Highlights
- •COVID-19 nurses in intensive care witness patients suffering.
- •COVID-19 patients in intensive care have some messages they want to convey to their families and loved ones.
- •Patients diagnosed with COVID-19 in intensive care need the psychosocial care of psychiatric nurses.
- •In the study, the opportunity for patients to express their feelings and thoughts was provided through letters.
- •By doing this, the family can be included in the care and the social support mechanism can remain active, even with the restriction policy in place.
Abstract
Background
Nurses who provide patient care in COVID-19 intensive care have witnessed that patients experience problems such as fear of death, loneliness, helplessness, uncertainty, anxiety, etc.
Objective
In this study, it was aimed to examine the messages written by the patients who receive treatment in the COVID-19 Intensive Care Unit (ICU) through letters and their feelings and thoughts which they wanted to convey to their families.
Method
This study employed a qualitative research design. The sample of the study consisted of 52 patients admitted to the ICU. The data of the study were obtained by examining the letters written by the patients who received treatment in the COVID-19 ICU between April 2021 and June 2021. The researchers collected the research data through document analysis, one of the qualitative research methods.
Findings
The messages that patients in the ICU wanted to convey to their families were identified as having two main themes: “emotions in the experience of illness” and “views on death.” The “views on death” theme included sub-themes such as fear of death, the meaning of life, acceptance of death and Saying halal for the rights over each other, and wills. The “emotions in the experience of illness” theme included sub-themes of love, hope/ hopelessness, loneliness, and longing.
Conclusion
It is assumed that patients have the risk of encountering a variety of problems during their stay in ICU due to COVID-19 and that providing good physical and psychosocial care will improve the coping mechanisms of patients.
Keywords
Introduction
COVID-19, which has affected the whole world, was declared a pandemic by the World Health Organization in March 2020 (
Fardin, 2020
; - Fardin A.M.
COVID-19 and anxiety: A review of psychological impacts of infectious disease outbreaks.
Arch Clin Infect Dis. 2020; 15e102779https://doi.org/10.5812/archcid.102779
Polšek and Huremović, 2020
). COVID 19 is an earth-shattering public health problem that causes the physical, mental and social health of individuals as well as their economic activities to change negatively (Polšek and Huremović, 2020
). As in the whole world, several measures (travel restrictions, social distancing, isolation, strengthening of health facilities, the introduction of the home working system, different protective measures in the social, business, and education fields, etc.) have been taken to reduce the negative effects of this epidemic and the speed of its spread in Turkey. Despite these preventive measures, the number of patients who caught the disease and were hospitalized in ICUs because of the disease increased day by day (Özkoçak et al., 2020
; Sahu, 2020
).Intensive care units, which are difficult to understand as a concept and their working system, where there are peculiar tools and equipment and where the treatment and care of patients whose general conditions are considered critical, have negative effects on the patient and his family (
Bartoli et al., 2021
; Tuğcu and Yılmaz, 2019
). However, it is emphasized that visitor restrictions imposed given the COVID-19 pandemic impact the mental health status of the patients admitted to the ICU and their families by increasing their emotional and psychological burden (Azoulay and Kentish-Barnes, 2020
; - Azoulay E.
- Kentish-Barnes N.A.
A 5-point strategy for improved connection with relatives of critically ill patients with COVID-19.
Lancet Respir. Med. 2020; 8e52https://doi.org/10.1016/S2213-2600(20)30223-X
Fardin, 2020
; - Fardin A.M.
COVID-19 and anxiety: A review of psychological impacts of infectious disease outbreaks.
Arch Clin Infect Dis. 2020; 15e102779https://doi.org/10.5812/archcid.102779
Stam et al., 2020
). The visitor restriction policy applied in intensive care is reported in the literature that by increasing the anxiety levels of family members, the recovery and psychological consequences of the patients are also adversely influenced (- Stam H.J.
- Stucki G.
- Bickenbach J.
European Academy of Rehabilitation Medicine
Covid-19 and post intensive care syndrome: a call for action.
Covid-19 and post intensive care syndrome: a call for action.
J Rehabil Med. 2020; 52jrm00044https://doi.org/10.2340/16501977-2677
Life Lines Team comprising, 2020
; - Life Lines Team comprising
Restricted family visiting in intensive care during COVID-19.
Intensive & Critical Care Nursing. 2020; 60102896https://doi.org/10.1016/j.iccn.2020.102896
Rose et al., 2021
; Wakam et al., 2020
). In the studies conducted with the families of patients in Covid ICUs to scrutinize the causes and effects of this situation it is stated that they are suffering because they cannot reach their hospitalized family member, that they want to protect their patients and provide emotional support, that they are worried about leaving them to die without their loved ones and that they do not know how their patients are provided with care (- Wakam G.K.
- Montgomery J.R.
- Biesterveld B.E.
- Brown C.S.
Not dying alone-modern compassionate care in the Covid-19 pandemic.
N Engl J Med. 2020; 382 (11) (Epub 2020 Apr 14. PMID: 32289215; PMCID: PMC7768603)e88https://doi.org/10.1056/NEJMp2007781
Creutzfeldt et al., 2021
; Montauk and Kuhl, 2020
). In this sense, providing concrete and satisfactory information that the patient is alive and receiving good care plays an influential role in reducing the emotional load.- Montauk T.R.
- Kuhl E.A.
COVID-related family separation and trauma in the intensive care unit.
Psychological Trauma: Theory, Research, Practice, and Policy. 2020; 12: S96-S97https://doi.org/10.1037/tra0000839
Patients admitted to COVID-19 ICUs owing to the potential risk in their lives are exposed to various stressors. Stressors caused by a study conducted; fear of sequelae, separation anxiety from family, contradictory statements by health care providers about covid treatments, and continued uncertainty. Stressors are explained to be fear of sequelae, separation anxiety from family, contradictory statements by health care providers about covid treatments, and continued uncertainty in a study. In the same study, it is stated that the presence of environmental perception disruptors and the presence of foreign devices can also cause this negative emotional state (
Tavakoli et al., 2022
). These stressors can cause restlessness and irritability in patients. In addition, patients who are in the process of ICU hospitalization have concerns about their own and relatives' health, concerns about their future (Fiorillo and Gorwood, 2020
), they feel lonely because they are socially isolated, and they may also experience negative emotions such as fear, anger, guilt, and confusion. Moreover, in studies examining the long-term negative consequences on patients discharged from ICUs and their families, it is expressed that depression, anxiety, post-traumatic stress disorder, decrease in quality of life, and the pathological or complicated grieving process in the case of death of patients (- Fiorillo A.
- Gorwood P.
The consequences of the COVID-19 pandemic on mental health and implications for clinical practice.
European Psychiatry. 2020; 63E32https://doi.org/10.1192/j.eurpsy.2020.35
Carfi et al., 2020
; Garrigues et al., 2020
; Van Veenendaal et al., 2021
).In this challenging process, it was reported that nurses and other health professionals were observed to provide telephone and video calls (
Kennedy et al., 2021
), have the patients keep diaries, and share these diaries with patient relatives in elimination of psychosocial problems experienced by patients (- Kennedy N.R.
- Steinberg A.
- Arnold R.M.
- Doshi A.A.
- White D.B.
- DeLair W.
- Nigra K.
- Elmer J.
Perspectives on telephone and video communication in the intensive care unit during COVID-19.
Annals of the American Thoracic Society. 2021; 18: 838-847https://doi.org/10.1513/AnnalsATS.202006-729OC
Brandao Barreto et al., 2021
; Haruna et al., 2021
). Additionally, it has been observed that nurses and healthcare workers often interview patients' relatives and share family photos. Virtual reality-based simulation studies have also been implemented in intensive care to improve psychological outcomes and enhance communication in healthcare services (Creutzfeldt et al., 2021
; Vlake et al., 2021
).- Vlake J.H.
- van Bommel J.
- Wils E.J.
- Korevaar T.
- Hellemons M.E.
- Klijn E.
- et al.
Virtual reality for relatives of ICU patients to improve psychological sequelae: study protocol for a multicentre, randomised controlled trial.
BMJ Open. 2021; 11e049704https://doi.org/10.1136/bmjopen-2021-049704
The COVID-19 pandemic has brought significant challenges for patients in intensive care units (ICUs). It is important to identify and address the difficulties that these patients may face during this process. Health care workers who care for ICU patients diagnosed with COVID-19 should also consider the psychological and social needs of these patients. This study aims to examine the emotions and perspectives of patients treated in the COVID-19 ICU, as expressed through messages to their families. The purpose of this research is to gain insight into the challenges and concerns of these patients during their time in the ICU and to understand the emotions and thoughts they wish to convey to their families.
Method
Study design
The researchers conducted this research using a qualitative research approach. Qualitative research presents research results based on codes and categories by reading the data one by one. In this context, it was considered that the most suitable research approach for this study, which attempts to assess the thematic status of the messages ICU patients during the COVID-19 pandemic desire to express to their loved ones, is qualitative research. The researchers collected the research through document analysis, one of the qualitative research methods. Document analysis entails analyzing written records offering information regarding cases to be investigated. Document analysis allows the study of documents generated during a certain time period concerning a research issue or documents created by several sources and at various times on a connected topic across a broad time span.
Population and sample of the study
The researchers conducted the study with patients in the treatment process in a COVID-19 intensive care unit in a state hospital in the south of Turkey. The research population consists of literate and conscious patients treated in the COVID-19 intensive care unit between 1st April and 1st June 2021 who did not have a physical handicap related to writing and accepted to participate in the study (giving written and verbal consent) (N = 60). During the data collection process, 60 patients were admitted to the intensive care unit, and 52 patients who met the inclusion criteria constituted the study's sample. We used a sampling approach that requires us to continue collecting data until sufficient size for saturation is reached to determine the sample size for qualitative study (
Streubert and Carpenter, 1999
; Creswell, 2015
). Consequently, the sample group consisted of 52 patients and data saturation was reached.Data collection
Both the ICU nurse and the researcher briefed the patients in the study, which examined the messages the ICU patients wanted to express to their families. The nurse informed the patients about;
- •The purpose of the study and participation in the study is voluntary,
- •Due to the potential of COVID-19 infection, no visitors are permitted in the critical care unit.
- •They could deliver any message, emotions, and ideas to their families through letters. (What messages do you want to convey to your family? What feelings do you want to convey to your family? What thoughts do you want to convey to your family?). They can also use a written expression or visual expression during the writing phase,
- •It was informed that a copy of this letter will be taken for research, and the original copy will be sent to their families upon request.
We conducted a preliminary application for four patients (pilot study) to evaluate the usability of the data collection form. No modifications were made to the data collecting form after it was pre-applied; therefore, the researchers included four patients in the study. The patients were given pen and paper in patient rooms and asked to write letters. The letters written by the patients were forwarded to their families and loved ones. Three letters could not be forwarded to the patients' families since the address was unknown. One of the patients participating in the study was deserted, and two did not want to forward the letter to their families.
Analysis
The researchers got the raw data by entering the data from each letter from the patients into a Word document, and then reviewing assertions that were repeated or similar from prior letters. The thematic statements created were reviewed while collecting the letters. When the qualitative data reached a certain saturation point, the data collection process was completed, and all the data collected by each researcher were grouped by reading repeatedly. As a consequence of the vast majority of the data not being interpreted numerically, it was taken into account that the results achieved could not be generalized and were specific to the individuals involved in the study. In the qualitative analysis of the data transferred to the computer environment, content analysis was carried out beyond the words by taking into account the prevalence of the comments contained in the responses given, the number of participants who made the same comment and used the same word, what was wanted to be said and the originality of the responses. They were combined taking their differences and similarities in the written texts written by the patients into consideration. After the raw data was carefully read by each researcher separately, the data was processed (coding of meaningful concepts and themes). Themes were created by combining the encoded data. During the analysis of the obtained data, raw data were given to two experts in their field who had researched qualitative research and an expert opinion was obtained. The codes were created by consensus on themes (
Streubert and Carpenter, 1999
; Creswell, 2015
).Ethical aspect of the research
The ethical suitability of the research was approved by the ethical council of the Clinical Research Ethics Committee of a university, with the decision dated March 03, 2021. It numbered 200, and Institutional permission was obtained from the hospital where the study was conducted. In addition, written permission (2021-02-01T14_58_00) was obtained from the Turkish Ministry of Health. In addition, written and verbal consent was obtained from the patients during data collection.
Results
The sociodemographic characteristics of patients treated in the COVID-19 intensive care unit of a state hospital in the south of Turkey are shown in Table 1.
Table 1Sociodemographic characteristics of patients in the treatment process in COVID-19 ICU.
| Min and max values | Mean ± SD | |
|---|---|---|
| Age | 34–91 | 62,6 ± 12,6 |
| Hospitalization time | 1–37 | 9,1 ± 7,1 |
| n = 52 | % | |
| Education status of the patients | ||
| Literate | 7 | 13,5 |
| Primary school | 30 | 57.7 |
| High school | 10 | 19.2 |
| University | 5 | 9.6 |
| Gender | ||
| Male | 34 | 65.4 |
| Female | 18 | 34.6 |
| Marital status | ||
| Single | 6 | 11.5 |
| Married | 46 | 88.5 |
| Status of hospitalization | ||
| Continues | 22 | 42.3 |
| Died | 11 | 21.2 |
| Discharged | 19 | 36.5 |
| Presence of individuals with COVID-19 diagnosis in the family/loved ones | ||
| Yes | 28 | 53.8 |
| No | 24 | 46.2 |
| Status of having children | ||
| Yes | 48 | 92.3 |
| No | 4 | 7.7 |
It was observed that the patients had intense emotional moments, sometimes crying and staring at the wall for a long time during and after the writing of the letter. It was noted that the patients asked their nurses whether their messages should be sent to their families or not. Those who received the letter expressed to the nurse who forwarded the letter that they were happy and experienced intense emotions due to the patient's handwritten writing (Table 2).
Table 2Themes obtained from the letters written by patients in the COVID-19 ICU to their families.
| Main theme | Sub-theme |
|---|---|
| Theme 1. Emotions in the experience of the disease |
|
| Theme 2. Views on death |
|
Themes
Theme 1. Emotions in the experience of the disease
Love
It was found that all of the patients undergoing treatment in the COVID-19 ICU expressed love for their family members and loved ones through their messages, using symbols and emotional language. These messages conveyed a sense of closeness and strong emotional connection to their loved ones. They were seen writing the names of their wives and children in the letters and drawing a heart and arrow sign where the names were. One patient expressed regret that he could not say unspoken words of love to his relatives before. Half of the patients who engaged in the study were satisfied with the treatment and care in the ICU and wrote messages of thanks to the health workers. Patients' statements regarding the theme of love are included below.
“Dear (Person A), my dear son (People B and C), believe me, I am very emotionally charged. I guess you do not doubt that I love you very much. My dear family, (People A, B, and C), I love you all without distinguishing you from one another.”(Patient 4)
“My dear wife, my dear children, my grandchildren, and my daughters-in-law, I love you very much in the presence of Allah. You are my only asset. Nothing means anything without you. It's impossible to separate you as a father. Your father who loves you all.”(Patient 17)
“We've never been so separated from each other. I love you guys so much that you never know. This disease has separated us, but even if I can't breathe while writing and my hands shake, I hold on tightly to the bitter truth for you.”(Patient 34)
“In my life, I couldn't say to you, ‘I love you so much’. Forgive me. But the truth is that I love you very much. I couldn't spare much time for you in the period before this.”(Patient 4)
“I would like to express my sincere thanks to the health workers and other personnel, especially our doctors, who work in the beautiful hospital of our beautiful city. Thank you. Don't forget healthcare workers we love you.”(Patient 2)
“I would like to thank the medical staff, our doctors, nurses, cleaning staff, security personnel, all of them individually.”(Patient 7)
Hope/hopelessness
COVID-19 ICU patients undergoing treatment reported hoping for recovery and believing that this disease is from God and can be cured with God's permission. They also stated that praying and worshiping have a positive impact on their healing process. Only a small number of patients (n = 4) said they felt hopeless. The following are the patients' statements on the theme of hope/hopelessness.
“Don't worry I'm in the intensive care unit, I'm not in a coma. It's been 12 days; I will stand up either today or tomorrow. I'm not leaving. I'm hopeful. I'll beat Covid”(Patient 19)
“I'm waiting for recovery. I have no fear, thank Allah, Allah is great. I'll get out”(Patient 23)
“By Allah's leave, I will succeed in this struggle. With your prayer and Allah's leave, I will win this process. I prayed to God a lot. I've never lost faith”(Patient 43)
“For two weeks, God has introduced me to the corona disease. I have never complained about what Allah has done, and I never will. I am wholeheartedly pleased with my appreciation as Allah deems appropriate. I benefit greatly from the suras and verses I have read. As long as the charity, the harvest, and the readings and prayers that my extended family and my great friends have done for me are with me, God's help will be with me. Keep praying. Thank Allah, Allah is with me and with you”(Patient 6)
“I have been going from one hospital to another hospital for 40-45 days, I am always in hospitals! I'm so desperate”(Patient 35)
“How many days have I been lying here is of no use. I guess I won't be able to recover”(Patient 46)
Loneliness and longing
Patients who were in the process of treatment in the COVID-19 ICU stated that they are bored due to being alone in the ICU, that they could not see their relatives on account of the risk of COVID-19 transmission, that they feel lonely owing to being separated from their loved ones and not being able to communicate with them, that health workers visit patients very often, that they miss their good days past, and that they are longing for being away from their loved ones and home. Patients' statements regarding the theme titled loneliness and longing are included below.
“I'm so lonely here because you're not there.”(Patient 26)
“How many days have I not seen anyone. I miss you so much. I'm so lonely right now, I only see nurses, staff.”(Patient 29)
“Here a nurse comes in the morning and does not exist until the evening. I can't drink any water with my eyes blind. I have no cleanliness; I have no purity. I'm scared on my own. No one. Silent as the grave. I can't turn to my right; I can't turn to my left. You know I'm miserable. I'm going crazy here. I'm afraid of losing my mind.”(Patient 47)
“My dear (Person A), I miss sitting on the balcony with you for coffee. Though coffee is an excuse, it is great to chat with joy☺ I will never leave you when I arrive. I don't want you to go away even for a second. We've been so separated from you like you've been away for 20 years.”(Patient 1)
“Sometimes tears flow from my eyes. Sometimes I think of the days when I walk around with my beloved children. But here I am alone with the walls with my feelings and thoughts. I want to get together with my children.”(Patient 41)
Theme 2. Views on death
Fear of death and meaning of life
Patients who were in the process of being treated in the COVID-19 ICU stated that being in intensive care evokes death, that they are afraid of dying, that they are sad, and if they are going to die, they want to die at home, not in the hospital. In addition, two patients stated that they regretted that they had not been well fed before, that they had become sick because of their smoking, that they questioned the meaning of life during this disease process, that life was invaluable and significant, that it was necessary to evaluate every moment well, and that they learned the meaning of life. A small number of patients (n = 2) were seen writing messages about the need for individuals in the community to follow the rules (mask distance, etc.). Patients' statements regarding the theme of death and the meaning of life are included below.
“My mother passed away in intensive care. Especially when I hear about people dying from corona in intensive care, I have a panic attack. It was so nice not to have Corona in the past. Now Covid Covid Covid. I hope we survive.”(Patient 18)
“Whether I die or stay, I may as well die at my home. Come for sure get me from here.”(Patient 46)
“There were no mornings for 12 days, what agony I suffered for 12 days. I always thought about that fine line between life and death. The goods of the world were always empty, everything was over for me.”(Patient 38)
“For this to happen, it is necessary to comply with the rules and regulations. For example, you're going to get vaccinated, you're going to follow distances, you're going to use your masks. This has a material burden as well as a moral burden.”(Patient 42)
Acceptance of death/valedictions/asking for and saying halal for the rights
Patients who were in the process of being treated in the COVID-19 ICU stated that they accepted death and did not want to die without saying goodbye to their relatives before they died. It was seen that all of the participants said goodbye by writing messages asking their friends and associates to say halal for their rights. Patients' statements regarding the theme of accepting death/valedictions are given below.
“I'm afraid that I'll pass away without seeing you”(Patient 18)
“I feel very sad. I don't want to die without seeing my children right now. Will I stay here? Will I go? I do not know.”(Patient 26)
“I'll go to the afterlife without seeing my daughters”(Patient 46)
“I give my right to all my friends and associates who love and don't love me. I want you to say halal for your rights, too.”(Patient 5)
“If you can't come, (Person D) say halal for your rights over me. Your father (Person E) who loves you. Greetings to all. Greetings to all brothers. If I can't get out of here, say halal for your rights over me.”(Patient 11)
Wills
Many of the patients who are in the process of being treated in the COVID-19 ICU have been seen writing various wills to their families. The following wills were identified based on the fact that they first entrusted the family members to one another, one indicating where his grave would be, what their unfinished works were, and asking them to complete these works, and they also made a will about the inheritance. Patients' statements regarding the theme titled Will are given below.
“My son, our family is entrusted to you”(Patient 4)
“If I can't get out, take care of my wife and son, don't victimize them. (Person F), do whatever is necessary for (Person G) and (Person H's mother). May Allah protect you.”(Patient 12)
“If something happens to me in (City X), bury me next to my husband”(Patient 30)
“The three children will be together as three siblings without discrimination in the company. Once a month, sacrifices will be slaughtered and given to dormitories. Identify orphaned children and help them for the sake of Allah. Always respect your mother, do not upset her, and do not hurt her. Everyone should respect him. Bless your right. Do some charity every month. Goodbye.”(Patient 36)
“My son (Person J), do not neglect things, make sure you water the seedlings. Water the trees too. My dear daughters, don't upset your mother.”(Patient 22)
“Don't worry about what you are, don't destroy yourself for a dry breath, life isn't ‘nothing’. We are trying to take it (breath) by force. (People A and B), take strength from each other and stand up. Whatever you're doing, make the best of it. Be one, be alive. Don't make yourselves fall apart, don't fight, and don't lose respect and love. Try to succeed and be very happy. Never lose your love”(Patient 28)
“My dear daughter (Person A), do not take alcohol, reduce smoking, do not fight at home. Protect each other. Be together in your difficult days. Don't waste your money, use it sparingly. Don't upset your mom.”(Patient 40)
Discussion
Nurses who provide patient care in COVID-19 ICUs have witnessed that patients have experienced problems such as fear of death, loneliness, helplessness, uncertainty, anxiety, etc. For this reason, the findings of this study, which was conducted to allow patients to express their feelings and thoughts and to reveal the messages they wanted to convey to their families, are discussed below in light of the literature. In this study, it was figured that the messages they wanted to convey to the relatives of the patients treated in the COVID-19 ICU included expressions of love, messages of love with symbols, and expressions of emotion based on love. The process of receiving treatment in ICUs is seen as equivalent to the physical and emotional crisis of individuals. According to a qualitative study, which examined the first six months after the admission of individuals diagnosed with COVID-19 in intensive care, patients expressed happiness at being alive and in contact with their loved ones in intensive care, but some participants also reported experiencing trauma (
Heiberg et al., 2022
). The uncertainty brought about by the COVID-19 disease and the fear of death caused individuals to feel lonely and helpless (Gawlytta et al., 2020
). In a study, it was reported that mental problems such as anxiety and depression were seen in patients in ICUs and that patients had negative experiences in ICUs (Tuğcu and Yılmaz, 2019
). These situations have been considered to cause individuals diagnosed with COVID-19 to remember their relatives and the love they feel for their relatives. Psychotherapeutic interventions for patients are necessary because the intensive care environment can cause trauma to patients (Gawlytta et al., 2020
).On the other hand, half of the patients who participated in this study were satisfied with the treatment and care they received in the ICU, and they wrote messages of thanks to the healthcare workers. According to a qualitative study by Moradi et al., individuals diagnosed with COVID-19 in ICUs often struggled to communicate effectively and felt uncomfortable due to fear of rejection by healthcare workers (
Moradi et al., 2020
). In this context, it is supposed that factors such as institutional policies, knowledge levels of health personnel regarding the care and treatment of patients diagnosed with COVID-19, fear of transmission, and workload affect communication with patients.In the study, it was found that the vast majority of patients receiving inpatient treatment in the COVID-19 ICU had a sense of hope for recovery. In addition, it was spotted that patients had thoughts that the disease came from Allah and that they would be cured by Allah's leave by praying and worshipping. Hope is expressed as a resource that allows one to cope with uncontrollable situations. Seen as one of the important factors which increase mental well-being during a global health crisis, hope significantly alters the healing power of patients. Research shows that patients with high hopes are more likely to use strategies to cope with life challenges (
Gallagher et al., 2021
; Lee and Gallagher, 2018
). One study reported that hope might be associated with resilience to chronic stressors associated with the COVID-19 pandemic (- Lee J.Y.
- Gallagher M.W.
Hope and well-being.
in: Gallagher M.W. Lopez S.J. The oxford handbook of hope. Oxford University Press,
2018: 287-298https://doi.org/10.1093/oxfordhb/9780199399314.013.20
Gallagher et al., 2021
). In our study, it was described that very few patients were hopeless. In the case study implemented by Frank, it is emphasized that the prolonged process of hospitalization increased despair. In this sense, as it is obvious in the study, the existence of the hopes of individuals for recovery is consequential. It is speculated that attempts should be made to increase the formation and development of a sense of hope in individuals and to reduce despair (Cutitta, 2020
).- Cutitta F.
What's important: The institutionalization of loneliness: My 100 days in the hospital with COVID-19.
The Journal of Bone and Joint Surgery. American Volume. 2020; 102: 1569-1571https://doi.org/10.2106/JBJS.20.01451
In our study, it was found that patients receiving inpatient treatment for COVID-19 infection were often bored due to being isolated in the ICU. They experienced loneliness because they were unable to see or communicate with their loved ones due to the risk of transmission of the infection. They missed their previous lives and experienced feelings of longing because they were away from their families and homes. In the studies carried out, it has been emphasized that one of the main problems experienced by many people during the COVID-19 process is loneliness and loneliness can cause numerous problems (
Van Tilburg et al., 2021
; Müller et al., 2021
; Wirkner et al., 2022
). According to Cutitta, loneliness can be as deadly as diabetes and heart disease, especially in older populations, and that loneliness can slow down the healing process. The same qualitative study adds that the case diagnosed with COVID-19 constitutes daily thoughts and feelings of loneliness (Cutitta, 2020
). Brooks et al. state that among the psychological effects of individuals quarantined by dint of the coronavirus pandemic, there are stress factors such as boredom on account of being alone, fear of infection transmission, and frustrations. In this sense, considering that the patients in the ICU are isolated in a single room, it is estimated that the emotional intensity and stress factors experienced by the patients influence boredom and loneliness (- Cutitta F.
What's important: The institutionalization of loneliness: My 100 days in the hospital with COVID-19.
The Journal of Bone and Joint Surgery. American Volume. 2020; 102: 1569-1571https://doi.org/10.2106/JBJS.20.01451
Brooks et al., 2020
). In another study (Bartoli et al., 2021
) which surveyed the experiences of family members of individuals diagnosed with COVID-19, it was stated that family members and patients in ICUs reported feeling lonely. In the same study, it is emphasized that it is important to produce the necessary solution-oriented alternatives for the loneliness of families. In another study, it was reported that individuals with COVID-19 infection missed their relatives very much during the disease process and counted the days to meet their relatives (Moradi et al., 2020
). In this respect, it is assumed that the isolation of the patients by virtue of the physical and mental problems caused by the disease itself, together with the measures taken for the effects of the disease during the treatment process, causes them to experience the feeling of loneliness intensely.In our study, it was uncovered that the patients were afraid of dying and wanted to die in their own homes, not in the hospital. It has also been found that being in intensive care evokes idea of death for patients. However, patients reported that they became ill because they did not eat well/smoked and regretted these situations. Patients also reported that they questioned the meaning of life during this disease process, that life is valuable and important, that it is necessary to evaluate every moment well, and that they learned the meaning of life. According to a study conducted by
Hoogveld et al., 2015
in the Netherlands, it is stated that some patients who were on the verge of dying wanted to die at home and 46 % of them were sent home at the request of the patients and their relatives. In the case report discussed by - Hoogveld L.M.
- Bergmans D.C.
- de Vries S.
- van Proemeren H.
- van den Beuken-van Everdingen M.H.
- Zijlstra J.G.
- van Mook W.N.
Intensive care patients who want to die at home: how can we fulfil this last wish?.
Ned Tijdschr Geneeskd. 2015; 159A8711
https://www.ntvg.nl/artikelen/ic-patienten-die-thuis-willen-overlijden
Date accessed: June 16, 2022
Özdemir et al., 2022
, it is stated that the individual who is in the process of being hospitalized in the COVID-19 ICU finds meaning in his illness and wants to change his life. It is stated that the participants in the Heiberg et al., 2022
study felt emotions such as fear of death, guilt, and regret which stimulated their curiosity about life in this process. It is stated that the participants in the Heiberg et al. study felt emotions such as fear of death, guilt, and regret, and stimulated their curiosity about life in this process. In a study, it is emphasized that individuals with high psychological distress of patients who experience COVID-19 disease should be supported mentally and spiritually (Toulabi et al., 2021
). It is stated that the events encountered in life, such as death and separation, cause individuals to question the meaning of life again. As one of these situations, the COVID-19 pandemic and all the situations and restrictions encountered as a result have caused people to reconsider the meaning of life (Sami et al., 2020
). A study reports that patients with COVID-19 are stressed and anxious because of the unknown nature of death. It is also emphasized that patients are afraid of death owing to COVID-19 (- Sami S.
- Toprak Y.
- Gökmen A.
Changes and transformations regarding the life perceived by youngsters during the COVID-19 pandemic (COVID-19 Sürecinde Gençlerde Hayatın Anlamına Yönelik Değişim ve Dönüşümler).
İlahiyat Akademi. 2020; (Available from): 217-256
https://dergipark.org.tr/tr/pub/ilak/issue/58981/773597
Date accessed: June 16, 2022
Toulabi et al., 2021
).In our study, patients who were in the process of being treated in the COVID-19 ICU stated that they accepted death and did not want to die without saying goodbye to their relatives before they died. It was seen that all of the participants said goodbye by writing messages asking their friends and associates to say halal for their rights over them. In a study, it was reported that the families and relatives of patients who had COVID-19 were afraid of death resulting from being alone (
Toulabi et al., 2021
). As a consequence of the unknown nature of death and the concern of never seeing their loved ones again, it is deemed that patients want to say goodbye to their families. Acceptance of death is related to the period of development of individuals and the meaning they attach to death (Kandemir, 2020
). When evaluated in this context, the death of individuals. It can be said that it will be easier for a patient to accept death if he perceives it as a natural, ordinary situation or a new beginning and getting rid of troubles. Additionally, it is believed that patients in intensive care may have a desire to say goodbye to their loved ones if they are facing the possibility of death. This can be seen as a way of coping with the loss of life and the sadness that comes with it. The process of giving and receiving blessings or farewells may be influenced by sociocultural factors and personal belief systems.In our study, it was seen that many of the patients who were in the process of being treated in the COVID-19 ICU wrote various wills to their families. In these last wishes, it was observed that patients often entrusted their family members to take care of each other, specified where they wanted their graves to be, mentioned any unfinished business they had, and asked their loved ones to complete these tasks. They also made provisions for inheritance in their final wishes. Although the concept of death varies according to different cultures and beliefs from past to present, although ceremonials are performed, deaths in the modern world mostly occur in hospitals. It is stated that deceased individuals write wills, distribute their assets and say halal for the rights in hospital rooms (
Kellehear, 2007
). The existence of expectations of collective goodness and sacrifice in society can be an influential factor in the writing of the wills of dying individuals (Yardley and Rolph, 2020
). Turkish individuals who create wills may include requests such as offering sacrifices to alleviate their sins after death, providing financial support to those in need, and being buried next to their loved ones due to the belief in being reunited with loved ones after death. These requests may be influenced by cultural and religious beliefs (- Yardley S.
- Rolph M.
Death and dying during the pandemic.
BMJ. 2020; 15 (PMID: 32295758)m1472https://doi.org/10.1136/bmj.m1472
Bahar et al., 2012
). In the study carried out by - Bahar Z.
- Beşer A.
- Ersin F.
- Kıssal A.
- Aydoğdu N.G.
Traditional and religious death practices in Western Turkey.
Asian Nurs Res (Korean Soc Nurs Sci). 2012; 6 (PMID: 25030977): 107-114https://doi.org/10.1016/j.anr.2012.08.003
Cook et al., 2015
on the identification and realization of the last wishes of dying patients, last wishes are indicated as requests to find family ties and missing loved ones, determination of post-mortem location, securing family members, provision of donations and educational support funds to family members, and similar 159 wishes. Healthcare workers can provide support to terminal patients in COVID-19 ICUs, even if they do not have family or loved ones present. This may include helping patients make decisions about their care and providing emotional support. At the same time, health professionals can enable to prevent the complicated or pathological grieving process that the relatives of the patients may experience and can play an influential role in overcoming this process comfortably.Conclusions
This study is one of the rare studies which inspect the feelings and thoughts of patients in COVID-19 ICUs through letters. In the study patients stated that they experienced boredom for loneliness during the intensive care process and that they felt a longing for their loved ones. During their time in intensive care, some patients may have hope that they will recover from the disease based on their overall condition, while others may feel a sense of hopelessness and believe that they will never be able to leave the ICU. Therefore, some of the patients had a fear of death and for this reason, they wanted to see their relatives and loved ones and wanted to say goodbye/ask for saying halal for their rights from them. Saying halal for each other's rights, which cannot be done face-to-face because of visitor restriction policies, has been seen to write their material and spiritual wills in detail by letter. Since individuals with the COVID-19 disease are affected in many areas, patients in ICUs entered into a search for new meaning in their lives with these changes in their lives. It has been observed that patients conveyed the meaning of life as they reached to their loved ones through letters.
Limitations
Since the data of this study were collected in two COVID-19 ICUs in one province of Turkey and the inability to generalize the study results by dint of the qualitative pattern of the study is one of the limitations. Another limitation is that patients had problems in transferring what they want to convey as a result of symptoms such as fatigue and fatigue brought on by the COVID-19 disease. The strength of this study is that there is no other study to determine emotional thoughts through letters to the families of patients in COVID-19 ICUs.
Consistent with these findings, fears of contagion and workload in intensive care units are linked to nurses' ability to limit conversation during the pandemic and insufficient information provided to patients' loved ones. This is thought to mean there is a possibility that the patient will receive inadequate psychosocial support. In this sense, psychiatric nurses and psychiatric counselling liaison nurses can shift support resources to the patient's loved ones, provide a hope-based approach appropriate to the patient's condition, and facilitate the grieving process in units such as the ICU, play an important role in empowering and manage deprived and vulnerable groups.
Clinical Trial Registration Number
Before initiating the research, the permission of the institution where the research will be carried out and the permission of the ethics committee from the Clinical Research Ethics Committee of a university(CRECU) were obtained. CRECU Number: 200/03/03/2021.
CRediT authorship contribution statement
Özcan Özdemir: Conceptualization, Methodology, Investigation, Data curation, Writing-original draft. Zeliha Yaman: Supervision, Conceptualization, Methodology, Writing-original draft, Writing-review & editing. Mualla Yılmaz: Supervision, Methodology, Writing-review & editing.
Data availability statement
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.
Declaration of competing interest
None of the authors has any conflict of interest with this study.
Acknowledgments
We would like to appreciate all the patients who contributed to this study.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Article info
Publication history
Published online: December 27, 2022
Accepted:
December 10,
2022
Received in revised form:
October 27,
2022
Received:
June 27,
2022
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
