Patient deaths from COVID-19 have been very difficult for families who are unable to be with loved ones during their dying process and at the time of death. Nurses at the bedside are providing support and fostering hope for families who are suffering. This document guides nurses through the grieving process as it relates to COVID-19

End-of-Life Nursing Education Consortium

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 _____________________________________________________________________________________________________________________ ELNEC Loss, Grief, and Bereavement Revised: 2020 Supplemental Teaching Materials The experience of COVID-19 is creating loss for everyone- loss of jobs, school, graduations, weddings, vacations, etc. It has disrupted everyone’s life in the US and globally. We are grieving those losses and trying to come to terms with a new reality: How to live amidst the coronavirus and the restrictions is has placed on society and the fears of illness and death.  Loss, grief, and bereavement are experienced by the patient, family and the nurse, and each one experiences grief in their own way: ➢ Using one’s own coping skills   ➢ In accordance with one’s own cultural norms, belief systems, faith systems   ➢ Past and present life experiences related to grief, loss, and bereavement  • Loss is defined as the absence of a possession or future possession, and with this comes the response of grief and the expression of mourning. Losses may occur before the death for the patient and significant others, as they anticipate and experience loss of health, changes in relationships and roles, and loss of life (anticipatory grief). After a death, the survivor experiences loss of the loved one. Most losses will trigger mourning and grief, and accompanying feelings, behaviors, and reactions to the loss. Patients (loss of health, financial security, loss of body part, etc.), family members, and survivors all experience loss.  • Grief is the emotional response to a loss. Grief is the individualized and personalized feelings and responses that an individual makes to real, perceived, or anticipated loss (Corless & Meisenhelder, 2019). The feelings associated with grief cannot be felt directly by others, but the reactions to the grief and associated behaviors may be assessed by the critical care nurse. These feelings can include anger, frustration, loneliness, sadness, guilt, regret, peace, etc. Types of grief include anticipatory, uncomplicated, complicated, disenfranchised, and unresolved grief. With many patients with COVID-19 dying alone due to visitation restrictions, we can anticipate many family members will experience complicated grief and will need counseling and support throughout bereavement.  • Bereavement begins with a death of someone close and provides dispensation from usual activities for a variable period of time. It entails loss, grief and recovery and associated processes (Corless & Meisenhelder, 2019).  • Mourning is the outward, social expression of a loss. How one outwardly expresses a loss may be dictated by cultural norms, customs, and practices including rituals and traditions. Some cultures may be very emotional and verbal in their expression of loss, some may show little reaction to loss, others may wail or cry loudly, and some may appear stoic and businesslike.   • There are many factors that affect the grief process: ➢ Survivor personality ➢ Coping skills   _____________________________________________________________________________________________________________________ ELNEC Loss, Grief, and Bereavement Revised: 2020 Supplemental Teaching Materials ➢ History of substance abuse ➢ Relationship to the deceased  Survivor age  Deceased age ➢ Survivor religious/spiritual belief system  ➢ Type of death  Sudden  From long, chronic illness  Suicide ➢ Survivor ethnicity, cultural traditions, rites and rituals ➢ There are variations among rituals and mourning practices in different cultures which provides a context for the grief experience. It gives members a sense of security and of coherence and the emotional, social, and physical resources in which to frame it (Cormack et al, 2019). Others  Suicidal tendencies  History of mental illness (i.e., depression)  Survivor gender  Support systems  Concurrent stressors  Experience and history of losses  Death preparation  • Grief assessment includes the patient, family members, significant others. Grief assessment begins at the time the patient is admitted to a hospital, nursing facility, assisted living facility, and at the time of diagnosis of acute or chronic illness, terminal illness. Grief assessment is ongoing throughout the course of an illness for the patient, family members, and significant others and for the bereavement period after the death for the survivors. Grief should be assessed frequently during the bereavement period to alert the critical care nurse to possible signs/symptoms/reactions of complicated grief (Corless & Meisenhelder, 2019).  • Post-intensive care syndrome-family (PICS-F) is a term proposed by the Society of Critical Care Medicine to describe this cluster of symptoms and complications [e.g., anxiety, PTS, etc.] (Davidson et al., 2012).  • Critically ill patients are often unable to participate in care discussions- particularly when prognosis is extremely poor. Family members are often faced with having to make difficult treatment decisions in an already emotionally charged situation (Petrinec et al., 2015). For many reasons, family caregivers of patients in critical care areas are at high risk for physical and mental health morbidity.  • Symptoms including anxiety, depression, PTSD and complicated grief have been explored and documented in family caregivers of critically ill patients   • While certain symptoms such as anxiety and depression have shown to decrease over time, there was high prevalence of posttraumatic stress and complicated grief which can have a profound impact on physical, emotional, mental and social functioning (Anderson et al., 2008)   _____________________________________________________________________________________________________________________ ELNEC Loss, Grief, and Bereavement Revised: 2020 Supplemental Teaching Materials  • What do family caregivers really want when they are grieving? (Northouse & McCorkle, 2015)  ➢ They want to know that their loved one’s wishes are being honored. ➢ The caregiver wants to be included in decision-making. ➢ They want support/assistance and practical help (i.e., ask caregiver if there is a neighbor, a friend, a colleague who could contact others to assist with food, grocery shopping, going to the pharmacy, etc.). ➢ They want honest conversation. ➢ They want to be listened to—presence is so important. ➢ They want to be remembered as being a “good” and compassionate caregiver. ➢ They want to be assured that they did all they could possibly do for their loved one.    Maintaining Hope • Hope is fluid and changes depending on where an individual is on their trajectory of life ➢ Patients newly diagnosed with coronavirus will hope to be cured ➢ Patients who are aware they will not survive the virus, will hope that their symptoms can be controlled and that they will not die alone  • Critical care nurses play a key role in fostering hope in health, illness and death. They can identify when patients and families feel hopeless, explore their concerns and offer support  • Maintaining hope is less about delivery and more about accepting that we don’t have to understand their experience; we just have to be present (Cotter & Foxwell, 2019)       _____________________________________________________________________________________________________________________ ELNEC Loss, Grief, and Bereavement Revised: 2020 Supplemental Teaching Materials REFERENCES  Cormack, C. Mazanec, P., & Panke, J. (2019). Cultural considerations in palliative care. In B. Ferrell & J. Paice, (eds.) Oxford textbook of palliative nursing (5th ed.) pp. 469-482. Oxford University Press.  Corless, I. B. & Meisenhelder, J. B. (2019). Bereavement. In B. Ferrell & J. Paice, (eds.) Oxford textbook of palliative nursing (5th ed.) pp. 390-204.  Oxford University Press.  Cotter, V. T. & Foxwell, A. M. (2019). The meaning of hope in dying. In B. Ferrell & J. Paice, (eds.) Oxford textbook of palliative nursing (5th ed.) pp. 379-389. Oxford University Press.   Davidson, J.E., Jones, C., & Bienvenu, O.J. (2012). Family response to critical illness: Postintensive care syndrome-family. Critical Care Medicine, 40(2), 618-624. doi:10.1097/ccm.0b013e318236ebf9.  ELNEC Critical Care Curriculum.  Available online at: https://www.relias.com/product/elnec-training  Northhouse, L.L., & McCorkle, R. (2015). Couples and caregivers of cancer patients. In J. Holland, W.S. Breibert, P.B. Jacobsen, M.J. Loscalzo, R.McCorkle, & P.N. Butow (Eds.), Psycho-oncology, 3rd edition, (Chapter 75, pp. 567-573). New York, NY: Oxford University Press.  Petrinec, A.B., Mazanec, P.M., Burant, C.J., Hoffer, A., & Daly, B.J. (2015). Coping strategies and posttraumatic stress symptoms in post-ICU family decision makers. Critical Care Medicine, 43(6), 1205-1212. doi:10.1097/ccm.0000000000000934.      

COVID-19: Loss, grief and bereavement information

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COVID-19: Loss, grief and bereavement information

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