PICU care has evolved substantially in recent years, both in terms of technology and humanization of care. Visits and the presence of parents at the bedside during a child's hospital stay were long forbidden. After World War II, with the mass separation of children from their parents, several studies emerged on the psychological effects of this separation during childhood, including hospital admissions (10). However, until the mid-20th century, children were still separated from their parents during hospitalization. At this time, a growing movement sought to raise awareness of the importance of meeting the psychosocial and developmental needs of children, as well as of the importance of the family in promoting child health and well-being. As research was published demonstrating the effects of separation of children from their families, many facilities began to adopted policies that encouraged parents to remain at their children's side during hospitalization and medical procedures (11).

The perspectives and information provided by the child's family play an important role in clinical decision-making, considering that the family is the main source of strength for the child (12). In addition, some pediatric patients are not able to verbalize their symptoms and desires, either due to their stage of development or their clinical condition, leaving parents in charge of communicating on behalf of the child and thus making collaboration between parents and health care workers particularly important (11).

In an attempt to change the way providers care for and interact with children and families, PFCC—a health care practice based on respect for individual needs and values (13), which encompasses comprehensive care and guides patient and family autonomy in care and decision-making (12)—was introduced in pediatrics. PFCC is an approach to planning, implementing, and evaluating health care based on collaboration between providers, patients, and the family, for the benefit of all; its core tenets are dignity and respect, information sharing, participation, and collaboration (14). These approaches lead to better health outcomes and wiser resource allocation, as well as greater stakeholder satisfaction (12). In Table 1, we cite some of the studies that address patient- and family-centered care.

PFCC guidelines include having the family present in the PICU, providing family support, and communicating with family members (13). The pandemic and the attendant increase in COVID-19 cases have led to economic, social, and political impacts in several countries, as well as implications for the availability of hospital beds, equipment, and other health resources (22). In order to contain the spread of the pandemic, several restrictive and restructuring measures were implemented, including in hospitals, with impacts on PFCC and on the mental health of those involved.

The U.S. Centers for Disease Control and Prevention (CDC) advises that visits to health facilities be limited during the pandemic. Visits to patients who are in COVID-19 isolation should be restricted to those who provide essential care, such as parents, with only one person allowed at a time. The presence of family members during aerosol-generating procedures or respiratory specimen collections is contraindicated (23). In most PICU settings, all visits were banned, only one parent or legal guardian was allowed to remain with the child and, even so, for shorter periods of time (24). At some hospitals, older children and adolescents were not allowed a chaperone when they were sedated. In addition to these restrictions, other issues can prevent parents from being with their children, such as COVID-19 infection itself, which requires isolation of the infected parent and reorganization of the family unit so that another responsible adult can chaperone the child.

Maintaining social distancing from one's family during hospitalization can lead to greater parental vulnerability, threaten parental autonomy, and risk returning to a disease-centered approach, neglecting patient- and family-centered care (25). Studies carried out before the pandemic showed that more than half of all parents of children admitted to a PICU experienced symptoms of anxiety or depression during their child's hospitalization, which remained for approximately 3 months after discharge (26). Of these, 10.5 to 21% were diagnosed with post-traumatic stress disorder (PTSD) and 84% continued to experience symptoms of this disorder after their child's discharge from the PICU, with mothers being most affected. Among children, 5 to 28% had a diagnosis of PTSD after PICU admission, and 35 to 62% had symptoms of PTSD (27).

Another study showed that parents of children hospitalized during the pandemic had significantly higher rates of anxiety and depression symptoms than parents of children hospitalized before the pandemic period (28). Children who have lost a parent to COVID-19 are more susceptible to mental health problems due to fear of circumstances and grief over the loss of the parent (29).

For children in palliative care and their families, visits are particularly important. Restricting visits in these cases increases anxiety, suffering, and moral damages, and negatively impacts patient quality of life (30, 31). In addition, the suffering of family members of children who die in the PICU can be made worse by being away from their support network (31).

The presence of family members during PICU hospitalization is essential to minimize the emergence of psychological symptoms in children and parents alike, both during hospitalization and after discharge. Given the current situation, new ways of providing PFCC are needed. Virtual meetings have been the strategy used in some facilities to bring parents closer to their children, sharing decision-making for care and minimizing the negative impacts of separation (9).

Family support refers to the support provided by health care workers to family members on issues including family education, involvement in care, use of tools for assertive communication and support of family decisions, as well as respect, recognition, and acceptance of the family's values and emotions when faced with a poor prognosis or the death of the patient, aiming to improve the mental health of parents during and after PICU discharge and increase family satisfaction with care (13).

Studies have shown that parents are satisfied with the care provided in PICU settings, especially with regard to providers' attitudes (32–34). During the COVID-19 pandemic, we have found that many health care workers have also been affected psychologically due to increased workload, fear of contamination, and shortage of human and material resources, among other factors (35). The risk of contagion, absence from work when infected, and even witnessing the deaths of colleagues and patients have created additional stress for many health care providers (36). The idiosyncrasies of health care work compound the aforementioned issues and include being undervalued, poor working conditions, unsafe physical infrastructure, inadequate staffing, poor flow along care pathways, lack of cooperation for teamwork, and support from leaders, among others (35).

The prevalence of mental disorders in front-line providers is expected to rise, as psychological disorders such as anxiety, depression, and PTSD have already been identified in health care workers after previous pandemics (37). Among nurses who worked directly in the care of patients with severe acute respiratory syndrome (SARS) during the 2003 outbreak, the development of psychiatric symptoms was linked to direct exposure to SARS patients, history of previous mood disorder, younger age, and perceived negative feelings (38).

In addition to the difficulty of providing support due to the absence of other family members at the PICU, we believe that the mental health of providers themselves also interferes with this practice, considering that they are also emotionally distressed and experiencing the consequences of the pandemic on their personal lives.

Availability of counseling within the hospital is of paramount importance to support the fight against COVID-19, as well as to support children and parents during treatment and hospitalization. The pandemic has hindered the provision of psychological and spiritual support to families (31). However, virtual care has been a method of providing support and helping to cope with the situation, with many services offered free of charge to the population (29, 39).

Several health facilities have also invested in hiring mental health teams to support their personnel, working to prevent and treat symptoms arising from the burden of working in a pandemic context.

Communication between health care workers, family members, and patients is a core feature of PFCC. Interdisciplinary meetings with the family help ensure assertive communication, increase trust in the team, and improve family satisfaction. Active listening and expressions of empathy and support must all be present in communications (13). The use of personal protective equipment (PPE) such as masks and gowns has been recommended both inside and outside the hospital. However, these interfere with nonverbal communication, which is of the utmost importance in interactions between providers, patients, and families, and can make it difficult for health care workers to gauge the emotional reactions of family members, of which they must also be aware (9, 40).

Shared decision-making between physician, patient, and family is at the heart of communication in PFCC. However, during the pandemic, difficult situations—such as the need to decide which patients will receive treatment and which will be denied due to limited resources—cause ethical stalemates, with psychological repercussions for health care workers; this interferes with provider-patient-family communication (22, 41).

The high workload of health personnel and the absence of family members at some moments during hospitalization have also interfered with communication. In this context, telemedicine has been used as a strategy to maintain communication with families, such as by holding video calls with parents during rounds and scheduling meetings to share decisions and care plans (9). Although not equivalent to face-to-face encounters (42), these strategies can minimize difficulties in communication.