A qualitative study of nursing practitioners' experiences with COVID-19 patients dying alone in Greece.

Background: In Greece, there is still limited research on death in isolation due to COVID-19. This deserves attention because of the recent financial crisis, which profoundly impacted public health, and the high relevance of the Hippocratic tradition to the moral values of clinical practice. Methods: A prospective qualitative study using in-depth interviews with 15 frontline nursing practitioners working in a COVID-19 ward or intensive care unit (ICU) was conducted from July 2021 to December 2021. Results: The inability of family members to say a final goodbye before, during, or after death by performing proper mourning rituals is extremely inhuman and profoundly impacts the mental health status of patients, family members, and nursing practitioners. Patients and their family members strongly desire to see each other. Epidemiology, liability, and proper nursing performance emerged as reasons for the enforced strict visitation restrictions. Participants emphasized that visitations should be allowed on an individual basis and highlighted the need for the effective use of remote communication technology, which, however, does not substitute for in-person contact. Importantly, physicians allowed "clandestine" visits on an individual basis. Nursing practitioners had a strong empathic attitude toward both patients and their families, and a strong willingness to provide holistic care and pay respect to dead bodies. However, they also experienced moral distress. Witnessing heartbreaking scenes with patients and/or their families causes nursing practitioners to experience intense psychological distress, which affects their family life rather than nursing performance. Ultimately, there was a shift from a patient-centered care model to a population-centered care model. Furthermore, we identified a range of policy- and culture-related factors that exaggerate the negative consequences of dying alone of COVID-19. Conclusion: These results reinforce the existing literature on several fronts. However, we identified some nuances related to political decisions and, most importantly, convictions that are deeply rooted in Greek culture. These findings are of great importance in planning tailored interventions to mitigate the problem of interest and have implications for other similar national contexts.

On Love, Dying Alone, and Community.

This paper examines the problem of dying alone in the context of no-visitors hospital policy during the COVID-19 pandemic. It critically analyses a rights-based solution, offering a democratized visitors policy alternative, premised on the value of legal justice. While an inclusive, participatory, and thoroughly justified visitors' policy, which takes into account the good of all stakeholders in the process, is indeed the right alternative to the paternalistic, top-down no-visitors policy, I argue that the democratized visitors' policy alternative ought to be grounded on reasons of both justice and love. Legal justice and claimable individual rights, though important, are limited and cannot fully capture the vicissitudes of mutual vulnerabilities and the moral stringency of duties of mutual care. In the context of suffering and death, instances of extreme vulnerability and interdependence, individual rights of autonomy and self-determination prove insufficient to meet our most basic needs for love, human presence, and accompaniment.

Dying From COVID-19: Loneliness, End-of-Life Discussions, and Support for Patients and Their Families in Nursing Homes and Hospitals. A National Register Study.

CONTEXT: Preparation for an impending death through end-of-life (EOL) discussions and human presence when a person is dying is important for both patients and families. OBJECTIVES: The aim was to study whether EOL discussions were offered and to what degree patients were alone at time of death when dying from coronavirus disease 2019 (COVID-19), comparing deaths in nursing homes and hospitals. METHODS: The national Swedish Register of Palliative Care was used. All expected deaths from COVID-19 in nursing homes and hospitals were compared with, and contrasted to, deaths in a reference population (deaths in 2019). RESULTS: A total of 1346 expected COVID-19 deaths in nursing homes (n = 908) and hospitals (n = 438) were analyzed. Those who died were of a more advanced age in nursing homes (mean 86.4 years) and of a lower age in hospitals (mean 80.7 years) (P < 0.0001). Fewer EOL discussions with patients were held compared with deaths in 2019 (74% vs. 79%, P < 0.001), and dying with someone present was much more uncommon (59% vs. 83%, P < 0.0001). In comparisons between nursing homes and hospital deaths, more patients dying in nursing homes were women (56% vs. 37%, P < 0.0001), and significantly fewer had a retained ability to express their will during the last week of life (54% vs. 89%, P < 0.0001). Relatives were present at time of death in only 13% and 24% of the cases in nursing homes and hospitals, respectively (P < 0.001). The corresponding figures for staff were 52% and 38% (P < 0.0001). CONCLUSION: Dying from COVID-19 negatively affects the possibility of holding an EOL discussion and the chances of dying with someone present. This has considerable social and existential consequences for both patients and families.

Responding to the fear of dying alone during COVID-19 pandemic.

A recent correspondence published in this journal rightly argues the meaning of creative ritual practices during the coronavirus disease 2019 (COVID-19) pandemic. Recent researches revealed the 'creative ways' to augment the need for spiritual and religious longing, complicated grief and different ways of coping with loss and coping mental health issues during the COVID-19 pandemic. This paper further adds the ways on how to mitigate the reality of dying alone during COVID-19 pandemic.

Dying alone and lonely dying: Media discourse and pandemic conditions.

BACKGROUND AND OBJECTIVES: This paper explores current concerns and practice related to older people dying alone in Intensive Care Units, care homes, and at home through media discussions during the Covid-19 pandemic and before. It addresses the historically-situated concept of a good death and a bad death and suggests why dying alone, whether completely alone or without significant others physically present, may be considered a bad death. METHODS: As evidence for collective fears about dying alone, we explored the treatment of these deaths in media using headline examples from the US New York Times and the English Guardian newspaper from the 19th century through Sept. 2020. RESULTS: A search of the New York Times located 39 articles with either lonely dying or lonely death in the headline. The Guardian had 25 articles with use of the term, but unlike the New York Times, no obituaries were included. Although the deaths profiled were deemed unusual, deaths by suicide were only minimally classed as dying alone. The condition of dying alone is represented as a stigmatised death. Themes addressed: 1) dying alone is a nonnormative event; 2) this death matters; and 3) where people die alone, societies should honour the death and learn from it. DISCUSSION AND IMPLICATIONS: Contemporary dying involves conditions for which we are unprepared as a society. We seldom address our civic obligations to each other. Few people have discussed their wishes about their preferences in dying and whether and how they want to be accompanied at their death, if possible. This is an invisible constraint of modern healthcare. Because of limited discussions and preparation, these deaths may lead to disenfranchised grief for the mourners. Cultural and societal responses to lonely dying are important in easing the emotional burden of dying alone, helping individuals prepare for this possibility and better integrating death with the life course. Recommendations include inclusion of accompaniment/nonaccompaniment at death as part of advance care planning and mitigation if this condition occurs. It is essential for individuals to find their own still point of acceptance within competing societal narratives of privileging the self in dying alone and the value of social connection.

New Normal Terminology.

The COVID-19 pandemic has required us to recognize a new normal and other additions to our general and clinical vocabulary. Some were preexisting terms that now have been broadened or changed during these unprecedented times. Others have helped to bring to light some of the issues or difficulties that healthcare professionals faced prior to this pandemic.