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The corona virus pandemic has been one of the deadliest and rapidly developing global health crises since the Spanish Flu. Even with the research and medical advances since 1918, the human race has very much been caught off guard with its global and deadly spread.

As we enter the second half of 2020, people have gradually adapted to the immediate impact of lock down regulations and social distancing, with many experiencing a multitude of short-to-medium term stressors (e.g. disrupted routine, financial difficulty, increased alcohol intake).

With many countries now lifting their lock down restrictions and as things gradually return to normal, it is likely that psychological effect of mass loss of life on individual and community level will gradually come to light.

Bad deaths

Whilst it’s easy to focus on the daily statistics of the death toll (which is approaching 10 million globally), we must not overlook the loved ones left behind and how their grieving process will be disrupted.

The perception of a loved one’s death being a “good death” is important for the grieving process. A good death, under normal circumstances, is characterised by physical comfort, emotional and spiritual support and being surrounded by family in a peaceful and dignifying environment. This results in anticipatory grief, which is a normal emotional response and usually passes over time.

“Bad deaths”, however, are the opposite. They are associated with physical discomfort, difficulty breathing, lack of awareness or preparation and being treated without respect. Bad deaths not only have a substantially more negative impact on loved ones’ grieving, but they are likely to lead to severe mental health consequences in relatives and friends such as major depression, anxiety, prolonged complex grief disorder or complicated grief, which can also affect cardiovascular health in the long term.

COVID-19 deaths

Unfortunately, COVID-19 deaths epitomize bad deaths. Discomfort or inability to breath and lack of cognitive awareness are both hallmarks of bad deaths and prominent symptoms of COVID-19.

The statistics show that around a quarter of elderly people would prefer to die in their homes, yet over three quarters are admitted to hospital (Centres for Disease Control and Prevention, 2020). The use of PPE equipment in the current crisis hides the identity of hospital staff and adds a level of depersonalisation for COVID-19 patients. It also creates problems with communication, which is an added stressor. Even in the pre-COVID-19 world, dying in hospital increased the likelihood of prolonged grief for loved ones, but unfortunately this is now the norm.

Hospitals and nursing homes implemented rules that do not allow families to be with their loved ones to restrict the contagion of the virus has led to thousands of virtual goodbyes via phone or video chat through plastic bags and a limited number of people allowed to attend the funeral.

Furthermore, bodies being removed from beds quickly and being held in designated areas may not have received the typical dignified treatment, as staff make way for other COVID patients. All these aspects of COVID-19 deaths violate cultural expectations for a peaceful death and increase the perceived suffering of loved ones.

Why COVID-19 grief is worse than a usual death

The pandemic has undeniably changed the way people grieve. The barriers presented by COVID-19’s bad deaths cause enhanced levels of anger and guilt in bereaved loved ones, with an increased likelihood of casting blame on self or others in order to process their unexpected loss.

Grieving is further disrupted by the presence of other pandemic-specific stressors that further delay recovery. There is a particular lack of emotional support due to being isolated from friends and family. People who have lost loved ones will also be carrying additional stress about their family’s safety from the virus and financial difficulty from mass redundancies, often accompanied by anxiety about their future economic situation.  These stressors occupy emotional capacity that would otherwise be used for grieving, which increases risk of long-term mental health consequences.

Mitigating grief

It is clear that COVID presents the potential for globally amplified grief. So, what can we do in apprehension of these obstacles?

To mitigate the intensity of COVID hospital environments for patients, some hospital workers have attached smiling mugshots of themselves to the front of their PPE. This reduces the sense of alienation and extreme isolation from regular human contact. Clear, empathic and written communication from hospital staff including assurances of comfort have been found to improve satisfaction of perceived end of life care for bereaved relatives.

Preparation for expected death of loved one will help preventing prolonged grief. If somebody is critically ill, conversations about grief in anticipation of death will reduce the impact if the loved one does not recover, even though this may be difficult. This is particularly important because of the rapid clinical decline seen in moderate/severe COVID-19 patients – the virus does not allow relatives much time to prepare.

Considering people are being forced to disregard traditional funeral services for virtual memorials, assisting older adults with technology and streaming services will be important to ensure the already diminished mourning experience is not made more stressful. We must also remember that older persons usually have a smaller number of close companions rather than several loose acquaintances, so continuity of relationships is important for volunteers supporting older bereaved persons.

For those grieving, recalling positive memories of loved one and sharing stories should be encouraged as a source of lifting inspiration. Reminding loved ones struggling with loss that the painful emotional reaction can be seen as the “price we pay for love”, which may provide hints of comfort and consolidation during desolate times.

For anybody in a position of care – professional or personal – self-compassion is an important emotional quality to practice. Awareness that one’s emotional suffering may be derived from the emotional suffering of those you care for, and taking time to recognise or alleviate this will improve the ability to attend to the needs of bereaved relatives or patients. Finally, we must familiarise ourselves and be observant of whether symptoms of grief are short lived or more serious, long term symptoms associated with mental illnesses such as clinical depression or PTSD.

Written by George Yerbury MSc MBPsP

References

Carr, D., Boerner, K., & Moorman, S. (2020). Bereavement in the Time of Coronavirus: Unprecedented Challenges Demand Novel Interventions. Journal of Aging & Social Policy, 1-7.

Center to Advance Palliative Care. (2020). CAPC COVID-19 response resources. New York: Center to Advance Palliative Care. Retrieved April 28, 2020, from. https://www.capc.org/ toolkits/covid-19-response-resources/

Eisma, M. C., Boelen, P. A., & Lenferink, L. I. (2020). Prolonged grief disorder following the Coronavirus (COVID-19) pandemic. Psychiatry Research288, 113031.

Neimeyer, R. A. (2000). Searching for the meaning of meaning: Grief therapy and the process of reconstruction. Death Studies, 24(6), 541–558

Sun, Y., Bao, Y., & Lu, L. (2020). Addressing mental health care for the bereaved during the COVID‐19 pandemic. Psychiatry and Clinical Neurosciences.

Wallace, C. L., Wladkowski, S. P., Gibson, A., & White, P. (2020). Grief during the COVID-19 pandemic: considerations for palliative care providers. Journal of Pain and Symptom Management.