Table 1.

Contexts of Grief Amid Rapid Changes/Impact Due to COVID-19 and Recommendations to Mitigate Grief

Changes Due to COVID-19	Impact	Context of Grief	Recommendations
Pandemic/spread of disease	Fear, worry, anticipation of spread Multiple losses in families; communities; long-term care facilities Individuals consider updates to advance directives—considerations for ventilation and resuscitation	Anticipatory grief for community—will someone I love be affected? When will the spread reach MY community? Anticipatory grief for medical personnel—planning for the “surge” Type6 and volume10 of losses a person experiences can impact complicated grief.	Preparing patients/families for a likely death is critical part of anticipatory grief work, which can impact likelihood for complicated grief. Utilize communication-based management, including recognizing, responding, and validating emotional responses, to address anticipatory grief.2 Approach difficult conversations directly and do not shy away from discussing emotions, grief, and overall patient and family distress during advance care planning conversations.22 During advance care planning, include discussions of desired ritual or spiritual practices and funeral/memorial plans.25 Connect patients/families to resources to help them consider postdeath planning needs and provide/refer to additional grief support through telehealth services. To enhance the role of self-care in overcoming accumulated stress and grief in providers, practice self-awareness.28 Some self-care strategies to help individuals cope with stress during an event include the following: being able to take breaks and disconnect from the disaster event, feeling prepared and informed in facilitating their response role, being aware of local resources and services to refer patients to for additional recovery assistance, and having adequate supervision and peer support while facilitating response.31
Social distancing or “stay at home” orders	Loss of financial security, loss of social/physical connections and support, loss of autonomy to move freely in the world Limitations in visitors or banning physical presence of family at bedside (in hospitals, long-term care facilities) Survivors must quarantine based on exposure to loved one Changes to end of life practices—how patients/family communicate/say goodbye; communication between patients & providers, between families & providers; Delays and limitations to funerals and/or burials	Overall, grief is an inherent part of our experiences due to the breadth of losses individuals are experiencing to “normal” life. Increase in likelihood for complicated grief (CG) for bereaved family based on impact as the following factors are associated with CG—inability to say “goodbye”4, preloss grief symptoms5, lower levels of social support5, lack of preparation for death6, guilt.9 Disenfranchised grief can occur when an individual does not follow social/mandated “rules” and becomes infected or spreads illness. Disenfranchised grief can occur when families are unable to grieve with normal practices of social support and rituals in burial and funeral services.
Increase in deaths, overburdening of hospital systems	Ethical considerations—triaging of resources, consideration of DNRs Providers may choose to isolate themselves from personal support systems to limit risk of exposure to family Guilt may be experienced by professionals who are unable to work due to exposure/contraction of COVID-19	Anticipatory grief for patients, families, providers—experiences that occur before death have lasting impact on grief4, 5, 6 Quality of the dying experience can impact occurrence of complicated grief in bereaved family. Potential for moral distress or secondary traumatic stress in medical personnel—use of avoidance, compartmentalization can lead to burnout and unresolved grief.14