A sudden, accidental, unexpected or traumatic death shatters the world as we know it. It is often a loss that does not make sense. We realize that life is not always fair and that sometimes bad things happen to good people. The sudden death leaves us feeling shaken, unsure and vulnerable.

Definitions
A Sudden Loss is one that occurs without any forewarning. A Traumatic Death is one that is sudden, unanticipated, violent, mutilating or destructive, random and/or preventable, involves multiple deaths or one in which the mourner has a personal encounter with death.

Common examples of sudden deaths include: heart attacks, strokes, ruptured aneurysms, accidents, post-operative complications, anaphylactic reactions (bee stings, severe allergies), rapidly fatal acute leukemias, sudden infant death syndrome and rapidly progressive infectious diseases such as respiratory anthrax, certain pneumonias, Legionnaire's. Sudden deaths also include suicide, homicide, natural disasters such as the Loma Prieta earthquake and human-caused disasters such as the Oklahoma City Bombing or the September 11th terrorist attack.

The grief response following sudden loss is often intensified since there is little to no opportunity to prepare for the loss, say good-bye, finish unfinished business or prepare for bereavement. Families and friends are suddenly forced to face the loss of a loved one instantaneously and without warning. This type of loss can generate intense grief responses such as shock, anger, guilt, sudden depression, despair and hopelessness.

A sudden tragic event shatters our sense of order and thrusts us into a world forever changed. Survivors of sudden loss may experience a greater sense of vulnerability and heightened anxiety. The safe world we once knew, no longer exists. We fear for ourselves, our family and friends. Survivors can become overwhelmingly preoccupied with thoughts that such a random act of violence might happen again.

Along with the primary loss of the person, families and loved ones may experience concurrent crises and multiple secondary losses: lost income, loss of home, loss of social status. The role the loved one held in the family is gone. It takes time for the family to reorganize. Family may be left feeling in a state of perpetual disarray with a lingering sense of unease and disorganization. Marital and other family relationships can become strained.

Additional problems arise if the grieving survivor was involved with the disaster or was physically injured. Memories of the accident or the disaster may dominate the person's mind. They may be taken up with feelings of numbness, unreality and fear. The bereaved person may suffer from "survivor guilt," wondering why they survived when others have died and believing that they could have or should have done more to prevent the tragedy.

The reaction to sudden deaths can be further complicated if the death is due to a violent act. If there is a trial, the grieving process may be unduly prolonged, stretching out to the time it takes for the trial. It may be particularly difficult on the family if the killer of their loved one is not be caught or goes unpunished.

Suicide is one of the most agonizing kinds of death for surviving spouses or family members to endure. This type of death can result in shame, anger and guilt if family members blame themselves, or are blamed for the death. Suicide is also one of the disenfranchised or publicly unacknowledged losses. Many times, it possible, the reason for a death due to suicide is hidden. The threat of social stigma contributes to family shame.

Families may feel unable to fully grieve and reach closure in situations when there is no positive confirmation of the death, when the physical body has not been recovered or if the body is available but the family is unable to view it. This factor can make it difficult to grasp the reality of the death has occurred as survivors continue to hope. Only when the reality is fully grasped can survivors move past the trauma to face the full realization and the pain of grief.

In public or particularly newsworthy events, survivors may also have to deal with intrusion by the media. As we well know the media can become an additional pain source—not respecting the families privacy, replaying tragic events—such as the explosion of the Challenger space shuttle or plane crashing into the World Trade Towers—over and over again. With criminal incidents families and survivors must deal with the police, investigators and lawyers.

Since the death was not anticipated, the deceased may have left unfinished business which the surviving family members may need to handle. These may be domestic concerns but could equally well be work-related or legal matters. Legal and financial affairs following certain types of death e.g. suicide, deaths in which the body is never recovered, may be complex.

The search for meaning of the loss can challenge a survivors religious and spiritual beliefs. Sudden losses in particular can precipitate an existential crisis as the survivor searches for meaning. They start questioning their internal belief system and values. Goals, plans and purchases which were important the week prior to the event, abruptly seem trivial in comparison. Survivors are forced to look at and re-evaluate life priorities.

1.  Natural vs. human-caused disasters
Natural losses are illnesses and natural disasters—heart attack, stroke, earthquake or hurricane. With natural losses the resulting anger is directed towards the deceased or God. Human-caused losses include homicide, bombings, or acts of war and may be due to individual hostile actions. In human-caused disasters the survivor’s anger can be focused on the responsible person(s).

2.  The degree of intentionality
In accidental deaths there is no clear focus of intentionality. There is a high degree of intentionality with deaths such as homicide. Anger and blame for the death can be directed at a responsible person. 

3.  The degree of preventability
Illnesses like a sudden heart attack or ruptured aneurysm and natural disasters earthquakes, hurricanes, tornadoes may not be perceived as being preventable. Others such as homicide may be highly preventable. When deaths are perceived as preventable, there may be a strong sense of the "What if’s." Preventable deaths are likely to increase a sense of guilt, especially if one feels responsible or a sense of anger or if one holds others at fault.

4.  Suffering
With some losses, the death is instantaneous. Immediate death may leave feelings that the person who died had no time to prepare for the death. Many survivors find the knowledge of an instantaneous death to be comforting. In others situations, there is a question whether the deceased suffered pain or anxiety prior to dying. These memories, particularly if the person's relative died in extremely distressing circumstances may dominate the person's thoughts, rather than the memories of the person themselves. This can become a diversion from grieving for the deceased person disrupting the grieving process. Imaginings or memories of the traumatic death may cause so much distress, that remembering the person who died may be actively avoided.

5.  Scope
The number of people affected by the loss can affect the intensity of grief. When large numbers of people are involved as with a devastating hurricane, the ability of others to offer support maybe limited, because of the extent of those involved. Conversely, highly public losses such as the September 11th tragedy, Littleton Shootings or losses due to war can result in a greater community response and demonstration of support, allowing survivors to bond and grieve together.

6.  The degree of expectedness
Some sudden losses are still somewhat expected, even if just retrospectively. The heart attack of someone at risk or the sudden loss of someone struggling with a life-threatening illness, frequently do not come as a total surprise. Other losses, such as accidents or random acts of violence, offer little to no forewarning and are a shock to the survivor.

Traumatic grief generally occurs when a death is:

• Sudden, unexpected - the result of natural causes but without a history of illness.
• Violent, Mutilating, Destructive - especially when caused by the actions of another person, an accident, suicide, homicide, or other catastrophe.
• Is viewed as random and/or preventable.
• Involves multiple deaths.
• Results in the survivor’s (mourner’s) own personal encounter with death.

The grieving process with traumatic grief is complex, intensified demanding even more than a normal response as the survivor struggles to cope with the loss and the aftermath. Traumatic losses are the ones that often require counseling and professional help from those knowledgeable in the field to help the grieving better cope with the loss.

• There is no warning, therefore no time to prepare. Unlike a hurricane or slow-rising flood, there is no way to get ready for a human-caused disaster.
• We don't expect this kind of disaster. Most of the disasters in this country are weather related or accidents.
• There have been few incidents of terrorist attacks occurring in the United States. The last notable one was the attack on Pearl Harbor, 60 years ago. Terrorist attacks happen somewhere else, not in the "safety" of the United States.
• It is difficult to comprehend how people could carefully and deliberately plan and execute a mission that would cause so much death and destruction and injuries.
• Terrorists acts can lead us to question our fundamental beliefs and values—what we know to the true, right and just in the world.
• TV, radio, and newspaper coverage make us all feel like part of the disaster. Many experienced the events "first-hand" watching the live media coverage. Thus even more people became secondary victims of the event.
• To feel safe again, we have given up some of the freedoms and life-style choices we have taken for granted in the past. Witness the changes in travel, restrictions on what can be taken on a plane, mail handling and increased security at public events.

It is human nature to want to answer the question "Why?" yet it may be difficult if not impossible to find an answer. Instead the question "Why?" is more of a plea for meaning and understanding. The thoughts of Rabbi Earl Grollman provide a useful perspective for coping with this difficult question:

Now death has shaken your faith, "Why?" "Why must life be one of sorrow?" "Why?" There are no pat answers. No one completely understands the  mystery of death. Even if the question were answered, Would your pain be eased, your loneliness less terrible?

"Why" may be more than a question. It may be an agonizing cry for a heart-breaking loss, an expression of distress, disappointment, bewilderment, alienation, and betrayal. There is no answer that bridges the chasm of irreparable separation. There is no satisfactory response for an unresolvable dilemma. Not all questions have complete answers. Unanswered "Why's" are part of life. The search may continue but the real question might be "How [do I] pick up the pieces and go on living as meaningful as possible?"

• Maintain a normal routine. Even if it is difficult to do regular activities, try to anyway. Putting more structure into a daily routine will help one to feel more in control.
• Get enough sleep, at least plenty of rest.
• It may be helpful to keep lists, write notes, or keep a schedule.
• Try and get some regular exercise. This can help relieve stress and tension.
• Keep a balanced diet. Watch out for junk food, or high calorie comfort food binges.
• Drink plenty of water.
• Drink alcohol in moderation. Alcohol should not be used as a way of masking the pain.
• Do what comforts, sustains & recharges.
• Remember other difficult times and how you have survived them. Draw upon the inner strength.
• Take it one hour at a time, one day at a time.

After a few months, support is most needed. Be prepared to listen. Give the bereaved time to talk about their loss if they want. Ask how you can help. You can offer to take them to or go with them to a support group if it's feels appropriate.

Over time it helps to remember the grieving on the difficult days—anniversaries, holidays, the birthday or the death day of the person who died. People like to know that others still remember their loved one.

Conclusions
Sudden losses, like all losses, are very distinct and are likely to affect survivors in many different ways. One cannot compare loss. The greatest loss is the one that the grieving person is suffering. Each loss, whether sudden or not, creates its own unique issues. It is important to allow survivors to grieve in their own individual way.

Sudden loss create distinct issues and problems for survivors. It also shares many reactions common to the grief process—being a process that survivors go through following a loss. Each type of sudden loss, whether a heart or a terrorist attack, leaves survivors bereaved, dazed and vulnerable.

Resources:
Dyer KA. 9-11: United in Courage & Grief. Why does my heart Feel so bad? October 7, 2001. Available at: http://www.journeyofhearts.org/kirstimd/911_bad.htm
Red Cross. When Bad Things Happen. 2001. At: http://www.redcross.org/services/disaster/keepsafe/badthings.html.
Rando TA. Complications in Mourning Traumatic Death. Chapter 11 in Doka KA (ed). Living with Grief After Sudden Loss: Suicide, Homicide, Accident, Heart Attack, Stroke. Washington D..: American Hospice Foundation, 1996.
Rando TA. Treatment of Complicated Mourning. Champaign, IL: Research Press, 1993.
National Association for Loss & Grief. Grief Reactions Associated with Accidental or Traumatic Death. Available at: http://www.grieflink.asn.au/traumatic.html.
Paul BJ. Reactions to Sudden or Traumatic Loss. 2001. Available at: http://www.aarp.org/griefandloss/articles/15_a.html.
Doka KJ. Sudden Loss: The Experiences of Bereavement. In Doka KJ (ed) Living with Grief After Sudden Loss: Suicide, Homicide, Aident, Heart Attack, Stroke. Washington D.C.: Hospice Foundation of America, 1996.
Grollman, E. Living When a Loved One has Died. Boston, MA: Beacon Press; 1995, p. 8.
Grollman RA. Why? Journeys Newsletter. Washington D.C.: Hospice Foundation of America, March 2001 p. 3.
Anderson M. Newcastle Centre for Family Studies: Death in the Family. Available at: http://www.ncl.ac.uk/ncfs/ncfs/document55.html.
Dyer KA. 9-11: United in Courage & Grief. Ways of Coping then Helping. October 7, 2001. Available at: http://www.journeyofhearts.org/kirstimd/911_cope.htm