Table 3.

Impacts of the pandemic on bereavement care practice

Theme	Illustrative quotes
1. Impact on services	Before COVID there needed to be an improvement in specialist bereavement services. The generic support provided by staff has become more difficult to provide - particularly during the height of COVID in the community setting when only essential visits were being done face to face. There still needs to be better access to bereavement services. Furthermore, there is no access to chaplaincy in the community setting which should be considered. (#582 palliative medicine doctor)
	As team leader of a small team of nurses providing a Hospice at Home service countywide. Prior to COVID −19 we had already identified there is a gap in follow up bereavement support for families of the patients who we have nursed. It is not something we have the capacity to do. (#670 community nurse)
	The staff adapted very professionally and quickly to ensure there were no gaps in sessions for those needing the service… We did have to write a whole new service protocol and generate new confidentiality statements and counselling contracts as the staff working with online platforms had to set out new boundaries for counselling and support, having looked into these boundaries, it was a bit scary at first because you have to protect the staff who can see into people homes and personal space and ensure there are no interruptions during the session with IT breaking down etc. However, now 5 months on from lockdown, we do find that the challenges and most clients engage well. (#475 head of information and supportive care services)
2. Impact on clinicians and relationships with patients	It has brought many challenges for both client and counsellor. Much of what happens in the counselling session is about reading body language and facial expressions. This has proven nearly impossible. Also it is much more difficult to build an empathic trusting relationship when there is a phone or computer in between client and counsellor. It has been harder to reach young bereaved people as not always appropriate to do telephone or video work. (#554 hospice bereavement counsellor)
	I found it really, really emotionally taxing. It is not in my normal day job to be having conversations. I found preparing patients and relatives for intubating knowing that may be the beginning of their grief journey incredibly hard. (#407 respiratory physiotherapist)
	This has been a difficult time for both the bereaved and staff. The bereaved have a reduced, non face to face service. The staff feel powerless and are restricted from doing the job they are passionate about. That said a great deal of learning has been going on and staff have been imaginative in finding new approaches. (#418 palliative care specialist nurse)
3. Impact on bereaved people	I feel it’s the isolation that is causing the greatest emotional and mental anguish. That, and the fact that many people saw their loved ones poorly at home, then taken to hospital, never to be seen again. This leaves very deep scars. So I feel peer support is fundamental to help bereaved families feel and share their story with others and, have a chance to hear someone’s else story. Grief is unique to every individual but community spirit helps heal, through a sense of belonging and walking with people who understand your pain. (#617 bereavement support worker/volunteer)
	The experience of grief is far more complex given majority of loved ones have been mostly separated from the dying person during the illness and even during most of the dying process… Families have experienced more complex guilt for feeling somehow they may have failed in their duty to shield vulnerable loved ones from the infection or that they couldn’t be united with their loved ones during the illness (#215 general practitioner)
	I have concerns that some bereavements may be more complex due to visiting restrictions - families may not have been able to say goodbye as they wished or had less time with their loved one. Some have changed their preferred place of death based on visiting restrictions. Some people dislike virtual support and prefer face to face, so it is likely that despite efforts, bereavement support has not been as high quality as it was. (#690 palliative care doctor)