed March 12, 2021.
Grief in Context
Remen R. The healer's art curriculum. Available at:http://www.rishiprograms.org/healers-art/the-healers-art-course-description/. Accessed January 14, 2021.
HCW Grief Prior to COVID-19
Factors Complicating COVID-19 Grief in the US
Incomplete Grief
- Dias E
- Jones RC.
CDC Funeral guidance for individuals and families. Available at:https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/funeral-guidance.html. Accessed January 14, 2021.
Disenfranchised Grief
Inadequate US Governmental Response
Social Injustice, Mistrust, and Racism
Guardian database “lost on the frontline.” Available at:https://www.theguardian.com/us-news/ng-interactive/2020/aug/11/lost-on-the-frontline-covid-19-coronavirus-us-healthcare-workers-deaths-database. Accessed March 12, 2021.
The Impact of COVID-19 Grief on Healthcare Workers
The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through water and not get wet.Rachel Naomi Remen, MDKitchen Table Wisdom
The Impact of COVID-19 on HCW Professional Grief
- 1)COVID-19 is causing a large number of deaths. In 2020, COVID became a top cause of death in the US and internationally. By the December 2020, COVID-19 became the leading cause of death in the U.S.40What resources clinicians may have had for dealing with patient deaths pre-COVID may be overwhelmed simply because of the sheer numbers of COVID-19 deaths. COVID-19 has brought death out of proportion to other diseases (such as cancer or influenza) that clinicians previously may have learned to manage or accept.
- 2)HCWs may be deployed to types and conditions of work (and the attendant COVID-19 deaths) for which they are unprepared. For example, during surges in overwhelmed hospitals, dermatologists or surgeons may be required to attend in swamped medical ICUs, or office-based nurses may be redeployed to cover in the emergency department, exposing clinicians to feelings of inadequacy, guilt, and overwhelm. HCWs are being asked or ordered to bear witness to types of deaths they are not used to and in settings they do not typically practice. Such clinicians may not have developed the personal or professional resources to manage such stresses.
- 3)The basic logistics of healthcare during the pandemic may conspire against adequate attention to clinician grief. Healthcare teams are often understaffed during COVID-19 surges, with the need for quarantining of exposed team members threatening healthcare team functioning. HCWs may feel a burdensome commitment to their team and to support each other, assessing the relative risks and costs of working on the COVID-19 frontline for themselves versus for each of their colleagues (e.g. based on age, pregnancy, presence of partners or family, or colleague medical issues). Clinicians may work long hours without adequate breaks throughout the day or relief over the course of days and weeks. Clinicians may not have adequate PPE to feel or be safe.
- 4)In the absence of a cure and ongoing uncertainty about the best ways to treat COVID-19, clinicians may feel impotent to help their patients. Clinicians may feel that their medical knowledge or skills, or both, are inadequate or out-of-date in the rapidly evolving pandemic. HCWs may feel that their healthcare systems or national resources are inadequate to provide the best care possible. Currently, in the context of promising vaccines, physicians are dealing with the slow roll-out of the vaccine, concerns about the social justice of vaccine distribution, and the possibility that the pandemic may get worse before it gets better.
- 5)The demographics of patients who are dying may present an additional stress to HCWs. Moral distress and guilt about the racial and economic inequities in COVID-19 epidemiology and deaths complicate and exacerbate clinician grief. Previously healthy or young people may suffer permanent disability or may die. Couples and multiple members of a single family may infect each other and die suddenly. Many clinicians have stories now of patients emerging from their own ICU stay, only to learn that their love one has died of the disease that nearly killed them.
- 6)The way patients are dying brings added distress for clinicians. Clinicians may be communicating with patients remotely much of the time. Although assessments about telemedicine identify the broad acceptability, satisfaction for patients, and even alternate sources of intimacy, many clinicians may feel like “it's not the same” as in-person care.41,42,43,44In addition to the distance (seeing patients through goggles or Zoom, touching them through PPE), the ethics of dying of COVID-19 may compound clinician grief. Anger about missed opportunities to prevent deaths due to a poor distribution of healthcare resources may intensify the clinicians’ sense of loss. And patients with COVID-19 may die unexpectedly, precipitously, increasing the risk for complicated grief for HCWs. Still other patients may linger in the ICU for weeks prior to dying, with HCWs deeply invested in and connected to them. Clinicians may develop false hopes about patient recovery only to find such patients readmitted to the hospital or dead after a transfer to a rehabilitation facility or discharge home.
- 7)Surrounded by such extremes of dying and with the potential impact of vaccine distribution systems that prioritize frontline HCWs for the initial limited supply of vaccines, clinicians may suffer a heightened sense of survivor's guilt. While HCWs may be recognized by their communities as “heroes” for their work on the frontlines (recognition that may be waning as the pandemic rages on), their own survival (due to prioritized access to PPE, vaccines, or other factors) contributes to their possible guilt while they bear witness to the misery of their patients and their communities.
- 8)COVID-19 has placed HCWs in a new and vulnerable place in the context of dying. Holding the smart phone or tablet up to the dying patient in the ICU, HCWs have been placed more clearly in the face of suffering. HCWs in the pandemic often serve as the surrogate comforter or communicator during times of virtual anticipatory grief and bereavement.4While many frontline HCWs have stepped up to serve as the “proxy family” of their patients to bridge the gaps created by social distancing, this exposure to intense suffering represents a new and stressful role for bedside care teams.
The Impact of COVID on HCW Personal Grief
The Impact of COVID-19 on the Mental Health of HCWs
- Knoll C
- Wakins A
- Rothfeld M.
Healthcare Worker COVID-19 Grief Preparation and Support
Hanbury R. The impact of COVID-related grief on palliative care clinicians. CACP resources. Available at:https://www.capc.org/events/recorded-webinars/impact-covid-related-grief-palliative-care-clinicians/. Accessed January 4, 2021.
Hanbury R. The impact of COVID-related grief on palliative care clinicians. CACP resources. Available at:https://www.capc.org/events/recorded-webinars/impact-covid-related-grief-palliative-care-clinicians/. Accessed January 4, 2021.
Historical Lessons
Individual Grief Preparation and Support Strategies: Resiliency and Rituals
Systemic Grief Preparation and Support Strategies: Structures and Leadership
Tucker, Rodney O., Huang CS. Meet my loved one. Available at:https://www.uab.edu/medicine/palliativecare/patient-care/covid-19-resources. Accessed January 15, 2021.
HCW Trainee Grief and COVID-19
Conclusion: Next Steps
Disclosures/Conflicts of Interest
References
- Dying during Covid-19.Hastings Cent Rep. 2020; 50: 13-15
- Caring for bereaved family members during the COVID-19 pandemic: before and after the death of a patient.J Pain Symptom Manage. 2020; 60: e70-e74
- Death and dying during the pandemic.BMJ. 2020; 369: 19-20
- Grief during the COVID-19 pandemic: considerations for palliative care providers.J Pain Symptom Manage. 2020; 60: e70-e76
John Hopkins Coronavirus Resource Center. Available at: https://coronavirus.jhu.edu/map.html. Accessed March 12, 2021.
CDC COVID Data Tracker. Available at:https://covid.cdc.gov/covid-data-tracker/#health-care-personnel. Accessed March 12, 2021.
Guardian database “lost on the frontline.” Available at:https://www.theguardian.com/us-news/ng-interactive/2020/aug/11/lost-on-the-frontline-covid-19-coronavirus-us-healthcare-workers-deaths-database. Accessed March 12, 2021.
- Prevalence of prolonged grief disorder in adult bereavement: a systematic review and meta-analysis.J Affect Disord. 2017; 212: 138e149
- Bereavement care in the wake of COVID-19: offering condolences and referrals.Ann Intern Med. 2020; 173: 833-835
- Supporting adults bereaved through COVID-19: a rapid review of the impact of previous pandemics on grief and bereavement.J Pain Symptom Manage. 2020; 60: e33-e39
- Who needs bereavement support? A population based survey of bereavement risk and support need.PLoS One. 2015; 10e0121101
- Preparedness for the death of a loved one and mental health in bereaved caregivers of patients with dementia: findings from the REACH study.J Palliat Med. 2006; 9: 683-693
- Adding value to palliative care services: the development of an institutional bereavement program.J Palliat Med. 2015; 18: 915e922
Remen R. The healer's art curriculum. Available at:http://www.rishiprograms.org/healers-art/the-healers-art-course-description/. Accessed January 14, 2021.
- Compassion fatigue among oncologists: the role of grief, sense of failure, and exposure to suffering and death.Support Care Cancer. 2020; 28: 2025-2031
- Nature and impact of grief over patient loss on oncologists' personal and professional lives.Arch Intern Med. 2012; 172: 964-966
- Disenfranchised grief and physician burnout.Ann Fam Med. 2017; 15: 375-378
- The emotional labor of personal grief in palliative care: balancing caring and professional identities.Qual Health Res. 2017; 27: 2211-2221
- Home care workers’ experiences of client death and disenfranchised grief.Qual Health Res. 2019; 29: 382-392
- Caring for oneself to care for others: physicians and their self-care.J Support Oncol. 2013; 11: 75-81
- Grief among healthcare workers: a comparative study.J Gerontol. 1982; 37: 604-608
- Virtual grieving: when pandemic death stares us in the face.Forbes. 2020; (Available at:)
- Last anointing..New York Times, 2020 (Available at:)https://www.nytimes.com/interactive/2020/06/06/us/coronavirus-priests-last-rites.htmlDate accessed: January 14, 2021
CDC Funeral guidance for individuals and families. Available at:https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/funeral-guidance.html. Accessed January 14, 2021.
- Ethics, end-of-life decisions and grief.Mortality. 2005; 10: 83e90
- COVID-19: US federal accountability for entry, spread, and inequities-lessons for the future.Eur J Epidemiol. 2020; 35: 995-1006
- We're not all in this together: on COVID-19, intersectionality, and structural inequality.Am J Public Health. 2020; 110: 2020-2022
- Systemic racism, chronic health inequities, and COVID-19 : a syndemic in the making?.Am J Hum Biol. 2020; : 1-8
- COVID-19 pandemic : disparate health impact on the Hispanic /Latinx population in the United States.J Infect Dis. 2020; 222: 1592-1595
- Diseases with health disparities as drivers of COVID-19 outcome.J Cell Mol Med. 2020; : 11038-11045
- Tracking the reach of COVID-19 kin loss with a bereavement multiplier applied to the United States.Proc Natl Acad Sci U S A. 2020; 117: 17695-17701
- Structural racism, social risk factors, and Covid-19 — a dangerous convergence for black Americans.N Engl J Med. 2020; 383: e77
- Racism and discrimination in COVID-19 responses.Lancet. 2020; 395: 1194
- Stigmatization, discrimination, racism, injustice, and inequalities in the COVID-19 era.Int J Health Policy Manag. 2020; 9: 484-485
- Coronavirus pandemic epidemiology consortium. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study.Lancet Public Health. 2020; 5: e475-e483
- Bereavement support on the frontline of COVID-19: recommendations for hospital clinicians.J Pain Symptom Manage. 2020; 60: e81-e86
- COVID-19: guidance on palliative care from a European Respiratory Society International Task Force.Eur Respir J. 2020; 562002583
- Supporting families in end-of-life care and bereavement in the COVID-19 era.Int Psychogeriatr. 2020; 32: 1245-1248
- Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic.JAMA. 2020; 323: 2133-2134
- COVID-19 as the leading cause of death in the United States.JAMA. 2021; 325: 123-124
- Telemedicine and the COVID-19 pandemic, lessons for the future.Telemed J E Health. 2020; 26: 571-573
- Effectiveness of telemedicine: a systematic review of reviews.Int J Med Inform. 2010; 79: 736-771
- Telehealth and patient satisfaction: a systematic review and narrative analysis.BMJ Open. 2017; 7e016242
- Predictive factors of physicians' satisfaction with telemedicine services acceptance.Health Informatics J. 2020; 26: 1866-1880
- Moral distress and its contribution to the development of burnout syndrome among critical care providers.Ann Intensive Care. 2017; 7: 71
- Moral distress: recognizing it to retain nurses.Nurs Econ. 2007; 25: 217
- COVID-19 lessons: the alignment of palliative medicine and trauma-informed care.J Pain Symptom Manage. 2020; 60: e26-e30
- Coping with trauma, celebrating life: reinventing patient and staff support during the COVID-19 pandemic.Health Aff (Millwood). 2020; 39: 1597-1600
- Psychological status of medical workforce during the COVID-19 pandemic: a cross-sectional study.Psychiatry Res. 2020; 288112936
- Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019.JAMA Netw Open. 2020; 3e203976
- Physician suicide.CMAJ. 2019; 191: E505
- I couldn't do anything’: the virus and an E.R. doctor's suicide.New York Times, 2020 (Available at:)https://www.nytimes.com/2020/07/11/nyregion/lorna-breen-suicide-coronavirus.htmlDate accessed: January 14, 2021
- Surfing the waves of the COVID-19 pandemic as a cardiovascular clinician.Circulation. 2020; 142: 98-100
Hanbury R. The impact of COVID-related grief on palliative care clinicians. CACP resources. Available at:https://www.capc.org/events/recorded-webinars/impact-covid-related-grief-palliative-care-clinicians/. Accessed January 4, 2021.
- Emergence of depression following job loss prospectively predicts lower rates of reemployment.Psychiatry Res. 2017; 253: 79-83
- Battle scars and resilience at the health care frontline.Acad Emerg Med. 2020; 27: 934-935
- Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after extremely aversive events?.Am Psychol. 2004; 59: 20-28
- Addressing postpandemic clinician mental health: a narrative review and conceptual framework.Ann Intern Med. 2020; 173: 981-988
- Mental health services required after disasters: learning from the lasting effects of disasters.Depress Res Treat. 2012; 2012970194
- Confronting another pandemic: lessons from HIV can inform our COVID-19 response.AIDS Behav. 2020; 24: 1977-1979
- The well-being of physicians.Am J Med. 2003; 114: 513-519
- Resilience: the science of mastering life's greatest challenges.Cambridge University Press, Cambridge2012
- Self-care of physicians caring for patients at the end of life: ‘‘being connected. a key to my survival.JAMA. 2009; 301: 1155e1164
- Palliative care professionals' inner life: exploring the relationships among awareness, self-care, and compassion satisfaction and fatigue, burnout, and coping with death.J Pain Symptom Manage. 2015; 50: 200-207
- Integration of palliative care into COVID-19 pandemic planning.BMJ Support Palliat Care. 2021; 11: 40-44
- Bereavement debriefing sessions: an intervention to support health care professionals in managing their grief after the death of a patient.Pediatr Nurs. 2010; 36: 185-189
- Peer-supported storytelling for grieving pediatric oncology nurses.J Pediatr Oncol Nurs. 2008; 25: 148-163
- Songs for the soul: a program to address a nurse's grief.Clin J Oncol Nurs. 2017; 21: 145-146
- Helping health care providers and staff process grief through a hospital-based program.Am J Nurs. 2019; 119: 24-33
- The effect of facilitated peer support sessions on burnout and grief management among health care providers in pediatric intensive care units: a pilot study.J Palliat Med. 2012; 15: 1178-1180
- Mental health treatment for front-line clinicians during and after the coronavirus disease 2019 (COVID-19) pandemic: a plea to the medical community [published online ahead of print, 2020 May 26].Ann Intern Med. 2020; : M20-2440
- Supporting patient and clinician mental health during COVID-19: via trauma-informed interdisciplinary systems.Can Fam Phys. 2020; 66: e190-e192
- Humanistic epidemiology: love in the time of cholera, COVID-19 and other outbreaks.Eur J Epidemiol. 2020; 35: 321-324
Tucker, Rodney O., Huang CS. Meet my loved one. Available at:https://www.uab.edu/medicine/palliativecare/patient-care/covid-19-resources. Accessed January 15, 2021.
- Traumatic stress within disaster-exposed occupations: overview of the literature and suggestions for the management of traumatic stress in the workplace.Br Med Bull. 2019; 129: 25e34
- Trauma, stress, and self-care in clinical training: Predictors of burnout, decline in health status, secondary traumatic stress symptoms, and compassion satisfaction.Psychol Trauma. 2017; 9: 416-424
- Factors associated with burnout and stress in trainee physicians: a systematic review and meta-analysis.JAMA Netw Open. 2020; 3e2013761
- Trustworthiness before trust - Covid-19 vaccine trials and the black community.N Engl J Med. 2020; 383: e121
- Inequity and the disproportionate impact of COVID-19 on communities of color in the United States: the need for a trauma-informed social justice response.Psychol Trauma. 2020; 12: 443-445