ICMR's manual for HCWs: How to tackle emotional turmoil of relatives and "self" in COVID era?

ICMR has recently released a manual for "Health Care Professionals" in providing "Psychosocial Support" to family members in bereavement in the time of COVID-19.The guidelines are aimed to assist clinicians in three ways:

1. Disclosing the news of Death to the family;

2. Providing immediate psycho-social (including emotional) support to the family members of the patients with COVID-19;

3. Helping Health Care Professionals to cope with their own emotional reactions due to Death.

The person who is bereaved goes through a series of grief reactions, which according to Kubler-Ross (1969), follows five stages: denial, anger, bargaining, depression, and acceptance. Although these reactions are natural and help in the mourning process, they must be sensitively handled.

The guidelines highlight following key points to be kept in mind while extending support to family members:

I. Principle underlying support: This includes three critical components of the counselling approach viz. empathy to family's emotional turmoil, genuine and honest counselling and providing a non-judgemental unconditional possitive regard to relatives.

II. Optimizing Communication While Wearing the Hazmat Suit: It is challenging to appear concerned or show empathy, while an HCW is entirely covered with PPE and interacts from a considerable distance.

• The guidelines advocate use of gestures as an excellent means of non-verbal communication eg. eye contact, body posture, hand signals, and facial expressions that reinforce a verbal message or convey a particular thought or emotion.

• Paralinguistic: Due to physical distancing norms, a HCW at COVID facility has to speak at a louder tone with family members. It is better to pre-inform the patients to avoid being misinterpreted as rude in this situation.

Further, healthcare professionals' role and responsibilities in such situations can be have been subdivided into four major categories. The first three address the family member affected by the Death, and the fourth is for the professional himself/herself in handling the whole process of handling the death trauma due to COVID-19.

A. Preparing family members for the possibility of the worst outcome due to COVID-19: It is absolutely essential to keep family members in the loop of the patient's deteriorating conditions. The "hope for best but prepare for worst" message should be conveyed. Allow time for reflection, silence or stress, emotional reactions and questions.

B. Breaking bad news (BBN): The process of breaking the bad news of Death could be initiated in person or through telephone (due to infectious nature of COVID-19).The following pointers can be kept in mind while doing so:

(a) Breaking the Bad (difficult) News Sensitively: Following a brief introduction of the doctor on call, hospital and reason for which a call has been made, it can be revealed in a very clear way without further delaying that death has happened. The doctor here needs to allow time for the family member to understand what has happened. They can re-assert the information if asked again.

(b) Empathetic Listening: Initial reactions of shock, despair, anger and numbness are common. Doctors should try and avoid giving advise at this point.

(c) Critical Decision Making: After undergoing initial turmoil, once family members gather strength to talk further, provide them with the required information. Most significantly, when it is possible for them to perform the cremation.

(d) Ending conversation gently: It is then important to brief relatives about the immediate next steps which need to be taken. The conversation moves towards closure by gently extending support (in the form of any further assistance till they reach the mortuary) if required.

C. Facilitating the grief process: A tailored "sensitised approach" needs to be practised to deal with the traumatic emotional reactions of the family. Some of the essential ways of facilitating adaptive grief reactions are:

1. Encourage Family Members to Ventilate Emotions: Letting an individual actively engage in the expression of trauma marks the beginning of the mourning process. It is important to understand that aggression at this point is a manifestation of the acute emotional turmoil they are going through currently, and there is no need to provide any explanation for any allegations or engage in any further argumentation.

2. Facilitating Family's Acceptance to the Reality of Death: The doctor can arrange for viewing the body bag till face. Spending time with the body of a loved one who has died helps mourners truly and fully acknowledge the reality of the death with all necessary and prescribed safety and precautions

3. Appoint a Supportive Family Member to Facilitate the Care.

4. Telecommunication with family members living far away can be initiated to facilitate the grief process in a similar process as detailed above.

D. Practicing "self-care": Vicarious trauma in professionals involved in breaking bad news in times of pandemic lead to a "spill-over" effect of "Compassion fatigue", which leads to a reduced capacity for empathy toward suffering in the future.

Striking a balance between all six domains of self-care (Figure) ensure optimal health and well-being to professionals.

1. Physical Self-Care: Good nutrition every day at regular intervals, ensuring sufficient rest or sleep and engaging in necessary exercise or yoga are the key componenets.

2. Psychological Self-Care: This includes engaging in self-reflection, learning new things, exercising mindfulness, and engaging in activities perceived to be relaxing like writing a journal, etc.

3. Emotional Self care: Strategies like acknowledging own's emotions, taking a mini-break to release emotions to a colleague or a friend, and practicing self compassion are key psychological support mechanisms for professionals.

4. Social Self-Care: finding some quality time for loved ones and people who are significant in one's life nourishes the need for nurturance and belongingness.

5. Spiritual Self-Care: It can involve anything that helps an individual develop a more profound sense of meaning, understanding, or connection with the universe.

6. Professional Self-Care: This refers to practicing self-care while at work such that a healthy work-life balance can be achieved. This includes time management in work, balancing workload, taking time for essential activities like having lunch or taking a mini relaxing break with peers etc.

In addition to striking balance between all six domains of self-care, it is crucial for HCW to continue practicing adaptive coping mechanisms to stressful situations in their lives, which involves confronting problems directly. The guidelines encourage the health professionals to tailor the approach, whenever required, as per the need of the situation.

Source: https://www.icmr.gov.in/pdf/covid/techdoc/ICMR_Psc_Bereavement_05052021.pdf