Grieving process of families who lost their loved ones by COVID-19: an integrative review

Processo de luto das famílias que perderam seus entes pela COVID-19: uma revisão integrativa

Abstract

Objective

This research aimed to identify, through an integrative literature review, the scientific production on the grieving process of those who lost loved ones due to the Coronavirus infection.

Method

For this purpose, methodologically, 124 articles were extracted from the BVS-Pepsic, SciELO, Lilacs, and MedLine databases in October 2021. From these, 22 articles were selected to compose the sample, which included empirical and review articles, theoretical studies, and experimental reports that specifically addressed the grief of family members over the age of 18 bereaved by COVID-19.

Results

As results, it was possible to observe the existence of particularities in the process of hospitalization and death due to the Coronavirus Disease, which can have an impact on the grieving process and generate mental health problems for the bereaved.

Conclusion

Therefore, it is concluded that the forecast of pandemic-related grief urgently requires effective strategies to identify, prevent, and treat functional impairments resulting from complications in the grieving process.

Keywords
Bereavement; Coronavirus; Family; Review

Resumo

Objetivo

Esta pesquisa teve como objetivo geral identificar, através de uma revisão integrativa da literatura, a produção científica sobre o processo de luto daqueles que perderam entes queridos pela infecção por Coronavírus.

Método

Em outubro de 2021, foram realizadas buscas nas bases de dados BVS-Pepsic, SciELO, Lilacs, e MedLine, com 124 artigos encontrados. Por fim, selecionou-se 22 para comporem a amostra, incluindo artigos empíricos, de revisão, estudos teóricos e relatos de experiência, que abordassem especificamente o luto de familiares maiores de 18 anos, que perderam seus entes pela COVID-19.

Resultados

Fi possível observar a existência de particularidades no processo de internação e morte pela Doença do Coronavírus, que podem repercutir no processo de luto, gerando problemas à saúde mental dos enlutados.

Conclusão

Conclui-se, assim, que a previsão de lutos em decorrência da pandemia demanda de maneira urgente estratégias eficazes para identificar, prevenir e tratar prejuízos funcionais decorrentes de complicações no processo de luto.

Palavras-chave
Luto; Coronavírus; Família; Revisão

The Coronavirus Disease (COVID-19) is an infectious respiratory illness caused by a novel human Coronavirus (SARS-CoV-2, Severe Acute Respiratory Syndrome Coronavirus 2). Its pandemic magnitude was declared on March 11, 2020, by the World Health Organization (World Health Organization, 2020). After reporting its first death from the disease on March 17, 2020, in the year 2022, Brazil surpassed the mark of 650,000 deaths (Freitas, 2022). There were even records of 4,249 deaths in 24 hours; over 4,000 Brazilians lost their lives within a day. These numbers placed Brazil as the second-highest country in the world in terms of deaths, second only to the United States (Ministério da Saúde, 2021).

Although the fight against the Coronavirus is a biological one, it closely resembles a war scenario, with so many lives lost, and such chaos spread worldwide (Fernandes & Silva, 2020). Moreover, mass deaths often generate various psychological implications, including the issue of grief.

Grief is a natural process of human response to the loss of a beloved object and the resulting psychological work of that loss (Freud, 1915/2010). It constitutes an important psychosocial transition, encompassing processes of adaptation and possible reconfigurations after the rupture of an affectionate bond (Braz & Franco, 2017; Parkes, 1998). The experience of loss leads the individual to an internal experience of security threats and requires significant readjustments in their presumed world (Parkes, 2009).

According to Kubler-Ross (1996), the grieving process consists of five stages, namely denial and isolation, anger, bargaining, depression, and acceptance. Parkes (1998), on the other hand, defines the grieving process as composed of dynamic and non-sequential processes, including numbness, yearning or searching for the other, disorganization, despair, and recovery. This process can unfold and manifest in various ways, depending on the social, cultural, and individual context of the bereaved (Dantas et al., 2020; Fuchs, 2018).

Epidemiological studies indicate that most individuals can go through the grieving process for a loved one without the need for professional intervention (Santos et al., 2017). However, some people experience a type of grief considered pathological, also known as complicated grief (Selman et al., 2020).

While normal grief involves understanding and accepting the loss, where the individual acquires coping resources for moving on without the loved one, complicated grief is characterized by a prolonged disorganization in the bereaved individual, preventing them from resuming everyday life with the same previous quality. Symptoms such as somatizations, tendencies toward isolation, depressive and self-destructive states, low self-esteem, and intense and persistent feelings can arise, even long after the death of the loved one (Braz & Franco, 2017). Parkes (1998) adds that, in complicated grief, individuals have difficulties in making transformations between their internal relationship with the loss and the world after the ruptured bond, leading to a stagnation in the grieving process.

Authors point out the existence of risk factors for the development of complicated grief, such as the nature of the death, the presence of simultaneous factors of emotional stress, among others (Bromberg, 2000). Furthermore, the impossibility of mourning through traditional funeral rituals is also considered a problematic factor in the construction and elaboration of grief (Oliveira et al., 2020). All these factors are present in most deaths caused by COVID-19.

The theme of grief in COVID-19 concerns the suffering of thousands of people, which, when researched, allows for an understanding of the issue and the variants that make it so problematic. From this perspective, this research contributes to the improvement of the care services provided by health professionals and psychologists in the hospital environment or later, in supporting families bereaved by COVID-19.

With this in mind and considering the particularities surrounding illness and death from the novel Coronavirus, the general objective of this research was to identify, through an integrative literature review, the scientific production on the grieving process of those beareaved by Coronavirus infection. Therefore, the specific objectives are:

• To analyze the particularities portrayed in the literature regarding illness and death from the Coronavirus and their consequent implications on the experience of family members whose loved ones were affected and died from COVID-19.

• To identify the possibility of complications in the grieving process for family members bereaved by COVID-19.

Method

This study is an Integrative Literature Review, and its organization was based on Souza et al. (2010). The Integrative Literature Review, as a broader methodological approach, allows a better understanding of the phenomenon by including various types of studies, including experimental and non-experimental studies, whose synthesis provides an overview of the phenomenon of interest. This expands the range of information about the study object, building a solid foundation for research analysis (Mendes et al., 2008; Soares et al., 2014; Whittemore & Knafl, 2005).

This review systematically followed eight steps for its development: (1) researcher training for conducting the review; (2) elaboration of the introduction; (3) formulation of the objective and guiding question; (4) definition and description of the method and establishment of eligibility criteria; (5) article selection from databases, and critical analysis and interpretation of the studies; (6) categorization, preparation, and presentation of results; (7) interpretation and discussion of results; (8) dissemination of the review (Whittemore & Knafl, 2005).

Souza et al. (2010) state that formulating the guiding question is the most important part of a review, as it objectively determines the studies to be included, the results to be analyzed, and the information to be collected, thereby contributing to the research objectives.

Thus, to better meet the study's design (Biruel & Pinto, 2011), the formulation of the guiding question followed the PVO model, an acronym representing Participants (condition or problem situation, participants, and context), Variables (study variables), and Outcomes (outcomes or results) (Silva & Otta, 2014). Following the PVO model, the constituent elements of the question in this study were P: the grieving process, individuals who lost a family member to COVID-19, and scientific productions; V: specificities in the emotional experience of the grieving process; O: emotional experience. Therefore, the guiding question used in this research was: What scientific evidence is available regarding the emotional experience of the grieving process for individuals who lost their loved ones to COVID-19?

With the aim of including a broad and diversified range of studies in the field, a search was performed in the electronic databases BVS-Pepsic, SciELO, Lilacs, and MedLine to identify existing national and international literature. Initially, a query of the descriptors was carried out in the defined databases. The following terms were cross-referenced: "luto" [grief], "COVID-19", "famili* [famil*]", and "psicologia" [psychology]; the asterisk (*) was added to encompass words with different suffixes, such as family or families, as suggested by the databases themselves. The descriptors were applied together and through search groups, using the Boolean operators "E" and "OU" in Portuguese and their variations "AND" and "OR" in English.

Carried out in 2021, the search did not set a publication timeframe since the topic emerged in 2020 with the onset of the pandemic, allowing only a short time interval for research and article production. The selection of articles was not limited to a specific language, as the researchers were interested in investigating worldwide contributions on the topic.

As inclusion criteria, articles were selected if they: (1) specifically addressed the grief experienced by family members bereaved by COVID-19; (2) were original articles published in national and international scientific journals, including empirical articles, theoretical studies, experimental reports, and review articles. Afterward, articles were excluded if they: (1) only addressed the grief of family members bereaved by COVID-19 as a secondary objective; (2) focused on grief in children and adolescents, due to the unique characteristics of this population, which would warrant a separate study.

Thus, a literature search was conducted on October 13, 2021, using combinations of the aforementioned descriptors. This search yielded 104 abstracts for analysis, excluding 20 duplicate works across different databases (16 from SciELO, 2 from BVS-Pepsic, 29 from Lilacs, and 77 from MedLine). After critically reviewing the titles and abstracts, 22 articles were independently selected for full-text reading by three researchers. All of these articles were included in the final sample for meeting eligibility criteria and being relevant to the objective and guiding question of this study. The steps for constructing the revised corpus followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol, summarized in Figure 1.

Figure 1
Stages for the construction of the revised corpus

All ethical principles and guidelines for the development of integrative reviews were followed, synthesizing the main results, focusing on the data that dialogued with the objective and the guiding question. Next, data collection was performed, and the gathered information was recorded using an instrument adapted from the one validated by Ursi (2005). The extracted data of interest included: article title, authors, year of publication, journal, language, country, database, and study types. The detailed categorization of the articles can be found in Table 1.

Table 1
Categorization of the selected articles by name, author and year of publication, journal in which they were published, language and country, database from which they were extracted, and research design

No.	Articles	Author (Year)	Journal	Language	Country	Database	Research Design
1	Approaching grief and death in family members of patients with COVID-19: Narrative review	Araújo Hernández et al. (2021)	Enfermería Clínica	Spanish	Spain	MedLine	Literature Review
2	The psychic demand of farewell rituals in the face of death in the COVID-19 (Sars - CoV - 2) ICU	Soares and Rodrigues (2020)	Revista aSEPHallus de Orientação Lacaniana	Portuguese	Brazil	Lilacs	Experience Report
3	A Phone-Based Early Psychological Intervention for Supporting Bereaved Families in the Time of COVID-19	Borghi et al. (2021)	Frontiers in Public Health	English	Italy	MedLine	Empirical Research
4	Psychological Risk Factors of Functional Impairment After COVID-19 Deaths	Breen et al. (2021)	Journal of Pain and Symptom Management	English	United States	MedLine	Empirical Research
5	The effect of suppressing funeral rituals during the COVID-19 pandemic on bereaved families	Cardoso et al. (2020)	Revista latino-Americana de Enfermagem	English	Brazil	SciELO	Theoretical Study
6	The Experiences of Family Members of Ventilated COVID-19 Patients in the Intensive Care Unit: A Qualitative Study	Chen et al. (2021)	American Journal of Hospice and Palliative Medicine	English	United States	MedLine	Empirical Research
7	Terminality, death, and grief in the COVID-19 pandemic: emerging psychological demands and practical implications	Crepaldi et al. (2020)	Estudos de Psicologia (Campinas)	Portuguese	Brazil	SciELO	Literature Review
8	Grief in the times of COVID-19: Challenges to mental health care during the pandemics	Dantas et al. (2020)	Revista Latinoamericana de Psicopatologia Fundamental	Portuguese	Brazil	SciELO	Experience Report
9	Impact and consequences of COVID-19 pandemic on complicated grief and persistent complex bereavement disorder	Diolaiuti et al. (2021)	Journal of Psychiatric Research	English	Italy	MedLine	Theoretical Study
10	Funeral rites in the COVID-19 pandemic and grief: possible reverberations	Giamattey et al. (2021)	Escola Anna Nery Revista de Enfermagem	Portuguese	Brazil	SciELO	Theoretical Study
11	Lived Experiences of Family Members of Patients With Severe COVID-19 Who Died in Intensive Care Units in France	Kentish-Barnes et al. (2021)	JAMA Network Open	English	France	MedLine	Theoretical Study
12	Prolonged grief related to COVID-19 deaths: Do we have to fear a steep rise in traumatic and disenfranchised griefs?	Kokou-Kpolou et al. (2020).	Psychological Trauma: Theory, Research, Practice, and Policy	English	United States	MedLine	Theoretical Study
13	Social and health implications that affect people bereaved by the death of family members by covid-19	Magalhães et al. (2020)	Revista Baiana de Enfermagem	Portuguese	Brazil	Lilacs	Literature Review
14	Phone follow up to families of COVID-19 patients who died at the hospital: families' grief reactions and clinical psychologists' roles	Menichetti Delor et al. (2021)	International Journal of Psychology	English	Italy	MedLine	Empirical Research
15	The mental health crises of the families of COVID-19 victims: a qualitative study	Mohammadi et al. (2021)	BMC Primary Care	English	Iran	MedLine	Empirical Research
16	"That goodbye, can't give": murder and suffering in COVID-19 times	Oliveira et al. (2020)	Enfermagem em Foco	Portuguese	Brazil	Lilacs	Theoretical Study
17	Grief and Nonviolence in a pandemic: precarity, mental health and other ways of living	Rente and Merhy (2020)	Psicologia & Sociedade	Portuguese	Brazil	SciELO	Theoretical Study
18	Bereavement Support on the Frontline of COVID-19: Recommendations for Hospital Clinicians.	Selman t al. (2020)	Journal of Pain and Symptom Management	English	United Kingdom	MedLine	Theoretical Study
19	'It's like being in a war with an invisible enemy': A document analysis of bereavement due to COVID-19 in UK newspapers.	Sowden et al. (2021)	PLoS One	English	United Kingdom	MedLine	Theoretical Study
20	Bereavement in Times of COVID-19: A Review and Theoretical Framework.	Stroebe and Schut (2021)	OMEGA - Journal of Death and Dying	English	Netherlands	MedLine	Theoretical Study
21	Correlates of Mental Health After COVID-19 Bereavement in Mainland China	Tang et al. (2021)	Journal of Pain and Symptom Management	English	China	MedLine	Empirical Research
22	Who suffered most after deaths due to COVID-19? Prevalence and correlates of prolonged grief disorder in COVID-19 related bereaved adults.	Tang and Xiang (2021)	Global Health And Development	English	China	MedLine	Empirical Research

Subsequently, extracted from the sample, were the main results that allowed for the identification of scientific evidence regarding the grief process of individuals who lost their loved ones to COVID-19. Based on this, the studies were classified into the following Analytical Dimensions: (1) Peculiarities of COVID-19 illness and death; (2) Mental health complications and incidence of complicated griefs among family members bereaved by COVID-19. The first analytical dimension aimed to identify the elements and specificities of the pandemic context that resonated with the emotional experience of the grief process. The second dimension gathered sample evidence that made inferences about the complicating factors in the experience of this process, related to the specificities of loss due to COVID-19. Additionally, results were presented regarding the impact of this experience on the emotional health indicators of the bereaved individuals.

Results

Among the selected articles, as categorized in Table 1, a prevalence of publications in the English language was observed, totaling 14 articles; seven articles were published in Portuguese, and one in Spanish. Furthermore, within the period of 2020-2021, it was observed that, regarding the country where the research was conducted, Brazil stood out with the highest number of articles, totaling eight publications, followed by the United States and Italy, each with three articles. Regarding the year of publication, the sample is evenly divided, with 11 articles published in 2020 and the remaining 11 in 2021. As for the journal of publication, the articles are distributed evenly across different journals, with only three published in the same journal, the Journal of Pain and Symptom Management.

Analyzing the types of research in the selected articles, a prevalence of non-empirical studies was observed, with 14 productions in this category, including theoretical studies, experience reports, and literature reviews. It is worth noting that theoretical studies were distinguished from literature reviews by the former's in-depth exploration of specific theories, while the latter aims to gather and systematize studies on a subject. Empirical research and experience reports were also differentiated, with the latter including descriptions of practices beyond data collection, encompassing the entire research process. Thus, the sample consisted of eight empirical articles.

After careful reading and analysis, the main findings of the selected works were extracted, revealing similarities in the results, allowing for their grouping and defining two Analytical Dimensions. The first dimension concerns the peculiarities of illness and death by COVID-19 that impact the experience of grief among family members, while the second dimension addresses potential mental health complications and the incidence of complicated grief resulting from the particularities mentioned in the first dimension. Therefore, all the studies are interconnected and enable the construction of a coherent and sequential analysis, as the specificities of loss can be precursors to complications in the grieving process.

First Dimension of Analysis: Peculiarities of Illness and Death by COVID-19

The first dimension of analysis explores the process of hospitalization and death from COVID-19 as consisting of peculiar elements that reflect in the experience of grief. These elements present themselves as potential stressors, which are linked to a higher occurrence of complicated grief in the context of loss due to COVID-19, according to the selected research. The particularities mentioned in the research are as follows: (1) social distancing, (2) poor communication with the healthcare team, (3) absence of funeral rituals, (4) guilt, and (5) multiple deaths within the same family unit.

Thus, a significant number of findings, encompassing 13 studies, indicated the existence of these elements, specifically: Araujo Hernández et al. (2021); Cardoso et al. (2020); Chen et al. (2021); Crepaldi et al. (2020); Dantas et al. (2020); Diolaiuti et al. (2021); Kentish-Barnes et al. (2021); Kokou-Kpolou et al. (2020); Magalhães et al. (2020); Menichetti Delor et al. (2021); Mohammadi et al. (2021); Oliveira et al. (2020); and Sowden et al. (2021).

Regarding social distancing, studies address it as a risk factor for complications in the grieving process, as it prevents moments of communion and solidarity with the bereaved by their support network (Soares & Rodrigues, 2020; Chen et al., 2021; Oliveira et al., 2020; Selman et al., 2020). Poor communication with the healthcare team is also a recognized aspect in the process of hospitalization and death from the Coronavirus, which can contribute to complicated grief. This is because the lack of clarity in the information received from medical bulletins leads to doubts about the care provided to the patient and fantasies about death, as stated by Diolaiuti et al. (2021) and Selman et al. (2020).

Some studies specifically address the issue of the absence of funeral rituals, which is a particular aspect of the pandemic loss experience. These ceremonies serve as organizers of grief and can mitigate its effects, while the non-performance of these rituals increases the likelihood of developing complications in the grieving process. Family members are deprived of paying tributes to the deceased that they consider honorable to their memory, which generates a sense of guilt, triggering anguish in the face of COVID-19-related death (Araujo Hernández et al., 2021; Chen et al., 2021; Diolaiuti et al., 2021; Giamattey et al., 2021; Oliveira et al., 2020; Rente & Merhy, 2020; Tang & Xiang, 2021).

Also in this regard, the imposition of sealed coffins during funerals presents an important peculiarity of COVID-19 deaths regarding the subsequent grieving process. It is considered that the experience of seeing the body of the deceased loved one allows for the acknowledgment of death, provides real and concrete data for the experience of loss, and ensures that the buried person is indeed the deceased loved one (Dantas et al., 2020; Kentish-Barnes et al., 2021).

Furthermore, in the face of the impossibility of visiting the sick person, family members experience feelings of guilt for not having made more efforts to ensure that their loved one was not alone during illness and death (Kokou-Kpolou et al., 2020). Guilt is also a factor due to the ease of disease transmission, in which family members consider themselves spreaders of the virus and, thus, responsible for the infection of the deceased loved one (Crepaldi et al., 2020; Dantas et al., 2020; Diolaiuti et al., 2021; Mohammadi et al., 2021; Oliveira et al., 2020).

Continuing with the particularities encompassed in the first dimension of analysis, the COVID-19 pandemic subjects individuals to a barrage of events with little or no time between them: the ease of contagion, the rapid deterioration of clinical conditions, and abrupt death, often affecting more than one person within the same family. Sudden deaths and the plurality of deaths within the same family unit are issues that reverberate in the individual's grieving process, as presented by Cardoso et al. (2020) and Crepaldi et al. (2020).

Second Dimension of Analysis: Mental Health Complications and Incidence of Complicated Griefs Among Family Members Bereaved by COVID-19

The second dimension of analysis addresses mental health complications and the incidence of complicated grief, which are possibly associated with the unique elements of the COVID-19 illness and death process. By specifically addressing the possibility of complications in the grieving process, this research included 15 studies that discussed complicated grief as a concern to be considered in the experience of COVID-19 deaths. Specifically: Soares and Rodrigues (2020); Borghi et al. (2021); Breen et al. (2021); Cardoso et al. (2020); Chen et al. (2021); Dantas et al. (2020); Diolaiuti et al. (2021); Giamattey et al. (2021); Kokou-Kpolou et al. (2020); Magalhães et al. (2020); Menichetti Delor et al. (2021); Oliveira et al. (2020); Stroebe and Schut (2021); Tang and Xiang (2021); and Tang et al. (2021).

From the articles found, it is noteworthy to highlight the emotional impact caused by the COVID-19 pandemic. The atypicality of the experienced period involves particularities that disrupt common grieving experiences, such as the inability to perform funeral rituals, leading to organic, emotional, and social consequences that can contribute to the occurrence of complicated grief and post-loss depression (Oliveira et al., 2020). The selected studies indicate that individuals bereaved by COVID-19 report higher and more acute levels of symptoms compared to those grieving natural causes of death. In many cases, they experience generalized anxiety, depression, dysfunctional grief, and functional impairment due to the loss (Breen et al., 2021; Kokou-Kpolou et al., 2020; Magalhães et al., 2020).

In the same vein, Kokou-Kpolou et al. (2020), Rente and Merhy (2020), Tang et al. (2021), and Tang and Xiang (2021) include traumatic aspect to the experience of complicated grief in the context of COVID-19. Specifically, the circumstances surrounding these deaths involve multiple traumatic characteristics, similar to those experienced in a war scenario. Furthermore, the experience of bereaved families during the COVID-19 pandemic can be compared to a situation of mass violence due to its peculiarities and the pandemic context that surrounds it. Factors that typically characterize traumatic losses, such as in disasters or wars, bear great resemblance to those experienced in COVID-19 deaths (Menichetti Delor et al., 2021).

Discussion

Considering the findings, the situation of humanitarian disruption and the disorganizing effect of the pandemic is undeniable. It is observed that individuals are facing constant unpredictability and fear, enveloped in sensations of loss of control and helplessness. Additionally, there is often a supression of important elements for the grieving process, such as time for processing, physical embrace, and support networks (Lopes et al., 2021).

Due to restrictions on hospital visits for health reasons and the need for social isolation to combat the pandemic, the absence of family members alongside the sick person is a constant situation when it comes to COVID-19 illness. This factor, which begins from the moment of hospitalization and persists throughout the course of the illness, up to its final moment, makes it impossible to say farewell and prepare for death (Morris et al., 2020).

Moreover, family members experience poor communication with the healthcare team due to the complex medical language. They deal with a diversity of professionals who do not always provide consistent information. Also, there's the inability of family members to be at the bedside to assess the severity of the condition and better understand the communicated medical reports. All these are factors that can instigate distrust in families regarding the healthcare team and generate a sense of lack of control and powerlessness (Fundação Oswaldo Cruz, 2020a; Selman et al., 2020).

Furthermore, funeral rituals, with archaeological records of their practice since prehistoric times, provide time for the traumatic event to be processed and the loss to be assimilated as a passage. Moreover, they mark a state of mourning that legitimizes the importance of the loss and allows the bereaved to be supported by their social support network (Oliveira et al., 2020). Bromberg (2000) also emphasizes the importance of seeing the body, participating in the wake, and religious ceremonies for all family members to facilitate the adaptation to the loss.

Based on the dual process model of coping, it is asserted that the bereaved individual oscillates between two psychological orientations: loss and restoration. The coping process involves oscillating between these two dimensions, confronting one and avoiding the other. The oscillation between loss and restoration allows the broken bond to be redefined throughout the individual's life, providing a process of construction of meaning for the loss (Stroebe & Schut, 1999). When there is an absence of oscillation between loss and restoration, and the individual predominantly orients themselves towards one of these two modes of orientation, the grieving process may be impaired, and its reactions may intensify (Parkes, 1998). By analyzing the particularities experienced by family members in the face of loss due to COVID-19, it can be inferred that the oscillations between loss and restoration described by the dual process model of coping were traversed by impositions and specificities of the pandemic context.

Families bereaved by the novel coronavirus, when unable to see the deceased's body or participate in farewell ceremonies, are left with feelings of incompleteness and unrealness of the loss (Dantas et al., 2020). Thus, without the possibility of verifying the reality of the loss, the process of oscillation and coping is affected, resulting in an impaired experience of grief (Fuchs, 2018). Furthermore, in the face of the multitude of deaths in the COVID-19 pandemic, many within the same family unit, relatives express feeling "numb, emotionally dormant", experiencing something that surpasses their capacity for processing, which can lead to complications in the grieving process (Dantas et al., 2020).

The literature supports such difficulty in processing. According to Freud (1915/2010), in war situations, numerous deaths in a short period expose the finitude of human life. This reality is threatening and difficult to assimilate. This is because the individual, while alive, does not have the experience of death itself, which is why there is no inscription of such experience in the psyche. Thus, for Freud (1915/2010), one does not symbolize the death of the other or one's own; it cannot be imagined or easily conceived psychologically. In this sense, what assists the individual in symbolizing the loss lies within their own resources, constructed from experiences of reality, in an attempt to elaborate on that which lacks psychic representation (Ogden & Simmonds, 2014).

In his conceptualization of grief, Worden (2013) describes that the process includes the possibility of growth through experience and the restoration of equilibrium, so that it can eventually be concluded. For this process to take place, some tasks need to be accomplished. These tasks, however, may occur without a prescribed order. The construction of one's conception of the world, once validated by the deceased person, loses its original meaning, requiring the bereaved individual to fulfill what the author describes as the tasks of mourning, which enable adaptation to the new reality, namely: accepting the reality of the loss, processing the pain of grief, adjusting to a world without the deceased, and finding an enduring connection.

However, due to numerous deaths occurring within only a few days, combined with constant feelings of uncertainty and fear of getting sick, individuals have been deprived of sufficient time to process the losses experienced before new events occurred. This sudden influx of events, which creates a scenario woven by difficulties in gradually processing the experience, hinders the aid of a resource that Horowitz (1990) states is important for the grieving process: time.

According to Freud (1917[1915]/1996), grief develops gradually, requiring time and psychic energy from the bereaved, in a constant attempt to process and psychically represent the loss. Similarly, given the specificities of the pandemic context, as it is an illness that develops acutely, it can be inferred that the excess of events occurring in rapid succession and in a turbulent manner contrasts with what is considered ideal for the processing of grief.

Commenting on the literature on the subject, it is worth noting that Freud (1917[1915]/1996), in his theorization, makes it clear that grief is a normal and expected reaction to the loss of a loved object and should not be immediately considered pathological and subjected to medical treatment. It is expected to be overcome with time. However, this time, an important condition for the grieving process (Freud (1917[1915]/1996; Horowitz, 1990), has been hindered by the pandemic experience. In the current scenario, many families go through the illness, hospitalization, and death of one or several of their members within a short period (Mayland et al., 2020; Morris et al., 2020).

Given the particularities observed in the process of hospitalization and death due to COVID-19, it is worth noting that the literature on the topic of death points out the existence of risk factors for the development of complicated grief. These factors include sudden death, communication permeated by myths and taboos about death, the existence of simultaneous factors of emotional stress, the construction of a belief system involving guilt regarding death, as well as a political and social context permeated by stigmas or catastrophic fears. Among other factors, a lack of knowledge about the prognosis and the physical absence of the family member alongside the patient is also present (Bromberg, 2000).

Therefore, due to the mental health issues triggered by inherent peculiarities related to illness and death from COVID-19, strategies have been studied and developed to care for the bereaved and prevent complications in the grieving process. Examples of strategies adopted in hospitals include conducting video conferences to bring patients and their families closer together (Fundação Oswaldo Cruz, 2020b), playing bedside audio recordings and reading letters in cases where patients are unconscious (Wang et al., 2020), and creating virtual memorials that provide a space to signify the importance of these deaths (Worden, 2013). Additionally, the communication between the family and the healthcare team is also a preventive strategy discussed in the literature, emphasizing the importance of preparing hospital teams to interact with family members (Fundação Oswaldo Cruz, 2020a).

However, it is important to note that despite the findings regarding the existence of particularities in the experience of loss due to COVID-19, which can influence individuals' grieving process, grief is also a personal experience for each individual. Although there are elements that bring people together, grief is experienced individually by each person, and it can develop in various ways based on the bereaved person's internal resources, past experiences, and the relationship that was shared (Ogden & Simmonds, 2014).

In summary, grief is a normal process of re-signification and elaboration that an individual must go through after losing something that was loved (Bousso, 2011). It is inherently present in human life through relationships with others, as a by-product of attachment and affection. Therefore, it is crucial to recognize its significance and provide care for the emotional complications that arise from experiencing this process, as grief not only reflects the relationship between the survivor and the deceased but also allows the bereaved person to continue living without their loved one while maintaining a constant connection.

Conclusion

In this research, it was found that the scientific production on the grieving process of those bereaved by Coronavirus infection has identified the presence of peculiar elements in the experience of loss due to COVID-19. Among them is the impossibility of caring for the ill, bidding farewell, and even receiving and offering condolences. Some families have experienced the difficulties of multiple deaths within the same family unit. At the same time, they experience guilt for disease transmission.

Through the analysis of the selected works, it was possible to observe a close relationship between the particularities found in the process of hospitalization and death from the virus and the possibility of complications in the grieving process, as well as mental health issues among the bereaved. Therefore, based on these findings and the literature used to connect them, it can be stated that the topic of complicated grief is an important aspect to be analyzed when it comes to death in the context of COVID-19.

Thus, it is suggested that new research gives voice to the experiences of family members who have lost their loved ones to COVID-19, so that the magnitude of the disease and the global impact of its effects are not forgotten. Furthermore, it is necessary for new research to address emerging strategies adopted by hospitals and institutions dedicated to supporting these families. This is because research aimed at preventing complications in the grieving process can benefit the reality of many families who lose their loved ones in healthcare facilities, extending beyond the scope of the Coronavirus disease.

• How to cite this article: Alves, M. C. M. C., Cunha, G. M. B., & Gallego, P. B. (2024). Grieving process of families who lost their loved ones by COVID-19: an integrative review. Estudos de Psicologia (Campinas), 41, e220066. https://doi.org/10.1590/1982-0275202441e220066
• Article based on the dissertation of M. C. M. C. ALVES, entitled "Mesmo sem te ver, acho até que estou indo bem': uma revisão integrativa acerca do processo de luto das famílias que perderam seus entes pela COVID-19". Universidade Federal de Uberlândia, 2022.

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Edited by

Editor

André Luiz Monezi de Andrade

Publication Dates

• Publication in this collection
  20 Sept 2024
• Date of issue
  2024

History

• Received
  06 Sept 2022
• Reviewed
  05 Apr 2023
• Accepted
  28 July 2023