Death, Dying, and Dignity in the Time of the COVID-19 Pandemic

If the first casualty of war is truth, the first casualty of coronavirus disease (COVID-19) for patients nearing death is human dignity. Although the pandemic has claimed *6800 Canadian lives, *60,000 people have died in Canada since the World Health Organization declared the novel coronavirus (COVID-19) outbreak a global pandemic. Given the insidious nature of this virus, care for patients dying of any cause has been distorted in ways previously thought unimaginable. Because of public health restrictions, patients are dying alone. Even for the sickest of sick, whether they are dying in palliative care units, medical or surgical wards, intensive care units, hospices, or long-term care facilities, limited visitation polices are being strictly enforced. The primary contact these dying patients have is with health care providers, with whom touch can only be experienced through layers of latex, eye contact through layers of goggles and plastic shields, and human presence through layers of anxiety, caution, and fear. A recent systematic review reported that hospitalized patients placed in isolation for medical reasons are more likely to experience depression, anxiety, anger, and loss of self-esteem; health care providers spend less time with them, impacting patient safety with an eightfold difference in adverse events related to supportive care failures. Other studies have shown that loneliness is a risk factor for mental disorders, such as depression, anxiety, adjustment disorder, chronic distress, and insomnia. Our own research has shown that lack of social support, symptom distress, and not feeling valued or respected can undermine a dying patient’s sense of dignity. Those who are isolated or avoided are especially vulnerable, inclined to feel that they may not only have a contagion, but that they are a contagion. Families barred visitation are denied the opportunity to bear witness, advocate for optimal health care, and must forgo final goodbyes. Not having access to their dying loved ones may put families at risk for complicated grief. Not being able to follow a path of least regret leaves many questions unanswered. Did their loved ones receive the best care possible? Were they in pain? What were they thinking about in those final weeks and days of life? Was someone with them when they died? As if that were not enough, the pandemic has meant that families must forgo community rituals of mourning. Funerals have been reduced to graveside services of 5 to 10 people, with live streaming alternatives the only option for those wishing to virtually pay their respects. After an outbreak of severe acute respiratory syndrome-related coronavirus in 2002–2004, the SARS commission final report noted that ‘‘those left behind had no opportunity to confront the reality of death and to honor the life of the deceased’’ (p. 943), with the proviso that ‘‘funeral rites must obviously carry lower priority than the need to contain the virulent public health threat’’ (p. 942). [Funerals and the suffering of families. SARS Commission Final Report; Volume III. Spring of Fear. archives.gov. on.ca/en/e_records/sars/report/ v3-pdf/Vol3Chp5v.pdf] These distortions in the process of death and dying foreshadow similar distortions in the process of grieving, and could mean higher risk of various psychiatric morbidities such as depression, anxiety, post-traumatic stress disorder, and suicidal ideation. The pandemic has seen health care providers being forced to engage in what some have called impoverished care, wherein the obligations toward patient care must be weighed against obligations for self-protection and that of one’s family. A recent study out of China described the experiences of physicians and nurses with no infectious disease expertise recruited to care for patients with COVID-19. They reported exhaustion due to heavy workloads and protective gear, fear of becoming infected and infecting others, feeling powerless to handle patients’ conditions, accompanied by a sense of being fully responsible for patients’ well-being. The pandemic has seen health care providers confronting multiple concurrent deaths, moral distress, helplessness, and burnout. It is too early to say what complications, such as depression, Posttraumatic Distress Disorder (PTSD), substance abuse, or suicide, will manifest. With dignity under assault, now is the time to be mindful of the ABCD’s of dignity-conserving care: A for attitude, B for behavior, C for compassion, and D for dialogue. Our research has shown that the way dying patients perceive themselves to be seem, reflective of health care provider attitude toward them, is the most ardent predictor of