Robin FiorellyGrief can be described many ways and affects people differently—from sadness to anger to regret. 2020 saw an increase in grieving as the COVID-19 pandemic swept the world. People not only grieved lost loved ones, but also grieved their lost connections. 

Robin Fiorelli is the senior director of bereavement and volunteers at VITAS. She has 30 years’ experience in the homecare and hospice industry, and has been on the bereavement steering committee for the National Hospice and Palliative Care Organization for 12 years. In her role at VITAS, she oversees 50 bereavement and volunteer programs. Fiorelli also contributed two chapters to “20 Common Problems: End-of-Life Care” by former VITAS Chief Medical Officer Barry Kinzbrunner.

At the start of the pandemic, VITAS transferred 400 in-person bereavement support groups into remote sessions via Zoom and phone. Anyone can access the free groups at Fiorelli sat down with HomeCare to discuss how the pandemic has complicated grief.

1. CNN recently reported on a “wave of grief” about to hit the United States, and the Hospice Foundation has urged action on the issue. What problems can unmanaged grief cause?
That's a great question. By way of background, the Centers for Disease Control & Prevention recently reported that there’s an average of nine bereaved for every life lost to COVID-19. So we're looking 4.5 million mourners and growing in this country, right now, who specifically had a COVID loss—and that doesn't even include those that lost a loved one to other causes. All mourners who have lost a loved one during the pandemic haven't been able to mourn in traditional ways in-person ways nor are able to have final rituals like funerals and memorials. So, the Hospice Foundation of America, the National Hospice and Palliative Care Organization and many other organizations are actively urging action because of these outstanding numbers to create a national campaign to really shore up bereavement services nationwide and to train health and mental health professionals about how to manage the longer-term grief affects from this pandemic. 

We view grief as a normal process that everyone goes through who loses a significant loved one. But grief can become more complicated if there's concurrent, stressful events—like this pandemic, the loss of employment, maybe being ill or elderly yourself, or the inability to access your typical support network, etc. This pandemic compounds the normal grief process. More complicated and unprocessed grief can certainly impact a mourner’s overall functioning, including their ability to sleep well, to eat well, to rest well. A few studies have actually looked at the impact of more complicated grief on work performance and shave shown that unprocessed grief can impact employee absenteeism, even injuries on the job, related to just being distracted, fatigued, emotionally overwhelmed and the like.

2. How can home health and hospice agencies help?
[VITAS Healthcare] actually has extensive and long-term experience in providing community-based bereavement support. Medicare requires that we take care of our own [family] caregivers for a year after the loss, but we also believe that our mission is to open up to our communities and offer bereavement support to mourners whether they received VITAS services or not. So we've been able to leverage our bereavement care in several natural disasters and public tragedies throughout our nation.

For instance, we were—and still are—very involved in providing bereavement support to the Parkland and Sandy Hook school shooting survivors. So that's an example where hospice agencies can really be of fundamental importance, because we have that experience of providing community-based bereavement care. 

The other thing, that hospices can do—that we certainly do in the community—is provide care to frontline health care workers. Because of the pandemic, they're experiencing tremendous compassion fatigue and grief and loss in the workplace. Most health care professionals are focused on treating their patients and making them better. They were ill prepared to medical manage sick COVID patients without medical treatment at their disposal. And they certainly were unused to providing the end of life support and presence to their patients because families were unable to be at the bedside. We launched an effort in all of our communities to really provide them bereavement services. 

3. What gaps do you see in caregiver training to provide for grief-stricken family members?
I think one of the most important things that we do and the most important care that we provide to families of patients that are dying is to help them understand what to expect during the dying process and what to expect afterwards for their long-term grief process. I think that education just reassures them that they're going to be able to do it. It's amazing how far that support and education really goes as far as validating after the death that what you're feeling is normal, it's called grief and you're not going crazy. 

The other thing that we did at the very beginning of the pandemic, was to launch a call to action to volunteers all over the country, as well as nursing schools. We ended up onboarding over 3000 students and volunteers to provide support and check-in calls both to our patients and our caregivers nationwide. Both patients and caregivers were feeling isolated or feeling lonely and worried about being infected, etc. Those calls were incredibly effective at just mitigating that anxiety and being that listening ear that provided support during such an uncertain time.

4. What kind of support services are needed for grief? What can ease the mental pain?
Well first, most of us have our own internal sort of reserves and coping strategies that we develop—especially if we've had a prior loss—we sort of know how to do it. We know that we're going to get through to the other side. But in addition to that, we rely on our social network, maybe our faith institution, our spirituality, etc., to get us through hard times. But we've learned is the way that hospice can be most helpful is to provide a variety of opportunities to mourners, to assist them in their grief process. Because not one size fits all; everybody’s grief experience is unique to that individual.

So in addition to the virtual bereavement groups and caregiver groups, [VITAS] also has a very robust Facebook bereavement support page—because we know that for some people that's the means or the medium that they're going to use to get that support. But for those whose grief is a little more complicated, or it it's impairing their ability to function, we do provide individual one-on-one support. We also do referrals to very experienced grief therapists in the community. 

5. How is VITAS Healthcare managing grief and bereavement during COVID-19?
So on top of the support groups, the Facebook page, the one-on-one counseling, and more, we’re providing grief support to frontline health care and mental health providers. We're also leveraging what we know about grief care and successful grief coping strategies and we're teaching those to health and mental health professionals in the community so they in turn, can help their clients. We’re also providing grief education to with schools so teachers and counselors can be on the lookout for kids that might be experiencing more complicated grief from a COVID loss or any loss. We also train mortuaries in the community on how to provide bereavement support. And finally, we train emergency medical personnel on how to provide that sudden, traumatic grief care.