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Vladan Novakovic
James D. Henneberry
Vivek Jain
Juan E. Mezzich


Introduction: The global challenge that the Covid-19 pandemic represented for humanity, included local experiences and encounters from which helpful lessons may be drawn.
Objectives: The primary objective was to assess and document death anxiety and death awareness among hospitalized intensive care unit (ICU) patients diagnosed with COVID-19 in a community-based teaching hospital. The secondary one was to reflect on mental health clinicians’ therapeutic styles and skills when caring for patients in critical care settings.
Methods: A series of hospitalized ICU patients diagnosed with COVID-19 at the height of the pandemic in New York City were evaluated in this study. Patients’ psychological distress symptoms, death awareness, and death anxiety were measured using the Revised Death Anxiety Scale. Seventeen COVID-19 positive patients with various comorbidities who had been admitted to the ICU at Staten Island University Hospital were compared with seventeen COVID-19 negative patients with various comorbidities who had been seen and evaluated on the same ward over the same time period. The Revised Death Anxiety Scale (25 items) was used on all subjects by the deployed psychiatrists. The clinicians’ experiences as recorded through diaries during this time were examined and reflected on.
Results: Out of seventeen COVID-19 positive patients who participated in this case series, eleven responded with heigh death anxiety scores as compared to the seventeen COVID-19 negative patients in which only three subjects were observed to have high scores. From the very beginning, the COVID-19 pandemic brought to the forefront massive challenges for both psychiatrists and patients. These challenges immediately affected rapport-building, often leading to an atmosphere of trust, but also exposing patients to additional distress. Prior to furthering and facilitating therapeutic dialogue, psychiatrists had to “anesthetize the therapeutic situation,” decrease the arousal level and be attentive throughout the encounter. This attentiveness had to be individually organized and modulated as patients displayed different personality styles, with variations in their internal world and severity of medical condition. In due course, individual patterns of reactions were observed such as fantasies concerning isolation and separation, contrasting attachment styles, need for punishment and guilt feelings and activation of panic and helplessness. The latter was particularly challenging as both patient and physician could become easily trapped in feeling helpless and confused, with strong interpersonal and relational overlays. Compassionate gestures and sensibility in connectedness conveyed vitality and much needed hope.
Discussion and Conclusions: Although death anxiety and death awareness seemed overwhelmingly prevalent among the COVID-19 positive patients in comparison to COVID-19 negative patients, differences have been observed in terms of being age-specific, having multiple comorbidities compounding on COVID-19 positive status (e.g., obesity and COPD). In general, the acute psychological distress of patients improved with medical treatment and when stabilized they were moved out of the ICU. Patients with high scores who had a COVID-19 positive status tended to have increased stay in the ICU. Future studies should assess the long-term consequences of COVID-19 on patients’ general mental health and particularly death awareness and death anxiety. Additionally, health systems may use similar studies to understand the labor and costs borne by mental health clinicians as well as other clinicians working in such settings. In terms of medical education and liaison work, such research may inform training of clinicians in internal medicine, critical care, and mental health.

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