Coronavirus. COVID-19. The virus.

Call it contagious and deadly, too. The disease that has quickly developed into a months-long pandemic — claiming thousands of lives in Texas, with Harris County accounting for the majority of deaths in the state — has signaled more than a wake-up call to deal with its impact.

It becomes personal.

In a COVID world, the virus has challenged our ability to grieve for loved ones, no matter the cause of death. Even the CDC offers guidance for grieving safely. Given how easily the virus is transmitted through close physical contact, a simple hug incurs risk. Offering or receiving comfort during a time of loss can be awkward if self-preservation takes priority. To that end, staying at least 6 feet apart from one another would appear the prudent thing to do until a vaccine becomes available.

On paper, a seemingly practical approach.

In practice? Hardly perfect.

Facing the risk of COVID-19

Amy Karlson knows this firsthand. She received word in June that her parents' conditions were worsening, her mother battling complications from diabetes and her stepfather at an advanced stage of lung cancer. Amy, who is lead editor of Creative Services at Houston Methodist, faced an additional obstacle — traveling out of state to see them.

She booked a flight to Florida — another coronavirus "hot spot" — and was admittedly apprehensive about risking her own health to see her parents.

"So I was afraid I might bring COVID to my mom, my stepdad, my sister, but I had to go — and I tried to be as safe as I could possibly be. I wore a mask, didn't touch anything I didn't have to, used hand sanitizer, and didn't eat, drink or use the bathroom at the airport or on the plane," Amy says.

On top of this, after going through security, Karlson wiped down her luggage and the areas adjacent to her seat on the plane, including the seat belt. "When I got into my brother-in-law's car, my sister laughed and told me I smelled like Clorox."

Amy arrived in time to say goodbye to her stepfather at home, telling him how much she loved him and thanking him for being such a great dad. He died several hours later, not long after midnight. He was 84.

It didn't end there

At the same time, Amy's mom was in the ICU recovering from diabetic ketoacidosis, a condition that stems from type 1 diabetes when not enough insulin is in the body to process glucose in the blood. Amy and her sister delivered the news to their mother about her husband.

"They let us in together to tell her. And all of her doctors and nurses came with us, just to make sure she would be okay."

Amy said that while everyone in the ICU wore masks, "It's hard to treat a patient and be socially distant. Rooms are small. It was a risk." The risk of infection, however, did not outweigh Amy's resolve. "I had no choice. It was my parents," she said.

Closure can be complicated during COVID-19

Planning a funeral became one less thing on Amy's plate. Her stepfather, an Army veteran, made arrangements in advance of his death to be cremated and his ashes placed in a crypt at the South Florida National Cemetery in Lake Worth. However, travel restrictions prompted by the pandemic hampered the ability of other family members looking to pay their respects, so Amy's family plans to have a small service at a later date.

For her, delaying the service also delays an important part of the grieving process — closure.

"It's a weird time … and not having a service kind of leaves it open," Amy says. "I am totally fine not having one right now, but it fosters the unreality of the situation."

Paying respect — and attention

When memorial services during a pandemic are scheduled to take place, the decision to attend was something Sheshe Giddens was prepared for by necessity.

Sheshe returned to Houston after taking a cruise in the Caribbean in March, when travel restrictions were starting to be issued in response to the coronavirus coming to the U.S. She had to self-quarantine for 14 days and tested negative before resuming her job as senior editor of Creative Services at Houston Methodist.

A few weeks later, she found out that an 80-year-old family member had died of natural causes in Huntsville, Texas, so she drove to the funeral. "I was very cognizant of social distancing. I went in with a mask on. I was told that there would be only 10 people allowed in at a time. There would be a viewing at the funeral home, and then a graveside service."

But rain prompted a change of plans. A brief service would be held instead at the funeral home, but the 10-person capacity meant that most of the 100 attendees would have to stand outside. "They locked the door once immediate family members filed inside for the funeral service," Sheshe explains.

"When I was there, I tried to keep my distance and wave. We talked to people, we all had our masks on … I spent most of the time outside." Some were in the foyer that was spacious enough for several people, she describes.

"I got there pretty early," she says. "I went in, viewed the body to pay my respects, and then quickly moved out because I wanted to be respectful of other people needing to go in and pay their respects."

But even the best of plans and intentions can get sidetracked.

Balancing grief and safety during coronavirus

Sheshe says that the funeral, held on April 4, took place before mandates were issued on wearing masks in public. During the service she attended, she observed that many of the younger family members were not wearing masks.

"Their thinking was that not wearing a mask wasn't that big of a deal," Sheshe says, "but funerals draw older people. You're going to get a disproportionate number of seniors, who would be at a greater risk of contracting the virus."

Sheshe spent about an hour paying respects and interacting with other family members and guests. And then, she was caught off-guard by another relative.

"One of my cousins … it was her mother who had passed … she had a mask on and I had a mask on, and we hugged," Giddens says. It was the only hug she gave before driving back to Houston.

A price for showing support?

Two months later, Sheshe received word that a close friend, who was in his 40s, died of brain cancer two weeks before his first wedding anniversary. Memorial services took place on June 6, about a week after COVID-19 restrictions were eased and businesses in Texas were allowed to reopen to 50% capacity.

Although there were fewer people at this funeral than the one she previously attended, Sheshe's vigilance over social distancing sometimes gave way to selfless exchanges of support. While she wore a mask throughout the funeral, "we had much more closer contact. There were definitely more hugs."

Difficult choices during the pandemic

Although the precautions alone could have left her too preoccupied to notice anything else, Sheshe did recall what her friend was facing during the months before his death — that his immune system was compromised because of his cancer treatment, and how his family had to maintain social distancing within the house during the pandemic.

Choices had to be made.

"We didn't get to hang out because of his cancer diagnosis even before COVID," Sheshe says sadly. "He and his family were doing a lot of extreme social distancing, given his compromised immune system. Even his daughter, who was a freshman in college, chose to go hang out with her friends during spring break.

"Because of this," Sheshe explains, "my friend told his daughter, 'Okay, you can go, but you are not coming back here.' She was staying at a relative's house, so that had to be very hard for her, not having that time with her dad."

"COVID created that separation," she says.

Tips for processing grief during COVID-19

The necessity of distancing in response to coronavirus raises questions about what people can do to appropriately help themselves or others in need during a pandemic. At Houston Methodist, support resources are available for adjusting to a new normal.

In a COVID world, the Kubler-Ross model of the five universal stages of grief — denial, anger, bargaining, depression and acceptance — works best with patience, according to the Rev. Allison R. Powell, senior chaplain with the Spiritual Care Values Integration Department at Houston Methodist.

An ordained minister since 1999, Rev. Powell recognizes the value of identifying the complex emotions involved in experiencing loss — and addressing them honestly.

"It's normal and difficult to feel grief, loss and pain, and some also may feel a measure of suffering during this pandemic crisis," Rev. Powell said. Her advice:

• First, give yourself the permission to engage your spirit. Engage your inner emotions. Grieve, cry, release the pain of losing your loved one or any type of loss or pain during COVID-19.
• Give yourself time to grieve. Sad, messy emotions take time to process. Allow yourself to process.
• Be patient with yourself and your bereavement process — and be patient with others if they are grieving, too.
• Tears and emotions are your friends. They are internal indicators that remind you that you have a need for help and healing.
• Finally, give yourself permission to talk to others about your grief. Join a grief support group or seek out your chaplain, counseling resources or other resources, such as employee assistance programs or clinical support for "talk therapy."