The COVID-19 global pandemic has disrupted virtually every facet of society, infecting millions of people and instilling lingering fear about what is yet to come. Lockdown procedures and guidelines have prevented families from being able to visit loved ones residing in nursing homes and hospitals. Even worse, COVID-19 has robbed people of the opportunity to say final goodbyes to those who have died. Nothing about this time is normal.

One nurse’s (Lange) personal experience

I entered nursing school with a specific interest in end-of-life care and, 2 years later, can say definitively that my heart is still there. Throughout my tenure as co-leader of the palliative care student interest group, I engaged in countless conversations about death and dying. In short, I thought I was “good” with death—at least intellectually.

Yet, about 3 months after my grandmother’s death, I was nearly overtaken by grief. My days were spent on the floor, crying, staring at a cherished photo of us from decades earlier. I can’t say whether I would have had the same reaction under normal circumstances, but nothing about this was normal. She died in April, towards the beginning of the COVID-19 pandemic in New York City, meaning we didn’t get to see her—not before making the difficult decision to send her to the emergency department alone, and not once it was clear she was dying. We didn’t get to bury her. We didn’t get to sit shiva.

At the time of her death, I hadn’t seen my family in months. We had a Zoom funeral, but I’ll always think about it as the “funeral.” I was angry with my family for talking about how lovely it was and angry when they marveled at the number of people who attended, as if that were an indication of anything. Six months later, I can see where they were coming from, but at the time it felt like a personal insult. Anger was easier than pain.

We had Zoom “shiva dates,” but they just made things worse. There’s nothing more awkward or isolating than sobbing alone on camera while people look at you with sympathetic eyes from their little squares, when all you really want is a private hug. I desperately needed to be held, which is precisely what the Jewish tradition of shiva provides, but I have never felt as acutely alone as I did in those moments.

We are not meant to grieve alone.

After the funeral, I cut off the handle of an old black tote bag to fashion a makeshift ribbon and pinned it to my shirt. The act of Kriah (literally, “tearing”) is an ancient Jewish tradition, an outward expression of grief and anger over the loss of a loved one. Typically, only immediate family participate, but tradition be darned. It was a Sunday afternoon, about a month into the pandemic, and the only people out were runners. The choice to wear black formalwear and a torn ribbon wasn’t out of a sense of obligation. It was a sign. I wanted to be seen. I wanted people to know what I was going through.

At the time of this writing, it’s been just over 6 months since my grandmother’s death. I’m still learning to take each moment as it comes. Feeling good or laughing doesn’t mean the pain is gone, just like spending a night crying doesn’t mean it will feel like this forever. We’re so quick to assign meaning, when some things just are. And grief, with all its ebbs and flows, is one of those things.

Characterizing grief

Whether personally or collectively, everyone is experiencing grief and bereavement to some degree due to the COVID-19 pandemic.

Anticipatory grief occurs when death is expected. Healthcare providers are experiencing anticipatory grief at unprecedented rates as COVID-19 cases and deaths continue increasing.

In times of crises, clinicians tend to compartmentalize emotions altogether in order to continue caring for patients; however, avoidance behaviors often lead to unresolved grief.

Many are experiencing feelings of disenfranchised grief as well, perpetuated by the inability to publicly mourn, participate in traditional rituals, and be in community.

The consequences of social distancing as a death occurs may increase potential for complicated grief. While presentation can vary by person, some common symptoms of complicated grief include ruminative thoughts about the individual who died, alienation from friends and family, anger, and anhedonia. Hospital and nursing home visitation restrictions have also led many to harbor chronic feelings of guilt.

Complicated grief is typically present among 10% to 20% of bereaved individuals (under pre-COVID-19 circumstances). A review by Gesi and colleagues posited that one death, on average, renders up to five grieving individuals. That means the number of people experiencing complicated grief could equate to the overall number of COVID-19 deaths in the coming months. Grief is not a novel concept, but the extent to which it is occurring at the individual, community, and societal levels is unprecedented. Therefore, it’s imperative that healthcare providers acknowledge and attempt to mitigate unhealthy grieving behaviors to the extent possible.

Here are some strategies for navigating grief throughout COVID-19 and beyond.

Going forward

The COVID-19 pandemic, although temporary, has caused unprecedented waves of grief for patients, families, and healthcare providers. Typical grief processes have been substantially disrupted, underscoring the need to safeguard normalcy where possible. The continuous stressors and lack of closure presented by the pandemic can place people at increased risk for complicated grief and bereavement. With no end in sight, integrating practices for navigating grief during COVID-19 and beyond may be useful. Above all, prioritizing personal wellness and self-care is of the utmost importance, as is proactively reaching out for professional help as needed.

Katie Nelson is a PhD candidate at Johns Hopkins University School of Nursing in Baltimore, and Rebecca Lange is a recent graduate of the school.

References

Billingsley L. Using video conferencing applications to share the death experience during the COVID-19 pandemic. J Radiol Nurs. 2020; in press. doi.org/10.1016/j.jradnu.2020.08.001

Gesi C, Carmassi C, Cerveri G, et al. Complicated grief: What to expect after the coronavirus pandemic. Front Psychiatry. 2020;11(489):1-5. doi.org/10.3389/fpsyt.2020.00489

Selman LE, Chao D, Sowden R, Marshall S, Chamberlain C, Koffman J. Bereavement support on the frontline of COVID-19: Recommendations for hospital clinicians. J Pain Symptom Manage. 2020;60(2):e81-86. doi.org/10.1016/j.jpainsymman.2020.04.024

Wallace CL, Wladkowski SP, Gibson A, White P. Grief during the COVID-19 pandemic: Considerations for palliative care providers. J Pain Symptom Manage. 2020;60(1):e70-6. doi.org/10.1016/j.jpainsymman.2020.04.012