First and final farewells, disrupted family connections and loss: A collective case study exploring the impact of COVID-19 visitor restrictions in critical care

Background: Patient and family-centred care is considered best practice. Such an approach is associated with high quality and positive experiences of care, and family presence at the bedside is encouraged and enabled. The COVID-19 pandemic, however, resulted in strictly enforced restrictions on hospital visitation, which threatened health professionals' ability to provide family-centred care.Aim: To explore the impact of COVID-19 visitor restrictions on family relationships during critical illness at the end of life in the intensive care unit.Design: A retrospective collective case study approach was taken, using semi-structured interviews, conducted via telephone or Zoom, in accordance with COVID-19 restrictions. Setting/participants: Two participant groups, bereaved next-of-kin of patients who died in the intensive care unit (n = 6) and critical care nurses (n = 3) from a major metropolitan hospital were included.Findings: Interviews with bereaved next-of-kin lasted 25-59 (mean = 41) minutes, and critical care nurse in-terviews lasted 31-52 (mean = 43) minutes. Inductive content analysis revealed five themes: (i) the first farewell, the significance not realised at the time; (ii) confusing rules and restrictions, which emphasised physical and created emotional barriers to family connections; (iii) inadequate communication, which further impacted next-of -kin; (iv) final farewells, which were rushed, emotional and afforded no privacy; and (v) reflecting back.Conclusions: This collective case study demonstrates the profound impact visitor restrictions have had on bereaved next-of-kin and the wider family. A family-centred approach to care, protecting and prioritising family connection, and recognising the patient as a person who is part of a larger family unit must be emphasised. Implications for clinical practice: Critical care teams must consider their own approach to end-of-life care during times of visitor restrictions, finding new, flexible and innovative ways to improve communication, promote family-centred care, maintain the patient-family connection and facilitate end-of-life cultural customs, and rit-uals imperative to next-of-kin and the wider family unit.