“In many Appalachian communities, silence is not avoidance—it’s how pain is carried with dignity.”

— Appalachian Regional Studies Journal

Several years ago, I took my first hesitant steps into the world of chaplaincy by enrolling in a unit of Clinical Pastoral Education—a form of professional ministry training that places students in real-world clinical environments, inviting them to reflect deeply on their encounters and grow through supervised experience. I didn’t want to be there. I walked in thinking I already knew what ministry was. After all, I’d preached sermons, sat at hospital bedsides, and prayed with grieving families. What more could they teach me?

That arrogance made my first unit a struggle. I butted heads with my supervisor more times than I can count. She had this way of calling me out—not unkindly, but directly. “You go into fix-it mode,” she’d say after a patient visit. “You’re trying to solve what can’t be solved. You need to stop talking so much. Get comfortable in the silence.”

“Get comfortable in the silence.” I remember thinking, What on earth is that supposed to mean? At the time, it sounded more like a fortune cookie than a clinical insight.

But years later, I’d come to understand exactly what she meant. In the sacred space between life and death, between hope and letting go, silence is often where the truth begins to speak. And as I stood with families facing impossible decisions about organ donation, it was that silence—not words—that held the most grace.

Silence was exactly what was needed to help another family let go—so their father could go on to save three lives through the gift of organ donation.

It was a sweltering summer afternoon when my AOC, or Administrator on Call, reached out. I was dispatched immediately for what we call a HOT approach. In our world, HOT stands for “Hand on Tube”—a signal that the family is at the bedside, preparing to withdraw life support, and that a donation conversation needs to happen without delay.

HOT approaches don’t leave much room for preparation. There’s no time to comb through the EMR—the electronic medical record—to piece together what happened or who this person was. You go in blind, your only focus: the family in front of you.

Thirty minutes later, I walked onto the unit and found the primary nurse. Before anything else, we always huddle with the care team—usually the nurse and attending physician—to align our approach. It’s not just about medical facts; it’s about presence, tone, and trust. We walk together so the family doesn’t feel like they’re walking alone.

In that huddle, I learned that the patient—a father—had died from an accidental overdose. His youngest daughter had handed him what she believed was a simple pain pill. It turned out to be laced with fentanyl.

The nurse pulled me aside before I could even approach the room. She let me know, in no uncertain terms, that the patient’s wife and son were extremely upset—and that any mention of donation would not be well received. “You may want to just let them withdraw,” she said gently, clearly trying to protect the family from more pain.

I nodded, thanked her for the insight, and reassured her that I would be careful—gentle. Nurses often become fierce guardians of the families they’ve cared for day after day, and I’ve learned to respect that deeply. But I’ve also learned something else: it’s not always that they’re opposed to donation. Sometimes it’s that they’ve seen the family endure so much already, and the idea of one more conversation—especially one this emotionally charged—feels like too much.

But what we offer isn’t just another conversation. It’s the possibility of meaning inside the chaos. It’s a sliver of light in the dark. It’s legacy. And while these discussions can feel impossibly heavy in the moment, I’ve seen time and time again how, months or even years later, families will reach back out—not in anger, but in gratitude. Gratitude for the chance to say yes. Gratitude that their loved one was able to live on through organ, tissue, and eye donation.