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Loss and Grief during the COVID-19 Pandemic

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Loss and Grief During the COVID-19 Pandemic Francine Cournos, MD Jameela Yusuff, MD, MPH Jonathan Fernández – Jiménez, PSY.D. June 17, 2020 1 Disclosures “This webinar is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $3,960,119 with zero percentage financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government.” 2 Disclosures The presenters have no financial relationships to disclose and will not be discussing the off-label or investigational use of products. 3 Objectives Describe what studies, surveys and first-person accounts reveal about the nature of loss and grief during the COVID-19 pandemic. Consider how current experiences with the COVID-19 pandemic may resonate with feelings of loss and grief associated with the HIV epidemic. Reflect on their own personal emotions and coping skills as we live through COVID-19 related losses and grief. 4 4 Loss is continuous during the COVID-19 pandemic. Losses that we all share include: Disruption of normal home and work routines Restricted opportunities for socialization Inability to gather in large groups, e.g. graduations, weddings, funerals, religious services Limited access to recreational activities, e.g. clubs, movies, sports, cultural institutions Loss of a sense of control and safety Loss and Grief During the COVID-19 Pandemic 5 5 . Serious and/or specific losses include: Job loss, especially in the context of limited economic resources Loss of a business Deaths of co-workers, neighbors and acquaintances Deaths of intimate partners, family members and close friends Loss of one’s own health as a result of COVID-19 infection and its sequelae. Loss and Grief During the COVID-19 Pandemic 6 6 . Loss of a sense of control and competence as we face a previously unknown pathogen Loss of a sense of safety at work Loss of the patients we could not save COVID-19 illness and even death among our colleagues on the frontlines of emergency responses, even at times by suicide Loss of physical touch as we seek to share our grief with our colleagues and provide comfort to patients’ families Loss and Grief among Healthcare Workers During the COVID-19 Pandemic 7 7 . In residential settings (e.g. hospitals, nursing homes) social distancing may have prevented loved ones from spending time with and comforting ill relatives. Health care providers may play an increased role in: Providing support to ill and dying patients Sharing good and bad news virtually with family members who have not been allowed to visit Offering words of comfort when giving news about a death Recognizing and coping with their own grief Role of Health Care Providers in Dealing with Loss and Grief During COVID-19 Pandemic 8 8 . Anna Duarte Velasco, Nurse, Spain* “The look of fear of dying in many people’s eyes will never be erased from my memory. I feel rage and helplessness because many families have not been able to say goodbye. So much lonely mourning…” “But it makes me feel a bit better to know that although their families were not there, we were there holding their hands in their last moments.” *Source: The New York Times 9 Anna Duarte Velasco, Nurse, Spain* Many of my colleagues have already been infected… It is terrifying to think that we can be a source of contagion… This makes many of us isolate ourselves, even from the people who live in our houses. Something that seemed temporary is becoming a way of life…without kisses, without hugs and without the warmth that we need so much at this moment. Seeing our patients recover is one of the best therapies. I feel like I’m in the right place.” *Source: New York Times 10 Jeffrey Oppenheim, Neurosurgeon, N.Y * “As a neurosurgeon, I’ve always found it important to contain my emotions. These last two months I’ve cried more than I have in decades. Allowing myself that vulnerability has been cathartic.” *Source: The New York Times 11 Cassidy Shemelia, MSW, LSW, US * Working through the pandemic daily has forced me to make adjustments in my personal life to protect the ones I love. I haven’t seen my parents in more than a month. It gives me peace of mind to know that even if I happen to be exposed, I would not be transmitting it to them. This also brings sorrow… This is quite a time of uncertainty that will have a lasting impact on us all.  “ *Source: The New Social Worker 12 Loss and grief were very pronounced among healthcare workers and their patients prior to effective antiretroviral treatment for HIV (before 1996). Even after 1996, our progress was slow and gradual before we could declare that HIV infection had become a manageable chronic disease. Reawakening of Losses and Grief During the HIV Epidemic 13 13 . Many healthcare workers with the skills and expertise to treat HIV infection are now being called upon to respond to COVID-19. Past HIV-related losses and grief may be powerfully re-evoked by the COVID-19 pandemic, accompanied by a similar sense of helplessness and confusion. Reawakening of Loss and Grief from the Early Years of the HIV Epidemic 14 14 . We all know grief, both personally and professionally Grief is a natural response to loss and is intrinsic to life. Symptoms of grief include shock, disbelief, sadness, anger, fear, guilt and physical symptoms. Grief usually goes through an intense phase and then gradually lessens. Cultures and individuals vary in how they express grief and conduct funeral rituals for those who have died. To manage grief, most people turn to their existing support systems for comfort. We now need on-line opportunities to grieve together. Grief 15 15 . Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis 59 papers met criteria for inclusion Studies examined risk and protective factors for the psychological well-being of healthcare workers in any clinical setting responding to COVID-19, SARS, MERS, Ebola and severe strains of Influenza A The authors made recommendations for healthcare workers responding to COVID-19 based on the results 16 Kisley, Warren, McMahon, Dalais, Henry, Siskind. BMJ, May 2020 Kisley, et. al Review: Some Strategies that May Help (Including with Loss and Grief in Accordance with Categories Created By the Presenter) Does our workplace care if we, and those we love, live or die? Provision of protective gear (PPE) Measures to increase safety (e.g. ventilation, reduced patient density, etc.) Training and education around infectious diseases Enforcement of infection control procedures Alternative accommodation for staff who are concerned about infecting their families Guaranteed food and daily living supplies 17 Kisley, et. al Review: Some Strategies that May Help (Including with Loss and Grief in Accordance with Categories Created By the Presenter) What supports improve coping? Sufficient rest, time off, breaks during work Clear and supportive communication in care settings Staff “buddy” system to support personal precautionary measures Peer and family supports Video facilities for staff to contact significant others Opportunities for reflection on the effects of stress Access to psychological interventions Recognition of staff efforts The recovery of colleagues and patients 18 Loss and Grief during the COVID-19 Pandemic 19 Jameela Yusuff, MD, MPH Medical Director, SUNY Downstate Medical Center Northeast/Caribbean AIDS Education and Training Center A Day in the Life… Patient Care Provider- Personal level Environmental -Number of critically patients -Complexity of patients -Managing remotely ill patients -Conduit between family-patient -Emotional taxing/draining -Unclear treatment protocols -Changing recommendations -Redeployment -Protecting yourself -Seeing colleagues ill/die -Dealing with ill family or friends -Living apart from family -Whole life disrupted…other plans?! -Homeschooling/HHA/career –life plans -Information overload -Supporting Staff/Colleagues -Hearing code alarms constantly -Emptiness of some parts of hospital -Remote work –isolation -Stress of securing protective equipment -Anxiety of “bringing home COVID” -Depersonalization—in PPE all the time -Screenings at the entrance -Tents in the streets -ICU—plastic dividers -Clinic Relocated Jameela J. Yusuff, MD MPH FACP Loss and Grief from the Eyes of a Mental Health Worker in Puerto Rico & the aftermath of COVID-19 21 JONATHAN FERNANDEZ-JIMENEZ, Psy.D Behavioral Health Faculty Northeast/Caribbean AIDS Education and Training Center Puerto Rico Let’s put this in context… Hurricane Maria: September 2017 Worst humanitarian crisis in the modern history of PR 4,645 deaths $90 billion in damages 95% power grid destroyed (2-7 Months without power) No cellular communication Ineffective local and federal response Suicide rates spiked (ASSMCA, 2018) Anxiety arise because people tried to survive day to day 22 Let’s put this in context… Re-construction, 2018 Almost 130,000 people left the island (4% population) Bureaucracy in government processes delayed the recovery of the economic sectors Most property insurance did not respond for damages Summer Uprising, 2019 Its was a collective catharsis spurred by societal trauma and the indignation by an uncaring government Tension between protester and security officials where held in the Old San Juan for weeks Governor announced his resignation on July 24, 2019 23 Let’s put this in context… New Years Earthquakes, 2020 Magnitude 6.4 (January 7, 2020) Power outage for one week Almost 9,000 refugees Trauma re-experienced The people for the people 24 COVID-19 On March 13, Puerto Rico closed all public schools, other academic institutions switch to remote education On the same day, Puerto Rico imposed people’s temperature check at all ports of entry Stay-at-home orders and social distancing guidelines were in place in Puerto Rico by March 15 People could only go out to purchase essential items or obtain essential services from 5:00 AM to 9:00 PM. All businesses, with the exception of grocery stores, supermarkets, gas stations, pharmacies, and medical providers, were required to close. 25 What we lost… Freedom: We still on lockdown until June, 29 (10:00 pm to 5:00 am) Social connectedness: If you know any Puertorriqueño you should know that “distanciamiento social” its not our way of life. Focus: The official data that we have from the department of health its confusing and change very often, this increase the perception of vulnerability and risk. What's its really happening? Trust: As a result of continued trauma and inefficient response to the emergency, people do not trust in officials and start recklessness behaviors that put themselves on risk. 26 What do we do… As healthcare providers Recognize and ventilate our own emotions, frustration and fear Be honest with yourself and your patients Don’t even try to be a superhero… people knows !!! Try to debrief with a colleague in a weekly basis Zoom video calls and happy hours Be careful with alcohol consumption Be prepared to recognize that you (by yourself) will not end this pandemic in a near future and the physical and psychological consequences will arise and increase through time. Keep focus on your wellbeing. 27 What do we do… As healthcare providers Try new ways to connect with your patients Change the easy way… Try new approaches Those are times of imminent change Try expand your help and referral network Recognize that not every service that your patient will need will be available and you will not cover all bases. Take care of yourself first, then tray to help others Its common to see colleagues struggling by this situation, be there, just be there… do not judge 28 What do we do… As healthcare providers If things gets complicated and you can not achieve emotional stability, find help… If you don’t find it…this is my number (787) 405-8634 Thank you! 29