As end-of-life doulas, we are often trained to think of our work as a form of celebration. We are prepared to help our clients create legacy projects, conduct a life review, and find a sense of positive closure. Still, there are rooms we enter that are not celebratory. There is, instead, a “heavy silence.” This silence is not peaceful. It is the dense atmosphere of profound, unresolved regret.

It is the sound of a client confronting what they fear is “a life not fully lived.” We are sitting with someone who is actively grieving the “loss of the life you expected to live.”

In this space, our standard tools of legacy work can feel hollow, inadequate, or even cruel. This blog post is a reflection on how to sit in that heavy silence. It is for the moments when our client, facing the end, feels their life was “worthless.”

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The Shape of Existential Despair

This profound feeling of a “worthless” life has a name. It is “existential despair” or “existential suffering,” a state that is defined by a “loss of meaning and purpose in life, loss of dignity… and loss of self-worth.”

The psychologist Erik Erikson framed the final stage of life as a profound developmental conflict: “ego integrity versus despair.”

“Ego integrity” is the state achieved when a person reflects on their life and feels it has been “successful and purposeful,” while “Despair” is its opposite. It is a final “retrospective accounting” of one’s life that results in “regret[ting] missed opportunities.” It is a deep “sense of regret and despair over a life misspent.”

This suffering is not a passing mood. It is a crisis of the soul. This level of despair can even be correlated with a “desire for hastened death.” Our first task is to understand the gravity of this pain and validate it, rather than try to dismiss it.

When Looking Back Brings Pain

We must proceed with great caution. Our instinct as caregivers is often to initiate a life review to help the client “find meaning,” but for a client mired in regret, this very act can be actively harmful.

The person “may not have time to repair the past or forge a new direction.” For them, regret is no longer a tool for future change; it is a final judgment and placing their attention on the mistakes of their lives, especially without time for repair, “may lead them to despair and a feeling of worthlessness.”

Furthermore, for clients who have a history of trauma, an unstructured life review can “unearth” painful memories and create a significant risk of “re-traumatization” at the end of life.

We must never ask a client to walk through their regrets “unless you know you can lead them out of that dark place to a higher, more healing perspective.” Our primary goal is not to excavate pain, but to honor the person who sits before us today.

A Life Not True to Oneself

If your client is expressing these profound regrets, it is essential to understand that they are not alone. This feeling of a “wasted” life is not their private shame. It is one of the most common, shared experiences of humanity.

Bronnie Ware, a palliative care nurse, recorded the most common themes she heard from the dying. She distilled these into her book, ‘The Top Five Regrets of the Dying.’¹

The single most common regret she witnessed, above all others, was this: “I wish I had the courage to live a life true to myself, not the life others expected of me.”

This is the voice of your client. They are speaking this universal, painful truth, while other common regrets echo this theme: “I wish I had the courage to express my feelings” and “I wish I had let myself be happier.”

Many, she found, had “suppressed their feelings in order to keep peace with others.” Their despair often comes not from a place of malice, but from a life of constrained goodness and self-suppression.

When you sit with your client, you are not sitting with a personal failure. You are sitting with a universal “lament” that is deeply, profoundly human.

The Power of Pure Witnessing

In this sacred space of profound despair, what is our true function? It is not to “fix.” It is not to cheer, correct, or reframe, instead it is, simply, to witness.

The core of the death doula model is “non-judgmental support.” We provide a “safe haven.” We “lend a listening ear.” We are, above all else, “present,” and this act of “bearing witness” is the most powerful and profound intervention we have.

The philosopher Simone Weil wrote that “attention is the rarest and purest form of generosity,”² while she also noted, “The capacity to pay attention to an afflicted person is something very rare, very difficult; it is nearly a miracle.”

Your focused, non-judgmental presence is this miracle. For a person who feels “invisible” or “worthless,” your full attention is the ultimate validation. It wordlessly communicates that their life, in its entirety, is worthy of witness. This act, in itself, begins to break the “existential isolation” that defines their despair.

Welcome Everything, Push Away Nothing

How, then, do we practice this pure witnessing when the energy in the room is so heavy? We adopt the principle taught by Frank Ostaseski, cofounder of the Zen Hospice Project: ‘Welcome Everything; Push Away Nothing.’³

This is one of the “Five Invitations,” and it is the key to our practice. To “Welcoming” the client’s despair does not mean we must “like” or “agree with” it. It means “we need to be willing to meet it, to learn from it.” We do not push away their regret. We do not counter their sadness with “positive affirmations.” We do not try to tidy up their pain.

We “welcome” the client’s full, authentic experience—the anger, the bitterness, the raw grief. Instead, by “pushing away nothing,” we create a space where the client no longer has to fight to prove the validity of their pain. They can simply be, and be seen. This simple, profound act of allowing is an “act of love.”

From Despair Toward Dignity

After establishing this foundation of deep, non-judgmental trust, a gentle exploration may become possible. We are not “fixing,” but we may be able to help the client find their own meaning, and here, we shift our goal from a traditional “Life Review” to the more focused “Dignity Therapy.”

Dignity Therapy is a brief intervention specifically designed to “address existential despair” and preserve a “sense of self,” and while the focus is not on a chronological “life story,” which, as one study notes, may be “dominated by their illness or situation.”

Instead, we use gentle, open-ended questions to probe for meaning. We avoid, “What are your accomplishments?” which for a person in despair, is a closed door.

We ask, “Tell me about the parts of your life that you feel are most important?,” and “What have you learned about life that you would want to pass along to others?,” or, “Are there particular things… you would want to take the time to say once again?”

These questions skillfully bypass the client’s narrative of “failure” and search for their narrative of values and wisdom. Even a life of regret is a life of profound learning.

Searching for the Unseen Ripples

The client’s core suffering is a feeling of “meaninglessness.” It is the fear of “being invisible, in life or in death.”

The existential psychiatrist Irvin Yalom offers a beautiful and powerful antidote to this fear: the concept of “rippling.”⁴ “Rippling,” Yalom writes, is the simple truth that “each of us creates… concentric circles of influence that may affect others for years, even for generations.”

The impact of our lives often spreads outward in ways we do not realize, forming a legacy “without our conscious intent or knowledge.” This unspoken inheritance—a “piece of wisdom, guidance, virtue, comfort”—is what we all leave behind, passed on to others, whether we are aware of it or not.

Your client may not see their ripples. They were not “grand monuments.” They were small acts of kindness , a specific trait, or a lesson learned through pain.

Building the Language of Trust

Trauma is rooted in betrayal. Re-traumatization is often caused by surprise. The doula works to make the environment safe by making it predictable.

This is the trauma-informed principle of “Trustworthiness” and “Transparency.” The doula ensures all communication is open, honest, and free of jargon.

They collaborate with the medical team, perhaps by saying, “The nurse will be here in five minutes. We have asked her to explain everything she is doing before she does it. You have the right to say ‘stop’ at any time.”

This simple act of narration builds a profound foundation of trust. It ensures the person is a participant in their care, not an object of it.

Witnessing Without Judgment

Perhaps the greatest healing a doula offers is not in doing, but in being. It is the practice of “bearing witness” to suffering and joy without judgment.

It is the willingness to “welcome everything, push away nothing,” sitting with a person in their fear or anger without trying to fix it or offer a spiritual bypass.

Dying is a “human event,” not just a “medical one.” It is a time that holds the potential for profound growth and meaning, even within great suffering.

We must also honor the deep “ambiguity” of this journey. This process does not have to lead to “closure.” The doula’s presence validates the reality of the uncertainty, offering resilience in its place.

A Path to a Gentle Peace

This compassionate approach weaves all these threads together. It acknowledges the body’s memory. It understands the triggers of the present. It creates a space of active safety. It uses the doula as an advocate to restore voice and choice in the smallest, most meaningful moments. This is how we create the conditions for a “peaceful and meaningful end-of-life experience.”

Trauma-informed care does not erase the past. It protects the present, allowing a person’s final chapter to be one of dignity, not of fear. The body’s memory is a sacred text. It holds the story of a life lived, a life that has learned to survive.

To care for a person with this history is not about demanding they forget the past. It is about finally creating a space, perhaps for the first time in their life, where their “No” is honored as sacred, and their “Yes” is actively and patiently sought.

We can offer them a simple framework for this completion. Dr. Ira Byock suggests that even in the most fractured relationships, peace often boils down to four simple phrases: “Please forgive me,” “I forgive you,” “Thank you,” and “I love you.”⁵

Byock reframes dying not as a medical failure but as a “developmental stage” full of potential for growth and repair. Offering these words—even to the air, or to a photo of someone long gone—can be a powerful act of “life completion.”

This is the ultimate act of “bearing witness.” It is the restoration of the sanctity of the self, allowing the body’s final story to be one of profound, and deeply earned, peace.

As you reflect on this, what is a small, specific way you have seen agency or choice honored that brought a sense of peace to a difficult situation?

References:

1. Ware, Bronnie. “The Top Five Regrets of the Dying: A Life Transformed by the Dearly Departing.” This memoir from a palliative care nurse shares the universal regrets heard at the end of life, offering profound wisdom on living with courage and authenticity. ↩︎
2. Weil, Simone. “Gravity and Grace.” This is a collection of profound philosophical and spiritual fragments exploring the nature of suffering, affliction, and the redemptive, miraculous power of pure, generative attention. ↩︎
3. Ostaseski, Frank. “The Five Invitations: Discovering What Death Can Teach Us About Living Fully.” The cofounder of the Zen Hospice Project shares five core principles for living and dying, centered on the practice of “welcoming everything and pushing nothing away.” ↩︎
4. Yalom, Irvin D. “Staring at the Sun: Overcoming the Terror of Death.” An existential psychiatrist explores death anxiety and offers “rippling” as a powerful way to find meaning in our lives by acknowledging our lasting and often unknown influence on others. ↩︎
5. Byock, Ira. “Dying Well: The Prospect for Growth at the End of Life.” A palliative care physician uses patient stories to reframe dying as a final, meaningful “developmental stage” of life, one that holds the potential for growth and completion. ↩︎