“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, in that sacred moment, was exactly what was needed—giving space for a family to let go, so their father and husband could go on to restore sight through eye donation and bring healing to countless others through the gift of tissue.

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.

As I entered the room, I saw them—two people, both broken, exhausted, and angry. I paused at the door, gently knocked, and asked for permission to enter their sacred space. “Come in,” they said.

I stepped inside, moved a chair across the room, and sat down at a respectful distance. “My name is Brent,” I began softly. “I’m here to help walk you through some of the options you have for next steps. But before we begin—would you mind sharing your names and how you’re related to Ricky?”

“I’m Carol,” she said. “Ricky’s wife. And this is our son, Blake.”

Blake looked like he hadn’t slept in days—his eyes heavy, his body sagging under the weight of grief. Still, he sat upright, trying to be strong for his mother, even as tears lingered just beneath the surface.

“Again, my name is Brent,” I said gently, “and I just want to say how truly sorry I am to be meeting you under these circumstances. Typically, I have a bit of time to review a patient’s chart before sitting down with family, but in this case, I wasn’t able to do that. Would you mind sharing with me what brought Ricky here?”

Carol didn’t hesitate.

“Morgan,” she said sharply. “Morgan is what brought him here. We told her these goddamned drugs were going to catch up to her eventually—we just never expected her dad to be the one who overdosed. He’s been sober for 20 years. Ever since the kids were born. That’s why he couldn’t handle the fentanyl.”

My heart dropped. “Oh no… I’m so sorry.”

“It’s not your fault,” Carol replied, waving off my apology. Then her face hardened. “Morgan just better hope the police find her before I do.”

“Mom…” Blake said quietly, his voice strained.

He glanced toward me, as if suddenly remembering I was still there. The room was thick with anger, pain, and the unbearable irony of a father’s overdose linked to the very daughter he’d stayed sober for. There was no easy path through this moment—only presence.

“A few days ago, me and Dad were working on the deck,” Blake said, his voice tight. “We were expanding it, and he did too much. Hurt his back. Morgan decided this week she was going to be back in our lives, and she was at home. She heard him say his back hurt, and she… she gave him one of her pain pills.”

He paused. The anger rose like heat.

“Now he’s dead. She fucking killed our dad, man. And now she’s on the run. The cops are looking for her.”

“I can’t even begin to imagine what you’re going through,” I said softly.

“They’ll get her,” Carol muttered, holding her stare on the wall. “We’ve got Ring cameras at the house. She’s got one at her apartment too. As soon as she shows up, we’ll know.”

Silence fell over the room. Long. Heavy. Sacred. We sat in it together. No words could touch the depth of what had just been said.

But I also knew that silence sometimes opens the door for something else—something redemptive.

Gently, I turned to Blake. “Blake, I heard you say earlier that your dad is dead. Would you mind sharing with me what Dr. Kline told you?”

Blake looked down at the floor. “Dr. Kline said Dad wasn’t going to recover, technically—that he’d still be alive—but he’d be on a ventilator for the rest of his life. It’s not living. It’s surviving. And Dad always said he never wanted that.”

Carol nodded quietly in agreement.

“That’s what Dr. Kline told me as well,” I said quietly. “And I’m just so sorry. So sorry that you all are having to go through this. Sometimes… life just isn’t fair.”

We sat there in silence for a few moments—each person wrapped in their own thoughts, each holding their grief in a different way. I didn’t rush to fill the quiet. Sometimes presence speaks louder than words.

After a while, Carol broke the stillness. “What happens now?”

I turned to her gently. “Well Carol, if I’m understanding what you said earlier—that Ricky wouldn’t want to live like this—then there’s an important decision ahead. And from what you’ve shared with me, it sounds like Ricky was the kind of man who gave without hesitation. You told me he was helping Blake when he got hurt. He just strikes me as someone who’d give the shirt off his back if he saw someone in need.”

Carol nodded slowly. “He really was. There was this one time—we were driving down the road in the rain, and Ricky saw a young man walking. He pulled over to give him a ride. I asked him what he was doing—‘this could be an axe murderer!’ I said—but he just looked at me and said, ‘He looked like he needed help.’ That’s who Ricky was. He just… helped.”

“Well,” I said gently, “I’m here to ask if Ricky might be willing to help—just one more time. In addition to supporting you through these next steps, I have the privilege of sharing how Ricky’s legacy could live on through others… through the life-saving gift of organ, tissue, and eye donation.”

“Yes!” Blake said without hesitation, his voice firm and clear. “Dad would want to do that. If he knew he could save lives, he’d do it in a heartbeat.”

Carol nodded slowly, tears rising in her eyes. “He really would,” she whispered, her voice catching.

“Thank you, Blake,” I said, humbled by the clarity of his response. “Would it be okay if I explained a little about what that process looks like?”

They both nodded.

And just like that, the room shifted—not away from grief, but into something sacred. A space where loss and generosity could coexist. Where goodbye could also mean giving life.

As I began to explain the process—what would happen next, what donation would mean for Ricky and for others—I saw something shift in Carol’s expression. It was subtle at first: a tightening around the eyes, a slow intake of breath. The look of realization. Not resistance or fear, but the quiet dawning that organ donation was a process. A real one. One with steps, timelines, and decisions. It was something she had been willing to say yes to in spirit—but now that it was real, she carried questions. Questions she may not have even known she had.

And that’s the thing. Most people never find themselves in this place. Only about 3 in every 1,000 deaths occur in a way that makes organ donation medically possible.[1] That means very few families ever walk this road—fewer still with any prior understanding of what lies ahead. The rarity of the moment doesn’t make it any less sacred, but it does mean that many families are asked to navigate the most significant decision of their lives in a space they never expected to be. And so, in those moments, it becomes our job not just to explain—but to sit, to honor, and to walk alongside them with grace.

So that’s what I did. I walked them through the ins and outs of the donation process—each step, each detail—careful not to overwhelm, but knowing it was already a lot. At one point, I paused and said, “I know this is a tremendous amount of information to take in. In just a few short hours, you’ve experienced every emotion imaginable—shock, sorrow, uncertainty—and now you’re being asked to absorb complex medical and logistical information while still trying to grieve.” I looked at them and added, “I’m sorry for that. I wish there were a gentler way to do this. But I want you to know I’m here. To walk with you through this, to answer your questions, and to be your support—for as long as you need me.”

“I just don’t know,” Carol said quietly.

They’re words I never want to hear—especially after a family has already agreed to donation. My mind began to race. Had I said something wrong? Was there a detail that shifted their decision? I felt the familiar tug of self-doubt begin to creep in.

“What questions do you have, Carol?” I asked gently.

She glanced at Blake, who looked down at the floor. They both did. The silence settled in, thick but necessary. My instinct was to start talking, to fill the space with reassurance or explanation—but I resisted. This wasn’t about me. This was their time. Their moment to grieve, to pause, to sit with the weight of what was being asked. To decide if they were still ready to walk this path.

We sat together in that quiet for a few more moments.

“I’ve been doing this a long time,” I finally said. “And honestly, most families don’t know what questions to ask. One of the most common things I hear is, ‘What if I can’t afford this?’ And that’s such an important question. What many families don’t realize is that donation comes at no cost to them. Once we complete the paperwork, my organization covers everything that happens from that point until the recovery is complete.”

“Oh, that’s good,” Carol said, exhaling just slightly. “I was worried about that.”

She paused again. “I just think… we need to pull the tubes now.”

“Carol, I completely understand,” I said. “If that’s what you feel is best, I can let Dr. Kline know that’s the decision. I’m here to support you, no matter what you choose.”

But something in my gut told me not to leave. Not yet.

I could see it—something unspoken hanging in the air. The way Carol and Blake kept glancing at each other, then back down at the floor, as if wrestling with a question they didn’t want to voice. There was a tension there. Not resistance, but hesitation. Almost embarrassment.

And then I did what I often do in those moments: I mentally scanned through every family I’ve ever sat with. Faces. Names. Tears. Questions. They all flashed through my mind, like a silent roll call of memory. What was I missing?

My role is to walk families through this process—to educate, support, and honor the gift of life through donation. But in this moment, I felt like I was overlooking something important. I knew they wanted to honor Ricky’s legacy. They told me that. I also remembered that Ricky was the sole provider. Carol had mentioned she hadn’t worked in years.

And then it struck me.

“You know,” I said gently, “when my dad died two years ago, it was completely unexpected. I was on my way to the hospital to talk to a family about donation when my phone rang. It was my mom. I almost sent it to voicemail—I was trying to get out the door—but it was Mom, so I answered.

‘I think Dad isn’t breathing,’ she said, almost as soon as I picked up.

I told her to call 911 and said I’d be right there.

In those moments, everything just… paused. And one of the first things I remember thinking—after the shock—was, How am I going to pay for the funeral? Dad didn’t have insurance. There was no plan. No safety net. Just grief, and the weight of what comes next.”

I looked at them both. “If you’re anything like we were—and like so many of the families I work with—that might be what’s sitting in the back of your mind right now. Not just grief. But the unknown. How the heck are we going to afford what comes next?”

Carol burst into tears. “Brent, I just don’t know how we’re going to pay for it,” she said, her voice cracking under the weight of it all. “This is all Morgan’s fault. I’ve lost everything.”

Blake stood and wrapped his arms around her. “Mom, Dad would want us to say yes,” he said quietly.

“I know, Blakey,” she replied, resting her head against his shoulder. “I know he would.”

I waited a moment, allowing them that space, then gently spoke. “Carol,” I said, “can I share something I often tell families about our process?”

She nodded through her tears. “Yes.”

“Donation is a process,” I began. “And it takes time. But I always tell families—don’t wish that time away. This process gives you something incredibly important right now: a pause. Time to breathe. Time to rest. Time to begin figuring out what comes next.”

I leaned in just a bit, keeping my voice steady. “You’ll be able to go home and call your friends, your family. You can tell them that Ricky has the potential to save lives—that he’s going to be a donor hero. And knowing the kind of man Ricky was, how quick he was to help anyone in need, I imagine you’re going to have people who are ready to return that kindness. People who will want to stand by you.”

She listened, tears still in her eyes, but her shoulders softened just slightly.

“Use this time, Carol,” I said. “Use it to rest. To make calls. To begin planning, to start figuring out the next steps—without having to do it all right now. We’ll walk through this together.”

“Let’s do it,” she said.

We signed the paperwork, and shortly after, Carol and Blake went home. A few days later, I returned to the hospital to support the honor walk and the final moments of extubation.

When I arrived, the unit was full—overflowing with people. Family. Friends. Neighbors. Some I recognized, many I didn’t. All of them gathered in quiet reverence, wearing matching shirts that read Justice for Ricky.

I found Carol and Blake standing off to the side.

Quite the impressive turnout,” I said softly.

Carol nodded, her eyes scanning the room. “I told you,” she replied. “He helped a lot of people. Everyone here has a story to tell—every single one of them. Ricky made sure of it.”

I smiled. “Well, I have something I’d like to present to you. I think it would be a fitting way to honor Ricky—and give everyone here a chance to show him just how much he meant.”

We gathered the group in the waiting room, and I presented Carol and Blake with the Donor Hero Medal, a token of recognition we give to families on behalf of their loved ones who choose to give the gift of life. Then, with the room quiet and full of emotion, I read the Moment of Honor—the reflection we share before a recovery begins, a moment set aside to honor the donor’s life and legacy.

In the time leading up to extubation, one by one, people came to me—friends, coworkers, neighbors. Each with a story. A ride given. A bill paid. Groceries dropped off without being asked. Gas money slipped into someone’s hand when times were tight. Over and over, I heard the same phrase: Ricky just showed up. Every time.

And so it was no surprise to anyone that he showed up one final time.

Although Ricky did not pass within the medical window needed for organ donation, he still gave the gift of sight to someone in need through eye donation. He will also help countless others through tissue donation.

His legacy lives not only in the lives he saved—but in the community he built. A community that showed up for him, just as he had shown up for them.

In Appalachia, loss wears many faces—but few have cut as deeply as the quiet devastation of overdose. It’s not just a crisis. It’s a wound that doesn’t scab. A mother who gets the call too soon. A grandmother raising a second generation. A town that learns to count eulogies by season.

Somewhere along the ridge lines and river valleys, death from overdose became less of an exception and more of a drumbeat. In 2020 alone, more than 7,000 lives were lost to opioid-related overdoses across the Appalachian region, accounting for over three-fourths of all drug fatalities that year[2]. That year, Appalachia’s overdose death rate was 50% higher than the national average[3]—a gap that continues to widen.

To put it plainly: if you live in rural Appalachia, you are significantly more likely to die from an overdose than your peers elsewhere. Recent studies show opioid overdose mortality rates 72% higher in Appalachian counties compared to non-Appalachian ones[4]. Among adults aged 25–54, that disparity reaches 64%[5]. These aren’t abstract numbers. They are lived realities—felt in funeral homes, empty chairs at Thanksgiving, and children left behind.

Between 2018 and 2021, the opioid-related death rate in rural Appalachian counties rose from 0.43 to 0.62 deaths per 1,000 residents[6]. And still, the region’s resources remain strained—its caregivers and advocates often operating without the institutional scaffolding afforded to more urban areas.

In these moments—these quiet, devastating losses—families are sometimes presented with a singular and sacred opportunity: the chance to say yes. The chance to allow legacy to take root in the very soil that grief has broken open. And for those of us who do this work, understanding the weight of Appalachian overdose is not just context. It is call.

Next Chapter: Chapter Three: The Anatomy of Advocacy