key: cord-0971322-5jxte1fc
authors: Patel, Preet S; Desai, Nimisha D.; Shah, Sandip H.; Shah, Saurabh N.
title: Lived Experiences of Bereaved Family Members During COVID-19 Pandemic in a Tertiary Care Hospital With Special Reference to Imposed Restrictive COVID Guidelines—a Qualitative Study
date: 2022-02-21
journal: Omega (Westport)
DOI: 10.1177/00302228221075207
sha: ff55a04386f02845bdba776ccf5f83d722b78ac3
doc_id: 971322
cord_uid: 5jxte1fc

This study aimed to understand the experiences of bereaved family members in view of restrictive COVID guidelines using qualitative approach. 10 Hindu, Gujarati bereaved family members who lost their loved ones during the first wave were interviewed telephonically after a month of their loss. Findings were difficulty in proper communication during hospitalization, disrupted end-of-life and funeral rituals and accepting harsh realities related to the changes imposed by using content analysis. Most of the family members felt that there was a need of staying with the patients. Telephonic mode of communication was not sufficient for them and created doubts related to death. Most of them felt remorseful as they were not able to see or bring their loved one home during their last moments and felt deprived of the traditional rituals. Also, they had to deal with their grief by themselves.

During the first acute surge of COVID-19 pandemic, strict lockdown measures were implemented to reduce infection rates such as restrictions in hospital stay or visiting the patient in the COVID hospital. Communication was also possible only via phone in case of hospitalized COVID patients. As a result of these measures, we saw a scenario of patients dying in the hospital without their loved ones by their side.

In Hindu traditions, dying at home is preferred. Family members provide care to their loved one at the time of death to facilitate the dying process. Funeral and postfuneral rituals are done to honor the deceased by facilitating the journey of their soul to achieve salvation and to provide comfort to the grieving family. According to Gujarati Hindu traditions, friends and extended family visit and stay with the bereaved, providing support to each other during the period of intense grief for about 13 days which is considered essential for the grieving process.

Various studies have shown that performing rituals might lead to externalization of feelings and foster the expression of emotions. (Mroz & Bluck, 2018; Rando, 1985) They help to maintain a meaningful bond with the deceased and also help in gaining control over the changes and uncertainties brought about by the loss. They help in accepting the reality and reorganizing their lives without the deceased. (Vale Taylor, 2009; Norton & Gino, 2014) The COVID-19 pandemic witnessed high mortality, leaving many grieving the sudden loss of their family members. Amid the COVID-19 pandemic, a shift is being witnessed around death-related rituals and practices. This includes taking the body of the deceased directly from the hospital to the cremation site, limiting the number of people at the crematorium, viewing the body from a distance, and restrictions in funeral rituals following appropriate social distancing norms (Government of India Ministry of Health and Family Welfare, 2020).

It is consequently possible that inability to be with their loved ones during their last days and not being able to carry out funeral rituals as per one's faith, beliefs and traditions can have detrimental effects on the bereaved, affecting their mental health and ability to cope with or process their grief (Gesi et al., 2020; Stroebe & Schut, 2020) . Studies done by Mohammadi et al. (2021) and Hamid and Jahangir (2020) have reported how changes in the funeral rituals have affected the grieving process in the Muslim community. Till date no studies have been done in Hindu culture. There is a need to hear their inner turmoil in respect to their loss and restricted funeral processes.

Qualitative research is an ideal method by which bereaved individuals can express their feelings and convey their thoughts regarding these unprecedented changes from hospitalization, death and funeral process following the death of their loved ones and its impact.

The purpose of this study is to understand the experiences of the bereaved family members during the loss of their loved ones due to COVID-19 virus and to obtain their perception on the changes in funeral rituals and capture the impact of restictive funeral guidelines.

This qualitative study was conducted at a tertiary care COVID dedicated teaching hospital located in urban area of central Gujarat amongst bereaved Hindu Gujarati family members as they represent majority of the population visiting this hospital.

As there are some differences in funeral and post-funeral rituals in every Hindu community, and study authors belong to Hindu of Gujarati culture, focus was only on Hindu Gujarati culture.

The Institutional Ethics Committee approval was taken and with due permission from the hospital authorities, we accessed the contact information of participants from Covid death register from the record section of the hospital for the month of October 2020.

Records of 35 Hindu Gujarati participants were obtained. Following the COVID-19 guidelines, specifying strict social distancing policies, they were contacted via phone in the month of December 2020 sequentially as per the register. Those participants who could not be contacted as their phone was either switched off or their number being not reachable, were skipped.

Among those who could be contacted, two refused and three did not respond to the second phone call.

In the first phone call, the researcher introduced herself and they were explained about the objectives of the study as per a transcript prepared in local language, that is, Gujarati. Informed consent to take part in the study and to audio record the interview was taken. They were assured about confidentiality and anonymity. Date and time of the interview was selected in accordance to their convenience.

In the second phone call, data was collected using a semi-structured interview. The interview guide included demographic details, questions regarding their family member's course of illness, death, funeral process, and their feelings about the restrictions made due to the pandemic.

The questions were mainly open-ended, and based on their responses, follow-up questions were asked to add more details. Initially, few general questions were asked such as: how the infection of their deceased family member progressed-their symptoms, diagnoses, reason for hospitalization and progress of their illness and death, their feelings from the diagnosis to death, their initial reaction when they heard about their death, restricted funeral processes, their feelings about limited rituals and how all this affected their lives and how they were coping. In many cases, two interviews were conducted for gathering data. The interviews continued till all the necessary information was obtained and no new information was acquired, that is, data saturation was reached. This was achieved after 10 interviews.

Immediately after each interview, one of the researchers listened to it multiple times and later transcribed it. As per interview guide, content was described into three major areas like information related to hospitalization till death, death, and death rituals including post-funeral rituals, and their views related to changes in death rituals. Total words of all transcript were around 6500. The second author independently reviewed it. The collected data was analyzed according to qualitative content analysis approach. Considering the explicit and implicit content and meaning, key words were extracted as codes. From this content, around 1000 keywords were identified with multiple repetitions and preliminary codebook containing 40 codes was developed. Then based on their similarities and differences, the codes were categorized until a theme was extracted. Finally themes and subthemes were defined and relevant quotes were selected. The entire process was repeated and checked by another researcher.

Our hospital is one of the main Covid designated tertiary care Government hospital in central Gujarat (consisting of a total of 575 Covid beds with all the required facilities-100 ICU beds with ventilator, 50 ICU beds without ventilator-at the time of study).

10 participants who lost a family member due to COVID-19 at our hospital in the month of October 2020 were interviewed.

The participants included 7 son's, 1 daughter, 1 wife, and 1 nephew. Average age of the participants was 40 years. The characteristics of participants presented in Table 1 .

Majority of the participants were male as the contact number provided by them to the hospital authorities belonged to a male member of the family. Even if the phone number belonged to a female, when contacted them, they would hand over the phone to a male family member to talk to, therefore, our sample had only two females interviewed. Male participants were employed, females were housewives.

Each interview lasted for approximately 30-50 minutes. We derived three Major themes as per interview guide with 12 subthemes from qualitative analysis. (Table 2 ).

This major theme was further divided into 4 subthemes related to different aspects of communication. (Table 2) 

Although measures such as not allowing visitors to visit or stay with the patients in hospital are necessary, they are restrictive in terms of the lack of communication they impose. Some of the participants were able to communicate with their family members during hospitalization via their own phone. (P2, P3, P5, P9, P10) All felt that phone calls provide temporary relief and reassurance but they do not resemble in-person meeting. The act of physical contact is still missing. One of the participants shared his experience-"My Father kept insisting to take him home as he did not like staying in the hospital. We were clueless. We had to motivate him on phone to stay strong. But we lost him…" (P3)

One participant forgot to give a phone to his mother in the hospital leaving them anxious the whole time.

'I would have repeated thoughts about her, whether she was doing ok, if she sleeping well at night. Those 10 days when she was admitted in the hospital were extremely difficult as we were not able to talk to her' (P4)

Communication regarding patient's condition from the hospital was actively made time to time which was also acknowledged by the participants. Procedural consent was asked whenever needed by health care workers.

However, the lack of empathy and limited information regarding the patient's condition provided to the family members via telephone made it even more stressful. Some also found it difficult to make real-time decisions based on limited medical knowledge.

As reported by one son-"Day by day situation was getting out of hand; doctors also said that her chances of survival were low so we refused for intubation. It was difficult for us to decide based on technical information" (P6)

The experience was bitter for the participants as they were left with many unanswered questions and doubts.

'We got a call from the hospital at night and were informed about his fall in the washroom. He lost his consciousness for around 10 minutes following which his O2 level dropped. By early morning, they informed us about his critical condition. He had to be intubated but could not survive. We weren't there in the hospital so we do not know what exactly happened; we have to believe what the doctor says' (P9)

Being present with the deceased in their last moments is a profound experience which was missing. The participants mentioned that their family member's death was so sudden and unexpected that they did not get a chance to talk to them.

All participants reported that, if they were able to see or meet their family member, it would have made it easier to accept the loss and they would have at least felt satisfied.

All felt miserable as their loved one was dying alone with no family around. They felt bad for themselves too as they could not be with them when they were needed the most. One of them expressed that: "If anybody was present during his last minutes and the patient's condition is getting worse, or if there is anything the patient wants to say, at least they get a chance to talk and share their last words. In not allowing anyone to stay with the patient, there are so many issues, today we are left without our father." (P5)

Most of the participants felt that at least one family member or care giver should be allowed to stay with the patient in the hospital.

According to them, even if 1 person is allowed, it would help in providing support and comfort to the patient. It would reduce the burden of the hospital staff in terms of patient's dietary and bowel needs. They also believed that it would have increased their survival chances.

'If anyone from our family could be with him in the hospital, we could have fed him, given proper care; chances of his recovery would have been possible' (P3) 'If either I or my sister could have stayed with our mother, we could have spent time with her in her last days and fulfilled her last wishes. 

This major theme was further divided into subthemes: before, during, and after funeral process. (Table 2) Before Funeral Process a) Initial Shock and Denial. For the majority, the news of their family members' death was shocking and unreal as their death occurred in such a short span of time and the patient's condition wasn't that critical on the day of admission. For all the participants, loss of their loved ones was very intense and caused psychological crisis leading to shock and denial. For few, the news was anticipated due to the critical condition of their loved ones. (P1, P6, P10).

'My father already had breathing difficulties due to asthma. We never received any positive news from the doctor so we did not have any expectations.' (P1) 'My father was very strong, physically and mentally so it was very difficult for me to believe that he had passed away. When he was admitted in the hospital, he had cough and weakness, nothing else.' (P3) 'When I heard the news of her death, I could not believe it. It was so sudden that I had difficulty accepting it. (P4) 'The news came as a shock to me. We had talked with the doctor too-he was getting proper treatment. We had gone to the hospital expecting to see him but we were informed that he had just passed away.' (P9) b) Tiring "Antim Darshan". According to the hospital protocols, two individuals were allowed inside the ICU, wearing PPE kit, to see the deceased. Later, the body was covered according to the guidelines and taken to the crematorium in the hospital ambulance. Majority of the relatives visited the hospital for "Antim darshan" (except P3, P9). For some of the participants, wearing the PPE kit made their situation even more stressful.

'I had breathlessness and suffocation because of the PPE kit. We had to wait for long for another dead body which had to be taken to the crematorium in the same ambulance. My sister had to remove the PPE kit as it was very hot and she was getting dehydrated.' (P10)

During Funeral Process a) No "Home Visit". All the participants expressed their regret in not being able to bring the body of their family member home. In cases where the COVID report was negative, the dead body was handed to the participants' family. (P6, P8) However, for safety reasons, they did not bring the dead body home and it was taken directly to the cemetery.

'I have children at home; we did not want to take any risk so did not bring his body home.' (P8) b) Limiting Cremation Ceremonies. At the crematorium, the bodies were cremated in gas or electric crematoriums. The process was done in the presence of limited number of people. According to the guidelines, religious rituals such as reading from religious scripts, sprinkling holy water and any other last rites that did not require touching of the body was permitted. Bathing, kissing, hugging, etc. of the dead body was not allowed. Due to fear of contamination and viral transmission, all the participants viewed the body of the deceased from a distance. Many couldn't visit as they were quarantined.

'I felt really bad, I was not able to see my father or even touch him.' (P3, P10)

'Only regret I feel is that we could not bring his body back home. We have done a few things like distributing The Bhagavad Gita, feeding the priests, made donations; so wherever his spirit is looking at us from, at least he will feel that his family is doing something for him.' (P9)

'At the crematorium, we did prayers with flowers and garlands. We felt that we couldn't complete all the rituals. But according to the situation we have to adapt. Thinking practically, we skipped everything.' (P6)

In Hindu tradition, "asthi visarjan" or immersion of ashes is an important funeral ceremony in which after the body is cremated, the ashes are collected which are then immersed in a significant river body symbolizing the final detachment with the physical body and eventually attaining salvation.

Most of the participants collected the ashes of the deceased on the second day of cremation under proper precautions. ' We were able to collect the ashes next day to complete the rituals for 'asthi visarajan'. (P2, P3, P5) After Funeral Process a) Mourning in Isolation. Friends and family visit the bereaved during the period of mourning which in Hindu traditions lasts for around 13 days. In Gujarati families, there is a belief that the departed soul rests on the rooftop of the house observing everything for the next 13 days. In a ritual called "Saravni,"-many new things are offered for the soul's new life journey, after which the journey begins. Reading of "Garuda purana" is done to console the family members. In some traditions, a gathering is done and food is fed to all. Donations are made in the name of the deceased. Due to the pandemic and related restrictions, each family member had to mourn alone with no relative beside them and the important rituals of these 13 days could not be done appropriately.

The initial days were difficult for the bereaved family members as the sudden loss was catastrophic. It was difficult for them to accept and they kept ruminating about it.

'Everything happened so suddenly that I find it difficult to believe that he is no more.' (P3) 'The first few days after his death were very challenging. I couldn't eat or sleep. I used to have constant thoughts about them. Memories of that day, in the hospital, would keep running in my mind. I did not know how I would manage everything without him; I had no energy to think about the future. I never imagined that such an incident would occur. We had so many unfulfilled dreams; my son is also very young; my whole life has been turned upside down' (P9) Friends and family offered their prayers virtually via phone/video call.

'Father has done so much for us. We couldn't even bring his body home for the last time. Other relatives also did not get a chance to see him. We had to do all the rituals via video call and phone.' (P5) Few of the participants had to take leave from work to cope with the stress. I had to take leave from work for a month, as it took a toll on me. My boss also said to join only after I felt emotionally stable. (P4) b) Concerns About Incomplete Ceremonies. The participants were dissatisfied as they could not hold the conventional funeral rituals.

Whenever they experienced any negative event, they believed it to happen because they were not able to organize a traditional funeral ceremony. They also believed that it might have affected post-death soul journey.

'No one in our family other than my brother and I were present for all the rituals. My maternal uncle had passed away 2 months ago but he lived in another city so no one could go there either. Since we couldn't bring his dead body home and perform all the rituals, our family believes that it might have affected my father's soul journey' (P1) c) Moving on with guilt and future concerns. Some of the participants also felt guilty for their family members' death as they felt that they couldn't do much for them.

'Even today I have doubts whether I was responsible for his death; if I had taken a different step like shifting him to a private hospital or given any other form of treatment; he could have survived. I try to keep myself busy and keep my mind diverted.' (P3) After the initial reaction and allowing time to heal, they gradually felt emotionally stable.

They then started thinking about their future and added responsibilities.

In the beginning I used to think that it would have been better if I too had passed away along with my husband, but then I have to think about my son's future too. After his school starts, I will search for a part time job.' (P9) d) Stigma and Complications in social interaction. Due to fear of viral transmission, some of the participants experienced hostile behavior from their neighbors and other relatives. Neighbors would talk that there was a positive case in the society and wouldn't allow the house help to work at their place due to risk of viral transmission. Even their relatives did not behave properly with them. Their narratives were-'Neighbors would talk that there is a positive case/spreader in the society, they would not allow the house help to work at our place' (P2)

'Immediately on hearing the news, no one visited. I felt hurt as my father always supported them but they did not even visit after his death. Few relatives visited after 10 days after knowing that we had tested negative for COVID-19' (P6)

'We went to our village with my aunt for further rituals but the villagers were terrified and upset, they did not respond well. Even today after so many days have passed, they maintain distance and do not visit or even pass by our home. We felt bad as he was always supportive towards the villagers but they did not provide any support or help.' (P7)

All the participants agree that the restrictions imposed are necessary in the current situation despite the emotional crisis that they had to undergo. Most of participants show concern related to what if someone contracts infection due to taking part in rituals, so it's better not to do. They believe that in this age of technology, all the rituals can be done virtually.

They report that changes are made keeping public health and safety in mind and it is advised to follow them strictly. Few of them even said that they wouldn't mind if stricter protocols are made. Some verbatims as reported by participants-'Everything is for safety of all, we cannot take risk by calling others at home, we have to adapt according to the situation.' (P1)

'In this situation, changes are necessary.

Whoever has left us has already gone. What if people come to our house to comfort us and someone falls sick, instead it is better we talk over the phone.' (P9)

'If we don't follow the guidelines, we are going to be in trouble. Safety should be our first priority. It is the age of technology. We can use video calls to communicate with others. We had done video call with my uncle's son from the crematorium since he could not come.' (P10)

This qualitative study investigated the experiences of bereaved family members in terms of restrictions imposed during the first wave of COVID-19 pandemic. In our study, three main themes were derived:

i) Difficulty in proper communication during hospitalization; ii) Disrupted end-of-life and funeral rituals; iii) Accepting harsh realities related to the changes imposed.

Similar studies have been done in France and in Iran in which few identical themes and subthemes were derived (Kentish-Barnes et al., 2021; Mohammadi et al., 2021) .

In a study of lived experiences of family members of patients with severe COVID-19 who died in intensive care unit in France during the first COVID wave, themes like distance communication being insufficient and disruption in end-of-life rituals were derived which were similar to our findings (Kentish- Barnes et al., 2021) .

The theme of Emotional shock consisting of catastrophizing, bitter farewell, stigmatization obtained in a study done in Iran was similar to our findings (Mohammadi et al., 2021) .

COVID-19 positive patients are separated from their loved ones during hospitalization due to the high transmissibility of the virus. We found that the only mode of communication was via phone, however, it wasn't sufficient. In cases where they were unable to give the phone to their family member, it resulted in tremendous stress. Even though hospital staff provided technical information related to patient's condition, family members felt dissatisfied along with many doubts in their minds. Few other studies also reported lack of rapport with the hospital staff and lack of empathy causing hindrance in proper communication. (Kentish-Barnes et al., 2021; Cardoso et al., 2020) Patients are dying in the hospital without their loved ones by their side. They did not get a chance to express their feelings or share their last words with their family. Family members were also overwhelmed by the thought of them dealing with the illness alone in the hospital. Study of Kashmiri Muslims also reported their misery of not being with their loved ones when they were needed the most (Hamid & Jahangir, 2020) .

Unable to see their loved ones for the last time made it difficult to accept the loss and resulted in denial. In a qualitative study of media reports, it was seen that their loved one's suffering and dying alone in hospitals were intensely distressing leading to a sense of unreality (Cardoso et al., 2020) .

Previous researches have studied the importance of family members staying with the patient in the hospital (Bhalla et al., 2014) and how it positively influences how they experience the period both before and after the death of their loved ones (Mossin & Landmark, 2011) .

In our study too, most of them wished that they were allowed to see/visit them during hospitalization. If they were able to do so, it would have made it easier to communicate with them. They wouldn't have felt so helpless and despaired. It could have possibly increased their chances of survival too.

Studies during previous infectious outbreaks have shown how changes in social norms, rituals, mourning practices, and loss of connection affect grief and bereavement. (Mayland et al., 2020) It has been seen that multiple losses have occurred due to death itself as well as due to changes in social norms, rituals, and mourning practices.

The sudden and unexpected nature of the death did not give them enough time to prepare for their loved one's death leading to shock and denial which was seen in other studies too. (Kentish-Barnes et al., 2021; Mohammadi et al., 2021; Hamid & Jahangir. 2020) We found that the major cause of regret among participants was the inability to bring the dying person home as in Hindu culture, individuals prefer to die peacefully at home. Similar experiences have been reported in other cultures as well (Hamid & Jahangir, 2020; Hanna et al., 2021; Fernández & González-González, 2020) .

COVID-19 has caused a major disruption in the way funeral process takes place. Due to the high transmissibility of the virus, the government has set up regulations for safe management of dead bodies. (Government of IndiaMinistry of Health and Family Welfare, 2020) Two persons were allowed to visit the hospital wearing PPE kit to see the deceased and to complete the formalities. For many, it was tiring as they were not used to wearing the PPE kit and the emotional turmoil affected the way they experienced it. Even the process where the body of the deceased was taken to the crematorium weakened them. Funeral staff wearing PPE kit, shortened funeral, limited persons, attending from a distance, all added to their distress leaving them helpless.

Similar experiences were shared in a qualitative study of media reports done in Brazil (Cardoso et al., 2020) .

Funeral rituals are an essential component of the Hindu religious mourning system. Hindus believe in the process of reincarnation according to which the body is just a vessel for the immortal soul. The soul continues its journey of birth, death, and rebirth and finally gains liberation to become one with "Brahma," the divine force and ultimate reality.

They believe that the body can prevent the soul from moving on to the next journey. Thus, the funeral rituals are done as early as possible within hours of death.

State of consciousness just before death is essential in determining the state of next life. Therefore, Hindus prefer death to occur at home surrounded by their loved ones.

A priest is usually called who along with them sing hymns, recite prayers, and chant mantras creating a spiritual atmosphere.

Immediately after death, family members wash the body, dress it in clean clothes, and cover with flowers and garlands. Friends and family gather to recite prayers and mantras. Offerings are made to help the soul unite with its ancestors.

The body is then carried to the cremation ground and placed on a pyre.

It is ideally cremated as they believe that burning enables the departed soul to abandon attachment from its previous body and move swiftly forward to the next chapter of life.

There is a period of mourning which follows immediately after the cremation which is usually 13 days. The whole family stays together, providing support to each other. They are encouraged to express their grief by mourning and crying which also helps in acknowledging the reality of death.

Limited funeral rituals evoke guilt amongst the bereaved because of their belief that it might affect the soul journey making their mourning process more difficult and painful as well as incomplete. This further increases the risk of complicated grief.

Due to the pandemic, families were deprived of the rituals that normally occur after death as some of them were themselves affected by the virus and were quarantined or couldn't visit due to restrictions imposed on travel.

They couldn't mourn or express their support and love which was also seen in the study conducted by Mohammadi, et al. (2021) .

Funeral ceremonies at home were done digitally. The lack of physical support intensified their social isolation and loneliness and they had to deal with their grief by themselves.

This may have set a platform for pathological grief reaction leading to increased vulnerability to psychological distress and grief.

This was also narrated in a recent study done by Kentish-Barnes et al. (2021) in France as "stolen moments" generating strong feelings of disbelief which can lead to complicated grief.

In our study, most of the participants experienced emotional crisis leading to guilt as they felt responsible for their loss. They would wonder if they could have survived if they had shifted them to a private setup instead or taken any other decision regarding their treatment. Such intense distress can lead to depression and other psychological morbidities (Eisma & Stroebe, 2017) .

Anxiety and fear along with limited knowledge about the disease can lead to social stigma.

Some of the participants experienced hostile behavior from their neighbors as well as relatives. Such experiences were also narrated in the study by Mohammadi et al. (2021) .

Overall, most of the participants were not fully satisfied with the way they handled the funeral rites leaving them scarred and more vulnerable to future psychological consequences in their lifetime.

Despite all the challenges they faced, the bereaved individuals accepted that there is no choice but to follow the rules and regulations related to the COVID-19 pandemic as public good should always come before personal loss. All the participants agree that these changes and restrictions are needed in the current scenario. They tried to rationalize the limitations in funeral/mourning process by giving reassurance to themselves that in this age of technology, funeral ceremonies can be done virtually. No other study has reported such accepting behavior till date.

Although this study has provided various insights into how the COVID-19 pandemic has changed the grieving process, it has a few limitations too.

The study was conducted via phone which has its own drawbacks such as missing out on visual and non-verbal cues with potential loss of contextual data.

Only 10 participants belonging to Hindu Gujarati families were included. This makes generalization of the study results difficult.

Majority of the participants were male. Only two females were interviewed. Future studies can be done via in-person interviews including a larger and diverse sample population to address these limitations.

Our study has put forth certain important findings that can guide decision-making at various levels such as individual, hospital as well as community.

Hospital policy makers could implement regulations that could possibly allow visitors inside the COVID hospital under strict protocols.

Hospital authorities can incorporate informed decision policies whereby if relatives wish to stay with the patient they can do so but under the risk of contracting infection.

Steps can be taken for improving communication at the hospital level such as providing information regularly to the family members and allowing them to visit if situation gets critical.

At individual level, social support can be made accessible so that they can open up and discuss matters which will ultimately facilitate them in taking important decisions and their mental health needs will be taken care of at the same time.

There is a need to innovate funeral customs with safety in our mind but fulfilling the meanings of those rituals with the use of technology and allowing performing traditional culture specific rituals in some way to smoothen their mourning process.

Strategies need to be implemented by mental health care providers to address the psychological needs of bereaved individuals, to identify their mental status and provide timely psychological intervention.

At community level, awareness and appropriate information regarding the disease need to be spread among the general public to reduce the negative perception and stigma associated with it. This can make sure that at least everyone is sensitized about others' emotional needs during these tough times and they try to help each other, if not physically then at least by indirect means.

This qualitative study during the first wave of COVID-19 pandemic studied the experiences of bereaved family member of hospitalized patients and found that unsatisfying communication practices and restricted funeral rituals has led to an emotional crisis in them. This needs immediate attention in handling their distress and implementing certain changes at policy level with due respect to family system.

As the pandemic is still ongoing, the findings throw light on the need to take preventive measures too.

Involvement of the family members in caring of patients an acute care setting

The effect of suppressing funeral rituals during the COVID-19 pandemic on bereaved families

Rumination following bereavement: an overview

The dead with No wake, grieving with no closure: illness and death in the days of coronavirus in Spain

Complicated grief: what to expect after the coronavirus pandemic

COVID-19: Guidelines on dead body management

Dying, death and mourning amid COVID-19 pandemic in Kashmir: A qualitative study

A qualitative study of bereaved relatives' end of life experiences during the COVID-19 pandemic

Lived experiences of family members of patients with severe COVID-19 who died in intensive care units in France

Supporting adults bereaved through COVID-19: A rapid review of the impact of previous pandemics on grief and bereavement

The mental health crises of the families of COVID-19 victims: a qualitative study

Being present in hospital when the patient is dying -a grounded theory study of spouses experiences

In memory: Predicting preferences for memorializing lost loved ones

Rituals alleviate grieving for loved ones, lovers, and lotteries

Creating therapeutic rituals in the psychotherapy of the bereaved. Psychotherapy: Theory, Research, Practice

Bereavement in times of COVID-19: A review and theoretical framework

We will remember them": A mixed-method study to explore which postfuneral remembrance activities are most significant and important to bereaved people living with loss, and why those particular activities are chosen

The authors would like to thank Dr.Parag Chavda, Assistant Professor, Community Medicine and other Residents of the Department of Psychiatry, GMERS Medical College, Gotri, Vadodara for the support during the study.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Nimisha D. Desai  https://orcid.org/0000-0002-8450-485X