“Psychosocial Support” to family members in bereavement in the time of COVID-19

Introduction

Death is almost always associated with emotional turmoil, whether it is expected or sudden. The person who is bereaved goes through a series of grief reactions, which according to Kubler-Ross (1969), follows five stages: denial, anger, bargaining, depression, and acceptance.

Although these reactions are natural and help in the mourning process, they must be sensitively handled. Doctors managing patients with COVID-19 battling for life are one of the most immediate witnesses of deaths. Especially those from medicine, critical care, intensive care units, high- risk wards where severe patients with COVID-19 are admitted with an increased possibility of Death or bereaved family members. Informing the family members or relatives about the Death of a patient with COVID-19 and managing their emotional reactions throughout the process comprises one of the prime responsibilities of the doctors and is often perceived to be a stressful experience. An understanding of the appropriate ways of handling the situation sensitively helps in performing the task effectively.

For simplification, healthcare professionals’ role and responsibilities in such situations can be subdivided into four major categories. The first three address the family member affected by the Death, and the fourth is for the professional himself/herself in handling the whole process of handling the death trauma due to COVID-19.

Preparing Family Members for the possibility of worst outcome due to COVID-19

Sudden Death brings about the most severe form of trauma because of being associatedwith loss along with shock and poor psychological preparedness with which it is introduced to the family members. Though, whether prepared or not, Death is going to elicit similar grief reactions, but it certainly impacts one’s ability to cope with it when expected. Thus, it is absolutely essential to keep family members in the loop of the patient’s deteriorating conditions to avoid sudden emotional trauma due to Death.

Whenever needed, the attending health professional can call the family member and briefthem on the deteriorating condition of the patient and the need to be prepared for anyeventuality that may occur. Ensure them that the best efforts are being taken but theresponse has not been satisfactory, and they need to be prepared forthe worst. Allow timefor reflection, silence or stress, emotional reactions and questions. Some of theimmediate queries can be handled patiently with objective facts and conversation morefrom the family member as this would be a catharsis can for the person with weighed and careful responses from the health professional. The conversation can end with theprovision of a contact number they can contact for any queries on the patient's progress. This intervention by the health professional will give the family some time to preparementally for the most inevitable and time to share with other family members on the needto prepare for the worst.

Breaking Bad News (BBN)

There is no best way to reveal bad news to anyone. However, due to challenges associated with divulging the information and helping the family go through it gradually,some of the followingfour key points can be considered.

Once the Death of a COVID-19 patient is confirmed, healthcare professionals can contact family members to reveal the difficult news. The process of breaking the bad news of Deathcould be initiated in person or through telephone. If the process of breaking the news is donein person, then the doctor must follow all the principles of safety and precautions. Generally, itis usually discouraged to inform about Death over the phone, as it excludes the possibility ofextending immediate support to the family. Nevertheless, due to the infectious nature of COVID-19, any medium of communication can be used, even the telephone, available easilyto most people. Despite whoever picks up the doctor’s call, it is essential to talk to an adult (not children or elderly with a serious condition until they are the only point of contact) whosecontact information was provided with the hospital. It is preferred to talk to the same personwho has been briefed about the patient’s critical nature of illness earlier.

Breaking the Bad (difficult) News Sensitively: Following a brief introduction of the doctor on call, hospital and reason for which a call has been made, it can be revealed in a very clear way that Death has happened. This must be expressed without unnecessary delay. Avoid euphemisms, for example, ‘passed away, and use simple and clear language such as ‘died’ or ‘dead’, so everyone is certain about what has happened, and there are no misunderstandings. The doctor here needs to allow time for the family member to understand what has happened. This may take time. They can re-assert the information if asked again.

Empathetic Listening: The doctor can act receptive to the range of emotional reactions aroused. Initial reactions of shock, despair, anger and numbness are common. It is significantto acknowledge initial emotional reactions. It is further important for doctors to know that, atthis critical point, empathetic listening to the family member’s concerns is far more essential than offering any form of advice. Empathetic listening simply refers to the practiceof being attentive and responsive to others’ input during the conversation. This requires the need to be considerate of the other personal concerns. Framing sentences like “I am sorry foryour loss”, “I can try to understand your distress” helps convey understanding to the family member. Statements that suggest meaning in Death (“He is in a better place”) or those prescribing any form of advice to adaptively manage the trauma (“You can pray for his peace”) can be avoided altogether. Furnish them with factual answers if they have any questions. Encourage them to ask questions or any doubts. Avoid answering questions with no absolute answer, or its answer lies beyond the doctor’s domain of expertise.

Critical Decision Making: After undergoing initial turmoil, once family members gather strength to talk further, provide them with the required information. Most significantly, when it is possible for them to perform the cremation. This is critical decision making, and responses can be immediately elicited by asking about the placement of the family members (their containment zone and if conditions allow them to visit the mortuary).For those residing in farway cities or overseas, the possibility is bleak, while those staying nearby can be further inquired about the logistics (when, how, where) of their visits to take the body.

Ending conversation Gently: It isthen important to brief relatives about the immediatenext steps which need to be taken. The conversation moves towards closure by gently extending support (in the form of any further assistance till they reach the mortuary) if required.

Facilitating the Grief Process in Family Members

It is important to understand that many traumatic stress reactions are expressed through emotional expressions. For any doctor, witnessing a bereaving family member is the most critical part of management. It demands a need for a sensitised approach for which many professionals may feel unprepared or challenging. Some of the essential ways of facilitating adaptive grief reactions are as follows:

Facilitating Grief Processes in Visiting Family Members

Encourage Family Membersto Ventilate Emotions: It is essential to know thatit is absolutely normal to experience emotional turmoil (for example- feeling of sadness, anger, abandonment, anxiety, stress) in response to losing anyone, specially compounded due to the complications associated with COVID -19. Though witnessinga bereaved human can naturally incline an individual towards providing any form of support within reach. However, it is professionally advisable to refrain from doing so (without appropriately knowing the family context, their ways of responding to traumaor the severity of trauma). Maintain the psychological presence with the family. Allowing the uninterrupted expression of emotion is in itself an intervention or a part of the human process to adjust to the new reality in life. Encourage them to talk about the patient’s illness, and if they open up, try to explain the efforts taken to save him/her and the inevitable outcome. Moreover, the doctor can further reduce the need to initiate active intervention by explaining to themselves that mourning to the grief is a gradual process and may take a lot of time and effort for the family members. Lettingan individual actively engage in the expression of trauma marks the beginning of the mourning process, and they must go on till a person gathers strength and courage to engage in the cremation process.

As a cautionary note, it may happen many times that the family member can blame the doctor or the treatment team during an emotional upsurge, followed by aggression towards them. It is important to understand that it is a manifestation of the acute emotional turmoil they are going through currently, and there is no need to provide any explanation for the same or engage in any further argumentation.

Facilitating Family’s Acceptance to the Reality of Death: As discussed in the previous point, its significant to process trauma and denial or disbelief can block this process of adjustment. Thus, to facilitate acceptance of the Death, the doctor can arrange for viewing the body bag till face and let family members spend some time withit to sink in reality. Spending time with the body of a loved one who has died helps mourners truly and fully acknowledge the reality of the Death with all necessary and prescribed safety and precautions. It also provides a precious last chance to say goodbye “in person.” The doctor should explain to family members about all the safety and precautions tobe followed during the cremation process while maintaining full dignity towards the deceased body. The doctors need to emphasise that while performing religious rituals, touching the dead bodies, like bathing, kissing and hugging etc., should be avoided.

Appoint a Supportive Family Member to Facilitate the Care: To facilitate care, the doctor can designate a support person of the family (the one who appears to be mostlycomposed during the crisis) to provide necessary help and assistance to the family members throughout the grief process. Further, the grieving process usually involves holding funerals, one of the most culturally acceptable ways of coping with grief. Sincethe COVID19 pandemic may deprive the bereaved of this important step, a support person or anyone more familiar with the technology can be suggested to hold tele- funerals such that family members feel a sense of comfort in virtual social connections.

As an immediate next step, the appropriate hospital staff should assist the relatives in completing the formalities like filling the forms or other details of the deceased to obtain a death certificate etc. Precautionary steps which must be followed throughout thecremation process may be re-explained clearly. Furthermore, as per the existing guidelines of the forensic department, the deceased body should be handled and their personal valuable belongings should be handed over to the family. 

Facilitating Grief Process in Non-Visiting Family Members

Family members of patients with COVID-19, who live in faraway places or those who cannot visit hospital due to various logistic issues involved in moving from containment zones, are deeply impacted with both the loss of loved one and inability to pay the last visit. Telecommunication becomes the only mode of communication in such situations, which often limits HCW’s ability to facilitate grief processes or extended support in the similar ways as defined above. Additionally, if the family member is living alone with no further support at home, coping with the loss of a loved one can become really difficult.

One of the prime responsibility of HCW in such a situation isfirst to break the difficult news, following step number one and two defined in the previous section, i.e., sensitively with enough empathetic listening. When discussing step number three, i.e., critical decision making, it is crucial to remember that family members may find it extremely hard to communicate that they would not be coming to the hospital to claim the body of the parted family member. HCW may need to empathetically listen to the family member’s communication of their decision for a hospital visit and show acceptance for their choice. At this point, people may really differ in the way they crisis situation. There may be many who would simply like to deal with all emotions by themselves and be unable to continue the further conversation with HCW. It is significant for HCW to respect the individual decision. HCW may simply provide grieving family members with at least one contact number of local mental health emergency services if they need to contact for any further assistance. HCW may show a willingness to support them further (if required), and on this note, the telephonic conversation may gently end the call. If the phone call is dropped suddenly, HCW may SMS the family member about the emergency contact services available in the near locality for further help.

For those family members, who require immediate support telephone, there were some of the steps HCW can keep in mind while responding to the crisis situation:

• HCW may allow the person to express their trauma in whichever way they prefer. Be it by crying, expressing shock, disbelief or anger. It is important not to interrupt them. Give them time to express their feelings.
• HCW can then assume the role of a support person and provide supportive counselling. This includes comforting, reassuring, and mostly listening attentively and empathetically. It is important to normalise the expressed emotions of the family member and validate them. False or over-promising for quick relief can be avoided altogether.
• HCW can then emphasise the nature of the mourning process, which is gradual and may take some time. Family members may be encouraged to acknowledge and express their feelings to their significant others rather than denying or suppressing them.
• At this point importance of social connections may be emphasised. The patient can be encouraged to identify their support network and maybe encouraged to actively connect to their loved one (using video calling or telephone) and share their emotions with them. It helps in accepting the reality of Death and in receiving required support. Participating in tele-funeral may also be advised to receive comfort in virtual social connections further.
• HCW may then introduce the concept ad process of teleconsultation for mental health services, which can be availed whenever required. Few immediately available contact details can be given on the phone or through SMS. The patient is encouraged to contact mental health professionals whenever they find the situation too difficult to handle.
• As the last step, it is vital for HCW to emphasise that they are not alone in this challenging time and that every form of help and support is available for them whenever required. The conversation moves towards closure by gently extending support.

Practicing Self-Care

It is crucial for the clinician or staff, especially in the event of COVID-19 related Death, to be aware of the concept of vicarious trauma in professionals. Vicarious trauma refers to the experience of a clinician who develops a traumatic reaction secondary to the client’s traumatic experience. It can be manifested in multiple ways such as feelings of helplessness, lack of trust in others, social withdrawal, becoming easily emotionally upset, vague feelings towards people and events, loss of connectedness to others and the self, hypervigilance and difficulty to experience joy and happiness. Also called as spilt over effect, the experiences often build within the context of compassion fatigue created by the trauma of helping others in distress, which leads to a reduced capacity for empathy toward suffering in the future. Since it has a deleterious impact on the mental health of the doctor as well as their clinical practice, it is essential to deal with it by regularly engaging in self-care. Self-care refers to regularly engaging in activities and practices which reduces stress and maintains or enhances health and well-being. Norton (1996) proposed following six wheels of self-care, which requires regular nourishment. Striking a balance between all six domains of self-care ensure optimal health and well-being to professionals.

Physical Self-Care: This refers to the process of ensuring that the physical health of a person is well-nourished and happy. Three most significant aspect of physical self-care includes: eating food with good nutrition every day at regular intervals, ensuring sufficient rest or sleep and engaging in necessary exercise or yoga. Timely attending to signs and symptoms of distress on the body along with taking care of pre-existing illnesses would also be an essential step towards optimising physical health.

Psychological Self-Care: It is the care one gives to their mind to ensure their wellbeing. It includes engaging in self-reflection, learning new things, exercising
mindfulness, and engaging in activities perceived to be relaxing. For example, writing a journal, making art, taking day trips or mini-vacation.

Emotional Self-Care: As it is significant to maintain physical hygiene, it is crucial to nourish one’s emotional health. Moreover, witnessing a frequent and large number of deaths of patients with COVID-19 and their bereaving family members can evoke strong emotional reactions in doctors. This may be especially difficult for those HCWs who can get reminded of their own personal tragedy in the family, internalisation of which may increase the vulnerability for the emotion experienced and has a deleterious impact on other clinical practice. Thus, it is certainly crucial to be compassionate towards family members experiencing the trauma, but it is equally significant to deal with emotions that an HCW goes through themselves while managing the crisis situation. Following are the important ways in which an HCW can cope with difficult emotions evoked due to Death or witnessing bereaving family members.

1. Acknowledge and Normalise the Emotion: It is crucial for an HCW to know that it is normal to have a range of emotions when someone they help dies. Denying the presence of unpleasant emotions or attempting to ignore or suppress them completely may actually escalate the emotion felt inside and sometimes may even create a barrier between the doctor and the bereaving family members. Thus, when exposed to such a situation, a doctor may not rush into the suppression of emotion, instead take a step back for a moment, where they acknowledge the presence of unpleasant emotions inside and try to normalise it as a most common occurrence which they will subsequently overcome.
2. Take a Break to Release Emotions: At any point during assistance to the family members, if the doctors find the situation emotionally overwhelming, it is essential to take a mini emotional break with a colleague, where they can express their Immediate difficult emotions and receive support for the same. However, it is crucial to understand that support from a peer should be voluntary and nonintrusive, aiming to provide a listening ear and extend support and encouragement to the fellow HCW. If the fellow colleague is themselves struggling with the distress of the situation, sharing concerns with a relatively composed person will be suggested. However, in a situation where no such assistance is available, visiting a silent corner of the room and ventilating emotions can help the doctor for getting immediate relief. Sometimes, sharing an emotional burden with a colleague going through the same crisis may help in validation of each other’s emotions and receiving mutual support to deal with the distress overall. Even though releasing emotion may not resolve the issue, it certainly minimizes the burden of emotion experienced from the distressing situation.
3. Practicing Self-Compassion: Witnessing the loss of many lives may lead to selfblame and guilt over the helplessness of the situation. Such emotion easily gives rise to harsh comments on self (for example, “you are good for nothing”, “you cannot do anything to help people”, etc.), which may severely impact the quality of care provided to the subsequent patient with COVID-19 where the concern over mortality can evoke similar feelings and thoughts. It is important to practice selfcompassion in such situations. Since there is no perfect treatment or recovery, rather than criticizing self, it would be productive to focus on doing what utmost is possible within the limits of their competency. Saying themselves statements like, “Given the reality of COVID-19, this was all that I could have done to manage the situation” releases the burden of self-blame and further helps in providing optimal care to patients.

Further, frequently engaging in pleasurable activities that add richness and meaning to life helps ensure emotional well-being.

Social Self-Care: Most people have the need for connectedness and building meaningful social relationships. Thus, finding some quality time for loved ones and people who are significant in one’s life nourishes the need for nurturance and belongingness.

Spiritual Self-Care: It can involve anything that helps an individual develop a more profound sense of meaning, understanding, or connection with the universe. Based on one’s affiliation with the philosophy of living, one can continue practicing activities perceived to be meaningful or peaceful for them, such as praying, meditating, volunteering for a cause, reading or writing literature on the same. It is crucial to note that this form of self-care entirely depends on whether a person perceives it to be significant or not, andhence it is not a prerequisite for self-care. Instead, those already affiliated with such philosophies may be encouraged to continue doing so.

Professional Self-Care: This refers to practicing self-care while at work such that a healthy work-life balance can be achieved. This includes time management in work, balancing workload, taking time for essential activitieslike having lunch or taking amini relaxing break with peers etc.

In addition to striking balance between all six domains of self-care, it is crucial for HCW to continue practicing adaptive coping mechanisms to stressful situations in their lives, which involves confronting problems directly. For example, making reasonably realistic appraisals of problems, recognising and changing unhealthy emotional reactions, actively seeking emotional support, and positive reframing of the situation, etc

Source : ICMR