Researchers from Weill Cornell Medicine and Memorial Sloan Kettering Cancer Center have published guidance on how physicians working on the front lines of the COVID-19 pandemic can compassionately inform family members of the painful news that their loved one has died.
The brief recommendations, appearing June 23 in Annals of Internal Medicine, are meant to help physicians experiencing an unprecedented number of deaths in such a short period console family members and provide a link to mental health support if needed.
The authors, who study bereavement, highlighted how grieving relatives may struggle because of the unique circumstances of the pandemic, in which many are unable to visit loved ones at hospitals, participate in traditional mourning rituals or get needed support because of social distancing protocols intended to reduce the spread of SARS-CoV-2.
"With the best of intentions, physicians might say the wrong thing at the wrong time, and we’re hoping that these recommendations, based on decades of hearing from bereaved family members who’ve been the recipients of these communications, will provide guidance on what is perceived by them to be helpful and what is hurtful,” said Dr. Holly Prigerson, the Irving Sherwood Wright Professor in Geriatrics and professor of sociology in medicine at Weill Cornell Medicine.
The authors also wanted to help physicians under extreme time pressures and emotional strains and who because of infection-control protocols may not be able to relay the news of a death in person. Some also may not have experience with these difficult conversations, or have not conducted them under the circumstances COVID has necessitated. For example, they may have never had the opportunity to meet surviving relatives, as they often do with patients who suffer a long-term illness, said Dr. Wendy Lichtenthal, a licensed clinical psychologist who is director of the Bereavement Clinic at Memorial Sloan Kettering.
“We tried to frame our suggestions for that weary clinician who is making these calls without much time, and has to figure out, ‘How do I offer my condolences after such an awful loss, and how can I figure out which bereaved family members might be struggling the most right now and might benefit from a mental health provider reaching out?’” added Dr. Lichtenthal, who is also an assistant professor of psychology in psychiatry at Weill Cornell Medicine.
Based on their experience with thousands of bereaved family members, Dr. Prigerson and Dr. Lichtenthal recommend that doctors use a patient’s first name, say how sorry they are for the family member's loss, and try to provide answers or reassurances when possible, such as answering questions about their relative’s last days or the medical care they received.
“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,” the authors write.
They advise physicians not to feel they have to “fix” the situation. “What can feel dismissive to a surviving family member is to say something like ’It’s for the best,’ ‘They’re out of their suffering,’ or ‘It could have been worse,’” added Dr. Prigerson, who is also co-director of the Center for Research on End-of-Life Care at Weill Cornell Medicine.
Grieving a loss can lead to increases in substance use or mental health disturbances, including major depressive disorder, post-traumatic stress disorder, and prolonged grief disorder. Prolonged grief disorder, a diagnosis that is recognized by the International Classification of Diseases and newly approved for inclusion in the psychiatric manual DSM-5-TR, refers to protracted, debilitating grief following the death of a loved one, linked to greater likelihood of disability or suicide.
Doctors can pose two questions to identify those who may be at greatest risk for more immediate bereavement challenges and may benefit from further evaluation by a mental health provider, the authors write. They suggest determining whether they are able to cope with their acute grief by asking whether they're “finding that their grief is making it hard just to get through the day,” and whether they have social support or are isolated by asking if they “have someone to help you out or talk to.”
A mental health provider from the healthcare system should follow up with an evaluation and possibly referral for care for family members who report difficulty coping or who lack support, as these individuals may be less likely to reach out for help themselves. For those who appear to have more coping resources, grieving relatives can be given contact information for hospital or community bereavement groups, some of which are available on the Center for Research of End-of-Life Care's grief resources page, to use if they feel they may need more support.
“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,” the authors note.
Ultimately the goal is to provide doctors with concise but consolatory words, and create “a critical link to bereavement services for those who may need it.”
The guidance, said Dr. Lichtenthal, “can be helpful for the physicians and also potentially beneficial to the families to help them feel like their loved one was not just another COVID statistic, but rather that they were seen and they mattered.”