Psychological Trauma: Theory,

Research, Practice, and Policy

Psychological Support During COVID-19 Death
Notifications: Clinical Experiences From a Hospital in
Mexico
Edgar Landa-Ramírez, Nadia A. Domínguez-Vieyra, Myriam E. Hernández-Nuñez, Lesly P. Díaz-
Vásquez, and Iveth A. Santana-García
Online First Publication, June 18, 2020. http://dx.doi.org/10.1037/tra0000679

CITATION
Landa-Ramírez, E., Domínguez-Vieyra, N. A., Hernández-Nuñez, M. E., Díaz-Vásquez, L. P., &
Santana-García, I. A. (2020, June 18). Psychological Support During COVID-19 Death Notifications:
Clinical Experiences From a Hospital in Mexico. Psychological Trauma: Theory, Research,
Practice, and Policy. Advance online publication. http://dx.doi.org/10.1037/tra0000679
 Psychological Trauma:
Theory, Research, Practice, and Policy
© 2020 American Psychological Association 2020, Vol. 2, No. 999, 000
ISSN: 1942-9681 http://dx.doi.org/10.1037/tra0000679

Psychological Support During COVID-19 Death Notifications: Clinical

Experiences From a Hospital in Mexico

Edgar Landa-Ramírez Nadia A. Domínguez-Vieyra and

Hospital General Dr. Manuel Gea González, Mexico City, Myriam E. Hernández-Nuñez
Mexico, and National Autonomous University of Mexico National Autonomous University of Mexico and Hospital
General Dr. Manuel Gea González, Mexico City, Mexico
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Lesly P. Díaz-Vásquez Iveth A. Santana-García

This document is copyrighted by the American Psychological Association or one of its allied publishers.

National University of San Marcos and Hospital General Dr. National Autonomous University of Mexico and Hospital
Manuel Gea González , Mexico City, Mexico General Dr. Manuel Gea González, Mexico City, Mexico

It is estimated that more than 300,000 people have died because of COVID-19 globally. The vast
majority of documented deaths have occurred within hospitals, leading to psychological impacts on both
family members and health care workers. This paper describes the actions (online death notification
education, remote crisis intervention, and support for health care professionals) taken at a hospital in
Mexico to address the psychological impacts of the notification of a COVID-19 –related death on both
the deceased’s relatives and the health care personnel involved.

Keywords: COVID-19, death notification, psychological support, Mexico

At the time of writing, May 20, 2020, it is estimated that
globally there have been more than 4 million cases of coronavirus
2019 (COVID-19) and 300,000 deaths caused by COVID-19 –
related complications (World Health Organization, 2020). In Mex-
ico, there have been more than 50,000 cases of COVID-19 and
6,000 deaths so far, and it is expected that both numbers will rise
sharply in the coming weeks because the country is currently in the
most acute phase of the pandemic (Secretaría de Salud [Ministry of
Health], 2020a).
Editor’s Note. This commentary received rapid review due to the time-
sensitive nature of the content. It was reviewed by the special section guest
editors and the journal Editor.—KKT
X Edgar Landa-Ramírez, Department of Emergency Psychology, Hos-
pital General Dr. Manuel Gea González, Mexico City, Mexico, and School
of Psychology, National Autonomous University of Mexico; X Nadia A.
Domínguez-Vieyra and X Myriam E. Hernández-Nuñez, School of Psy-
chology, National Autonomous University of Mexico, and Department of
Emergency Psychology, Hospital General Dr. Manuel Gea González;
X Lesly P. Díaz-Vásquez, School of Psychology, National University of
San Marcos, and Department of Emergency Psychology, Hospital General
Dr. Manuel Gea González; X Iveth A. Santana-García, School of Psy-
chology, National Autonomous University of Mexico, and Department of
Emergency Psychology, Hospital General Dr. Manuel Gea González.
Correspondence concerning this article should be addressed to Edgar
Landa-Ramírez, Department of Emergency Psychology, Hospital General
Dr. Manuel Gea González, Calz. de Tlalpan 4800, Belisario Domínguez
Secc 16, Tlalpan, 14080 Ciudad de México, CDMX. E-mail: edgar_
landa_ramirez@yahoo.com.mx
How Is the Pandemic Affecting the Mexican
Population From a Mental Health Perspective?
News of a loved one’s death can, by itself, cause great emotional
distress for the family member receiving the news (Fallowfield &
Jenkins, 2004). In the COVID-19 context, however, death notifi-
cations can be even more challenging given that, because of the
measures taken by several governments to avoid more infections,
family members do not receive this news face to face; they cannot
say good-bye to their loved one; and, furthermore, they cannot
carry out the funerary rituals specific to their cultural beliefs
(Ingravallo, 2020).
These conditions mean that, when hearing about the death of
their relatives, family members experience great emotional distress
and often become worried about the possibility of being infected
with COVID-19 (Wakam, Montgomery, Biesterveld, & Brown,
2020). Similarly, it has been reported that health care professionals
experience difficulty communicating a death notification, namely
because of the little formal training they have had to do so properly
(Shoenberger, Yeghiazarian, Rios, & Henderson, 2013); because
of the work overload when dealing with patients’ needs; and,
additionally, the limited guidance they have to address family
members’—and their own— emotional response, which can also
become a strenuous emotional burden (Ingravallo, 2020; Shoen-
berger et al., 2013; Wakam et al., 2020).
How Do People Respond to the Situation in Mexico?
In Mexico there are deep-rooted beliefs around burial and rites
that must be carried out when a loved one dies. For instance, it is
customary for loved ones to perform a 9-day praying cycle after
the burial. These beliefs come from a cultural syncretism between

1
 2 LANDA-RAMÍREZ ET AL.
pre-Hispanic indigenous customs and Catholic beliefs (Sulkes &
Wein, 2012). Given the current situation in the country, relatives
cannot access the hospital to say good-bye to their loved ones. The
Mexican government has encouraged people to cremate rather than
bury deceased COVID-19 patients, and attendances to funerary
rituals are restricted (Secretaría de Salud [Ministry of Health],
2020b). This context has generated great emotional distress among
the relatives of deceased patients.
How Is Health Care Currently Organized?
In Mexico, various efforts have been made to help preserve the
mental health of the general population as well as health care
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
professionals. Both public and private institutions have made ef-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
forts to provide information and free-of-charge psychiatric and
psychological remote therapy for different problems, like the psy-
chological impact of lockdown, domestic violence, and psycho-
logical burden on the frontline health care personnel. Despite the
effort, there seem to be few recommendations for health care
professionals providing death notifications within this context.
What Is Helpful and What Is Not Helpful in
Addressing the Situation?
Given this lack of guidance, the emergency psychology depart-
ment of a general hospital in Mexico City has implemented inten-
sive preparatory clinical actions that have been useful to support
the communication of COVID-19 death notifications. Below we
describe these actions.
Online Death Notification Education
An online course was created with the aim of training health
professionals in providing death notifications in the COVID-19
context. This course ensured that, if needed, health care profes-
sionals were able to use psychological first aid principles (World
Health Organization, 2011) to assess safety during serious distress
of relatives reacting to a death notification. The course also covers
listening to relatives and helping them cope with distress when
their loved ones die and, if required, referring family members to
psychological support specialized in crisis intervention. Nine steps
were adapted from two international protocols to communicate bad
news and death notifications. Both protocols have in common that
promote the privacy of the notification, identify the relative’s level
of knowledge before receiving the news, provide information
about the news in a clear way, promote respect for the emotional
response of the person receiving the news, and specify the proce-
dure to follow once the notification is completed (Baile et al.,
2000; Hobgood, Harward, Newton, & Davis, 2005). The course
lasts 2 hours and, in addition to providing theoretical information,
uses videos that behaviorally model the steps to follow for remote
death notifications. Role plays conducted by video or telephone
between medical staff and professional actors who play the role of
a family member receiving the bad news are also available (Sec-
retaría de Protección Civil [Civil Protection Ministry], 2020).
Remote Crisis Intervention
To carry out a remote crisis intervention, eight psychologists
from the emergency psychology department were trained to use
the following stages and skills by telephone: (a) connect with the
person; (b) focus the call; (c) relieve any emotional stress; (d)
promote coping strategies; and (e) decide on the next steps (Kitch-
ingman, Wilson, Caputi, Woodward, & Hunt, 2015). Similarly, the
principles of knowledge, competence, ethical standards, profes-
sional standards, security, confidentiality, and local legal regula-
tions recommended for telepsychology practice were followed
(Joint Task Force for the Development of Telepsychology Guide-
lines for Psychologists, 2013). Currently these psychologists are
providing both face-to-face and remote psychological support—
including crisis interventions because of death notification—to
relatives of hospitalized patients with COVID-19.
Support for Health Care Professionals
Recent research has documented that medical staff, as well as
frontline health care workers, may experience psychological bur-
den when they communicate death notifications (Lai et al., 2020;
Shoenberger et al., 2013; Wakam et al., 2020). In this hospital,
voluntary psychological online assessments have been introduced
to identify the emotional state of health care staff. In addition,
information and relaxation techniques for emotional regulation,
problem-solving techniques, stigma management, adjustment of
negative thoughts, social support, and teamwork have been shared
with health care professionals. Health care staff who want to
access individual interventions have the option to do so at a
hospital or remotely.
Finally, it is in the interest of the authors that this description
helps to showcase the importance of psychology concerning the
transmission of death notifications in the COVID-19 context.
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Received April 22, 2020
Revision received May 20, 2020
Accepted May 22, 2020 䡲