Month: December 2020

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Headlines Don’t Capture the Horror We Saw

I chronicled what COVID-19 did to a hospital. America must not let down its guard.

By Kasey Grewe

You likely know that the number of patients hospitalized with COVID-19 is surging across the country. But headlines from distant states do not capture the horror of a hospital without enough intensive-care beds. I was an anesthesiology resident in a large academic medical center at the peak of the pandemic in New York City this spring.

During a time when journalists had little access to what was happening inside New York hospitals, I wrote regular email updates to friends and family. These messages—edited for length and clarity below—showcase the frightening reality of what care looks like in an overwhelmed hospital. (Where I describe individual cases in significant detail, I’ve obtained the consent of the patient or family in question.) The emails relate the experiences of health-care workers, and young doctors in particular: the anxiety, the fear, the overwhelming responsibility, and the ethical burden of hard decisions. Even after the pandemic is over, the weight of these experiences will remain with us for a lifetime.

These messages form a chronicle of what COVID-19 has already done in America and a reminder of what it could do again this winter.

Thursday, March 26

A senior anesthesiology resident holds the stat intubation pager, which goes off when a patient anywhere in the hospital needs a breathing tube right away. My co-residents and I first noticed that things were changing when the pager started to go off every few hours, and then every hour. When the hospital ran out of ICU beds, my department swiftly converted our operating rooms into a giant ICU. A co-resident and I spent Tuesday pushing beds and anesthesia machines around to plan how to fit up to four beds in an operating room. The “OR-ICU” fits multiple COVID-19 patients into one operating room, ventilated via the anesthesia machine’s ventilators. Their daytime doctor, an anesthesia resident in PPE, doesn’t leave their side until their nighttime doctor—another anesthesia resident in PPE—comes to take over.

On Tuesday night, one of my co-residents did 17 emergency intubations. Upon running to respond to yet another intubation page, she was horrified to see that the patient was one of our supervising physicians. Today, one of our surgeons was intubated. Off duty in my Upper West Side apartment, I hear an ambulance go by every 10 minutes. It’s hard to sleep. My colleagues wonder out loud: Is this chest pain from the virus, or just intense anxiety?

Wednesday, April 8

I spent the past few days and nights working in the OR-ICU. It is truly a scene from a science-fiction movie. When I put on my PPE (N95 mask, goggles, face shield, hair cover, gown, and two pairs of gloves) to enter the operating room, it almost feels as though the goggles are a virtual-reality headset. Upon entering the OR, I am confronted with the sight of four patients, all deeply sedated, each intubated and connected to an anesthesia-machine ventilator and many, many pumps for IV medications. Some—the lucky ones—are also connected to machines that perform dialysis. It’s loud. Huge fans filter viral particles from the air, and there are hundreds of overlapping beeps from the monitors, ventilators, and pumps. And it’s a mess. For days I wondered about some patient belongings in the corner: a pile topped with a pair of dark jeans and a cotton polo shirt. I inspected it more closely and saw the name tag of a patient who had passed away several days earlier. Yesterday I noticed a loose paper on the ground and picked it up. “Body Bag Instructions,” it read.

My team is responsible for the care of 12 ventilated patients. Of the 12, six are age 50 or under. Most are showing no signs of progress. One is a relatively young person who has been intubated for more than 10 days. We became optimistic that this patient, who had been breathing well with little support from the ventilator, could be disconnected from the machine. On Monday morning we removed the breathing tube, but the patient quickly deteriorated, and we had to re-intubate.

End-of-life care has always been the work of intensivists. It’s hard but profoundly rewarding to feel that you can help families through some of the most vulnerable moments in their lives. It’s part of the reason I chose to become a critical-care doctor. Pre-COVID, we were used to seeing patients pass away with at least one family member at their side. ICU doctors are desensitized to death, but even for us, the fact that people are dying alone is devastating to watch.

We have a team of doctors—who because of their age or other conditions are at high risk for the coronavirus—working from home as “family liaisons.” They call the family members of every ICU patient to give updates and help make decisions about care. When I arrived at work in the morning, our family liaison informed me that a family wanted to withdraw care from their father. He asked me to call into a Zoom meeting so they could see their dad and make a final decision.

Normally, we meet families in the ICU, but in this case I had never met the family. I called in wearing my full PPE, and was met with the faces of the patient’s children, who looked to be about my age. I introduced myself and asked what their understanding of the situation was. They explained that they understood their dad was very sick and that they didn’t want to keep treating him so aggressively. I expressed that I agreed with their assessment of his condition, and that we would support whatever decision they made. I explained that what they were about to see would likely be disturbing—that their dad might be unrecognizable to them—and asked again if they were sure they wanted to see. They insisted that they did. I slowly went to his bedside and flipped the camera so they could see his face. They immediately started to cry. I cannot imagine how jarring it must have been to see him for the first and last time with a breathing tube, deeply sedated, and in shades of yellow and purple. “That’s not Dad anymore,” one of the children said. I showed them the many machines and IV medications he was connected to. They agreed that he wouldn’t have wanted all this, and said they wanted to proceed with the withdrawal.

I asked if they wanted to say anything to him. I put my phone up to his ear, and one of them said, “I love you, Dad.” I asked if there was any music he liked that they wanted me to play. They said that he didn’t really like music. I offered to call a chaplain to pray with him and they said he would like that. I said, “I’m really sorry. This isn’t fair. I wish things were different.” They said, “Thank you, Doctor. Please let us know when it is done.”

I left the room and wiped my phone aggressively with bleach wipes. I called the chaplains’ office, only to learn that in-person visits were not being made to COVID-19 patients. The family accepted this. I asked a nurse to turn off the patient’s dialysis machine. I turned off the medications supporting his blood pressure, turned down his ventilator, and turned up all his sedative medications to make him more comfortable. I watched him die from outside the room on a vitals monitor while looking over data for other patients. I came back to do the official death exam and pronounce him dead. The nurse was overwhelmed, so I took out all his lines and bandaged him myself. I cleaned the grime off his face.

I called his son and told him that he’d passed away peacefully. His son confided that he was unsure whether they’d made the right decision. Their dad was very sick, and his chances of recovering to his baseline were definitely slim. But there is so much we don’t know about the disease. This man was in his 60s, a little younger than my father. If he were my dad, would I have withdrawn care? What would I have wanted to hear from a doctor on the other end of the line? “There is no right decision,” I said. “The best answer is just what you think he would have wanted. When we turned everything off, he passed away very quickly without the support. Maybe that was his way of telling us.” The son seemed to take solace in that.

During sign-out I told the overnight ICU supervising physician that I had withdrawn care on this patient. She marked on her map that we would have another open bed. “Oh, was he on dialysis?” she asked. “You freed up a machine. Maybe I can salvage this guy downstairs whose potassium is 8”—a level typically considered incompatible with life.

My lesson so far is that this disease, for the subset of patients who become critically ill to the point of requiring mechanical ventilation, is far worse than we ever imagined. It is certainly not pure respiratory failure. At the moment, we still have enough ventilators, but more and more I feel that this won’t save us. Our patients’ kidneys are failing, they remain febrile for weeks with no bacterial infection, they form blood clots in all their lines and likely their pulmonary vasculature, and, most strikingly, even the ones who look entirely ready to breathe on their own often fail when we remove mechanical support. The public conception that one ventilator means one life saved is evidently false.

Two of our own physicians remain intubated in the medical ICU.

Even when speaking to other doctors, my colleagues struggle to explain our situation. While we scramble to stay afloat, doctors from fancy hospitals in other states go on TV in makeup. Frankly, I’m not interested in what’s happening at Massachusetts General Hospital, or Stanford, or the Mayo Clinic. When people academically pontificate on possible treatments from afar, I feel frustrated by their lack of understanding of the issue. We have tried virtually every drug and none of them has worked. We are struggling to provide basic ICU supportive care. None of the experimental drugs will be of any utility in an environment where there are not enough hospital beds, doctors, and nurses.

Wednesday, April 22

I’ve been really shaken by the emergency intubations this week. The patients have been terrified. By the time I’m called, they are gasping for air. Because no visitors are allowed, they are alone. These encounters are emergencies and can be chaotic. We are all wearing PPE, so they can’t see our faces. I try to be kind and reassuring. I ask if they have any questions. But so often, as a result of the patient’s respiratory distress and the oxygen mask over their face, I can’t make out what they are trying to say. I have to say, “I’m sorry, I can’t really understand. We are going to put you to sleep now and put in a breathing tube.” I push medications to sedate and paralyze them, and then put a tube through their vocal cords. Looking down at them as they go to sleep, I’m the last person they see. And for the ones who don’t survive, I will have been the only one to hear—or rather, not hear—their last words.

The main resources we lack are respiratory therapists and ICU nurses. Our department has organized a huge operation in which doctors explicitly fill the roles of nurses and respiratory therapists outside of our regular physician shifts. This week, I’m working two overnight shifts as a respiratory therapist. The chair of my department is walking from room to room suctioning breathing tubes. Senior physicians are brushing patients’ teeth.

In the ICU, patients become voiceless and personless. We take care of their bodies for weeks: examining them, adjusting their ventilators, titrating their sedation, and carefully considering their medical management. But in the absence of family contact, we have no idea who they truly are. Last week, when we were rounding in the OR-ICU, I noticed my intern perusing a colorful website rather than the medical record. A note from a family-liaison doctor had pointed him to a support site for one of our patients. We saw for the first time that this patient was a teacher. The website had hundreds of comments from students and parents: “We are thinking of you every day!” and “We are praying that you make it through this!” There were dozens of photos of a middle-aged man with his students—in the classroom, at school sporting events, wearing different silly costumes. He had a huge, toothy grin. My intern stared at the website, stunned. It took my breath away. My attending physician said, “I can’t look at this. Please close it.” We get through our day in the OR-ICU by compartmentalizing—by ignoring the fact that our patients are people who are deeply suffering. When reality cuts through our fantasy, the job can be unbearable.

I’ve been asked when I think this will be over. There is a human impulse to believe that something this horrible will inevitably improve. But we cannot mistake fewer sirens for organic progress. If the curve has flattened, it is only through the deliberate work of millions of people who have accepted the reality of homeschooling their children, missing their friends and relatives, and forgoing their income. I think we have to trust the scientists who argue that reopening in the absence of a robust testing program or a vaccine will fail. Thank you for all of the sacrifices you have made, and continue to make, in the name of protecting those who are the most vulnerable.

Complete Article ↪HERE↩!

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What to read when you’re grieving a loved one

By Yvonne Abraham

I am a great grief compartmentalizer. I can put sadness into a box or write about it, pretending to be a detached expert. My therapist tells me I don’t feel it, though. She claims I have one button for all emotions, and that by turning off the grief, I also prevent myself from experiencing joy, hope, and excitement. You can’t get the good without the bad, she claims. I hate that.

There are a zillion wonderful books about loss, but none of them helped me feel. But a script did it. It unstuck the button. “Fleabag: The Scriptures,” Phoebe Waller-Bridge’s compilation of scripts from the show, includes pages of dialogue showing her character’s compartmentalized grief, which was all too familiar. On page 331, in a flashback, Fleabag considers the loss of her mother, and tells her best friend, ”I don’t know what to do with it —” “With what?” the friend, Boo, asks. “With all the love I have for her. I don’t know … where to — put it now.” Reading that, I was able to see all the love for my late mom that has been following me for years, with nowhere to go. I’m learning to give it to others. “I’ll take it,” Boo offers Fleabag. “No, I’m serious. It sounds lovely.”

MEREDITH GOLDSTEIN

Letters for life

The opening words of Donald Hall’s “Letter After a Year,” addressed to his late wife and fellow poet Jane Kenyon, are: “Here’s a story I never told you.”

Hall proceeds to describe a time, long before he met Kenyon, when he discovered letters in the attic of a rented house that a previous tenant had written to a lover who had died in a plane crash. He recalls his puzzlement back then: “She’s writing to somebody dead?”

But Hall came to understand, and act on, that same impulse after Kenyon died at 47. The proof of that is “Without,” a 1998 collection of poems (many of them with the word “Letter’’ in the title) that falls somewhere between conversation and correspondence. These poems are written about and to Kenyon, who succumbed to leukemia in 1995 on the New Hampshire farm where she and Hall lived.

Now, it would be a mistake to read “Without’’ in the expectation of bromidic uplift. Hall was too honest a poet — and too faithful a husband — for that. There is overwhelming pain in these pages, numerous times when, in Hall’s words, “grief’s repeated particles suffuse the air.” In “Letter in the New Year,” Hall writes to Kenyon that “this new year is offensive because it will not contain you.” For him, grieving is not a linear process but a flailing struggle to stay afloat amid a flood.

Yet within the quasi-epistolary structure of “Without” can be discerned the hope that, on some indefinable level, a relationship is not over so long as one partner lives. Hall updates Kenyon on the doings of children, grandchildren, and friends; he tells her about watching the Red Sox; he describes the springtime arrival of goldfinches and the emergence of daffodils on the hillside. And he evokes the numberless little moments that made up their life together, from shopping to lovemaking to holiday rituals like Kenyon’s habit of opening the daily Advent calendar window and then reading the Gospels. “Ordinary days were best, when we worked over poems in our separate rooms,” Hall tells Kenyon.

To be “without,” obviously, is a fate that befalls many of us. What Hall’s poems suggest is that memory, and perhaps an untold story or two, can help sustain just enough “with” to pull us through.

DON AUCOIN

Walking with grief

Grief of any kind obeys a logic all its own. But a parent’s grief over the loss of a child must defy logic altogether. “Because how can one articulate logical, coherent, human speech when the foundations of logic and proper order, the so-called natural order, the order whereby parents should not mourn their children — have foundered?”

So writes the Israeli author David Grossman, who lost his own son in Israel’s Second Lebanon War in 2006. Some five years after that shattering event, Grossman, in keeping with this observation, corralled the materials of his own mourning not into a coolly coherent memoir but into a kind of haunting parable.

A grieving man gets up from dinner one night and sets out to walk around his village in ever-widening circles. He has left behind normal life to search for his departed son, to seek out an elusive place described only as “there,” to trace on the land his own spiraling itinerary of loss and boundless yearning. The man begins his walk alone but is quickly joined by others who have also lost children, each one inevitably trapped within a kind of private exile yet now, suddenly, walking together.

Narrated in spare, poetic language, “Falling Out of Time” is a story of reckoning and reclamation — of learning to live with, and without, the dead. The novel, which was recently adapted by composer Osvaldo Golijov into a tone poem of the same name, also constitutes its own act of co-walking with the grieving, a way of broadening outward from sharp solitude of private sorrow. Finally, it is a meditation on the working through of a wild, impossible grief until the point that, as Grossman writes, “there is breath inside the pain.”

JEREMY EICHLER

Keep moving forward

“It’s okay. She’s a pretty cool customer.”

That’s what a social worker says to a doctor who’s wondering how to tell Joan Didion that the heart attack suffered barely an hour ago by her husband, the novelist John Gregory Dunne, had proven fatal.

Anyone who knows the chill, clipped control found in Didion’s novels and essays realizes how well “cool customer” describes her as a writer. How it does and doesn’t apply to her as a grieving widow is the burden of “The Year of Magical Thinking.” It won the 2005 National Book Award for Nonfiction, but to think of so searching and personal a work in terms of something as transitory as a literary prize doesn’t so much miss the point as ignore it.

The point is that neither grief nor life stops. It’s not just the consequences of Dunne’s death that Didion writes about but also dire health crises affecting their daughter, Quintana, over the same period of time. To lose one’s spouse and then possibly one’s only child? The Old Testament may offer the closest literary counterpart: the Book of Job. That “Magical Thinking” and its author merit the comparison is no small compliment to Didion as writer and human being both.

MARK FEENEY

Complete Article ↪HERE↩!

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Plants do something weird when they grow near human corpses, scientists say

“This led us to look into plants as indicators of human decomposition.”

By Victor Tangermann

It’s like an episode of “True Detective.”

How do you find human remains in a massive natural ecosystem like the Amazon rainforest? According to a new paper published in the journal Trends in Plant Science, tree and shrub canopies could guide search and rescue teams to find human remains, as CNN reports.

As they decompose, human remains create “cadaver decomposition islands,” the researchers write, altering the surrounding soil, roots and leaves. These changes could even be “detected remotely.”

“In smaller, open landscapes foot patrols could be effective to find someone missing, but in more forested or treacherous parts of the world like the Amazon, that’s not going to be possible at all,” explained senior author Neal Stewart Junior, a professor of plant sciences at the University of Tennessee, in a statement. “This led us to look into plants as indicators of human decomposition, which could lead to faster, and possibly safer body recovery.”

The researchers are planning to test their new cadaver discovering technique at the University of Tennessee’s “body farm,” more formally known as the Anthropology Research Facility, where they will assess changes in these cadaver decomposition islands including minute changes in the coloration and fluorescent signatures of individual leaves.

“The most obvious result of the islands would be a large release of nitrogen into the soil, especially in the summertime when decomposition is happening so fast,” Stewart said. “Depending on how quickly the plants respond to the influx of nitrogen, it may cause changes in leaf color and reflectance.”

There’s one key problem: humans aren’t the only mammals dying in the woods. That means the team will have to find a human specific way to spot these metabolic processes that differ, say, from a dead deer.

“One thought is if we had a specific person who went missing who was, let’s say, a heavy smoker, they could have a chemical profile that could trigger some sort of unique plant response making them easier to locate,” Stewart suggested. “Though at this stage this idea is still farfetched.”

Stewart and his team are hoping their research could make recovering human bodies — and possibly nearby survivors — in large forested ideas far more efficient.

“When you start to think about deploying drones to look for specific emissions, now we can think of the signals more like a check engine light,” he explained. “If we can quickly fly where someone may have gone missing and collect data over tens or even hundreds of square kilometers, then we’d know the best spots to send in a search team.”

Complete Article ↪HERE↩!

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Anxiety Is a Stage of Grief You May Not Recognize

By Seth J. Gillihan, PhD

You’ve probably heard of the stages of grief—denial, anger, bargaining, depression, and acceptance. However, grief is a complex and personal experience, and there are many aspects of it that don’t fit neatly into this model.

One common, but often unrecognized, grief response is feelings of tremendous anxiety. Some individuals may be aware that they’re feeling anxious; for others, it’s hard to identify specific emotions that make up their overwhelming pain.

Grief-related anxiety is often rooted in our concerns about how we will cope. When we experience a significant loss, it can feel like our world is falling apart around us, and we wonder whether we’ll fall apart, too—especially if we’re grieving a loved one whose support we depended on in exactly these kinds of situations.

We might also have counted on a person in practical ways, and wonder whether we can shoulder the increase in responsibilities. For example, the untimely death of a spouse might require a person to adjust to the demands of being a single parent. When we’re focused on our sadness and loss, it might be hard to realize that we’re afraid, too.

It’s disorienting when we lose someone or something that’s integral to our lives, and it can trigger the fear of what else we might lose. The death of a parent, for example, might trigger worry about losing the other parent, or one’s spouse. For many people, the fear is less specific but equally powerful—more a vague sense of threat and unease.

Anxiety can also come from the stress on our minds and bodies, which leads to a state of high alert as our fight-or-flight system is stuck in the “on” position. You might be exhausted but unable to let go of tension—“tired and wired”—which can show up as trouble sleeping and feeling constantly on edge.

Keep in mind that grief can follow many experiences of loss, not just death. We can grieve the loss of a career, and feel anxiety about our unknown financial future. We can grieve the loss of health, and worry about further decline. We can grieve the loss of a relationship, with anxiety about ending up alone.

Part of what we grieve following a loss is the illusion that anything is permanent. It’s like an earthquake—the ground that normally seems so solid suddenly shakes and shifts. What’s left is a different reality than we knew before. The terrifying realization that nothing lasts forever can shake our sense of safety and security.

If you’ve experienced anxiety as part of grief, here are some suggestions that may help you cope:

  • Reach out to those around you. No matter what kind of loss you’ve experienced, stay connected to the important people in your life. Few things are more grounding than meaningful relationships. Don’t be afraid to ask for ongoing support—it takes time to grieve, and there’s no expiration date on the comfort of family and close friends. Seek out the support you need as you adjust to your altered world.
  • Give yourself time to heal. In a similar way, allow yourself the time needed to process what has happened to you. Beware of the idea that you need to “get back to normal”—your world has changed, and it takes time to adjust to those changes. Don’t be surprised if the grief comes in waves, or is different from day to day. You might have reactions to the anniversary of your loss, as well.
  • Reduce optional stress. Part of healing is treating yourself gently while you’re grieving. It is probably not a good time to take on difficult new projects or challenges. This is not to say that you’re weak, but rather to direct your strength wisely. Also look for opportunities to process stress and loss in ways that work for you—for example, meditative practices, exercise, massage, or walks with a friend.
  • Make space for whatever you’re feeling. There’s no wrong way to grieve. Sometimes we suppress our feelings because we don’t understand them, or we’re scared of them, or in some way we think we don’t deserve to have them. Whatever you’re experiencing is OK, whether it’s sadness, anxiety, a feeling you can’t describe, or any other aspect of grief.

Complete Article ↪HERE↩!

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The coronavirus pandemic has forced mourners to think of different ways to honor the dead and say goodbye

Sofia Moreno, 1, and her cousin, Ashlyn Hernandez, look at photos of their grandfather, Ruben Beltrán, during his visitation service at Symonds-Madison Funeral Home on Nov. 13, 2020, in Elgin.

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Hours before the grandfather died on a COVID-19 hospital floor, his closest kin entered the room two at a time, all covered in protective gowns, gloves, masks and face shields.

Barely breathing, the family patriarch pointed to each of his loved ones, then to his heart, and raised a fist in the air.

This was not how relatives had envisioned their last moments with 68-year-old Rubén Beltrán of northwest suburban Hanover Park, one of more than 12,000 lives lost to the new virus in Illinois and 1.4 million worldwide.

“But it was a blessing that we were able to say goodbye,” said granddaughter Amairani Jarvis, who planned Beltrán’s funeral in November. “Because I know a lot of people are dying alone right now, and they’re not allowed to say goodbyes to their loved ones.”

Just as the pandemic has altered so many aspects of life, it has also disrupted the experience of death and grieving. In response, mourners are creating new and innovative ways to honor the dying and departed while keeping within the bounds of pandemic protocols.

Many of these adaptations draw on cultural customs and ancient religious rites, said Roy Grinker, an anthropology professor at the George Washington University in Washington, D.C., who is co-leading a yearlong study on changes in funeral practices during the pandemic.

“There’s an extraordinary resilience and creativity of people to figure out how to do what they need to do in order to mourn, in order to grieve,” Grinker said.

A Muslim funeral director in Australia began giving out smaller bottles of perfume used during the ritual shrouding of a body, because the smell was such a powerful connection to the dead. She explained how family members would traditionally wash and shroud their loved one, but when this practice was interrupted by the pandemic, next-of-kin expressed difficulty coming to terms with the loss, sometimes wondering if their parent or spouse or sibling had even died. The familiar fragrance helped the grieving process.

“They could then use that as a very sensory way of remembering their loved one,” the funeral director said during a virtual roundtable discussion on the impact of COVID-19 regulations on death and dying.

In upstate New York, a funeral director commemorated the life of a beloved football coach by sending whistles to mourners, a tactile and aural reminder of the deceased. At a funeral in Oklahoma, clear masks enabled mourners who were deaf to read lips and see facial expressions.

In another case the anthropologists studied, around 100 people attended a funeral but only 10 were permitted at the gravesite; the other 90 friends and family members stayed out of the cemetery but climbed a fence lining the perimeter, to view and be a part of the moment the coffin was lowered into the ground, Grinker recounted.

Loss and healing rely in so many ways on the five senses. The sight of a body at an open-casket funeral. The scent of flowers at a memorial. The taste of certain foods while sitting shiva, in the tradition of Jewish mourning. The comforting melody of dirges and chanting. An embrace in shared grief.

There is a near-universal need for communal mourning, which becomes increasingly difficult with physical distance requirements, said Grinker, who was born and raised in Chicago.

“Whatever religion, whatever tradition we’re talking about, one of the common threads is the difficulty of not being able to be with others in large groups, to touch each other and to stimulate each other’s emotional release,” he said.

For the study, called Rituals in the Making, researchers are interviewing clergy, funeral directors and mourners; the project was funded by the National Science Foundation and is expected to be complete in May.

“We’re doing these things in different ways than we did before,” he said. “We are still trying to manage this important transition in social life, where we need to not only deal with our own emotional concerns but also have to carry out the cultural practices of transitioning somebody from the world of the living to the world of the dead.”

Disconnect from death

The Beltrán family gathered for the visitation on Nov. 13 at Symonds-Madison Funeral Home in Elgin. Everyone donned black masks bearing the inscription “forever in our heart” in gold letters.

The message professed their eternal love for the deceased. The material served as a tangible defense against the virus that Beltrán had battled for a month, before his lungs collapsed and he could no longer breathe on his own.

The colors matched the black and gold urn holding his cremated remains. A Spanish version of the mask, “siempre en nuestro corazón,” was sent to Beltrán’s relatives in Mexico, along with a small packet of his ashes to be scattered near the home where he was born and raised.

“We gave him a pretty good farewell,” Jarvis said. “We sent him to Mexico, gave him a celebration here. We did it to the best of our ability.”

Daniel Symonds, a second-generation funeral director who arranged Beltrán’s services, fears for the emotional burden of those left behind when they aren’t able to grieve in a typical manner.

He recounts a group of siblings who lost a brother early in the pandemic. Another sibling was high-risk for contracting the virus, so they decided to pay for a memorial and have the body cremated, but wait to hold services until they could gather safely.

That memorial still hasn’t happened. Symonds worries that this family and others in a similar state of limbo won’t be able to process their loss or begin healing.

“When you can’t see them, you can’t say goodbye to them, that causes guilt, anger sadness, frustration, depression,” he said. “We are a communal society. That’s something we need to get through the pain.”

Narratives on social media sites offer a glimpse at some of the heartache of survivors who feel a disconnection from death.

A Texas woman on the website Reddit recalled how her 93-year-old mother-in-law died of COVID-19 without any loved ones by her hospital bedside.

“My mother-in-law created a huge family, she dedicated her life to all these offspring and remembered everyone’s birthdays and loved catching up on family news good and bad,” the comment said. “And she was there alone — probably the first time in her life she’d been alone. … This is not what she deserved.”

A New York rabbi posted on Twitter in April about presiding over the burial of 95-year-old Holocaust survivor. The rabbi explained that under normal circumstances, members of Jewish burial societies would have come to perform tahara, a ritual cleansing of the body.

“It is the most dedicated and conscious act, to perform these rites,” the rabbi said. “Not this day. Tahara is not happening. It’s not safe. Typically the body is watched until burial. Guarded by members of the community. Her son called me heartbroken. … No guard. Her body, like ours is to be alone.”

Since then, various Jewish burial societies have created virtual components of the ritual or modifications designed to minimize exposure, like misting the body instead of washing, and integrating strict rules for infection control as well as use of personal protective equipment.

The modified version used by a Jewish burial society in Boston includes the prayer: We ask your forgiveness for any distress we may cause you during this tahara, most of all for the ways in which we have had to modify the ritual preparation of your body for its final journey. … During this time of plague that besets and endangers all, the changes we make are an affirmation of the life you have lived and the lives of those who care for you now.

Present, at a distance

There’s a certain closure in viewing a final resting place.

Until Jarvis saw her grandfather’s ashes lowered into the ground, she didn’t quite believe he was gone.

Beltrán, a cancer survivor, had been in and out of the hospital for years even before he contracted COVID-19. Until the interment, Jarvis kept thinking her grandfather was just hospitalized like before and would be coming home again soon.

Days before services, the arrangements had to be revamped due to rapidly evolving limits on gatherings amid a surge of COVID-19 cases. Only 10 relatives were permitted at the gravesite, a difficult mandate for the large, tight-knit clan. Beltrán was survived by his wife of 48 years, six children, 16 grandchildren and two great-grandchildren.

“My family was upset,” Jarvis said. “But we all understood what the regulations were. We all understood why. We had just gone through that with my grandfather. It started with COVID. COVID took his life.”

Like other large gatherings, funerals without social distancing precautions have been linked to coronavirus outbreaks in Chicago as well as other cities, according to the Centers for Disease Control and Prevention and media reports.

To be safer, some funerals have begun integrating cars into the service, a modern twist to preserve ancient customs or accommodate big crowds.

A funeral director in Washington state recalled a March burial for a grandmother who just arrived months ago from Ukraine; the family longed for an open-casket service, a cultural tradition, so the funeral home arranged for an open coffin viewing in its van at a site a near the cemetery, encircled by the cars of loved ones to maintain some privacy.

“It wasn’t what they wanted — it wasn’t what they ever would have envisioned — but it was something,” the funeral director said.

A funeral home in Texas recently built a drive-in funeral theater, where services on a large outdoor screen are viewed by relatives and friends from their parked cars.

“This also allows the family to feel the love and support they need at a time of loss and grief,” the funeral home’s website said. “The service concludes with three honks representing comfort, support and love as they drive away.”

A large part of the George Washington University study examines how traditional death rituals are being transformed into virtual practices, from “Zoom funerals” to video-recorded memorials to livestreamed visitations.

Results have been mixed. Some mourners said glitches and Wi-Fi outages compromised the occasion; there were instances where the grieving reported clicking on a link that took them to the wrong funeral or memorial, Grinker said.

In other cases, virtual rituals were surprisingly gratifying — even rivaling traditional in-person rites and practices.

Screens helped Grinker, the anthropologist, navigate his own grief earlier in the pandemic after his 95-year-old mother died of natural causes in Chicago. The family held a virtual memorial, the first time Grinker’s 93-year-old father ever spoke to anyone using a computer.

The online gathering allowed more people across the country to mourn together, he said, expanding his father’s opportunity to celebrate his mother’s life.

“It was actually quite emotionally powerful for him in a way I think it perhaps wouldn’t have been if people had been able to visit at the house,” Grinker said. “It’s about creating social bonds. These are times when we reaffirm our relationships. And if we can’t do that, it makes us feel all the more isolated.”

As for Jarvis, she described feelings of guilt that she was among the 10 relatives standing at the gravesite, potentially taking the place of another relative during that pivotal moment of interment.

To help include everyone, she created a Facebook page with photos and a livestream of Beltrán’s funeral. Relatives across the country and in Mexico were able to pray along with the funeral Mass and see the gravesite immediately, an experience the family wouldn’t have thought to create if it weren’t for the pandemic.

“We were able to make people present, while still keeping distance,” she said.

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11 Salves for Holiday Grief in the Time of COVID.

By Karuna Duval, LICSW

Grief during the holidays is tough enough.

Now, let’s pile on a pandemic for the past year, and you have an even more difficult holiday season.

Being isolated and disconnected from our usual support systems has been a great hardship for many—most certainly for those who have lost a loved one. As the holidays approach, those who are grieving find themselves further burdened by even more unknowns.

Here are some suggestions and perspectives to consider for this holiday season if you are grieving or if you know someone who is grieving.

A Holiday in a box

If you can’t get together with loved ones because you are not traveling or they are not traveling, put together a “Thanksgiving in a box” or “Christmas in a box” or “Chanukah in a box” or “Kwanza in a box” or “(insert your holiday) in a box.” Let this serve as a sort of care package with more than just gifts. Include things like games, puzzles, poems, books, sweets, and other things that you may have shared if you were together.

Easy meals

If you choose to be alone this holiday (which is perfectly fine), opt for a TV dinner or preprepared meal. Many are tasty and include the traditional holiday foods. This also reduces stress in prep and cleanup. Or have your meal delivered. So many stores and restaurants are increasing their deliveries and offering yummy options for the holidays.

Forgo the “have-tos”

Often, the holidays are propelled by the traditions we have, which in and of themselves are not bad. However, if you don’t feel like putting up a tree or lights, or making certain foods, even though you have done that for years with your deceased family member, there is no obligation to do so. Sometimes other family members may be challenged by this; kids may want the traditions to be the same (even if they aren’t going to be around this year). The only obligation you have is to yourself. Do what you want to do this year.

Listen to your wants

If you want a smaller scale (or larger scale) decorated home this year, that’s fine. One woman I know vowed not to have any decorations this year. She and her deceased husband normally put out lots of decorations, but she didn’t have the energy for that now. However, when she found herself at a local big-box store, she was inspired to buy lights. She heard within herself, “Bring light in this year.” At another store, she was drawn to a small living tree, which she plans to plant in her garden after the holiday. She listened to herself. Even though she had thought she wasn’t going to decorate at all, that inner voice offered something different and something meaningful for her this year.

Conserve your energy

What can you make happen with the energy, time, and resources you have? And what is just not possible? The holidays often compel us to extend ourselves beyond our means, both financially and energetically. This could fit into the “have-tos” section as well. Gifts, especially, are not the purpose of the holidays—connection is. If you don’t have the energy and time, ask yourself what matters to you now and how can you do what matters with what you have? This is a question many who are grieving ask daily: What matters to me now?

Focus on the long-term

This year, connecting and being together means something different. If we are not with the people we want to be with now because we don’t live together, it is advised to remain separated. Especially for those who are older or already compromised in some way, don’t risk the unknown and long-term effects of this illness for short-term experience. The most serious long-term effects are hospitalization and death. Conserve your energy and time by connecting virtually. If you live in a warmer climate, you may be able to gather outside. Again, take the proper precautions. Remember that in the long-term, we will be able to be together again. Someone said, “A large gathering this holiday is not worth a small funeral later.”

Allow yourself to change your mind

Even if you want to do something with others, it’s okay to change your mind, even at the last minute. It is helpful to prepare others for this too. Tell them, “I need to warn you that I may need to change my mind, depending on how I feel.” People who know you and know your situation will understand. This also applies to events you may sign up for online. When you register for an event, check the refund policies.

Sit this one out

Some who are grieving don’t want to be a part of anything related to the holidays this year. This is just fine. While some people (even some close to you) may feel this is not a good thing, you have to decide what is right for you. Sitting out this holiday doesn’t mean you will never celebrate again. It just means for right now, you need to be with you, figure out what you want, watch or listen to what you want, eat the food you want, cry when you need, sleep when you need, and talk to who you want to (or not). Remember, you are the boss of you.

Celebrate when you can

For some, celebrating on the actual holiday is not possible or even desired. Some folks gather (even virtually) before the holiday or after it. One person said they celebrate the holidays in the summer when everyone can make it. It’s too late for that this year, but maybe you’ll choose that next year, after we, hopefully, can gather again. Getting together in the summer will allow for an even sweeter celebration.

Pulling inward

As we go into the darkest time of the year, our natural inclination is to hibernate. For those who are grieving, this can be a greater pull. With the holidays being so different than they ever have been, it seems like we have an even better reason to pull inward. We can shift our focus from outside ourselves to within ourselves, from doing to being—being with ourselves, being with others (mostly virtually), and being with what is, right now.

Be in the present

This year, we have experienced how things can change day-to-day. Being present for the experiences right now will support you in your grief. Being present to how you feel can help you to make choices about what you want and how you want your life to be. Worrying about what is out of your control expends energy that could otherwise be used for what you can control. Being present allows you to ask, “What is in my control now?” When we discover what is in our control, we find we have more choices. When we focus on what is out of our control, we find fewer choices and feel more helpless.

If you need additional assistance as you are grieving in this time, there are many folks who can help and support you. Local hospice organizations often have resources, especially during the holidays. There are many websites that offer written, video, and even live/Zoom events with information and support. If you find yourself struggling and need immediate assistance, call 911 or your local emergency mental health services for support.

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End-of-life coach

— The art of dying well

For most of us, the word “doula” is firmly associated with a coach helping a mother through childbirth. A modern-day version of a traditional midwife, a doula, is not a healthcare professional, but rather a guide, whose goal is to comfort and support women in labour both physically and emotionally.

Derived from the Greek word δούλα (“servant-woman”), doula stands for a woman who lends her knowledge, experience and presence of mind during the arduous process of childbirth. In the Western world, the popularity of birth doulas started to gain traction in the early days of the reproductive justice movement back in the ’70s.

Striving for more natural and less medical experiences women turned to doulas, who’d often act as advocates for women and babies in hospitals which weren’t always friendly and accommodating.

Recent years have seen the rise to a different kind of doulas, quite the opposite of those attending to childbirth. These are “death doulas” who support people in their end-of-life journeys. Also referred to as “death midwives”, their vocation is a relatively recent phenomenon emerging as part of the mindset recognising death as a natural, accepted, and honoured part of life.

Death doulas are by no means there to assist in ending one’s life (at least in the countries where euthanasia is illegal), but rather to ease the transition both for the passing person and his or her loved ones, who stay behind/Sharon McCutcheon via Unsplash

There are remarkable parallels between being born and dying, and in both life scenarios, doula’s aim to reduce anxiety and confusion, manage the pain, and, if possible, make the experience more peaceful. Just as birth doulas are coaching mothers on birthing a baby, death doulas are coaching people on dying. They provide non-medical aid which is a mix of emotional and practical counselling that can make all the difference.

Christy Moe-Marek, an end-of-life doula from Minnesota, says that doulas emerged from the Baby Boomers, behind the natural birthing movement. They decided to take things into their own hands as far as dying goes: “They’re saying, no, I don’t want the death my parents had. We are rich in possibility, why can’t I make this whatever I want it to be?”

Death doulas – just like midwives – have been around since the beginning of humanity. Traditionally their roles were played by the wise women from the community or extended family.

However, with the disintegration of traditional societies and the extended family per se, we have lost touch with our roots as we often find ourselves helpless in the face of the imminent. Death customs and practices within families have all but vanished as palliative care was delegated to hospitals and the funeral industry was commercialised. But these days people are yearning for a better life – and death! – and this is when doula’s role becomes so crucial.

According to The New England Journal of Medicine, the number of Americans wishing to die at home rather than in a hospital environment is the highest it’s been since the early 1900s/Dominik Lange via Unsplash

They want to pass away surrounded by their family and friends, who could be overwhelmed by witnessing the final days of their loved ones while feeling helpless and powerless. The trade of a modern death doula has emerged as a response to the people’s fear of facing death and even contemplating it. Death doulas have started a conversation about dying and have, in some way, given voice to those making the transition. After all, these days many more people get a chance to linger on a bit longer despite terminal illnesses thanks to the advances in modern healthcare. In many cases, they do need someone to discuss their transition with and make it more meaningful.

Unlike death midwives of the past, our contemporaries are women (and sometimes men) old and young, coming from different paths of life. They help people on the threshold of passing to write letters to their unborn grandchildren, to arrange farewells with relatives; they may perform traditional or religious rituals for their charges or offer assurances.

Doulas bridge the gap between the dying and their families, facilitating conversations about death, explaining things and advising when it’s finally time to let go. Some say that working with a death doula opens people up to a more spiritual side of death with less anxiety and trepidation/Manikandan Annamalai via Unsplash

As death doulas are gaining more mainstream attention, there’s been an ongoing debate, whether they should provide free services rooted in the community. For instance, in communities of indigenous people or African people death doulas have continued to be a steadfast part of the culture. On the other hand, most of today’s end-of-life professionals aren’t being supported by specific communities and, thus, cannot afford to render their services for free. In big cities, where tightly-knit communities ceased to exist a long time ago, death doulas are usually hired by the family of the person nearing the end of life. Still, their responsibility remains with the dying, whether they are being attended to at home, or in a hospice.

In traditional cultures, the art of attending to the dying is passed down from generation to generation. But a skillset of a death doula isn’t “god-given”.

It is something that can be learned. These days one can learn the ways of a death doula by attending training courses or seminars. Neither in the US or Europe are there national regulatory agencies that would provide licensing and oversight. Most likely, their creation is just a matter of time. The decision to become a death doula is often made after attending a dying family member. Others translate years of experience as nurses and palliative care specialists into a new dimension, and some feel the need to make traditional passing-related rituals available to members of their communities. Groups that train death doulas are usually led by nurses and social workers who want to change the impersonal nature of the dying experience most people faces. In the US organisations like The Doula Program to Accompany and Comfort, in New York, The International End of Life Doula Association (INELDA), or Lifespan Doulas and other groups train people to become death doulas.

In Russia, death doulas are virtually non-existent, because palliative care is still in its infancy, and people are culturally opposed to an open conversation about death and dying/Bret Cavanaugh via Unsplash.

However, the need to make dying less clinical and remove the fear and stigma surrounding death has become tangible. Society seems to have gradually realised that dying people, in whose shoes we’ll all end up one day, deserve greater compassion and companionship in their final days. Shelby Kirillin, an end-of-life doula, based in Richmond, Virginia, reasonably wonders “Can you imagine if a woman was going through labour and no one around her was talking about it or preparing for it? There’d be an uproar if we treated birth like we treat death”.

When it comes to dying, traditions and modernity don’t necessarily have to clash. Indigenous cultures have long regarded death as an essential part of life, and even though thanks to modern healthcare options the process of dying these days can be virtually painless, a “good death” is more than just a painless one. That being said, the emergence of death doulas is, perhaps, the best thing that’s happened to humanity in a long time.

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