The death of a loved one, whether it’s a close friend, partner, parent, child, or other relative, can be overwhelming and difficult at any time. But during a pandemic, which has already impacted all other aspects of life, it can be even more difficult to navigate for plenty of reasons. For many, COVID-19 has compelled us to come face-to-face with our own mortality and contemplate what a ‘good death’ would look like to any individual.
The notion of what constitutes a ‘good death’ varies between people and is often influenced by one’s social, cultural and religious beliefs. Within healthcare, it usually encompasses the whole end-of-life phase: from before the patient’s passing; to the time of a patient’s death; to the funeral arrangement; and finally to the post-funeral bereavement follow-up. Under normal circumstances and across most communities, a ‘good death’ involves: dying with dignity; without prolonged pain or before one’s time; accompanied by loved; in familiar surroundings; with the preferred ritual procedures; and finally respecting the patient’s preferred type of corpse disposal (e.g. burial/cremation).
At the time of writing, the total number of registered deaths due to COVID-19 was 160,824 (up to 24th of September 2021) in the UK. (GOV.UK, 2021) Between the 12th February and 24th September 2021, the number of COVID-19 deaths was lowest in those aged ≤15 (57 deaths) and highest in those aged 75≥ (17202 deaths) (Figure 1).(Office-for-National-Statistics, 2021)
These statistics showcase how devastating the effect of COVID-19 was, with it claiming the lives of so many, irrespective of age. Over the course of the pandemic, the media kept the public updated on the number of COVID-19 deaths and tended to highlight the particularly grievous deaths of very young victims - often describing their lives as having been ‘cut short’, whilst the prime minister himself had expressed that people would ‘lose loved ones before their time’. As a society, we are drawn to believe this widespread narrative, grieve these deaths, and are reminded that, in this respect, COVID-19 is causing many tragic deaths as opposed to ‘good’ ones.
Within the UK, the introduction of the Coronavirus Act 2020 enabled national/local authorities to decide between burial or cremation in the ‘most extreme situations’, which resulted in concerns raised regarding the prospect of ‘enforced cremation’. In order to minimise the risk of spreading the virus (due to the body still being a site of contagion), this meant that direct cremations were recommended to be carried out in some places. A qualitative study by Simpson et al. used rapid ethnographic methods to examine the main concerns, regarding death within the context of COVID-19, of both faith and non-faith communities across the UK. Within that study, it was clear that cremation was unacceptable to some Jewish, Christian and Muslim communities and even some people of no-faith expressed similar sentiments with particular preference to burial instead. From this perspective, COVID-19 has caused certain communities’ steadfast belief in what they consider the ideal corpse disposal method, fitting of their version of a ‘good death’.
Though it is tempting to think of a ‘good death’ only in terms of how a person dies, from a social, religious or cultural standpoint, the way in which a person’s death is marked, is another way of dictating the value of a person’s death. This usually means holding memorial gatherings that celebrate the deceased’s life and allow their recently bereaved a chance to mourn their loss in the presence of others. COVID-19 restrictions during various tiers and periods over the course of the pandemic have meant that normal funeral services could not go ahead and were instead subject to strict legal regulations including: limits to the number of people attending; limited mixing of people from different house-holds; people being required to self- quarantine even if they were close family members to the deceased; and not being allowed to be held in a private dwelling. Social distancing and the required public use of facemasks even meant that those who were in attendance at such services were not allowed to partake in normal practices of emotional/social support behaviours (e.g. reassuring touches, hugging, embracing or seeing full facial expressions of sympathy). The absence of these formal and informal rituals may significantly burden the wellbeing and health of the bereaved. Though many communities tend to hold large funerals, smaller funerals can be viewed in a positive light as being ‘intimate’ ceremonies for some groups. Moreover, the introduction of live-streaming the service to those who were not allowed to attend in-person did attempt to address some of the issues that COVID-19 had brought about (e.g. increasing the number of people commemorating the life of the deceased). There also exists the option of post-dating the funeral service in order to do right by their (the deceased’s) memory when restrictions are eased- though this choice can understandably seem too delayed for some. COVID-19 has for the most part, negatively affected the impact of what these funeral services help to do in: commemorating the lives that the deceased have led; acknowledging their legacy; and enabling mourners an appropriate outlet for their grief; which all contribute to the idea that COVID-19 has, in this respect, not changed the importance of holding typical funeral services in order for a death to be marked as ‘good’.
It is worth noting that before the pandemic there existed less popularised narratives around dying alone that did not necessarily equate to being ‘bad’. For examples, in the USA, though suicide is often considered the ‘ultimate lonely death’, in some traditional Japanese cultures, suicide is considered ‘honourable’ and ‘altruistic’. In a different light, some people do choose to enforce a kind of ‘social death’ of their own (time of self-imposed social isolation) preceding their imminent biological death. In 2013, The National Bereavement Survey (VOICES) found that 81% of patients in England undergoing end of life care preferred to die at home, and it has been a key policy driver to encourage/facilitate this practice wherever medically possible. (Joint-Strategic-Needs-Assessment, 2015) However, due to the infectious nature of the virus and government restrictions relating to: national lockdowns, and social distancing; it has meant that many people have been dying of COVID-19 (and non-COVID-19 related circumstances) in social desolation and in hospitals/Intensive Care Units (ICUs). In this regard, COVID-19 is seen to be causing what most people consider the opposite of a ‘good death’. This master narrative is being challenged in some cases, for instance with Erin K. Willer who eulogises the death of her friend, Katherine, in her autoenthography. She outlines her ‘reframing’ of what ‘lonely dying’ means in its relation to a ‘good death’ when Katherine dies from COVID-19 alone in the ICU. She discusses how people’s grief and shame over COVID-19 fatalities are exacerbated by this ‘good death’ master narrative which stigmatise the circumstances of these deaths as inherently ‘bad’. She concludes that being ‘present’ with the dying person is not limited to being physically at their bedside but includes being continually informed of the patient’s condition, being aware of their needs, and conveying compassion and empathy even if that is via technology. A paper by Wang et al. highlighted some measures that could be implemented to tackle this concern including: live video-conferencing sessions to allow patients to see and converse with their loved ones; sending pre-recorded messages (e.g. audio recordings, letters, etc.) from loved ones to patients; and loved one’s being allowed to leave ‘comfort objects’ (e.g. treasured items) with patients which can serve as a linking/bonding object between them and possibly a substitute for their constant physical presence. Through the implementation of these measures, the more traditional mind-set of what constitutes ‘a good death’ can be made more inclusive of exceptional circumstances, such as the pandemic.
All in all, a pre-pandemic ‘good death’ is seen by the majority of people as one that: allows people to die in the company of loved ones, in familiar surroundings, with dignity; whilst their bodies undergo the preferred customary procedures and corpse disposal; as well as holding the appropriate funeral services. COVID-19 has impacted all of these aspects but influenced a few of them to change their meaning for some. Regarding the notion of dying ‘before one’s time’, holding the appropriate funeral services, and to an extent the decision to cremate for some communities, the pre-pandemic views on a ‘good death’ for the majority remained unchanged. COVID-19 has also changed the meaning of what ‘dying alone’ means in its relation to achieving a ‘good death’ and highlighted how incredible the healthcare service providers were in facilitating this shift in perspective. Finally, it is important to acknowledge the grievous impact that COVID-19 has left on our society with the loss of so many loved ones, but also ensuring that we do right by their memory whilst acknowledging our efforts to create the best circumstances for their deaths, despite the difficulties we all faced during this pandemic.
