COMMUNITY CASE STUDY published: 03 May 2021 doi: 10.3389/fpsyt.2021.608973 End of Life Intervention Program During COVID-19 in Vall d’Hebron University Hospital Anna Beneria 1,2*† , Eudald Castell-Panisello 1† , Marta Sorribes-Puertas 1 , Mireia Forner-Puntonet 1,2,3 , Laia Serrat 1 , Sara García-González 1 , Maria Garriga 4 , Carmen Simon 4 , Consuelo Raya 4 , Maria José Montes 4 , Giuliana Rios 4 , Rosa Bosch 1,3,5 , Bárbara Citoler 1 , Helena Closa 1 , Montserrat Corrales 1,3,5 , Constanza Daigre 1,2,5 , Edited by: Mercedes Delgado 1 , Maria Emilia Dip 1 , Neus Estelrich 1 , Carlos Jacas 1 , Benjamin Lara 2 , Marie-José H. E. Gijsberts, Jorge Lugo-Marin 1 , Zaira Nieto-Fernández 1 , Christina Regales 1 , Pol Ibáñez 2 , Vrije University Brussel, Belgium Eunice Blanco 4 and Josep Antoni Ramos-Quiroga 1,2,3,5 Reviewed by: 1 Department of Psychiatry, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain, Robert Neimeyer, 2 Group of Psychiatry, Mental Health and Addictions, Vall d’Hebron Research Institute, Barcelona, Spain, 3 Department of University of Memphis, United States Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain, 4 Department of Social Work, Lidia Borghi, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain, 5 Biomedical Network University of Milan, Italy Research Centre on Mental Health (CIBERSAM), Barcelona, Spain *Correspondence: Anna Beneria abeneria@vhebron.net Introduction: The coronavirus disease 19 (COVID-19) and its consequences have † These authors have contributed placed our societies and healthcare systems under pressure. Also, a major impact equally to this work on the individual and societal experience of death, dying, and bereavement has been observed. Factors such as social distancing, unexpected death or not being able to Specialty section: This article was submitted to say goodbye, which might predict Prolonged Grief Disorder (PGD), are taking place. Public Mental Health, Moreover, hospitals have become a habitual place for End of Life (EOL) situations but a section of the journal not in the usual conditions because, for example, mitigation measures prevent families Frontiers in Psychiatry from being together with hospitalized relatives. Therefore, we implemented an EOL Received: 22 September 2020 Accepted: 06 April 2021 program with a multidisciplinary team involving health social workers (HSW) and clinical Published: 03 May 2021 psychologists (CP) in coordination with the medical teams and nursing staff. Citation: Objectives: We aim to describe an EOL intervention program implemented during Beneria A, Castell-Panisello E, Sorribes-Puertas M, COVID-19 in the Vall d’Hebron University Hospital (HUVH). We present its structure, Forner-Puntonet M, Serrat L, circuit, and functions. Descriptive analyses of the sample and the interventions that García-González S, Garriga M, Simon C, Raya C, Montes MJ, Rios G, required psychological and social attention are reported. Bosch R, Citoler B, Closa H, Material and methods: The total sample consists of 359 relatives of 219 EOL patients. Corrales M, Daigre C, Delgado M, Dip ME, Estelrich N, Jacas C, Lara B, Inclusion criteria were families cared for during the COVID-19 pandemic with family Lugo-Marin J, Nieto-Fernández Z, patients admitted to the HUVH in an EOL situation regardless of whether or not the Regales C, Ibáñez P, Blanco E and Ramos-Quiroga JA (2021) End of Life patient was diagnosed with COVID-19. Intervention Program During Results: Our program is based on family EOL care perceptions and the COVID-19 COVID-19 in Vall d’Hebron University Hospital. Front. Psychiatry 12:608973. context features that hinder EOL situations. The program attended 219 families, of which doi: 10.3389/fpsyt.2021.608973 55.3% were COVID-19 patients and 44.7% had other pathologies. The EOL intervention Frontiers in Psychiatry | www.frontiersin.org 1 May 2021 | Volume 12 | Article 608973 Beneria et al. End of Life Intervention Program program was activated in most of the EOL situations, specifically, in 85% of cases, and 78% of relatives were able to come and say goodbye to their loved ones. An emotional impact on the EOL team was reported. It is necessary to dignify the EOL situation in the COVID-19 pandemic, and appropriate psychosocial attention is needed to try to minimize future complications in grief processes and mitigate PGD. Keywords: end of life, intervention program, COVID-19, mental health, grief, prolonged grief disorder, death, mourning INTRODUCTION et al. (22) found more severity in grief reactions after COVID- 19-related bereavement compared to natural bereavement (but On March 11, 2020, the World Health Organization (1) declared not unnatural bereavement). Along the same lines, Eisma and the severe acute respiratory syndrome coronavirus 2 (SARS- Tamminga (23) demonstrated that people who experienced a CoV-2 or COVID-19) outbreak a pandemic disease. In Spain, recent loss during the pandemic had higher grief levels than the first case of COVID-19 was diagnosed on January 29 (2). people who experienced it before the pandemic. On March 14, the Spanish Government declared a national Also closely linked to losses and mourning processes, we emergency, which implied the imposition of quarantine on the would like to focus on End of Life (EOL) situations in the entire population (3). Such mitigation measures clearly helped hospitalization context, which have become challenging for contain the disease and flatten the curve (4) but they had families, causing them confusion and distress (24). Partial or total an impact on psychological health (5) and important socio- restrictions on relatives’ visiting have been imposed, driven by the economic repercussions (6). need to limit spread of the disease (25). Lack of information on The pandemic has seriously challenged our national the process and inconsistency of the mitigation measures prevent healthcare system (7), as well as the professionals’ mental health relatives from adapting properly to the situation (24). This (8). One of the key features of COVID-19 is its severity, with a might well-affect relatives either with or without family members mortality rate around 5.7% (9). To date, more than 100 million diagnosed with COVID-19 because government policies applied cases of COVID-19 have been confirmed, and 2,455,331 deaths to all hospitalized people (26). Actually, most recent research have been registered (10). Therefore, death has been around reports on the shocking experience of relatives who have lost their more than ever before. loved one in a COVID-19 hospitalization context: being apart Death and grief are universal, inevitable, and during hospitalization and death, cold communication of bad multidimensional experiences and imply losses which can news, lack of social support and death rituals, unexpected and occur at any stage of life (11). The grieving process reflects a fast death or feeling of unfairness (27). unique convergence of responses (affective, cognitive, behavioral, All these features can hinder proper care of EOL situations physiological, and spiritual adjustments) which affect both the (28). Managing death and mourning during COVID-19 has individual (12) and the family system (13). In 2013, the become crucial, not only to avoid situations of dying in absolute Diagnostic and Statistical Manual of Mental Disorders (DSM- isolation but also to give patients and relatives the chance to 5) (14) proposed Persistent Complex Bereavement Disorder be accompanied in EOL situations (29). Families definitely care (PCBD) and recently prolonged grief disorder (PGD) was about how their relatives depart, and this includes providing formally included in the 11th revision of the International the desired physical comfort, emotional support, the possibility Classification of Diseases (15). Despite the fact that bereavement to participate in decision-making processes, treating the end is a typically severe stressor that implies painful grief symptoms with respect, coordinating the care provided, and taking their which can interfere in peoples’ lives through higher symptom emotional needs into account (30). This goes together with the intensity and/or duration, there is usually no need for clinical desire of the patients in an EOL situation to relieve their relatives’ intervention (16). burden and strengthen contact with them (31). However, it has been observed that COVID-19 conditions The COVID-19 pandemic has contributed to increasing might exacerbate the chance of developing PGD (17). Several difficult circumstances and the potential for amplified grief. studied factors associated with PGD occur and challenge the Therefore, healthcare clinicians need tools and resources to mourning processes (18). From a general perspective, we are mitigate the grief with which patients and families must cope aware that PGD is more likely to take place in disasters with. The Psychiatry Department of Vall d’Hebron University with many casualties (19). Specific features that increase the Hospital (HUVH) identified the need to develop an “EOL chance of PGD appearance include the lack of preparedness intervention program” formed by clinical psychologists (CP) or unexpected death, not knowing about the quality of the and healthcare social workers (HSW) that provided face-to-face caregiving or dying experiences, absence of physical social support to relatives in EOL situations. We aim to describe the support (20), or grief rituals (e.g., saying goodbye or viewing structure, circuit, and functions of the intervention program, and and burial of the body) (21). Indeed, most recent literature is also to analyze which type of sample and interventions required reporting on bereavement responses during COVID-19. Eisma psychological and social attention. Frontiers in Psychiatry | www.frontiersin.org 2 May 2021 | Volume 12 | Article 608973 Beneria et al. End of Life Intervention Program CONTEXT In this severe context, national and hospital policies determined whether hospital visits were allowed. In light of Socio-Demographic Characteristics of the COVID-19, much tougher restrictions were established to protect Population in the HUVH the patients, hospital staff, and visitors (42, 43). Initially, and only HUVH is located in the north of Barcelona, within the Horta- for a few days, visits were completely suspended. However, on Guinardó district. It is a public hospital of the Hospital Network March 26 visits to patients in EOL situations were allowed. The of the Catalan Health Institute and is a referral center in requirement to attend these families was immediately detected, the comprehensive healthcare area of the north of the city, and from March 30 to April 2, the EOL program was designed, which includes three districts, Horta-Guinardó, Nou Barris, coordinated and structured, starting officially on April 3 and Sant Andreu, and the city of Montcada i Reixac, with a total lasting May 31. From May 27, visitors were permitted, with population of more than 480,000 inhabitants. However, HUVH restrictions that were adapted to requirements over time. From is a tertiary care hospital, so it receives patients from all over then until now, the EOL service has been working, if necessary, the country. with the liaison and inter-consultation unit. Among the socio-demographic characteristics of the To support those relatives who came to the hospital in tough population that attends the HUVH, we highlight the aging emotional conditions, it was necessary to reorganize and increase population, which is especially concentrated in the covered areas the number of specialized staff delivering EOL care. Initially, (47.59% aged over 65) (32, 33). Moreover, Nou Barris is the the EOL care circuit was attended to by professionals from the district of Barcelona with the lowest average annual income per Citizen Service Unit of the hospital. Subsequently, due to the household and person, and has one of the highest percentage families’ perceived emotional and psychosocial support needs, of migrants in the city, 17% (32). These socio-demographic social work professionals, together with CP, attended to the characteristics can become risk factors in health-disease EOL processes. processes, and can place them in a situation of high vulnerability and social exclusion (34–37). In the context of the pandemic, Key Programmatic Elements: EOL these social determinants of health have become notorious in Intervention Program the HUVH (38), especially since Nou Barris became the district The EOL Intervention Program arose from the need to attenuate most affected by COVID-19 in Catalonia during lockdown. the hospital’s environment restrictions during the COVID- Some specific factors that may increase the population’s 19 pandemic (44). HSW and CP assessed the importance of burden were observed: first, home-isolation difficulties, due addressing this moment of change to facilitate the mourning to the overcrowding or infra-housing situation, causing the process. The aims of the intervention program are based on contagion of entire families or cohabitation units; economic- the importance of a dignified farewell (see Table 1). These labor fragility situations such as unemployment or submerged experiences will become part of the family’s history, and economy (39); and finally, migrated families often without a the team considered them a basic rightfor both the dying socio-familial network (40). All these factors have converged and patient and the family to be able to say goodbye to each caused stress on grief processes and the reorganization of their other (45). family systems. Six HSW from the Social Work Department and eighteen CP from the Psychiatry Department (eleven physicians and Setting seven residents) were included in the program. Both teams were One of the main challenges of the pandemic outbreak was the trained in psychopathology related to somatic issues, working need to transform the activity and capacity of the hospital to with integrative theoretical models of reference. Main clinicians’ attend patients with COVID-19, often withdrawing treatment from other patients who had non-pandemic-related health needs (41). TABLE 1 | Aims of the EOL intervention program. On March 10, 2020, the contingency plan of the HUVH 1 Minimize the impact of the state of alarm produced by the COVID-19 was approved and subsequently communicated to the staff pandemic on families in a hospitalization context organization. During the following weeks, the hospital had How: supporting families in a farewell situation in a hostile context to reformulate all the spaces progressively, starting with the 2 Give the family the chance to say goodbye to their dying loved one and Emergency Department as well as COVID-19 and non-COVID- support them during this moment of crisis 19 areas. In this process of transition, the usual 56 intensive care How: Allow relatives to say farewell to their loved one face to face with all the required protective measures and offer support during this process unit (ICU) beds available were multiplied by almost seven. When 3 Care for an individual’s mourning process, consequently guiding them the epidemic reached its peak, the HUVH had 700 COVID-19 toward the most healing path, as well as reducing risks beds, and it was 50 beds away from collapse. How: Offer psychosocial support during the EOL process and address Health professionals had to adapt to the pandemic in a identified risk factors for PGD development very short time, experiencing changes in their working shift 4 Ease access to clinical psychologists in case of excessive pain, too intense organization, and increasing the burden of care. At the same and lasting, which requires specialized attention time, the global surge in demand led to shortages in protection How: Psychological assessment of the relatives’ emotional state, needs and risk factors and consequently refer them to the appropriate public mental equipment, masks, and other medical devices like respirators. health services All this exacerbated concerns about the increased risk of infection (8). EOL, end of life. Frontiers in Psychiatry | www.frontiersin.org 3 May 2021 | Volume 12 | Article 608973 Beneria et al. End of Life Intervention Program FIGURE 1 | Action circuit for EOL program. ER, emergency room; EOL, End of Life. therapy approaches were cognitive-behavioral, systemic, and circuit followed in the EOL Intervention Program is presented humanistic. Part of the team was trained in grief counseling, and in Figure 1. moreover a few of them belonged to the health consultation- The interventions delivered by the EOL team were divided liaison psychology and social work service. Main HSW tasks into two basic kinds of cases: (1) EOL situations (see Table 2) and were to identify social vulnerability settings and needs in order (2) family interventions to communicate a loss to an inpatient to address them (e.g., inform on funeral procedures, refer to (see Table 3). All the interventions were based on studied factors social service centers). CP were able to assess the emotional of EOL family caring such as proper communication, respect, state and needs of relatives and consequently intervene (e.g., compassion, emotional support, and promotion of emotional facilitate emotional expression, refer to specialized grief or family expression (46, 47). An essential key of the program was non- support programs). Coordination with healthcare teams (HCT), intrusive emotional accompaniment, respecting the variability consisting of doctors and nurses, was required in every attended and individuality of reactions and emotional expressions in the case. The EOL program covered 24-h shifts every day of the face of a crisis (e.g. some needed a safe place to express the sorrow week, and each shift was made up of two professionals from they felt; others required more technical information about each of the aforementioned categories. The night shift, lasting funeral procedures). In some cases, this meant accompanying in from 8:00 p.m. to 8:00 a.m., was covered by just one HSW silence; in others, it consisted of active listening, and in a few who could contact the Psychiatry Ward if necessary. The action the team had to resort to specific techniques for anxiety or crisis Frontiers in Psychiatry | www.frontiersin.org 4 May 2021 | Volume 12 | Article 608973 Beneria et al. End of Life Intervention Program TABLE 2 | EOL psychosocial intervention. Phases Setting Content Activation and coordination Telematic coordination between HCT and EOL team Basic information gathering after detection of an EOL situation. - Prognosis of the patient - Number of relatives - What information relatives have - Relatives’ contact information Social assessment Telematic contact between Social Worker and Social assessment relatives. - Patient’s support network - Main caregivers - Socioeconomic situation Schedule an appointment to come to the hospital Psychological assessment and Face-to-face meeting of the EOL team with the First basic psychological assessment pre-intervention relatives in the hospital hall. - Explore necessity of psychological support - Emotional state - Emotional needs - Psychopathological background, if required Bad news communication Face-to-face meeting of the EOL and HCT with the Information of bad news: relatives in a private room. - Explanation of the evolution - Explanation of the prognosis Psychological support - Promote emotional expression - Promote the expression of doubts and worries regarding the disease course and death - Facilitate the farewell when difficulties facing it Farewell Face-to-face and private farewell in the patients’ Assure privacy in the farewell moment room. Provide protection measures to prevent contagion Post-intervention Face-to-face meeting of the EOL team with the Psychological support relatives in a large private room. - Promote emotional expression - Validate experience of loss - Give meaning to the experience - Validate common grief reactions - Promote identified protective factors - Psychoeducate on phases of mourning - Inform about mourning rituals and how to adapt them to COVID-19 context - Advise on how to deliver the news to children - Specific anxiety techniques (e.g., relaxation) if needed Final psychological assessment - Protective factors: social network support, adaptive reactions, anticipation of alternative grief rituals - Risk factors: psychopathological background, high levels of expressed emotion, other symptomatology suggestive of specialized attention Social information: - Funeral services contact and procedures - Bureaucratic aspects - Public aids in socioeconomic risk situations - Specialized contact information: referral to specific resources if needed (e.g., EOL contact, family support program, grief-specific program…) EOL, end of life; HCT, health care team. intervention. We emphasize the fact that working together as addictions was converted into a temporary room for crisis a team seems to have promoted higher coordination and also attention and intervention. helped with emotional support among the professionals. We highlight the fact that this entire program was being Caring Team’s Experience carried out on the go, and it was modified and improved as The EOL team tried to give the best human and emotional regulations in the hospital evolved, and the EOL team faced attention to the families coming to bid farewell to their loved new problems and needs. For example, at first, there was a ones. We shared painful and sad moments, emotions of love and strict rule that only one relative could bid farewell to a patient, tenderness, and tough situations with each and every family, at but as weeks of the pandemic progressed, this was expanded a both personal and professional level. Initially, the team had to and more relatives were allowed. Also, the location in which to retrain in crisis care and mourning, adjust to a new daily reality, address relatives was problematic, and spaces of every available with newcare cases, while ensuring that they complied with the unit were adapted. Finally, the room for dual pathology and safety protocols introduced by the pandemic, such as the use of Frontiers in Psychiatry | www.frontiersin.org 5 May 2021 | Volume 12 | Article 608973 Beneria et al. End of Life Intervention Program TABLE 3 | Communication of bad news psychosocial intervention. Phases Setting Content Activation and coordination Telematic coordination between HCT and EOL team Coordinate how to manage the information in between patients, HCT and after detection of the death of an inpatients’ loved one. families. Initial contact Telematic contact between the EOL team and relatives. Assessment of needs - Doubts regarding safety issues at the hospital or safepass to come - Doubts about how to deliver the bad news - Emotional state and needs Schedule an appointment to come deliver the bad news Meeting with the EOL team Face-to-face meeting of the EOL team with the relative in Psychological support a large private room. - Promote emotional expression - Normalize associated feelings (e.g., guilt) - Advise on how to deliver the bad news - Information about what reactions to expect - Information about the possibility of psychological intervention with the patient Bad News Communication Face-to-face communication of the bad news to the Assure privacy in the delivery of bad news patient by his relative in privacy in the patients’ room. Provide protection measures to prevent contagion Coordinate with HCT Post-intervention Offer to the relative face-to-face meeting with the EOL Psychological support team. Debriefing and closure EOL, end of life; HCT, health care team. personal protective equipment. The EOL team was not exempt Concerning the functioning of the program, it was activated from a huge emotional impact. in most situations (85%), although in some cases it was not, After reviewing the experience with the team, all the EOL mostly during the night shift. This was due to communication professionals expressed this impact, referring to coping with difficulties because of the chaotic environment and the shift their fears, their work as professionals, wondering whether the changes between the usual HCT and ward HCT. In general, program was meeting the needs for which it was created, whether up to 78% of relatives were able to come and say goodbye to it was worth the trouble, and whether they could help families their loved ones. From among the total sample, in one-third of deal with the pain of their losses. They also mentioned being cases (31.8%), the intervention was performed after the death of afraid of their emotions, of reliving the deaths several times a the patient (see Table 5). This could be explained because the day, of the feelings emerging day by day and having to cope with family could not arrive to say goodbye or because the urgency them during their interventions, of infection and of infecting of the situation made it necessary to prioritize the farewell, their relatives. The team also referred to all they had learned, intervening afterwards. the rewarding aspect of teamwork, the excellent collaboration Main interventions were EOL type (92.5%), and in most cases between coworkers, the need to share with others, to help and they were performed face to face (76.2%). Despite that, 23.8% be helped, to take care of each other. All the team members were telephone-based, either because they decided not to come or appreciate kindness of all the families they helped, who, although because of illness or other conditions that prevented them from undergoing extreme pain, also cared for the professionals who coming. The main reasons were being infected with COVID- were helping them, and not least, the vast amount of personal 19, belonging to a risk group, or living far away in a lockdown health resources human beings have in critical situations. context. In a few cases, families reported not wanting to come because of the emotional impact or the emotional distance with their relative. Despite the telematic intervention, the quality of RESULTS the setting was taken into account, and relatives had full access to psychological and social work aids if necessary. Regarding After approval by the Clinical Research Ethics Committee communication of loss interventions, almost all were performed (CEIm) of Vall d’Hebron University Hospital PR(AG)435/2020, in COVID-19 cases (96%). It could be explained because this we analyzed descriptive data collected during the EOL group had substantially more hospitalized relatives, probably program implementation. because of family clusters transmission. The results obtained from data gathering during the EOL program intervention are shown below. Table 4 shows the socio- demographic data of the patients and their families, describing DISCUSSION the main characteristics of the sample. The program attended 359 relatives from a total sample of 219 patients, of which 55.3% This study aimed to describe the first face-to-face structured were COVID-19 and 44.7% had other pathologies. Mean age experience of an EOL intervention program during the COVID- of patients in EOL situations was 70.86 (14.85), and 53% were 19 pandemic. Our experience agrees with the review of Mayland men. As regards relatives, 59.3% were women, and 94.8% had a et al. (48), which shows that the pandemic context leads to a first-degree relationship, 57.3% being consanguinity related. disruption, affecting an individual’s ability to connect with the Frontiers in Psychiatry | www.frontiersin.org 6 May 2021 | Volume 12 | Article 608973 Beneria et al. End of Life Intervention Program TABLE 4 | Socio-demographic data of the patients and their families* . All Patients COVID-19 Other pathologies Patients attended N = 219 n = 121 (55.3%) n = 98 (44.7%) Men 116 (53%) 58 (47.9%) 58 (59.2%) Women 103 (47%) 63 (52.1%) 40 (40.8%) Mean age 70.86 (14.85) 71.22 (13.95) 70.42 (15.95) Men 68.37 (12.54) 67.88 (11.51) 68.86 (13.57) Women 73.67 (16.71) 74.30 (14.34) 72.68 (18.86) Area of origin Barcelona city 169 (77.2%) 105 (86.8%) 64 (65.3%) Metropolitan area 33 (14.1%) 10 (8.3%) 23 (23.5%) Other 17 (7.8%) 6 (4.9%) 11 (11.2%) Date of hospitalization Before March 9 (4.1%) 6 (5%) 3 (3.1%) As of March (included) 210 (95.9%) 115 (95%) 95 (96.9%) Hospitalization time (days) 12.16 (14.35) 16.51 (16.67) 7.37 (9.21) Month of intervention Attended to in April 130 (59.4%) 86 (66.2%) 44 (33.8%) Attended to in May 89 (40.6%) 35 (39.3%) 54 (60.7%) Inpatient death 195 (89%) 103 (85.1%) 92 (93.9%) Relatives attended 359 212 (58.3%) 147 (41.7%) Men 146 (40.7%) 94 (44.3%) 52 (35.4%) Women 213 (59.3%) 118 (55.7%) 95 (64.6%) Average number of relatives attended to 1.76 (1.11) 1.84 (1.18) 1.65 (1) Relationship degree* N = 211 First-degree** 200 (94.8%) 114 (96.6%) 86 (92.5%) Other 11 (5.2%) 4 (3.4%) 7 (7.5%) Relationship Consanguinity 121 (57.3%) 69 (58.5%) 52 (55.9%) Affinity 31 (14.7%) 12 (10.2%) 19 (20.4%) Both 59 (28%) 37 (31.4%) 22 (23.7%) Families with other members hospitalized 25 23 (92%) 2 (8%) *The data collection was done for a clinical purpose and there’s information lost that caused an attrition of eight subjects in some variables. **At least one first-degree relative. deceased both before and after death. This can impact grief, and initially not contemplated that the program ended up covering the usual societal and cultural rituals may appear to be rushed, and adapting to. Most EOL interventions took place on the same altered, or absent. Since hospitals became the usual place for EOL day or the day before the decease. Also, most of the relatives situations, and families, especially socio-economically vulnerable could come to the hospital in person to bid farewell to their loved ones, were under great stress, it was necessary to develop an EOL ones. Sadly, due to the unpredictability and severity of COVID- program. Our program took all this into account and was based 19, some relatives arrived after the death of their loved one. In on both specific COVID-19 recommendations (e.g., support to other cases, the team did not even have time to contact them adapt funerals or rituals) (44) and families’ perceptions of EOL because of the sudden death of the patient while being admitted care (e.g., emotional support) (45). to the hospital. As expected, (27), due to COVID-19-related restrictions, Regarding the staff ’s experience, we highlight the reported families with COVID-19 patients as well as families with emotional impact due to the nature of the work and the fact that it no COVID-19 patients were affected and benefited from the was carried out in unusual conditions (49). Working and sharing program, even when the curve was finally beginning to flatten. as a team, or being on shifts that were not too long was considered Regarding the interventions, during the day shift most of the by the team as ways to mitigate the perceived impact. face-to-face interventions were psychosocial, while the rest were As stated, to our knowledge no other face-to-face EOL attended only by the HSW when the need for psychological programs have been formally presented in the COVID-19 aid was not detected. Although most of the interventions were context. Only one similar program during the COVID-19 EOL, some of them involved supportive communication with the pandemic was found in a phone-based format (50), and although relatives of a deceased person. This is an example of a situation no quantitative efficacy assessment was reported they identified Frontiers in Psychiatry | www.frontiersin.org 7 May 2021 | Volume 12 | Article 608973 Beneria et al. End of Life Intervention Program TABLE 5 | Types of intervention. EOL Communication of a death COVID-19 Other pathologies Total COVID-19 Other pathologies Total Number of interventions n = 123 n = 81 N = 204 n = 26 n=1 N = 27 Case type 54,3% 38,2% 92.5% 7% 0.5% 7.5% Average interventions by case 1,22 (0.48) 1.14 (0.4) 1.19 (0.45) 2 (1) 1 1.93 (1) Intervention type Face-to-face 44.2% 32% 76.2% 50% 7.1% 57.1% Telephone 14.5% 9.3% 23.8% 42.9% 0% 42.9% Shift Day shift 46.5% 24.4% 70.9% 92.9% 7.1% 100% Night shift 12.2% 16.9% 29.1% 0% 0% 0% Localization Hospitalization 22.1% 18.6% 40.7% 28.6% 7.1% 35.7% ICU 24.4% 11.1% 35.5% 64.3% 0% 64.3% Emergency department 12.2% 11.6% 23.8% 0% 0% 0% Day of intervention Day of death 34.6% 26.5% 61.1% – – – One day before death 11.1% 6.2% 17.3% – – – Other 13.6% 8% 21.6% – – – Moment of intervention Before death 33.8% 18.9% 52.7% – – – After death 14.9% 16.9% 31.8% – – – Both 10.8% 4.7% 15.5% – – – ICU, intensive care unit. several useful roles CP can play in this scenario (29). Other night shifts with psychological aid, the shifts should be unified EOL programs in ICU prior to the pandemic were found (45), for all professional categories. using different approaches involving multidisciplinary family meetings, communication facilitators, and collaborations with palliative care professionals. Most of the interventions were not CONCLUSION found to be effective because they were not guided by families’ Structured programs addressing EOL situations and taking care perceptions and needs, an aspect we made sure to incorporate of families and patients during the death and mourning processes whenever possible. should be a priority to prevent PGD and other associated complications. The COVID-19 pandemic placed the health STRENGTHS AND LIMITATIONS system in a critical situation, where more programs responding to patients’ psychosocial needs and those of their families Among the strengths of this study, the face-to-face nature of are required. our program, in the midst of the high-restriction pandemic context, constitutes its main effectiveness. Another strength is its feasibility and ability to adapt and grow in an DATA AVAILABILITY STATEMENT unstable context and chaotic environments. We also value its The datasets used and analyzed during the current study will multidisciplinarity. On creating teams formed of HSW and CP in be made available by the corresponding author upon reasonable coordination with the HCT, we managed to provide a combined request interdisciplinary intervention. Nevertheless, it has some limitations. The first one is the lack of efficacy assessment of PGD prevention, basically due to ethical ETHICS STATEMENT considerations. In further studies, outcomes measured to assess the efficacy of intervention should be taken into account, in order The studies involving human participants were reviewed and to evaluate the potential impact of the interventions on both approved by Clinical Research Ethics Committee (CEIm) of Vall families and professionals. Regarding the emotional impact on d’Hebron University Hospital. Written informed consent for the team, we believe a higher level of rotation could help to participation was not required for this study in accordance with mitigate it. Finally, to create a greater team spirit and to cover the national legislation and the institutional requirements. Frontiers in Psychiatry | www.frontiersin.org 8 May 2021 | Volume 12 | Article 608973 Beneria et al. End of Life Intervention Program AUTHOR CONTRIBUTIONS ACKNOWLEDGMENTS All the authors have contributed to the intervention, design, The authors are grateful to the Citizen’s Advice Service of the acquisition, analysis, interpretation, and/or review of the work HUVH for all the facilities provided, to the Support Team for its and agree to be accountable for all aspects of the work, ensuring coordination and help during this process, and most especially, that questions related to the accuracy or integrity of any part of to all the families that trusted us in their hardest moments of loss, the work are appropriately investigated and resolved. a sincere thank you for letting us stay. REFERENCES 18. Farahmandnia B, Hamdanieh L, Aghababaeian H. COVID- 19 and unfinished mourning. Prehosp Disaster Med. (2020) 1. Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. 35:464. doi: 10.1017/S1049023X20000631 Acta Biomedica. (2020) 91:157–60. doi: 10.23750/abm.v91i 19. 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Conflict of Interest: JR-Q was on the speakers’ bureau and/or acted as consultant SSM Population Health. (2020) 12:100628. doi: 10.31235/osf.io/4wtz8 for Eli-Lilly, Janssen-Cilag, Novartis, Shire, Takeda, Bial, Shionogui, Lundbeck, 40. Mia MA, Griffiths MD. Letter to the editor: the economic and mental Almirall, Braingaze, Sincrolab, Medice and Rubió in the last 5 years. He also health costs of COVID-19 to immigrants. J Psychiatr Res. (2020) 128:23– received travel awards (air tickets + hotel) for taking part in psychiatric meetings 4. doi: 10.1016/j.jpsychires.2020.06.003 from Janssen-Cilag, Rubió, Shire, Takeda, Shionogui, Bial, Medice and Eli- Lilly. 41. Thornton J. Clinicians are leading service reconfiguration to cope with Covid- The Department of Psychiatry chaired by him received unrestricted educational 19. BMJ. (2020) 369:m1444. doi: 10.1136/bmj.m1444 and research support from the following companies in the last 5 years: Eli-Lilly, 42. Hermann A, Deligiannidis KM, Bergink V, Monk C, Fitelson EM, Robakis Lundbeck, Janssen- Cilag, Actelion, Shire, Ferrer, Oryzon, Roche, Psious, and T, et al. Response to SARS-Covid-19-related visitor restrictions on labor Rubió. and delivery wards in New York City. Arch Womens Ment Health. (2020) 793–4. doi: 10.1007/s00737-020-01030-2 The remaining authors declare that the research was conducted in the absence of 43. Wakam GK, Montgomery JR, Biesterveld BE, Brown CS. Not dying alone — any commercial or financial relationships that could be construed as a potential Modern compassionate care in the Covid-19 pandemic. N Engl J Med. (2020) conflict of interest. 382:e88. doi: 10.1056/NEJMp2007781 44. Selman LE, Chao D, Sowden R, Marshall S, Chamberlain C, Copyright © 2021 Beneria, Castell-Panisello, Sorribes-Puertas, Forner-Puntonet, Koffman J. Bereavement support on the frontline of COVID-19: Serrat, García-González, Garriga, Simon, Raya, Montes, Rios, Bosch, Citoler, recommendations for hospital clinicians. J Pain Symptom Manage. (2020) Closa, Corrales, Daigre, Delgado, Dip, Estelrich, Jacas, Lara, Lugo-Marin, Nieto- 60:81–6. doi: 10.1016/j.jpainsymman.2020.04.024 Fernández, Regales, Ibáñez, Blanco and Ramos-Quiroga. This is an open-access 45. Chen C, Michaels J, Meeker MA. Family outcomes and perceptions of end- article distributed under the terms of the Creative Commons Attribution License (CC of-life care in the intensive care unit: a mixed-methods review. J Palliat Care. BY). The use, distribution or reproduction in other forums is permitted, provided (2020) 35:143–53. doi: 10.1177/0825859719874767 the original author(s) and the copyright owner(s) are credited and that the original 46. Ó Coimín D, Prizeman G, Korn B, Donnelly S, Hynes G. Dying in acute publication in this journal is cited, in accordance with accepted academic practice. hospitals: voices of bereaved relatives. BMC Palliat Care. (2019) 18:1– No use, distribution or reproduction is permitted which does not comply with these 16. doi: 10.1186/s12904-019-0464-z terms. Frontiers in Psychiatry | www.frontiersin.org 10 May 2021 | Volume 12 | Article 608973