Complicated Grief During the pandemic: Strategies to deal with it

As of May 2022, around 6,274,323 have died from COVID-19 (World Health Organization, 2022). For each COVID-19 death, an estimated nine close bereavements are associated (Selman, et al., 2021; Albuquerque, Teixeira, & Rocha, 2021). Second wave of the pandemic was the worst yet, with the highest death rates. Especially, India saw a record breaking cases and deaths. Experiencing loss of loved ones; is in itself an overwhelming and painful experience; which can trigger mental health issues, if not dealt and coped with adaptively. But, experiencing loss during a pandemic, can be especially more painful.

Contents

1. Introduction

2. Impact on Healthcare Workers and their Immediate Family

3. Grief During the Pandemic

4. Disenfranchised Grief

5. COVID-19 Restrictions and Impact Summary

6. Prolonged Grief Disorder During the Pandemic

7. Children and Adolescent Grief During the Pandemic

8. Strategies to Deal with Grief

a. During Hospitalization: The power of Accompaniment.

b. After Death

c. Finding ways to grieve and creating rituals:

d. Anticipatory Grief

e. A Positive Psychology Approach

Introduction

Apart from primary loss, which involves death and major life transitions as a consequence of it (such as financial security loss etc.); there are secondary losses as well. Secondary losses can include, loss of certain needs the relationship was satisfying such as companionship, physical intimacy, affection etc. Another important secondary loss is emotional social support, that bereaved relatives receive in case of death; which is absent due to rules of the pandemic (banning social gatherings). Individuals may also experience stigmatized loss, for contracting and transmitting COVID-19; which can lead to alienation (Zhaia & Duc, 2020).

Patients also experience ambiguous loss, due to the quarantine and isolation measures; even though their immediate family is present for psychological support. Not being able to be present with them physically and being unable to support them through the illness can be especially painful for family members. Not being able to spend their last moments can weigh heavily on a person during the grieving process. Not getting a chance for a goodbye and spending last moments with them is a risk factor for poor bereavement outcomes (Selman, et al., 2021). Lack of proper burial rituals, funerals etc. can also lead to disenfranchised grief. Additionally, with the lack of social support systems, and other factors above can impair the grieving process and lead to prolonged grief disorder (Zhaia & Duc, 2020). In this article, we discuss what grieving during a pandemic feels like, the risk factors attached to the pandemic that leads to disenfranchised, complicated and prolonged grief, grieving among children, adolescents, and strategies and techniques that can be used to deal with overwhelming loss during the pandemic.

Impact on Healthcare Workers and their Immediate Family

The real heroes of the pandemic have been the frontline healthcare workers. They and their families have been the worst affected. Working with long hours without breaks, sometimes without proper protection on, without proper equipment due increased demand and its consequential inability to meet those demands; the whole healthcare system, doctors and nurses working on the frontlines has had a toll on their physical and mental health. And often times their motivation to continue working in such a high-risk situation for themselves, their families; have been largely altruistic in nature. Working in high-risk conditions of high transmission, higher loads of infection, likelihood of severe infections; healthcare workers and their immediate family members have gone through an unimaginable stress. Wearing PPE kits, face shields and gloves for long hours also led to skin diseases, nasal bridge tightness, dryness etc. Depression, anxiety, distress, fear and burnout was heightened among the healthcare workers. Almost 3/4th of them reported disturbances in sleep, insomnia etc., due to excessive and often uncertain workload and work-related stress, seeing high number of deaths and witnessing people dying (Das, Singh, Varma, & Arya, 2021). As of October 2021, WHO estimates the global death toll of healthcare workers ranges from 80,000 to 1,80,000 (World Health Organization, 2021). In India, 1,492 doctors have succumbed to the coronavirus pandemic (Krishnan, 2022), with about 594 doctors succumbing in second wave alone (as reported by IMA in 2021) (Hindustan Times, 2021).

Death of frontline healthcare workers has been a point of intense grief for both their immediate family members and colleagues. Bereaved immediate family of healthcare workers are prone or are more likely to develop prolonged grief disorder, poor bereavement outcomes, post-traumatic stress etc. Due to the nature of coronavirus, physically being present with the patient, saying a last goodbye was not possible for many people, which is a known risk factor for prolonged grief disorder and PTSD (Selman, et al., 2020).

Grief During the Pandemic

Earlier times, during ancient times; life expectancies were low, child mortality was high and diseases were rampant due to unhygienic conditions. Hence, death was common and for some it was a on a daily basis. Although it was just as painful, it was as natural as life (Fernández & González‑González, 2020). During the middle ages and renaissance, rituals were created around death, they held certain significant meanings; a sort of consolation that, the departed is now in heaven with god. The bereaved were surrounded by family members, honoring the departed, consoling and supporting the living. The sense of support from family, a comfort in the thought that the rites and rituals were fulfilled helping the departed find their way to God and being cremated surrounded by holy ritual chanting etc., gave a sense of peace, helped the bereaved cope with grief and come to an acceptance; to relish the memories and move on with life.

Especially in India, being a collectivistic community, religious rituals, traditions are held to have a significant meaning and importance. And hence, so does the rituals surrounding death. Especially in South Indian communities, the departed is brought home for the family members to offer their final goodbyes, after which there are certain rituals which are done; ending in the departed being cremated. Depending on each community’s practices there is a period of mourning (13 days or more), where post-cremation rituals maybe performed. This helps the immediate family surrounded by their social support systems; to come to terms with death and helps them deal with grief and cope effectively. Hindu mythology doesn’t see death and life in a linear fashion, but rather as a cycle (Samarth, 2018). Death is not seen as the end, but as a transition and new beginning of another life. The rituals are then viewed as a medium of help for the soul to peacefully transition into their afterlife. “Ritual performance eradicates the possibility of harm to the family and ensures the smooth transition of the dying to deceased to a corpse, soul, and into the afterlife” (Samarth, 2018, p. 16).

But the pandemic changed all that. Due to the nature of infection, that is it being extremely contagious, family members couldn’t visit the patient, couldn’t see them or say their last goodbyes one last time and neither could they hold funerals and its associated rituals, nor could the bereaved have the comfort and support of their family members around them due their tough times. In short, all the aspects that help a person during their grief, are absent due to the pandemic. As a doctor in Spain said,

“That’s the cruelest thing about this pandemic. The thousands who have died from COVID-19, passing away alone. In a hospital ward or a room in an old people’s home. Without family members near them. Not one goodbye or farewell.” (Fernández & González‑González, 2020, p. 6).

Another important aspect that, all the rituals, last goodbyes give the living is a sense of closure (Fernández & González‑González, 2020).This lack of closure can lead to a more prolonged, complicated grief. As we have seen earlier, saying the last goodbyes, getting a last chance to see the departed before cremating, fulfilling the rituals and rites; hold significant meanings traditionally and help the bereaved get closure and last goodbyes, which are significant psychologically for a healthy grieving process. Due to the conditions imposed during the pandemic, guilt about passing the infection; self-blame for death, the conditions themselves, the way patient was handled, lack of equipment, the way healthcare professionals handled visits (or denied them any at all), broke the news of death; can lead to lingering guilt and anger; prolonging the grieving process and leading to complicated grief. The lack of emotional support present; physically at least, can lead to an exacerbation of loneliness; which the grieving might already feel due to the loss.

Another aspect with COVID-19, was how sudden and quick, it all happened; death and the processes after that. Especially when the patient passes away while in intensive care units, which maybe sudden, can be especially traumatic for family members; leading to complicated grief, depression etc. Admitting into an intensive care unit, death and cremation may all be completed within two days; due to guidelines. The sudden loss, cremation can be very difficult and overwhelming to go through. Research which sought to identify complicated grief of relatives; who’s loved one died in an ICU; identified that 52% of them showed signs of complicated grief. The risk factors were not getting a chance to say goodbye, not being able to be present with them in their final moments, loved one dying while intubated, and lack of or low communication with doctors. All of which are present in the pandemic (Santos, et al., 2021).

It is extremely painful to have one family member pass away; it is next to impossible and inconceivable to even imagine what an experience of losing multiple family members pass away due to COVID-19. Children have lost their parents; people lost their fathers and husbands at the same time; especially during the second wave in India. Many after the multiple losses reported, missing hugs from the departed, not being able to get over the last days they spent with them, not being able to say goodbye, visit physically (some were allowed video calls), a sense of void, loneliness, being upset with the whole situation, death immediately followed by cremation; with no rituals and family members present. This quote summarizes how painful death and grief during this pandemic is:

“A look at the data made it possible to see that it was as if this pandemic killed two times over, since it first isolates victims from their families just before dying. Then it does not allow anybody to achieve emotional closure. It strips the dead of their dignity and aggravates the grief of the living.” (Fernández & González‑González, 2020, p. 11).

In summary the common themes that comes up across research papers are intense grief, heartbreak, distress, hopelessness, stemming from inability to visit, hold or attend rites and rituals, lack of emotional support due to restrictions and loved ones dying alone in the hospital. There was also a recurring theme of anger, frustration and feelings of injustice stemming from not being able to hold the funeral the departed deserved. The rituals, rites were connected to the dignity of and respect for the departed. People also expressed the shock, over the quick and sudden loss of their loved ones and feeling of the all of it being ‘unreal’ (Selman, et al., 2021; Fernández & González‑González, 2020). Factors that can heighten the risk of developing complicated grief, prolonged grief disorder etc. are if the family members themselves are in isolation due to COVID-19; inability to hold last rites, funeral, and inability to receive physical consolation from relatives; thoughts of self-blame with regards to transmitting the infection; all of which can delay coping strategies that help individuals deal with grief. Other known risk factors are, presence of previous mental health condition, untimely and sudden death, relationship with the departed etc.

Disenfranchised Grief

During the pandemic grief has been disenfranchised. What this means exactly, we see in the coming paragraphs. The concept of disenfranchised grief was first introduced by Kenneth Doka in 1989 and defined it as follows:

“The process in which the loss is felt as not being “openly acknowledged, socially validated, or publicly mourned.” (Albuquerque, Teixeira, & Rocha, 2021, p. 1).

This experience of disenfranchised grief can lead to complications in processing and expression of grief, since it is not recognized socially. It can lead to non-expression of grief and the emotions attached to it; often leading to an impasse; which can lead to mental health concerns in the future. It can put a limit on social support that is significant during grieving; helping the bereaved have a sense of emotional support and comfort; especially when they have a sense of loneliness (Albuquerque, Teixeira, & Rocha, 2021).

Disenfranchised grief can be of two types. The first is disenfranchisement imposed externally and second disenfranchisement imposed internally; also known as self-disenfranchisement. External disenfranchisement, as Doka says, is when society doesn’t acknowledge or legitimize a death, the resulting grief that the bereaved experiences, is seen as undervalued, unacknowledged. An important aspect of after death processes are conduction of funerals, rituals and rites associated with it. And non-conduction of these rituals and direct cremation of the departed; can lead to feelings of neglect and dehumanization towards their departed beloved; which leads to complicated and prolonged grief. Bromberg identifies the therapeutic aspects of after death rituals; listing that these rituals help the bereaved come into terms with the reality, helps them gain the emotional and social support one needs and in understanding that death and grief are all part of life (Albuquerque, Teixeira, & Rocha, 2021). Touch can also be very important during grief (a hug, holding hands). It can help a person, understand that they are not alone, there is someone they can hold on to and helps them be in the here and now.

Self-Disenfranchisement on the other hand is, when a person has difficulty in recognizing their grief as being legitimate. An associated emotion of this process is guilt. In the current context this might translate to; guilt of not being there with the person in the hospital, constant doubts that they might be the reason for their death (because of the thought that they transmitted the infection to them). Another aspect is that the person might not have the safe space to process their emotions and cope with grief (Albuquerque, Teixeira, & Rocha, 2021). Some factors that contribute to this maybe their own isolation due to COVID and the anxiety and fear associated with it or another person falling ill again, multiple immediate family members passing away, general rise in the anxiety and depression during the pandemic, the secondary looses after death of identity, financial losses, lack of social and emotional support etc. all lead to an overload of additional stressors on top of the overwhelming aspect of grief. This overload can have many mental health consequences and directly affect how one deals with grief. It can lead to burnout, emotional and physical exhaustion, helplessness, hopelessness and either chronic grief or absent grief (Stroebe & Schut, 2016). Read More.

COVID-19 restrictions and Impact Summary

COVID-19 Restrictions	Impact
​Lack of funerals, rites and rituals	​Not being able to say goodbye. Feelings of stolen moments, loss of dignity of the departed and inhumaneness towards them. Prolonged grief due to inability to hold the funerals their family members deserved.
​No visitation or limited to video calls	​Unfinished business and guilt for not being there for them. Powerlessness, feelings of unreality and abandonment
​Limitation on social gathering and meeting	​Loss of social and emotional support
​Societal Stigma	Guilt, disenfranchisement (society not acknowledging by people not visiting because of a COVID death in the house even when others have tested negative)
​Sudden losses (especially after admitting in the ICU)	​Guilt, feelings of incapability, thoughts about healthcare worker incompetence, blame assigning, depression and complicated grief.
​Overload of primary and secondary losses	​Helplessness, hopelessness, absent grief and prolonged grief, burnout, physical/emotional exhaustion.

Common impacts noted across various academic articles.

Prolonged grief disorder During the pandemic

Before we move on to see prolonged grief disorder during COVID -19, lets first understand the criteria for prolonged grief disorder. In DSM V it’s called Persistent Complex Bereavement Disorder (PCBD). The following is the criteria for it in DSM V:

Criteria A: The individual experienced the death of a close relative

Criteria B: At least one of the following is experienced on most days in a degree clinically significant for at least 12 months in adults and 6 months for children since the death:

1. Persistent longing for the departed. In children they may show it through play or behavior indicating separation and uniting with the departed

2. Intense sorrow and emotional pain in response to death

3. Preoccupation with the departed

4. Preoccupation with the circumstance of death. In children it maybe expressed through play and behavior

Criteria C: At least six of the following is experienced on most days in a degree clinically significant for at least 12 months in adults and 6 months for children after the death:

Reactive distress to death:

1. Difficulty in accepting the death

2. Disbelief and emotional numbness over the death

3. Difficulty in positive reminiscing about the departed

4. Experiencing anger over the loss

5. Maladaptive self-appraisals over the death or the departed such as self-blame etc.

6. Avoidance of places, people or situations associated with the departed that remind them of the loss. In children it maybe avoidance of thoughts and feelings.

Social/Identity disruption

7. Expression off a desire to die, so that they can be with the departed

8. Difficulty trusting others since the death

9. Feelings of loneliness and detachment from other people since the death

10. Loss of meaning in life, emptiness in life or feeling that they cannot function without the departed

11. Reduced sense of identity or confused about their role in life. Feelings of losing a part of themselves with the death of their beloved.

12. Difficulty or reluctance to pursue their interests since the death. Reluctance to plan for the future.

Criteria D: The above disturbance is causing functional deficit, with impairment in social, occupational and other important realms.

Criteria E: The bereavement reaction is disproportional to cultural and religious norms.

Although family members could talk to the healthcare professionals and could see through video calls to the patient, it was not enough (Hanna, et al., 2021). A study conducted among 422 participants, to see the prevalence of Prolonged Grief Disorder (PGD) in ICD-11 and Persistent Complex Bereavement Disorder (PCBD) in DSM-V. The results suggested that, 37% met the criteria for PGD and 29% met the criteria for PCBD. “Demonstrating that over one-third of COVID-19 related bereaved individuals suffered from PGD or PCBD” (Tang & Xiang, 2021, p. 6). If each COVID-19 death leaves behind nine bereaved people and usually around five to 10 percent develop prolonged grief under usual circumstances, it can be safe to assume that, that number would increase during a pandemic. Millions of people could be at risk of PGD.

“A March 2021 poll from the Associated Press–NORC (AP-NORC) Center for Public Affairs Research found that about 20 percent of people surveyed in the U.S. had lost a relative or close friend to COVID-19. That means a potential bereaved population of about 65 million, and it could push numbers of new prolonged grief cases into the millions” (Courage, 2021).

Children and Adolescent Grief During the Pandemic

During the pandemic, fear of death of their loved ones can be exacerbated. How grief is expressed, understood and processed is different in children and adolescents from adults. “Child grief can manifest in different ways throughout their development and lifespan, adding complexity to its adequate evaluation” (Albuquerque & Santos, 2021, p. 2). And although early detection and intervention is key for any mental health concerns, recognizing complicated or maladaptive grief in children may be difficult. The reasons being, there may be significant behaviors, but the connection between the behavior and loss may not be made; because maladaptive behaviors stemming from loss may mimic other mental health disorders. Anger, aggression, rebellious behavior; maybe labelled as oppositional defiant disorder. It is also important to take into consideration the developmental stage the child is in, and as the child develops, their awareness, knowledge and understanding about loss and what it entails also develops. Hence, they may exhibit grief in different ways (Albuquerque & Santos, 2021). Studies have shown that, for every COVID-19 related death, it leaves 2.2 and 4.1 bereaved children and grandchildren respectively. Under usual circumstances, around 5-10% of children and adolescents experience mental health difficulties after the loss; but this number maybe higher due to the pandemic (Albuquerque & Santos, 2021).

Infants do not understand death as irreversible or permanent, they show distress in the absence of primary caregiver. During the pre-operational stage of child development (2-7 years), due to the characteristic of magical and egocentric thinking, children may come to the conclusion that, they are somehow responsible and caused the death with their thoughts or actions; which may lead to guilt. As concrete thought develops, they may understand the irreversible nature of death, and the egocentrism fades, they may start to worry and think about others around them as well. They may show interest in knowing about death and the causes leading to it etc. As abstract thought develops in adolescents, they begin to understand its universal, non-functional aspect of death and their grieving process can start to look like that of adults (Santos, et al., 2021). Children may complain about some physical discomfort and taking them to a doctor could give them reassurance that, they are alright. They might react to their overwhelming emotions by anger.

An important risk factor for future mental health disorders for parent-bereaved children, is how their living parent and immediate family are dealing with the loss. Their status of mental health, how they are processing and dealing with grief, the number of secondary losses they are facing, socio-economic status and how they are dealing with it; weighs on the child (Santos, et al., 2021). Surviving parent who is supportive, engages and encourages their child to express their emotions, thoughts, who are empathetic, who listen to them; show that these children are better adapted, form close bonds with them and process grief adaptively. Parents who engage in avoidant coping, don’t communicate to the child, doesn’t give the child space to express; leads to maladaptive functioning after the loss. Children who avoided emotional expression, suppressed their emotions showed exacerbated risk of mental health disorder symptoms as opposed to children who were more emotionally expressive (Howell, Shapiro, Layne, & Kaplow, 2015). Read More

It is also important to understand that, children might be experiencing death and loss for the first time in their lives. They may not be in a place to understand it developmentally and might not have the cognitive abilities yet on how to cope and deal with grief. Hence, it becomes the caregiver’s job to understand and be supportive to the child. Children might show and express emotions in different ways and they may show it intermittently; characterized by usual behaviors such as play in between expressing sadness, anger etc. Dual process model explains this. It is defined as “as a back and forth in focusing feelings of grief and loss (Loss coping orientation–LO) and coping with everyday life stressors and taking a “time off ” from grieving (Restoration coping orientation–RO).” (Albuquerque & Santos, 2021, p. 2).

Given the pandemic, some of the RO strategies maybe disrupted due to restrictions; making things more complex. Restoration coping strategies like playing with friends, sports or any outdoor activities are closed due to restrictions. And social media and news with constant updates on deaths and suffering can keep triggering the child’s memories of death and loss, making it hard for the child to move into restoration coping strategies. Children, who often turn to their caregivers for help; may also be distressed and overburdened by secondary losses such as financial status, identity etc. The child might miss on certain important loss oriented coping strategies such as emotional expression, support from caregivers, who provide a safe space for them to grieve. Restrictions on funerals, lack of last goodbyes can also lead to a lack of closure in children (Albuquerque & Santos, 2021).

• Importance of communication with children: Children who experienced bereavement, show more anxiety, depression symptoms than children who didn’t. Loss of a parent in children is associated with post-traumatic stress disorder, substance abuse, lower quality in peer relations, work etc. Worden mentions that grief process involves four aspects. Accepting the loss, dealing with the pain associated with grief, adapting to a life without the departed and finding ways to remember the departed in their life. Accepting the loss can be an important step in coping with grief, and this is usually achieved with funerals and the post death rituals. Involving the child in the funerals, helping them do developmentally appropriate tasks can be empowering, could help them achieve a sense of control, closure etc. Since, that is not possible during the pandemic, giving the child space to express their emotions, support and communicating with them can be extremely helpful. Communicating to them about the virus, the restrictions and the reasons behind it, about death, asking them to express how they are feeling about the situation, helping them identify their emotions, asking them to write down what they want to say to the departed are important. Involving the children in lighting of the candle, with flower arrangements (choosing and arranging the flowers) of the departed picture, choosing what food to make in remembrance of the departed etc., can help the child give closure.

Adolescents

Adolescence is in itself an important stage where, they experience a move towards peers and away from family, an important stage for individual identity formation (who am I), rather than the one given from family and need for novelty, risk-taking etc. It is also the stage, which has a greater impact on their future and adult life; both personally and professionally. And adolescence is also associated as a risk factor for the onset of mental health disorders. And a loss during this highly sensitive stage, can hinder the achievement of the developmental tasks and make transitions into adulthood complicated (Weinstock, Dunda, Harrington, & Nelson, 2021). Grief in adolescents can get complicated if there is no social support system for them, and bereaved adolescents are particularly prone to depression, suicide, disturbed educational performance etc. Studies in the United Kingdom have suggested that, around 25% of adolescents who experienced bereavement committed suicide and 41% of youth offenders experienced bereavement, as compared to the 4% among the general population (Weinstock, Dunda, Harrington, & Nelson, 2021). Many studies in India, support this as well. Parental loss was associated with suicide and high suicide risk, depression etc. (Radhakrishnan & Andrade, 2012). In students as well, the absence of a parent was associated with suicide (Ponnudurai, 2015). One study also suggested that, parental loss was associated with suicide, even without the presence of depression after the loss (Gupta, 2021).

Certain aspects of adolescent developing brains, can be key to understanding why adolescent grief can be complicated and why they are more prone to developing complicated grief. The key may lie in their pain and reward related pathways. O’Connor et al. have conceptualized social relationships as addictive. A recent study suggested that, people with complicated grief; when looking at the picture of their departed loved one, their reward related pathways were activated; which prolongs the grieving process. This activation is also the same process that makes adolescents prone to high-risk behaviors and addictions. Adolescents, actively seek sensations, activating their reward pathways; which might make them prone to addictions and high-risk behaviors. Hence, this might also prone them to the development of complicated grief.

Apart from biological factors environmental/societal factors also turn into risk factors for adolescent grief. The increasing incidence of loneliness among youth, our modern society’s view of grief and our rise towards individualism are all risk factors. There have been associations between societal move towards individualism and loneliness (Weinstock, Dunda, Harrington, & Nelson, 2021). Pitman AL et al. in their study showed on associations between loneliness and bereavement showed that “people who report feeling lonely after a sudden bereavement are more likely to make a suicide attempt after their loss” (Weinstock, Dunda, Harrington, & Nelson, 2021, p. 3). Social media has its advantage in this context allowing adolescents to express their grief on their social media accounts and on certain online communities of people going through similar experiences. But the disadvantage lies in the accessibility of their departed one’s photos, videos, making it harder to let go. With the reward pathways activating when seeing the pictures, this may prone adolescents to develop complicated grief and prolonging the grief process (Weinstock, Dunda, Harrington, & Nelson, 2021). And COVID-19 has made these even worse. Social isolation, no access to social support systems even when adolescents wish for it, fear and anxiety of COVID-19, worried about the health of their other immediate family members, secondary losses can lead to prolonged and complicated grief. But there is also the option of virtual connections with friends and family, online therapy etc. It might be helpful for adolescents if they reach out for help and form social support systems through technology.

Strategies to Deal with Grief

During Hospitalization: The power of Accompaniment.

The following are for front line workers who can play a key impact on the grieving process of immediate family.

• Advance Care Planning (ACP), where there is a discussion with patient or their immediate family members to ensure that the care provided matches their outlook and values about life.

• Constant empathetic communication on part of the hospital staff with the immediate relatives, giving constant updates etc. The hospital can assign one person for this for each patient. Assurances of comfort and non-abandonment should be communicated to the family. Video calls can also be arranged. Poor communication on part of the healthcare professionals to family members is associated with prolonged grief disorder.

• It is also important for the hospital staff to screen family members going through anxiety, fear, distress and other risk factors for poor bereavement outcomes and set them up with professionals who can offer them support and treatment.

• It is important to allow family members with low risk, with sufficient precautions to visit the patient who is at the end of their life. It can have a great positive impact in the future on their grieving process. If other family members cannot attend, it is important to do video call.

• In the case of immediate family members are in quarantine themselves at home and/or cannot visit the hospital; if possible, they can be requested to record what they wanted to say to the patient; and the hospital staff can play the recordings to the patient. A video call can be arranged during this as well. (Selman, et al., 2020; Morris, Moment, & Thomas, 2020).

After Death

• Legacy making activities can be arranged for the family members. Family members during the pandemic do not get the comfort of seeing their departed for the last time and of rites and rituals; hence, a keepsake for the family members can be of some comfort. Keepsakes like hair, hand molds of the patient, cardiac tracings etc. can be done. These can help maintain a connection and offer some comfort; helping in better bereavement outcomes. (Morris, Moment, & Thomas, 2020).

• Hospital staff and doctors can be trained on how to communicate the difficult news with sensitivity to the family members.

• If a person had been appointed for each patient; as discussed earlier, he/she can sit with the family members and listen to them, empathize, offer support etc. He/she can also be trained in psychological first aid. They can also identify people who are the risk of developing prolonged or complicated grief and put them onto a mental health professional.

• The hospital can offer a condolence letter to the family.

• Awareness can be raised on be prolonged and complicated grief, the behaviors involved, the risk factors etc. This can empower family or friends to put them on to a psychologist and help them get the help they need. The hospital can also send a list of local establishments who offer grief counselling. (Selman, et al., 2020; Morris, Moment, & Thomas, 2020).

Finding other ways to grieve and creating other rituals:

Video calls, audio calls, messages has helped in people feeling less isolated, given the comfort of seeing their departed, cremation etc. Families can also find ways to see their departed, some families have said their goodbyes from their car windows, some said through lighting a candle, some through prayer and some through song. Some were asked to place certain items in the coffin, some coped through remembering the departed through food etc. (Borghi & Menichetti, 2021).

Anticipatory grief

It is important for healthcare professionals to communicate when the patient is in their last stages of life; to prepare the family members beforehand. This anticipatory grief, can prepare individuals to adjust to life after death. Sudden and ICU deaths have been known to and as mentioned earlier lead to complicated and prolonged grief. Hence, preparing the family members, anticipatory grief can help the family members visit for their last moments and communicate what they want to say. It gives them closure and paves a way for them to get used to a different reality; a reality without the departed and form new relationships and strengthen old ones which helps in the grieving process (Yap, Garcia, Alfaro, & Sarmiento, 2021).

A positive psychology approach

Times of extraordinary pain, sadness and trauma; humans still have the amazing quality to bounce back, hope and make meaning, maybe even a purpose, concentrating on the greater good out of these experiences. Time to reach such stage may vary, but every individual has the capacity to heal. And it becomes our duty as a community or family or healthcare workers to give that environment necessary for individuals to heal. Post traumatic growth can be achieved by every individual.

Family can play a very important role to facilitate an individual towards post traumatic growth. Even though pandemic rules can deter this, members can still call, message or video call to offer support. It is also important to express that, the range of emotions they might be experiencing are understandable, universal, normal and natural. Simple listening, making an effort to call and naturalizing their emotions can have a great positive impact on the bereaved, especially in times like these. It communicates to them of support, it strengthens their relationships and also puts them on the track towards adaptive coping. Some experience self-blame, guilt, anger etc. Here it becomes important to listen and empathize first, then help them understand the limits of

control humans can exercise and that they have done their best. One can also help them look for accountability at a local or even national level (Walsh, 2020).

Families and mental health professionals should work on rekindling hope (realistically and not false hopes) and resilience. Grieving individuals would have lost hope and the future can seem uncertain and bleak. It is important to support them through the lost hopes and when ready it is important to help them see hopes they can achieve. “As studies have found, resilience is fostered by focusing efforts to master the possible, accepting that which is beyond control, and coming to terms with what cannot be changed” (Walsh, 2020, p. 14).

Spirituality can also help during the tough times. People can find comfort in prayer, meditation, religious congregations, sermons etc. In case of restrictions with some of the above, a connection can be re-established with nature, support animals etc.; if the individual is interested in them. People can also find comfort in engaging in things that their departed enjoyed, a nature walk, music, cooking, reading, praying etc.

In conclusion, individuals often emerge from life-shattering losses with remarkable transformations: gaining appreciation of life and new priorities; warmer, closer relationships; enhanced personal strengths; recognition of new possibilities or paths in life; and deepened spirituality (Walsh, 2020, p. 16).

References

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