April 2026: Grief's Complexities and Questionable Causes of Death

The Author: For more than 40 years, William G. Hoy has been counseling with the bereaved, supporting the dying and their families, and teaching colleagues how to provide more effective care. After more than 17 years in hospice care, he served as Clinical Professor of Medical Humanities at Baylor University in Waco, Texas from 2012 to 2024. In his semi-retirement, he continues to write and provide resources and training seminars to colleagues who care for the bereaved. He can be reached at Bill_Hoy@baylor.edu.

Dylan had struggled with substances since high school, and his parents had paid for rehab twice in his young adult years. Nevertheless, when he was found dead from a drug overdose at the age of 27, his family found his death not altogether unexpected. But when the medical examiner ruled the death as a “suicide” rather than what they assumed to have been an accidental overdose, their world was rocked. How could he have chosen to end his own life, despite the difficulties with drugs with which he had grappled for nearly a decade?

Samantha was a young mother of three. The motor vehicle crash that caused her death seemed to have been a tragic, single-vehicle accident. But the medical examiner and police investigators concluded that the lack of skid marks, working condition of the automobile’s braking system, and the daylight time of the accident pointed to an intentional crash; her death was ruled a suicide.
 
In caring for families following the expected death of an older loved one from “natural causes,” rarely will there be a reason for family members to question the cause of death. Occasionally, there might be a question between a sudden cardiac arrest and a CVA (stroke), or family members might object to “obesity” or “smoking” or “alcohol consumption” as a “contributing” cause of death, but such differences rarely create complication for bereaved family members. However, when death is sudden and unexpected, and especially when the question is between whether a death was ruled as an accident, suicide, or homicide, the differences for family members can be substantial. As you support individuals struggling with the “official ruling” on causes of death, keep these principles in mind.
 
Understand cause of death language . You might be the most important interpreter of otherwise-confusing language on a death certificate or autopsy report. To the level of your knowledge, experience, and training, help bereaved individuals understand the documents they receive. Strictly speaking, the cause of death refers to the immediate, underlying, and contributing illness or injuries that led to the death. An underlying cause of death is the single illness, condition, or injury that “starts the chain of events” that leads to the death. Intracranial hemorrhage might be an immediate cause of death but there should be an underlying cause of death showing what started the dying process.
 
Somewhat different from the cause of death is the manner of death , listed separately on the death certificate and autopsy report. The manner of death is the classification scheme that assigns responsibility for the cause: natural, accident, suicide, or homicide. In our example, the intracranial hemorrhage might have been caused naturally by a CVA/stroke (making it a “natural” death), by falling down the stairs and hitting one’s head (accident), or by an assault (homicide). In my experience, it is conflict over the manner of death that causes most distress for family members, especially when a death that was thought to have been an accident or a homicide is ruled by authorities as a suicide.
 
When the cause and/or manner of death cannot be immediately determined, the medical examiner will usually list these as “deferred.” When toxicology studies are required, for example, the causes and manner of death will usually be deferred for several weeks until these studies are complete. Though the delay is difficult for families, in my experience it is far more difficult when a cause and manner are listed soon after the death, only to be changed by the medical examiner several weeks later. I have seen this happen often enough and it is never good for families.
 
Inquire about the bereaved individual’s response to the cause. One family with whom I worked initially thought their brother had died when his car caught fire and their assumptions were suggested first by the law enforcement officers who notified the next of kin about the death. As the investigation progressed over the next few days, law enforcement, arson investigators, and the medical examiner realized the automobile had been packed with explosives and highly flammable materials; the deceased’s written manifesto found in his home indicated that he had intended to create a car bomb to detonate near a national landmark. Family members quickly moved from blaming the automobile manufacturer for using flammable materials in constructing the car and the slow response of fire department to shame that their brother had intended to harm innocent people and destroy a national treasure. Helping them process those changes in emotions is long-term, complex therapeutic work.
 
I like to ask individuals when they report having received the death certificate or autopsy report, “What most surprised you about what you read?” or “This is a different explanation than you were working with; how are you making sense of this new information?” These are especially important questions when the causes are deferred; bereaved individuals often express imaginative ideas about what the final cause of death will be.

Provide support as the bereaved person seeks more information. Complex medical information and forensic investigation is beyond the training and knowledge of most clinicians so be careful to remain within your own scope of practice. However, you might join bereaved individuals in making a plan for how they will learn more information. Perhaps a visit with the deceased’s physician or law enforcement officials would help to answer questions of a more technical nature.
 
When I was a young pastor, a congregant died in the operating room undergoing a procedure intended to prevent a heart attack. When the surgeon got the autopsy results, he invited family members to come to the office over the lunch hour to talk about the findings; they asked me to accompany them to that visit. While I could contribute little to the conversation other than rewording a question the widow could not seem to make understood to the physician, I did little other than sit by, listen, jot down a few notes for the family, and support them in the discussion that ensued on at their own at home. That presence, I realized in retrospect, was the best gift I could have given them.

  Recognize the changing emotions that occur in traumatic bereavement over time. In an interaction with a bereaved mother who initially thought her son died when a drug dealer had provided “fentanyl laced cocaine,” later realized her son had indicated in his journal his intention to die on that Saturday evening. As this realization became clearer to the mom, her rage turned away from her son’s supplier to her son himself, exclaiming, “I just don’t get how he could treat himself so carelessly when we cared so much for him.” She and her husband had taken funds from their retirement account to fund two failed attempts at rehabilitation and her anger was palpable.
 
Clinicians must be ready to hear a diversity of changing emotions in our work with bereaved people, always aware that both the nature of the experience and the object of anger or guilt can change over time. As more information becomes clear, these reactions often change, too.
 
The bereavement experiences when cause of death and manner of death are different than originally expected can be a roller-coaster for bereaved individuals. Part of the therapeutic alliance, however, is they often become a roller-coaster for us, as well.