Nation's warriors have unique needs as they face their last days

Peaceful deaths hindered by guilt, unresolved trauma

Some of the principles instilled in military men and women during their service are what make it so difficult for the same people to achieve peace while dying, experts say.

Stoicism, never surrendering, and ignoring emotional pain are qualities that might make it easier for a person to engage in mortal combat, but they can be barriers to serenity at the end of life.

"Soldiers are indoctrinated to not go down without a fight, so the idea of surrender is not part of their mentality," says Deborah Grassman, ARNP, hospice coordinator at the Bay Pines VA in Bay Pines, FL. Grassman has long worked with veterans at the end of life, and she trains health care professionals in how to improve care of dying veterans.

"The whole idea with dying in hospice care is you're helping people to let go, to surrender, so peacefulness will come," Grassman says.

But for men and women who were taught during their youth and formative years to think like disciplined warriors, the message is very powerful and lasting, Grassman notes.

"For soldiers, learning to fight and kill has to become instinctual so they'll survive in combat, and those qualities do not surrender easily, even when a person is facing death 50 years later," Grassman adds. "So that complicates a person's death and it impairs their ability to go gently into the night."

For combat veterans, there are other issues that hinder their ability to accept all that hospice providers can give them. Grassman describes some of these issues and offers advice on how hospice professionals can help veterans overcome them:

1. Traumatic memories and emotions are kept buried deep.

All of the traumatic memories they've kept sublimated for decades may begin to surface as they die, Grassman explains.

"Before they had the strength to run or hide from them, but when you're on your deathbed, those kinds of coping mechanisms to keep memories contained start losing their power and come forth," Grassman says. "We commonly see this happen; not a week goes by that I don't see it at least once."

So hospice professionals might be the first health care providers to help veterans deal with the strong emotions emerging during their delayed post-traumatic stress disorder (PTSD).

One of these emotions is paralyzing guilt, Grassman says.

"So they have killed and then they come to their death bed, getting ready to meet their maker," Grassman says.

They see their lives and the worst moments seem immediate, and this is when their guilt begins to interfere with the peacefulness of their deaths, she explains.

2. Alcoholism can be a problem.

"Often as a mechanism for running from the guilt or trying to numb traumatic memories, there can be a lot of flighty-type behavior, such as alcohol use," Grassman says. "A lifetime of alcohol usage means some unfinished business, a numbing out instead of confronting difficult situations, and this comes crashing down sometimes when a person faces death."

Alcoholism might not be rare in the general hospice population, but the military culture once encouraged drinking, which makes it common among veterans, Grassman notes.

"The military used to make alcohol easily available," Grassman says. "When soldiers were away from home and lonely and 18 or 19 years old, they would drink, and it shouldn't be surprising that there's a high incidence of alcohol use among veterans."

3. Some wars were valued more than others.

Dying veterans may experience their deaths differently, depending on which war they fought.

For instance, the veterans of World War II, which includes the largest group of veterans who are dying in hospice care now, experienced unity and support from the American public, Grassman says.

"The reason we were in the war was undisputed, especially after Pearl Harbor, and the soldiers were all there for the duration of the war," Grassman says. "They didn't come home until they were killed or the war ended."

When they did return home, they were greeted as heroes and the public was eager to hear their victorious war-time stories, Grassman says.

The positive impact of public support has helped many of these veterans cope with their traumatic experiences, she says.

The soldiers who fought in Korea and Vietnam were not so fortunate, Grassman says.

"The Korean War wasn't even called a war," she says. "It was a conflict or police action, and that, in my mind, tends to show how we minimize or neglect their conflict contributions."

Korean veterans often suffer from the effects of frostbite and lost limbs, and the simple act of putting a sheet over their legs may cause them to flinch or jump, Grassman says.

"Then there was Vietnam," Grassman says. "Korea taught us how to ignore the soldiers, and Vietnam taught us how to shame them."

Due to extensive TV coverage of the Vietnam War, Americans were no longer shielded from the brutality of war, she explains.

The Vietnam War ushered in years of protest, and this divided the nation.

"The most important thing from that war was when our soldiers returned home they were greeted with protest signs calling them murderers and baby killers and that sort of thing," Grassman says. "We did not want to hear about this war, so they clamped up."

And psychological experts now know that the worst thing you can do about a traumatic experience is lock it up in silence, Grassman says.

"So when we talk about what hospices can do, one of the things we can do is thank veterans for their service to our nation," Grassman says.

"We can thank them and acknowledge that it was a sacrifice," she adds. "While the rest of us are learning skills to form families, getting schooling, advancing our careers, they're doing the opposite things, and they're making sacrifices."

Often just by thanking veteran patients, hospice workers will open the door to hear their stories, Grassman says.

"The second thing is if they are Vietnam war veterans or Korean war veterans, we can apologize to them for the way we treated them," Grassman says.

"It's not unusual for me to get down on my knees to say, 'I am so sorry for how we treated you; I'm so sorry for the scorn you had to endure because of our ignorance,'" Grassman says. "What you often see is that this is all that is needed — all they wanted was for someone to say, 'I'm sorry you had to do this and that we treated you like this.'"

Sometimes the simple act of apology will allow the veteran to finally open up about his experience, shame, and bitterness, and release these emotions, she says. (See tips on speaking with veterans, below.)

Here are some strategies for hospices working with veterans

Expert, VA offer these tips

Hospice professionals who would like to improve their care of veterans can create opportunities for release and healing by asking the following questions and following this advice, according to the U.S. Department of Veterans Affairs in Washington, DC, and Deborah Grassman, ARNP, hospice coordinator at the Bay Pines VA in Bay Pines, FL:

  • Are you a veteran?
  • Are you a combat veteran?
  • If the previous answer is yes, then say, 'Combat veterans have often told me how ugly war is. I'm just wondering if there's anything from that war you were in that still might be troubling you now.' Grassman says.

"Then, and here's the important piece that people often forget, you have to sit quietly for 15 to 30 seconds, just sitting without expectation," she says. "When we ask a question about whether there is anything still troubling someone about the war, then we have to shift into a different mode with a low, quiet energy that lets the question hang in the air."

Pushing for an answer can cause damage when a person is not ready to tell his or her story, Grassman adds.

"I think we have done even more damage by not opening the door because that abandons the patient," Grassman notes. "Our hospice responsibility is to know how to open the door without pushing, and how to create a comfortable emotional environment in which they can step forward with their story if they so choose."

  • Show genuine interest.

"People with PTSD do not trust easily, and they can sniff out a phony," Grassman says. "One of the underlying principles is each of us has to be honest and real with them and genuine and caring."

If a hospice worker has prejudices toward veterans with PTSD, then the worker needs to come to grips with it and work through it before attempting to help the veteran with his or her trauma and unresolved issues, Grassman suggests.

  • When hospice and other medical professionals wish to learn whether a veteran is experiencing PTSD, the VA suggests they ask this question: "In your life, have you ever had an experience so frightening, horrible, or upsetting that, in the past month, you….

- Have had nightmares about it or thought about it when you did not want to?
- Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
- Were constantly on guard, watchful, or easily, startled?
- Felt numb or detached from others, activities, or your surroundings?

"It's never too late to bring our soldiers home," Grassman says. "We can do it one soldier at a time, and the last opportunity to do that is on their deathbed."

Hospice professionals have the awesome responsibility of providing the last opportunity for healing for a veteran, Grassman adds.

4. Combat veterans have three different trajectories for coping with the trauma.

"This is overly simplified, but its value is that it provokes people into thinking about this issue," Grassman says.

In the most difficult cases, the veteran has never confronted or worked through the traumatic experiences and his feelings about them. These are the veterans who may suffer from post-traumatic stress disorder, Grassman says.

"For whatever reason, the trauma has been at least partially contained, instead of integrated," Grassman says. "It continues to knock at the door, begging for integration."

Some of these veterans may have peaceful deaths, but others won't. It depends on their residual memories and feelings of guilt and whether they've been treated for PTSD, Grassman says.

For this group, there still might be survivor's guilt and a share of the suffering many veterans experience with regards to whether their military and combat service had any greater meaning, she says.

"How strong is that stoicism that has encapsulated and isolated them from parts of their own selves?" Grassman says. "Those are all factors I believe affect whether PTSD will come out on their death bed."

Grassman calls the middle trajectory the latent PTSD group in which the veterans have returned from the war and appear to be free of PTSD but, in subtle and not-so-subtle ways, the trauma remains, sabotaging their lives in little ways.

"They don't attribute their problems to the war," Grassman says. "They're especially good at building thick, strong walls to segregate that trauma into another area where they don't have to look at it."

Veterans in this group might first experience PTSD symptoms while they are dying in hospice care, she adds.

The ideal trajectory involves full integration and acceptance of their service and lives afterwards.

These veterans have been healed emotionally and have worked through healing after their trauma, Grassman says.

"When they come to the end of their lives, what they say is, 'I faced death before the war, and I have not been afraid of death since,'" Grassman says. "So they truly face death without fear of death."

These veterans might say they view every day as a gift they didn't expect to have since they had gone to war expecting to die, she says.

"That's what I call the trajectory of integration," Grassman says. "They integrated the war trauma into their non-trauma, post-war lives, and that doesn't happen automatically or easily."

Grassman worked with a veteran who had fully integrated his World War II experiences into his life, and the trauma was resolved.

When she met the man and asked him how he was doing in hospice care, he answered, "I am blissful," she recalls.

The man told her the story of how 10 years after the war he was an art professor and was contacted by an opera house in Germany, which asked him to be their set designer for a show.

He declined at first because of the bad memories he had of being a prisoner of war in Germany during the war, but then he realized it would be a dream come true, so he took the job and returned to Germany, Grassman says.

His PTSD symptoms were contained until it came to hearing the German language, which brought back memories of his POW experience. The man got through this experience by learning the German language well enough to direct the opera house workers and to become an interpreter for others, Grassman explains.

"When he confronted those fears within himself, that's when he became free," she adds.