Background: The COVID-19 pandemic has caused millions of deaths worldwide, leading to symptoms of grief among the bereaved. Neither the burden of severe grief nor its predictors are fully known within the context of the pandemic. Aim: To determine the prevalence and predictors of severe grief in family members who were bereaved early in the COVID-19 pandemic. Design: Prospective, matched cohort study. Setting/Participants: Family members of people who died in an acute hospital in Ottawa, Canada between November 1, 2019 and August 31, 2020. We matched relatives of patients who died of COVID (COVID +ve) with those who died of non-COVID illness either during wave 1 of the pandemic (COVID −ve) or immediately prior to its onset (pre-COVID). We abstracted decedents’ medical records, contacted family members >6 months post loss, and assessed grief symptoms using the Inventory of Complicated Grief-revised. Results: We abstracted data for 425 decedents (85 COVID +ve, 170 COVID −ve, and 170 pre-COVID), and 110 of 165 contacted family members (67%) consented to participate. Pre-COVID family members were physically present more in the last 48 h of life; the COVID +ve cohort were more present virtually. Overall, 35 family members (28.9%) had severe grief symptoms, and the prevalence was similar among the cohorts ( p = 0.91). Grief severity was not correlated with demographic factors, physical presence in the final 48 h of life, intubation, or relationship with the deceased. Conclusion: Severe grief is common among family members bereaved during the COVID-19 pandemic, regardless of the cause or circumstances of death, and even if their loss took place before the onset of the pandemic. This suggests that aspects of the pandemic itself contribute to severe grief, and factors that normally mitigate grief may not be as effective.

Background Under the pandemic conditions created by the novel coronavirus of 2019 (COVID-19), physicians have faced difficult choices allocating scarce resources, including but not limited to critical care beds and ventilators. Past experiences with severe acute respiratory syndrome (SARS) and current reports suggest that making these decisions carries a heavy emotional toll for physicians around the world. We sought to explore Canadian physicians’ preparedness and attitudes regarding resource allocation decisions. Methods From April 3 to April 13, 2020, we conducted an 8-question online survey of physicians practicing in the region of Ottawa, Ontario, Canada, organized around 4 themes: physician preparedness for resource rationing, physician preparedness to offer palliative care, attitudes towards resource allocation policy, and approaches to resource allocation decision-making. Results We collected 219 responses, of which 165 were used for analysis. The majority (78%) of respondents felt "somewhat" or "a little prepared" to make resource allocation decisions, and 13% felt “not at all prepared.” A majority of respondents (63%) expected the provision of palliative care to be “very” or “somewhat difficult.” Most respondents (83%) either strongly or somewhat agreed that there should be policy to guide resource allocation. Physicians overwhelmingly agreed on certain factors that would be important in resource allocation, including whether patients were likely to survive, and whether they had dementia and other significant comorbidities. Respondents generally did not feel confident that they would have the social support they needed at the time of making resource allocation decisions. Interpretation This rapidly implemented survey suggests that a sample of Canadian physicians feel underprepared to make resource allocation decisions, and desire both more emotional support and clear, transparent, evidence-based policy.

ObjectivesPatients, physicians and the healthcare system are faced with the challenge of determining, and respecting, the medical wishes of an aging population. Our study sought to describe who participates in advance care planning (ACP) and decision-making for patients in long-term care and designated assisted living.MethodsIn 2008, Alberta Health Services initiated its ‘Advance Care Planning: Goals of Care Designation’ (Adult) policy in the Calgary zone. This policy encouraged discussions about goals of care and used a tracking form to capture these conversations. A postpolicy implementation chart review was performed at 3 time points: at baseline, at 6 months and at 18 months post implementation in long term care (LTC) and designated assisted living sites.Results166 charts were reviewed and 90% had a documented goals of care order. Less than half of residents (47%) were documented as participating in conversations and they were less likely to participate if they had cognitive impairment and were living in LTC. Documented family participation was more prevalent in LTC (51% vs 11%). Nurses participated in 67% of documented conversations with only 34% of discussions documenting physician involvement.ConclusionsThis study identifies the lack of documented resident participation in ACP in LTC. While this finding may be explained by the high prevalence of cognitive impairment in our population, it raises questions about the optimal approach to ACP in LTC. In this setting, ACP appears to be more about relational autonomy than it is about patient autonomy.

ObjectiveTo compare end-of-life in-person family presence, patient–family communication and healthcare team–family communication encounters in hospitalised decedents before and during the COVID-19 pandemic.DesignIn a regional multicentre retrospective cohort study, electronic health record data were abstracted for a prepandemic group (pre-COVID) and two intrapandemic (March–August 2020, wave 1) groups, one COVID-19 free (COVID-ve) and one with COVID-19 infection (COVID+ve). Pre-COVID and COVID-ve groups were matched 2:1 (age, sex and care service) with the COVID+ve group.SettingOne quaternary and two tertiary adult, acute care hospitals in Ottawa, Canada.ParticipantsDecedents (n=425): COVID+ve (n=85), COVID-ve (n=170) and pre-COVID (n=170).Main outcome measuresEnd-of-life (last 48 hours) in-person family presence and virtual (video) patient–family communication, and end-of-life (last 5 days) virtual team–family communication encounter occurrences were examined using logistic regression with ORs and 95% CIs. End-of-life (last 5 days) rates of in-person and telephone team–family communication encounters were examined using mixed-effects negative binomial models with incidence rate ratios (IRRs) and 95% CIs.ResultsEnd-of-life in-person family presence decreased progressively across pre-COVID (90.6%), COVID-ve (79.4%) and COVID+ve (47.1%) groups: adjusted ORs=0.38 (0.2–0.73) and 0.09 (0.04–0.17) for COVID-ve and COVID+ve groups, respectively. COVID-ve and COVID+ve groups had reduced in-person but increased telephone team–family communication encounters: IRRs=0.76 (0.64–0.9) and 0.61 (0.47–0.79) for in-person, and IRRs=2.6 (2.1–3.3) and 4.8 (3.7–6.1) for telephone communications, respectively. Virtual team–family communication encounters occurred in 17/85 (20%) and 10/170 (5.9%) of the COVID+ve and COVID-ve groups, respectively: adjusted OR=3.68 (1.51–8.95).ConclusionsIn hospitalised COVID-19 pandemic wave 1 decedents, in-person family presence and in-person team–family communication encounters decreased at end of life, particularly in the COVID+ve group; virtual modalities were adopted for communication, and telephone use increased in team–family communication encounters. The implications of these communication changes for the patient, family and healthcare team warrant further study.