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

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).

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?”

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).

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 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).

COVID-19 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.