Meaningful Communication Before Death, but Not Present at the Time of Death Itself, Is Associated With Better Outcomes on Measures of Depression and Complicated Grief Among Bereaved Family Members of Cancer Patients

How to talk about dying? The development of an evidence-based model for communication with patients in their last days of life and their family caregivers

Objective

To help healthcare professionals (HCP) act with more confidence when communicating about approaching death, we sought to develop a communication model for HCP to facilitate conversations with dying patients and family caregivers (FC) in nonemergency situations.

Methods

We used a four-phase integrative approach: (1) creation of a preliminary model based on a systematic literature review and expert knowledge, (2) review of the model draft by international palliative care experts, (3) review by key stakeholders, and (4) final appraisal by communication experts.

Results

After the clinical recognition of dying, the communication model provides a structure and practical communication aids for navigating the conversation based on three phases. It describes the content and relational level as core dimensions of effective conversations about approaching death and highlights the importance of HCP self-awareness and self-care when caring for the dying.

Conclusion

Based on systematic involvement of key stakeholders, the model supports clinicians navigating challenging conversations about approaching death with dying patients and their FC successfully and with more confidence.

Innovation

This study expands the theoretical basis for communication about approaching death and offers a pragmatic model for educational interventions and clinical use.

Grieving During the COVID-19 Pandemic: In-Person and Virtual "Goodbye"

This study examined the relationship between having an opportunity to say goodbye to a dying family member or friend in person or virtually, as well as attending their funeral services in person or virtually, and the bereaved individuals' psychological distress and complicated grief during the COVID-19 pandemic. Five hundred and nineteen US adults who had lost a family member or a friend between January 2020 and June 2021 completed an online survey for this study. Only a small proportion of participants were able to say goodbye to their dying family member or friend in person, and saying goodbye virtually was associated with higher levels of complicated grief and psychological distress. Those who physically attended a formal, in-person funeral or memorial service reported lower levels of psychological distress. The findings suggest a complicated process of saying goodbye in different formats during the pandemic.

Memory making in critical care: A qualitative thematic synthesis

BACKGROUND

Caring for bereaved families is an important aspect of the nursing role in critical care. Memory making practices are one way in which dying, death and bereavement can be acknowledged and supported within critical care. Memory making was introduced into the care of stillborn babies and neonatal deaths to improve parents' experiences of bereavement, and has since become common practice in adult critical care.

AIMS

The aim of this qualitative thematic synthesis was to explore families' experiences of memory making in critical care, with a view of gaining greater understanding of the ways in which memory making impacts bereaved families.

METHODS

A systematic search strategy was developed, and five databases were searched (Medline, CINAHL, PsychINFO, Embase and ASSIA). Seven qualitative studies were included: four were conducted in adult and three in paediatric critical care settings in which memory making was initiated between 2014 and 2020. Memory making practices included, patient diaries, general keepsakes, word clouds and photography.

RESULTS

The thematic synthesis generated four main themes to describe families' experience of memory making in critical care: 'connection', 'compassion', 'engagement and creation' and 'continuation'.

CONCLUSIONS

Memory making is a meaningful activity for families whose loved one dies in critical care; it brings focus and meaning during a devastating process in a highly technical environment. Families rely heavily on nursing staff for support and guidance. The creation of memories and/or keepsakes can have a positive impact on the bereavement experience for families and can facilitate a continuing bond with their loved one.

RELEVANCE TO CLINICAL PRACTICE

Memory making is a worthwhile practice to support and guide family bereavement within critical care. It can provide structure and purpose during an emotionally challenging transition, by supporting families to focus on a meaningful activity during a devasting time.

The Impact of Problematic Internet Use on Adolescent Loneliness-Chain Mediation Effects of Social Support and Family Communication

Purpose

To explore the relationship between adolescents' problematic Internet use and loneliness and the mediating roles of social support and family communication.

Methods

A questionnaire survey of 2483 adolescents aged 12-17 years in 148 cities in China was conducted using the Problematic Internet Use Scale, the Collaborative Social Support Scale, the Family Communication Scale, and the Loneliness Scale. The data were statistically analyzed by SPSS 26.0 and validated by AMOS 28.0. Structural equation modelling (SEM) was conducted to test the effects of problematic Internet use on adolescents' loneliness and the mediating effects of perceptions of social support and family communication.

Results

There was a significant positive effect of adolescents' problematic Internet use on loneliness (B-0.471, P<0.001), and the mediating effects of perceptual social support (0.003, 0.012) and family communication (0.008, 0.019) were found to play a chain effect between adolescents' problematic Internet use and loneliness, respectively. Use and feelings of loneliness played a chain mediating role (0.002, 0.006).

Conclusion

This study identified the effects of adolescent problematic Internet use on loneliness and its mechanism of action, emphasized the importance of social support and family communication, and provided practical insights for improving family parenting styles and preventing and intervening in adolescent loneliness problems.

Bereavement During and Not During the Pandemic in Terms of Complicated Grief and Social Support

Mandated measures to reduce the risk of spreading the coronavirus (e.g., social distancing and travel restrictions) led to isolation and reshaped the dying process as well as grief rituals for loved ones of deceased individuals due to COVID-19 and other causes of death. The purpose of this study was to investigate the difference between those who lost a loved one during and not during the global pandemic in terms of complicated grief and perceived social support. A cross-sectional quantitative approach was employed, surveying 580 individuals, all of whom had experienced the loss of a loved one. Our findings suggest that bereavement during the COVID-19 era uniquely intensified the Complicated Grief experience. However, the perceived social support did not vary based on the timing of the bereavement. The strengths, limitations, and future research directions are further explored.

Prevalence of prolonged grief disorder and its symptoms among bereaved individuals in China: a systematic review and meta-analysis

Background

The prevalence of prolonged grief disorder (PGD) and its symptoms among the bereaved population in China vary considerably.

Aims

This meta-analysis aims to estimate the prevalence of PGD and its symptoms among bereaved individuals in China.

Methods

We conducted a literature search in major Chinese and English databases from their inception to 4 October 2023, for cross-sectional studies on the prevalence of PGD or its symptoms in bereaved Chinese individuals. The risk of bias of the included studies and certainty of the evidence were assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Studies Reporting Prevalence Data ('JBI checklist') and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE), respectively. The 'metaprop' package in R V.4.1.2 was used to synthesise the prevalence.

Results

A total of 28 studies involving 10 994 bereaved individuals were included in the analysis, with JBI checklist scores between 3 and 7. The combined prevalence (95% confidence interval) of PGD and its symptoms was 8.9% (4.2% to 17.6%) and 32.4% (18.2% to 50.8%), respectively. PGD and its symptoms were most prevalent among those who had lost their only child (22.7%) and those bereaved by earthquakes (80.4%), respectively. The GRADE system assigned a very low certainty level to the evidence for the pooled prevalence of PGD and its symptoms.

Conclusions

The pooled prevalence of PGD and its symptoms indicate a potential high need for grief counselling services among bereaved individuals in China. This need is particularly pronounced in those who have lost their only child and those bereaved due to earthquakes. Further methodologically rigorous studies are needed to provide more accurate prevalence estimates.

PROSPERO registration number

CRD42023432553.

Relatives' grief at three moments after death of a loved one during COVID-19 pandemic (the CO-LIVE study)

COVID-19 has complicated grieving experiences. Rich qualitative description of these experiences is lacking. We interviewed 10 bereaved relatives (mainly daughters) 2-3 times each: shortly after their relative died in the first wave of COVID-19 pandemic, and after 12 and 18 months (29 interviews in total). Analyses took place according to inductive content analysis. Losses were threefold: the loss of the loved one; of the (desired) way to say farewell, and of social support. We identified five ways in which the three COVID-19 related loss experiences interacted: overshadowed grief, cumulative grief, triggered grief, derailed grief, and conciliatory grief. This study demonstrated that pre-COVID-19 diagnoses and understandings of grief are not sufficient to picture grief during and after the COVID-19 pandemic. These grief experiences are more complex and deserve further exploration.

The Impact of Visitor Restrictions During COVID-19 Pandemic on Bereaved Family Members of Patients in Palliative Care Units

COVID-19 pandemic has impacted the families of patients in Palliative Care Units because of the visitor restrictions which were introduced to reduce the risk of infection. This study investigates how the bereaved families of the patients who died in end-of-life care during the pandemic evaluate the visitor restrictions and how the lack of direct communication with the patient affected them. We conducted a quantitative survey using an anonymous self-administered questionnaire. Participants were the bereaved families of patients who died in a Palliative Care Unit from April 2020 to March 2021. Their perspectives on the negative impact of COVID-19 pandemic on visitations, visitor restrictions, the quality of medical care in the month before the death of the patient, and online visitations were recorded in the survey. The results show that most participants experienced a negative impact on visitations. However, most respondents felt that the restrictions were unavoidable. According to visitor permissions in patients' last days, bereaved families were satisfied with the medical care provided for the patient and the amount of time spent with the patient in his/her last days. The importance of direct meetings during the last days of the patients' life for their family members was presented. We suggest further research to find measures which enable visitation in palliative care units, as caregiving from family and friends and maintaining COVID safety regulations are equally significant in end-of-life care.

Bereaved Families Views on the Death of Loved Ones Due to COVID 19: An Integrative Review

Families encounter some issues after the death of their loved one due to COVID-19. Therefore, this study aimed to explore the family's views on the death of their loved one due to COVID-19. This integrative review was conducted from May to Jan 2021. We searched PubMed, Google Scholar, Scopus, Web of Science, CINHAL, Magiran, and SID databases. Fifteen studies met the inclusion criteria. The results were classified into two categories, including before and after death. The issues raised before the death of the loved ones include no visit and absence at death time, fear of being infected with the COVID-19, death anxiety, failure to perform religious rites at death, and psychological problems. The after-death issues were related to funeral, burial, rituals, prolonged grieving, maladaptation, loneliness, and repeated mourning. Therefore, health policymakers should provide support before and after the death of loved ones for families.

The perception of life and death in patients with end-of-life stage cancer: A systematic review of qualitative research

PURPOSE

This study aims to clarify the perceptions on life and death among patients with the end-of-life stage cancer through a systematic review.

METHODS

The search strategy combined MeSH terminology with free text searches, and was applied to the PubMed, CINAHL, Embase, and ICHUSHI (Japan Medical Abstracts Society) databases covering from 2010 to 5/2022. To ensure the quality of the research included, the Critical Appraisal Skills Program Qualitative Studies Checklist was used. Data relating to the perceptions of life and death of patients with the end-of-life stage cancer was extracted and analyzed with reference to qualitative meta-synthesis methods.

RESULTS

Ultimately, 50 studies were included. Five themes were derived based on the perceptions of life and death of patients with the end-of-life stage cancer: despair, making sense of death, how to live the rest of life, special feelings for loved ones, and fluctuation. By making sense of death in their own way, and reconciling it with their current situation, patients with the end-of-life stage cancer, even in despair over their impending death, look ahead into the future and their surroundings and consider how they would live the remaining time they have. During this time, the special feelings they have for their loved ones make an impact.

CONCLUSIONS

An important new finding from this study lies in the fact that the patients' desire to live as ordinary people who were not patients were expressed as a face that they hid from their families. Further research is needed in low-income countries/regions.

Latent class analysis of grief-related beliefs among recently bereaved adults

Grief-related beliefs play an important role in bereavement adjustment. This study aimed to investigate the patterns and correlates of grief-related beliefs among recently bereaved adults (n = 311). Latent class analysis results suggested three meaningful grief belief classes could be identified: the High grief belief class (24.1%), Predominantly counterfactual thoughts class (42.4%), and Low belief class (33.4%). Members in the High grief belief class reported the highest levels of grief symptoms, depression and PTSD symptoms, loneliness, and functional impairment. Compared with the Low belief class, unmarried people, people in poor health, individuals who lost parents, partners, or children, and those who experienced violent or unexpected death were more likely to belong to the High grief belief class. Findings of this study support the importance of examining grief-related cognitions in research and clinical practice, especially counterfactual thoughts about the death, which may need to be specifically screened and targeted in treatment.

Perceptions of Palliative and End-Of-Life Care Capacity Among Frontline Staff and Administrators in Long-Term Care Homes During the COVID-19 Pandemic in Ontario, Canada: A Mixed-Methods Evaluation

OBJECTIVES

The COVID-19 pandemic has greatly affected the morbidity and mortality of residents in long-term care (LTC) homes. However, not much is known about its impact on staff's perception of their capacity to provide palliative and end-of-life (EOL) care for LTC residents over the course of the pandemic. We investigated changes in self-reported confidence among LTC workers and their experience in providing palliative and EOL care to residents before and during the COVID-19 pandemic.

DESIGN

Mixed-methods evaluation using a survey (n = 19) and semistructured interviews (n = 28).

SETTING AND PARTICIPANTS

Frontline workers from 9 LTC homes who participated in Communication at End-of-Life Program in Ontario, Canada, between August 2019 and March 2020.

METHODS

The survey captured LTC staff's confidence level, including attitudes toward death and dying; relationships with residents and families; and participation in palliative and EOL care. The interviews identified facilitators and barriers to providing palliative and EOL care during the pandemic.

RESULTS

The COVID-19 pandemic negatively impacted frontline LTC staff's confidence in their role as palliative care providers. Participants also reported notable challenges to providing resident-centered palliative and EOL care. Specifically, visitation restriction has led to increased loneliness and isolation of residents and impeded staff's ability to build supportive relationships with families. Furthermore, staffing shortages due to the single-site work restriction and illness increased workload. Psychological stress caused by a fear of COVID-19 infection and transmission also hindered staff's capacity to provide good palliative and EOL care.

CONCLUSIONS AND IMPLICATIONS

Frontline LTC staff-even those who felt competent in their knowledge and skills in providing palliative and EOL care after receiving training-reported notable difficulties in providing resident-centered palliative and EOL care during the COVID-19 pandemic.

Preparedness for caregiving and preparedness for death: Associations and modifiable thereafter factors among family caregivers of patients with advanced cancer in specialized home care

The purpose of this study was to (1) explore associations between preparedness for caregiving and preparedness for death among family caregivers of patients with advanced cancer and (2) explore modifiable preparedness factors, such as communication and support. Data was derived from a baseline questionnaire collected in specialized home care. The questionnaire included socio-demographics, the Preparedness for Caregiving Scale, and single items addressing preparedness for death, received support and communication about incurable illness. Data was analyzed using descriptive statistics and Spearman correlations. Altogether 39 family caregivers participated. A significant association was found between preparedness for caregiving and preparedness for death. Received support and communication about the illness was associated with higher levels of preparedness for caregiving and death. This study contributes to evidence on the association between preparedness for caregiving and death, but also that communication and support employed by healthcare professionals could improve family caregiver preparedness and wellbeing.

COVID-19 and Family Distancing Efforts: Contextual Demographic and Family Conflict Correlates

Since the COVID-19 outbreak, family members have spent more time together at home. This study introduces the concept of "family distancing"-the efforts to prevent the spread of the coronavirus to family members. We explore which demographic characteristics are associated with family distancing efforts and how the family distancing efforts are associated with family conflicts. Survey data were collected from adults (N = 324, M = 37 years; SD = 10.5 years; 65.1% female) in Korea. We found that gender, education, marital status, physical health status, and number of family members who live together were significantly associated with family distancing efforts. In addition, lower compliance with the request for family distancing was significantly associated with a higher degree of negative emotions (i.e., anger), which in turn was associated with more family conflict. The findings highlight the potential importance of family distancing efforts to maintain health but also their potential to increase family conflict.

"The communication I had with him back then is still stuck in my mind." Bereaved families of cancer patients' experiences for end-of-life communication

PURPOSE

Communication with family members is important to end-of-life care for patients with cancer. It is an interactive engagement between terminally-ill cancer patients and their families through which they expand their mutual understanding to cope with losses and find meaning in death. This study aimed to describe the experiences of end-of-life communication between patients with cancer and their family members in South Korea.

METHODS

This is a qualitative descriptive study using in-depth semi-structured interviews. Ten bereaved family members with end-of-life communication experience with terminal cancer patients were recruited through purposive sampling. Data were analyzed using qualitative content analysis.

RESULTS

A total of 29 constructed meanings, 11 sub-categories, and the following 3 categories were derived: "Offering a space for patients to reminisce and reflect," "Building a bond," and "Reflections on what we need." End-of-life communication primarily centered on the patients, with families struggling to share their stories with them. Although the families coped well, they also regretted the lack of meaningful communication with the patients, indicating a need for support to facilitate effective end-of-life communication.

CONCLUSION

The study highlighted concrete communication for finding meaning at the end-of-life for cancer patients and their families. We found that the families have the potential to communicate appropriately to cope with the patients' end-of-life. Nevertheless, end-of-life presents a unique challenge in which families require adequate support. Given the increasing number of patients and families dealing with end-of-life care in hospitals, healthcare providers should be mindful of their needs and help them cope effectively.

The Concept of a Good Death from the Perspectives of Nurses Caring for Patients Diagnosed with COVID-19 in Intensive Care Unit

We have witnessed increasing numbers of cases of COVID-19 and associated deaths worldwide. Therefore, the purpose of this descriptive and cross-sectional study was to determine the perception of a good death and the factors contributing to it by nurses caring for patients diagnosed with COVID-19 in the intensive care unit (ICU). It was carried out with nurses caring for patients diagnosed with COVID-19 in the ICU (n = 369). Data were collected using a questionnaire and the Good Death Scale. The mean score of the participants scale was 56.84 ± 7.51. In this study, nurses have seen as important statements that include "ensuring a peaceful death", "being with their loved ones", "meeting a person's spiritual needs", and "having an opportunity to say goodbye" for the good death. The factors contributing to the perception of a good death were gender, marital status, and feeling sad when caring for a dying patient (p < .05).

Impacts of the COVID-19 Pandemic on the Bereaved

The COVID-19 pandemic has killed millions across the world in only two years. Government health restrictions aimed at preventing transmission have impacted typical mourning practices such as funeral gatherings and in-person grief support services. This research examines the potential impacts that the pandemic may have had on people's ability to grieve. We employed a mixed methods study design to ask those who have lost a loved one during this time to reflect on their mourning practices with an anonymous survey. Our results present themes of complicated grief, the uncertainty of who to blame for frustrations, and common needs requested by the bereaved to help them mourn during these unprecedented times. These findings may help inform grief support and bereavement services during current and future mass death and pandemic health concerns.

Experience of application of the meaning-centered psychotherapy to Japanese bereaved family of patients with cancer – A mixed-method study

Objectives

This study aimed to adapt the meaning-centered psychotherapy (MCP) to treat post-bereavement grief in Japanese bereaved families who lost their loved ones to cancer and to examine the feasibility of the intervention using both quantitative and qualitative methods.

Methods

A modified version of MCP was developed with cultural consideration. Bereaved individuals aged ≥18 years who had lost their family members to cancer at least 6 months before and had severe or persistent grief with a score of ≥26 on the Inventory of Complicated Grief (ICG-19) were included in the study. The participants received the modified version of MCP, which was provided in a 5-session monthly format. The levels of grief (ICG-19), depression (Center for Epidemiologic Studies Depression Scale [CES-D]), general health (General Health Questionnaire-12), and post-traumatic growth (Post-traumatic Growth Inventory -Short Form) were compared before and after the intervention.

Results

Five bereaved individuals were enrolled, and all the participants completed the program. The mean scores of the ICG-19. The participants’ sense of regret, guilt, and being separated from the deceased person gradually shifted to the reappraisal of the experience, leading to a broadened view of the relationship with the deceased, and rediscovery of the core values, identity, and roles of the participants through the process of rediscovery of the meaning of life.

Significance of results

A modified version of the MCP was well accepted by Japanese bereaved families. The intervention appears to promote the rediscovery of the meaning of life and appears to have the potential to alleviate the bereaved individuals’ depression and grief-related symptoms and to facilitate their post-traumatic growth.

Dying during the COVID-19 Pandemic in Sweden: Relatives' Experiences of End-of-Life Care (the CO-LIVE Study)

Background: The COVID-19 pandemic has seen many deaths, but the majority were for causes other than COVID-19. However, end-of-life care in all settings has been affected by measures limiting the spread of the virus, for patients with and without COVID-19. The Swedish coronavirus strategy was different compared to many other countries, which might have affected end-of-life care. The aim was to describe the experiences of end-of-life care for bereaved relatives in Sweden during the “first wave” and to compare the experiences for deaths due to COVID-19 with the experiences for deaths for other reasons. Methods: A random sample of addresses for 2400 people who died during March−September 2020 was retrieved from the Swedish Person Address Registry. Relatives were contacted with a questionnaire regarding their experience of end-of-life care, with a focus on communication, participation, and trust. Results: In total, 587 relatives (25% response rate) answered the questionnaire (14% COVID-19-deaths, 65% non-COVID-19-deaths, 21% uncertain). In the COVID-19 group 28% of the relatives were allowed visits without restrictions compared to 60% in the non-COVID-19 group (p < 0.01). Only 28% of the relatives in the COVID-19 group reported that the person received “enough care from physicians”, significantly fewer than the non-COVID group (65%, p < 0.01). Conclusion: Relatives’ experience of end-of-life care for persons with COVID-19 was significantly worse than relatives of persons without COVID-19, but relatives for persons without COVID-19 were also negatively affected.

Potential risk factors for acute grief during the COVID-19 pandemic: The mediating role of avoidance processes

Bereavement during the COVID-19 pandemic may have some unique characteristics that become potential risk factors (e.g., absence of grief rituals, no opportunity to say goodbye to the deceased and loneliness caused by social distancing) for acute grief. Avoidance processes could be significant mediators in the context of the pandemic. The current study aimed to investigate whether and how these COVID-19-related risk factors were related to acute grief severity. Bereaved adults (n = 319) who lost significant others during the COVID-19 pandemic completed a self-report questionnaire package measuring COVID-19-related factors, grief severity and depressive and anxious avoidance. Regression analyses suggested that among the three potential risk factors (loneliness, grief rituals and opportunity to say goodbye), loneliness was significantly associated with acute grief after controlling for basic demographic and loss-related information. Structural equation models suggested that depressive avoidance and anxious avoidance partially mediated the associations of loneliness with acute grief severity. The findings indicate that dealing with loss during the COVID-19 pandemic warrants further exploration concerning how potential environmental risk factors may impede adaptation to loss. Depressive and anxious avoidance processes may play important roles in grief interventions for isolated and lonely bereaved people.

A qualitative study of nursing practitioners' experiences with COVID-19 patients dying alone in Greece

Background

In Greece, there is still limited research on death in isolation due to COVID-19. This deserves attention because of the recent financial crisis, which profoundly impacted public health, and the high relevance of the Hippocratic tradition to the moral values of clinical practice.

Methods

A prospective qualitative study using in-depth interviews with 15 frontline nursing practitioners working in a COVID-19 ward or intensive care unit (ICU) was conducted from July 2021 to December 2021.

Results

The inability of family members to say a final goodbye before, during, or after death by performing proper mourning rituals is extremely inhuman and profoundly impacts the mental health status of patients, family members, and nursing practitioners. Patients and their family members strongly desire to see each other. Epidemiology, liability, and proper nursing performance emerged as reasons for the enforced strict visitation restrictions. Participants emphasized that visitations should be allowed on an individual basis and highlighted the need for the effective use of remote communication technology, which, however, does not substitute for in-person contact. Importantly, physicians allowed "clandestine" visits on an individual basis. Nursing practitioners had a strong empathic attitude toward both patients and their families, and a strong willingness to provide holistic care and pay respect to dead bodies. However, they also experienced moral distress. Witnessing heartbreaking scenes with patients and/or their families causes nursing practitioners to experience intense psychological distress, which affects their family life rather than nursing performance. Ultimately, there was a shift from a patient-centered care model to a population-centered care model. Furthermore, we identified a range of policy- and culture-related factors that exaggerate the negative consequences of dying alone of COVID-19.

Conclusion

These results reinforce the existing literature on several fronts. However, we identified some nuances related to political decisions and, most importantly, convictions that are deeply rooted in Greek culture. These findings are of great importance in planning tailored interventions to mitigate the problem of interest and have implications for other similar national contexts.

Implications of end‐of‐life home care compared with hospital‐based care during the COVID‐19 pandemic: A case report

Restriction on hospital visits for COVID‐19 infection control continues to have a significant negative impact on patients and their families. For a patient receiving palliative care, this social isolation may deteriorate their mental health. In such situations, home care could be a viable solution to this problem.

In the COVID‐19 pandemic, providing end‐of‐life care at home may allow patients to spend more time with their families, improve communication between them and their health professionals and reduce the possibility of hospital‐acquired infections.

Psychometric properties, stability, and predictive validity of the Korean version of the Prolonged Grief Disorder Scale (PG-13-K): A longitudinal study among bereaved Koreans

This study aims to investigate the psychometric properties, stability, and predictive validity of the PG-13-K. Two subsamples were used: the first subsample (N = 153), participated at Time 1 only, and the second subsample (N = 184) participated at both Time 1 and Time 2. At each time point, reliability, test-retest reliability, and validity were adequate, and the hypothesized two-factor model indicated good to excellent fit. Moreover, the PG-13-K was able to predict the correlation between prolonged grief disorder (PGD) and negative psychological factors. The PG-13-K is a useful and valid instrument for measuring PGD symptoms in Korean settings.

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.

Private or shared room? A nationwide questionnaire survey on bereaved family members' perceptions of where patients spend their last days

BACKGROUND

Where patients receive end-of-life care influences their quality of life.

OBJECTIVES

To clarify the effects of staying in a private or shared room in inpatient hospices.

DESIGN

A part of a Japanese multicentre survey to evaluate the quality of end-of-life care.

SETTING/PARTICIPANTS

779 bereaved families whose relatives who died from cancer in inpatient hospices.

MEASUREMENTS

The primary outcome was family-perceived need for improvement in environment-related professional care. Secondary end-points included: family satisfaction, environment-related family perception, and quality of death and dying (Good Death Inventory: GDI).

RESULTS

574 responded (73.7%). 300 patients were in a private room from admission to discharge, 47 were in a shared room less than 50% of the time, and the remaining 85 were in a shared room 50% or more. There were significant differences in the need for improvement in shared (vs private) rooms, and in favour of private rooms for: 'privacy was protected', 'easy for visitors to visit', 'could discuss sensitive issues with medical staff without concern', and 'could visit at night.', as well as 'living in calm circumstances' and 'spending enough time with family' of the GDI. Contrarily, significant differences were found in favour of shared rooms for: 'the patient could interact with other patients'. There was no significant difference in family satisfaction and total score of GDI.

CONCLUSION

There are the advantages and disadvantages of spending one's final days in a private or shared room, and adjusting rooms according to patients and their families' values is necessary.

Caring for a Relative With Dementia in Long-Term Care During COVID-19

OBJECTIVES

The COVID-19 pandemic created unique stressors for caregivers of persons with dementia living in long-term care (LTC) facilities. The purpose of this qualitative study was to identify the challenges associated with caring for a relative with dementia in LTC during the pandemic, as well as resources, strategies, and practices caregivers found helpful in coping with COVID-19.

DESIGN

This study was conducted within the context of an ongoing randomized controlled trial of a psychosocial intervention to support caregivers. Open-ended survey responses (n = 125) and semistructured interviews with a subset of the sample (n = 20) collected between June 2020 and June 2021 explored caregivers' experiences during COVID-19.

SETTING AND PARTICIPANTS

Participants included 125 family caregivers of persons with dementia living in residential LTC.

METHODS

Thematic analysis was used to identify themes capturing caregivers' experiences.

RESULTS

In addition to concerns about COVID-19 infection, participants reported key challenges such as the difficulty of maintaining contact with relatives because of visiting restrictions, lack of information about relatives' health and well-being, worries about overburdened LTC staff, impossibility of returning relatives home from the LTC facility, and fears about relatives dying alone. Participants also identified resources, strategies, and practices that they perceived as helpful, including effective infection prevention within the LTC facility, good communication with LTC staff, and creative strategies for connecting with their relatives.

CONCLUSIONS AND IMPLICATIONS

This qualitative analysis informs recommendations for practice within LTC facilities, as well as supports that may help caregivers manage stressful situations in the context of COVID-19. Vaccination and testing protocols should be implemented to maximize family caregivers' opportunities for in-person contact with relatives in LTC, as alternative visiting modalities were often unsatisfactory or unfeasible. Informing caregivers regularly about individual residents' needs and status is crucial. Supports for bereaved caregivers should address complicated grief and feelings of loss.

Spirituality for Coping with the Trauma of a Loved One's Death During the COVID-19 Pandemic: An Italian Qualitative Study

Spirituality may be a key factor in reducing the negative psychological effects of traumatic events and a means by which the experience of grief can be processed. The objective of the present research is to assess whether and how spirituality provided concrete support in those who lost a loved one during the COVID-19 pandemic. The participants are 8 people from the most affected cities in northern Italy. They were interviewed in depth, the interviews were transcribed and the texts were analyzed through Interpretive Phenomenological Analysis. The results show that spirituality has been found to be a protective factor with regard to the processing of grief in crisis situations such as the COVID-19 pandemic, in particular with regard to the belief that the deceased loved one is now in an otherworldly dimension. In addition, the celebration of a funeral rite offers support to the grieving person in the early stages of mourning thus laying the foundation for a healthy grieving process. It is therefore important to support individual spirituality, which can be a useful tool for processing the traumatic experience, especially in difficult times such as the COVID-19 pandemic.

A three-step support strategy for relatives of patients dying in the intensive care unit: a cluster randomised trial

BACKGROUND

In relatives of patients dying in intensive care units (ICUs), inadequate team support can increase the prevalence of prolonged grief and other psychological harm. We aimed to evaluate whether a proactive communication and support intervention would improve relatives' outcomes.

METHODS

We undertook a prospective, multicentre, cluster randomised controlled trial in 34 ICUs in France, to compare standard care with a physician-driven, nurse-aided, three-step support strategy for families throughout the dying process, following a decision to withdraw or withhold life support. Inclusion criteria were relatives of patients older than 18 years with an ICU length of stay 2 days or longer. Participating ICUs were randomly assigned (1:1 ratio) into an intervention cluster and a control cluster. The randomisation scheme was generated centrally by a statistician not otherwise involved in the study, using permutation blocks of non-released size. In the intervention group, three meetings were held with relatives: a family conference to prepare the relatives for the imminent death, an ICU-room visit to provide active support, and a meeting after the patient's death to offer condolences and closure. ICUs randomly assigned to the control group applied their best standard of care in terms of support and communication with relatives of dying patients. The primary endpoint was the proportion of relatives with prolonged grief (measured with PG-13, score ≥30) 6 months after the death. Analysis was by intention to treat, with the bereaved relatives as the unit of observation. The study is registered with ClinicalTrials.gov, NCT02955992.

FINDINGS

Between Feb 23, 2017, and Oct 8, 2019, we enrolled 484 relatives of ICU patients to the intervention group and 391 to the control group. 379 (78%) relatives in the intervention group and 309 (79%) in the control group completed the 6-month interview to measure the primary endpoint. The intervention significantly reduced the number of relatives with prolonged grief symptoms (66 [21%] vs 57 [15%]; p=0·035) and the median PG-13 score was significantly lower in the intervention group than in the control group (19 [IQR 14-26] vs 21 [15-29], mean difference 2·5, 95% CI 1·04-3·95).

INTERPRETATION

Among relatives of patients dying in the ICU, a physician-driven, nurse-aided, three-step support strategy significantly reduced prolonged grief symptoms.

FUNDING

French Ministry of Health.

Prevalence of grief disorders in bereaved families of cancer patients: A meta-analysis

BACKGROUND

Cancer caregiving is a distressing experience and loss of a loved one can lead to intense grief and other adverse effects. However, the prevalence of grief disorders among families associated with cancer-related deaths remains unknown.

AIM

This study aimed to determine the prevalence of grief disorders among families of patients with cancer to better inform clinicians, researchers, and policymakers.

DESIGN

Meta-analysis, PROSPERO number CRD42020209392.

DATA SOURCES

The databases of CINAHL, Embase, MEDLINE, PubMed, Scopus, PsycINFO, and Web of Science were comprehensively searched with no language restrictions. The quality of included studies was assessed with Hoy's criteria.

RESULTS

Among the 3046 records screened, 19 studies were eligible for meta-analysis, with a total of 14,971 participants. The pooled prevalence rate of grief disorders was estimated at 14.2% (95% CI, 11.7%-16.7%), ranging from 7% to 39%. The prevalence was higher in females (10%; 95% CI, 8.2%-12.1%), those who are religious (9.55%; 95% CI, 8.97%-10.16%), spouses of the deceased (7.78%; 95% CI, 6.08%-9.69%), and families of patients with neurological cancers (6.4%; 95% CI, 0.10%-19.9%). Educational levels, study locations, diagnosis tools, time post-after loss, and study methods seemed not to affect the prevalence of grief disorders in families of patients with cancer.

CONCLUSIONS

As the prevalence of grief disorders in cancer-related bereavement is substantial, therefore, support including palliative care is important to reduce the burden of caregiving. In addition, future studies are needed to identify and explore effective strategies that can help reduce the burden caused by grief disorders after the death of the patient.

Lived Experiences and Challenges of the Families of COVID-19 Victims: A Qualitative Phenomenological Study in Tehran, Iran

Being COVID-19 positive and then dying causes a slew of personal, familial, and social issues for family members. Therefore, the current study was carried out to analyze the lived experiences and issues of COVID-19 victims' families in Tehran, Iran. The phenomenological approach was used in the qualitative analysis of 21 first-degree relatives of COVID-19 victims. From August 22 to October 21, 2020, data was gathered by phone (4 people) and in-person (17 people) using semi-structured interviews. The subjects were chosen through purposeful and snowball sampling. The MAXQDA-2018 program was used to organize the data, and the Colaizzi analytical technique was used to analyze it. Guba and Lincoln's criteria were also used to assess the findings' quality. After analyzing the data, 2 main categories and 14 subcategories were extracted, including (1) challenges in caring for a COVID-19 patient (being rejected, limited access to medical facilities, dissatisfaction with the behavior of medical staff, disruption of family life, the challenge of managing family members' behavior with the patient, and living with doubts and worries (2) challenges after a COVID-19 patient's death (incomplete farewell to the corpse, unbelievability of the death, ambiguity and tension in the burial process, lonely burial, the twinge of conscience, worry about not respecting the deceased, incomplete condolences, and abandonment). The troubles of victims' families can be ameliorated by developing the skills of caring for COVID-19 patients at home, providing medical and psychological services to families before and after the patient's death, appropriately informing the families to guarantee them about dignity and respect and respect of the deceased at the interment, and developing a culture of virtual condolence to provide emotional support to survivors.

Prediction Models for Impending Death Using Physical Signs and Vital Signs in Noncancer Patients: A Prospective Longitudinal Observational Study

Background: Accurate information on the prognosis in the last days of life is essential for providing better end-of-life care; however, few studies have examined the signs of impending death (SID) or developed short-term prediction models in noncancer patients.

Objective: To investigate the prevalence and onset of SID and to develop models that predict death within 7 days, 72 hours, and 24 hours in noncancer patients.

Design: This is a prospective longitudinal observational study.

Setting/Subjects: Subjects were noncancer patients admitted to a hospital in Japan between 2019 and 2020.

Measurements: We investigated 11 physical signs and vital signs every 12 hours until death after confirming a reduced daily oral intake to less than a few mouthfuls.

Results: We analyzed data from 50 noncancer patients. The prediction model “pulselessness of the radial artery OR respiration of mandibular movement OR the shock Index (SI) >1.0” predicted death within 7 days with an accuracy of 83.9%, whereas the models developed to predict death within 72 and 24 hours had an accuracy of 65.0% or less. The median onset of all signs was within 3 days of death. The frequencies of decreased response to verbal stimuli and decreased response to visual stimuli were 76.0% and 74.0%, respectively.

Conclusions: The prediction model using physical signs and SI predicted death within 7 days in noncancer patients with high accuracy. The prediction of death within 72 and 24 hours in noncancer patients requires investigation of physical signs not examined in this study.

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.

The effect of structured virtual patient visits (sVPVs) on COVID-19 patients and relatives' anxiety levels in intensive care unit

AIM AND OBJECTIVES

To determine the effect of structured Virtual Patient Visits (sVPVs) on the anxiety, satisfaction, hospital anxiety and depression levels of intensive care unit (ICU) COVID-19 patients and their relatives.

BACKGROUND

There is no evidence regarding the direct effect of virtual patient visits in the ICU.

DESIGN

The STROBE statement guided this study. This investigator-initiated, prospective and single-centre study included COVID-19 patients and their relatives in an adult ICU between July and December 2020. We implemented daily sVPVs between all patients and their relatives. The study's primary outcome was the daily anxiety levels of patients and relatives immediately before and after sVPVs. The secondary outcomes were as follows: 1) hospital anxiety (HADS-A) and depression (HADS-D) levels during admission to and after discharge from the ICU and 2) satisfaction levels regarding the ICU and sVPVs of patients' relatives.

RESULTS

A total number of 301 daily sVPVs were conducted between 50 patients and their relatives. There was a significant difference between daily anxiety levels before and after sVPVs in both patients (2.97 vs. 1.49) and their relatives (5.70 vs. 3.53; p > .05). Whereas the anxiety levels of patients with basic face or high flow nasal cannula and non-invasive mechanical ventilation decreased statistically significantly more than those with IMV after a sVPV (p < .001), there was not a significant difference in decreased anxiety levels of patients' relatives according to the type of respiratory support provided to the patient (p > .05). HADS-A levels of relatives decreased statistically significantly after discharge/death. There was no statistically significant difference in HADS-A and HADS-D levels after discharge/death between the relatives of patients who died or did not die (p > .05). Furthermore, the overall ICU satisfaction rates were statistically significantly lower in relatives of patients who died than those who did not die (p < .05).

CONCLUSION

Regardless of whether the patients were intubated, sVPVs reduced the anxiety levels of all patients and relatives. The sVPV programme offered emotional support to patients and family members, with high levels of satisfaction, as well as provided regular informative updates and the opportunity for daily visits or final goodbyes.

RELEVANCE FOR CLINICAL PRACTICE

The sVPV programme is essential for all ICUs during the COVID-19 pandemic.

Expressing grief through metaphors: family caregivers' experience of care and grief during the Covid-19 pandemic

Purpose: The COVID-19 pandemic has disrupted thousands of individuals’ experience of caregiving and grief. This qualitative study aimed to gain in-dept understanding of family caregivers’ lived experiences of caregiving and bereavement in the context of the COVID-19 pandemic in Quebec, Canada. The study also aimed at providing new insight about caregiving and bereavement by analysing the metaphors family caregivers use to report their experiences. Methods: The design of this study was guided by an interpretative phenomenological approach. In-depth interviews were conducted with twenty bereaved family caregivers who had lost a loved one during the first waves of the pandemic. Results: Results indicate that bereaved family caregivers lived and understood their experience in terms of metaphoric cut-offs, obstructions and shockwaves. These three metaphors represented the grief process and the bereaved’s quest for social connection, narrative coherence and recognition. Conclusion: By identifying the meaning of the bereaved’s metaphors and the quest they reveal, our study underlines the singularity of pandemic grief and points to the value and meaning of caregiving with regard to the grieving process.

A Modified Delphi Process to Prioritize Experiences and Guidance Related to ICU Restricted Visitation Policies During the Coronavirus Disease 2019 Pandemic

To create evidence-based consensus statements for restricted ICU visitation policies to support critically ill patients, families, and healthcare professionals during current and future pandemics.

DESIGN

Three rounds of a remote modified Delphi consensus process.

SETTING

Online survey and virtual polling from February 2, 2021, to April 8, 2021.

SUBJECTS

Stakeholders (patients, families, clinicians, researchers, allied health professionals, decision-makers) admitted to or working in Canadian ICUs during the coronavirus disease 2019 pandemic.

MEASUREMENTS AND MAIN RESULTS

During Round 1, key stakeholders used a 9-point Likert scale to rate experiences (1-not significant, 9-significant impact on patients, families, healthcare professionals, or patient- and family-centered care) and strategies (1-not essential, 9-essential recommendation for inclusion in the development of restricted visitation policies) and used a free-text box to capture experiences/strategies we may have missed. Consensus was achieved if the median score was 7-9 or 1-3. During Round 2, participants used a 9-point Likert scale to re-rate experiences/strategies that did not meet consensus during Round 1 (median score of 4-6) and rate new items identified in Round 1. During Rounds 2 and 3, participants ranked items that reached consensus by order of importance (relative to other related items and experiences) using a weighted ranking system (0-100 points). Participants prioritized 11 experiences (e.g., variability of family's comfort with technology, healthcare professional moral distress) and developed 21 consensus statements (e.g., communicate policy changes to the hospital staff before the public, permit visitors at end-of-life regardless of coronavirus disease 2019 status, creating a clear definition for end-of-life) regarding restricted visitation policies.

CONCLUSIONS

We have formulated evidence-informed consensus statements regarding restricted visitation policies informed by diverse stakeholders, which could enhance patient- and family-centered care during a pandemic.

Antibiotic stewardship program (ASP) in palliative care: antibiotics, to give or not to give

Antimicrobial therapy in terminally ill patients remains controversial as goals of care tend to be focused on optimizing comfort. International guidelines recommend for antibiotic stewardship program (ASP) involvement in antibiotic decisions in palliative patients. The primary objective was to evaluate the clinical impact of ASP interventions made to stop broad-spectrum intravenous antibiotics in terminally ill patients. This was a retrospective chart review of 459 terminally ill patients in Singapore General Hospital audited by ASP between December 2010 and December 2018. Antibiotic duration, time-to-terminal discharge for end-of-life care, time-to-mortality, and mortality rates of patients with antibiotics ceased or continued upon ASP recommendations were compared. A total of 283 and 176 antibiotic courses were ceased and continued post-intervention, respectively. The intervention acceptance rate was 61.7%. The 7-day mortality rate (47.3% vs 61.9%, p = 0.003) was lower in the ceased group, while 30-day mortality rate (76.0% vs 81.2%, p = 0.203) and time-to-mortality post-intervention (3 [0-24] vs 2 [0-27] days, p = 0.066) did not differ between the ceased and continued groups. After excluding the 57 patients who had antibiotics continued until death within 48 h of intervention, only time-to-mortality post-intervention was statistically significantly shorter in the ceased group (3 [0-24] vs 4 [0-27], p < 0.001). Of the 131 terminally discharged patients, antibiotic duration (4 [0-17] vs 6.5 [1-14] days, p = 0.001) and time-to-terminal discharge post-intervention (6 [0-74] vs 10.5 [3-63] days, p = 0.001) were shorter in the ceased group. Antibiotic cessation in terminally ill patients was safe, and was associated with a significantly shorter time-to-terminal discharge.

End-Of-Life Care in the Time of COVID-19: Communication Matters More Than Ever

CONTEXT

The COVID-19 pandemic resulted in visitation restrictions across most health care settings, necessitating the use of remote communication to facilitate communication among families, patients and health care teams.

OBJECTIVE

To examine the impact of remote communication on families' evaluation of end-of-life care during the COVID-19 pandemic.

METHODS

Retrospective, cross-sectional, mixed methods study using data from an after-death survey administered from March 17-June 30, 2020. The primary outcome was the next of kin's global assessment of care during the Veteran's last month of life.

RESULTS

Data were obtained from the next-of-kin of 328 Veterans who died in an inpatient unit (i.e., acute care, intensive care, nursing home, hospice units) in one of 37 VA medical centers with the highest numbers of COVID-19 cases. The adjusted percentage of bereaved families reporting excellent overall end-of-life care was statistically significantly higher among those reporting Very Effective remote communication compared to those reporting that remote communication was Mostly, Somewhat, or Not at All Effective (69.5% vs. 35.7%). Similar differences were observed in evaluations of remote communication effectiveness with the health care team. Overall, 81.3% of family members who offered positive comments about communication with either the Veteran or the health care team reported excellent overall end-of-life care vs. 28.4% who made negative comments.

CONCLUSIONS

Effective remote communication with the patient and the health care team was associated with significantly better ratings of the overall experience of end-of-life care by bereaved family members. Our findings offer timely insights into the importance of remote communication strategies.

'Saying goodbye' during the COVID-19 pandemic: A document analysis of online newspapers with implications for end of life care

BACKGROUND

News media create a sense-making narrative, shaping, reflecting and enforcing cultural ideas and experiences. Reportage of COVID-related death and bereavement illuminates public perceptions of, and responses to, the COVID-19 pandemic.

AIM

We aimed to explore British newspaper representations of 'saying goodbye' before and after a COVID-related death and consider clinical implications.

DESIGN

Document analysis of UK online newspaper articles published during 2 week-long periods in March-April 2020.

DATA SOURCES

The seven most-read online newspapers were searched: The Guardian, The Daily Mail, The Telegraph, The Mirror, The Sun, The Times and The Metro. Fifty-five articles discussed bereavement after a human death from COVID-19, published during 18/03-24/03/2020 (the UK's transition into lockdown) or 08/04-14/04/2020 (the UK peak of the pandemic's first wave).

RESULTS

The act of 'saying goodbye' (before, during and after death) was central to media representations of COVID bereavement, represented as inherently important and profoundly disrupted. Bedside access was portrayed as restricted, variable and uncertain, with families begging or bargaining for contact. Video-link goodbyes were described with ambivalence. Patients were portrayed as 'dying alone' regardless of clinician presence. Funerals were portrayed as travesties and grieving alone as unnatural. Articles focused on what was forbidden and offered little practical guidance.

CONCLUSION

Newspapers portrayed COVID-19 as disruptive to rituals of 'saying goodbye' before, during and after death. Adaptations were presented as insufficient attempts to ameliorate tragic situations. More nuanced and supportive reporting is recommended. Clinicians and other professionals supporting the bereaved can play an important role in offering alternative narratives.

Sadness, despair and anger when a patient dies alone from COVID-19: A thematic content analysis of Twitter data from bereaved family members and friends

BACKGROUND

To inform clinical practice and policy, it is essential to understand the lived experience of health and social care policies, including restricted visitation policies towards the end of life.

AIM

To explore the views and experiences of Twitter social media users who reported that a relative, friend or acquaintance died of COVID-19 without a family member/friend present.

DESIGN

Qualitative content analysis of English-language tweets.

DATA SOURCES

Twitter data collected 7-20th April 2020. A bespoke software system harvested selected publicly-available tweets from the Twitter application programming interface. After filtering we hand-screened tweets to include only those referring to a relative, friend or acquaintance who died alone of COVID-19. Data were analysed using thematic content analysis.

RESULTS

9328 tweets were hand-screened; 196 were included. Twitter users expressed sadness, despair, hopelessness and anger about their experience and loss. Saying goodbye via video-conferencing technology was viewed ambivalently. Clinicians' presence during a death was little consolation. Anger, frustration and blame were directed at governments' inaction/policies or the public. The sadness of not being able to say goodbye as wished was compounded by lack of social support and disrupted after-death rituals. Users expressed a sense of political neglect/mistreatment alongside calls for action. They also used the platform to reinforce public health messages, express condolences and pay tribute.

CONCLUSION

Twitter was used for collective mourning and support and to promote public health messaging. End-of-life care providers should facilitate and optimise contact with loved ones, even when strict visitation policies are necessary, and provide proactive bereavement support.

Health and social care professionals' experiences of providing end of life care during the COVID-19 pandemic: A qualitative study

BACKGROUND

Health and social care professionals' ability to address the needs of patients and their relatives at end of life is likely to have been impacted by the COVID-19 pandemic.

AIM

To explore health and social care professionals' experiences of providing end of life care during the COVID-19 pandemic to help inform current/future clinical practice and policy.

DESIGN

A qualitative interview study. Data were analysed using thematic analysis.

SETTING/PARTICIPANTS

Sixteen health and social care professionals working across a range of clinical settings in supporting dying patients during the first wave (March-June 2020) of the COVID-19 pandemic in the United Kingdom.

RESULTS

Participants reported emotional and practical challenges to providing end of life care during the pandemic, including increases in patient numbers, reduced staffing levels and relying on virtual platforms for sensitive, emotive conversations with relatives. Participants were central to promoting connections between patients and their families at end of life and creating opportunities for a final contact before the death. However, the provision of support varied as a consequence of the pressures of the pandemic. Results are discussed under two themes: (1) challenges and facilitators to providing end of life care, and (2) support needs of relatives when a family member was dying during the COVID-19 pandemic.

CONCLUSION

There is a need for flexible visiting arrangements at end of life during a pandemic. A systems-level approach is necessary to promote the wellbeing of health and social care professionals providing end of life care during and after a pandemic.

Life-and-Death Attitude and Its Formation Process and End-of-Life Care Expectations Among the Elderly Under Traditional Chinese Culture: A Qualitative Study

Introduction

With the global aging process intensified, the demand for end-of-life care has surged, especially in China. However, its development is restricted. Understanding the life and death attitude among the elderly and its formation process, and clarifying their needs, are so important to promote social popularization of end-of-life care.

Methodology

This qualitative study included 20 elderly residents in Nan and Shuangbei Communities, Chongqing City, People’s Republic of China. Data were collected through semistructured in-depth individual interviews and processed by thematic analysis method.

Results

Three themes and eight subthemes were identified: Characteristics of formation process (passive thinking, closed and single), life-and-death attitude (cherish and enjoy life, quality of life priority, let death take its course) and expectations of end-of-life care (preferences, basic needs, good death).

Discussion

Life-and-death attitude and end-of-life care expectations of the elderly support the development and delivery of end-of-life care. Furthermore, the individual-family-hospital linkage discussion channel needs to be further explored.

'Face time' for the first time: Video communication between relatives and junior doctors in the COVID-19 pandemic

Working on a COVID-19 ward presents a number of challenges to staff, with communication between families, patients and staff being highlighted as a key challenge. Novel methods are needed to overcome the barriers presented by COVID-19, with many turning to technology to offer solutions. Recognising these challenges as an area for improvement on our own ward, we sought to introduce new methods of communication to improve patient, relative and staff understanding and wellbeing. Through our own experiences and a discussion of the literature on this topic, we have identified some key themes which we believe can assist in the development of communication strategies in the developing pandemic.

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'.

Pandemic grief in Poland: adaptation of a measure and its relationship with social support and resilience

Millions of people are mourning the death of a loved to COVID-19. According to previous studies, the circumstances of coronavirus disease-related deaths may lead to dysfunctional grief. The purpose of this study was to introduce the Polish adaptation of the Pandemic Grief Scale (PGS) as well as to assess the relationship between dysfunctional grief due to a COVID-19 death, resilience and perceived social support. The adaptation was carried out on a general population sample of 286 individuals aged 18-54 years, with the evaluation being performed on a group comprising 214 people aged 18-78 years, who lost a loved one during the pandemic. The Polish version of PGS revealed a single-factor structure with strong internal consistency (α = 0.89). The PGS scores were associated with measures of complicated grief (Inventory of Complicated Grief), depression (Kutcher Adolescent Depression Scale) and lower resilience (Resilience Scale 14), which confirmed the scale's convergent validity. No relation between PGS scores and health behaviors (Inventory of Health Behaviors) was observed, which confirmed the scale's discriminant validity. The results of the bootstrapping technique revealed that resilience mediates the relationship between perceived social support (Multidimensional Scale of Perceived Social Support) and dysfunctional grief (total mediation). The results of this study suggest the need for practitioners to focus on resilience-enhancing interventions and perceived social support in order to improve mental health in people who lost their loved ones during the new coronavirus pandemic.