Bereavement Services Research Articles

From Susceptibility to Immunity: The Pandemic of Homicide Grief

Grief from homicide is a global phenomenon. A pattern of structural racism and systemic inequities have shaped Black homicide deaths and have increased the prevalence, susceptibility, spread, and impact of homicide grief for Black communities throughout the global diaspora. A complex interplay of structural vulnerabilities has constituted a worldwide pandemic of homicide grief for Black communities. In this paper, homicide grief is conceptualized as a pandemic. Historical and structural factors that create vulnerability to homicide loss, enhance susceptibility, and facilitate the spread of homicide grief for Black communities is described. A public health framework incorporating prevention, protection, and mitigation strategies is critical to addressing pandemics. A public health framework that incorporates anti-Black racism and other sociopolitical factors that render Black communities disproportionately vulnerable to homicide grief is proposed. Recommendations for reducing the prevalence and interrupting the inequitable spread of homicide grief within Black communities is discussed, including improved access to culturally responsive grief and bereavement services, influencing policy structures, and increasing culturally attuned research efforts.

Learning About Grief Triggers Through an Exploratory-Descriptive Study

A qualitative study was undertaken to identify what triggers grief in the first two years following the death of a beloved family member, determine how often triggered grief occurs, and gain lived insight into what can be done (if anything) to manage triggers and also triggered grief. Four themes highlighting an uncertain process associated with grief triggers were identified: (a) my whole life was grief, (b) frequently hit by “hard-grief” triggers, (c) reaching a balance with grief and grief triggers to absorb the losses and reshape life, and (d) shifting to good and welcome memories, triggers that keep the person alive. These themes are described, with quotes illustrating their relevance for advising bereaved people about the grief triggers they may encounter. This evidence adds to a limited body of evidence on grief triggers and offers new insights for developments in grief theory and bereavement programs or services.

Bereavement and Grief Among Employees in an Arab University Setting: A Cross-Sectional Study.

Several mental health outcomes develop following bereavement. Little research has examined bereavement in the workplace and the associated risk factors, particularly in Arab populations. The objectives of this cross-sectional study were to determine the sociodemographic characteristics of bereaved employees, measure the prevalence of their dysfunction, establish the type of closeness and conflict in their relationship with the deceased, determine the available resources to the bereaved, and determine the proportion of bereaved employees who needed help. A study was conducted on Arabian Gulf University employees (91) in Bahrain. The revised Two Track Bereavement Questionnaire (TTBQ3-CG11) was utilized to assess bereavement outcomes. The response rate of the study was 28%. The composition of the study population was as follows: 51.6% males, 37.4% in the age range of 40-49 years, 86.8% married, 39.6% Bahraini, and 51.6% academicians. Over half of the participants had biopsychosocial dysfunction, 35.2% had active relational grief and trauma (ARGT), 36.3% had a conflict with the deceased, and half were close to the deceased. Total TTBQ3-CG11 scores showed that 28.6% of the bereaved had a low score (14-22), 61.5% medium (23-28), and 9.9% high (29 or more), with more females than males in the high category. The majority reported receiving adequate support from the administration and colleagues following their loss. There is a need to establish bereavement policies and procedures at tertiary educational institutes. This study may inform future policies to advance bereavement services in the educational institutions of the region.

Developing a best-practice agenda for music therapy research to support informal carers of terminally ill patients pre- and post-death bereavement: a world café approach

BackgroundInformal carers of terminally ill patients play a vital role in providing palliative care at home, which impacts on their pre- and post-death bereavement experience and presents an up to 50% greater risk for mental-health problems. However, developing and implementing effective bereavement support remains challenging. There is a need to build the evidence base for music therapy as a potentially promising bereavement support for this vulnerable population. This study aimed to co-design an international best practice agenda for research into music therapy for informal carers of patients pre- and post-death bereavement.MethodsOnline half day workshop using a World Café approach; an innovative method for harnessing group intelligence within a group of international expert stakeholders (music therapy clinicians and academics with experience of music therapy with informal carers at end-of-life). Demographics, experience, key priorities and methodological challenges were gathered during a pre-workshop survey to inform workshop discussions. The online workshop involved four rounds of rotating, 25-minute, small group parallel discussions using Padlet. One final large group discussion involved a consensus building activity. All data were analysed thematically to identify patterns to inform priorities and recommendations.ResultsTwenty-two consented and completed the pre-event survey (response rate 44%), from countries representing 10 different time zones. Sixteen participated in the workshop and developed the following best practice agenda. The effectiveness of music therapy in supporting informal carers across the bereavement continuum should be prioritised. This should be done using a mixed methods design to draw on the strengths of different methodological approaches to building the evidence base. It should involve service users throughout and should use a core outcome set to guide the choice of clinically important bereavement outcome measures in efficacy/effectiveness research.ConclusionsFindings should inform future pre- and post-death bereavement support research for informal caregivers of terminally ill patients. This is an important step in building the evidence base for commissioners and service providers on how to incorporate more innovative approaches in palliative care bereavement services.

It Takes a Village: Coordinating and Streamlining Access to Palliative Care Resources through a Centralized Referral and Contact

Introduction/Background: The Couchiching Ontario Health Team (COHT) is a first-round health team in rural Ontario, Canada, designed as part the Provincial Government’s new model of health care delivery that puts patients, families and caregivers at the center of the health care system. The COHT members include Family Health Teams, primary care physicians, home care support services, an acute care hospital, Indigenous healing providers, community housing support services, a fulsome Patient and Family Advisory Council and many others. As part of the year-one priority population strategy, improving resource allocation and multi-provider care delivery for Palliative Patients was identified as of utmost importance. 
 The COHT Palliative Care Network identified multiple doors of resource access, multiple referrals and a variety of disparate services available, but not formally connected, for one of the most vulnerable populations. We heard from patients, families and caregivers that they were confused about who to contact first, specifically those without a Primary Care Provider, and would often turn to acute care services as a result.
 Engagement – Shared Values and Vision: The Palliative Care Network Working Group brought together a fulsome compliment of multi-sectoral, interdisciplinary team members, on a monthly basis, to work towards a common goal; ensuring one-door access to all palliative care services within the Couchiching area.
 After a gap analysis identified not only gaps in the system, but also instances where work was being duplicated (from a lack of shared care plans and standardized communication), the group started to focus on identifying the needs for the palliative population, and their caregivers to access a fulsome resource complement, geared to every stage of their care journey, by ensuring no door would be the wrong door.
 This led to the creation of One-number and One-referral accessed by Primary Care, Nurse Practitioners, Nurses and even community members themselves, for the purpose of accessing and navigating necessary services. By completing one referral form and answering a few simple questions a patient or their caregiver can be directed to Nursing Services for symptom relief or end of life goals, Hospice to inquire about a bed, Social Work for grief and bereavement services, volunteer or faith groups and even connected with Primary Care.
 System Wide Governance and Leadership: By assigning governance through shared accountability agreements, to a multi-organizational OHT, each group member feels responsible for the outcomes of the population as a whole, providing a team-based approach to care delivery. While still working within the constraints of traditional funding principles, organizations are dividing up work, and creatively finding ways to ensure care is provided to patients in their preferred setting, which is often their own home. With human health resource scarcity, and burnout at the forefront of healthcare, the centralized referral’s ability to triage patients with the greatest needs, and share that responsibility with other Working Group members has been incredibly impactful and has allowed for the navigation, and coordination of integrated services to be seamlessly delivered by a varied group of providers to offer wraparound care for the most vulnerable population.

Assessment of Quality of Life, Grief, and Psychosocial Need Among Bereaved Caregivers of Children with Cancer.

Cancer is the leading disease-related cause of death for children in the United States; however, limited data exists on caregivers' needs and evidence-based bereavement interventions are lacking. This is a cross-sectional study of primary caregivers of children who died from cancer. Participants completed five surveys assessing well-being and an optional semi-structured, in-depth qualitative interview. Caregiver's greatest unmet needs were finding meaning in the death, personal wellness, and social activities. Bereaved caregivers with greater unmet needs reported poorer quality of life in the energy/fatigue (p = .01), role limitations due to emotional problems (p = .01), pain (p = .01), and emotional well-being (p = .02) domains. Interview themes elicited include inadequate bereavement services, support for siblings, desired contact with the medical team, and connections to other bereaved caregivers. Findings support the need for intensive, evidence-based bereavement programs for families of children who died from cancer, to attempt to mitigate poor bereavement-related outcomes.

Mapping MAiD Discordance: A Qualitative Analysis of the Factors Complicating MAiD Bereavement in Canada.

Medical assistance in dying (MAiD) is an evolving practice in Canada, with requests and outcomes increasing each year, and yet controversy is present-with a vast spectrum of ethical positions on its permissibility. International research indicates that family members who experience disagreement over their loved one's decision to have MAiD are less likely to be actively involved in supporting patients through the practical aspects of the dying process. Family members with passive involvement in the assisted dying process may also experience more significant moral dilemmas and challenging grief experiences than those who supported the decision. Given these previous findings, we designed this study to explore the factors complicating family members' experiences with MAiD in Canada and to understand how these complicating factors impact family members' bereavement in the months and years following MAiD. We conducted narrative interviews with 12 MAiD-bereaved family members who experienced disagreements, family conflicts, or differences in understanding about MAiD. Documenting and analyzing participants' experiences through storytelling allowed us to appreciate the complexity of family members' experiences and understand their values. The analysis generated five factors that can complicate the MAiD process and bereavement for family members: family discordance, internal conflict, legislative and eligibility concerns, logistical challenges, and managing disclosure and negative reactions. To our knowledge, this is the first Canadian study that explores how family discordance can impact bereavement following MAiD. Future bereavement services and resources should consider how these complicating factors may impact bereavement and ensure that Canadians with diverse MAiD experiences can access appropriate support.

The COVID-19 Pandemic: Bereavement Experiences Between Hospital and Home Deaths in Palliative Care

BackgroundAustralian COVID-19 public health measures reduced opportunities for people to communicate with healthcare professionals and be present at the death of family members/friends. AimTo understand if pandemic-specific challenges and public health measures during the COVID-19 pandemic impacted end-of-life and bereavement experiences differently if the death, supported by palliative care, occurred in a hospital or at home. DesignA cross-sectional online survey was completed by bereaved adults during 2020–2022. Analyses compared home and in-patient palliative care deaths and bereavement outcomes. Additional analyses compared health communication outcomes for those identified as persons responsible or next of kin. Setting/participantsOf 744 bereaved people; 69% (n = 514) had a death in hospital and 31% (n = 220) at home. ResultsThe COVID-19 public health measures influenced people's decision to die at home. Compared to hospital deaths, the home death group had higher levels of grief severity and grief-related functional impairment. Only 37% of bereaved people received information about bereavement and support services. 38% of participants who were at least 12 months postdeath scored at a level suggestive of possible prolonged grief disorder. Levels of depression and anxiety between the two groups were not significantly different. ConclusionsThese findings highlight the need for health services to recognize bereavement as fundamental to palliative and health care and provide pre- and post death grief and bereavement care to ensure supports are available particularly for those managing end-of-life at home, and that such supports are in place prior to as well as at the time of the death.

Palliative care services in paediatric oncology centers across Europe: A cross-sectional survey

BackgroundPalliative care (PC) is an integral part of cancer treatment. However, data on service availability is limited in childhood cancers. AimTo describe the availability of PC services in paediatric oncology centres across Europe, and to identify barriers and facilitators for implementing and providing paediatric palliative care (PPC). MethodsPaediatric oncology centres across Europe were invited to complete an online questionnaire. ResultsA total of 158 paediatric oncology centres from 27 European countries participated. More than half of the centres (n = 102, 64.6 %) reported offering specialised PPC (defined as 24/7 coverage services with a specialised physician and a multidisciplinary team). Most centres included a multidisciplinary care team (n = 123, 80.9 %) and PC at home (n = 105, 69.1 %). In 38.7 % centres, service capacity was reported to be lower than demand. In most centres, PC consultation was initiated for a refractory neoplasm (n = 126, 81.2 %). Few centres (n = 11, 7.1 %) offered PC consultation at the time of a new cancer diagnosis. Eighty-two centres (52.6 %) reported having bereavement services. Negative parental perception (n = 99, 64.7 %) and late referrals (n = 91, 59.5 %) were major barriers to implementation perceived by health care providers. ConclusionOur results suggest that specialised PPC is available in more than half of paediatric oncology settings across Europe. Although half have had PPC available for > 10 years, many cannot fulfil the demand for service. Barriers to implementation (i.e., parental education, staff training) should be addressed, with resources and services further expanded to cover the demand for PPC, including bereavement care.

Heartbeat recordings in music therapy bereavement care following suicide: Action research single case study of amplified cardiopulmonary recordings for continuity of care

Bereavement services incorporating family-centered practices are emerging within hospital-based care but are often time-limited and lack personalization. This action research single case study explored one father’s experience of music therapy using amplified cardiopulmonary recordings (ACPR) during bereavement following his son’s death by suicide, to critique current norms and inspire transformative change in systems of care. As co-researchers, a bereaved father, his music therapist, and a music therapy researcher used iterative cycles to qualitatively analyze a series of dialogic reflections upon an 8-year experience of ACPR to construct two overarching themes: 1) continuity experienced as compassion, and 2) process of music therapy with ACPR as tool for resilience and positive growth. Aspects of continuity in the ACPR process, in relation with the music therapist, in journeying through grief, and in the heart and heartbeat were perceived as overwhelming compassion that fostered positive growth in the face of profound loss. We see our study as a first step in promoting culture change by exposing underlying practices, assumptions and policies within the context of hospital-based bereavement care and identifying an exceptional example of possibilities. Our findings add to the literature on action research for transformation by demonstrating that the process of relational knowledge co-creation can be perceived as part of the therapeutic journey.

A global assessment of access to pediatric palliative care for children with cancer in resource-constrained settings.

87 Background: Pediatric palliative care reduces suffering, improves communication, and enhances quality of life for children with complex disease, especially children with cancer. Despite a disproportionate burden of pediatric cancer in resource-constrained settings) the provision of pediatric palliative care services is limited. We aim to describe the global landscape of palliative care services for pediatric hematology/oncology patients using data from the Abbreviated PrOFILE (Pediatric Oncology Facility Integrated Local Evaluation), a 360-degree evaluation tool assessing care capacity and guiding the development of an improvement strategy in institutions caring for children with cancer. Methods: One hundred and twelve institutions across 23 countries completed the Abbreviated PrOFILE from 2019-2021. We extracted data from questions regarding pediatric palliative care personnel and training, medications for symptom management, and patient outcomes. Results were stratified by World Bank income level. Results: The analyzed hospitals were from low (LIC) (6), lower-middle (LMIC) (34), upper-middle (UMIC) (55), and high (HIC) (17) income levels. They self-identified as primarily cancer hospitals (19%), children’s hospitals (22%), general hospitals (45%), and pediatric oncology institutions (12%). Access to specialists varied by income level with 71% of HICs, 41% of UMICs, 32% of LMICs, and 17% of LICs reporting almost always having access to palliative care specialists. These specialists were more likely to have formal education in childhood cancer in HIC (59%) compared to low- and middle-income countries. Oral morphine was reported available in 100% of HICs, 76% of UMICs, 27% of LMICs, and 33% of LICs. Injectable morphine had similar results with 100% of HICs, 96% of UMICs, 41% of LMICs, and 33% of LICs reporting almost always having availability. Ibuprofen, acetaminophen, dexamethasone, ondansetron, metoclopramide, omeprazole, diazepam, phenobarbital, and phenytoin were reported as almost always or frequently available in at least 50% of institutions in each income level. End-of-life and bereavement services were less available in LICs (17%), LMICs (18%), and UMIC (36%) than HICs (53%). Following completion of the Abbreviated PrOFILE tool, 50% of the regional cohorts set a priority to improve supportive, palliative, or end-of-life care. Conclusions: Access to pediatric palliative care services varies by income level. Despite increased need for palliative services in LMICs, there is less access to trained providers and essential medications, especially in those with decreased resources. These results will inform the implementation of improvement interventions among institutions providing care for children with cancer.

The impact of Covid-19 on bereavement care in Ireland: A national survey of bereavement care providers.

Objectives: To a) describe bereavement care providers' experience of demand and type of need for bereavement care during the first year of the pandemic; b) describe the self-assessed impact on care providers; c) identify service adaptations and challenges currently faced.
 Methods: Data was collected via an online survey of Irish bereavement service workers (n=199) during the 2021 level 5 restrictions enforced due to the COVID-19 pandemic.
 Results: 47% of respondents noted an increase in the demand for their service, with many reporting higher levels of distress and more complex needs among service users. 47% reported an increase in the emotional impact of the work. Many service providers altered their service provision and/or developed new services, in part, to meet the changing pattern of need. The positive changes and opportunities resulting from the pandemic were also noted, some of which they intended to continue post-pandemic.
 Conclusion: The pandemic and related restrictions shone a light on the way we die and grieve in Ireland. With the current focus on bereavement, now may be the time to develop a national policy for bereavement care, which should provide direction for service provision and pathways, alongside public education to meet bereavement needs.

Survey Study of a Hospital-Based Bereavement Program During COVID-19: Insights to Improve Support of the Bereaved.

Background: The COVID-19 pandemic has highlighted that bereavement care is under-recognized with few hospitals offering universal bereavement services. Methods: One hundred sixty-nine bereaved individuals, whose loved ones died at our hospital during 2021 and 2022, completed a survey about their experience with the bereavement program. Results: Of respondents who recalled receiving bereavement outreach, 79% rated speaking to a team member soon after the death as having a positive impact on their bereavement, and 75% rated receiving a condolence call or note from the team positively. Feedback also identified opportunities for improvements in care: (1) importance of compassionate communication and connection with family members after a death; (2) more flexible hospital visitation policies; and (3) additional support for families during the end-of-life (EOL) period. Conclusions: The findings demonstrated that a hospital-based bereavement program can positively impact an individual's bereavement experience with a formal letter of condolence, psychoeducation information, and direct outreach from team members soon after death, being positively evaluated.

A Longitudinal Study of the Impact of a Suicide Bereavement Service on People Bereaved by Suicide.

Whilst the body of research on the impacts of suicide bereavement interventions continues to grow, there is little understanding of the impact over time. This study measured changes in suicidality, levels of loneliness and grief reactions over time between those receiving support from a community-based suicide bereavement service (StandBy) compared with those that did not receive this support. Data were collected through an online survey with participation at baseline being varying times post loss, and three-months post-baseline (StandBy n = 174, Comparison n = 322). Statistical analysis included linear mixed-effects modelling for repeated measures. Results were consistent with earlier studies showing the positive impact of StandBy on participants' grief responses, loneliness and suicidality, specifically within the first 12months after their loss. However, these outcomes were not retained over time, with the exception of suicidality. Further longitudinal studies consisting of more than two time-points and a greater period between time-points is warranted.

Alzheimer's Disease and Related Dementias: Caregiver Perspectives on Hospice Re-Enrollment Following a Hospice Live Discharge.

Background: The number of individuals dying of Alzheimer's disease and related dementias (ADRDs) is steadily increasing and they represent the largest group of hospice enrollees. In 2020, 15.4% of hospice patients across the United States were discharged alive from hospice care, with 5.6% decertified due to being "no longer terminally ill." A live discharge from hospice care can disrupt care continuity, increase hospitalizations and emergency room visits, and reduce the quality of life for patients and families. Furthermore, this discontinuity may impede re-enrollment into hospice services and receipt of community bereavement services. Objectives: The aim of this study is to explore the perspectives of caregivers of adults with ADRDs around hospice re-enrollment following a live discharge from hospice. Design: We conducted semistructured interviews of caregivers of adults with ADRDs who experienced a live discharge from hospice (n = 24). Thematic analysis was used to analyze data. Results: Three-quarters of participants (n = 16) would consider re-enrolling their loved one in hospice. However, some believed they would have to wait for a medical crisis (n = 6) to re-enroll, while others (n = 10) questioned the appropriateness of hospice for patients with ADRDs if they cannot remain in hospice care until death. Conclusions: A live discharge for ADRD patients impacts caregivers' decisions on whether they will choose to re-enroll a patient who has been discharged alive from hospice. Further research and support of caregivers through the discharge process are necessary to ensure that patients and their caregivers remain connected to hospice agencies postdischarge.

The experiences of family members witnessing the diminishing drinking of a dying relative in hospital: A narrative inquiry

Background: The optimal management of diminishing drinking at the end of life is contentious. Clinicians and family members may understand the phenomenon differently and hold divergent priorities regarding care. Family members can be distressed by diminishing drinking and its management, particularly when in a hospital environment. Aim: To explore the experiences of family members when witnessing the diminishing drinking of a dying relative. Design: A narrative inquiry methodology, derived from pragmatism. Setting and participants: Thirteen recently bereaved family members were recruited through the bereavement services of three UK hospitals. Inclusion criteria included having an adult relative who died in hospital of any diagnosis more than 48 hours from admission and who had had noticeable diminishing drinking. Findings: Participants experienced diminishing drinking as an unfolding process that was part of overall decline. They all believed it to be detrimental. Three groups of responses were identified: promoting, accepting and ameliorating. Supportive measures included offering equipment to support drinking, staff being present and communicating about expectations and care management aims. Conclusions: There is potential to improve family members’ experiences through re-conceptualisation of diminishing drinking aligned to their experiences, supporting family members by listening to their experiences with insight and strengthening their agency within the management of their relatives with diminishing drinking.

End-Of-Life Care Planning and Bereavement Practices Among Adult Day Services Centers, 2018.

Introduction: This study describes the end-of-life (EOL) care planning and bereavement practices among adult day services centers (ADSC) when an ADSC participant is dying or has died. Methods: Data are from the 2018 National Study of Long-term Care Providers' biennial survey of ADSCs. Respondents were asked about the following 4 practices: 1) honoring the deceased in some public way in this center; 2) offering bereavement services to staff and participants; 3) documenting in the care plan what is important to the individual at the end of life (EOL), such as the presence of family or religious or cultural practices; and 4) discussing spiritual needs at care planning conferences. ADSC characteristics included US Census region, metropolitan statistical area status, Medicaid authorization, electronic health records (EHR) use, for-profit status, employment of aides, services provision, and model type. Results: About 50% to 30% of ADSCs offered the EOL care planning or bereavement services. Honoring the deceased was the most common practice (53%), followed by bereavement services (37%), discussing spiritual needs (29%), and documenting what is important at EOL (28%). Fewer ADSCs in the West had EOL practices relative to the other regions. The EOL planning and bereavement practices were offered more often in ADSCs that used EHRs, accepted Medicaid, employed an aide, provided nursing, hospice, and palliative care services, and were categorized as medical models, compared with ADSCs without these characteristics. Conclusion: These results highlight the importance of understanding how ADSCs provide EOL and bereavement care to participants who are near EOL.

A Phenomenological and Clinical Description of Pandemic Grief: How to Adapt Bereavement Services?

Some studies suggest that individuals having lost a loved one during the COVID-19 pandemic report higher levels of grief reactions than people bereaved from natural causes. Little is known about the lived and subjective experience of individuals who lost a loved one under confinement measures. This research aims to provide a phenomenological description of pandemic grief (PG) that can be useful in clinical settings and bereavement services. Seventy-six qualitative phenomenological interviews have been conducted with 37 individuals who have lost a loved one during the first wave of the pandemic. Interpretative phenomenological analysis was performed following Tracy's criteria for rigorous qualitative research. The experience of PG comprises clinical manifestations and can be described as "a type of grief occurring in the context of a pandemic, where applicable public health measures have precedence over end of life and caregiving practices as well as funeral rituals, overshadowing the needs, values, and wishes of the dying individuals and those who grieve them." This study is the first to provide a phenomenological and experiential understanding of PG. Our phenomenological description can be helpful in clinical settings such as bereavement services within palliative care teams.

Understanding the influence of bereaved family caregivers’ perception of a good death on their caregiving experiences: A meaning making perspective

This retrospective qualitative study aimed to examine the influences of bereaved family caregivers’ perception of good death for their dying spouse or parent on their caregiving experiences. A purposive sample of 15 participants were recruited from a hospice and their narratives were analyzed. Using the interpretative phenomenological analysis approach, five key components of a perceived good death that intermixed well-established Western attributes with deeply rooted Asian values were identified and meanings ascribed to their caregiving experiences were based on that. These findings suggested implications for practice on the entire service continuum from palliative and end-of-life care to bereavement services.

Impacts of the COVID-19 Pandemic on the Bereaved.

The COVID-19 pandemic has killed millions across the world in only two years. Government health restrictions aimed at preventing transmission have impacted typical mourning practices such as funeral gatherings and in-person grief support services. This research examines the potential impacts that the pandemic may have had on people's ability to grieve. We employed a mixed methods study design to ask those who have lost a loved one during this time to reflect on their mourning practices with an anonymous survey. Our results present themes of complicated grief, the uncertainty of who to blame for frustrations, and common needs requested by the bereaved to help them mourn during these unprecedented times. These findings may help inform grief support and bereavement services during current and future mass death and pandemic health concerns.