This study adopted a qualitative, narrative, cross-sectional multiple case study design (Stake, 2006; Sehn et al., 2022). This approach allows for an in-depth understanding of individuals’ experiences across different contexts, considering both the singularities and commonalities of their lived experiences as well as the complexity of the phenomenon under investigation (Sehn et al., 2022; Stake, 2006).

The study included four women aged 21 to 51 years (mean age = 37.8 years; standard deviation = 11.7). Each participant had lost two family members to COVID-19 (Table 1 presents sociodemographic data and information regarding the sequential losses). These participants were drawn from a broader study (n = 13), titled [information omitted], which examined processes of loss, grief, and resilience following the death of one or more loved ones due to COVID-19. For the present investigation, participants were selected from among those who had experienced the loss of two or more family members (n = 7)¹.

Participant selection followed Stake’s (2006) recommendation to include cases that offer the greatest opportunity for learning about the phenomenon of interest, while also ensuring contextual diversity. Accordingly, participants were chosen to represent different kinship relationships with the deceased, as well as varying age groups and family configurations. The number of participants is also consistent with methodological guidance for multiple case study designs, which recommends the inclusion of at least four cases to ensure the analytic advantages of this approach (Stake, 2006).

Table 1

Variable	Astromélia	Begônia	Camélia	Dahlia
Age (years)	46	33	51	21
Race/Ethnicity	White	White	Black	White
Family configuration	Married, three children	Married, one child	Widowed, no children	Single, no children
Region	South	Northeast	Southeast	Southeast
Educational level	High school	Some college	College degree	College in progress
Average family income*	R$ 7,000.00	R$ 4,000.00	R$ 10,000.00	R$ 5,000.00
Contracted COVID-19	Yes	Yes	Yes	No
Hospitalization due to COVID-19	No	Yes	No	No
Deceased family members and timing of deaths	Father, November/2020; Brother, November/2021	Mother, March/2021; Maternal grandmother, April/2021	Husband, June/2021; Sister-in-law, June/2021	Maternal aunt, January/2021; Maternal uncle, June/2021

*

In calculating average family income, the monthly financial earnings of all household members living with the participant were considered.

For recruitment purposes, the broader study was disseminated through social media platforms (Instagram and Facebook), as well as among individuals who participated in support groups for bereaved family members during the pandemic. This process was facilitated by professionals who coordinated these groups in different regions of the country. Inclusion criteria for the project [title omitted] were as follows: being Brazilian; residing in Brazil; being 18 years of age or older at the time of data collection; having lost one or more family members to COVID-19; having internet access that allowed participation via video call; and providing authorization for interview recording.

Data collection was conducted remotely via the Zoom platform through structured interviews carried out in a semi-directed manner. With specific regard to the four cases included in the present study, interviews were conducted by two psychologists, both master’s students in Psychology, between June and October 2022. Interview duration ranged from 96 to 146 minutes (mean age = 122.7 years; standard deviation = 22.5).

The study was conducted in accordance with Resolution No. 510/2016 of the Brazilian National Health Council and was approved by the Research Ethics Committee of Federal University X (CAAE: X; Approval No.: X) [information omitted]. All participants completed the procedures related to informed consent. To ensure confidentiality and preserve anonymity, sensitive information that could lead to participant identification was omitted. In this regard, flower-related pseudonyms were used, chosen to symbolize the re-signification of the cycles of life and death. These systems involve structures that germinate, bloom, and die, while also leaving substrates that may generate new life and nourish the soil, representing a legacy that encompasses both fragility and potential.

Two instruments were administered, both developed for the broader study and reviewed by two experts in the fields of illness, death, and grief (both psychologists, one holding a PhD in Psychology and the other a PhD in Nursing):

Sociodemographic data form. This instrument collects information on age, place of residence, family configuration, educational level, occupation, income, and general health conditions.

Interview on loss, grief, and resilience during the COVID-19 pandemic. This instrument is composed of thematic blocks addressing the following topics: the pandemic and changes in daily life; the pandemic and mental health; illness experienced by the participant and/or family members; family losses; perceptions of grief processes; resilience; and social support. Each block consists of questions and follow-up probes designed to deepen understanding of participants’ experiences.

All interviews were audio-recorded and transcribed verbatim. After repeated readings of the transcripts, the first author of this study (a psychologist with a master’s degree in Psychology) initiated an in-depth construction of the case narratives (Stake, 2006), with support from the third author (an undergraduate Psychology student). Subsequently, an inductive thematic analysis was conducted (Braun & Clarke, 2019), with the participation of the second and last authors (both psychologists, holding PhDs in Health Sciences and Psychology, respectively).

The case narratives and transcribed material were read and discussed by the authors in a recursive and reflexive process (Braun & Clarke, 2019). This process initially enabled familiarization with the data, followed by the generation of initial codes based on participants’ accounts of sequential family losses due to COVID-19. The narratives of each case were progressively refined as the themes were developed. Both the initially coded excerpts and the full transcripts were continuously revisited as part of the iterative process characteristic of inductive thematic analysis (Braun & Clarke, 2019).

Ultimately, three themes grounded in participants’ narratives were identified: the context of multiple deaths; farewell rituals and funeral ceremonies; and grief processes related to sequential losses. The narratives of each case were written in detail and included verbatim excerpts illustrating these themes. This approach allows readers to assess transferability, that is, the extent to which the findings of the present study may be useful for understanding similar cases (Sehn et al., 2022). These procedures also enabled cross-case analysis (Stake, 2006).

Born into a large family, Astromélia lived with her husband and three children. During the first year of the COVID-19 outbreak, eight members of her family were simultaneously infected. Faced with the hospitalization of both her mother and father, the participant assumed responsibility for receiving medical updates and communicating them to other family members: “It was a huge responsibility, and I understood how important it was at that moment. At that moment, I felt very, very strong.” Astromélia’s father died on the eighth day of hospitalization, while her mother was discharged after 20 days in the hospital.

Approximately 1 year later, Astromélia’s brother contracted COVID-19 and died, imposing yet another bereavement experience on the participant: “We were still swallowing our father’s death, still taking care of our mother’s sadness, and then my [brother] came.” Because she perceived herself as the family member most capable of dealing with illness-related situations, Astromélia took the lead during all three hospitalizations (father, mother, and brother), managing decisions and even filtering information provided by the health care team: “I received the medical report. After I had processed it, … I found the right words to pass it on to them in a way that I wasn’t lying, but also wasn’t using such harsh words.”

Regarding farewell rituals, Astromélia reported that family members were able to say goodbye to her father via video call “We were all together, the nieces, the whole family… It was the last time we managed to talk to our father, everyone looking at him, him seeing everyone… There was a farewell, and the next day he passed away.” In contrast, she was able to be physically present throughout her brother’s hospitalization and emphasized the importance of accompanying him closely until the end:

Astromélia reflected on the differences between these experiences: “With my father, I was at home, seeing everything from afar. With my brother, I was inside the hospital, with him, holding his hand, going through the pain and the fears.” In both cases, funeral ceremonies were limited to brief cremation services with a restricted number of attendees. With regard to grief processes, Astromélia described difficulties in connecting with the emotions triggered by the sequential losses, reflecting on her emotional and behavioral responses: “I don’t cry, I’m not externalizing sadness, anger, resentment, or hatred. I’m just closing myself inside my cocoon, inside my world, maybe because I want to.” When recalling difficult moments during the interview, she stated: “I was surprised that I cried [during the interview]. Because I was in this process of darkness, without feeling… Remembering what happened, having someone give me time to talk, to talk and hear myself.”

It is possible that, by avoiding direct contact with the pain of loss, the participant preserved emotional resources to assume a decision-making role amid the distress of other family members, whom she also supported in their grieving processes. Reflecting on the deaths of her father and brother, as well as on human finitude, Astromélia stated: “I’m not a sad person, because I understand death and I understand life, I understand the situation, but I see that life is gray… a piece of me is missing, a piece that went with them.” She also emphasized the absence left by her father and brother within the family system as a whole: “There’s a void, an emptiness, that space at the table, that space at a party, at a family gathering, at dinner, at lunch. That emptiness of the two of them remained. We have two empty seats at the table that no one will ever fill.”

Begônia lived in the Northeast region of Brazil with her husband and her son, who was born in 2019. As both her family of origin and her husband’s family lived in the Southeast (approximately 2,500 kilometers away), they had not met in person since 2018. In 2020, the couple planned a trip to visit their families, which was postponed to 2021 due to the pandemic: “I bought the ticket 8 months in advance because, in my mind, the pandemic would be under control… When April 2021 arrived, the pandemic actually got worse… That’s when everything started to change.” The deaths occurred in the context of this long-awaited trip.

As a precaution, Begônia’s mother took a rapid COVID-19 test prior to the arrival of her daughter, son-in-law, and grandson, as she had been in contact with a coworker who tested positive. Because the result was negative, the trip was maintained. After the nuclear family arrived, Begônia’s mother and grandmother developed flu-like symptoms that progressively worsened, leading them to seek emergency care. The grandmother was medicated and discharged, whereas the mother required hospitalization.

Begônia emphasized that, at the time of her mother’s hospital admission, she fully believed in her recovery: “In my head, everything would be fine. I didn’t grasp how serious the situation was.” While her mother was hospitalized and her grandmother was symptomatic, Begônia and her sister were tested and received positive COVID-19 results. Within a few days, the grandmother’s condition deteriorated, and she was also hospitalized. Due to the severity of symptoms within the family, Begônia sought medical care and was advised to be hospitalized to prevent further worsening. While completing admission procedures, she received the news of her mother’s death. After 11 days of hospitalization, Begônia was discharged. A few hours after she left the hospital, her grandmother also died.

Regarding farewell rituals, Begônia was unable to say goodbye in person to either her mother or grandmother due to visitation restrictions. In addition, her grandmother’s hospitalization overlapped with her own. During the interview, she reflected on the meaning attributed to this experience: “It was better, you know? Because, one way or another, I said goodbye. I saw my mother being admitted [to the hospital], I was able to tell her that I loved her and hear from her that she loved me. That’s better than seeing her there, in a coffin.” For Begônia, remembering her mother alive brought comfort and connected her to positive shared memories. The death of her mother was experienced as unexpected, unlike her grandmother’s death: “I didn’t cry, it was like I was expecting it. With my grandmother, I swear, I was kind of expecting it.” Due to pandemic restrictions, no funeral ceremonies were held, and Begônia’s husband managed the practical arrangements following the deaths.

In the grief processes related to the sequential losses, Begônia reported experiencing mixed emotions, such as sadness and a sense of estrangement: “I was sad… completely out of it, outside my comfort zone, but I was distracted.” These accounts suggest the particularities of adapting to a world without the deceased, which Begônia described as especially difficult, as she had not experienced previous losses before her mother’s and grandmother’s deaths: “Before, I had this feeling that everything worked out. I had never lost anyone.” Thus, her perception of vulnerability changed following the experience of sequential deaths.

In the initial phase of processing grief-related pain, the participant described a sense of “emptiness,” both emotionally and physically: “I remember that when I went [to my mother’s and grandmother’s house], I didn’t feel anything. It felt like it was just a house. I tell everyone this, there was no longer their smell.” Although she had not seen her nuclear family members in person since 2018, Begônia maintained daily contact, particularly with her mother: “We talked all the time, constantly, through WhatsApp video calls… We had such a strong connection.” She also reported feelings of anger and hopelessness, along with attempts to suppress grief-related emotions: “I blocked everything… I didn’t cry; I didn’t do anything. When I thought I was about to get sad, I thought about something else.” To some extent, this emotional control was motivated by the need to care for her young child: “You’re grieving, and you have a 1-year-old child to take care of, while all you want is to lie down.”

As a result of the deaths, the participant expressed sadness over losing the main reference figures in her maternal family and, to some extent, their legacy, particularly because her mother was an only child. Reflecting on this situation, Begônia stated: “My family, on my mother’s side, literally no longer exists… You know those family stories, when you wonder, ‘Was it really like that?’ And now there’s no one left to ask.”

Camélia and her husband were a childless couple who, according to the participant, had a satisfactory marital relationship. After a period of heightened isolation in 2020, both contracted COVID-19 in 2021 following contact with infected family members. Among these relatives was a sister-in-law (the husband’s sister), whose hospitalization was supported by Camélia. A total of 5 days after Camélia and her husband received their diagnoses, her husband required hospitalization. The losses occurred in this context, in which both the husband and the sister-in-law were hospitalized simultaneously.

Camélia assumed responsibility for communicating with the health care teams caring for both patients, as her sister-in-law had no other emotionally close relatives able to fulfill this role. Her husband’s clinical condition deteriorated rapidly, requiring intubation. This intervention, however, was not successful, and he died. Faced with intense suffering following the loss of her spouse, Camélia delegated communication with the healthcare team caring for her sister-in-law to her own sister. The sister-in-law also died nine days later.

Regarding farewell rituals, the participant recalled a particularly meaningful moment in which she was able to speak with her husband via video call during his hospitalization: “Someone was holding the phone for him and he said goodbye to me… I didn’t know it, but that was the last time I spoke to him.” Camélia was later contacted to authorize a medical procedure and asked the physician for permission to see her husband, who died a few hours after that encounter: “I found my husband weakened… I touched his body, he was already thinner… I looked at the monitors and saw everything beeping, red… I saw that he was no longer there, but I didn’t want to admit it.”

With respect to funeral ceremonies, Camélia reported that her sadness was intensified by the impossibility of being physically close to members of her socio-affective network during a moment of profound grief: “We held an outdoor ceremony, just among ourselves, because people didn’t want to come either. People were afraid to go. And so no one hugged, no one held hands… We just stood around the coffin crying.” This funeral ceremony did not align with the participant’s expectations of how her husband’s memory should be honored: ““Nothing close to what I consider ideal, what I would consider dignified. But at least I didn’t see him inside a black bag, like I saw on TV.”

Regarding the death of her sister-in-law, Camélia was the last family member to see her alive, as the hospital did not allow patients to keep their mobile phones: “I just filled out a form and they immediately took her away in a wheelchair. She turned back, called me, and waved goodbye from a distance.” Neighbors and Camélia’s sisters assisted with organizing the funeral ceremony, which the participant felt unable to attend: “I felt like I needed to do something to help my sister-in-law, but I couldn’t. I felt lost, completely helpless, not knowing where to start. And in the end, I did nothing.”

With regard to grief, Camélia reflected: “Grief has the part where you just suffer, because you loved deeply. So grief is proportional to the love you felt for the person who died. And there’s another part, I think grief is feeling incomplete.” During the initial period of processing the pain associated with the sequential losses, Camélia reported intense suffering: “I didn’t even know what to do, and I spent two months lying down, without getting up. I only got up… because my sisters forced me to… I lost 17 kilograms… I suffered a lot.” She experienced the repercussions of grief across multiple areas of her life, struggling to adapt to the reality of the losses. Fearing loneliness, Camélia moved back into her parents’ home. However, she noted that not all members of her socio-affective network understood her grieving process: “I feel that people don’t know how to deal with someone who is going through a loss, or multiple losses, which was my case. It’s as if you turn a key after a year and that’s it, you’ve already lived your grief. But it’s not like that.”

In addition, because Camélia and her husband did not have children, his family claimed a portion of the couple’s shared assets, which generated distress and frustration and overlapped with the process of grieving. Thus, beyond the deaths of her husband and sister-in-law, adapting to her new reality also involved distancing from other family members:

Dahlia was an only child and lived with her parents in the same municipality where most of her extended family also resided, which she described as being “very close-knit.” Several members of her family contracted COVID-19; five required hospitalization, and two died. In particular, at the end of 2020, her maternal aunt, one of Dahlia’s primary caregiving figures during childhood, was hospitalized due to COVID-19-related complications and died in early 2021. The family received news of her death during the New Year’s Day lunch: “My aunt’s death happened in a way that the whole family found out together… Since she had shown improvement in the previous days, we decided that on January 1st, those who had tested negative would have lunch together.”

Approximately six months later, the context of loss was repeated. Dahlia’s maternal uncle tested positive for COVID-19 and initially remained at home due to mild symptoms. However, his condition deteriorated suddenly, requiring admission to an intensive care unit (ICU), and he died after three days of hospitalization. Dahlia expressed anger and indignation regarding this situation, noting that it occurred during a period of relaxed social distancing, despite hospitals being overwhelmed:

With respect to farewell rituals, Dahlia reported being unable to say goodbye to her relatives in an appropriate manner during hospitalization. Regarding her aunt, information was relayed by the healthcare team, and only one video call took place, on Christmas Day: “The most painful part was not being able to be there in those moments, because it feels like we abandoned her. Because we couldn’t call, we couldn’t talk, we couldn’t be there. That was very difficult for me.” No farewell ritual prior to death was possible in the case of her uncle, who was admitted directly to the ICU and subsequently intubated.

Dahlia also reflected on adaptations to funeral ceremonies. Regarding her aunt, she stated: “Not having that last contact, that farewell. And then, at the burial, the coffin was closed. It was 5 minutes there, at the cemetery gate, no wake at all… That affected me deeply.” Despite these difficulties and restrictions, the participant described alternatives adopted by the family to make the moment more meaningful: “My cousin, her son, asked us to print a photo of her, because since the coffin was sealed, at least we could place a photo.”

In the case of her uncle, family members followed the funeral vehicle to the crematorium. Seeking to preserve his memory, the ashes were placed in two distinct and meaningful locations for both the uncle and the family - water and land:

On that same occasion of posthumous tribute, the family also planted a tree in memory of the deceased aunt: “We also paid tribute to my aunt by planting a tree for her, even though there were no ashes.” According to the participant, these rituals were important for re-signifying the losses and honoring the legacy of the deceased family members: “It gave a new, new meaning… like saying, ‘Your presence matters to us, you are still here with us.’”

Regarding grief processes, Dahlia reported initial difficulties in assimilating the losses, marked by disbelief, anger, and a desire to distance herself from people outside the family system: “That anger would come. So many times, not contacting people was exactly because of that, to avoid making comparisons like, ‘What did I do to… deserve this?’” Additionally, after her uncle’s death, the participant described a further complication of her grief experience, particularly due to fear that another family loss might occur: “That ‘new normal’ didn’t exist for me. For me, tomorrow would be another loss. That stayed very strong with me… I was just waiting for the next loss.”

Although her aunt and uncle were not members of her nuclear family, they were emotionally close and present in Dahlia’s daily life: “Losing my aunt was losing all that care, all that being pampered. Losing my uncle was losing the joy of the family.” She also reflected on the impact on the extended family: “Sunday lunches were always together. Not having the presence of two people feels like it reduced us so much, like we were so big and now we’re so small. That’s when you realize how much two people are missed.” Reflecting on the grieving process, Dahlia concluded:

The narratives of the four participants align with the perspective that sequential deaths occurred within a broader context of multiple concurrent losses, including disruptions to daily routines, in-person contact, and life projects. This scenario required individuals and families to reorganize and interact in new ways during the pandemic in order to preserve life (Hanauer et al., 2023; Stroebe & Schut, 2021). Thus, despite adherence to public health measures aimed at containing the spread of COVID-19, all cases involved simultaneous infection among several family members. This finding highlights the challenges faced during the public health emergency, in which disease transmission occurred despite efforts to restrict face-to-face contact, given that viral characteristics increased the risk of serial contagion among individuals sharing the same physical space (Canuto et al., 2023; Faghani et al., 2023; Sola et al., 2023). Within this theme, a singular aspect of Case B deserves attention. The participant postponed, for eight months, a planned trip to reunite with her extended family, anticipating that the pandemic would have subsided. However, the deaths occurred during this visit. This finding illustrates the unpredictability and instability that permeated the health crisis, both in relation to health-disease processes and to broader aspirations and plans (Schmidt et al., 2022; Sola et al., 2023).

Another salient aspect of the multiple-death context was the hospitalization of family members, particularly when hospitalizations occurred concurrently. This situation kept families in a continuous state of uncertainty, worry, and fear (Crepaldi et al., 2020; Ghezeljeh et al., 2023; Paiva, 2023). Participants also reported emotional overload, especially those who assumed responsibility for managing communication with healthcare teams and relaying information to other members of the socio-affective network (Cases A and C). Although these participants volunteered to act as intermediaries, they reported experiences of isolation (Case A) and exhaustion (Case C), at times neglecting their own needs. These findings are consistent with those reported by Ghezeljeh et al. (2023) in a study of family caregivers of patients with COVID-19 admitted to ICUs in Iran.

Furthermore, the anticipation of clinical improvement contrasted sharply with the occurrence of sequential deaths within a few days (Cases B and C), potentially affecting the process of accepting the reality of the losses (Eyetsemitan, 2022; Hanauer et al., 2023). Similarly, difficulties in believing that the deaths had actually occurred were reported (Cases B and D), which may be related to the rapid progression to death caused by a disease that was, at the time, still poorly understood (Aguiar et al., 2022; Faghani et al., 2023). The novelty of COVID-19 worldwide may have contributed to perceptions of infection, and especially death, as distant possibilities which became tangible only when participants and their family members were directly affected (Canuto et al., 2023). In this regard, three participants were simultaneously coping with relatives’ illness and hospitalization while themselves being infected (Cases A, B, and C), including the need for hospital care (Case B). Thus, stressors accumulated during a period in which participants were also striving for their own survival (Buckley et al., 2024; Crepaldi et al., 2020).

Across all cases, the experience of grief overlapped with the need to redefine family roles within a short time frame, resulting in overload within the family system (Paiva, 2023; Stroebe & Schut, 2021). In Case C, in particular, the intersection of the husband’s and sister-in-law’s deaths with loneliness led the participant to leave the home she shared with her spouse and return to live with her family of origin. This finding aligns with the notion that the absence of a very close person, such as a spouse, may generate an overwhelming sense of emptiness, as also reported by Aguiar et al. (2022) in a study of Portuguese individuals bereaved during the pandemic. In Case D, sequential deaths triggered anger, frustration, and a sense of injustice (Eyetsemitan, 2022), directed both toward the virus and toward segments of the population who failed to comply with social distancing measures, a response also observed by Selman et al. (2021).

Taken together, findings from the four cases reveal the complex context surrounding sequential family losses due to COVID-19, encompassing abrupt deaths occurring within a short period, caused by a poorly understood disease, as well as emotional, relational, and social dimensions linked to the pandemic scenario. According to participants’ narratives, illness and death processes were followed by multiple additional events requiring adaptation, including changes to farewell rituals and funeral ceremonies, with potential repercussions for grief processes (Crepaldi et al., 2020; Eyetsemitan, 2022; Schmidt et al., 2022), as discussed below.

With respect to farewell rituals and funeral ceremonies, both contrasts and similarities emerged across participants’ experiences. These differences were related to the context of multiple deaths, including hospital policies governing contact with patients’ socio-affective networks, patients’ clinical conditions, family members’ circumstances at the time of death, sociocultural aspects of each family, and public health measures in force at the time.

Regarding farewell rituals, two participants reported having a final contact via video call with at least one family member during the end-of-life process (Case A: father; Case D: aunt), emphasizing the importance of this moment. In this sense, remote farewell strategies may function as protective factors in the context of loss, as the opportunity to say goodbye in a meaningful way before death can facilitate the grieving process (Crepaldi et al., 2020). However, Selman et al. (2021) highlighted the ambivalence surrounding the use of information and communication technologies in farewell rituals, as such adaptations do not always meet families’ expectations. In Case D, despite the video call with the aunt prior to death, physical absence at the time of dying was described as distressing and associated with guilt related to feelings of abandonment of the ill relative (Selman et al., 2021).

In contrast, two participants were able to be physically present during the end-of-life process of at least one family member (Case A: brother; Case C: spouse). In Case A, close accompaniment of the brother during hospitalization and death was described as a unique and meaningful experience, aligning with the notion of quality of death for the patient and quality of life for the surviving family member (Schmidt et al., 2022). In Case C, however, despite the opportunity to visit the spouse a few hours before death, the encounter did not allow for the sharing of important relational experiences or for expressions of gratitude or requests for forgiveness, elements that are typically associated with farewell rituals and more adaptive grief outcomes (Crepaldi et al., 2020). Notably, the participant in Case C also had video contact with her husband during hospitalization, though not within a farewell ritual context. In Case B, the participant’s own illness and hospitalization precluded participation in farewell rituals with either her mother or grandmother. This finding is consistent with previous studies suggesting impairments in the ability to say goodbye among families experiencing multiple infections and deaths due to COVID-19 within a short time frame (Crepaldi et al., 2020; Eyetsemitan, 2022).

Regarding funeral ceremonies, only one participant attended the cremation services of both deceased family members (Case A). In Case B, no funeral ceremonies were held due to public health restrictions. In Case C, funeral ceremonies took place for both losses, but the participant felt able to attend only one. In Case D, the participant accompanied the funeral procession to the crematorium for one loss and participated in a brief farewell at the cemetery gate, with a sealed coffin, for the other. In Cases C and D, despite recognizing that these arrangements represented the best possible option at the time (Mitima-Verloop et al., 2021), participants expressed frustration, perceiving the ceremonies as insufficient to honor the deceased and to provide or receive mutual support in the face of loss (Schmidt et al., 2022; Selman et al., 2021). In Brazil, funeral practices typically involve open-casket wakes and burials attended by large numbers of people, with physical contact playing a central role in expressions of condolence (Crepaldi et al., 2020). The absence of these practices during the pandemic may have contributed to perceptions of funeral inadequacy, as reported in Cases C and D. In Case D, these factors may also have been associated with disbelief regarding the losses (Paiva, 2023; Worden, 2018).

Beyond changes to conventional farewell rituals and funeral ceremonies, the pandemic also fostered adaptations and the creation of posthumous tributes and memorials (Mitima-Verloop et al., 2021; Schmidt et al., 2022; Sola et al., 2023). In Case D, for example, family members planted trees and scattered ashes at sea to honor the deceased, acts that facilitated meaning-making in relation to the losses (Corona et al., 2022) and enabled tributes perceived as dignified (Sola et al., 2023). In addition, all participants referred to affective memories associated with deceased loved ones and emphasized the importance of recalling shared moments and family history, which may support grief processes (Qian et al., 2022). Thus, particularly in Case B, despite the impossibility of engaging in farewell rituals or funeral ceremonies, participants were able to attribute meaning to the losses (Qian et al., 2022; Schmidt et al., 2022), with the preservation of memories and shared experiences serving as sources of comfort.

Across the four participants’ accounts, the findings indicate an overlap of stressors, encompassing not only the sequential losses themselves but also the circumstances surrounding the deaths and the changes to farewell rituals and funeral ceremonies. Thus, primary losses (the deaths of family members due to COVID-19) and secondary losses (aspects of participants’ lives that changed as a result of these deaths), combined with the singularities and restrictions of the public health crisis, may have further complicated adaptation to a world in which loved ones were no longer physically present (Stroebe & Schut, 2021). This may be partially explained by the concept of grief overload, in which individuals or families experience losses in succession within a relatively brief period. Under such circumstances, there may be insufficient time to process the pain associated with one loss before the next occurs, such that each subsequent loss tends to intensify emotional reactions triggered by prior losses (Corona et al., 2022; Tobin et al., 2020).

In this regard, a sense of emptiness and a tendency toward social withdrawal were reported by all participants during their bereavement, in line with the literature (Aguiar et al., 2022; Eyetsemitan, 2022). In two cases (A and B), the narratives also suggested difficulties in connecting with one’s own emotions. Since these two participants occupied primary caregiving roles within their families, avoiding direct contact with grief-related pain may have functioned as a way to preserve themselves in order to manage daily responsibilities and provide support to other family members (e.g., children), with implications for their grieving processes (Worden, 2018). This highlights the intersection of gender in bereavement experiences: women, who frequently serve as primary caregivers within family relationships, may face an increased burden of emotional demands and practical responsibilities after the death of a loved one, which tends to complicate the grieving process (Schmidt et al., 2022).

In contrast, Case C was marked by an openness to experiencing profound sorrow. In addition to the death of her sister-in-law, this participant also lost her husband, with whom she described a high-quality marital relationship. Grief following spousal loss is often especially challenging, as the spouse is frequently a confidant with whom the bereaved person shared daily experiences, dreams, and life projects (Eyetsemitan, 2022). Moreover, in Case C, the husband’s death was followed by a reduction in household income and, additionally, a dispute over assets, culminating in the participant’s distancing from her late husband’s family of origin. In general, the literature highlights reduced family income and changes in social roles as common consequences of conjugal loss (Eyetsemitan, 2022; Worden, 2018). In Case C, specifically, the challenges related to these two factors appeared to be intensified by the legal conflict, as the participant also lost connections with individuals who had previously been part of her socio-affective network, which tends to further complicate grief processes (Corona et al., 2022; Harrop et al., 2023).

A related pattern was observed in Case B, in which the participant lost her mother and maternal grandmother, her two main reference figures within her family of origin, thus broadly affecting her socio-affective network. Although she lived geographically distant from her family, she maintained daily contact via video calls and described a strong emotional bond with her mother. After the death, she reported substantial difficulty adapting to her mother’s absence (Aguiar et al., 2022; Worden, 2018). Thus, despite the experience of sequential losses, she emphasized most strongly the pain associated with her mother’s death, expressing distress that her mother’s life had been interrupted prematurely (Eyetsemitan, 2022) in a rapid and relatively less expected manner than her grandmother’s death.

In Case D, among the emotional reactions described in the grief processes related to sequential losses, the participant reported persistent fear and worry about the possibility of a new infection and death due to COVID-19 among family members (Faghani et al., 2023; Stroebe & Schut, 2021). This finding is also consistent with the notion of grief overload in contexts of multiple losses, in which individuals fear the future and anticipate that another emotionally close person may die, which can provoke psychological distress and hinder the resumption of daily life (Corona et al., 2022).