TUESDAY, May 9, 2023 (American Heart Association News) -- Kyme Holman-Williamson was always close to her older brother, Eddie. So when she learned he needed a heart transplant, she immediately prepared a room for him in her Maryland home, where she could care for him after his surgery.

What she didn't prepare for was his death.

Eddie Holman, a former Marine, survived a seven-week wait for a donor. Wearing a heart pump, he walked nearly 7 miles each day up and down hospital corridors to stay strong. He survived transplant surgery and the critical first few days that followed last November. He promised his sister he'd be OK. And for a while, it seemed he might be.

But then his kidneys failed. The following weeks brought more complications – and more surgeries. After eight weeks, a decision was made to remove him from life support, and he died.

"I'm having a hard time processing it," said Williamson, 54. "I am somewhere between disbelief, pain, anger, deep sorrow and spiritual acceptance. One day I am so sad for him, then the next I am so sad for me. He said he was going to be OK, and I believed him."

Heart disease is the leading cause of death in the United States. Sometimes, death follows a long illness. Other times, it's sudden and unexpected.

Regardless of how it occurs, for the families of roughly 696,000 people in the U.S. each year, heart disease brings loss. Stroke is the No. 5 cause of death, affecting the loved ones of nearly 163,000 people each year.

It's not unusual for family members and friends to struggle with how they feel in the wake of a loved one's death, especially when the loss is unexpected, said Mary-Frances O'Connor, an associate professor of psychology at the University of Arizona in Tucson.

"Because we have no preparation for it, the brain is taken completely off guard," she said. This can lead to severe, prolonged grief for some. "But others may have an acute reaction and then go on to adapt quite resiliently. Not everyone who has an unexpected loss has a prolonged grief."

O'Connor said many people expect to go through what are known as the five stages of grief: denial, anger, bargaining, depression and acceptance. Initially described by Swiss psychiatrist Elisabeth Kübler-Ross as the emotional stages a person experiences when they learn they are dying, they have since come to describe a framework for dealing with many types of loss.

But what many don't understand, O'Connor said, is that these stages don't necessarily occur in sequence and may not occur at all. "Grief does not happen in a linear way," she said. "You don't go through one stage at a time."

Instead, the feelings associated with loss come in waves, she said. Over time, "yearning for the deceased tends to decrease and acceptance tends to increase. Waves of grief are less intense. Eventually, we have the ability to find comfort when we are having a wave or accept that waves come and go and not feel so hopeless over that person being gone."

For some people, knowing a loss is coming can help lessen the unsettling crash of emotions that follow, because it allows time to think about what to say or do for a loved one before they die, O'Connor said.

"Having a chance to have closure conversations where we get to say, 'I love you' and 'I'm grateful' and 'I forgive you' or 'Please forgive me' can be helpful later when we are grieving and look back," she said.

Although Williamson never expected her brother to die, she is comforted by the knowledge that she was able to sit by his side during his final days.

"I have my periods of pure gratitude despite my mourning, knowing my brother knew how much I loved him and that I stayed by his bedside fighting with him and for him so lovingly," she said. "I always said, 'You're my hero, baby sister loves you, you are doing great.' I never wanted him to lose his will or feel like anyone was losing hope. I held his hand, not knowing if he was afraid or not."

O'Connor said it's important for people who are grieving to recognize that feeling a range of emotions is not unusual.

"This is a normal process," she said. "Many experiences we have during grief are surprising. People don't expect it to be so intense. Or to maybe feel relief or blame or anxiety."

It's important to recognize that having any or all of these feelings is OK, O'Connor said. "Just knowing what you are going through is normal can help."

People who are grieving also should allow themselves whatever time they need to process these feelings and not feel like they are taking too long – or not long enough, she said.

"Grief is not on anyone else's timeline," she said. "It's a type of learning. You are learning what life is like without this person, what life is like now. That takes time."

American Heart Association News covers heart and brain health. Not all views expressed in this story reflect the official position of the American Heart Association. Copyright is owned or held by the American Heart Association, Inc., and all rights are reserved.

By Laura Williamson, American Heart Association News