Psychological Risk Factors of Functional Impairment After COVID-19 Deaths

Predictors of Complicated Grief During the COVID-19 Pandemic: A Cross-Classified Analysis

The COVID-19 pandemic left many people grieving multiple deaths and at risk for developing symptoms of complicated grief (CG). The present study is a prospective examination of the role of neuroticism and social support in the development of CG symptoms. Findings from cross-classified multilevel models pointed to neuroticism as a risk factor for subsequent CG symptoms. Social support had a stress-buffering effect, emerging as a protective factor following the loss of a first degree relative. More recent loss and younger age of the deceased were both independently associated with heightened CG symptoms. Results from the present study provide insight into heterogeneity in CG symptom development at the between-person level, and variability in CG symptoms within individuals in response to different deaths. Findings could therefore aid in the identification of those at risk for the development of CG symptoms.

The mental health of Australians bereaved during the first two years of the COVID-19 pandemic: a latent class analysis

BACKGROUND

The COVID-19 pandemic disrupted many areas of life, including culturally accepted practices at end-of-life care, funeral rites, and access to social, community, and professional support. This survey investigated the mental health outcomes of Australians bereaved during this time to determine how these factors might have impacted bereavement outcomes.

METHODS

An online survey indexing pandemic and bereavement experiences, levels of grief, depression, anxiety, and health, work, and social impairment. Latent class analysis (LCA) was used to identify groups of individuals who shared similar symptom patterns. Multinomial regressions identified pandemic-related, loss-related, and sociodemographic correlates of class membership.

RESULTS

1911 Australian adults completed the survey. The LCA identified four classes: low symptoms (46.8%), grief (17.3%), depression/anxiety (17.7%), and grief/depression/anxiety (18.2%). The latter group reported the highest levels of health, work, and social impairment. The death of a child or partner and an inability to care for the deceased due to COVID-19 public health measures were correlated with grief symptoms (with or without depression and anxiety). Preparedness for the person's death and levels of pandemic-related loneliness and social isolation differentiated all four classes. Unemployment was associated with depression/anxiety (with or without grief).

CONCLUSIONS

COVID-19 had profound impacts for the way we lived and died, with effects that are likely to ricochet through society into the foreseeable future. These lessons learned must inform policymakers and healthcare professionals to improve bereavement care and ensure preparedness during and following future predicted pandemics to prevent negative impacts.

Prolonged grief in relatives of deceased patients due to COVID-19 is associated with anxiety and depressive symptoms: A survey-based study in Peru

Objective

Funeral practices have undergone significant changes during the COVID-19 pandemic. Thus, the death of a family member from this disease has altered the typical course of the bereavement process. Therefore, this study seeks to determine the relationship between the levels of grief, anxiety, and depression in relatives of patients who died from COVID-19 in Peru.

Methods

A total of 250 volunteers were obtained, but after applying the inclusion criteria and not being able to contact five of them, the sample consisted of 115 participants over 18 years of age who lost a family member to COVID-19 between 2020 and 2021. They developed the Prolonged Grief Questionnaire-13 and the Zung Anxiety and Depression Questionnaires, in virtual surveys using Google FormTM (Google, CA).

Results

Our analysis revealed that all cases of anxiety (18.3%) were present in individuals experiencing prolonged grief (76.5%), while 49.5% (57/115) of participants exhibited symptoms of depression. Furthermore, we identified a significant association between prolonged grief and both anxiety (p = 0.005) and depression (p < 0.001). Prolonged grief predominantly affected females (45.2%) and individuals aged 31-40 years (28.7%) (p < 0.001). Regarding predictors of anxiety symptoms, we found that both age group (p = 0.035) and grief (p < 0.001) played significant roles. Gender (p = 0.019) and grief (p < 0.001) emerged as predictors of depression, while gender alone predicted grief in relatives of individuals who succumbed to COVID-19 (p = 0.019).

Conclusion

Our results suggest a clear association between prolonged grief and mental health issues among relatives of COVID-19 patients who have passed away. Consequently, it is imperative to provide comprehensive psychological and spiritual support throughout the grieving process, aiming to mitigate the negative impact of traumatic events.

Long-term bereavement outcomes in family members of those who died in acute care hospitals before and during the first wave of COVID-19: A cohort study

BACKGROUND

Severe grief is highly distressing and prevalent up to 1 year post-death among people bereaved during the first wave of COVID-19, but no study has assessed changes in grief severity beyond this timeframe.

AIM

Understand the trajectory of grief during the pandemic by reassessing grief symptoms in our original cohort 12-18 months post-death.

DESIGN

Prospective matched cohort study.

SETTINGS/PARTICIPANTS

Family members of decedents who died in an acute care hospital between November 1, 2019 and August 31, 2020 in Ottawa, Canada. Family members of patients who died of COVID (COVID +ve) were matched 2:1 with those who died of non-COVID illness (COVID -ve) during pandemic wave 1 or immediately prior to its onset (pre-COVID). Grief was assessed using the Inventory of Complicated Grief (ICG).

RESULTS

Follow-up assessment was completed by 92% (111/121) of family members in the initial cohort. Mean ICG score on the 12-18-month assessment was 19.9 (SD = 11.8), and severe grief (ICG > 25) was present in 28.8% of participants. One-third (33.3%) had either a persistently high (>25) or worsening ICG score (⩾4-point increase between assessments). Using a modified Poisson regression analysis, persistently high or worsening ICG scores were associated with endotracheal intubation in the deceased, but not cause of death (COVID +ve, COVID -ve, pre-COVID) or physical presence of the family member in the final 48 h of life.

CONCLUSIONS

Severe grief is a substantial source of psychological morbidity in the wake of the COVID-19 pandemic, persisting more than a year post-death. Our findings highlight an acute need for effective and scalable means of addressing severe grief.

Public stigma toward prolonged grief and COVID-19 bereavement: A vignette-based experiment

We investigated the effects of cause of death and the presence of prolonged grief disorder (PGD) on eliciting public stigma toward the bereaved. Participants (N = 328, 76% female; Mage = 27.55 years) were randomly assigned to read one of four vignettes describing a bereaved man. Each vignette differed by his PGD status (PGD diagnosis or no PGD diagnosis) and his wife's cause of death (COVID-19 or brain hemorrhage). Participants completed public stigma measures assessing negative attributions, desired social distance, and emotional reactions. Bereavement with PGD (versus without PGD) elicited large and significantly stronger responses across all stigma measures. Both causes of death elicited public stigma. There was no interaction between cause of death and PGD on stigma. With increased PGD rates expected during the pandemic, the potential for public stigma and reduced social support for people bereaved via traumatic deaths and people with PGD requires mitigation.

Impact of long COVID-19 on posttraumatic stress disorder as modified by health literacy: an observational study in Vietnam

BACKGROUND

The prevalence of posttraumatic stress disorder (PTSD) has increased, particularly among individuals who have recovered from coronavirus disease 2019 (COVID-19) infection. Health literacy is considered a "social vaccine" that helps people respond effectively to the pandemic. We aimed to investigate the association between long COVID-19 and PTSD, and to examine the modifying role of health literacy in this association.

METHODS

A cross-sectional study was conducted at 18 hospitals and health centers in Vietnam from December 2021 to October 2022. We recruited 4,463 individuals who had recovered from COVID-19 infection for at least 4 weeks. Participants provided information about their sociodemographics, clinical parameters, health-related behaviors, health literacy (using the 12-item short-form health literacy scale), long COVID-19 symptoms and PTSD (Impact Event Scale-Revised score of 33 or higher). Logistic regression models were used to examine associations and interactions.

RESULTS

Out of the study sample, 55.9% had long COVID-19 symptoms, and 49.6% had PTSD. Individuals with long COVID-19 symptoms had a higher likelihood of PTSD (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.63-2.12; p<0.001). Higher health literacy was associated with a lower likelihood of PTSD (OR, 0.98; 95% CI, 0.97-0.99; p=0.001). Compared to those without long COVID-19 symptoms and the lowest health literacy score, those with long COVID-19 symptoms and a 1-point health literacy increment had a 3% lower likelihood of PTSD (OR, 0.97; 95% CI, 0.96-0.99; p=0.001).

CONCLUSION

Health literacy was found to be a protective factor against PTSD and modified the negative impact of long COVID-19 symptoms on PTSD.

Mental health consequences of parental death and its prevalence in children: A systematic literature review

The death of a loved one can occur at any stage of life and can have a profound clinical impact on the patient. During childhood and adolescence, smoking has a functional impact on key aspects of family, school, and social life. The negative effects of parental death on children's mental health and its prevalence are unknown. Therefore, this systematic literature review aimed to describe the effects of parental death on children's mental health and its prevalence. The PubMed/Medline, WoS, and Cochrane Trials databases were searched for articles on patients aged 4-18 years. This review examines three articles. Anxiety and depression were identified as the predominant mental health outcomes, with a prevalence ranging from 7.5 % to 44.67 % of the mental health consequences associated with parental death.

Death Unpreparedness Due to the COVID-19 Pandemic: A Concept Analysis

The COVID-19 pandemic imposed changes upon the capacity of healthcare systems, with significant repercussions on healthcare provision, particularly at end-of-life. This study aims to analyze the concept map of death unpreparedness due to the COVID-19 pandemic, capturing the relationships among the attributes, antecedents, consequences, and empirical indicators. Walker and Avant's method was used to guide an analysis of this concept. A literature search was performed systematically, between May 2022 and August 2023, using the following electronic databases on the Elton Bryson Stephens Company (EBSCO) host platform: Medical Literature Analysis and Retrieval System Online (Medline), Psychological Information Database (PsycINFO), Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete, Cochrane Library, and Nursing and Allied Health Collection. Thirty-four articles were retrieved. The unexpected and unpredictable impositions associated with inexperience and unskillfulness in dealing with COVID-19 configured challenges for healthcare professionals, family/caregivers, and even the dying person. Nine key attributes emerged in three main domains: (1) Individual: (a) disease-related conditions, (b) separation distress, and (c) scarcity of death and grief literacy; (2) Relational: (a) Dying alone, (b) poor communication, and (c) existential issues; and (3) Contextual: (a) disrupted collective mourning and grieving, (b) disrupted compassionate care and, (c) pandemic social stigma. This study contributed a full definition of death unpreparedness in a global pandemic scenario such as COVID-19. In this sense, feeling unprepared or unready for death brought new challenges to the bioecological resources of those affected. It is essential to embrace strategies capable of providing emotional and spiritual support in the dying process and to respect patient wishes. The lessons learned from COVID-19 should be applied to events with a comparable impact to minimize their consequences.

Measuring Grief in the Context of Traumatic Loss: A Systematic Review of Assessment Instruments

Following traumatic loss, defined as the death of a loved one due to unexpected or violent circumstances, adults may experience a myriad of grief-related problems. Given the addition of Prolonged Grief Disorders into the Diagnostic and Statistical Manual for Mental Disorders Fifth Edition, Text-Revision and influx of unexpected deaths due to the global Coronavirus pandemic, there is heightened interest in the measurement of grief-related processes. We conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify measures of grief used in studies of adults who experienced traumatic loss. Searches yielded 164 studies that used 31 unique measures of grief-related constructs. The most commonly used instrument was the Inventory of Complicated Grief-Revised. Half of the measures assessed constructs beyond diagnosable pathological grief responses. Given the wide variation and adaptations of measures reviewed, we recommend greater testing and uniformity of measurement across the field. Future research is needed to adapt and/or design measures to evaluate new criteria for Prolonged Grief Disorder.

Prolonged grief during and beyond the pandemic: factors associated with levels of grief in a four time-point longitudinal survey of people bereaved in the first year of the COVID-19 pandemic

Background

The COVID-19 pandemic has been a devastating and enduring mass-bereavement event, with uniquely difficult sets of circumstances experienced by people bereaved at this time. However, little is known about the long-term consequences of these experiences, including the prevalence of Prolonged Grief Disorder (PGD) and other conditions in pandemic-bereaved populations.

Methods

A longitudinal survey of people bereaved in the UK between 16 March 2020 and 2 January 2021, with data collected at baseline (n = 711), c. 8 (n = 383), 13 (n = 295), and 25 (n = 185) months post-bereavement. Using measures of Prolonged Grief Disorder (PGD) (Traumatic Grief Inventory), grief vulnerability (Adult Attitude to Grief Scale), and social support (Inventory of Social Support), this analysis examines how participant characteristics, characteristics of the deceased and pandemic-related circumstances (e.g., restricted visiting, social isolation, social support) are associated with grief outcomes, with a focus on symptoms of PGD.

Results

At baseline, 628 (88.6%) of participants were female, with a mean age of 49.5 (SD 12.9). 311 (43.8%) deaths were from confirmed/suspected COVID-19. Sample demographics were relatively stable across time points. 34.6% of participants met the cut-off for indicated PGD at c. 13 months bereaved and 28.6% at final follow-up. Social isolation and loneliness in early bereavement and lack of social support over time strongly contributed to higher levels of prolonged grief symptoms, while feeling well supported by healthcare professionals following the death was associated with reduced levels of prolonged grief symptoms. Characteristics of the deceased most strongly associated with lower levels of prolonged grief symptoms, were a more distant relationship (e.g., death of a grandparent), an expected death and death occurring in a care-home. Participant characteristics associated with higher levels of prolonged grief symptoms included low level of formal education and existence of medical conditions.

Conclusion

Results suggest higher than expected levels of PGD compared with pre-pandemic times, with important implications for bereavement policy, provision and practice now (e.g., strengthening of social and specialist support) and in preparedness for future pandemics and mass-bereavement events (e.g., guidance on infection control measures and rapid support responses).

Community-based end-of-life care in Singapore and nursing care implications for older adults in the post-COVID-19 world

PURPOSE OF REVIEW

To render holistic overview on community-based end-of-life care in the context of Singapore, with analysis of nursing care implications for older adults requiring end-of-life care services.

RECENT FINDINGS

Healthcare professionals caring for older adults with life-limiting conditions had to play an active role in the constantly evolving healthcare landscape during the coronavirus disease 2019 (COVID-19) pandemic. Usual meetings and community-based end-of-life care interventions were converted to online mode, utilizing digital technology. In order to provide value-based and culturally relevant care, further studies are warranted to evaluate healthcare professionals, patients and family caregivers' preferences whilst utilizing digital technology. As a result of COVID-19 pandemic restrictions to minimize infection transmissions, animal-assisted volunteering activities were conducted virtually. Regular healthcare professionals' engagement in wellness interventions is necessary to boost morale and prevent potential psychological distress.

SUMMARY

To strengthen the delivery of end-of-life community care services, the following recommendations are proposed: active youth engagement via inter-collaborations and connectedness of community organizations; improving support for vulnerable older adults in need of end-of-life care services; and enhancing healthcare professionals well-being through the implementation of timely support interventions.

Experience of loss and grief among people from Germany who have lost their relatives during the pandemic: the impact of healthcare professionals' support

Background

Due to public restrictions during the early stages of the COVID-19 pandemic, many people were unable to visit and bid a proper farewell to their dying loved ones. This study aimed to address the loss-oriented aspects of grief and bereavement of relatives and relate these to the support they may have received from their dying relative's caring professionals.

Materials and methods

People from Germany who experienced bereavement during the COVID-19 pandemic were enrolled in a cross-sectional study between July 2021 and May 2022, using standardized questionnaires (i.e., ICG, Inventory of Complicated Grief; BGL, Burdened by Grief and Loss scale; WHO-5, WHO-Five Wellbeing Index; and 5NRS, perception of burden related to the pandemic).

Results

Most participants (n = 196) had the opportunity to visit their relatives before death (59%). When this was not possible, being burdened by grief and loss was significantly higher (Eta2 = 0.153), while this had no significant influence on complicated grief or psychological wellbeing. Furthermore, 34% of participants felt well-supported by the treatment/care team. Their own support was moderately correlated with BGL scores (r = -0.38) and marginally with ICG scores (r = -15). Regression analyses showed that complicated grief symptoms as the dependent variable were predicted by (low) psychological wellbeing, relational status, and the perception of COVID-19-related burden (R2 = 0.70). In contrast, BGL as the dependent variable can be best explained by the perception of emotional affections because of restricted visits shortly before their death, by the (short) duration of visits before death, and by the relational status (R2 = 0.53). Although both were interconnected (r = 0.44), their predictor pattern was different.

Conclusion

Being able to visit dying relatives was important for the mourning and bereavement processes. This emotional aspect was more relevant to the normal, non-pathological grief and loss processes than to complicated grief processes. Support from their dying relatives' treatment/care team was highly relevant to the mourning process, but the visiting relatives often lacked information about additional resources such as psychologists or pastoral care professionals or had limited access to them.

Losing a Close Friend or Family Member Due to COVID-19 and Mental Health among LGBTQ Youth

This study examines the association between having lost a close friend or family member to COVID-19 and mental health outcomes among lesbian, gay, bisexual, transgender, or queer (LGBTQ) youth. Data come from 33,993 respondents in the United States, ages 13 to 24, who completed an online survey of LGBTQ youth mental health. Multivariate logistic regression was used to determine the adjusted odds of recent anxiety, depression, considering, or attempting suicide in the past year based on whether or not the youth reported having lost a close friend or family member to COVID-19. Among the full sample, experiences of COVID-19 loss were associated with recent anxiety (adjusted odds ratio (aOR) = 1.29, 95% confidence interval (CI) = 1.20-1.40), recent depression (aOR = 1.23, 95% CI [1.15, 1.32]), seriously considering suicide in the past year (aOR = 1.22, 95% CI (1.14, 1.30)), and attempting suicide in the past year (aOR = 1.55, 95% CI (1.41, 1.69)). These findings highlight the urgent need for investment in low-barrier, affirming mental health services for LGBTQ youth who have experienced COVID-19 loss to support their grief, overall mental health, and healthy development.

A Psychometric Analysis of the Spanish Version of the Grief Impairment Scale: A Screening Tool of Biopsychosocial Grief-Related Functional Impairment in a Salvadoran Sample

The objective of this study was to translate and psychometrically evaluate a Spanish version of the Grief Impairment Scale (GIS) using a sample of bereaved adults from El Salvador (N = 579). The results confirm the unidimensional structure of the GIS, and solid reliability, item characteristics, and criterion-related validity, where the GIS scale significantly and positively predicts depression. However, this instrument only showed evidence of configural and metric invariance between different sex groups. Overall, these results support the Spanish version of the GIS as a psychometrically sound screening tool for health professionals and researchers to use in their clinical work.

Pandemic grief in El Salvador: factors that predict dysfunctional grief due to a COVID-19 death among Salvadoran adults

Thousands of people have died of COVID-19 in El Salvador. However, little is known about the mental health of those who are mourning the loss of a loved one to COVID-19. Therefore, the objective of this study was to examine the dysfunctional grief associated with COVID-19 death among Salvadoran adults. A sample of 435 Salvadorans (M = 29 years; SD = 8.75) who lost a family member or loved one to COVID-19 completed a digital survey using the Google Forms platform, during April 2 and 28, 2022. The results revealed that 35.1% reported clinically elevated symptoms of dysfunctional grief and among those mourners, and 25.1% also exhibited clinical levels of coronavirus anxiety. A binary logistic regression revealed that predictor variables such as COVID-19 anxiety (p = .003), depression (p = .021), and COVID-19 obsession (p = .032) were significant (χ² = 84.31; Nagelkerke R² = .242) and predict a 24.2% chance of dysfunctional bereavement.

Differences in Functional Level and Central Symptom of Network Structures in the Patients Seeking Treatment for Panic Disorder Before and During the COVID-19 Pandemic

OBJECTIVE

Mental health problems such as anxiety, panic, and depression have been exacerbated by the coronavirus disease-2019 (COVID-19). This study aimed to compare the symptom severities and overall function before and during the COVID-19 pandemic among patients with panic disorder (PD) seeking treatment compared to healthy controls (HCs).

METHODS

Baseline data were collected from the two groups (patients with PD and HCs) in two separate periods: before COVID-19 (Jan 2016-Dec 2019) and during COVID-19 (Mar 2020-Jul 2022). A total 453 participants (before COVID-19: 246 [139 patients with PD and 107 HCs], during COVID-19: 207 [86 patients with PD and 121 HCs]) was included. Scales for panic and depressive symptoms and overall function were administered. Additionally, network analyses were performed to compare the two groups within the patients with PD.

RESULTS

The results of two-way analysis of variance analyses showed that patients with PD enrolled during COVID-19 showed higher levels of interoceptive fear and lower overall functioning. In addition, a network comparison test revealed that a significantly high strength and expected influence for agoraphobia and avoidance in patients with PD during COVID-19.

CONCLUSION

This study suggested that the overall function could have worsened, and the importance of agoraphobia and avoidance as a central symptom may have increased in patients with PD seeking treatment during COVID-19.

Associations between Mental Health and COVID-19 Status among 18- and 19-Year-Old Adolescents: A Multi-Country Study

The aim of this study was to describe the mental health status of 18- and 19-year-old adolescents who were infected or affected by COVID-19 during the first wave of the COVID-19 pandemic. This was a secondary analysis of a dataset collected from 152 countries between July and December 2020. Dependent variables were anxiety, depression, and post-traumatic stress symptoms. The independent variable was COVID-19 status (tested positive for COVID-19, had COVID-19 symptoms but did not test, had a close friend who tested positive for COVID-19, knew someone who died from COVID-19). Three multivariable logistic regression analyses were conducted to determine the associations between the dependent and independent variables while adjusting for confounding variables (sex—male, female, and country income level). Data of 547 participants were extracted, and 98 (17.9%) had experienced depression, 130 (23.8%) had experienced anxiety, and 219 (40.0%) had experienced post-traumatic stress symptoms. Knowing someone who died from COVID-19 was associated with significantly lower odds of having post-traumatic stress symptoms (AOR: 0.608). Having COVID-19 symptoms but not getting tested was associated with significantly higher odds of having anxiety symptoms (AOR: 2.473). Results indicate diverse mental health responses among adolescents aged 18–19-years old as a sequela of COVID-19. This needs to be studied further.

A Phenomenological and Clinical Description of Pandemic Grief: How to Adapt Bereavement Services?

Background

Some studies suggest that individuals having lost a loved one during the COVID-19 pandemic report higher levels of grief reactions than people bereaved from natural causes. Little is known about the lived and subjective experience of individuals who lost a loved one under confinement measures.

Aim

This research aims to provide a phenomenological description of pandemic grief (PG) that can be useful in clinical settings and bereavement services.

Methods

Seventy-six qualitative phenomenological interviews have been conducted with 37 individuals who have lost a loved one during the first wave of the pandemic. Interpretative phenomenological analysis was performed following Tracy's criteria for rigorous qualitative research.

Results

The experience of PG comprises clinical manifestations and can be described as "a type of grief occurring in the context of a pandemic, where applicable public health measures have precedence over end of life and caregiving practices as well as funeral rituals, overshadowing the needs, values, and wishes of the dying individuals and those who grieve them."

Discussion/Conclusion

This study is the first to provide a phenomenological and experiential understanding of PG. Our phenomenological description can be helpful in clinical settings such as bereavement services within palliative care teams.

The Many Faces of Grief: A Systematic Literature Review of Grief During the COVID-19 Pandemic

Coronavirus disease 2019 (COVID-19) pandemic has halted life all around the world. The disease, along with quarantine, social distancing, unemployment, and displacement, has led to myriad losses. There is a rising concern for the epidemic of grief that can result from these multiple losses. The present study aimed to investigate how grief is understood and discussed in the extant literature during the COVID pandemic. A systematic literature review was conducted using PsycArticles, Web of Science, and Scopus databases. The qualitative synthesis of 33 articles indicates that grief can be manifested at various levels such as grief for self, relational grief, collective grief, and ecological grief. Another theme emphasizes some of the factors that could intensify the grief process leading to prolonged grief disorder. A third theme relates to the focus of grief processes as experienced by individuals in different developmental periods from childhood to senescence. The study contributes theoretically by expanding our perception and understanding of varied forms of grief.

Factors Associated With Higher Levels of Grief and Support Needs Among People Bereaved During the Pandemic: Results from a National Online Survey

We identified factors associated with higher levels of grief and support needs among 711 people bereaved during the COVID-19 pandemic in the UK (deaths 16 March 2020-2 January 2021). An online survey assessed grief using the Adult Attitude to Grief (AAG) scale, which calculates an overall index of vulnerability (IOV) (range 0-36), and practical and emotional support needs in 13 domains. Participants' mean age was 49.5 (SD 12.9); 628 (88.6%) female. Mean age of deceased 72.2 (SD 16.1). 311 (43.8%) deaths were from confirmed/suspected COVID-19. High overall levels of grief and support needs were observed; 28.2% exhibited severe vulnerability (index of vulnerability ≥24). Grief and support needs were higher for close relationships with the deceased (vs. more distant) and reported social isolation and loneliness (p < 0.001), and lower when age of deceased was above 40-50. Other associated factors were place of death and health professional support post-death (p < 0.05).

Last Honors and Life Experiences of Bereaved Families in the Context of COVID-19 in Kashmir: A Qualitative Inquiry About Exclusion, Family Trauma, and Other Issues

This study examined the changing character of the last honours of those who died of COVID-19 in Kashmir and the life experiences of the families of the deceased. A semi-structured interview schedule was used to collect information from 21 participants. Using qualitative data analysis approaches, five key themes were identified vis-à-vis the impact of COVID-19 on burial rituals and customs; effects on bereaved families, shades of grief, bereavement care, community response, and coping with loss. Based on examining the pandemic-induced changes related to customs and rituals around death, the study found that the bereaved family members were in danger of marginalization, economic burdens, psychological traumas, and overall reduced quality of life. This study would be a credible addition to the existing literature on death practices as there is a shortage of research on funeral rituals during the post-pandemic period in Kashmir.

Parental perspectives on the grief and support needs of children and young people bereaved during the COVID-19 pandemic: qualitative findings from a national survey

Background

During the COVID-19 pandemic, many children and young people have experienced the death of close family members, whilst also facing unprecedented disruption to their lives. This study aimed to investigate the experiences and support needs of bereaved children and young people from the perspective of their parents and guardians.

Methods

We analysed cross-sectional qualitative free-text data from a survey of adults bereaved in the UK during the pandemic. Participants were recruited via media, social media, national associations and community/charitable organisations. Thematic analysis was conducted on free text data collected from parent/guardian participants in response to a survey question on the bereavement experiences and support needs of their children.

Results

Free-text data from 104 parent/guardian participants was included. Three main themes were identified: the pandemic-related challenges and struggles experienced by children and young people; family support and coping; and support from schools and services. Pandemic-challenges include the impacts of being separated from the relative prior to their death, isolation from peers and other family members, and disruption to daily routines and wider support networks. Examples were given of effective family coping and communication, but also of difficulties relating to parental grief and children’s existing mental health problems. Schools and bereavement organisations’ provision of specialist support was valued, but there was evidence of unmet need, with some participants reporting a lack of access to specialist grief or mental health support.

Conclusion

Children and young people have faced additional strains and challenges associated with pandemic bereavement. We recommend resources and initiatives that facilitate supportive communication within family and school settings, adequate resourcing of school and community-based specialist bereavement/mental health services, and increased information and signposting to the support that is available.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01066-4.

Postvention as Prevention: Coping with Loss at School

Many Pre-K through grade 12 (PK-12) students have experienced traumatic events throughout the pandemic in a myriad of ways including the death of family members and peers, loss of social interaction and increased violence at home. The consequences can be traumatic and manifest themselves in fear, anxiety, anger, isolation, and loneliness. Too often this leads to depression, anxiety, grief, substance use disorders, post-traumatic stress disorder, suicidal ideation and even suicides. This study assesses the impact of an innovative virtual human role-play simulation that prepares PK-12 educators, administrators, and school staff to respond to a student death in the school community by creating communities of support to help manage traumatic loss. The simulation addresses crisis response planning, postvention plans, and provides learners with role-play practice in using evidence-based motivational interviewing communication strategies in conversations with students and colleagues after the occurrence of a death. The sample consisted of educators and staff who were recruited from geographically dispersed areas across the US between January 2021 through December 2021. Matched sample t-tests and ANOVAs were used to assess quantitative data, and a qualitative analysis software, MAXQDA, was used to assess open-ended response data. Results show statistically significant increases in school personnel's preparedness and self-efficacy to recognize signs of trauma in their students and colleagues, and to approach them to talk about concerns and, if necessary, make a referral to support services. Simulations such as this hold tremendous potential in teaching educators how address trauma due to a student death.

Measurement of Risk Factors Associated With bereavement Severity and Deterioration by COVID-19: A Spanish Validation Study of the Pandemic Grief Risk Factors

The present study translated and evaluated the psychometric evidence of the Pandemic Grief Risk Factors (PGRF) in a sample of 363 people from the general population of Peru who suffered the death of a loved one by COVID-19 (63-4% women and 36.6% men, where 78.5% were between 18 and 29 years old). The findings indicated that the PGRF is a unidimensional and reliable measure. The PGRF items can differentiate between individuals with different levels of risk factors and thus cover a wide range of the latent construct. Also, a greater sense of distress for each of the risk factors for pandemic grief is necessary to answer the higher response categories. Risk factors significantly and positively predict COVID-19-associated dysfunctional grief. The results indicated that the PGRF in Spanish is a measure with adequate psychometric properties to measure risk factors for pandemic grief.

Bereavement outcomes in family members of those who died in acute care hospitals before and during the first wave of COVID-19: A cohort study

BACKGROUND

The COVID-19 pandemic has caused millions of deaths worldwide, leading to symptoms of grief among the bereaved. Neither the burden of severe grief nor its predictors are fully known within the context of the pandemic.

AIM

To determine the prevalence and predictors of severe grief in family members who were bereaved early in the COVID-19 pandemic.

DESIGN

Prospective, matched cohort study.

SETTING/PARTICIPANTS

Family members of people who died in an acute hospital in Ottawa, Canada between November 1, 2019 and August 31, 2020. We matched relatives of patients who died of COVID (COVID +ve) with those who died of non-COVID illness either during wave 1 of the pandemic (COVID -ve) or immediately prior to its onset (pre-COVID). We abstracted decedents' medical records, contacted family members >6 months post loss, and assessed grief symptoms using the Inventory of Complicated Grief-revised.

RESULTS

We abstracted data for 425 decedents (85 COVID +ve, 170 COVID -ve, and 170 pre-COVID), and 110 of 165 contacted family members (67%) consented to participate. Pre-COVID family members were physically present more in the last 48 h of life; the COVID +ve cohort were more present virtually. Overall, 35 family members (28.9%) had severe grief symptoms, and the prevalence was similar among the cohorts (p = 0.91). Grief severity was not correlated with demographic factors, physical presence in the final 48 h of life, intubation, or relationship with the deceased.

CONCLUSION

Severe grief is common among family members bereaved during the COVID-19 pandemic, regardless of the cause or circumstances of death, and even if their loss took place before the onset of the pandemic. This suggests that aspects of the pandemic itself contribute to severe grief, and factors that normally mitigate grief may not be as effective.

Grief Impairment Scale: A biopsychosocial measure of grief-related functional impairment

Though most mourners are resilient, a minority of the bereaved experience disabling grief accompanied by clinically significant impairment in important areas of functioning. Although impairment measures exist, they have notable limitations in the context of bereavement. Therefore, the objective of this study was to develop and evaluate the Grief Impairment Scale (GIS), which was designed to identify the impact of grief on biopsychosocial functioning. The resulting 5-item scale, which was based on 363 adults who are struggling with grief, demonstrated solid reliability, factorial validity, and convergent and divergent validity with correlations with measures of impairment, prolonged grief, and psychological distress. The GIS also measures grief-related functioning equivalently across demographic groups and satisfactorily discriminates between persons with and without impairment using an optimized cut score of ≥ 9 (79% sensitivity and 74% specificity). These results provide preliminary support for the GIS as a flexible tool for clinical research and practice.

Pandemic-Related Stress May Be Associated with Symptoms of Poor Mental Health Among African Americans

The COVID-19 pandemic has disproportionately affected African Americans and has been a significant source of stress for this population due to increased economic hardship and social isolation. This study characterized the associations between COVID-19 vulnerability (e.g., contracting the illness or losing a loved one), pandemic-related stress, and symptoms of poor mental health among African Americans. The study sample included African Americans (N = 304) who responded to an online survey. Symptoms of poor mental health were assessed using the PHQ-4, which assessed symptoms of depression and anxiety. Vulnerability to COVID-19 was measured via self-report in three ways: (1) personal vulnerability, (2) family vulnerability, and (3) community vulnerability (i.e., friends, neighbors, and co-workers). Pandemic-related stress was measured by asking participants to rate how difficult it has been to access essential resources and services, manage finances, and plan or attend social events since March 13, 2020. Data were analyzed using multivariable logistic regression. Results showed that COVID-19 vulnerability was not associated with symptoms of depression or anxiety, but pandemic-related stress was consistently associated with symptoms of poor mental health. Study findings highlight the need to monitor and intervene on pandemic-related stress to prevent further psychological distress within this vulnerable and underserved population.

COVID-19, economic problems, and family relationships in eight Middle East and North African countries

OBJECTIVE

The aim was to assess the reported family relationships during the COVID-19 pandemic and the association between these relationships and individual, interpersonal, and country-level income in eight Middle East and North Africa (MENA) countries.

BACKGROUND

COVID-19 causes fear of infection, loss of loved ones, and economic problems that may affect family relationships.

METHODS

Data were collected from eight MENA countries using an online survey (July-August 2020). The dependent variable was change in family relationship during COVID-19, and the independent variables were individual, interpersonal, and country-level factors represented by sociodemographic factors, COVID-19 status, financial impact (whether participants lost or had reduced wages) and country income. Multilevel logistic regression analysis was conducted.

RESULTS

There were 1854 responses, mean (SD) age of 30.6 (9.9) years, 65.8% were female, 3.4% tested COVID-19 positive, and 20.8% reported lost/reduced wages. Family relationships were more likely to improve or remain unchanged (84.3%) for participants who had a history of COVID-19 (adjusted odds ratio [AOR] = 3.54, 95% confidence interval [CI]: [1.25, 10.01]). However, family relationships were more likely to not improve for those who knew someone who died of COVID-19 (AOR = 0.76, 95% CI [0.58, 0.99]) and those with lost/reduced wages (AOR = 0.69, 95% CI [0.52, 0.94]).

CONCLUSION

Family relationship improved or remained unchanged for those who tested positive for COVID-19 and did not improve for those who lost wages or lost someone due to COVID-19.

IMPLICATIONS

Policy makers should develop strategies to provide social and financial support to employees to reduce the losses and adverse social impact caused by the pandemic.

Examining the Impact of COVID-19 Experiences on Reported Psychological Burden Increase in Older Persons: The Effects of Illness Severity and Social Proximity

Previous findings have provided indications that experience of COVID-19 illness of self and other affect mental health unfavorably. However, prior studies do not satisfactorily differentiate according to severity of COVID-19 illness or social proximity, which are both hypothesized to be relevant factors for increased psychological burden. This study provides an in-depth examination of the impact of Covid-19 experience of self and other on mental health, considering illness severity as well as proximity to the infected person (self, close and distant network). It used data on an older population (50+ years) from 28 European countries (n > 40 000 persons) surveyed in summer of 2021 using the Survey of Health and Retirement in Europe (SHARE). Aside from bivariate analyses, a logistic regression model was computed to test the effects of illness severity by personal proximity over and above other stressors of life in the pandemic. Severity of illness was shown to be a contributor to psychological burden increase with the strongest effects among persons who reported own illness experiences or experiences in the close network. Regression analysis confirmed the impact of severe Covid-19 experience in self, close and distant relations. Moreover, even a less severe course impacted burden unfavorably when experienced in the own person and more distant relations. These results prove troubling. Psychological burden is impacted by infection, with experiences in self or close persons being strongest, while even 'lighter' experiences in the distant network also have an unfavorable effect, emphasizing the need to gain control of the present pandemic.

Bereavement in Pakistan during the COVID-19 pandemic: Psychometric analysis of the Pandemic Grief Scale-Urdu Version (PGS-UV)

With nearly 4 million deaths worldwide, COVID-19 has resulted in a great loss of life. For many of the bereaved, the grieving process has been especially difficult due to COVID-19 spatial distancing procedures and the traumatic circumstances of this particular form of loss. Consequently, a large number of the world's bereaved are experiencing dysfunctional levels of grief. To assess such grief, the Pandemic Grief Scale (PGS) was created to identify those affected who may benefit from professional support. This study aimed to psychometrically analyze the properties of the Urdu version of the scale, among a sample of 272 Pakistanis who lost a loved one to COVID-19 from March to June 2021. Results revealed that the scale was found to be a reliable and valid tool for assessing dysfunctional pandemic grief for both men and women. However, unique gender differences were found. Additional research should further confirm the psychometric properties of the PGS on other culturally diverse samples.

It's like standing in front of a prison fence - Dying during the SARS-CoV2 pandemic: A qualitative study of bereaved relatives' experiences

BACKGROUND

Since the onset of the SARS CoV2 pandemic, protective and isolation measures had a strong impact on the care and support provided to seriously ill and dying people at the end-of-life.

AIM

Exploring bereaved relatives' experiences of end-of-life care during the SARS-CoV2 pandemic.

DESIGN

Qualitative interview study with bereaved relatives.

PARTICIPANTS

Thirty-two relatives of patients who died during the pandemic, regardless of infection with SARS-CoV2.

RESULTS

Three core categories were identified: needs, burden and best practice. Relatives wished for a contact person responsible for providing information on the medical and mental condition of their family members. The lack of information, of support by others and physical closeness due to the visiting restrictions, as well as not being able to say goodbye, were felt as burdens and led to emotional distress. However, case-by-case decisions were made and creative ways of staying in touch were experienced positively.

CONCLUSIONS

Our results indicate that the strong need for closeness when a family member was dying could not be met due to the pandemic. This led to suffering that can be prevented. Visits need to be facilitated by making considered decisions on a case-by-case basis. For easy communication with relatives, approaches should be made by healthcare professionals and support for virtual communication should be offered. Furthermore, the results of the study can help to implement or develop ideas to enable dignified farewells even during pandemics.

Risk factors associated with poorer experiences of end-of-life care and challenges in early bereavement: Results of a national online survey of people bereaved during the COVID-19 pandemic

BACKGROUND

Experiences of end-of-life care and early bereavement during the COVID-19 pandemic are poorly understood.

AIM

To identify clinical and demographic risk factors for sub-optimal end-of-life care and pandemic-related challenges prior to death and in early bereavement, to inform clinical practice, policy and bereavement support.

DESIGN

Online national survey of adults bereaved in the UK (deaths between 16 March 2020 and 2 January 2021), recruited via media, social media, national associations and organisations.

SETTING/PARTICIPANTS

711 participants, mean age 49.5 (SD 12.9, range 18-90). 628 (88.6%) were female. Mean age of the deceased was 72.2 (SD 16.1, range miscarriage to 102 years). 311 (43.8%) deaths were from confirmed/suspected COVID-19.

RESULTS

Deaths in hospital/care home increased the likelihood of poorer experiences at the end of life; for example, being unable to visit or say goodbye as wanted (p < 0.001). COVID-19 was also associated with worse experiences before and after death; for example, feeling unsupported by healthcare professionals (p < 0.001), social isolation/loneliness (OR = 0.439; 95% CI: 0.261-0.739), and limited contact with relatives/friends (OR = 0.465; 95% CI: 0.254-0.852). Expected deaths were associated with a higher likelihood of positive end-of-life care experiences. The deceased being a partner or child also increased the likelihood of positive experiences, however being a bereaved partner strongly increased odds of social isolation/loneliness, for example, OR = 0.092 (95% CI: 0.028-0.297) partner versus distant family member.

CONCLUSIONS

Four clear risk factors were found for poorer end-of-life care and pandemic-related challenges in bereavement: place, cause and expectedness of death, and relationship to the deceased.

Utilization of Palliative Care for Patients with COVID-19 and Acute Kidney Injury during a COVID-19 Surge

BACKGROUND AND OBJECTIVES

AKI is a common complication of coronavirus disease 2019 (COVID-19) and is associated with high mortality. Palliative care, a specialty that supports patients with serious illness, is valuable for these patients but is historically underutilized in AKI. The objectives of this paper are to describe the use of palliative care in patients with AKI and COVID-19 and their subsequent health care utilization.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a retrospective analysis of New York University Langone Health electronic health data of COVID-19 hospitalizations between March 2, 2020 and August 25, 2020. Regression models were used to examine characteristics associated with receiving a palliative care consult.

RESULTS

Among patients with COVID-19 (n=4276; 40%), those with AKI (n=1310; 31%) were more likely than those without AKI (n=2966; 69%) to receive palliative care (AKI without KRT: adjusted odds ratio, 1.81; 95% confidence interval, 1.40 to 2.33; P<0.001; AKI with KRT: adjusted odds ratio, 2.45; 95% confidence interval, 1.52 to 3.97; P<0.001), even after controlling for markers of critical illness (admission to intensive care units, mechanical ventilation, or modified sequential organ failure assessment score); however, consults came significantly later (10 days from admission versus 5 days; P<0.001). Similarly, 66% of patients initiated on KRT received palliative care versus 37% (P<0.001) of those with AKI not receiving KRT, and timing was also later (12 days from admission versus 9 days; P=0.002). Despite greater use of palliative care, patients with AKI had a significantly longer length of stay, more intensive care unit admissions, and more use of mechanical ventilation. Those with AKI did have a higher frequency of discharges to inpatient hospice (6% versus 3%) and change in code status (34% versus 7%) than those without AKI.

CONCLUSIONS

Palliative care was utilized more frequently for patients with AKI and COVID-19 than historically reported in AKI. Despite high mortality, consultation occurred late in the hospital course and was not associated with reduced initiation of life-sustaining interventions.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_02_24_CJN11030821.mp3.

Bereavement during the COVID-19 Pandemic: Impact on Coping Strategies and Mental Health

The COVID-19 coronavirus has caused 5.4 million deaths worldwide, including over 800,000 deaths in the United States (as of December 2021). In addition to these staggering statistics, an even greater number of individuals have died from other causes during the COVID-19 pandemic. As a result, a large portion of the global population has faced bereavement during the COVID-19 pandemic and resulting quarantine. The often rapid and unexpected nature of COVID-19 deaths and the presence of pandemic-related stressors and living restrictions make it more difficult for individuals bereaved during the pandemic to implement effective strategies for coping with the loss compared to non-pandemic periods. Quarantine-related constraints (e.g., social distancing, availability of and access to resources) impede coping strategies that have been found to be adaptive after a loss, such as supportive (e.g., seeking emotional and instrumental support) and active (e.g., problem-focused and cognitive reframing) coping, and they augment avoidant strategies (e.g., substance use, denial, and isolation) that have been found to be maladaptive. Poorer mental health outcomes (including prolonged grief disorder; PGD) have been associated with less healthy coping. This article reviews research findings regarding bereavement during the COVID-19 pandemic, discusses the effects of pandemic-related stressors on bereavement coping strategies, and proposes how different types of coping during the pandemic may account for the poorer mental health outcomes described in recent reports. Interventions for promoting adaptive coping strategies and minimizing maladaptive coping strategies are also outlined.

COVID-19, natural, and unnatural bereavement: comprehensive comparisons of loss circumstances and grief severity

BACKGROUND

Acute grief appears more severe after COVID-19 deaths than natural deaths. Prolonged grief disorder (PGD) also appears prevalent following COVID-19 deaths. Researchers hypothesize that specific loss characteristics and pandemic-related circumstances may precipitate more severe grief following COVID-19 deaths compared to (other) natural deaths. Systematic research on these hypotheses may help identify those most at risk for severe grief reactions, yet it is scant.

OBJECTIVE

To compare loss characteristics, loss circumstances, and grief levels among people bereaved due to COVID-19, natural, and unnatural causes.

METHODS

Adults bereaved through COVID-19 (n = 99), natural causes (n = 1006), and unnatural causes (n = 161) completed an online survey. We administered self-report measures of demographic variables (i.e., age, gender), loss characteristics (i.e., time since loss, relationship with the deceased, intensive care admission, expectedness of death), loss circumstances (i.e., saying goodbye appropriately, COVID-19 infection, quarantine, financial setbacks, social support satisfaction, altered funeral arrangements, funeral satisfaction), and prolonged grief symptoms.

RESULTS

COVID-19 deaths (vs. other deaths) more often were parental deaths and less often child deaths. COVID-19 deaths (vs. natural deaths) were more often unexpected and characterized by an inability to say goodbye appropriately. People bereaved due to COVID-19 (vs. other deaths) were more often infected and quarantined. COVID-19 deaths (vs. other deaths) more often involved intensive care admission and altered funeral arrangements. COVID-19 deaths yielded higher grief levels than natural deaths (but not unnatural deaths). Expectedness of the death and the inability to say goodbye appropriately explained this effect.

CONCLUSIONS

Bereavement due to COVID-19 is characterized by a unique set of loss characteristics and circumstances and elevated grief levels. Improving opportunities to say goodbye before and after death (e.g., by means of rituals) may provide an important means to prevent and reduce severe grief following COVID-19 deaths.

HIGHLIGHTS

COVID-19 deaths have unique loss characteristics and circumstances and elicit more severe grief than natural deaths.Death expectedness and the ability to say goodbye appropriately appear important in understanding, preventing and treating grief following COVID-19 deaths.

Psychosocial factors associated with complicated grief in caregivers during COVID-19: Results from a preliminary cross-sectional study

The COVID-19 pandemic has changed how end-of-life ceremonies are performed, affecting grief processing and bereavement experiences. In this study, caregivers of patients who died with COVID-19 during the first wave of the pandemic were asked to complete an online survey designed to detect psychosocial factors associated with the presence of complicated grief (CG). The results show CG present in 48.4% of caregivers. The marital and cohabitant status during lockdown, the perceived sense of guilt and depression levels were significantly associated with the presence of CG, whereas attendance at the funeral and social support were found to be significant protective factors.

Six Month Trajectories of COVID-19 Experiences and Associated Stress, Anxiety, Depression, and Impairment in American Adults

Background

The COVID-19 pandemic has had a profound impact on health and well-being worldwide. There is increasing research seeking to better understand the psychological impact of COVID-19 experiences. However, this research has largely been limited in size and scope.

Methods

The present study examined longitudinal trajectories of COVID-19 experiences on COVID-19 related stress, anxiety, depression, and functional impairment in a convenience sample of 788 American adults recruited through MTURK. Data was collected across four waves between March and October 2020.

Results

COVID-19 experiences were consistently associated with higher odds of probable anxiety and depression diagnoses. COVID-19 related stress also predicted large proportions of variance in anxiety, depression, and functional impairment in latent variable analyses. Overtime, the results indicated that while anxiety and depression decreased, functional impairment remained stable.

Conclusions

These findings highlight the emotional toll of the COVID-19 pandemic over time. Decreases in COVID-19 related stress, anxiety, and depression over time may reflect resiliency among respondents. Importantly, these results underscore the continued need for mental health services as associations between COVID-19 and functional impairment remained consistent over time.

Children's palliative care education and training: developing an education standard framework and audit

BACKGROUND

The need to align the range of guidance and competencies concerning children's palliative care and develop an education framework have been recommended by a UK All-Party Parliament Group and others. In response to these recommendations the need for a revised children's palliative care competency framework was recognized. A Children's Palliative Care Education and Training Action Group, comprising champions in the field, was formed across UK and Ireland in 2019 to take this work forward. Their aim was to agree core principles of practice in order to standardize children's palliative care education and training.

METHODS

Over four meetings the Action Group reviewed sources of evidence and guidance including palliative care competency documents and UK and Ireland quality and qualification frameworks. Expected levels of developing knowledge and skills were then agreed and identified competencies mapped to each level. The mapping process led to the development of learning outcomes, local indicative programme content and assessment exemplars.

RESULTS

Four sections depicting developing levels of knowledge and skills were identified: Public Health, Universal, Core, Specialist. Each level has four learning outcomes: Communicating effectively, Working with others in and across various settings, Identifying and managing symptoms, Sustaining self-care and supporting the well-being of others. An audit tool template was developed to facilitate quality assurance of programme delivery. The framework and audit tool repository is on the International Children's Palliative Care Network website for ease of international access.

CONCLUSIONS

The framework has received interest at UK, Ireland and International launches. While there are education programmes in children's palliative care this is the first international attempt to coordinate education, to address lay carer education and to include public health.

"Saying goodbye all alone with no close support was difficult"- Dying during the COVID-19 pandemic: an online survey among bereaved relatives about end-of-life care for patients with or without SARS-CoV2 infection

BACKGROUND

During the SARS-CoV2 pandemic, protection measures, as well as visiting restrictions, had a severe impact on seriously ill and dying patients and their relatives. The study aims to describe the experiences of bereaved relatives of patients who died during the SARS-CoV2 pandemic, regardless of whether patients were infected with SARS-CoV2 or not. As part of this, experiences related to patients' end-of-life care, saying goodbye, visiting restrictions and communication with the healthcare team were assessed.

METHODS

An open observational post-bereavement online survey with free text options was conducted with 81 bereaved relatives from people who died during the pandemic in Germany, with and without SARS-CoV2 diagnosis.

RESULTS

67/81 of the bereaved relatives were female, with a mean age of 57.2 years. 50/81 decedents were women, with a mean age of 82.4 years. The main underlying diseases causing death were cardiovascular diseases or cancer. Only 7/81 of the patients were infected with SARS-CoV2. 58/81 of the relatives felt burdened by the visiting restrictions and 60/81 suffered from pandemic-related stress. 10 of the patients died alone due to visiting restrictions. The burden for relatives in the hospital setting was higher compared to relatives of patients who died at home. 45/81 and 44/81 relatives respectively reported that physicians and nurses had time to discuss the patient's condition. Nevertheless, relatives reported a lack of proactive communication from the healthcare professionals.

CONCLUSIONS

Visits of relatives play a major role in the care of the dying and have an impact on the bereavement of relatives. Visits must be facilitated, allowing physical contact. Additionally, virtual contact with the patients and open, empathetic communication on the part of healthcare professionals is needed.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00023552).

Risk factors for dysfunctional grief and functional impairment for all causes of death during the COVID-19 pandemic: The mediating role of meaning

The COVID-19 pandemic, coupled with significant social changes due to legislative and public health requirements, has changed the way in which people experience grief. We examined whether dysfunctional grief symptoms, disrupted meaning, risk factors, and functional impairment differed between people bereaved from COVID-19 and from other natural or violent causes in this same period. A sample of 409 participants (67.73% male; M = 37.54 years) completed an online survey in June 2021. There were no statistically significant differences between the three groups on any of the outcome variables; all three groups manifested clinical levels of functional impairment equal to or greater than bereaved groups diagnosed with complicated or prolonged grief disorder prior to the pandemic. Disrupted meaning partially mediated the relationship between risk factors on the one hand and functional impairment and dysfunctional grief symptoms on the other. Findings indicate that deaths during COVID-19, rather than deaths from COVID-19, may precipitate symptoms of significant clinical concern.

Are public health measures and individualised care compatible in the face of a pandemic? A national observational study of bereaved relatives' experiences during the COVID-19 pandemic

BACKGROUND

COVID-19 public health restrictions have affected end-of-life care experiences for dying patients and their families.

AIM

To explore bereaved relatives' experiences of quality of care and family support provided during the last days of life; to identify the impact of factors associated with perceived support.

DESIGN

A national, observational, open online survey was developed and disseminated via social media, public fora and professional networks (June-September 2020). Validated instruments and purposively designed questions assessed experiences. Analysis used descriptive statistics, logistic regression and thematic analysis of free-text responses.

PARTICIPANTS

Individuals (⩾18 years) who had experienced the death of a relative/friend (all care settings) within the United Kingdome during the COVID-19 pandemic.

RESULTS

Respondents (n = 278, mean 53.4 years) tended to be female (n = 216, 78%); over half were 'son/daughter' (174, 62.6%) to the deceased. Deceased individuals (mean 81.6 years) most frequently died in their 'usual place of care' (n = 192, 69.3%). Analysis established five conceptual themes affecting individualised care: (1) public health restrictions compounding the distress of 'not knowing'; (2) disparate views about support from doctors and nurses; (3) challenges in communication and level of preparedness for the death; (4) delivery of compassionate care; (5) emotional needs and potential impact on grief. Male respondents (OR 2.9, p = 0.03) and those able to visit (OR 2.2, p = 0.04) were independently associated with good perceptions of family support.

CONCLUSION

Despite public health restrictions, individualised care can be enabled by proactive, informative communication; recognising dying in a timely manner and facilitating the ability to be present before death.

Assessment of Dysfunctional Grief due to Death from COVID-19 in Peru: Adaptation and Validation of a Spanish Version of the Pandemic Grief Scale

This study evaluated the psychometric properties of the Pandemic Grief Scale (PGS), using Classical Test Theory (CTT) and Item Response Theory (IRT) methods, in a sample of 458 people who have suffered the loss of a loved one due to the COVID-19 pandemic. The Pandemic Grief Scale, Patient Health Questionnaire-2 (PHQ-2), the two-item Generalized Anxiety Disorder Scale (GAD-2), and a single item on suicidal ideation were used. The unidimensional model had good fit and reliability; furthermore, convergent validity was demonstrated based on the relationships between dysfunctional grief, anxiety symptoms, depression, and suicidal ideation. Additionally, a higher presence of dysfunctional grief is required to answer using the higher response categories. The evidence of validity and reliability of the PGS in its Spanish version, using traditional and modern methods, is confirmed in Peru.

Correlates of Mental Health After COVID-19 Bereavement in Mainland China

CONTEXT

Pioneering empirical studies show that people bereaved due to COVID-19 experience elevated acute grief, posttraumatic stress, anxiety, and depressive symptom levels, which relate to functional impairment. However, studies focused on Western samples and multivariate analyses of relations between potential risk factors and mental health in this population are lacking.

OBJECTIVES

To assess the mental health of Chinese adults bereaved due to COVID-19. To elucidate the associations of demographic and loss-related characteristics with mental health after COVID-19 bereavement.

METHODS

Four hundred twenty-two Chinese adults (56% male; Mean age: 32.73 years) recently bereaved due to COVID-19 completed an online survey. Demographic and loss-related characteristics and prolonged grief, posttraumatic stress, anxiety, and depressive symptoms were assessed.

RESULTS

Clinically relevant prolonged grief (49%, n = 207), posttraumatic stress (22%, n = 92), depressive (70%; n = 294), and anxiety symptoms (65%; n = 272) were reported by a substantial group of participants. In four multiple regressions predicting each mental health indicator, Fs(15,406) = 5.08-7.74, Ps < 0.001, loss-characteristics (i.e., a shorter time since loss, βs =  -.12-.11, loss of a first-degree relative, βs =  .18-.37) and subjective loss experiences (i.e., feeling traumatized by the loss, βs =  .13-.18, or a close and/or conflictual relation with the deceased, βs =  .12-.23) related most consistently to mental health problems.

CONCLUSION

Many Chinese adults bereaved due to COVID-19 experience severe mental health problems. The recent loss of first-degree relatives, feeling traumatized by the loss, and having a close and/or conflictual relationship with the deceased may elevate risk for these mental health problems, which could require indicated psychological treatment.

Beyond a traumatic loss: The experiences of mourning alone after parental death during COVID-19 pandemic

Millions of adolescents around the world lost their loved ones due to the COVID-19 pandemic; at the same time, health protocols in many countries do not allow mourners to practice their familiar rituals around death and dying. This study explored the experience of 15 Iranian adolescents who had lost their parent(s) during the pandemic through a phenomenological approach. Two main themes including distress in a shattered life and crisis in crisis were extracted from the interviews. Findings highlight the importance of immediate and alternative ways of support for adolescents who lost their parents during the pandemic.

Commentary on: A Call to Action: Facing the Shadow Pandemic of Complicated Forms of Grief

In this contribution, we respond to a letter in Omega: Journal of Death and Dying by Doka. Signatories of this letter to the President of the United States convey concerns that deaths during the COVID-19 pandemic will lead to a higher prevalence of severe and persistent grief, i.e., prolonged grief disorder. We support their call to action to direct government funding to helping those who develop this condition during the COVID-19 pandemic. However, we think that concerns about prolonged grief disorder during the pandemic can be more convincingly conveyed by firmly embedding such concerns within scientific literature. Therefore, we highlight prior scientifically informed opinion pieces from various international researchers who voiced similar concerns in the early months of the pandemic. Additionally, we provide an overview of pioneering empirical research elucidating whether prolonged grief disorder and related mental health problems will become more prevalent during the pandemic.

Circumstances of the death and associated risk factors for severity and impairment of COVID-19 grief

This study examined the relationship between reactions of the bereaved to conditions of the pandemic and severity of their grief and levels of impairment. A total of 831 American adults who lost a loved one to COVID-19 responded to validated measures of dysfunctional grief and functional impairment, as well as items assessing unique complications associated with the pandemic (e.g. resentment toward doctors, social isolation). In combination, circumstantial risk factors accounted for 59% of the variance in social impairment and fully 71% of the variance in pandemic grief, leading to the development of an inventory of Pandemic Grief Risk Factors (PGRF), which displayed a unified factor structure, high reliability and strong convergent validity. Implications for psychological screening and intervention for those bereaved by COVID-19 are briefly noted.

A qualitative study of bereaved relatives' end of life experiences during the COVID-19 pandemic

BACKGROUND

Meeting the needs of relatives when a family member is dying can help facilitate better psychological adjustment in their grief. However, end of life experiences for families are likely to have been deleteriously impacted by the COVID-19 crisis. Understanding how families' needs can be met during a global pandemic will have current/future relevance for clinical practice and policy.

AIM

To explore relatives' experiences and needs when a family member was dying during the COVID-19 pandemic.

DESIGN

Interpretative qualitative study using semi-structured interviews. Data were analysed thematically.

SETTING/PARTICIPANTS

A total of 19 relatives whose family member died during the COVID-19 pandemic in the United Kingdom.

RESULTS

In the absence of direct physical contact, it was important for families to have a clear understanding of their family member's condition and declining health, stay connected with them in the final weeks/days of life and have the opportunity for a final contact before they died. Health and social care professionals were instrumental to providing these aspects of care, but faced practical challenges in achieving these. Results are presented within three themes: (1) entering into the final weeks and days of life during a pandemic, (2) navigating the final weeks of life during a pandemic and (3) the importance of 'saying goodbye' in a pandemic.

CONCLUSIONS

Health and social care professionals can have an important role in mitigating the absence of relatives' visits at end of life during a pandemic. Strategies include prioritising virtual connectedness and creating alternative opportunities for relatives to 'say goodbye'.

The Utility of the Pandemic Grief Scale in Identifying Functional Impairment from COVID-19 Bereavement

Background: Meeting the needs of people bereaved by COVID-19 poses a substantial challenge to palliative care. The Pandemic Grief Scale (PGS) is a 5-item mental health screener to identify probable cases of dysfunctional grief during the pandemic. Objective: The PGS has strong psychometric and diagnostic features. The objective was to examine the incremental validity of the PGS in identifying mourners at risk of harmful outcomes. Design: A cross-sectional survey design involving sociodemographic questions and self-report measures of pandemic grief, generalized anxiety, depression, post-traumatic stress, separation distress, functional impairment, meaning-making difficulties, and substance use coping. Setting/Subjects: A sample of people bereaved through COVID-19 (N = 1065) in the United States. Results: Fully 56.6% of participants scored above the cut score of ≥7 on the PGS for clinically dysfunctional pandemic grief and 69.7% coped with their loss using drugs or alcohol for at least several days in past two weeks. PGS scores were not associated with time since loss. Hierarchical multiple regression models demonstrated that the PGS uniquely explained variance in functional impairment, meaning-making difficulties, and substance use coping, over relevant background factors, bereavement-related psychopathology, and separation distress. In the final model, the standardized regression coefficients for the PGS were 2-15 times larger than for the other competing measures in explaining each of the three outcomes. Conclusions: The findings underscore the clinical utility of this short and easy-to-use measure in identifying risk of deleterious outcomes across a range of functional and behavioral domains.