VA experts offer advice on care for combat veterans at end of life

Veteran deaths at all-time high

Record numbers of veterans will die this year, and veteran deaths will remain high for the next decade, experts say.

Community hospices provide care to many of these veterans at the end of their lives, sometimes without hospice staff knowing their patients were in the service. Experts say hospice professionals often do not realize how their patients' military service or war-time experiences might color the way they face their own deaths.

The number of veteran deaths is expected to reach an all-time high of more than 680,000 in 2006, and it's expected that 600,000 veterans will die each year through 2016, says Christine Cody, RNC, MSN, national program manager of hospice and palliative care at the Department of Veterans Affairs in Washington, DC.

World War II veterans, now in their 80s, are the main reason for the increased numbers of veteran deaths, Cody adds.

The VA offers hospice services as a covered benefit, defined the same as the Medicare hospice benefit, to all enrolled veterans, Cody says.

"The mission of the program is to honor the veteran's preferences in preparing for end of life," Cody says. "There are studies of veterans and their families, asking them where they would prefer to die, and, overwhelmingly, veterans would prefer to die at home or in a supportive environment — not in an acute care unit."

For several years, the VA has enhanced end-of-life programs and services, focusing on staff and community education, and the change has produced positive results.

The percentage of VA inpatient deaths in a designated hospice bed has increased 49 percent from fiscal year 2004 to fiscal year 2005, Cody says.

Eight percent of VA inpatient deaths occurred in a designated hospice bed in FY 2003, compared with 12 percent in FY 2004 and 17 percent in FY 2005, she adds.

In the VA's Home Based Primary Care Program, the number of veterans receiving palliative care has increased from 200 in FY 2003 to 1,600 in FY 2004 to 2,600 in FY 2005, an increase of 58 percent between FY 2004 and FY 2005, Cody says.

VA deaths with a palliative care consult increased from 28 percent in FY 2003 to 33 percent in FY 2004 to 40 percent in FY 2005, she says.

The U.S. Department of Veterans Affairs is working to educate VA hospice and palliative care staff, as well as community-based hospice workers about the unique problems and needs of veterans at the end of life.

For example, combat veterans might suffer from a sudden onset of post-traumatic stress disorder (PTSD) in which traumatic memories have surfaced as a result of their confronting their own deaths, says Deborah Grassman, ARNP, hospice coordinator at Bay Pines VA in Bay Pines, FL. Grassman educates hospice staff and others about how to care for veterans, and she has created a DVD that demonstrates the best strategies for helping veterans at the end of life.

"Our conscious minds start receding, and our unconscious minds start expanding as we die," Grassman says. "As our conscious mind gets weaker, it is less able to push down those traumatic memories."

The VA has created a model for educating end-of-life workers and others about how to care for dying veterans, whose needs often are more complex than those of non-veterans at the end of life.

The VA's program goals are to increase veteran access to hospice and palliative care in both inpatient and outpatient settings; to promote quality improvement through program development and outcome measurement, and to enhance staff expertise in delivery of end-of-life care, Cody says.

"We help educate community providers who are caring for veterans," Cody says.

"One of the campaigns is to have hospices ask patients if they are veterans," Cody says. "We also have a national relationship with the National Hospice and Palliative Care Organization."

With 23 years of experience working with veterans and 11 years of exclusive hospice work, Grassman has cared for more than 3,000 dying veterans.

One generalization she can make of veterans is that they typically value stoicism, a behavior that was indoctrinated into them as young soldiers, Grassman says.

While stoicism was necessary during their military service, it can create difficulty as they come to the end of their lives, Grassman adds.

"The degree to which they incorporated that stoicism as a value after the military is the degree to which they can die a peaceful death," Grassman says. "People who are stoic underreport their pain and fear and behave as though everything is always fine on the outside when it may not be so fine on the inside."

This is one of the reasons why the VA is educating hospice professionals to ask patients whether they are veterans.

The VA directed all facilities to start a palliative care consult team in February, 2003, as part of a leadership move among the department's top officials, who recognized the need to improve end-of-life care for veterans, says Dwight Nelson, MSW, Veteran Integrated Service Network (VISN) 23 coordinator, extended care and rehab services line at the VA Midwest Health Care Network in Minneapolis, MN.

The VA's Hospice-Veteran Partnership Initiative promotes VA alliances with community partners. The VA provides no direct comprehensive home hospice services, but does work with community hospices where these services are available to veterans.

"We can't claim to have a real hospice model in many of our VAs because it involves bereavement and volunteers and so on," Nelson says. "We're working towards that."

Instead, the VA uses the PCCT approach, making a core team available to other staff across the continuum, including medicine, surgery, mental health, and extended care. The PCCT promotes hospice and PC services, and refers to community hospices when indicated, Nelson explains.

"Around the time the directive came out, the VA launched a series of training sessions for VISN teams," Nelson says. "They asked each VISN to set up what were called VISN-level hospice and palliative care teams to promote and be a resource to facility PCCT teams, and so that's been underway."

The teams consist of a physician, social worker, chaplain, and nurse, he adds.

"The VISN teams serve as consultants and oversee the PCCTs at all sites," Nelson says.

The project's goals are to improve care, educate staff, and improve end-of-life care access for veterans and their families, Nelson says.

"We work with and educate community hospices about the unique needs of veterans," Nelson says. "This especially is about combat veterans and their unique experience in a war combat zone."

For instance, the VA has created small reference cards that provide advice to health care providers who work with veterans, including those who are receiving end-of-life care.

The reference card suggests that providers begin discussions with patients with these four openers:

  • Tell me about your military experience.
  • When and where do you/did you serve?
  • What do you/did you do while in the service?
  • How has military service affected you?

Here are some other questions providers might ask patients, according to the VA's reference card:

  • Were you a prisoner of war?
  • Did you see combat, enemy fire, or casualties?
  • Were you wounded, injured, or hospitalized?
  • Did you ever become ill while you were in the service?

Whether or not veterans are referred by the VA to a community hospice's care depends on what the veterans and their families' desire, Nelson says.

"If a veteran is at a point where he or she might need a lot of support and there's not a family caregiver in the picture, or if there's an elderly wife who can't provide the level of care needed at home, and then the veteran might end up staying with us in one of our primary care beds," Nelson explains.

"Like hospices in the private sector, we have many veterans and families who have a strong desire to go back home for as long as they can," Nelson adds. "In those cases, whenever possible, we might make a referral for community hospice care."

Need More Information?

  • Christine Cody, RNC, MSN, National Program Manager, Hospice and Palliative Care, Department of Veterans Affairs, 810 Vermont Ave., NW, Washington, DC 20420.
  • Deborah Grassman, ARNP, Hospice Coordinator, Bay Pines VA, P.O. Box 5005, Bay Pines, FL 33744. Email:
  • Dwight Nelson, MSW, VISN 23 Coordinator, Extended Care and Rehab Service Line, VA Midwest Health Care Network, VA Medical Center, One Veterans Drive, Minneapolis, MN 55417. Telephone: (612) 467-5786.
  • More details are available at the Web sites: or