Box 1.

Study implications for clinicians, policy makers and journalists.

Implications	Rationale
Avoid assuming that a COVID-19 death is inherently bad or worse than a typical death	Since media narratives affect the public, people’s fears, concerns and anxieties are likely to arise from media messaging. Negativity and lack of nuance were found in a study of media coverage of remote medical consultations during the pandemic 47 ; we found similar features in coverage of death and bereavement. The lack of positive advice for those affected, or examples of a ‘good enough’ death, may further stoke anxieties and reduce health-seeking behaviours. Avoiding assumptions that a COVID-19 death is ‘bad’ or ‘worse’ than a ‘typical’ death may be more supportive than following the common media narrative.
Use videolinks with caution and prioritise bedside access	Media portrayals demonstrate the strength of specific cultural concepts of a ‘good death’ and ‘good grief’. Whilst there is no single culturally accepted notion of ‘good death’ in the UK, 48 end-of-life care policy focuses on a particular set of attributes, 49 one of which is not dying alone. Adapted ways of saying goodbye, such as the use of videolinks or clinicians being present instead of loved ones, were generally portrayed as unnatural and insufficient. Recognising the power of these cultural narratives requires a cautious and individualised approach to the use of video-links at the end of life,50,11 and prioritising PPE availability in end-of-life care to enable in-person bedside access where possible.
Understand the importance of each stage of ‘goodbye’	We identified three stages of ‘saying goodbye’ (prior to, at the moment of, and after death). The importance of each stage will vary for everyone, reflecting feelings, preferences and cultural and religious values. The ability to say goodbye in a preferred manner is correlated with better social adjustment 51 in bereavement; however, where someone’s wishes cannot be met due to infection control restrictions, a meaningful goodbye might still be possible. Findings from Japan suggest meaningful communication, rather than physical presence, improves outcomes for bereaved people. 52 Clinicians will ideally understand the relative importance of each stage of saying goodbye for individual patients and families. Public health messaging to encourage Advance Care Planning or ‘What Matters Most’ conversations prior to serious illness can help patients, families and their care teams to work towards a life and death which is in line with patients’ and families’ wishes and values and ensure important conversations aren’t missed.45,46
Signpost families to bereavement services and provide support after a death	The unnaturalness and profound distress evident in media portrayals highlights the importance of signposting to bereavement services and proactively identifying and supporting those at particular risk of poor outcomes.4,53 Cumulative disrupted goodbyes may mean bereaved people require extra support, particularly in understanding how these missed opportunities affect their grieving process. Articles indicated that bereaved people may experience guilt and shame; professionals should be mindful that the choices bereaved people had to make may have ongoing mental health implications. Emerging evidence suggests more support is needed: a national survey (n = 532) found that 36% of bereaved people felt not at all supported by healthcare professionals immediately after the death and 51% were not provided with any information about bereavement support. 35
Health and social care staff can engage with the media and the public to share their stories and present an alternative narrative	Health and social care professionals and those working in bereavement services, supported by press offices where available, can play an important role in communicating with the media, engaging in public discourse and, crucially, offering the public an alternative narrative about healthcare, death and bereavement in the context of COVID-19. Many clinicians have taken on such a role during the pandemic, to great effect. 54 Social media can be a useful way to share stories, influence debates and contribute expertise, however clinicians should know social media posts might be printed in the media. Professional guidance exists to support healthcare staff. 55
Journalists could support the public and bereaved people by providing diverse narratives and practical guidance	We found little nuance in how end-of-life and bereavement experiences were portrayed, and little practical or useful guidance, for example, regarding what support might be available or what kind of funeral service might be possible. Newspaper reportage could raise awareness of the dying process, showcase a wider range of experiences of grief, and provide support to bereaved people. By providing diverse narratives and practical guidance, journalists could play an important supportive role.