Bereavement Care in the Wake of COVID-19: Offering Condolences and Referrals.

The coronavirus disease 2019 pandemic has left, and will continue to leave, hundreds of thousands of bereft family members in its wake (1). These deaths are unlike others in recent history. Unprecedented conditions—massive numbers of casualties; forced separations during a patient's final days; and denial of physical touch, final goodbyes, and traditional mourning rituals—pose threats to bereaved family members' mental health, leaving them vulnerable to intense and enduring psychological distress.

Front-line physicians are uniquely positioned to provide critically needed psychosocial support to bereaved family members. Regardless of medical specialty, physicians are now caring for more dying patients than ever before and, concomitantly, are tasked with talking to a deceased patient's family members. Many well-intentioned but weary and emotionally depleted physicians search for the words to say and wonder how to know when a bereaved family member is at risk and when they should refer them to a mental health professional.

To address this need, we offer words to say and guidance on when to make referrals to offset the risks that the pandemic has posed to family members' mental health. We recognize that communicating condolences in the context of a pandemic is challenging for many reasons, including the sheer volume of deaths, barriers to communication imposed by social distancing, time pressures, compassion fatigue, and mental and physical exhaustion. Our tips aim to make this difficult but potentially impactful interaction both easier for physicians responsible for talking with surviving family members and more comforting and beneficial for the bereaved family members. Specifically, we suggest ways to communicate compassionately, assess risk for acute bereavement challenges, and refer to a mental health professional when indicated (Table and Figure). This guidance is based on decades of research and clinical experience; we acknowledge that studies have not yet confirmed a link between these recommendations and better outcomes, nor their cultural universality.

Table. CARE: A Framework for Physicians' Condolence Communication With Surviving Family Members

Figure.

Sample script using CARE.

CARE = Communicate compassionately, Assess risk for acute bereavement challenges, Refer when appropriate, and Educate about resources.

Communicate Compassionately

Physicians speaking with family immediately after the death of a patient should begin by expressing how sorry they are for their loss, using the deceased patient's first name to personalize the death. They may have an impulse to say things to “fix” the situation, but in working with bereaved persons, we have learned that there are no easy fixes. Grieving family members have taught us that what they most appreciate is a physician's empathic presence—that is, a willingness to stay with their grief, feel their pain, and take a moment to acknowledge their loss and sorrow. Family members want to know that their loved one mattered. Physicians may ask if the family members have questions about the patient's final days or moments or the medical care that the patient received near death and may provide answers or reassurances. Finally, care should be demonstrated by asking how they are coping and waiting for a response (for example, not speaking while counting to 10). Some family members may seem numb, angry, or in shock, but this should not be interpreted as a lack of appreciation for the physician's effort. Communicating compassion is a way to show respect for the deceased patient and the bereaved family member; reduce feelings of abandonment by the medical team; and promote a sense of support, concern, and care (2).

Assess Risk

Providing adequate bereavement care requires the ability to identify and triage those in greatest need of targeted mental health services (3, 4). Bereavement poses risk for serious physical illness, including takotsubo cardiomyopathy, or “broken heart syndrome” (5); increases in substance use; and mental health disturbances (6), including major depressive disorder, posttraumatic stress disorder, and now prolonged grief disorder, a newly recognized psychiatric illness in the International Classification of Diseases, 11th Revision, and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) text revision (7). (As of this writing, the DSM-5 Text Revision Steering Committee formally approved prolonged grief disorder for inclusion as a new mental disorder. See www.psychiatry.org/psychiatrists/practice/dsm/proposed-changes.) Although there are multiple factors that increase bereavement risk (for example, sudden death, not having an opportunity to say goodbye, social isolation, dependence on the deceased, and history of mental health problems [3, 7]), physicians can ask 2 telling questions as an initial risk assessment: “Would you say that you've felt so overwhelmed by your loss and grief that you're having trouble coping; that is, that you're finding it hard just to get through the day?” and “Do you have support; that is, do you have someone to help you out or to talk to?”

Refer When Appropriate and Educate About Resources

On the basis of responses to these simple questions, physicians can distinguish those who may be in greatest immediate need and should be directly contacted by a mental health provider from those who can be provided with referrals and resources to use in the future should they need them. Physicians should let family members who are having difficulty coping or who lack even minimal support know that someone from their team will follow up with them. If possible, they should then alert a mental health provider from their team or hospital mental health services to contact these survivors for an evaluation; support; and, if indicated, a referral for specialized mental health care. If these resources are not available or if bereaved family members appear able to cope and do have support, they should be offered contact information for hospital bereavement services and community bereavement resources (see https://findingourway.prolongedgrief.com/ and the Supplement, available at Annals.org).

Indeed, not everyone needs or benefits from professional grief support (8). Caution should be taken not to pathologize intense mental and physical distress in the weeks and months immediately after loss because these are normal, expected reactions to a loved one's death. Clinicians should be more concerned about bereaved persons presenting with multiple bereavement risk factors or debilitating psychological symptoms, including suicidality (see Supplement Tables 1 and 2, available at Annals.org, for information on risk factors and distinctions between normative grief and bereavement-related mental disorders [3, 4, 7, 9, 10] and https://endoflife.weill.cornell.edu/grief-resources for additional grief resources).

Conclusion

Coronavirus disease 2019 has resulted in disturbing circumstances of death known to heighten risk for pathologic grief reactions (3). Physicians are well positioned to comfort and create a critical link to bereavement services for those who may need it. We offer brief guidance on how to assess risk and when to make a referral to a mental health provider, providing a road map for physicians who are navigating these challenging conversations and giving crucially needed support to bereaved family members in the wake of this pandemic.

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