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Pacific Island Countries and Territories (PICTs) are typically regarded as being among the world’s most exposed to natural hazards. With climate change, these hazards may lead to losses and damages that pose a near existential threat for some communities. PICTs are highly diverse, but we show that they are being impacted by climate change in ways that are shared across the region, and different to many other parts of the world. The global narrative, institutionalized by the United Nations Framework Convention on Climate Change (UNFCCC), is often at odds with the local priorities and realities of loss and damage from climate change in small countries with scattered populations, limited infrastructure, little access to insurance, and significant circular subsistence economies. For many in the PICTs, informal economies, religion and indigenous norms are key to social and economic life; and land and sea are fundamental to identity. In contrast to the global narrative, loss and damage is often intangible, impacting mental health, tradition, lifestyles, biodiversity, and social cohesion. This paper identifies these features and highlights the implications for tackling loss and damage. There are significant justice issues that need to be addressed in the context of a ‘just transition’ towards a climate resilient future.