Sustaining the unsustainable: Rapid implementation of a Support Intervention for Bereavement during the COVID-19 pandemic

Dear Editor,

At the end of October 2020, there have been over 1100,000 deaths globally from COVID-19, with more than seven million people bereaved. Usually, complicated grief (CG) is a chronic impairing condition that occurs in about 7% of bereaved people [1], but higher rates are expected after the SARS-CoV-2 pandemic, as this crisis encompasses several factors associated with the risk of complicated grief [2,3]. Among them, social distancing and visitor restrictions in healthcare facilities adversely affect medical providers, patients, and their families. Poor communication with relatives is also associated with CG [4,5]. Finally, bereaved individuals may themselves be treated in hospitals or isolated as suspect cases, therefore they may experience fear, worry about themselves, and stigma, while grieving the loss of family members. These factors may have lasting consequences after the worst of the pandemic has passed; thus, it is vital to provide bereavement support as soon as possible [6,7].

In order to prevent CG or intervene early, we rapidly deployed a creative telehealth solution that allowed us to support families and to deliver bereavement care. The aim was also to provide informal peer-support to frontline staff. We report the successful and rapid implementation of a Support Intervention for Bereavement (SIB) in a large academic hospital.

We recruited a multidisciplinary team and prepared a SIB in a matter of days. There were three steps for the support. The SIB involved screening for risk factors for CG, then referral if the family member agreed. Family members could have a one-time intervention or longer-term follow-up. We collected data screening risk factors for CG (Table 1 ). Between March 24th and May 14th (lockdown, March 16th-May 13th), the hotline received nineteen calls for an intervention. For full details on the participants and methods, please refer to Supplementary Material.

Table 1.

Data collected during the first-line intervention.

	Non related to COVID-19	Related to COVID-19
Hospital contact calling the SIB	Resuscitator doctor (ICU)/ psychologist/COVID-19 unit/ER/ mortuary
Socio demographic	-Age, sex, location, socio-economic status
Medical	-Antecedents -Previous mental health problem (previous complicated grief), actual follow-up	Infectious contamination
Environment	-Social support (may be lacking during the lockdown) -Presence of other relatives infected by COVID-19
Reasons for the call	-Help for announcement to other bereaved relatives -Request for help -Request for a relative -Other (free text)
Primary contact person relationship	Parent, child, partner, sibling, other
Grief context	Acute/ adaptation to loss/complicated grief
Death context	Brutal or not
Other recent losses or grieves	May concern other type of losses (jobs)	Lack of preparedness or limited opportunity to say « goodbye »
Previous trauma		Other deaths from COVID-19
Cultural/religious aspect		Observance of a ritual

ICU, Intensive Care Unit; ER, Emergency Room.

Complete description of results is also provided in supplementary material (quantitative and qualitative data). During the lockdown, there were 145 deaths in the hospital (36% from COVID-19). The hotline received 19 nineteen calls for an intervention of the SIB. The hospital contacts were various, including mortuary (10%) (Supplementary material, Fig. 1). At the beginning of the SIB deployment, we had several calls to support family of patients who were not dead (but with a high lethal risk). As caring for families prior to the patient's death facilitates post-loss adjustment [4], we agreed to include these relatives in the SIB. Fifteen relatives were followed, among them thirteen bereaved for ten deaths (on 52 deaths from COVID-19, 20%). The intervention was always individual (one on one). The breakdown of primary contact person's relationship with the deceased is described in Supplementary Material (Fig. 2). Most of the contacted relatives were female (79%) and were lacking social or familial support. All contacts (children, 53%, partner, 32%) reported several risk factors for a CG (no “goodbye”, 100%, no funeral rituals, 83%). Among the calls, 27% reported an infectious contagion via the dead/ill relative. 38.4% of the bereaved contacts asked for help in the funerary rituals, 31% sought help for the announcement to the other members of the family, 30% reported prior history of traumas, and 20% had experienced another bereavement in the past twelve months. The characteristics of the nineteen situations of the SIB are detailed in supplementary material.

Of our thirteen bereaved contacts, six were referred for psychological follow-up with volunteers of the SIB. They reported no suicidal intentionality but half of them expressed a heightened sense of guilt. Two bereaved felt stigma and felt ashamed to announce the cause of death to friends.

To our knowledge, this is the first study to report the rapid implementation of psychological support for bereaved individuals during the COVID-19 crisis. In designing our program, we benefitted from the wisdom of colleagues experienced in crisis intervention [8,9]. Proactively reaching out surrounding grief and loss may normalize the bereavement process, or at least help prevent traumatic reactions or CG. Two important issues to be addressed are the absence of funeral rituals and the high proportion of COVID-19 infections (and the intense feeling of guilt) among the relatives.

Another complementary approach was designed few days after the implementation of the SIB, for the whole region of Paris, with a dedicated hotline. However, we think that local interventions and on-site outreach teams allow a more personalized approach, in collaboration with COVID-19 frontline staff. This staff was particularly important for screening in complex situations, in which the bereaved might have lacked the capacity to seek help on their own. Reciprocally, allowing time to mediate and discuss challenging situations and grief can also be helpful to prevent burn-out and other grief-related troubles in frontline staff [10].

In conclusion, the current pandemic increases risk for CG in bereaved relatives. We hope that all hospitals implement basic bereavement outreach programs to prepare families for death and to support them afterwards, as well as provide basic support to frontline staff. After the crisis, other structures will be needed, such as bereavement support groups for relatives who lost someone during this pandemic.

Funding source

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

JM, HC, YLS, CD, MC: conception and design of the study; JM, HC, MC: acquisition of the data; JM, YLS, CD: analysis of data; JM: drafting the manuscript or figures; CD, YLS, JM, HC, MC: critical contribution to the final draft.

Appendix A. Supplementary data

Supplementary material 1: Figures

Supplementary material 2: Results

Supplementary material 3: Table 2

Supplementary material 4: Method

Data availability

Data will be made available on request.