Systematic review sources 

We identified several systematic reviews on the different aspects of caring for acute or sudden bereavement, and an evidence summary from the Centre for Evidence-Based Practice (CEBaP) about communication with bereaved or grieving people.

Spending time alone with the deceased

A systematic review of the sudden death of children found consistencies across many studies showing that parents want time to hold and be with their deceased child to say goodbye. Some qualitative studies described that when parents desired but were unable to have a private and peaceful space to say goodbye to their child, it increased their regret and grief. However, a minority of bereaved parents strongly felt that they did not want to see their deceased child (Garstang et al., 2014). 

Knowing the “how” and the “why”

Based on the same systematic review by Garstang et al. (2014), evidence found consistencies across many studies of child deaths that parents want to know how and why their child died. Studies revealed that the information of the child’s death helps parents in making sense of the tragedy and facilitates the grieving process. Particularly when the death is unexpected, finding out the cause of death is important to help reduce parents’ emotional stress. Information can also reassure parents that the child did not suffer and that everything possible was done to save their life. This knowledge can help to reduce any guilt parents might feel. Some bereaved parents tend to suspect that a lack of information means authorities are deliberately withholding knowledge from them. 

Talking about grief

An evidence summary from CEBaP in 2019 found limited evidence demonstrating the benefits of talking about grief (Dockx et al., 2020). The evidence is of very low quality and results are considered imprecise due to a low number of events and lack of data. While we did not identify a causal relationship between the results, we did conclude specific associations between grief and speaking about it.

In bereaved parents of deceased children, evidence showed that there is a statistically significant association between a decrease in grief and positive communication about one’s grief as time increased from the loss of the child. However, a statistically significant association between a partner’s concern for their grieving partner, and actual grief of both partners, could not be demonstrated.

Studies also identified statistically significant associations between relationships outside that of a parent and child.

• In bereaved siblings, there was a statistically significant association between talking about loss and a decrease in grief and anxiety. There was also an association between satisfaction and the amount of time spent talking about the loss.
• In the bereaved children of a deceased parent, studies showed a statistically significant association between the remaining parent or caregiver’s positive, emotional words and a decrease in the bereaved children’s anxiety and depression, especially as time increases since the loss. Moreover, there is a statistically significant association between the decrease in unhealthy grief and the increase in mother communality. However, a statistically significant association between a decrease in depression and an increase in mother communality could not be demonstrated.
• In bereaved partners, a statistically significant association between increased disclosures of emotion at 4, 18- or 25-months post-bereavement and a decrease in distress could not be demonstrated. However, at 11 months post-bereavement, there was a statistically significant association between increased disclosure of emotions and an increase in distress.
• In bereaved students, a statistically significant association between more open family communication about grief and a decrease in feeling grief could not be demonstrated.

The same evidence summary demonstrated harm caused by avoiding communication. The evidence is of very low quality and results are considered imprecise due to a low number of events and lack of data. While we did not identify a causal relationship between the results, we did identify several specific associations:

• There was a statistically significant association between not talking to one’s parents about a deceased sibling and both unresolved grief and anxiety.
• The evidence showed that increased partner-oriented self-regulation (when partners avoid talking about their loss and try to appear strong in each other’s presence) resulted in a statistically significant increase in bereaved parents’ grief seven months after a loss. There was also a statistically significant association between an increase in current partner-oriented self-regulation and an increase in grief.
• A statistically significant association between bereaved students’ grief and communication avoidance could not be demonstrated. 

Communicating and receiving emotional support

The evidence summary also identified studies that looked at communicating with grieving or bereaved people in general (not specifically grief-related communication). The evidence is of very low quality and the results are considered imprecise due to limited sample size and large variability. They could not infer any causal relationship from the results outlined below.

• In bereaved fathers of deceased children, results showed a statistically significant association between decreased grief and talking with friends.
• In bereaved children of a deceased parent, results showed a statistically significant association between both decreased anxiety and depression and an increase in parent-child communication.
• In bereaved adults, a statistically significant association between grief and communication within a family could not be demonstrated.
• In a healthcare setting, results showed that a phone call from the neonatologist led to a statistically significant decrease in loneliness, depression and feelings of guilt, compared to no phone call. However, a statistically significant decrease in anger and hostility with or without a phone call could not be demonstrated.

Psychological first aid

Psychological first aid is a method of helping people in distress to feel calm and supported in coping with their challenges. It addresses both the emotional and social needs of individuals, with the intention of helping people use their resources, enhance their resilience and make informed decisions. There are a limited number of studies that researched the effectiveness of psychological first aid as a complete programme. Two existing systematic reviews on psychological first aid both concluded that there is a lack of controlled studies to support it (Dieltjes et al., 2014; Fox et al., 2012). However, as it is unlikely to have adequate representation of randomised controlled trials using interventions for traumatic events, interventions need to be informed by good practices and psychological first aid is supported by expert opinion. 

Non-systematic review 

In addition to the evidence from the systematic reviews, we also identified best practices as described by Kent and McDowell (2004), and from bereavement care practice guidelines.

Good practice from bereavement care practice guidelines

There are some studies regarding the development or application of bereavement care practice guidelines. A systematic review further identified a large variation in the quality of these guidelines (Kent et al., 2020).  Nonetheless, the guidelines from the review share the following core values:

• Work with respect and integrity.
• Provide dignity to bereaved individuals and their deceased loved one.
• Provide high-quality, collaborative, accessible and adequately resourced care.

Updating friends and family every 10–15 minutes on any resuscitation progress

The bereaved must not feel excluded during the resuscitation process. Studies suggested that frequent updates of the patient’s situation during resuscitation reduced the feeling of helplessness. Meanwhile, the feeling of exclusion and helplessness and remaining uninformed may lead to anger in the grieving process. Studies also showed that witnessing the resuscitation may help the bereaved to cope better with grief over time (to which there is no evidence that viewing would interfere with the resuscitation process). However, a nurse needed to accompany the bereaved. 

Spending time alone with the deceased

It is important to allow relatives and friends time alone with the body; to see, touch and talk to the deceased as much as they are comfortable. They should be prepared for what the deceased will look like before viewing the body, especially when the deceased has been severely injured or disfigured. Spending time with the body can facilitate grieving and reduce feelings of guilt, helplessness and isolation. 

Accommodating cultural or religious rituals

Accommodation of cultural and religious rituals show respect for the deceased and the bereaved, which will facilitate the grieving process. In supporting a bereaved family, it is important to pay attention to how the family addresses the dead body and to be aware of and receptive to the cultural and religious differences of different families so that helper can facilitate the family to say goodbye to the deceased in a humane and dignified way (Morgan et al., 2006). 

Providing information and discussing relevant issues

If appropriate, the bereaved may wish to discuss issues such as organ or tissue donation, post-mortem, funeral arrangement and attending support groups. Some studies revealed that the donation of organs or tissues makes the death meaningful and helps the bereaved family members accept their loss. 

Providing a hospital contact number and name of support nurse or doctor for follow-up care

Follow-up care from the hospital allows the bereaved family an opportunity to get more information about the death and may also be a source of comfort. 

Psychological first aid intervention principles

Psychological first aid, provided by trained persons, is widely supported by expert opinion and rational conjecture as a tool to help people who have experienced a traumatic event(s) (Shultz & Forbes, 20104).

Through observation and expert experience, there is a widespread consensus and support for the five intervention principles that should guide and inform any psychosocial support intervention and prevention efforts at the early to mid-term stages of an emergency. These principles facilitate survivors’ short-term adjustment and long-term adaptation after a crisis (Hobfoll et al., 2007). The five principles involve the promotion of:

• calm
• hope
• connectedness
• a sense of safety
• a sense of self and community efficacy.

First aid for mental health problems

In 2019 the Belgian Red Cross-Flanders developed guidelines to provide first aid to people experiencing mental health problems based on a systematic review of scientific evidence (evidence summaries developed by CEBaP, as mentioned above), expert opinion and the preferences of the target population (Dockx, submitted for publication). The guidelines include specific recommendations to support people exposed to shocking events. 

Supporting families in facing death and dying or ambiguous loss

Witnessing loved ones’ sudden death or not knowing the whereabouts of loved ones can be one of the most distressing and traumatising experiences in one’s life. It is critical for helpers to provide appropriate and adequate support for the families at this vulnerable stage. Unlike death, when the loved ones go missing or disappear, there is uncertainty about whether they are dead or alive and such uncertainty leads to an ambiguous loss for the family. The fact that the person may still be alive somewhere; the fact that no remains have been recovered means that the family cannot hold a burial ceremony and move forward with the grieving process as if the person is dead. This ambiguous loss sometimes remains unacknowledged which causes further distress to the families (ICRC, 2017).

Families who experience loss can react in a multitude of different ways. Below are just some of the ways people may respond to loss (Pernille et al., 2012).

• Feelings: The person who experiences a sudden loss may have a range of feelings, including shock, numbness, intense sorrow and pain, sadness, depression, dejection, anxiety, tense, denial, anger, irritability, guilt, self-blame, self-criticism, insecurity, helplessness, hopelessness, yearning, and nostalgia. Families with ambiguous loss may also feel emotionally isolated as they may believe that others do not understand their suffering (ICRC, 2017).
• Thoughts: Grief can cause worrying, feelings of disbelief, denial of what has happened, confusion, problems with memory and concentration, preoccupation and rumination over the loss, idea of the presence of the missing or dead family member. Some may also experience feelings of alienation, unfamiliarity with their surroundings, the experience of unreality, suicidal thoughts, depersonalisation and hallucinations.
• Physical sensations: Grief can cause physical sensations such as tightness and heaviness in the chest or throat, choking, nausea or stomach-ache, dizziness, headaches, numbness, muscle weakness, tension, or fatigue. It may make the person vulnerable to illness.
• Behaviours: Grief can cause avoidance of memories of the deceased, weeping, sobbing, crying, hypo-or hyperactivity, sleep problems (reduced or interrupted sleep or excessive sleep), and increased use of medication, alcohol or other drugs. Physical complaints such as headache, stomach-ache, nausea etc. may arise without identifiable physical cause. Sudden loss may trigger shock symptoms such as screaming, howling to shaking, difficulty in drinking or eating, crying spells and becoming more aggressive or irritable. Another extreme of the continuum of behaviour, such as staying numb, unresponsive to the outside world, inability to talk or move, and loss of interest in daily activities, may also arise. Families with ambiguous loss may also present obsessive thoughts and speech, as well as repetitive and rigid patterns of behaviour (ICRC, 2017).
• Social behaviours: Grief can cause social withdrawal or isolation. Families with ambiguous loss may feel unable to resume their familial and marital roles, rules and rituals, as they do not know whether the missing family member will ever return. In extreme cases, life seems to come to a standstill. They may also isolate themselves and refuse to reach out for help to avoid stigmatisation. Stigmatisation can be even more serious especially when the family member went missing in a violent conflict between two or more groups and others became sceptical that the family is connected to “rebel” groups (ICRC, 2017).

Children may have distinct reactions and changes too (Pernille et al., 2012; ICRC, 2017).

• Restlessness and change in activity level.
• Fearfulness and/or anger, especially when being left alone, or asking questions like “why did it happen?”, “will this happen to me or others?”.
• Regression to younger behaviours such as bedwetting despite having been toilet-trained, thumb sucking, and refusal to sleep alone.
• Clinging to parents or showing anxiety to separation or fear of strangers.
• Withdrawal and unwillingness to discuss the loss.
• Symptoms of illness such as nausea, loss of appetite, and diffuse aches and pains.
• Feeling guilty and placing blame on themselves.

Families of missing persons often require intensive psychosocial support during the difficult process of investigating disappearances. During the process of recovering and identifying remains, painful memories and intensive emotions may surface. Particularly when the families are asked to provide ante-mortem data and blood or saliva samples for obtaining conclusive proof of death of the missing person, are informed of their loved one’s death, are present when the remains are recovered, and/or are asked to identify or claim the remains and personal belongings of their loved ones (ICRC, 2017).

Systematic reviews

Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2018). Evidence summary Grief – Communication. Will be available via publication by Dockx et al (see below).

Dieltjens T, Moonens I, Van Praet K, De Buck E, Vandekerckhove P. (2014). A systematic literature search on psychological first aid: lack of evidence to develop guidelines. PLoS One. Dec 12; 9(12):e114714.

Dockx, K., Stroobants, S., Scheers, H., Borra, V., Brier, N. D., Verlinden, S., Kaesemans, G., De Buck, E., Lauwers, K., Vandekerckhove, P. (2020). Providing first aid to people experiencing mental health problems: development of an evidence-based guideline [unpublished manuscript]. Frontiers in Public health.

Fox, J. H., Burkle, F. M., Bass, J., Pia, F.A., Epstein, J.L., & Markenson, D. (2012). The effectiveness of psychological first aid as a disaster intervention tool: research analysis of peer-reviewed literature from 1990-2010. Disaster medicine and public health preparedness, 6(3), 247-252.

Garstang, J., Griffiths, F., & Sidebotham, P. (2014). What do bereaved parents want from professionals after the sudden death of their child: a systematic review of the literature. BMC Pediatrics, 14, 269.

Kent, K., Jessup, B., Marsh, P., Barnett, T., & Ball, M. (2020). A systematic review and quality appraisal of bereavement care practice guidelines. Journal of Evaluation in Clinical Practice, 26, 852-862.

Non-systematic reviews

Belgian Red Cross-Flanders. (2019). Luister! Eerste hulp bij psychische problemen [Listen! First aid for mental health problems]. Rode Kruis-Vlaanderen.

Hobfoll, S.E.,Watson, P.E., Ruzek, J.I., Bryant, R.A., Brymer, M.J., Pynoos, R.S. (2007). Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry, 70, 283-314.

International Committee of the Red Cross. (2017). Guidelines on Mental Health and Psychosocial Support. Geneva; Switzerland.

IFRC Reference Centre for Psychosocial Support. (2020). Loss and grief during COVID-19. Denmark: Copenhagen.

IFRC Reference Centre for Psychosocial Support. (2018). A Guide to Psychological First Aid for Red Cross and Red Crescent Societies. Denmark: Copenhagen.

Inter-Agency Standing Committee. (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. IASC.

Kent, H., & McDowell J (2004). Sudden bereavement in acute care settings. Nursing Standard, 19(6), 38-42.

Morgan, O., Tidball-Binz, M., & Van Alphen, D. (2006). Management of dead bodies after disasters: a field manual for first responders. Pan American Health Organization (PAHO).

Pernille, T. et al., (2012). Booklet 1: Understanding children’s wellbeing. Retrieved from https://resourcecentre.savethechildren.net/node/7101/pdf/6004_0.pdf

Shultz, J. M., & Forbes, D. (2014). Psychological first aid: Rapid proliferation and the search for evidence. Disaster Health, 2(1), 3-12.

World Health Organization. (2011). War Trauma Foundation and World Vision International. Psychological first aid: Guide for field workers. WHO.