INTRODUCTION

The pandemic situation generated by the SARS-CoV-2 virus has placed healthcare professionals in a truly complex scenario in which they have had to adapt and reinvent themselves, both at work and personally (Ezquerra et al., 2020; Hernández-Sanz, 2020; Vila, 2020).

Several factors seem to be contributing to the complicated situation:

1. The global impact it is having at all levels and in all spheres: health, economic, social, etc. (WHO, 2020a; WHO, 2020b; WHO, 2020c; Carrasco, 2020; Moya et al. (WHO, 2020a; WHO, 2020b; WHO, 2020c; ) (Carrasco, 2020; Moya et al., 2020; Nicola et al., 2020; Pakpour & Griffiths, 2020; Xiong et al., 2020). In this aspect, the healthcare professionals themselves, whose job has been to ensure the physical and psychological well-being of the citizen, have also been influenced, constituting a population at risk as they are exposed to real physical danger as well as to critical situations and decision making with a high emotional impact (Chacón-Fuertes, Fernández-Hermida and García-Vera, 2020; Legido-Quigley, Mateos-García, Campos, Gea-Sánchez, Muntaner, & McKee, 2020; Chacón, 2020a; Chacón, 2020b; Villacañas, Felix-Alcántara, & Buiza, 2020; De Pablo et al., 2020; Arango, 2020; Xiang et al., 2020; Lai et al., 2020) (Arango, 2020; García-Vera & Cordero, 2020; Legido-Quigley et al., 2020; Pablo et al., 2020; Xiang et al., 2020).

2. It is a situation unknown to the present generations, who have never before faced an event of these characteristics and dimensions (Brody, 2020; García-Vera, 2020a; Moya et al., 2020; Arango, 2020) (Arango, 2020; Brody, 2020; Moya et al., 2020).

3. The existence of a complex scenario where a series of variables converge and contribute to amplify the perception of risk ¹ (Chakraborty, 2020; Cori, Bianchi, Cadum, & Anthonj, 2020; Slovic, 1992). Thus, like any virus, SARS-CoV-2 is invisible to the human eye; the assumption of the risk it poses is not only involuntary but uncontrollable, even for governments and health authorities themselves; it is an unusual risk with no remedy or specific treatment at present, of unknown origin (which fuels conspiracy theories, putting the focus on a possible human origin), disproportionately impacting vulnerable populations, potentially endemic and with no observable benefits for the population immersed in a global crisis; and there is poor confidence in those managing the situation, fueled by factors such as the lack of consensus in the scientific community, erratic policies to control the virus and the way information is handled. Research shows a positive correlation between risk perception and pandemic fear and anxiety (Ari, Yilmaz, & Arikan, 2020) that could lead to adoption and compliance with preventive measures (Burger, Christian, Maughan-Brown, Rensburg, & Rossouw, 2020; Cori et al., 2020; Khosravi, 2020; Weerd, Timmermans, Beaujean, Oudhoff, & Steeenbergen, 2011), but also motivate people to use unproven methods (Ho, Chee, & Ho, 2020). Inadequate risk information management can lead to psychological mechanisms of neutralization, denial or minimization of risk, rumor spreading, unease, alarm or, at the other extreme, discouragement and indifference (Robles & Medina, 2008). AsMorillo (2020) points out, the invisibility of the threat posed by the virus can hinder the adoption of individual and collective prevention measures while adherence to them can be affected by the lack of a visible and tangible impact of the actions implemented (Chapman & Loewenstein, 2020) ² .

4. This event was somewhat unexpected for a large part of the population, despite the fact that scientists had already warned of this possibility (Cheng, Lau, Woo, & Yuen, 2007). At first, what was happening in other countries was seen as something very distant, and its severity, capacity and speed of propagation were underestimated ( ; ATLAS, 2020) (Raffio, 2020).

5. There is a media coverage of the event that has never been observed before in history. The WHO itself (2020d), prior to declaring the situation a pandemic, had already warned of the existence of a massive "infodemic" due to an excess of information ³ (in some cases, imprecise, uncertain or not very timely), which has made it difficult for people to find reliable sources and adequate guidance. Media overexposure, particularly at the height of the pandemic, may have posed a threat to the well-being of particularly vulnerable people, increasing the sense of health risk and amplifying responses and issues associated with stress, anxiety and depression (Ashokkumar & Pennebaker, 2020; Carrasco, 2020; Gao et al., 2020; Garfin, Silver, & Holman, 2020; Moghanibashi-Mansourieh, 2020; Olagoke, Olagoke, & Hughes, 2020; Xiong et al., 2020).

6. It is a situation that is being maintained over time, and with it high levels of stress, which are affecting the physical and psychological health of the population in general and of at-risk and especially vulnerable groups in particular (Villacañas et al., 2020; García-Vera, 2020a).

7. Finally, it is a reality that is leading to a decline in one of the main coping and protection strategies that human beings have, which is social support. We are a contact society. In this situation of collective affectation, not only has it been possible to experience one's own drama, but many people have been exposed to the drama of family and friends. In normal situations these natural networks can serve as support, but here they may be ineffective as they are also affected ( ; García-Vera, 2020a) (Moya et al., 2020).

It can be said that, if anything is characterizing this pandemic, it is the changing scenarios and the uncertainty they entail, as well as the need to adapt to them in short spaces of time ( ; Colegio Oficial de la Psicología de Madrid, 2020) (Moreno et al., 2020; Moya et al., 2020). This circumstance, for many people, is generating high levels of stress that manifest themselves at the cognitive, physiological, motor and emotional levels (Colegio Oficial de la Psicología de Madrid, 2020), although it is not the subject of this article due to its length.

But if anything has really shocked the world, it has been the high number of deaths ⁴ , especially during the peak of the contagion curve, many of whom have died alone without the possibility of communicating with their loved ones. This has been a major challenge for healthcare professionals who have not only assumed the functions of their job, but also, on many occasions, have taken charge of the emotional needs of patients in their last moments ( ; Chacón, 2020b) (Hernández-Sanz, 2020). This situation has involved an added psychological strain to which, on many occasions, the communication of bad news to family and relatives has had to be added, since it has been carried out remotely and not in person. Thus, professionals have had to face a highly stressful and difficult reality, with the tools available at the time, which in many cases have turned out to be scarce, diminished, deficient or inappropriate (Chacón-Fuertes et al., 2020; Villacañas et al., 2020; Hernández-Sanz, 2020) (Chacón-Fuertes, Fernández-Hermida, & García-Vera, 2020; Hernández-Sanz, 2020), as has been the case with the notification of bad news by telephone (Moriconi & Valero, 2020); an aspect on which the present article has tried to focus.

COMMUNICATION OF BAD NEWS

Many are the definitions that have been given of "bad news", from the classicBuckman (1992) which states that it consists of "any news that drastically and negatively alters the vision that a person has of himself and his future"; to that given byNomen (2008) for whom bad news is "that information (...) capable of drastically altering the vision that a person may have regarding his future, either because it affects him directly and personally, or because it refers to a loved one"; to that given byBor, Miller, Goldman, and Scher (1993) who define it as a "situation where there is a feeling of hopelessness, a threat to the mental or physical well-being of the person, risk of altering an established lifestyle or where the message delivered conveys few life options"; to the one presented byBascuñán (2013) who defines as bad news "any information that negatively affects the patient's expectations of himself and his future". In short, it can be seen that bad news is information that entails negative consequences and/or loss of gratifying stimulation for the recipient (Muñoz, Fernández, Parada, Martínez, & García, 2001), alters future expectations and therefore represents a vital turning point for the recipient (Pacheco, Garrosa, López, & Robles, 2012).

Bad news, therefore, does not necessarily imply a patient's death or critical deterioration, although this article will focus on these issues.

Communicating information that is known to have a negative impact on another person is neither an easy nor a pleasant task for the person who has to do it. Moreover, authors such as BBernardo and Brunet (2010) point out that many professionals consider it to be the most difficult task to perform despite their training and experience in the area, which might lead one to think that they are used to it and that it does not pose any difficulty for them.

Thus, despite the empirically proven benefits (Ribes, 1990; Gómez-Batiste et al, 2003; Curtis, 2004; Kübker-Ross and Kessler, 2005) (Curtis, 2004; Kübker-Ross & Kessler, 2005; Ribes, 1990) that a correct communication of bad news can have for the receiver (reduction of uncertainty and thus of anxiety, increase of behaviors that increase the perception of competence and controllability of the situation, growth of autonomy in decision making improving self-concept and self-esteem, promotion of behaviors that increase the immunocompetence of the person, improvement in the psychological adaptation to the situation, reduction of emotional isolation, satisfaction with the attention received...) and for the sender (increase of confidence and the feeling of competence, reduction of emotional isolation, satisfaction with the attention received...).) and for the sender (increased confidence and feeling of competence, reduced anxiety and frustration, reduced risk of burnout, improved therapeutic relationship...); this type of communication is still a pending issue due to the difficulties involved from the point of view of the sender, the receiver and, of course, the system (Bascuñán, 2013).

As authors such asAlves (2003) orGómez (2008) point out, as far as the sender of the message is concerned, it is not uncommon to encounter fears associated with the unknown, with causing pain, with being blamed (by action or omission), with not knowing what is happening or how to act, with saying "I don't know", to over-empathize or sympathize with the person receiving the news, to over-identify with the person (sometimes over-involving oneself), to be negatively evaluated as professionals, but also as human beings (often because of the feeling of responsibility for the information given), even death itself.... Fears that can regularly lead to the adoption of dysfunctional attitudes such as flight, haste in notification, concealment of information or delay in communicating it, overprotection of the recipient, distancing from the latter, dehumanization and even early referral to other professionals or an inappropriate multi-care approach.

In relation to the receiver, the most frequent difficulties are found in the handling of the information, denial of the situation, its consequences and the resulting emotional reactions, or mistrust (in the information, the professional, the system...).

From the point of view of the system, the lack of information and adequate training of professionals and the lack of resources (time, adequate space for proper communication, trained professionals...), constitute the main stumbling block.

Communicating bad news may be an inherent part of medical care functions and a central aspect of clinical practice (CEEM, 2010; ) (Bascuñán, 2013), but until now it has not been given the value it really has for the well-being of the interlocutors. This is embodied in aspects such as the fact that the complaints presented by patients often do not focus on the absence of clinical competence per se, but on the perception of a lack of communication and an inability on the part of the professional to adequately convey a sense of care (DoH, 2000), with these communication problems often being an important factor in litigation (Levinson, Roter, Mulhooly, Dull, & Frankel, 1997).

As can be intuited, bad news is not only difficult to hear but also to transmit. This has often led to the desire to hide the information, omit it or distort it, despite the benefits that knowing the truth, today it is known, has for both the sender and the receiver (Bascuñán, 2013).

In the health field, the law is clear (Law 41/2002), stating that the patient has the right to determine what he/she wants to know and the professional has the duty to communicate it to him/her in a way that he/she is able to hear and process it. Hiding the truth from those who wish to know it can be as reprehensible and maleficent as forcing a person to hear it if they do not want to (Bascuñán, 2013).

People not only need to be adequately informed, but they also need this information to be transmitted by a competent professional with skills and knowledge in the field. Thus, a study carried out in 1995 by the European Federation of Traffic Accident Victims on the main needs expressed by those affected by an accident in case of communication of bad news, indicated as main priorities: 1st) to be informed of the death of their loved ones by a person qualified for this task, 2nd) to have access to the body and 3rd) to receive professional support, both psychological and practical and legal (Bernardo & Brunet, 2010).

On the other hand, different studies have found that although health professionals are the ones who think about death the least, they are the ones who fear it the most (Antonelli, 1990), sometimes adopting distorted attitudes such as not wanting to name it or putting into words pathologies that "attract" it, not looking patients or relatives in the eye, incongruence between what they say nonverbally and what they express verbally, or an increase in technological attention as opposed to empathic-affective attention ⁵ (Gala et al., 2002). This leads us to propose, as a first step for the correct communication of bad news, the need to be aware of one's own limitations, since personal history, culture, defense mechanisms, coping styles and strategies of each human being... and in short, the attitude towards death, losses and changes in general, greatly influence the way of communicating (Alves, 2003).

The professional cannot change the situation, cannot alter the circumstances that have led the person to die or to be in this process, but the way he/she communicates it will determine whether it facilitates or hinders the person's acceptance and adaptation to this new reality. And for this, not only the experience or preparation of the health professional is important, but also his or her personal and emotional background (Pacheco et al., 2012).

COMMUNICATION OF BAD NEWS, BEREAVEMENT AND COVID-19

Mourning can be defined as the "set of psychological and psychosocial processes that follow the loss of a person with whom the bereaved, the debtor, was psychosocially linked" (Tizón, 2004). Bowlby (1993), details grief as "all those psychological processes, conscious and unconscious, that the loss of a loved one sets in motion, whatever the outcome". More broadly, it could be said that grief is a normal and natural response to a loss or separation (real or symbolic), with the loss of a loved one being the most painful experience especially when its cause has been death (Montés, Jiménez, & Jiménez, 2019).

Grief ⁶ , which comes from the Latin dolus (pain), is personal and unique, and as Montoya-Carrasquilla (2004) points out, it affects the whole person, in all areas and at all levels (psychological, emotional, family, social, physical and spiritual). Mourning is, therefore, a biopsychosocial process in the face of a significant emotional loss, whether material or symbolic (Robles & Medina, 2008). Overcoming it involves a process of readaptation. It implies, therefore, a series of psychological processes that involve the adaptation and acceptance of a new internal (emotions, cognitions, fantasies) and external reality (a space where the person, in this case, is no longer) (Tizón, 2004).

Grief can be caused by emotional losses (separations, deaths...), social losses (unemployment, retirement, change of status...), physical losses (amputations, illnesses...) or losses inherent to the evolutionary process (loss of childhood or youth...), but it cannot be ignored that the main losses are often linked to others of an initially secondary nature (Brickell & Munir, 2008; Montesinos, Román, & Elías, 2013). When a loved one dies, as has happened so many times during this pandemic, it is not only their presence that is lost, not being able to hug or kiss them again. You may lose a life project, the belief in a safe, fair and meaningful, benevolent world, where most things are thought to be controllable... With the death of that person, part of oneself vanishes, the one built relationally with the other (Moriconi, 2020).

If there is one thing that is certain, despite the little that is known about it and the uncertainty it arouses, it is the existence of death. And despite this, in our current society, we are not adequately prepared for it (Cabodevilla, 2007; Gala et al., 2002; González, 2013). The research carried out by Herrán, Rodríguez and De Miguel (2019), on the inclusion of death awareness in the Spanish educational curriculum determines this, pointing out that despite being present in all spheres of life, "death is a secondary content that is tangentially included in other priority areas".

The impact of the bereaved after the loss and the subsequent mourning process depend on multiple factors (Montés et al., 2019): the object lost, the value given to it, the idiosyncrasies of each person at the biological, psychological and social level, the relational bond, the circumstances of the death.... Thus, if there are some variables that influence the difficulty or ease of mourning (in addition to the personal characteristics, resources, life and circumstantial history of the mourner, and the kinship and attachment relationships with the deceased), these are the type of death, which in this pandemic situation, in many cases has been unexpected and highly traumatic (something that involves a double effort for the mourner: the elaboration of the loss and the elaboration of the trauma ⁷ ), and the lack of real and/or perceived social support before, during and after the death of the loved one (a situation that has also occurred as a result of the collective impact of the pandemic).

In cases of death by COVID, there are many factors that the scientific literature (Pangrazzi, 2008; Robles & Medina, 2008; Tizón, 2004; Worden, 2013), place as predictors of complex, complicated and even pathological grief ⁸ , that we can find. As various experts report (Araujo, García, & García-Navarro, 2020; Fouce, 2020; García-Vera & Cordero, 2020; González, 2020; Ho et al., 2020; Lacalle & Barbero, 2020; Moriconi & Valero, 2020; Moriconi, 2020), in addition to the unexpected and, in many cases, sudden nature of death due to a rapid worsening of the clinical condition, during the worst moments of the health crisis caused by COVID-19 there have been traumatic separations of the deceased who, after being hospitalized, lost all contact with family and relatives. The impossibility of seeing and communicating with their loved one, of having constant updates on their state of health from a reference professional, or not being able to accompany the deceased in the last moments of their life (sometimes for fear of contagion, generating guilt), has left "unfinished business ⁹ " and unanswered questions for the bereaved, making it difficult to deal with the loss. To this has been added, on many occasions, the impossibility of seeing the body to mourn and watch over it, preventing personal and social rituals such as funerals, which could facilitate the acceptance of the new reality, the assumption of new roles, the validation of emotional reactions and the reinforcement of social cohesion, making the death less painful. The bereaved has had to face all this in a context of multiple losses, starting with the loss of a way of life that articulated their identity, their relationships, their beliefs and their way of facing a now unknown world. On many occasions, the news of the death of their loved one has reached them while confined and alone, having to face the loss at the same time as their own isolation and perhaps that of other close relatives of the deceased who, due to different circumstances (age, previous pathologies) have had to remain in quarantine due to contact with the affected person, in a state of special vulnerability. The social isolation of the survivors in quarantine has prevented the reception of physical signs of affection and affection, so important in bereavement due to biopsychosocial issues (Moriconi, 2020).

As already pointed out at the beginning of this text, the support networks that previously facilitated the coping of complex situations for the person, when also affected by this situation, have not been useful on many occasions, generating frustration, anger, guilt, shame... both in the habitual sender of this support and in the mourner.

Factors that can complicate the elaboration of grief also present on numerous occasions in this type of death by COVID, have been the age of the mourners (a large number in late life)11, high degree of dependence, having been caregiver of the deceased (many of them, in this pandemic, had previous pathologies that have made them more vulnerable to the coronavirus and to require care prior to it) ¹⁰ , the existence of previous pathologies in the debtor such as anxiety or depression (which may have been accentuated either by the pandemic situation itself or by its consequences such as confinement, the scarcity or inadequacy of health and mental health care resources or the fear of going to a specialist due to the risk of infection) (Brooks et al., 2020; Chacón-Fuertes et al., 2020; Ho et al., 2020; Mazza et al., 2020; Wang et al., 2020; Xiao, 2020; Zhou, 2020; Özdin & Özdin, 2020) or the fact of living alone, having little socio-familial support (real and/or perceived) and having few personal resources such as work or hobbies (Lei et al., 2020; Xiong et al., 2020). All of these variables are present in a high percentage in a sector of the population particularly affected by the pandemic, the elderly (Chacón-Fuertes et al., 2020). It should also be noted that the highest number of deaths in Spain has occurred during a state of alarm in which people had to remain confined to their homes ("limitation of freedom of movement") as an exceptional measure to mitigate the consequences of the coronavirus and reduce its transmission ¹¹ . This meant limiting leisure activities, but also work activities. Therefore, to the health crisis should be added the existence of other concurrent crises: social, labor, economic (Perez, 2020).

On the other hand, deaths in Intensive Care Units (ICU), which have occurred so frequently in recent months, are associated with an increased risk of psychological sequelae in the relatives of the deceased (Kentish-Barnes et al., 2015; Probst, Gustin, Goodman, Lorenz, & Gregorio, 2016). As noted by Moriconi (2020), bereavement following the death of a family member in an ICU is associated with worse acceptance of the loss and with symptoms compatible with complicated grief (5% - 52%), post-traumatic stress disorder (PTSD) (14% - 50%) and depression (18% - 27%).

Finally, two risk factors should be taken into account in the acceptance and elaboration of death. One is the distance from the traditional socio-religious and family support system that the person may have had, as in the case of immigrants in different parts of the world (Ho et al., 2020; Petralanda, García-García, Vizcaya, & Complicado, 2001). And two, the so-called disavowed duels, which, as defined by Alba Payás (2017), are those that "are neither socially recognized nor (grief) publicly expressed". This can occur when the relationship is not recognized as socially significant (e.g., the death of a lover, an ex-partner, a friend, a non-admitted homosexual partner or a patient), when what is not recognized as socially significant is the loss (e.g., loss of the child in the perinatal period, death of a person with severe incapacitating illness or the death of a pet), when the mourner is not validated (e.g., people with intellectual disabilities, children or elderly people with severe neurological diseases) or when the type of death is not socially accepted (e.g., death by suicide or death by overdose or having deliberately exposed oneself to risk). As Payás (2017) points out, this type of unrecognized grief is more likely to lead to pathological grief, as it involves a cumulative trauma (the pain of loss is compounded by the damage caused by the failure to obtain support and social recognition).

Taking this last point into account, it is essential to consider not only the complexity of loss in these circumstances for the bereaved, but also for the professionals (Chacón, 2020b), who have had to add to their own personal losses others, perhaps not socially validated. The loss of patients with whom they may have established an emotional bond, the loss of the ability to decide how to make the person's last moments of life easier and perhaps accede to their wishes for family reunion or not being able to communicate the news in the most suitable way possible (in person, dedicating the necessary time...), has, in many cases, shaken their beliefs and negatively affected their mood.

We could therefore say, on the basis of the above data, that the type of death that health professionals have had to deal with in this pandemic has been traumatic for many bereaved. The grief that follows these deaths is usually more devastating than other bereavements, since the suddenness of the death shatters the survivor's confidence about the world and confirms that it is an insecure, unpredictable and anxiety-provoking place, so that the bereaved have a strong sense of unreality and disbelief, finding the environment they knew strange and often feeling guilt (towards themselves and/or others) and the need for answers (Moriconi, 2020). Similarly, scientific studies (Echeburúa, 2005; García-Viniegras & Pérez, 2013) indicate that survivors of a traumatic death may experience more intense and lasting depressive manifestations than when the death is expected. Likewise, in this type of death, previous pathologies may be aggravated and even new ones may appear, including post-traumatic ¹² stress symptoms (Moriconi, 2020) such as: re-experiencing the event in the form of nightmares, thoughts or images that generate discomfort; avoidance of places, people or conversations that may remind the person of what happened; inability to remember aspects of the event; persistent negative emotional state (anger, guilt or shame); feeling of detachment from others or inability to experience positive emotions; irritable or reckless behavior; concentration problems and sleep disturbances.

Helping people who have suffered a loss to accept it, process it and integrate it, firstly involves listening to it and processing it (not only at a cognitive level, but also at an emotional level) and here a correct communication of bad news can be an essential facilitator.

TELEPHONE COMMUNICATION

The current pandemic has meant that many relatives of people affected by SARS-CoV-2 have had to receive news about the deterioration of the health or death of their loved one in a non-face-to-face manner (generally by telephone), either because of the need to maintain physical distance to avoid new infections, or because of the mobility restrictions imposed on the population (Belli, 2020; Hernández-Sanz, 2020). This type of remote communication, although the scientific literature discourages it in this type of situation (notification of adverse information) (Belli, 2020), has existed and has been a major challenge for health professionals who have had to adapt, document, train and finally put it into practice (Ferrer, 2020).

While telephone communication can have important advantages in certain contexts and situations by being fast, cheap, saving time and effort, facilitating the resolution of urgent issues and even neutralizing difficult relationships or cooling hot issues (Acinas, Alonso, Alonso, Peláez, & Suárez, 2019); it also presents important disadvantages in circumstances where physical presence becomes necessary (Kendrick, 1997).

As far as differentiating aspects are concerned, in telephone communication, paralinguistic elements (tone, volume, speed, intonation...) acquire special relevance. These elements have a very important weight during the conversation, since due to the lack of any kind of visual information during communication, they are the ones that convey the emotional dimension (of the sender and receiver) (Rizo, 2015). Another characteristic, therefore, of this type of communication, is that the interlocutors cannot see each other, there being no body language to accompany this exchange of information. AsAcinas et al. (2019) point out, the telephone thus becomes an intermediary, an interpersonal mediator in the communication process.

In remote communication by telephone, one of the major handicaps that discourages its use in certain circumstances, such as the communication of bad news, is the loss of nonverbal elements that facilitate knowing the state in which the person may be, as well as whether he/she has really understood the information transmitted and whether the consequent reaction is adaptive. Thus, different experts (Pettinari & Jessop, 2001; Taylor, 2007), point out that remote communication should be avoided at all costs in these contexts, mainly because effective communication depends, to a large extent, on body language, so that the exchange of information through a telephone call tends to be less effective.

Other drawbacks of this type of communication are (Acinas et al., 2019; Rocamora, 2013): a greater speed in the resolution of the call than if it were a face-to-face conversation; poor suitability in the circumstances in which the call may occur (lack of privacy and that others hear the conversation or see the person in a state that in another situation they would not like, being performing or going to perform a risky activity such as driving, social support not present, health circumstances that discourage situations of a high emotional impact of an abrupt nature....); health problems of the receiver that hinder communication (such as hearing or speech impairments); difficulty in capturing the attention of the interlocutor and fragility in communication, which can be interrupted at any time and, in the most complex cases, prevent knowledge of the physical and psychological state of the receiver who could carry out disruptive or inadvisable behaviors in response to the information received.

In summary, it can be pointed out that the absence of eye contact and the fragility of the relationship make communication by telephone unsuitable for the transmission of information that is known to have a strong impact on the receiver, and its response will also have an impact on the sender.

COMMUNICATING BAD NEWS IN TIMES OF COVID-19: TELEPHONE COMMUNICATION

Knowing how to adequately communicate bad news is perhaps one of the most important tasks in the healthcare setting and yet it is often considered a minor skill, especially when compared to other technical aspects of healthcare activity (Belli, 2020). Professionals point out this practice as one of the most stressful to develop (Bernardo and Brunet, 2010; Bascuñán, 2013; Bousquet et al., 2015; Arnold and Koczwara, 2016; Torregrosa, Gempeler and Silva, 2020) (Bascuñán, 2013; Bernardo & Brunet, 2010; Bousquet et al., 2015; Torregrosa, Gempeler, & Silva, 2020) and yet not enough resources are devoted to the preparation and training of healthcare workers in this area (Almanza, 2003; Belli, 2020; Monden, Gentry, & Cox, 2016; Suquilanda & Manuel, 2016). Thus, when communicating bad news, in addition to the fears already existing in the professional, there is deficient training that does not provide sufficient coping resources or adequate training in communication skills to enable him/her to perform this task optimally. This fact increases the levels of stress and anxiety in the healthcare professional, reducing the effectiveness of the task, which in turn affects his self-confidence and security for future communications and can influence the appearance of problems such as burnout ¹³ .

People need to know the information, and they need to know it as soon as possible in order, as far as possible, to reduce the chances of a death becoming traumatic because of its unexpected or surprising nature and what this entails. Something that has not always been possible during the worst moments of the contagion curve. Adequate communication in terms of mode, time and space can facilitate the process of acceptance and adaptation after the loss or, on the contrary, hinder it.

The psychological impact of a traumatic death, such as many of those that occurred during the pandemic, is greater than that generated by other types of deaths. If we understand that a traumatic death usually involves a series of characteristics, we will also understand how adequate communication can reduce the appearance of many of these variables and thereby reduce the likelihood of greater psychological damage. As Alba Payás (2017) points out, a traumatic death is usually defined by: surprise (if the death cannot be anticipated, the person cannot prepare), helplessness (being surprising, there is no capacity to respond), incomprehension (the lack of information makes it difficult to understand the reasons for what happened), speed (there has been no time to assimilate the death), loneliness at the moment of death or communication of the death (the fact that the event is surprising, the person may receive the information without the support of anyone at the time) and subsequent loneliness (the bereaved has had no one with whom to share what has happened). Therefore, if there is a possibility of anticipating and preparing the person for the death of their loved one, although this does not reduce the grief of the mourner, it will favor a better readaptation to the event, having given rise to a gradual emotional preparation for the changes that will occur and having allowed to progressively come to terms with the loss (Montés et al., 2019).

Far from what might be thought, when communicating bad news, good intentions or common sense are not enough, even in times of crisis such as the current pandemic; it is necessary to have knowledge, skills, preparation and supervision (Buela, 2008; Mirón, 2010). Taking care of the "what" and "how" is transmitted is especially relevant if the communication is done at a distance through the telephone. As expressed by Montés et al. (2019), "words are not neutral, on the contrary, they can carry an enormous emotional charge, and can act as a lacerating whip on our thoughts and, consequently, on our emotions". Therefore, knowing how to communicate information properly will not only reduce the psychological impact on the receiver, but also on the sender, who will face fewer scenes with high emotional content (Montés et al., 2019).

This pandemic situation has posed significant challenges for health professionals, who had never before faced a health emergency situation of these dimensions and which has required adapting to it with the resources existing at the time, which have sometimes proved ineffective or insufficient (Chacón-Fuertes et al., 2020; Emanuel et al., 2020; Ezquerra et al., 2020; Legido-Quigley et al., 2020; Linconao, 2020; Lorenzo, 2020; Mcmahon, Peters, Ivers, & Freeman, 2020). At the care level, the communication of bad news has acquired special importance due to the magnitude and characteristics of the situation. This fact has led to an increase in the stress levels of professionals, since, in addition to having to communicate bad news, the unconventional way of doing so, usually by telephone, has been added to the unconventional way of doing so, at a distance. AsBelli (2020) points out in relation to this aspect, professionals have had to face a series of particular obstacles: a) the little or no training in this type of communication skills that most of them have, b) the absence of body language in this type of exchange, which is one of the bases of effective communication of bad news, and c) the scarce literature available to guide those who must perform this task, as this type of remote communication is not recommended, except in exceptional situations such as the present one. In addition, it should be added that on many occasions the communication has been carried out by professionals who had never performed this task before, as it is not within their usual competencies. The characteristics of the situation (care congestion, difficulty in the organization of shifts and functions of the professionals, rapid worsening of the clinical condition of many patients, contagion of the health care professionals themselves...) ( ; Chacón, 2020a; Villacañas et al. , 2020) (Ezquerra et al., 2020; Ferrer, 2020; Rodríguez-Leor et al., 2020) have also meant that, frequently, during the most critical moments of the pandemic there was no relational link with the interlocutor, who lacked a professional reference who could keep him/her informed of the evolution or situation of his/her family member.

The communication of bad news in the field of emergencies is a process that pursues clear objectives: to minimize the psychological impact of the loss (especially if it is sudden or unexpected), to help people to use their coping skills to adapt to the situation (for example, seeking social support), to favor emotional relief, to support and facilitate the start of the grieving process by identifying risk factors and indicators of possible complicated or pathological grief, and to reduce the probability of the appearance of physical and/or psychological pathologies in the short, medium and long term. AsPacheco et al. (2012) point out, "for adequate communication there must be a basic ability to know how to communicate in professionals, as well as a knowledge of the basic technical guidelines". And this becomes especially relevant when it is necessary to mitigate the inconveniences that a telephone communication of bad news entails.

As regards basic communication skills for conveying negative information (empathy, active listening, appropriate use of verbal and nonverbal communication strategies, etc.), the positive aspect is that they can be learned and improved through adequate education and training (Fallowfield, Saul, & Gilligan, 2001; Fellowes, Wilkinson, & Moore, 2004; Razavi et al., 2000; Wilkinson, Gambles, & Roberts, 2002). All individuals may have certain skills more or less innately, but they can always be polished and nuanced, making them a more effective tool. This is essential because, asFellowes et al. (2004) note, many of the complaints from patients, family members or relatives who receive bad news focus on deficiencies in communication, with the professional's "willingness to listen and explain" being the most valued attributes (Moore, Wilkinson, & Mercado, 2004).

With regard to basic guidelines to facilitate communication, and as we have already pointed out, despite the existing models in hospital and even prehospital care practice, there is practically no literature that provides guidance on how to properly carry out remote communication (Belli, 2020). In this sense, we have proceeded to adapt classic strategies to the requirements that this type of remote communication implies.

CONCLUSIONS

Communicating bad news, especially if it involves a death or the drastic and irreversible worsening of a patient's clinical condition, is not an easy task. The SARS-CoV-2 pandemic has posed great challenges for health professionals who have been forced to confront the situation with the resources available at the time, which in many cases have proved to be insufficient, ineffective or inadequate.

Providing adverse information remotely, in this case by telephone, except in exceptional circumstances and situations such as the one experienced, should never be the procedure of choice, since the non-verbal component, key in communication, is lost, the relationship established is more fragile and we miss information that in many cases may be vital to know. All this reduces the likelihood of a truly effective communication where the interlocutor has the feeling of having been properly served.

Adequate communication of bad news has benefits for both the transmitter and the receiver. For the receiver it can be a facilitator for acceptance and adaptation to the new situation. The literature tells us that the way in which bad news is given and the subsequent actions taken can influence the grieving process (Wright, 1996). For the sender, it means gaining security for future communications, improving his/her self-concept, self-esteem and thus reducing the probability of the appearance of problems such as burnout. In short, for the professional it means increasing the probability of effective future communications.

But for a correct transmission of information that is known to be unfavorable, common sense, good intention or simply experience is not enough (Fellowes et al., 2004), it is necessary for the professional to be properly trained and educated. Knowing and properly using communication skills, as well as the basic technical guidelines for action, is essential.

A well-conducted communication can be therapeutic in itself. It is not only a matter of transmitting painful information, but also of cushioning its impact, providing resources for containment and coping and preventing future complications. Therefore, it will be essential to take care of the language used during communication, listen actively, adopt an appropriate attitude (show empathy and genuine interest), manage emotions properly, control reactions, maintain concentration, take care of the voice (intonation, articulation and rhythm are the most relevant characteristics of the voice in telephone communication) and feel confident in what is being done, in one's own skills and in the usefulness and importance of the work being performed. All this without losing sight of a key element, the axis of communication, the interlocutor; to whose idiosyncrasies, times, needs and circumstances the professional must adapt.

For years, knowing how to communicate unfavorable news appropriately has been considered a minor skill compared to other technical aspects of healthcare practice. The current pandemic has demonstrated its importance for professionals, patients and their families and relatives.

In view of the above, specific protocols (and the training of professionals in them) are necessary in situations such as the one experienced, beyond the adaptation of the classic models, mostly designed for face-to-face communication.

In short, we must not forget that the purpose of a correct transmission of bad news is not to eliminate the pain but to help the person to cope with it, reducing as much as possible the impact of the news, accompanying the mourner and guiding him/her in whatever he/she needs at that moment.

REFERENCES