Pursuing a Good Death in the Time of COVID-19

Journal of Palliative MedicineVol. 23, No. 6 Letters to the EditorFree AccessPursuing a Good Death in the Time of COVID-19Samuel S.Y. Wang, Winnie Z.Y. Teo, Chee Wai Yee, and Yong Woon ChaiSamuel S.Y. WangAddress correspondence to: Samuel S.Y. Wang, BMed, MD, Fast Program, Alexandra Hospital, National University Hospital System, Singapore E-mail Address: [email protected]Fast Program, Alexandra Hospital, National University Hospital System, Singapore.Search for more papers by this author, Winnie Z.Y. TeoFast Program, Alexandra Hospital, National University Hospital System, Singapore.Department of Hematology-Oncology, National Cancer Institute Singapore (NCIS), National University Health System, Singapore.Search for more papers by this author, Chee Wai YeeGrief Matters, Montfort Care, Singapore.Search for more papers by this author, and Yong Woon ChaiPalliative Program, Alexandra Hospital, National University Hospital System, Singapore.Department of Palliative medicine, National Cancer Institute Singapore (NCIS), National University Health System, Singapore.Search for more papers by this authorPublished Online:29 May 2020https://doi.org/10.1089/jpm.2020.0198AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail Dear Editor:Dying in Isolation: How Do We Support Patients and Family through Grief and Bereavement?The ongoing COVID-19 pandemic has brought about much mental and social anguish as it has physical suffering.1 The population that has the highest rate of mortality are those who are advanced in age, have multiple comorbidities, or are at an end stage of a life-limiting illness.1 However due to the highly infectious nature of COVID-19, it often leads to patients facing their final journey in social desolation. Additionally, due to stretched health-care resources and strict infection precautions, a dignified death may be compromised.2 As health-care professionals, we should aim to provide all terminally ill patients with the basic right of a dignified and peaceful death.2 This letter aims to highlight various measures one can undertake to reduce risk of infection transmission when providing end-of-life care to COVID-19 patients.Communication OptionsThe first step is to identify patients who are at high risk of deterioration. A discussion should be held with the patient's next of kin (NOK) and the patient to explore end-of-life options within the respective settings. Depending on prevailing isolation/social distancing policies and resources, the NOK can conduct videoconferencing sessions in the hospital.3 However, briefing must be done beforehand to prepare the NOK regarding the patient's condition and possibly how they appear visually. Additionally, the meeting must be supported by professional staff, with anticipation of psycho-emotional outbursts. Subsequent follow-up of the patient's and NOK's coping post videoconferencing is recommended in order to offer optimal support.Alternatively, a call-in option may be considered.3 Other options include prerecorded messages in the form of letters or audio recordings in conjunction with comfort objects, for example the patient's or NOK's treasured items can serve as a linking object for the patient and NOK. These items can be kept in the casket to signify a continuing bond between the patient and NOK. Other technology may include employing robots with the NOK's face, with audio available.3Upon a Patient's PassingUpon passing, the team can consider providing a dignified image of the deceased's face to the NOK with permission from the patient and NOK. This is important, as this might be the only visual evidence of the patient's death and it is also cathartic for the NOK who were unable to visit or communicate with the patient prior to their passing.4 Regarding funeral arrangements, a list of certified funeral companies who are able to comply with infection precautions should be provided. In Singapore, funerals are held with a windowless casket and are limited to a maximum of 3 days, with no more than 10 in attendance. Quarantined/vulnerable NOK are advised not to attend and are given the option of video streaming. Post-funeral bereavement should be assessed by the team with phone/video. A special Memorial Day can be arranged for families once permitted, with compliance to social distancing rules. These processes from start to end can be seen in Table 1.Table 1. Summary Showing Measures to Support Patients and Families through Grief and Bereavement during COVID-191. Prior to patient's passing2. Upon patient's passing3. Funeral arrangements4. Post-funeral bereavement follow-upIdentify patients at high risk of deterioratingDignified image of the deceased's face for visual evidence of the death and emotional catharsis(a) Wakes should be of short duration(a) Assess risk of NOK of not coping with bereavement(b) Offer video-streaming options for non-attendees(b) Offer support by phone/video for those under quarantine(c) Infection precautions during funeral wakes: minimize large crowds; provision of face masks, sanitizers, and individually packed food to guests; natural ventilation Videoconferencing in hospital if resources available and situation permissibleaProvide NOK with list of funeral companies that are certified to handle the caseConsider direct cremation with live streaming, video recording, and/or photography supportRefer NOK for longer-term follow-up with counsellors for prolonged grieving processWritten information regarding bereavement preparation related to COVID-19 may be providedAlternative options: Offering grieving and support using technology: set up online transfer of condolence money, stream videos and photo collages of the deceased and the send-off processConsider a special memorial for bereaved NOK for all deceased patients once pandemic is resolving • Call-in options • Audio recording • Written letters • Comfort objects to serve as emotional linkageaPotential concerns: (1) patients who are in ICU with various tubes and lines, with visual images that may potential cause disturbance; (2) NOK who are elderly, living alone, poor social support, with psychiatric history/suicidal risk.NOK, next of kin; ICU, intensive care unit.As Dame Cecily Saunders said, “How people die remains in the memory of those who live on.” Ultimately, the humanistic aspect of care to provide grief and bereavement support should stand tall, even in the tsunami of a pandemic. References1. Armitage R, Nellums LB. COVID-19 and the consequences of isolating the elderly. Lancet Public Health 2020 Mar 19 [Epub ahead of print]; DOI: 10.1016/S2468-2667(20)30061-X. Crossref, Google Scholar2. Ezer T, Lohman D, de Luca GB. Palliative care and human rights: a decade of evolution in standards. J Pain Symptom Manage 2018;55:S163–S169. Crossref, Medline, Google Scholar3. Ostherr K, Killoran P, Shegog R, et al. Death in the digital age: a systematic review of information and communication technologies in end-of-life care. J Palliat Med 2016;19:408–420. Link, Google Scholar4. Conlon MSC, Caswell JM, Knight A, et al. Impact of comprehensive hospice palliative care on end-of-life care: a propensity-score-matched retrospective observational study. CMAJ Open 2019;7:E197–E202. 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Levene28 December 2020 | Palliative Medicine Reports, Vol. 1, No. 1Grief of COVID-19 is a mental contagion, first family suicide in IranAsian Journal of PsychiatryBereavement in the Time of Coronavirus: Unprecedented Challenges Demand Novel Interventions18 May 2020 | Journal of Aging & Social Policy, Vol. 32, No. 4-5Death care during the COVID-19 pandemic: understanding the public health risksEnvironmental Health Review, Vol. 63, No. 2 Volume 23Issue 6Jun 2020 InformationCopyright 2020, Mary Ann Liebert, Inc., publishersTo cite this article:Samuel S.Y. Wang, Winnie Z.Y. Teo, Chee Wai Yee, and Yong Woon Chai.Pursuing a Good Death in the Time of COVID-19.Journal of Palliative Medicine.Jun 2020.754-755.http://doi.org/10.1089/jpm.2020.0198Published in Volume: 23 Issue 6: May 29, 2020Online Ahead of Print:April 20, 2020 TopicsCOVID-19 PDF download