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The Unspoken Nursing Skills of End-of-Life Conversations 

Posted on by Joseph Gerard

health care worker comforting a patientWritten by Marchelle Abrahams.

Some conversations are hard to have. And nothing can prepare you. Not a textbook. Not an online tutorial. Not a deep breath before delivering the bad news.

Once you have taken the Nurses’ Pledge of Service, talking to a patient about the end of their life is part of the package. Maybe you were warned how difficult it would be. Maybe you thought you’d cross that bridge when you got there.

The truth is that it doesn’t get easier. Sometimes the opposite. As long as you treat your patient and their family with dignity, the right words will form. Also, there are certain skills nobody has taught you until now.

Words Have Gravity

To you, words are something you speak to share information. An individual who doesn’t have the luxury of time can find comfort or hurt in them.

The journal Federal Practitioner published a paper titled The Meaning of Words and Why They Matter During End-of-Life Conversations several years ago. The advice still holds.

Author Grace Cullen goes into extensive detail on how essential effective communication is in healthcare delivery. However, misinterpretation can influence the quality of the care. 

The former palliative care nurse practitioner (NP) says that discussions must be handled with accuracy and precision. They must be conducted in a timely fashion and require skills that take practice to sharpen.

So, what are those skills?

With her years of experience, Cullen has learned that nurses don’t control how the conversation flows. 

“We approach patients with a blank canvas, open to receive messages that will be shared and reacted to accordingly.” – Grace Cullen, DNP, FNP-BC, ACHPN, AOCNP, RN-BC.

That’s why end-of-life (EOL) talks require compassion, an inherent human trait that isn’t taught in textbooks. Instead, it’s cultivated with training and application, advises Cullen.

Suggested Communication Phrases

Do not use medical terms. Talk in simple language and repeat the information. The truth should be gradually introduced to the patient.

Don’t leave families to their own devices. Offer administrative help, such as suggestions for hospice or palliative care. (Flugelman MY. How to talk with the family of a dying patient. BMJ Supportive & Palliative Care 2021;11:418-421.)

When speaking about advanced planning, Healthier Washington Collaboration Portal suggests the following:

  • What’s your understanding of your current situation?
  • If there ever came a time when you couldn’t make decisions for yourself, who would you trust to do that for you?
  • When you think about dying, have you thought about what the end would be like or how you would like it to be? 

Look to Mentors for Advice

You’ll probably get the best advice from your mentors. And yet, they’ll admit that no matter how many times you have the conversation, it still stings.

That’s why it’s important when finding a preceptor for a nurse practitioner to latch onto someone with years of experience in the EOL field. They can guide you on the best practices and share their wisdom on what works and what doesn’t.

In most cases, a nurse practitioner (NP) preceptor is a proficient clinician. They bridge the gap between classroom theory and real-world practice. In other words, you’re in good company.

ClickClinicals advises using professional NP preceptor matching services to ensure you’re matched with a preceptor aligned with your goals. They’re a sound option for nurse practitioner clinical placement help, and they’ll find you an NP preceptor fast.

Missed Opportunities for EOL Care Discussions

Timing is everything. Having the conversation too late can do more harm than good. A qualitative study published in the JAMA Network revealed a few insights. 

About 140 oncology patients were surveyed. Only 21 (5%) of encounters included EOL discussions. The study found that early EOL care preferences improve clinical outcomes. Unfortunately, most talks occur a month before death, despite most patients wanting information earlier.

Discussions about end-of-life care shouldn’t wait until a patient needs hospice, psychiatrist Natalie Jacobowski tells the Cleveland Clinic. She views it as counterintuitive.

Ask for permission to speak about the “what ifs” when starting treatment to prolong a patient’s life, advises Dr Jacobowski.

Create a Safe Space

Talking about someone’s imminent death is taboo, to say the least. It’s also uncomfortable and morbid.

A patient might not want to broach the topic, as it may appear weak or negative. Dr Jacobowski suggests taking your cue from them. Watch their body language. Acknowledge their fears. 

Take this as a step in the right direction. 

Frame the conversation as: “I imagine there are a lot of thoughts and worries. Is there anything that’s standing out to you that’s worrying you the most?”

That way, the patient will know you’ve created a safe space for them to voice their concerns.

Validate and Respond

Not every conversation goes according to script. Emotions are fraught. Anger. Sadness. Frustration. Grief. Patients are feeling them all at once.

Don’t gloss over their response and carry on like normal. Recognize their emotion and name it. For example: “I can see that this is incredibly difficult and upsetting to hear.”

Always lead the conversation, but also prioritize open-ended questions, because they’ll have many.

Validate their feelings. No judgment needed. Allow for silence. Remember, they’re only just processing the news. It takes time.

 

FAQs: End-of-Life Conversations in Clinical Practice 

  1. Why are end-of-life conversations delayed in healthcare settings?
    Many clinicians hesitate due to discomfort, fear of removing hope, or uncertainty about timing. 
  2. What is the most important communication skill during end-of-life discussions?
    Clarity paired with compassion. Using simple, non-medical language helps patients and families better understand and process the situation.
  3. How can clinicians create a safe space for these conversations?
    By asking open-ended questions, observing body language, and validating emotions without judgment.
  4. How do preceptors help nurse practitioners improve in end-of-life care?
    Experienced preceptors provide real-world exposure, model difficult conversations, and offer feedback that helps refine communication skills.

Key Statistics at a Glance 

Topic Finding Insight
EOL Discussions in Oncology Encounters  5% (21 out of 140 patients)  Very few clinical encounters include EOL discussions.
Timing of EOL Conversations  Often, within one month before death  Conversations are happening too late, limiting patient autonomy and preparedness. 
Patient Preferences  The majority prefer earlier discussions  Patients want transparency sooner, not at critical decline stages. 
Communication Risks  Misinterpretation affects care quality  Poor wording or unclear messaging can negatively influence patient understanding and care decisions. 

 

Parting Words

You chose to become an NP for a reason. And that reason is to care for and help people heal. Keep that in mind whenever sensitive patient discussions arise.

Lectures and textbooks can only teach so much. The rest is up to you. 

Whether you’re at the start or in the middle of this big, bold, beautiful journey called nursing, never forget why you are here.

References:

 

Author bio

Marchelle Abrahams is an award-winning writer (RDMA Awards 2019) who found her voice after carving a niche as a features writer for Independent Media. Currently, she freelances for various print and online publications, while ghost-writing blogs for several clients. 

 

 

Please also review AIHCP’s Grief Counseling Certification, as well as its Child and Adolescent Grief Counseling Program, Pet Loss Grief Counseling Program, Christian Grief Counseling Program, Grief Diversity Counseling Program, Grief Perinatal Program, Grief Practitioner Program and finally its Grief Support Group Leader Program.

Grief Counseling: Death of an Estranged Loved One Video Blog

Posted on by Mark Moran

Unfortunately, when someone dies it does not always occur under the best family conditions.  Some families may be divided, estranged, or not speaking.  In some cases, the estrangement between the deceased and the living family member.  These situations add complications to already a sad and grieving situation.  This video reviews some of the complexities associated with death of a estranged loved one.

Please also review AIHCP’s Grief Counseling Certification Program

The Creative Grief Cycle: Stage 1 – Creation

Posted on by Joseph Gerard

Where Grief First Finds Language

Written by Daniel Stern

A Conceptual Model Emerging from Lived Experience

The Creative Grief Cycle is a conceptual framework that emerged from my own experience of grief and the process of writing through it. In the time following loss, I found that writing did not begin as expression or communication, but as something more immediate—an attempt to give form to experience before it could be fully understood. What I describe here reflects that process. It is not a formal clinical model, but an effort to articulate a pattern that became visible through lived experience, considered alongside existing research in expressive writing, narrative psychology, and grief theory.

In a previous article, I introduced what I call The Creative Grief Cycle—a way of understanding how grief moves through creative expression. In that earlier piece, I described how grief often begins in silence; this stage begins at the point where that silence first breaks into language. This article focuses on that transition: the moment when experience first enters language.

The cycle has three stages:

  • Creation — where grief first takes form in language
  • Communication — where that expression connects with others
  • Rediscovery — where the work can be revisited over time, allowing meaning to evolve

Here, I want to focus on the first stage: Creation.

Research in expressive writing and grief has shown that writing about emotional experience can improve psychological and physical well-being (Pennebaker & Chung, 2011). This aligns with work in expressive and therapeutic writing (Mazza, 2017; Stepakoff, 2009), and with research emphasizing the role of narrative in helping individuals organize and make sense of loss (Neimeyer, 2001; McAdams, 2001). What receives less explicit attention, though, is an earlier phase—the point before writing becomes expressive or communicative, when pre-verbal emotional experience first begins to take form in words. While elements of this transition appear across existing research, they are not typically isolated as a distinct phase in grief writing itself.

 

Writing Begins as Pressure

In my experience, grief did not begin in words. It began as something closer to pressure—diffuse, persistent, and not yet nameable.

This pressure did not feel like a thought or even a clearly defined emotion. It was more constant than that—something ambient, but insistent. It did not organize itself into sentences or ideas. It accumulated.

At times, it felt physical: a weight in the chest, a tightening, a sense of something pressing inward or outward without direction. At other times, it was harder to locate—an internal density, a sense of saturation, as though experience had nowhere to go.

Research in trauma and affective processing suggests that overwhelming emotional experience is often encoded in sensory, bodily, and affective forms before it becomes available to language (van der Kolk, 2014). Putting feelings into words can also change how those experiences are processed (Lieberman et al., 2007). In this sense, what I describe as pressure may reflect a stage where experience is present but not yet organized in language.

What defines this state is not just intensity, but a lack of structure. Something is there—persistently—but it cannot yet be articulated or fully understood.

It is this pressure, rather than intention, that seems to initiate writing.

Writing does not begin here as expression. It begins as a response. Something pushes toward language—not clearly or steadily, but in fragments that appear, recede, and return.

Words surface incompletely: a phrase, an image, a line that will not leave. There is often hesitation, even resistance. The act begins not because there is something clear to say, but because something can no longer remain entirely internal.

In practice, this early movement often appears in small, recurring fragments before anything fully forms. For example:

From “A Picture on the Wall”

A small square of pigment
leaned out of its silence
and took me by the collar.

Or:

From “Between Two Gravities”

Between what demands I shine
and the gravity that pulls me inward…

These lines do not yet explain, resolve, or interpret the experience—they simply hold it in place. What they do is more immediate: they allow something to remain present long enough to be encountered.

At this stage, what appears on the page is not meaning in the usual sense. It is better understood as what I call proto-meaning— the earliest linguistic shape of an experience before it has become explanation, insight, or story.

Experience begins to take shape in language, but it is not yet narrative, explanation, or reflection. What emerges instead are fragments—images, lines, repetitions—that allow experience to exist outside the self for the first time.

This shift is subtle but significant. What was previously diffuse and internal begins, however slightly, to cohere.

Seen this way, fragmented or image-based writing is not a failure of clarity, but the beginning of it.

At this point, writing is not oriented toward communication or interpretation. Its function is more basic. It brings experience into form—giving it just enough structure to be encountered rather than only endured.

This is the first movement of Creation: not clarity, but necessity.

 

When Language Creates Distance

Once experience begins to take form in words, something shifts.

Language introduces structure. Even a single line creates a boundary—this word instead of another, this image held long enough to be seen. What was previously diffuse begins, however slightly, to take shape.

This does not immediately produce understanding. The experience may still feel unclear. But something important changes: distance becomes possible.

Not detachment—but perspective.

The experience is no longer entirely internal. Some part of it now exists outside the self, where it can be returned to. The writer is no longer completely inside the feeling. Something has been set down, even if only partially.

Research on expressive writing shows that, over time, people begin to organize emotional experience into more structured language—connections, causality, and meaning (Pennebaker & Chung, 2011; McAdams, 2001). Before that happens, a more basic shift occurs: experience becomes something that can be held and revisited (Neimeyer, 2001).

Writing begins to do more than respond—it begins to shape.

That shaping is not linear. It circles. It revisits. It approaches the same experience from different angles. But even in fragments, something changes: what was uncontained is now being held, line by line.

 

Why Grief Turns to Metaphor

Even as writing begins to create structure, it rarely does so through direct explanation.

Grief often resists that kind of language. Statements like “I feel empty” or “I am overwhelmed” may be accurate, but they flatten the experience. They fail to capture its movement, its contradictions, and the way it shifts over time.

So the writing moves toward image.

This is not simply stylistic. In early grief writing, metaphor may become necessary because direct language can feel too limited.

In early drafts, grief often appears not as a statement, but as a force. The fragment returns, unchanged:

From “Between Two Gravities”

Between what demands I shine
and the gravity that pulls me inward…

Here, the experience is not named directly. It is approached through something else—gravity, pressure, distance. Not because these are more precise, but because they make the experience possible to hold.

This aligns with work in poetry therapy, which suggests that metaphor provides an accessible structure for experiences that resist direct articulation (Mazza, 2017; Stepakoff, 2009). Cognitive linguistics similarly proposes that metaphor acts as a bridge between emotional and conceptual experience (Lakoff & Johnson, 1980).

In early grief writing, metaphor functions less as ornament and more as a tool.

By mapping internal experience onto something more concrete, metaphor creates a structure capable of holding what would otherwise remain diffuse. It gives shape without requiring full understanding. It allows movement—an image can shift, return, and evolve in ways a direct statement cannot.

Through metaphor, writing does not simply express experience—it begins to uncover it.

 

Writing as Discovery: Aphelion

In my own experience, the first poem I wrote after loss—Aphelion—began without intention. It did not start as an effort to express or explain anything. Instead, it emerged in fragments: isolated lines, images that appeared without context, and a persistent sense of movement that I could not yet name.

The central metaphor developed gradually rather than by design. Aphelion—the point in an orbit where a body is farthest from the center it moves around—became a way of approaching an internal state that resisted direct articulation: a simultaneous sense of distance and attachment, of being pulled away while still held in relation.

An early passage reflects this movement:

Some slip the constellations we hope to trace,
following a hidden geometry,
their own unseen law.

And when they reach aphelion—
that farthest point
where distance feels eternal—
we feel their silence
more sharply than their light.

Early lines did not explain this. They circled it. Images of distance, gravity, and motion appeared before any clear conceptual link was made. The metaphor did not begin as meaning; it functioned first as a container—something stable enough to hold a shifting internal state.

As the poem developed over several weeks, that structure allowed movement. The metaphor could shift, return, and reconfigure in ways that direct language could not. What had been entirely internal began to exist externally—not as a coherent narrative, but as something visible and revisitable.

By the time the poem was complete, the experience itself had not resolved. But it had changed form. What had been diffuse became structured enough to be encountered.

This pattern is not unique to a single piece. Across early grief writing, metaphor often emerges not as stylistic choice, but as necessity—providing the first framework capable of holding experience before it can be interpreted.

At this stage, there is often:

  • no audience
  • no intention to explain
  • no clear endpoint

 

The process itself is the point. Writing is not expressing experience—it is creating the conditions under which experience can be known.

 

The Function of Creation

It is important to be clear about what writing in this stage does—and does not—do.

Writing does not resolve grief.
It does not produce immediate understanding.
It does not yet create stable meaning.

What it does is more foundational.

It transforms experience from something uncontained into something structured enough to be encountered. It brings experience into language—not as explanation, but as form.

What emerges at this stage is not fully developed meaning, but something closer to proto-meaning—the first structures capable of holding experience in language.

This can be understood as a process of linguistic emergence, in which pre-verbal emotional experience begins to take early linguistic form. Through this process, experience becomes something that can be returned to, engaged with, and gradually understood over time.

From this point, the later stages of the Creative Grief Cycle become possible:

  • Communication, where expression becomes relational
  • Rediscovery, where meaning evolves across time

But neither occurs without this first shift.

Before grief can be shared or understood, it must first take form in language.

 

Author’s Bio:

Daniel Stern is a retired engineer turned astronomer and astrophotographer whose poetry explores grief, silence, memory, and renewal. His work lives at the intersection of science and emotion, where observation becomes reflection and language reaches for what cannot be measured. He is the author of Aphelion, his debut book of poetry, and the chapbook The Roar of Silence, a collection born from personal loss and the search for meaning in its wake. In his work as an astronomer, his astrophotography has been recognized numerous times by NASA (APOD). He has discovered deep-sky objects and, in collaboration with others, has been published in peer-reviewed astrophysics journals. Stern lives in Delray Beach, Florida, with his wife, Randie.

Website:           Http://www.theroarofsilence.com

Email:                dstern@mea-obs.com

 

 

 

References

Baikie, K. A., & Wilhelm, K. (2005). Emotional and physical health benefits of expressive writing. Advances in Psychiatric Treatment, 11(5), 338–346.

Lakoff, G., & Johnson, M. (1980). Metaphors we live by. University of Chicago Press.

Lieberman, M. D., Eisenberger, N. I., Crockett, M. J., Tom, S. M., Pfeifer, J. H., & Way, B. M. (2007). Putting feelings into words: Affect labeling disrupts amygdala activity in response to affective stimuli. Psychological Science, 18(5), 421–428. https://doi.org/10.1111/j.1467-9280.2007.01916.x

Mazza, N. (2017). Poetry therapy: Theory and practice (2nd ed.). Routledge.

McAdams, D. P. (2001). The psychology of life stories. Review of General Psychology, 5(2), 100–122. https://doi.org/10.1037/1089-2680.5.2.100

Neimeyer, R. A. (2001). Meaning reconstruction and the experience of loss. American Psychological Association.

Pennebaker, J. W., & Chung, C. K. (2011). Expressive writing: Connections to physical and mental health. In H. S. Friedman (Ed.), The Oxford handbook of health psychology (pp. 417–437). Oxford University Press.

Stepakoff, S. (2009). From destruction to creation, from silence to speech: Poetry therapy principles and practices for working with suicide grief. The Arts in Psychotherapy, 36(2), 105–113. https://doi.org/10.1016/j.aip.2009.01.007

van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking.

 

 

 

Please also review AIHCP’s Grief Counseling Certification, as well as its Child and Adolescent Grief Counseling Program, Pet Loss Grief Counseling Program, Christian Grief Counseling Program, Grief Diversity Counseling Program, Grief Perinatal Program, Grief Practitioner Program and finally its Grief Support Group Leader Program.

Narrative Therapy and Grief

Posted on by Mark Moran

There are numerous modalities and therapies to help individuals face grief and loss in a healthy way.  Most psychotherapies share equal positive results in helping individuals deal with anxiety, grief, or other mental problems.  In the case of depression, as well as prolonged grief disorders, they also share in efficacy but many counselors prefer integrated approaches sharing from one discipline and incorporated another.  One type of therapy that many grief counselors find effective for grief and loss is Narrative Therapy.  While Narrative Therapy may not be for everyone, nor the sole answer, it can play a part in helping individuals understand their loss in a more constructive and adaptive way.

Narrative Therapy helps the client find new meaning in the loss. Please also review AIHCP’s Grief Counseling Certification

Please also review AIHCP’s Grief Counseling Certification Program and see if it meets your academic and professional goals.

What is Narrative Therapy?

Narrative Therapy is a type of constructivist therapy with postmodern philosophies developed by Michael Kingsley White and David Epston (Tan, 2022).  According to Tan, postmodernism is a world view that truth is not objective or tied to merely observation or within the systems of language in which is described and hence is open to subjective experience (2022). Social Constructionism applies this principle that the client is the expert on what one  experiences and understands one’s own subjective truth best without judgement of others (Tan, 2022).  Narrative Therapy falls under this type of philosophy, albeit, many of its techniques can be applied outside its rigid definitions.

Narrative Therapy is closely tied to meaning making and in that regards in some ways to Existentialist Therapy and the importance of finding subjective meaning to one’s issues.  Meaning is then created through social relationships, especially in one’s use of language in stories or narratives one shares.  Due to this, meaning and subjective reality can be rewritten or reframe or re-understood by the client through Narrative Therapy (Tan, 2022).  Narrative Therapy views human nature as basically positive and able to form new and better constructive directions through formulating healthier meanings about the past and present.  This is especially true regarding grief, trauma and loss.  Narrative Therapy opens the door for others to rewrite the story and replace past narratives that are saturated in negative and oppressive overtones.

Narrative Therapy finds many of its uses in David Neimeyer and his work utilizing meaning making and meaning reconstruction in grief counseling and loss.

Narrative Therapy at Work

A strong therapeutic relationship between client and counselor is required in Narrative Therapy.  It borrows this from many Rogerian concepts that utilize empathy and understanding and a true connection.  This type of connection is key in any type of grief counseling regardless of therapy and should be a fundamental concept for any one hoping to console the bereaved.    Due to the fluid nature of grief, Narrative Therapy does not propose a guide book of handling grief or emphasizing one technique over another.  It instead teaches that there is no true right or wrong way to conduct the therapy again applying to Rogerian person centered theories, as well as its social constructivist ideals (Tan, 2022).

Still, there are tools that are generally applied to individuals to help them move beyond their oppressive past narratives.  The attempt is to better understand the past or loss or whatever narrative, reframe it with new meaning, and incorporate it into the overall life of the person.  Much like any meaning reconstruction, where a person’s life is a likened to a book with various chapters, some good, some bad, but all delivering a theme and message of the wholeness of the person.

Journaling and reconstructing oppressive past narratives is key in Narrative Therapy and critical in Grief Couneling

First, question is key in Narrative Therapy.  The therapist or grief counselor will ask a variety of questions to help assist the person in understanding oneself.  The attempt is to help identify past oppressive narratives and to help the person become unstuck from those perceptions.  The second tool is externalization and deconstruction.  In this, the therapist hopes to help the person realize that he or she is not the problem, but the problem is the problem (Tan, 2022).    The problem or attribute is detached from the individual and seen as an independent and external parasite in itself.  This externalization serves as the starting point in facilitating deconstruction from the oppressive narrative (Tan, 2022).   Narrative Therapy will help the client map the problem and its influence on one’s life and how profoundly or deeply it has negatively altered one’s life.  Many times when  mapping, the counselor will look to label the problem and again externalize it from the person during the deconstruction phase.  A third tool is searching for unique outcomes.  This is more solution based and the therapist helps the client identify times the client dealt successfully with the issue and how this can be incorporated again and at a more efficacious result. Fourth, therapists help clients reauthor their story and find different future outcomes from what they feel by the past oppressive narrative.  They are also aided in reframing that story and taking control of it and finding meaning in that story.  Finally, documenting the evidence of client’s progress is key.  Therapist will include letters that the client later re-read that reinforces and summarizes the therapy when they are feeling less or discouraged.

Highly involved also in healing is writing.  Clients are encouraged to journal, write letters to oneself or unsent letters to others, similar to Gestalt Therapy.  Journaling is key to identifying oppressive feelings and themes, as well as controlling the narrative through the power of the subjective reality of the person writing their story.  This is not to dismiss the event, or even to dismiss facts, but to reinterpret these events and meanings in a more conducive way to healing which sometimes means looking at the loss, event, or problem in a different light.

Ultimately the therapy looks to help clients to control their own narrative through cognitive processes and writing processes to form a new narrative.  The client names the problem, explores how the problem has adversely affected him/her and explores new ways to interpret the the issue or find different meanings.  In addition, the counselor helps the client identify times when he/she successfully dealt with said issues, as well providing the client with encouragement on imagining a sound and healthy future beyond the problem (Tan, 2022).

Conclusion

One can see the useful elements of Narrative Therapy and some of its independent tools in helping individuals, especially with grief.  Individuals suffering from loss, or in some cases, pathological and traumatic loss need a therapeutic relationship that is filled with patience and empathy but they also need ways to face the past loss.  They need to remove the negative narrative that haunts them regarding the loss and find new meaning about the loss and how to incorporate it into one’s life.  This type of Meaning Reconstruction is a key element in Narrative Therapy and helps the person not only understand the past and find new meaning and authority over it, but also how to cope and develop a meaningful future that respects the past loss but also adjusts to it in a healthy and secure way.

New narratives can help individuals move forward from loss in a healthy way. Please also review AIHCP’s Grief Counseling Certification Program

Grief Counselors who are clinically licensed can utilize this therapy for those suffering from prolonged grief disorder, while in some cases, elements of it can be used for those not suffering from pathological or complicated grief reactions.  Journaling is a healthy element of Narrative Therapy for any case in understanding a loss and finding meaning in it.

Please also review AIHCP’s Grief Counseling Certification Program which is applicable for both non-clinical professionals as well as clinical professionals.  Of course, only clinical professionals can utilize Narrative Therapy with those suffering from complicated, traumatic or prolonged grief disorders.

Reference

Tan, S-Y. (2022). Counseling and psychology: A Christian perspective (2nd Edition). Baker Academic.

AIHCP Blogs

Honoring Endings-Access here

Grief Journaling- Access here

Additional Resources

Ackerman, C. (2026). “What Is Narrative Therapy? Techniques & Worksheets”. PositivePsychology.com.  Access here

Clark, J. (2025). “How Narrative Therapy Works”. VeryWellMind.  Access here

Guy-Evans, O. (2025). “Narrative Therapy: Definition, Techniques & Interventions”. Simple Psychology.  Access here

Narrative Therapy. Psychology Today.  Access here

 

 

What Makes Traumatic Grief Different?

Posted on by Joseph Gerard

Grief - human hands holding black silhouette wordWritten by Marko,

The idea of saying goodbye to someone you love forever is heartbreaking. 

But, as hard as it is, it’s a different kind of hurt when you compare it to losing someone out of the blue. It’s sad, but the truth is, being able to say goodbye is a privilege not everyone gets. 

You have time to sit with it, and to hold your loved one’s hand, even if it’s for the last time.

Then there’s the other way, when you’re just living your normal life. And someone knocks on your door and tells you your loved one is just… Gone. Just like that. No last conversations, no warnings. One minute they’re here, the next, they aren’t, and there’s nothing in between that. 

This kind of shock leaves your brain stuck, and that stuck place is called traumatic grief.

In this article, we’ll go over the differences between traumatic grief and what people call normal grief. And if you’re wondering why that difference is important, it’s because you can’t recover unless you know what you’re recovering from.

How Grief Usually Unfolds When Loss Is Expected

Grief always hurts. There’s no way around that. It doesn’t matter if loss is expected; nobody can prepare for it in a way that doesn’t hurt. 

But the hurt usually doesn’t come all at once. Instead, it follows a somewhat steady path. Imagine if a person has a family member who’s terminally ill. They know what’s coming, and the hard moments come little by little. The whole thing feels like this heavy burden they’re carrying around all the time, and when the time comes, and they finally lose their loved one, they already saw it coming.

This all gives the brain some time to prepare.

That doesn’t mean that there’s a way to be actually ready for what’s going to happen, but you can’t help but have a sort of mental rehearsal going on in your head. So, you might cry in your car every few days, or you might imagine what your life is going to look like once that person is no longer here. There’s time, which means there can be closure, and closure is the first step towards healing.

Time also means emotions can adjust. 

By no means does that mean it follows neat little stages that come one after the other. Grief is messy, and some days are better than others. Still, the little things like going to work and making dinner help in keeping you grounded.

And as time heals you, you’ll still have all the memories of the person who’s no longer with you, but it’ll stop hurting (as much, anyway).

If the loss comes without any warning, though, none of this can happen.

What Changes with a Sudden, Traumatic Loss

It’s very frowned upon to say that one kind of grief is harder than another because everyone deals with grief in their own way. 

You can’t know how someone else is feeling, and you can’t be sure that you have it better or worse than they do. With that being said, the grief that accompanies traumatic loss is very different from the grief that happens after an expected loss, and some might say it’s harder. 

And they wouldn’t be wrong.

The hardest part of traumatic grief is that you now have to deal with two things at once. 

Sudden or violent loss measurably increases risk of prolonged grief/trauma (e.g., PTSD-like reactions). – National Institute of Mental Health

You feel the emotional loss, which is heavy enough on its own. But along with that, you’re also in complete and utter shock. And shock and sadness are two different emotions. 

When you’re in shock, it’s basically your brain slamming the brakes even though there was no yield or stop sign in sight.

For the most part, people go numb right after they hear the tragic news. Not in a cold way like they don’t care, but just blank.

Acute stress reactions )e.g., numbness, confusion, dissociation, etc.) are common side-effects of experiencing traumatic events. – Substance Abuse and Mental Health Services Administration

So, they’ll stare at a wall for an hour, or they’ll answer the door and forget they did it a few seconds later. They’ll hire a wrongful death attorney for fatal car crashes in Chicago when they should have hired one in Joliet, where they live. From the outside, this seems absolutely ridiculous, but two things are happening here: one, the brain is trying to protect you. 

And two, that loss made no sense, so it’s pretty much impossible to accept what’s happening. 

The brain keeps searching and searching for a connection between one moment where life was normal, and the next when it fell apart.

On top of all this, there’s also the real-life stuff to handle because there’s no grace period. You have to sign the papers here, make the calls there, decide on funeral arrangements and finances, and yes, hire a lawyer if someone else is to blame for the tragedy. 

It’s not that hard to believe that, because of dealing with all this, a person would forget they opened the door or hired a lawyer in the wrong city, isn’t it?

How Traumatic Grief Feels Different in Daily Life

Normal grief is heavy, but traumatic grief? That’s both heavy and confusing at the same time. 

Here’s what the difference looks like in everyday life.

There’s No Time to Prepare Mentally

If the loss came out of nowhere, the brain didn’t get any of the warning signs. 

No hospital stays, no bad test results, no slow decline, no last conversations… Nothing. As a result of this, the mind will continue acting as if the person is still alive, regardless of the fact that reality is different.

A person who’s grieving could find themselves picking up a phone to call their deceased loved one, or setting an extra plate for dinner. You might say this is pure denial and nothing else, but that’s not the case here. The brain is having a hard time catching up with what’s actually happening because nothing makes sense. 

The worst part is that this can go on for months.

The Body Stays Stressed

Grief consumes both mental and physical health, and with traumatic grief in particular, the body acts as if the danger is still here. You stay in that terrible fight-or-flight mode for a long time. You might notice your heart starts to race at random times, or you’ll jump at small noises.

Your body can stay in a constant state of heightened stress after experiencing trauma; this can negatively affect sleep, heart rate, body regulation, etc. – National Institute of Mental Health

And sleep? Now, that’s a battle every single night. 

You’ll either sleep too much or too little, but either way, you’ll never truly rest.

As crazy as it sounds, all this is normal. This is basically your nervous system doing exactly what it’s designed to do. The problem here is that there’s no ‘real’ threat to handle. Your mind thinks there is a threat, so it reacts accordingly.

Thoughts Keep Going Back to The Dreadful Event

Normal/regular grief revolves around someone’s memories about the person that’s gone (for the most part). These are inside jokes, things you’ll miss (laugh, jokes, routines, etc.) – the good times.

Traumatic grief is different. This type of grief is stuck on death where your mind replays a few moments over and over again. And it’s difficult to get out of that loop.

Core features of trauma-related conditions  are intrusive (negative) memories and repeated mental replay of the trauma. – U.S. Department of Veteran Affairs

The phone call, the news, the moment you found out, rinse and repeat, over and over.

You don’t consciously choose to think this; it simply shows up. The hardest part about this is that the brain is so focused on that tragic event that you can’t hold onto the happy memories.

It’s not that they’ve disappeared, but they’re buried under that replay button that refuses to stop.

It’s Harder to Find Closure

Harder, and even impossible. 

Normal grief gives you an ending. It’s not a happy ending, but it’s an ending nevertheless, where you might even get to hold the person’s hand and tell them you love them. It all makes sense, as painful as it is.

But there’s no ending with traumatic grief, and nothing makes sense anymore. 

Because of the absence of anticipatory coping/closure after experiencing unexpected loss a person can experience prolonged grief. – Harvard Medical School

So, in order to make it all feel sensical, the ‘what ifs’ start to pop up. What if they left 5 minutes earlier? What if someone had been there? 

None of that helps, but it also can’t go away. You know it’s irrational to play those scenarios over and over, but without a proper goodbye, your mind can’t wrap around the fact that this tragedy happened, and it can’t move past it.

Conclusion

None of this has anything to do with how much you loved the person. 

The only thing that matters is how the tragedy happened: was it expected, or was it a shock? And you might say that neither is worse, but truthfully, traumatic grief hits on more levels. Aside from the deep sadness, there’s also shock and pressure, with no soft landing in sight. It’s like your life just attacked you all of a sudden.

Make no mistake; just because you understand the difference doesn’t mean you can fix anything. But it’s useful because it explains why recovery is slower, and why everything feels more unpredictable. 

At the end of the day, if all you can know is that you’re not going insane, that’s still something.

Author Bio 

Marko is an adamant and eager content writer with a decade of experience in various niches,  with healthcare being one of them. With his way of implementing storytelling, comparisons, and examples into hard-to-grasp topics, Marko’s able to make complex things sound interesting and relatable – key ingredients to make something understandable. As a hobby, Marko enjoys offroading, board games, and spending time with his family and his dog Cezar.

 

 

Please also review AIHCP’s Grief Counseling Certification, as well as its Child and Adolescent Grief Counseling Program, Pet Loss Grief Counseling Program, Christian Grief Counseling Program, Grief Diversity Counseling Program, Grief Perinatal Program, Grief Practitioner Program and finally its Grief Support Group Leader Program.

The Creative Grief Cycle

Posted on by Joseph Gerard

The Creative Grief Cycle

Creation, Communication, and Rediscovery in Grief Writing 

Written by Daniel Stern

Grief disrupts the narrative of life. When a profound loss occurs, the future we imagined with that person vanishes, and the past becomes newly charged with memory and absence. 

Yet paradoxically, grief is also one of the most powerful generators of creative expression. Poetry, painting, music, and storytelling have historically emerged from loss, giving shape to emotions that are difficult to express. 

For many writers, including myself, poetry becomes the place where grief first learns to speak. 

I’m not a clinician. What I’m describing comes from my own experience writing poetry about grief. I found that creative expression did more than document loss; it initiated a cycle of emotional processing. My experience aligns with research on expressive writing, poetry therapy, and meaning-making in grief—that creative expression can help people process loss and make sense of it. 

From this intersection of lived experience and research, I began to notice a pattern in how grief can move through creative expression. I refer to this pattern as The Creative Grief Cycle. 

  1. Creation — the act of writing transforms grief into language 
  2. Communication — the work becomes a bridge between the grieving individual and others 
  3. Rediscovery — the creative work can be revisited repeatedly, allowing grief to evolve into reflection 

Together these stages form a self-reinforcing cycle that moves grief from raw emotional experience toward shared understanding and lasting meaning. 

Research on expressive writing, meaning reconstruction, and poetry therapy supports key elements of this cycle.

 

Journaling about loss is a creative and expressive way to cope with grief

Stage One: Creation — Writing as Emotional Processing

The first stage of The Creative Grief Cycle is the act of creation itself. 

When grief is written, it changes form. What was once diffuse emotional pain becomes structured language. Words, metaphors, and images impose order on an experience that initially feels chaotic. 

Psychologist James W. Pennebaker, whose research pioneered the study of expressive writing, demonstrated that writing about emotional experiences improves psychological and physical well-being. His studies showed that expressive writing helps individuals organize traumatic memories into coherent narratives, supporting emotional processing that might otherwise remain unresolved (Pennebaker & Chung, 2011). 

Scholars in poetry therapy also describe writing as a structured way of processing emotional experience (Mazza, 2017). Neimeyer (2012) has similarly emphasized that grief often involves reconstructing meaning after loss, frequently through narrative and creative expression. 

Subsequent studies have found similar benefits. A comprehensive review in Advances in Psychiatric Treatment found that expressive writing can reduce stress, improve mood, and enhance coping with traumatic experiences (Baikie & Wilhelm, 2005). 

In grief specifically, expressive writing has been associated with meaning reconstruction, a central process in bereavement. Neimeyer (2001) describes mourning as rebuilding meaning after a loss disrupts one’s life narrative. 

These findings mirror my own experience writing poetry after the loss of my son. In one poem I wrote: 

“A poem begins in blood. 

My son is gone, yet I write— 

each word a slice of myself.” The Price of a Poem 

Writing did not remove grief. Instead, it transformed grief into something that could be examined and understood. 

Researchers studying poetry therapy describe this process as the movement “from silence to speech.” Stepakoff (2009) explains that poetry allows individuals to represent traumatic grief symbolically, making it possible to approach experiences that initially feel unspeakable. 

In The Creative Grief Cycle, creation is therefore the first step in transforming grief into meaning. 

 

Stage Two: Communication — The Social Function of Grief Poetry 

The second stage of The Creative Grief Cycle occurs when the work is shared with others. 

Grief is inherently isolating. Individuals experiencing loss often feel that their emotions cannot be adequately explained to those who have not lived through similar experiences. 

Poetry can bridge this gap. 

Because poetry communicates through metaphor, rhythm, and imagery, it can convey emotional realities that ordinary explanation cannot. Readers encountering grief poetry can recognize aspects of their own experiences within the work, creating a moment of shared understanding. 

Maybe creative expression can help individuals communicate their complex grief experience when traditional conversation is difficult.

Stroebe (2018) highlights that poetic language can complement scientific models by illustrating the lived experience of grief, bringing emotional depth to processes identified in research. Psychological frameworks describe processes of mourning, but poetry can capture the lived texture of grief—its contradictions, memories, and silences. 

This communicative dimension is visible in many grief poems. In one of my own poems, I describe writing as a way to keep a voice present in the world: 

“I write 

because my voice still walks the earth 

even when his footsteps do not.” Don’t Live Inside That Silence 

The poem becomes more than a personal reflection; it becomes a message others can encounter. 

Communication also allows grief to move across generations. In another poem, written about telling stories to my granddaughter after her father’s death, I wrote: 

“I give her my son 

the only way I still can— 

one story at a time.” Tell Me a Daddy Story 

In this moment, poetry functions as inheritance. Memory travels through language into the future. 

In The Creative Grief Cycle, this is when grief moves from private experience into shared understanding. 

 

Stage Three: Rediscovery — Revisiting the Work 

The third stage of The Creative Grief Cycle emerges and can evolve over time. 

Unlike spoken conversation, creative works endure. A poem written during an intense period of grief can be reisited months or years later. This creates a powerful reflective process. When the writer returns to the poem, they revisit the emotional state that existed when it was written. The poem becomes a preserved record of grief at a particular moment in time. 

Poetry can preserve the emotional complexity of grief in ways that allow both writers and readers to return to the experience with evolving perspectives.

In practical terms, a poem becomes an emotional time capsule. The writer who reads it years later is no longer the same person who wrote it. The grief may have softened, deepened, or transformed. 

In one poem, I tried to capture how silence evolves over time: 

“Silence becomes a cathedral, 

vast and unforgiving, 

its arches built of absence.” The Roar of Silence 

This rediscovery stage allows grief to evolve from raw emotion into reflection. 

In The Creative Grief Cycle, rediscovery completes the cycle by enabling the work to continue generating meaning over time. 

 

The Creative Grief Cycle 

Taken together, the three stages form a continuous cycle: 

Creation → Communication → Rediscovery 

  1. Grief is transformed into language through writing. 
  2. The work communicates the experience to others. 
  3. The work can be revisited repeatedly, generating new insight. 

Each stage reinforces the others. Writing enables communication. Communication deepens meaning. Rediscovery inspires further creative expression. 

This cycle offers an explanation as to  why creative work often continues long after the initial loss. Once grief has been expressed through art, the creative impulse frequently expands into other forms of expression. 

In one poem reflecting on transformation through grief, I wrote: 

“Grief softens us, 

wonder reshapes, 

creation strikes sparks 

across even the softest anvil.” The Furnace Never Cools 

Grief melts what once felt rigid. Creativity reshapes it. 

 

Conclusion 

Grief cannot be eliminated. Loss remains one of the defining experiences of human life. But creative expression changes how grief exists in the world. 

Through The Creative Grief Cycle, grief moves through a process of creative transformation:  

  • Writing transforms emotional experience into language  
  • Communication connects that experience with others  
  • Rediscovery allows the work to continue generating meaning over time 

In this way, poetry does not simply document grief. 

It allows grief to become something else: connection, reflection, and enduring voice. Loss may silence a person’s presence in the world. But through poetry, the conversation continues. 

 

About the Author

Daniel Stern is a retired engineer turned astronomer and astrophotographer whose poetry explores grief, silence, memory, and renewal. His work lives at the intersection of science and emotion, where observation becomes reflection and language reaches for what cannot be measured. He recently published The Roar of Silence, a collection of 15 poems born from personal loss and the search for meaning in its wake. He also authored Aphelion, a book of poetry fused with his deep-sky astrophotography. In his work as an astronomer, his astrophotography has been recognized numerous times by NASA (APOD). He has discovered planetary nebulae and, in collaboration with others, has been published in peer-reviewed astrophysics journals. Stern lives in Delray Beach, Florida, with his wife, Randie. 

 

Website: www.theroarofsilence.com 

Email: dstern@mea-obs.com 

 

References 

 

Baikie, K. A., & Wilhelm, K. (2005). Emotional and physical health benefits of expressive writing. Advances in Psychiatric Treatment, 11(5), 338–346. https://doi.org/10.1192/apt.11.5.338 

Mazza, N. (2017). Poetry therapy: Theory and practice (2nd ed.). Routledge. 

Neimeyer, R. A. (2001). Meaning reconstruction and the experience of loss. American Psychological Association. 

Neimeyer, R. A. (2012). Techniques of grief therapy: Creative practices for counseling the bereaved. Routledge. 

Pennebaker, J. W., & Chung, C. K. (2011). Expressive writing: Connections to physical and mental health. In H. S. Friedman (Ed.), The Oxford handbook of health psychology (pp. 417–437). Oxford University Press. 

Stepakoff, S. (2009). From destruction to creation, from silence to speech: Poetry therapy principles and practices for working with suicide grief. The Arts in Psychotherapy, 36(2), 105–113. https://doi.org/10.1016/j.aip.2009.01.007 

Stroebe, M. (2018). The poetry of grief: Beyond scientific portrayals of mourning. Omega: Journal of Death and Dying, 77(1), 3–16.

 

 

Please also review AIHCP’s Grief Counseling Certification, as well as its Child and Adolescent Grief Counseling Program, Pet Loss Grief Counseling Program, Christian Grief Counseling Program, Grief Diversity Counseling Program, Grief Perinatal Program, Grief Practitioner Program and finally its Grief Support Group Leader Program.

Divorce and Heartbreak Grief Video Blog

Posted on by Mark Moran

The pain of a breakup and divorce has many levels of loss and secondary losses.  While each can be horrible for a person, different individuals have different experiences for a variety of reasons.  This video takes a closer look at the multiple factors in relationship loss and grief.

Please also review AIHCP’s Grief Counseling Certification

 

Grief Counseling: Different Grieving for Different Deaths

Posted on by Mark Moran

They say the only two certain things in life are death and taxes.  Death is indeed definite.  Ironically though is part of life.  Every breath and heart beat is determined from then on and into the future the very moment a the infant takes its first breath outside the womb and its first heartbeat within it.  Every day brings one closer to death but when living, the inevitability of death is rarely focused on or discussed.  Death anxiety is a cultural norm.  The myth and fear that one should not speak about such fearful things as to summon it remains fixed in society.  The moment of death is shunned while birth is celebrated.  Even those of faith, still fear its grasps despite the hope of a better world to come.  Due to the unknown and fear, death subjects become taboo or too morbid to discuss in some families as if the grim reaper is outside the door itself.

The types of deaths we experience in life differ objectively but also subjectively based upon multiple accidental qualities

Obviously such fears of death, or to even discuss the critical part of our entire existence is not healthy.  Death and loss occurs everyday and eventually death finds one’s family and friends.  Those who flee death are less prepared, while those who study it and discuss it understand its implications.  This does not guarantee one escapes the pain of loss associated with death of a friend or loved one, but it does recognize the reality which is crucial in understanding and coping with loss.

With every death, there is pain and loss experienced within a family, community, or culture.  It is unavoidable because with death comes change.  The change of no longer sharing a life with someone or being able to speak with someone or experience that person’s friendship.  Death of a loved one brings emptiness and sadness, but these are not adverse or pathological reactions to be dismissed, rejected, or hidden.  They are instead natural responses to losing someone that is loved.  The reactions of death and loss are a result of love.  Without love or attachment to someone, then there is no grief.  There may be the simple statement of regret for that family, or person, or at a communal level or national level, a sense of anger and injustice, but true loss and pain is directly correlated with a more intense connection.  Connection and attachment correlate with the degree of adjustment and pain in loss.

Every loss is unique and one cannot judge a mere relationship or assume connection with every type of death one experiences within a family or community.  Different deaths have different meanings for people and how they react.  One could lose a parent and be devastated over the loss, while someone estranged to a parent one never knew may feel no connection or intense pain.  One may lose a pet that was the center of one’s world, while another may just see a pet as a pet.  In other cases, one may be deeply struck by losing a grandparent, while others may not even know their grandparent.

In this blog, I preface that while we will discuss types of deaths, this is a general guide to reactions and common feelings.  It in no way attempts to say this is the way one will feel if this person or that person dies.  This should be seen as a general map of the more common grief reactions based on healthy connections without extraordinary circumstances.   So, very well, the reader may connect to one point, but completely disagree with his or her own experience in the next.   So, consider these different types of grief to different types of deaths as a general review.

Please also review AIHCP’s Grief Counseling Certification and see if it matches your academic and professional goals.

Accidental Qualities to Consider in Death and the Reaction to It

Accidental qualities are the unique elements that make deaths different for different people experiencing them.  One could classify a particular relational death but the accidental and subjective aspects the story can increase emotional intensity or decrease.  Some can complicate normal trajectory of grieving into complicated and prolonged grief disorders itself.  Here are some things to consider as accidental qualities

Sudden Death or Expected Death

This is a huge factor in complications in grieving for some.  While complicated grief is less common than normal grieving, complications are tied to sudden deaths at a higher level.  Sudden death also brings more shock and awe and denial than other types of death.  It is the sudden call on the phone at night with the horrible news.  It is the call that one wishes was a nightmare and forever changes one’s life.  One can be at work, or dinner, or at an event and the sudden news forever shatters the person.  Sudden death can also create and imprint upon the person a fearful death anxiety.  Unexpected death makes one question one’s own mortality.

Likewise, expected death while not as abrupt can bring about different reactions.  If someone is very elderly, or if someone is terminal, the death is expected.  One in fact is experiencing anticipatory grief and may be grieving already before the death occurs.  The death can be seen as a relief for caregivers, or for family members who see the deceased as free from suffering.  Some may experience guilt for this reprieve but they should not allow it to overtake them.  Others may feel the intense pain of choosing to take a person off life support or a particular drug.  The choices of palliative care can be a painful one for a family. Family should openly discuss their feelings when someone terminal or elderly finally passes.  Again, this loss could be far more intense for a child who dies of cancer, as opposed to an elderly person in palliative care.  Does this mean the loss is painless or not deserving to be experienced based on these things?  Obviously, one is more tragic, but one should not be felt to pretend to be happy merely because one is finally relieved of suffering.  There is an ambiguous as well as bitter sweet feeling when one loses an elderly family member over a stretch period of time.

Tragic Loss

Sudden loss carries with it a litany of accidental qualities added to the relationship of the death. Please also review AIHCP’s Grief Counseling Program

A tragic loss usually coincides with a sudden loss but also includes a horrible death scene, or way the person died.  This could involve war, a murder, or a tragic violent act.  This can lead the survivor into a deep sense of mourning and anger.  In addition, successful suicides can deeply hurt with with additional emotions of anger, guilt, or increased suicidal thoughts oneself.  Tragic loss does not necessarily mean complications for the survivors, but it can lead to it.

Ambiguous Loss

Some family losses remain ambiguous and one never experiences closure.  These deaths involve unrecovered bodies in war, or acts of nature.  In addition, mourning a person who is kidnapped or loss leaves a person with a perpetual what if scenario.  One cannot grieve death for fear of accepting it or even worst a horrible situation existing for a loved one.

Estranged Family Relationship

Estranged family relationships can intensify or lessen the impact of a loss.  In some cases, when a family member who passes is estranged, there can be a feeling of anger, guilt, or a mixture of sadness and anger.  Whether the justification for estrangement was legitimate or not, it can lead to an array of issues at the funeral with other family members who may feel estranged members are not welcome.

Abuse and Trauma

Abuse leaves trauma and when an abusive family member dies there may exist sadness, but also joy and justification.  Some may feel a mixture of these feelings.  Abuse can also make the abused feel guilty for the death of the abuser.

Emotional Connection

How attached to someone is essential to the equated pain, suffering and adjustment.   Some individuals are closer to siblings or cousins than others.  Some have a deeper connection to a friend than a different friend.  So the mere title of the relationship does not always entail the emotional response.  The more attached and connected to a person emotionally, physically, spiritually and financially, the more intense the change.  Loss always equals change which equals grief.

Age of the Griever 

Children grieve differently than adults.  Those with mental issues also express grief differently.   It is important to be aware of the age of the griever and their relationship with the deceased to fully understand their ability to understand death, much less express it in a healthy way.

Family Support

Support or no support plays a large role in reaction to loss.  One who loses a spouse and has no other family or friends can experience deeper loneliness and pain.  Those with support can share their grief and also receive additional care in funeral planning and post funeral life.

One can consider numerous other accidental qualities to even add to this list which make every death for someone unique and different in their grieving journey

Types of Losses to Death

Loss of a Child

From a purely objective status, the loss of the child is the greatest grief loss

This is considered objectively to be the most painful loss despite subjective accidental qualities.   Losing a child has its own accidental qualities that have a strong universal impact on any healthy parental relationship with the child.   Again, the way it occurred suddenly in an accident, or in a cancer ward, shapes different experiences, but the emptiness, pain, and life long mark upon the heart never leaves.   Losing a child in the womb, at birth, in infancy, adolescence, or young adult are all horrible in their own unique ways for the parent.  It is singularly the most destructive change agent in a person’s life.   The universal component captures the essence of unnatural.  Children bury their parents, not the other way around.  So while, some situations may give different perspectives on the loss, the grim reality remains a parent has buried his or her child.  This type of loss that individuals like to avoid to even think about.  The intense anxiety that the  thought itself produces in the mind is painful enough.  The intrusive image, or even conversation usually is immediately dismissed abruptly.  One can then only imagine the nightmare and pain a parent carries in his or her heart when this loss occurs within any accidental possibilities.  The nature of itself is horrible enough to keep one awake at night.

Loss of a Parent

Losing a parent is considered objectively to be the second most painful loss.  Again, without a variety of accidental qualities, this loss ties oneself to one’s very existence.  The caregiving and connection over life itself bonds the child to the parent.  This attachment matures and changes throughout life to different needs.  Obviously a child who loses a parent experiences a far greater blank in life.  The pain of growing up without the parent and experiencing the parent in one’s life into adulthood.  For adults who lose their parents, there is still a pain but it does follow a logical and natural course of burying an elderly parent.  This too can have complications in whether the parent suddenly passed away or was terminal.   Grievers may feel they are no orphans to the world when the final piece of source of physical existence no longer remains.  For many, this emptiness comes sooner while others are blessed to experience this pain far later, but whether sooner or later, the loss of a parent leaves a deep emptiness and existential question of self.  It also shifts one responsibility.  One becomes, in adulthood, the new patriarch or matriarch of the family and with that new responsibilities and worries.

Loss of a Grandparent

For many, the loss of a grandparent is something that occurs in younger adulthood.  Again, it can strike at any age which also creates different responses.  For some, a grandparent may have raised them while others may have rarely seen the grandparent.  Grandparents usually represent the first experience of death at a intimate and closer level of relationship for individuals.  It introduces the person to the reality of death and that everyone will eventually die.  For others, a grandparent represents unconditional love.  In many cases, one represents reprieve from harder discipline that comes from parents.  They are sources of wisdom, family history, and wit them dies a certain era and part of one’s life. Some may even feel guilt for not seeing them enough, which is a natural reaction and not one that should be allowed to fester.

Loss of a Sibling

Losing a sibling, especially, at a younger age, or in a sudden and horrible accident can have great impacts on an individual.  For many, siblings, as well as cousins, are a a loss a long term relationships that are meant to span across one’s entire life. Siblings should be a person’s first friend.  A shared story and identity in culture and family values and traditions binds brothers and sisters, and cousins, together.  The assumed outcome is a long life, but when lives are shortened, this can bring one to horrible life changes and death anxieties.    The closer the bond, even twins, the more intense the pain of loss.

Loss of a Spouse

Losing a spouse should be an intense loss equal to that a parent in some cases.  With divorce and so many bad decisions, the modern world has come to see spouses as replaceable, but for those truly in love, losing a partner can leave one truly alone in life.  A younger couple who experiences this may subjectively suffer differently from a couple with children as opposed to a couple who has spent 50 years of marriage together.  With these losses, unique challenges emerge.  Younger spouses look to rebuild, spouses with children look to raise children alone, and older spouses may very well die of a broken heart.   With these losses, roles of duties, income disparity, and other secondary losses with groups of people can all emerge and create further pain and discomfort in the new adjustment of life.

Loss of a Pet

This is the most disenfranchised of losses because according to some, pets are not people.  The connection and love that human beings share do not need to be confined to merely other humans.  In fact, many pets carry higher family values than some actual family members.  Many pets are considered children to the person and play a deep connective and important emotional role to the person.  While, pathology can exist in some extreme cases, for most pets, they are family and deserve the same love and grief when they are gone and people will grieve their pets as grieving any other family member.  In fact, this is normal in itself and should be respected.

Conclusion

Please also review AIHCP’s Grief Counseling Certification Program

While the death of a person creates loss for other people, the type of death and the accidental qualities surrounding it make one singular event a very different experience for other people.  Grief Counselors need to be aware of the whole story surrounding the grief of someone who has lost a friend or family member.  Grief Counselors can just not assume the loss will be felt in a certain way due to relationship status, but must instead understand the subjective relationship the person had with the deceased.  There will be some common threads with particular losses but there will also be numerous accidental qualities to a particular loss that can play a key role how the person reacts and how the person adjusts to the loss.

Please also review AIHCP’s Grief Counseling Certification, as well as its Child and Adolescent Grief Counseling Program, Pet Loss Grief Counseling Program, Christian Grief Counseling Program, Grief Diversity Counseling Program, Grief Perinatal Program, Grief Practitioner Program and finally its Grief Support Group Leader Program.

All programs are open to qualified clinical and non clinical professionals.

Additional Blogs

Death of a Friend: Click here

Child Grief and Death. Click here

Additional Resources

Fisher, J. (2023). 5 stages of grief: Coping with the loss of a loved one. Harvard Health Publishing. Access here

Solomon, D. (2025). Do’s and Don’ts When a Loved One Is Dying. Psychology Today.  Access here

Ten Reasons Why Losing a Grandparent Still Hurts Deeply as an Adult — Understanding Adult Grief and Ways to Cope. Grief Support Center. Access here

Bahou, C. (2025).  “Coping with the loss of a parent: Handling grief and more”. MedicalNewsToday.  Access here

The Myths That Silence the Most Important Question in Healthcare

Posted on by Joseph Gerard

healthcare power of attorney advance directive papers with on a table with a pen near itWritten by Dr. Erin Jenkins

As healthcare professionals, many of us will never forget 2020. During a global pandemic, millions of people died, and families were forced to grieve losses they never imagined they would face. Loved ones were taken by a virus that moved quickly and unpredictably, leaving little time to prepare emotionally or practically. During this period, I was working in hospital based palliative medicine. In more typical times, our work focused on supporting people living with chronic illness, managing symptoms, and helping patients clarify how they wanted to live while navigating conditions such as COPD, CHF, and cancer.

During the pandemic, that work shifted dramatically. Patients who had long been managing chronic disease were suddenly confronted with a virus that disproportionately affected those same conditions. Regardless of diagnosis, one reality remained constant: COVID significantly increased the risk of death for patients with chronic illness.

End of life conversations became part of our daily work. We spoke with patients struggling to breathe, many dependent on oxygen or ventilatory support, including individuals with no prior respiratory disease. Yet, when asked about their wishes, most patients did not have clear answers. Families often struggled to accept that their loved one might die. Hope persisted, as it always does in medicine, but it became increasingly apparent that many patients and families were completely unprepared to make these decisions. Some waited until it was too late.

It was during this time that I began to fully grasp how many Americans lack end of life plans, even those who regularly interact with the healthcare system. Research suggests that fewer than one third of U.S. adults have completed an advance directive to guide care during times of crisis (Auriemma, Halpern, Asch, Van Der Tuyn, & Asch, 2020). These rates vary based on age, education, and other social determinants. Together, these findings highlight the gap between clinical recommendation and real-world readiness. It suggests a broader disconnect between patients and providers, as well as between patients and their families, leaving many unprepared to make critical decisions under duress. The question is, why?

One persistent myth in healthcare is that end of life planning is only for the elderly or those with terminal illness. This belief delays conversations that are both necessary and appropriate for all. End of life planning is for everyone and involves more than signing a document. It is a process designed to align care with what matters most to patients and their families. While these discussions can feel uncomfortable, proactive conversations lead to better alignment of care, reduced moral distress, and support clearer decision-making during times of crisis. These discussions include preferences regarding CPR versus DNR status, surrogate decision makers, mechanical ventilation, artificial nutrition, and post death wishes. While formal documentation is important, the most critical step is initiating the conversation. Without clarity, families are left to make life altering decisions under intense emotional strain, and clinicians are placed in ethically challenging positions.

Another common myth is that discussing end of life planning takes away hope. During the pandemic, many clinical teams hesitated to initiate these conversations out of concern that they might cause anxiety or signal that death was imminent. But our experience in palliative care showed the opposite. Even when the focus of conversation is a difficult topic, patients often felt less anxious and more supported. Additionally, research shows that advance care planning improves proximal outcomes, including communication quality, decisional confidence, and patient-surrogate congruence (Malhotra et al., 2022).Trust between patients and their care teams also increases. These discussions are not about removing hope. They are about preserving dignity, honoring autonomy, and reducing unnecessary suffering.

There is also a common misconception that patients will bring up these conversations “when they are ready”. In reality, no one ever feels ready for these discussions. Patients cannot ask for guidance around decisions they do not yet understand or know need to happen. That is where we come in. As healthcare professionals, part of our role is to guide patients through complex medical decisions, including those related to end-of-life care. Many clinicians who consulted our palliative care team in 2020 did so because they were unsure how to begin these conversations. Some were waiting for patients to say they were ready, while others felt that they were not equipped to lead the discussions themselves. While palliative and hospice teams are often seen as the experts in end-of-life discussions, the responsibility for these discussions is shared. At their core, these are conversations about goals and values. When framed that way, they become more approachable for both patients and clinicians.

Another misconception is that there simply is not enough time during a visit to address end of life planning. Anyone who has worked in primary care understands the challenge of limited time within the appointment. But these conversations do not need to be lengthy. They also do not need to occur in a single visit. Clinicians can begin with a simple question: “I was hoping we could talk a little about your goals in case there came a time when you could not make decisions for yourself.” From there, some foundational questions can be explored: who would serve as a surrogate decision-maker, what types of interventions the patient would or would not want, and how they wish their body to be cared for after death, including organ donation. These discussions frequently can unfold over two or three brief visits. What matters most is our willingness to normalize and prioritize them.

Despite the documented benefits of advance care planning and strengthened communication between patient and clinician, barriers remain. Many clinicians report lack of training or confidence in initiating end-of-life discussions, time constraints that reduce opportunities for discussion, and concerns about disrupting the clinician-patient relationship. Yet, when these conversations occur, they contribute to greater alignment of care with patient values and help prevent crisis-driven decision-making that may not reflect what patients would choose.

So, the question becomes this: have you had these conversations with your patients? And if not, what are you waiting for?

Author Biography:

Dr. Erin Jenkins is a certified Family and Psychiatric Nurse Practitioner with 23 years of experience in critical care, family medicine, neurosurgery, and palliative medicine. She owns Your Full Potential Psychiatry & Wellness in Southern Nevada, where she helps people improve their overall wellbeing using integrative medicine. Dr. Jenkins also serves as an Advanced Practice Registered Nurse in the U.S. Air Force Reserve, working in base operational medicine and focusing on military psychiatry. Learn more at https://www.yfpwellness.com and connect with her on LinkedIn at https://www.linkedin.com/in/erinjenkinshealth .

References:

Auriemma, C. L., Halpern, S. D., Asch, D. A., Van Der Tuyn, M., & Asch, J. M. (2020). Completion of advance directives and documented care preferences during the Coronavirus Disease 2019 (COVID-19) pandemic. JAMA Network Open, 3(7).  Access link here

Malhotra, C., et al. (2022). What is the evidence for efficacy of advance care planning … BMJ Open, 12(7). Access link here

 

 

 

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