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Challenges of using body bags for COVID-19 deaths from the healthcare provider perspective – a qualitative study
  1. Mayumi Toyama1,
  2. Hiroko Mori1,2,
  3. Akira Kuriyama1,
  4. Makiko Sano1,3,
  5. Haruki Imura1,
  6. Mayumi Nishimura1,
  7. Takeo Nakayama1
  1. 1Department of Health Informatics, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan
  2. 2Section of Epidemiology, Shizuoka Graduate University of Public Health, Shizuoka, Japan
  3. 3Department of Nursing, School of Health Sciences, Bukkyo University, Kyoto, Japan
  1. Correspondence to Dr Mayumi Toyama; toyama.mayumi.7f{at}kyoto-u.ac.jp

Abstract

Background During the COVID-19 pandemic, numerous issues regarding end-of-life care for COVID-19 patients have been discussed. Among these issues, challenges related to the use of body bags following the death of COVID-19 patients have been suggested. This study aimed to identify the challenges faced by healthcare professionals (HCPs) when using body bags after the death of patients infected with COVID-19 in medical settings.

Methods We conducted a qualitative descriptive study with semistructured in-depth interviews using inductive thematic analysis. From August to December 2021, we interviewed nurses and doctors who provided end-of-life care to COVID-19 patients focusing on their experiences with the use of body bags for the deceased.

Results Of the 25 interviewees who mentioned body bag use, 14 were nurses (56%) and 13 were women (52%). The mean interview length was 52.0 min (SD 9.6 min). Challenges associated with body bag use were classified into four themes with eight categories: preserving the dignity of the deceased, consideration for the bereaved saying a final goodbye to a loved one in a body bag, the physical and emotional impact on HCPs, and diverse opinions on body bag use.

Conclusion Our findings include ethical concerns about the dignity of the deceased, empathy for the grief of bereaved families, and the emotional and physical distress experienced by HCPs struggling with the recommendation to use body bags based on limited evidence. The diverse perspectives of HCPs in this study highlight potential issues that developers should consider when formulating more appropriate and acceptable guidelines/guidance and policies.

  • COVID-19
  • Critical care
  • Health policy
  • Qualitative research

Data availability statement

No data are available. To ensure privacy of interviewees, no data are available.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjoq-2023-002548

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • During the COVID-19 pandemic, the dignity and rights of the dead and their families were neglected, respectively.

    • The use of body bags caused distress among the bereaved, but healthcare professionals’ (HCPs) experiences of using body bags for COVID-19 deaths have not been adequately examined.

    • In formulating policy during the pandemic, policy-makers selected only expert advisors and overlooked those with expertise rooted in lived experience.

    WHAT THIS STUDY ADDS

    • We identified the challenges associated with the use of body bags for deceased COVID-19 patients in medical settings from the perspective of HCPs.

    • HCPs involved in the end-of-life care of COVID-19 patients reveal ethical concerns about the dignity of the deceased, empathy for grieving families, and the emotional and physical distress of struggling with the use of body bags based on limited evidence.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • This study will provide further insights into the use of body bags for COVID-19 patients, aiding guideline developers and policymakers in creating more appropriate and acceptable guidelines or policies.

    Introduction

    During the COVID-19 pandemic, many difficulties arose not only concerning patients and their families but also for healthcare professionals (HCPs) and facilities in providing end-of-life care for COVID-19 patients.1–6 Infectious disease control measures led to visiting restrictions that caused separation between patients and families7–12 limited care by HCPs,12–14 communication difficulties between patients, their families and HCPs,11 12 15 16 and patient isolation.17–19 It has been suggested that the high workload for HCPs affected the quality of end-of-life care, prioritising urgent physical care over emotional, social and spiritual aspects.12

    The management of bodies after COVID-19 deaths also emerged as a significant social issue during the pandemic. Among these issues, challenges related to the use of body bags following the death of COVID-19 patients have been suggested. In Japan, the media reported that bereaved families could not say their final goodbyes to COVID-19 patients or see the faces of the deceased in person, with some reports highlighting families’ inability to view the faces of loved ones placed in body bags. Some studies suggest that the use of body bags caused distress to families who saw their loved ones in body bags.20

    There was a wide variety of guidelines and guidance regarding the management of bodies from COVID-19 deaths. While some guidelines allowed families to see their deceased loved ones without limitations, others required all possible precautions to be taken.21 The WHO guideline of March 202022 stated, ‘Body bags are not necessary, although they may be used for other reasons (eg, excessive body fluid leakage)’, and the guideline of September 202023 updated, ‘Do not use body bags, unless they are recommended by standard mortuary practice’, such as ‘when there is excessive fluid leakage’ or ‘for postautopsy procedures’. In contrast, Japan’s guidelines of July 2020 ‘recommended’ body bag use for all COVID-19 deaths until January 2023.24 25 Concerning this diversity in the content of guidelines and guidance, Yaacoub et al indicated that although many guidelines suggest specific strategies for managing corpses, no studies have provided direct evidence supporting the adoption of these strategies.26 Despite the limited evidence regarding the use of body bags for COVID-19 patients, a significant negative impact of their use can be inferred. However, the challenges associated with using body bags in medical settings during the COVID-19 pandemic seem to have been largely overlooked.

    This study aims to identify the experiences and challenges of HCPs when using body bags for deceased COVID-19 patients in hospitals during the pandemic. Based on our findings, we propose considerations that should be incorporated into the updating of guidelines/guidance for the management of deceased COVID-19 patients in medical settings.

    Methods

    Study design

    We conducted a qualitative descriptive study using in-depth, semistructured interviews with inductive thematic analysis that focused on the experiences of HCPs who used body bags while COVID-19 patients.27–29 The design was appropriate for describing the informants’ experiences in a language similar to their own.30 This study is a part of a comprehensive research project exploring HCPs’ experiences of COVID-19 patients, which is termed the PRECA-C (Providing end-of-life care for COVID-19) study.18 This study was reported in accordance with the consolidated criteria for reporting qualitative research reporting guidelines.31 32 In addition, we verified trustworthiness in our qualitative research by employing four rigour criteria: credibility, transferability, dependability and confirmability.28 33–36 To increase the credibility, three researchers cross-referenced preliminary findings with archived raw data (referential adequacy), and the inquiry process underwent external scrutiny through peer debriefing. To ensure data transferability, we conducted purposive sampling for thick descriptions. All interviews were recorded, field notes were taken both during and after the interviews, and an audit was also conducted during data analysis to ensure dependability. For confirmability, the validity of data interpretation was discussed with the research team to triangulate the results (online supplemental appendix 1. The trustworthiness of qualitative research and strategies applied in our study).

    Supplemental material

    Setting/sampling

    From August to December 2021, we recruited nurses and doctors who had provided end-of-life care to COVID-19 patients in intensive care units, COVID-19-specialised wards or general wards for all regions in Japan.

    We performed maximum variation sampling (a type of purposive sampling), which samples for heterogeneity.37 First, with the cooperation of a network of researchers at Kyoto University School of Public Health, we sent emails to the members to invite them to participate in this survey. Subsequently, three gatekeepers of the members introduced their clinical colleagues, considering their circumstances and burdens. We approached potential participants through these gatekeepers to ensure diversity in terms of age, gender, region and hospital size by purposive sampling strategies.

    HCPs with psychiatric symptoms such as depression or those who might feel distressed when recalling their experiences were excluded. Candidates received an email with detailed descriptions of the study. They were asked to read the study description, including an agreement on video and/or audio recording, and to provide consent electronically if willing to participate.

    Data collection

    Before beginning the PRECA-C study,18 we conducted a pilot study with two infectious disease physicians. An interview guide that included key questions such as, ‘What kind of end-of-life care did you provide to dying COVID-19 patients and their families?’ and ‘How did you feel as a medical professional after experiencing the end-of-life care of coronavirus patients?’ was developed through a pilot study (online supplemental appendix 2. Interview guide). At that point, we had not noticed HCPs’ concerns associated with the use of body bags for COVID-19 deaths. Three researchers (MT, female, a medical doctor; MN, female, an occupational therapist; and MS, female, a nurse) conducted personal, closed, semistructured interviews in Japanese using a videoconferencing system. These interviewers had received training from an experienced researcher (HM, female, an academic researcher). After primary study started and conducted 10 interviews, we noticed that the participants had strong concerns about the use of body bags. To better understand how HCPs felt about body bags, all participants, except those who had voluntarily talked about body bags, were asked a neutral probing question such as ‘What do you think about body bag use?’. Thirty of the 33 participants had not met the interviewers before the study.

    Supplemental material

    Data analysis

    We used inductive thematic analysis because it is suitable for problem identification and hypothesis generation.38 The following steps were taken to analyse the data. First, the researchers familiarised themselves with the transcribed data through multiple readings. Subsequently, two independent researchers (MT and HM) inductively coded the data transcribed from the recorded interviews using thematic analysis.28 MT and HM created a codebook independently and referenced to each other. They combined similar codes and generated categories and themes through multiple discussions until consensus was reached. MN reviewed the transcripts to ensure that no new codes could be identified. The analysis was conducted during sampling and interviewing. Once no new codes were generated, three more interviews were conducted to confirm that no new codes emerged, and data saturation was confirmed.39 To triangulate the results, the validity of data interpretation, categorisation and labelling was discussed with the research team, including two clinicians who treated COVID-19 patients. Then, the results of the final analysis were derived. After conducting the analysis in Japanese, we asked a specialised company to translate the code book into English. The authors further back-translated the English version and repeatedly discussed the precision of the translation. To avoid further burden on participants in the midst of the pandemic, we decided not to return the transcripts to them for member checking and not to provide feedback on the findings. The data were analysed by using NVivo V.12 (QSR International).

    Results

    Of the 37 persons recruited for the PRECA-C study, 1 withdrew due to scheduling conflicts, and 3 others did not reply to our email within the recruitment period. In total, 33 interviews were conducted, and 25 respondents mentioned body bags (table 1). Fourteen participants (56%) were nurses, 13 (52%) were women and 20 (80%) were ≥30 years of age. The mean interview length was 52.0 min (SD 9.6 min), and one person was interviewed twice due to a restricted time schedule. The characteristics of eight persons who did not mention body bags are as follows: five were doctors (63%), six were men (75%) and six were ≥30 years of age.

    View this table:
    Table 1

    Characteristics of the participants and their hospitals

    The challenges associated with the use of body bags for deceased COVID-19 patients were classified into the following four themes, which in turn spanned eight categories: preserving the dignity of the deceased, consideration for the bereaved saying a final goodbye to a loved one in a body bag, physical and emotional impact on HCPs, and diverse opinions on body bag use (table 2).

    View this table:
    Table 2

    Themes and categories, with illustrative quotations

    Theme: preserving the dignity of the deceased

    The interviewed HCPs expressed strong concerns that the use of body bags violated the dignity of those who had died of COVID-19. In particular, they were uncomfortable with the body bag specifications.

    Discomfort with body bag specifications

    HCPs felt that the colour, shape and material of the body bags were similar to those of garbage bags. The bags were made of vinyl, and their colours were black, white or transparent. Black body bags were particularly unpopular: ‘It didn’t even look like a person was inside’ (20s, female, nurse). Transparency was important since it allowed recognition of the patient’s face and body: ‘It was transparent, so we could see the face to some extent, or maybe we could identify the patient from their shape’ (40s, female, nurse). If the body bag zipper was directly above the face of the deceased, some HCPs attempted to improve this situation: ‘We pushed the zipper aside so that it wouldn’t strike the patient’s face and the face could be seen’ (40s, female, nurse).

    Abbreviated death care

    One HCP described placing the deceased in a body bag with only abbreviated death care as ‘treating the dead body like garbage’ (20s, male, nurse). Even under such situations, several HCPs noted that they were attentive to the body’s condition even after it had been placed in the body bag.

    Theme: consideration for the bereaved saying a final goodbye to a loved one in a body bag

    Empathy toward family distress at seeing a loved one in a body bag

    The HCPs were concerned about the psychological impact on families of seeing the patient in a body bag at the first visit after death: ‘The viewing could only be done through a body bag. I just wondered if there wasn’t a better way to do this’ (20s, female, nurse). Several family members stated that they felt awkward saying goodbye to someone in a body bag. In most hospitals, family visits were restricted or prohibited even at the end of the patient’s life. HCPs struggled to create opportunities for families to say their final goodbyes after a COVID-19 patient’s death. In some cases, the hospital sent their bodies directly to funeral homes in body bags without giving families an opportunity to see the patient after death.

    Importance of family having one last look at their deceased loved one

    One HCP noted that some families were happy just to see the patient, even for a moment and even in a body bag, because early in the pandemic, some media outlets had reported that visitations were forbidden even after death.

    Theme: physical and emotional impact on HCPs

    Some HCPs handled body bags for the first time in their careers. It was not only unnerving to see body bags, but handling them also entailed a substantial physical burden.

    Burden of using body bags

    The use of body bags added to HCPs’ physical burden. Placing a deceased patient into a body bag was a painstaking process. The scarcity of available staff forced nurses to place the deceased into body bags without any assistance: ‘Every time we had to place a dead body into a bag, it was very tough. If something similar happens in the future…I think it will be just as painful’ (40s, female, nurse). Occasionally, HCPs asked for assistance from other departments, but doing so also brought an emotional burden: ‘We had to ask for help to place bodies in body bags. Four or five people could handle it. At our hospital, medical clerks don’t encounter death or dying people. So asking them to help with this kind of work, well, we felt very bad’ (50s, female, nurse).

    Shock of seeing a body bag

    HCPs were stunned to see body bags for the first time and shocked at the need to place their patient in them. They were strongly discomforted by the mere sight of a body in a bag. Others expressed psychological reluctance, emotional pain and remorse: ‘It was the first time that we had to place dead people into body bags, and we were very resistant’ (50s, female, nurse).

    Theme: diverse opinions on body bag use

    Interviewees expressed a range of opinions on the need for body bags and the criteria needed for adaptation.

    Necessity of body bags

    Some HCPs were sceptical about the need for body bags. They believed that droplet infection from a dead body was theoretically unlikely: ‘The dead are not going to cough or sneeze, so no aerosols will be generated’ (40s, male, doctor). Others feared that the potential for COVID-19 transmission via contact with the corpse was undeniable: ‘There may still be a risk of infection’ (30s, male, doctor).

    Criteria for body bag use

    One HCP mentioned that body bags had been used in deaths that were not directly due to COVID-19. Having once been diagnosed with COVID-19 meant that even if the patient died from post-COVID-19 complications rather than an active infection, the current guidelines/guidance dictated body bag use: ‘A number of patients were placed in body bags even though they were no longer actively infected with COVID-19’ (30s, male, nurse).

    Discussion

    We interviewed HCPs who provided end-of-life care to COVID-19 patients in Japanese hospitals. Most of them expressed concerns that using body bags for patients who had died of COVID-19 compromised patients’ dignity. They also empathised with family distress at seeing a loved one in a body bag. HCPs who had never used body bags experienced a considerable emotional and physical burden. Some questioned the necessity of using body bags for a COVID-19 death or the presence of valid evidence.

    Challenges of body bag use for COVID-19 patients

    The interviews revealed concerns about disregarding the dignity of the dead, such as the perceived resemblance of body bags to garbage bags. The HCPs spoke out against the black/vinyl material and how faces were covered, arguing these shrouds were inappropriate for the deceased. The study participants repeatedly stressed how important it was for families to see the faces of the deceased and mentioned how seeing their loved ones in body bags pained the bereaved families.

    In addition to prioritising the safety of HCPs and all interested parties, corpse management must respect the dignity of the dead and their loved ones throughout death care as part of the continuum of medical care.40 To support the grieving process, bereaved family members should be allowed to spend as much time as possible with the deceased.41 42 However, similar to a previous study,20 the bereaved families were distressed by seeing their loved ones in body bags. By creating more ethically and culturally conscious body bags, including the choice of colour, shape and material, the emotional burden of all concerned would be reduced. If conventional body bags must be used, measures to ease the impact on bereaved families’ emotions at the very least must be considered. It is worth considering allowing families to visit the deceased before they are placed in a body bag by having families take standard precautions against infection, such as the use of personal protective equipment. There was variation in hospital policies concerning visits to COVID-19 patients before and after their death.18 It is essential to explore ethically and socially appropriate approaches in each situation and setting.

    Objectives of body bag use in COVID-19 patients

    Most HCPs in our study used body bags for the first time during this pandemic. While they followed Japan’s governmental guidelines and local government directives regarding the use of body bags,24 some participants remained sceptical about the necessity of body bags.

    Body bags are generally used during disasters.43 In such situations, many unidentified deceased patients require care, and their bodies may be damaged or bodily fluids may leak. Body bags play a vital role in ensuring an appropriate widespread response in rapid discovery, collection, transportation, housing, documentation, testing, identification and release to families of the deceased.42 However, the functions of body bags during a disaster differ from those after an individual COVID-19 death in a hospital. In most cases, patients were identified, their families were contacted, and the patient had died in a hospital bed after receiving medical care. During cluster outbreaks, some hospitals were compelled to temporarily store multiple bodies in hospital rooms. Even so, the primary purpose of using body bags for COVID-19 fatalities was to prevent transmission through contact with the deceased. The specifications for body bags, designed to facilitate the collection and transfer of many bodies during a disaster, are typically not necessary for managing COVID-19 fatalities in hospital. In the early phase of the current pandemic, the media reported a shortage of body bags.44 By proposing a simplified body bag designed to meet the specific demands of the situation, we could avert such shortages in the future. Furthermore, the need for body bags in the medical settings should be evaluated early. During the initial stages of the pandemic when sufficient evidence is lacking, infection control measures were a crucial priority. However, guidelines and guidance should be updated promptly to reflect a comprehensive perspective.

    Who are the stakeholders in corpse management?

    The HCPs in this study raised fundamental yet crucial concerns regarding the utilisation of body bags in medical environments, including a valuable perspective from the family’s point of view derived from observing families.

    In formulating policy during the pandemic, policymakers selected only expert advisors and overlooked those with expertise rooted in lived experience.45 Interventions outlined in the guidelines/guidance must be feasible and acceptable in the field.46 Furthermore, stakeholder engagement is a crucial element in the formulation and implementation of guidelines.47 In addition to families, communities and funeral homes, HCPs should be recognised as key stakeholders. Previous studies have emphasised the extreme stress and challenges faced by HCPs treating COVID-19 patients during the pandemic.48–51 The additional burden of end-of-life care for patients could be one of the factors pushing the healthcare system toward collapse.

    Our findings include ethical concerns about the dignity of the deceased, empathy for the grief of bereaved families, and the emotional and physical distress experienced by HCPs struggling with the recommendation to use body bags based on limited evidence. Some of these were identified in previous disasters and pandemics.40 42 Additionally, we discovered challenges specific to the COVID-19 pandemic, such as how body bag use, with recommendations based on limited evidence, might add to the emotional and physical distress of already overburdened HCPs.

    To prepare for future pandemics, we must institute planning that incorporates corpse management and considers related ethical aspects.52 During the beginning stages of the approach, guideline/guidance developers must listen to stakeholders and address their diverse views to identify potential issues in each country/region/community, aiming to create better guidelines/guidance. This study will provide further insight into the use of body bags for COVID-19 patients and encourage guideline/guidance developers or policymakers to consider the perspectives of each individual affected by their use.

    Limitations

    Since this study was conducted in Japan, country-specific factors, such as the local COVID-19 pandemic status at the time of the interviews, Japan’s medical system and cultural profile, may have impacted our findings. As backgrounds differ by nation, region and community, perceptions of body bags may vary as well. In this study, doctors and nurses who used body bags following the deaths of COVID-19 patients were interviewed. Family members, other hospital staff or funeral home staff may be able to provide further insight into additional issues associated with the use of body bags.

    Conclusion

    Appropriate and acceptable corpse management calls for a heightened level of consciousness to maintain the dignity of the deceased while mitigating the adverse impact of body bag use on both bereaved families and HCPs. In the event of a future pandemic, it would be essential to promptly revise the guidelines or guidance related to corpse management considering the gradually accumulated evidence and the comprehensive needs of stakeholders.

    Data availability statement

    No data are available. To ensure privacy of interviewees, no data are available.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and the Ethics Committee of Kyoto University approved this study (IRB No. R3027). Participants gave informed consent to participate in the study before taking part.

    References

    1. ↵
      1. Mitchell S,
      2. Maynard V,
      3. Lyons V, et al
      . The role and response of primary healthcare services in the delivery of palliative care in epidemics and pandemics: a rapid review to inform practice and service delivery during the COVID-19 pandemic. Palliat Med 2020;34:1182–92. doi:10.1177/0269216320947623
      OpenUrlCrossRefPubMed
    2. ↵
      1. Gesell D,
      2. Lehmann E,
      3. Gauder S, et al
      . National and international non-therapeutic recommendations for adult palliative and end-of-life care in times of pandemics: a scoping review. Palliat Support Care 2022;20:854–66. doi:10.1017/S1478951521001772
      OpenUrl
    3. ↵
      1. Connolly M,
      2. Bell M,
      3. Lawler F, et al
      . Hospital-based palliative and end-of-life care in the COVID-19 pandemic: a scoping review. Am J Hosp Palliat Care 2022;39:1105–20. doi:10.1177/10499091211057049
      OpenUrl
    4. ↵
      1. Hanna JR,
      2. Rapa E,
      3. Dalton LJ, et al
      . A qualitative study of bereaved relatives' end of life experiences during the COVID-19 pandemic. Palliat Med 2021;35:843–51. doi:10.1177/02692163211004210
      OpenUrlCrossRefPubMed
    5. ↵
      1. Roulston A,
      2. Ross J,
      3. Dobrikova P, et al
      . The impact of COVID-19 on palliative care social work: an online survey by a European Association of palliative care task force. Palliat Med 2023;37:884–92. doi:10.1177/02692163231167938
      OpenUrl
    6. ↵
      1. Harrop E,
      2. Goss S,
      3. Farnell D, et al
      . Support needs and barriers to accessing support: baseline results of a mixed-methods national survey of people bereaved during the COVID-19 pandemic. Palliat Med 2021;35:1985–97. doi:10.1177/02692163211043372
      OpenUrl
    7. ↵
      1. Ersek M,
      2. Smith D,
      3. Griffin H, et al
      . End-of-life care in the time of COVID-19: communication matters more than ever. J Pain Symptom Manage 2021;62:213–22. doi:10.1016/j.jpainsymman.2020.12.024
      OpenUrl
    8. ↵
      1. Agorastos A,
      2. Tsamakis K,
      3. Solmi M, et al
      . The need for holistic, longitudinal and comparable, real-time assessment of the emotional, behavioral and societal impact of the COVID-19 pandemic across nations. Psychiatriki 2021;32:15–8. doi:10.22365/jpsych.2021.010
      OpenUrl
    9. ↵
      1. Rose L,
      2. Yu L,
      3. Casey J, et al
      . Communication and virtual visiting for families of patients in intensive care during the COVID-19 pandemic: a UK national survey. Ann Am Thorac Soc 2021;18:1685–92. doi:10.1513/AnnalsATS.202012-1500OC
      OpenUrlPubMed
    10. ↵
      1. Hanna JR,
      2. Rapa E,
      3. Dalton LJ, et al
      . Health and social care professionals' experiences of providing end of life care during the COVID-19 pandemic: a qualitative study. Palliat Med 2021;35:1249–57. doi:10.1177/02692163211017808
      OpenUrlCrossRefPubMed
    11. ↵
      1. Feder S,
      2. Smith D,
      3. Griffin H, et al
      . Why couldn't I go in to see him?’ bereaved families' perceptions of end-of-life communication during COVID-19. J Am Geriatr Soc 2021;69:587–92. doi:10.1111/jgs.16993
      OpenUrlPubMed
    12. ↵
      1. Zee MS,
      2. Bagchus L,
      3. Becqué YN, et al
      . Impact of COVID-19 on care at the end of life during the first months of the pandemic from the perspective of healthcare professionals from different settings: a qualitative interview study (the CO-LIVE study). BMJ Open 2023;13:e063267. doi:10.1136/bmjopen-2022-063267
    13. ↵
      1. Mitchinson L,
      2. Dowrick A,
      3. Buck C, et al
      . Missing the human connection: a rapid appraisal of healthcare workers' perceptions and experiences of providing palliative care during the COVID-19 pandemic. Palliat Med 2021;35:852–61. doi:10.1177/02692163211004228
      OpenUrlPubMed
    14. ↵
      1. Wernly B,
      2. Rezar R,
      3. Flaatten H, et al
      . Variations in end-of-life care practices in older critically ill patients with COVID-19 in Europe. J Intern Med 2022;292:438–49. doi:10.1111/joim.13492
      OpenUrl
    15. ↵
      1. Ferreira EAL,
      2. Valete COS,
      3. Santos AFJ dos, et al
      . Health care professionals and end-of-life care during the COVID-19 pandemic. Rev Assoc Med Bras 1992;67:1261–7. doi:10.1590/1806-9282.20210417
      OpenUrl
    16. ↵
      1. Galazzi A,
      2. Binda F,
      3. Gambazza S, et al
      . The end of life of patients with COVID-19 in intensive care unit and the stress level on their family members: a cross-sectional study. Nurs Crit Care 2023;28:133–40. doi:10.1111/nicc.12783
      OpenUrl
    17. ↵
      1. Hamid W,
      2. Jahangir MS
      . Dying, death and mourning amid COVID-19 pandemic in Kashmir: a qualitative study. Omega (Westport) 2022;85:690–715. doi:10.1177/0030222820953708
      OpenUrl
    18. ↵
      1. Nishimura M,
      2. Toyama M,
      3. Mori H, et al
      . Providing end-of-life care for patients dying of COVID-19 and their families in isolated death during the pandemic in Japan: the providing end-of-life care for COVID-19 project. Chest 2023;163:383–95. doi:10.1016/j.chest.2022.10.009
      OpenUrl
    19. ↵
      1. Wynne KJ,
      2. Petrova M,
      3. Coghlan R
      . Dying individuals and suffering populations: applying a population-level bioethics lens to palliative care in humanitarian contexts: before, during and after the COVID-19 pandemic. J Med Ethics 2020;46:514–25. doi:10.1136/medethics-2019-105943
      OpenUrlAbstract/FREE Full Text
    20. ↵
      1. Testoni I,
      2. Azzola C,
      3. Tribbia N, et al
      . The COVID-19 disappeared: from traumatic to ambiguous loss and the role of the Internet for the bereaved in Italy. Front Psychiatry 2021;12. doi:10.3389/fpsyt.2021.620583
    21. ↵
      1. Dijkhuizen LGM,
      2. Gelderman HT,
      3. Duijst W
      . Review: the safe handling of a corpse (suspected) with COVID-19. J Forensic Leg Med 2020;73. doi:10.1016/j.jflm.2020.101999
    22. ↵
      1. World Health Organization (WHO)
      . Infection prevention and control for the safe management of a dead body in the context of COVID-19: interim guidance. 2020. Available: https://apps.who.int/iris/handle/10665/331538
    23. ↵
      1. World Health Organization
      . Contact tracing in the context of COVID-19. interim guidance. Pediatr Med Rodz 2020;16:33–9. doi:10.15557/PiMR.2020.0005
      OpenUrl
    24. ↵
      1. Japan Ministry of health labour and welfare and Ministry of economy trade and industry
      . Guidelines for the handling, transportation, funerals, and Cremation of individuals who have passed away or are suspected of having COVID-19 Ver 1. 2020. Available: https://www.mhlw.go.jp/content/000653447.pdf
    25. ↵
      1. Japan Ministry of health labour and welfare and Ministry of economy trade and industry
      . Guidelines for the handling, transportation, funerals, and Cremation of individuals who have passed away or are suspected of having COVID-19 Ver 2. 2023. Available: https://www.mhlw.go.jp/content/001033541.pdf
    26. ↵
      1. Yaacoub S,
      2. Schünemann HJ,
      3. Khabsa J, et al
      . Safe management of bodies of deceased persons with suspected or confirmed COVID-19: a rapid systematic review. BMJ Glob Health 2020;5:e002650. doi:10.1136/bmjgh-2020-002650
    27. ↵
      1. Sandelowski M
      . Whatever happened to qualitative description Res Nurs Health 2000;23:334–40. doi:10.1002/1098-240x(200008)23:4<334::aid-nur9>3.0.co;2-g
      OpenUrlCrossRefPubMedWeb of Science
    28. ↵
      1. Nowell LS, et al
      . Thematic analysis: striving to meet the trustworthiness criteria. Int J Qual Methods 2017;16.
    29. ↵
      1. Vaismoradi M,
      2. Turunen H,
      3. Bondas T
      . Content analysis and thematic analysis: implications for conducting a qualitative descriptive study. Nurs Health Sci 2013;15:398–405. doi:10.1111/nhs.12048
      OpenUrlCrossRefPubMed
    30. ↵
      1. Neergaard MA,
      2. Olesen F,
      3. Andersen RS, et al
      . Qualitative description - the poor cousin of health research BMC Med Res Methodol 2009;9:52. doi:10.1186/1471-2288-9-52
    31. ↵
      1. Tong A,
      2. Sainsbury P,
      3. Craig J
      . Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007;19:349–57. doi:10.1093/intqhc/mzm042
      OpenUrlCrossRefPubMedWeb of Science
    32. ↵
      1. EQUATOR Network
      . Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups, Available: https://www.equator-network.org/
    33. ↵
      1. Guba EG
      . Criteria for assessing the trustworthiness of naturalistic inquiries. Educ Technol Res Dev 1981;29:75–91.
      OpenUrl
    34. ↵
      1. Lincoln Y, S.a.G., E. G
      . Chap.11 establishing trustworthiness in naturalistic inquiry. Sage Publications, 1985: 289–331.
    35. ↵
      1. Tuckett AG
      . Part II. rigour in qualitative research: complexities and solutions. Nurse Researcher 2005;13:29–42. doi:10.7748/nr2005.07.13.1.29.c5998
      OpenUrlCrossRefPubMed
    36. ↵
      1. Forero R,
      2. Nahidi S,
      3. De Costa J, et al
      . Application of four-dimension criteria to assess rigour of qualitative research in emergency medicine. BMC Health Serv Res 2018;18:120. doi:10.1186/s12913-018-2915-2
    37. ↵
      1. Creswell JWC a. JD
      . Research Design: Qualitative, Quantitative, and Mixed Methods Approaches6th edition ed. 2020: SAGE Publications, Inc,
    38. ↵
      1. Braun V,
      2. Clarke V
      . Using thematic analysis in psychology. Qualitative Research in Psychology 2006;3:77–101. doi:10.1191/1478088706qp063oa
      OpenUrlCrossRef
    39. ↵
      1. Morse JM
      . Qualitative health research: creating a new discipline. Abingdon, Oxon: Routledge, 2016. doi:10.4324/9781315421650
    40. ↵
      1. ICRC,International Federation of Red Cross and Red Crescent Societies (IFRC)
      2. World Health Organization (WHO)
      . COVID-19 – general guidance for the management of the dead in humanitarian settings. 2020. Available: https://missingpersons.icrc.org/library/covid-19-interim-guidance-management-dead-humanitarian-settings
    41. ↵
      1. Selman LE,
      2. Chao D,
      3. Sowden R, et al
      . Bereavement support on the frontline of COVID-19: recommendations for hospital clinicians. J Pain Symptom Manage 2020;60:e81–6. doi:10.1016/j.jpainsymman.2020.04.024
      OpenUrlPubMed
    42. ↵
      1. International Committee of the Red Cross (ICRC)
      . Management of dead bodies after disasters: A field manual for first responders. 2006. Available: https://www.icrc.org/en/publication/0880-management-dead-bodies-after-disasters-field-manual-first-responders
    43. ↵
      1. Loomis PW
      . Disaster victim identification. Forensic Odontology: Principles and Practice 2018:81–102.
    44. ↵
      1. British Broadcasting Corporation (BBC)
      . Coronavirus: body-bag stocks 'in danger of running out. 2020. Available: https://www.bbc.com/news/health-52205655
    45. ↵
      1. Richards T,
      2. Scowcroft H
      . Patient and public involvement in COVID-19 policy making. BMJ 2020;370. doi:10.1136/bmj.m2575
    46. ↵
      1. National Cancer Institute
      . Qualitative methods in implementation science. 2020. Available: https://cancercontrol.cancer.gov/sites/default/files/2020-09/nci-dccps-implementationscience-whitepaper.pdf
    47. ↵
      1. Petkovic J,
      2. Riddle A,
      3. Akl EA, et al
      . Protocol for the development of guidance for stakeholder engagement in health and healthcare guideline development and implementation. Syst Rev 2020;9:21. doi:10.1186/s13643-020-1272-5
      OpenUrlPubMed
    48. ↵
      1. Liu Q,
      2. Luo D,
      3. Haase JE, et al
      . The experiences of health-care providers during the COVID-19 crisis in China: a qualitative study. Lancet Glob Health 2020;8:e790–8. doi:10.1016/S2214-109X(20)30204-7
      OpenUrl
    49. ↵
      1. Eftekhar Ardebili M,
      2. Naserbakht M,
      3. Bernstein C, et al
      . Healthcare providers experience of working during the COVID-19 pandemic: a qualitative study. Am J Infect Control 2021;49:547–54. doi:10.1016/j.ajic.2020.10.001
      OpenUrlCrossRefPubMed
    50. ↵
      1. Kuriyama A,
      2. Sakuraya M,
      3. Kinjo M, et al
      . Burnout and turnover intention in critical care professionals during the COVID-19 pandemic in Japan: a cross-sectional survey. Ann Am Thorac Soc 2023;20:262–8. doi:10.1513/AnnalsATS.202201-029OC
      OpenUrl
    51. ↵
      1. Kuriyama A,
      2. Shikino K,
      3. Moriya M, et al
      . Burnout, depression, anxiety, and insomnia of internists and primary care physicians during the COVID-19 pandemic in Japan: a cross-sectional survey. Asian J Psychiatr 2022;68:102956. doi:10.1016/j.ajp.2021.102956
      OpenUrlPubMed
    52. ↵
      1. Wahidie D,
      2. Altinok K,
      3. Yılmaz-Aslan Y, et al
      . Strategies, guidelines and recommendations for coping with the COVID-19 pandemic in palliative and Hospice care facilities. results of a Scoping review. Z Gerontol Geriatr 2022;55:151–6. doi:10.1007/s00391-022-02016-8
      OpenUrl

    Supplementary materials

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    Footnotes

    • Contributors MT, MN, AK, MS and HI performed data collection. MT and HM coded the data. All authors contributed to the data analysis and article writing. All authors are responsible for the overall content as guarantors. The lead author, MT, and last author, TN, had full access to all of the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis.

    • Funding This study was funded by the Kyoto University research grant [no award/grant number], the Data-oriented Area Studies Unit (DASU) Research Units for Exploring Future Horizons Phase II [no award/grant number], and Kyoto University Research Coordination Alliance [no award/grant number].

    • Competing interests All authors completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.