COVID-19 is an infectious disease that is not only posing significant risk to public health and the way we cope with our daily lives; it is also posing a significant challenge to how we are dying and how we are mourning loved ones.
Death and Dying
Physical distancing restrictions related to COVID-19 have meant that many individuals are dying – or facing the prospect of dying – without the presence of family and friends around them, causing them feelings of isolation and psychological distress. Due to the strains facing health care workers and facilities, individuals in palliative care may also not be having their advanced-care directives fully realised (e.g., preferred location of death, life-prolonging measures).[i] This can be particularly problematic and distressing for those who are cognitively aware that their directives are not being met.
Those same restrictions are also causing distress for family and friends who are not being permitted to be with loved ones when they are ill or dying, thereby preventing the opportunity to hold someone’s hand, have a last meaningful conversation, affirm a bond, make amends, or simply say good-bye.[ii] Further causing distress is the haste with which some current provincial restrictions are forcing families to decide where to send a body within 1-3 hours of death, depending on whether the death occurred in hospital or in a long-term care facility.
Impacts on Mourning
Different cultures have their own customs and rituals for mourning. Physical distancing restrictions are also making it hard for people to come together socially with other mourners to grieve, spend time with or pay their final respects to the deceased, provide support to one another, and/or find comfort in their cultural or secular traditions, thereby contributing to grieving challenges and feelings of isolation.[iii]
When loved ones do not have the opportunity to say good-bye and cannot come together to provide physical comfort, they may not have the necessary closure – also known as ambiguous loss – they need to properly grieve.[iv] They may feel anger at those that have put the restrictions in place; regret at not having a chance to hold someone’s hand or make amends; worry that a loved one may not be being given appropriate care or necessary pain relief; and guilt over one’s own powerlessness and inability to be with a loved one in their time of need.
It is unknown how long physical distancing measures will be in place; as such, it is important for people to find new ways to both recognize the dying process and cope with grief. During the dying process, to the extent possible, video calling can connect patients with family members who are separated because of travel and/or visitor restrictions, offering some sense of comfort to patients in their last days and moments. Following death, friends and family can come together virtually, make use of online memorials, write more elaborate obituaries, and/or plan to hold services at a time when physical distancing restrictions are no longer in place.[v] While these measures are providing some means of honouring the deceased, they nonetheless cannot replace the physical comfort and connectedness one feels from a hug or hand-shake.
Disrupted, Complicated or Prolonged Grief
Although grief is a normal response to loss, “the grieving process itself is very individualized and personal such that everyone processes and experiences grief differently”.[vi] For many, coming together for a funeral or other cultural ritual to honour the death of an individual is an essential – and normal – step in the bereavement process. Not being able to come together to mourn may not only lead to ambiguous loss, these circumstances may also increase the likelihood of one experiencing disrupted, complicated or prolonged grief.
When Psychological Distress Becomes Too Much
Individuals experiencing disrupted, complicated or prolonged grief are at increased risk of substance use, sleep disorders, impaired immune functioning and suicidal thoughts.[vii]
While spiritual leaders are themselves being restricted from being with individuals as they pass and performing any last rites of passage, they can be a source of comfort to loved ones to help them cope with the loss. Psychologists and other mental health providers can also help with disrupted, complicated or prolonged grieving.
If the following signs and symptoms increase or worsen over time and impair overall functioning, they might signal need for help to cope with one’s grief:
- Sleeping poorly, too much or too little
- Avoiding others, even within the confines of social distancing
- Experiencing headaches, stomach problems, neck or back pain
- Crying excessively and all the time
- Talking less and being withdrawn
- Feeling dazed or disconnected from self or the reality
- Feeling anxious, depressed or having panic attacks
- Feeling angry, guilty, helpless, numb, or confused
- Not wanting to get out of bed
- Having difficulties concentrating or focusing
- Excessive eating for comfort
- Drinking more alcohol or taking prescription drugs more than prescribed
- Having little patience
- Feeling overprotective of loved ones
It is important to remember that most of us have had some of the signs and symptoms listed above at one time or another, and that COVID-19 has led to increased stress for most people. If you have a number of these signs and symptoms and they
- persist beyond a couple of weeks
- persist to the point where you are not able to carry out the home or work-related activities permitted by social distancing advisories
- are accompanied by intense feelings of despair, hopelessness, helplessness or suicidal thoughts
you are well advised to consult a regulated health care professional such as a psychologist, your family physician, psychiatrist, or other mental health provider.
Ontario Palliative Care Network, 2020. Planning for Palliative Care Delivery during the COVID-19 Pandemic. http://www.virtualhospice.ca/covid19/
Where do I go for more information?
To obtain important and up to date information about COVID-19, visit the Public Health Agency of Canada (PHAC) website at https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection.html
Provincial, territorial, and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, please visit: https://cpa.ca/public/whatisapsychologist/PTassociations
This fact sheet has been prepared for the Canadian Psychological Association by Dr. Lisa Votta-Bleeker, Deputy Chief Executive Officer, Canadian Psychological Association; Dr. Katy Kamkar, Clinical Psychologist, Centre for Addiction and Mental Health (CAMH) and Chair of the CPA’s Traumatic Stress Section; and Ms. Eva Sheppard-Perkins, Canadian Psychological Association.
Date: May 11, 2020
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[i] Arya, A., Buchman, S., Gagnon, B. and Downar, J., 2020. Pandemic palliative care: beyond ventilators and saving lives. Canadian Medical Association Journal, 192(15), pp. E400-E404.
[iii] Leong, I., Lee, A., Ng, T., Lee, L., Koh, N., Yap, E., Guay, S. and Ng, L., 2004. The challenge of providing holistic care in a viral epidemic: opportunities for palliative care. Palliative Medicine, 18(1), pp.12-18.
[v] Wolfelt, A., 2020. Exploring the Natural Complications of the “Whys” of Funerals During the Coronavirus Pandemic – Center For Loss & Life Transition. [online] Center for Loss & Life Transition. Available at: https://www.centerforloss.com/2020/04/funeral-whys-during-coronavirus/.
[vii] Shear, K.M. 2015. Complicated Grief, New England Journal of Medicine, Vol. 372, No. 2, pp: 153-160..