Experiences of Grief Grief in bereaved relatives during COVID-19 pandemic 
Academic paper Title

Lived Experiences of Family Members of Patients With Severe COVID-19 Who Died in Intensive Care Units in France

Kentish-Barnes, Nancy, Zoé Cohen-Solal, Lucas Morin, Virginie Souppart, Frédéric Pochard, and Elie Azoulay. “Lived Experiences of Family Members of Patients With Severe COVID-19 Who Died in Intensive Care Units in France.” JAMA Network Open 4, no. 6 (2021): e2113355-e2113355.

Grief is a universal experience when humans come face to face with mortality.The tribulations of achieving the sense of closure from a loved one’s passing have been immensely exacerbated in the pandemic COVID-19 era. 
We as HCWs ought to equip ourselves with the qualitative experiences of relatives of bereaved that had to grief differently because of the pandemic. It is knowledge that is, in our opinion, essential in establishing rapport and support for those who need to grieve in the new age. 
Synopsis of paper 
What is the main aim of the paper?

How is the Results section organised? 
Comfort from physical touch, emotional support, and communication channels for families of patients who are dying have been deleteriously impacted by the COVID-19 crisis. Understanding how the above needs of families aren’t met during a global pandemic can help facilitate better psychological adjustment in their grief.Effective facilitations will aid in informing clinical practice and policy making Aim of paper was to explore experiences of bereaved family members of patients who died in an ICU during the COVID-19 pandemic

Results section organised as:
Difficulty in building a relationship with ICU HCWs
-Challenges brought about by new restriction rules 
-Effects of separation with the patient in the ICU
-Disrupted end-of-life rituals and the feeling of “stolen moments” with the deceased. 
Prominent experiences identified 

Challenges in building relationship with ICU team through telephone 
– More structured communication needed
– Lack of protocol for distance communication associated with breakdown of trust in institution

“We were in need of explanations, I can tell you. Because my husband went to the hospital on his 2 feet, although he wasn’t in good shape. Then it was just a nightmare, with no explanations.… So, then, they did take some time to help us understand, but it was too late. For me, it was too late. I didn’t trust them anymore.
”When done well…“They really understood me, they showed empathy. They said, ‘We know it’s hard for you. This is a difficult situation. We’re doing the best we can with so many patients, but we know how you’ve waited for this call, so we want to take the time to explain and discuss things with you.’
Two-way conversation vs information-dumping

Medical team mostly gave updates on patient’s physical condition, lack of conscientious empathising of family that facilitated effective communication
Paraverbal communication neglected
Tone, pace, rhythm, phrasing of medical team used were distressing
Family who had opportunity to meet with ICU team face to face
Felt soothed and able to trust medical team more 
“We went from black to white, because clearly, when on Friday we were told, ‘We’ll call the police if you come,’ and on Saturday, when I did go, the nurse said ‘If you wish I can come with you [to the patient’s room], and I can stay with you if you don’t want to be alone.’… She was just perfect. I couldn’t have dreamed of a better nurse.”

Challenges brought about by new restriction rules 
Inability to see patient’s condition made their passing and the hospitalisation experience unreal“It was like being in a film, I didn’t understand what was going on. What’s this story? How can it be possible that he’s gone? How did he die? Really, even today, I just don’t understand.”Clinical trajectory of patients unknown, family received mix of positive and negative updates – emotional roller coaster of stress and relief as a result “It was an absolute nightmare, I was living to the rhythm of the ICU phone calls, with ups and downs because there was this Monday when things were going rather well, and then the next day when we were told it wasn’t going well.… It was awful, just awful.”

Effects of separation with the patient in the ICU
Feelings of powerlessness as unable to help suffering patient “The greatest pain for me was the absence. It was such a cut, such a brutal break with him. It was unbearable. Unbearable.… I asked them if I could see him, but they said no. Not seeing each other? The fact that no one could be there to hold his hand and tell him we’re at his bedside, it was my brother’s sure death.”Feelings of abandonmentFelt that not letting patient die alone is paramount Feelings of frustrationOnly allowing visits when patient about to pass was deemed unacceptable “I asked the doctor if I could come and see him. She said, ‘We don’t let families come except when we really have no hope anymore’… And what I said was, ‘But this is when he needs me at his side, now more than ever, not just when there’s no more hope. That’s just not enough.’”

Disrupted end-of-life rituals and the feeling of “stolen moments” with the deceased. 
Before funeralRestrictions kept family away from body of deceased Felt like deceased was dehumanised in the process“All the people who died from COVID[-19] were put naked in plastic body bags and then straight into the coffin, without even preparing the body! [Silence] And you can never see the person again. It’s over. I don’t know who made these decisions but it was difficult. It’s extremely violent.”Sense of disbelief, doubt, and ambiguity Challenges faced with ceremonies Restrictions limited the number of people attending funerals, if even allowed so.Heavy restricted things that can be done in funeralDeep sense of frustration and guilt that they did not do enough to send deceased off “It was appalling.… We weren’t allowed to do anything. We couldn’t touch the coffin, we couldn’t bring flowers, nothing at all. I feel like we abandoned him! He left the hospital all alone, in his coffin, with all the other bodies waiting. No real ceremony, nothing at all. It lasted 14 minutes, with just me and the kids, 9 people.”

Incomplete ceremonies left family feeling disembodied, angry, deprived
Seen as barriers to grieving: 
“It’s hard to grieve. Sometimes, I tell myself she will come back, it’s not possible, we didn’t bury her. For me, she’s here, she’s somewhere. I have her things at home, I didn’t tidy anything up, I didn’t touch anything, and everything is here.”

Successful rituals facilitated grief. Great relief experienced when ceremonies done up to expectation
“I fought for things to happen… And it felt good for everyone. And the battle I fought afterwards felt good for me, too. I managed to have a mass.… We scattered the ashes in the cemetery when I thought it wasn’t going to be possible.… My grandchildren were able to come, although they live in different regions. That was important, very important. We were able to pay tribute to him, to talk about him.”

“I came home from the memorial service yesterday.… I can now say to myself, ‘Well, that’s it, that’s it, it’s over.’ It makes me cry, but at the same time, it’s a relief, too. I now feel like I can start something else.”
What do these prominent experiences mean? 
Challenges in building relationship with ICU team through telephone Quality of communication with the ICU team seems central in shaping family members’ experience, both during the patient’s stay and after death
Effective communication includes, other than technical information, verbal and nonverbal communication, active listening, and empathic statements
Facilitates the feeling of supported, trustful, and validated
Facilitating presence of family members in ICU should remain priority 

Effects of separation with the patient in the ICU
Not being able to witness patient end of life moment adds further trauma to an already traumatic experience Ability to comfort patient, to say goodbye allows family members to anticipate their separation, and these are steps of crucial importance in end-of-life care rituals

Disrupted end-of-life rituals and the feeling of “stolen moments” with the deceased. 
Families were deprived of important rituals following a death, Possible shift in how people experience dying, death, and grievingMembers often feel alone to deal with grief and lossReadjustments in funeral policies to better take the bereaved family members’ fundamental needs into account need to be made to prevent development of compliated grief
Key messages for HCP
HCWs when dealing with patients and family
Make time for daily updates for family on how patient is doing
Be mindful of ultilising your nonverbal communication, active listening, and empathic statements to maximise effectiveness in reassuring family
Facilitate face to face sessions with medical team whenever possible
Facilitate family face to face with patients whenever possible 

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