key: cord-0929037-2587pno5
authors: Cardoso, Érika Arantes de Oliveira; da Silva, Breno César de Almeida; dos Santos, Jorge Henrique; Lotério, Lucas dos Santos; Accoroni, Aline Guerrieri; dos Santos, Manoel Antônio
title: The effect of suppressing funeral rituals during the COVID-19 pandemic on bereaved families
date: 2020-09-07
journal: Revista latino-americana de enfermagem
DOI: 10.1590/1518-8345.4519.3361
sha: a163d144fe6608396f8acd753930f930856db49a
doc_id: 929037
cord_uid: 2587pno5

OBJECTIVE: amidst the greatest health crisis in history triggered by COVID-19, this documental study was intended to understand the meanings individuals who have lost loved ones in this context assign to the phenomenon of suppressed funeral rituals. METHOD: based on the theory of grief, the corpus of this study was composed of documents published in digital media containing personal writings and reports of experiences freely and easily available to the public. Two researchers with expertise in the field used inductive thematic analysis to interpret data. RESULTS: the experiences shared in the reports reflect the suffering experienced by the sudden death of a significant person, which is amplified by the absence or impediment to performing familial farewell rituals. The suppression or abbreviation of funeral rituals is a traumatic experience because family members are prevented from fulfilling their last homage to the loved one who has suddenly passed away, causing feelings of disbelief and indignation. CONCLUSION: alternatives and new ways to celebrate passage rituals in emergencies of strong social commotion such as a pandemic are needed to provide support and comfort to family members, friends, and relatives. These rituals help survivors to overcome the critical moment, decreasing the risk of developing complicated grief.

. It is estimated that 80% of the infected individuals develop mild or moderate forms of the infection while 20% manifest the severe version of the disease. Of these, 5% manifest the most severe form, which can rapidly progress to severe acute respiratory syndrome and other complications that may lead to death (3) .

There is a great concern worldwide with the novel coronavirus' high rate of transmissibility, which has caused different and devastating impact (4) (5) , forcing local governments to establish, in addition to health emergencies and states of calamity, exceptional administrative measures for funeral services. As a result of the crisis, traditional rituals to honor the dead and comfort mourners needed to be abbreviated or even interrupted. Therefore, the COVID-19 pandemic has demanded many aspects of the dying experience and its rituals to be reformulated in the Eastern and Western worlds (6) .

Psychology has long recognized the emotional value and structuring role of rites and rituals in different societies and cultures. Rites comprise a broader category, including rites of passage or healing, while a ritual is a set of gestures and actions that make up the rites. Human rituals are common to all peoples and are symbolic actions, repetitive, standardized, and highly valued behaviors that help individuals to channel emotions, and share beliefs and transmit values (7) (8) .

Marking the transience of life, funeral rituals have always been present in history (9) (10) (11) to demarcate a state of mourning, acknowledging the value and importance of those who have passed away, favoring change of roles and allowing the transition of the cycle of life (10) .

One should also consider the role funeral rituals play in psychological maturation, as they help individuals to face concrete loss and trigger a grieving process, allowing people to publicly manifest their grief (10) .

A lack of rituals when a physical body parts makes it difficult to psychologically acknowledge the loss. Additionally, sudden and unexpected deaths prevents mourners to prepare themselves to deal with the loss, considering that physical death does not accompany social and psychological death, which may lead people to face difficulties when facing their mourning process. When intense, these barriers may favor the so-called complicated grief, characterized by long-lasting disorganization that makes it difficult or impede psychological reorganization and the resumption of life. There may be also exacerbated symptomatic manifestations, such as an expression of intense feelings, somatization, social isolation, depressive episodes, low self-esteem, self-destructive impulse (12) , frequent thoughts directed to the deceased, inability to accept loss, self-blame, and difficulty imagining a meaningful future without the loved one (13) .

The elements that contribute to complicated grief may be divided into factors of personal risk, associated with the history and prior events in the life of the bereaved individual, and risk factors related to the circumstances of the death of the loved one. The latter comprise the death of a child or youth, death of wife or husband, lack of psychological preparedness to deal with death, death in a hospital, among others (14) (15) (16) . On the other hand, protection factors against complicated grief include the availability of psychological and social support (14) , clear communication between the health staff and family members of the deceased (17) , demonstration of empathy by other family members and the community (18) , and the meanings assigned to the death of the loved one (19) (20) (21) .

There are many factors in the context of the COVID-19 pandemic that may hinder one's grief, such as sudden death, being totally isolated in a hospital facility, the experience of death in a situation of intense distress and physical pain, less time available for people to give meaning to the loss, exposure to stigma and social discrimination, fewer rites and rituals, lack of social support, family relationships subject to greater tension, and other losses that occur simultaneously with death. In this adverse context, interventions mediated by the use of digital technologies have been proposed to alleviate the suffering of families and friends (22) . This study's objective was to understand the meanings individuals who experienced the loss of loved ones in the context of the COVID-19 pandemic assigned to the phenomenon of suppressed funeral rituals.

Documentary research with a qualitative approach.

Qualitative studies can adopt different instruments to compose the research corpus, among which documents (written material) that have not been previously analyzed or systematized. This type of study is intended to analyze the content of the documents chosen to compose the study corpus by establishing a hypothesis of interest, being considered an important resource in qualitative research in which documents are means of communication (23) . The type of the document chosen will depend on the study objective and the great challenge of researchers is to know how to select and treat data and interpret the results (24) . This type of study www.eerp.usp.br/rlae 3 Oliveira-Cardoso EA, Silva BCA, Santos JH, Lotério LS, Accoroni AG, Santos, MA.

is intended to produce new knowledge by exclusively using the document analysis method. Researchers need to understand documents as a means of communication and take into account the fact that documents were developed considering that someone who would have access to their content (25) .

In this study, the documents addressed include: written personal documents, freely available to the public, and not produced specifically for this study, that is, the corpus was composed of texts that existed even before this study was planned (23) . These are spontaneous productions, with the intent to communicate or share Brazilian websites freely and openly available to the public, which had aired content concerning experiences with the pandemic, were previously selected to delimit this study's search universe. In addition to being easily accessible, the websites and materials were chosen considering the criterion of impact, which was estimated by the number of accesses, likes, and interactions with the content posted. After selecting the texts of interest in line with the study's objective, the excerpts were collected that reported discourse, experiences, and testimonies shared by adult individuals concerning how they were dealing with the illness and loss of family members.

The websites used to collect data were the Twitter and Google platforms. Twitter makes available an "advanced search" tool with which one can select the period of the publications, language, degree of interaction, words, and even specific phrases. News on the Google platform was filtered by openly accessible news reporting losses due to complications caused by COVID-19, whether confirmed or suspected. The following combinations of search terms were used in Twitter: "Covid19" and "Mourning", "Covid19" and "Funeral", "Covid19" and "Loss", "Covid19" and "Sad", and also a combination of "Coronavirus" and "Mourning", "Coronavirus" and "Funeral", "Coronavirus" The Kappa (25) index was calculated to verify agreement between the two researchers, and a Kappa coefficient of 0.83 indicated almost perfect agreement between them. At the end of this first selection stage, 84 reports were recovered from Twitter and 17 from Google. Then, the texts selected by the researchers were compared and divergences concerning the inclusion or exclusion of content were resolved by consensus.

The material collected was read once again with a view to refining content that strictly answered the study's objective. Twenty-three publications remained in the final selection and comprised the study's corpus.

The researchers organized and analyzed the reports extracted from the texts selected according to inductive thematic analysis (26) , considered an accessible and flexible approach that is appropriate for qualitative research. Its objective is to identify and analyze patterns www.eerp.usp.br/rlae 4 Rev. Latino-Am. Enfermagem 2020;28:e3361.

in the reports collected to interpret the constitutive aspects of the contents.

Two researchers with expertise in the phenomenon of mourning, who had not participated in the previous stages, conducted the analysis, involving: 1) exploration of the material: inspection and exhaustive reading of each text transcribed in sequence; 2) generation of the initial codes; and 3) search for themes. In step 1, the narratives that compose the study's corpus were fully read. In step 2, the researchers coded data, meaning that the texts were read numerous times and content was associated with key-ideas based on the question "what is it that is written here?" Subsequently, the researchers reviewed all the transcriptions to ensure that nothing was left out of consideration and discussed the codes and initial themes with the rest of the team (step 3).

This last step was crucial to the analysis because, in qualitative research, it is not expected that fully exempt researchers reach the same representations of a given event. Rather, some level of agreement, even if temporary, is expected, understanding that this representation of reality is acceptable. This kind of an agreement that different observers may achieve regarding a given phenomenon legitimates the analysis presented (27) . The discussions and suggestions indicated the need to expand or change the analysis, establishing and naming the final themes, rigorously obeying what is recommended by the analysis method adopted. The process of mourning the dead, of gathering the family and friends to get comfort and solidarity was summarily interrupted: It is the saddest thing in the world to lose a child and not be able to go to his burial, not being able to do anything. It is really, really, really difficult. It is unbearable (mother).

Additionally, with the increase in cases and rapid acceleration of the pandemic, the terrible humanitarian catastrophe is added to a sanitary and funeral emergency: Amidst the pandemic, the scenario that is presented gains dramatic contours that potentiate the pain and distress of family members, as it becomes impossible to receive social support due to the stigma associated with the disease: Now that the isolation period the physician recommended is over, I confess that I'm afraid to go out on the streets. It is as if we may contract a disease that will never be cured (daughter).

The mourner ceases to be an object perceived as www.eerp.usp.br/rlae 6 Rev. Latino-Am. Enfermagem 2020;28:e3361.

Various factors have hindered the process of mourning the loss of loved ones among families in the global scenario of the first wave of COVID-19 (28) : the fact that there is little scientific knowledge about the dynamics of this disease; its high lethality rate (29) ; the vertiginous speed at which SARS-CoV-2 is spread; in addition to the mandatory restriction of physical proximity, suppressing the ideal conditions for families to receive social support, fomenting the stigma related to the disease. (30) (31) .

In addition to dealing with a traumatizing loss, coffin cannot be exposed (32) , impeding a ritualization that is a fundamental part of the Brazilian culture.

Therefore, in addition to the brutal loss of a loved one, people experience the impossibility to celebrate the final rites that give the opportunity of communion, complicity, connection with the sacred, and start a necessary process of detachment (10) . Paying the last tribute to a loved one is a mental health gesture that allows individuals to make amends and reconcile with life. In the exceptional regime determined by the pandemic, however, funerals were abolished and necessary limitations were imposed on burials, creating disturbances rather than comforting (10) . The feeling that remains is that "one stage was skipped", as it is essential to share grief and receive social support after the death of a loved one (33) . These restrictions favor the risk factors for the development of complicated grief or at least maximize difficulties to elaborate normal grief.

Among potential protective factors, families report trust in the health staff, especially regarding the sharing of information. This relationship with workers may be capable to promote the humanization of relationships by providing information, validating messages, and remotely interacting with families (17) . Considering the importance of this communication for families, its inclusion in the care process is extremely important. In this sense, researchers have worked on manuals and other didactic resources directed to family members, given the need to plan the flow of communication to mitigate the risks of people developing complicated grief and post-traumatic stress in the context of the pandemic (22) . This need to assign a noble and humanitarian meaning to the death of a loved one may provide some relief to the experience of an imponderable situation. In fact, in some studies, finding a purpose and meaning for the life that has suddenly ceased is reported to be related to fewer characteristics of complicated grief and lower levels of stress (19) (20) (21) .

The process of assigning meaning to death, especially in an unexpected and exceptional situation, is seen as a protective factor against complicated grief (19) (20) (21) .

In this sense, it is necessary to encourage care practices and psychosocial support centered on a search for meaning (14) , including encouragement to humanitarian campaigns, social solidarity and activism, participation www.eerp.usp.br/rlae The support provided to families and friends, and also to health workers and other workers involved in the tasks linked to funeral rites and rituals, can help mourners to overcome the critical moment, decreasing the risk of developing complicated grief. The greatest danger to be avoided is that the farewell ritual loses its meaning and fails to fulfill its role in aggregating family members in the distillation and psychological elaboration of shared pain.

Based on the analysis of the reports collected, we could verify that, in addition to serious harm to the mental and physical health of those affected, this novel disease also imposes challenges that need to be considered when planning psychosocial interventions.

From the perspective of integral care, actions need to be comprehensive and include both those who became sick and people who, despite remaining healthy or asymptomatic, witnessed family members who faced the more severe form of the disease and even died. Throughout human history, funeral rituals have serve as existential milestones in the process of elaborating and re-signifying the death of a loved one. The acute grieving process triggered by a loss is important for psychological health because it is an opportunity to elaborate on the finite nature -of others and oneself. From the moment in which family members are prevented from performing farewell rituals due to the restrictions imposed by the pandemic, the mourning may become even more painful and even incomplete. It may trigger psychological distress that tends to go on indefinitely, providing raw material for the development of complicated grief.

To mitigate the impact of these problems, which humanity will have to learn to live with from now on in predictable new epidemic outbreaks, it is imperative to innovate how funeral rituals are performed, certainly making them safer to minimize the risk of contamination by the novel coronavirus, and even shortening these events, however, without emptying their meaning. This situation may be remedied with the help of technology, which permits preserving physical distance (which is not necessarily social distance) or even proposing new configurations to celebrate the traditional rituals specific to each culture.

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