Veterans have unique needs at EOL
Veterans have unique needs at EOL
VA/NHPCO program to be specific to vets
It's not unusual for soldiers who have returned from war never to discuss the war with their families or friends, which creates an aura of mystery or a sense that their loved ones somehow cannot fully understand them now that they have returned to civilian life.
What might be surprising is that often those very soldiers who attempt to shield themselves or others from their wartime experiences may re-experience the associated emotions pain, fear, guilt, helplessness, etc. at the end of life (EOL), according to Deborah Grassman, ARNP, nurse practitioner at Bay Pines VA Medical Center in St. Petersburg, FL, who has been with the Veterans Administration (VA) for 26 years and has been the director of the hospice program at the VA for 15 years.
Grassman was a plenary presentation speaker on "Wounded Warriors: Their Last Battle" at the recent 11th Clinical Team Conference and Pediatric Intensive, "Performing in the Key of E: Excellence in Interdisciplinary Care" sponsored by the National Hospice and Palliative Care Organization (NHPCO).
Because soldiers, particularly those who have seen combat, often have unique needs at the end of life, the VA and the NHPCO have teamed up to offer a program available to all hospices that has been developed to meet these special needs of America's veterans. The program can be accessed at www.WeHonorVeterans.org which, at press time, was scheduled to open in October. It is designed to address the following: military history checklist; veteran benefits and the VA organizational structure; recognition ceremonies; veteran-to-veteran programs; outreach materials; and staff and volunteer training modules.
Contrasts from different wars
Veterans might experience different trauma, depending on how they were received by the public after returning to the United States. In World War II, "everyone was involved in this war effort," Grassman noted.
For example, the Red Cross and other organizations would send pictures to soldiers overseas so that they would know that they were supported. "Also, there was no television coverage in World War II for the most part," she said. "Therefore, that meant that war could be glamorized; the American public could be shielded from the brutality of war, which fostered a lot of unity for the war. Also, the mission was pretty clear and largely undisputed in World War II, especially after Pearl Harbor."
World War II soldiers returned to the United States as victors. Because transportation was not as advanced at that time, "it took a while for them to get home, so there was time . . . to externalize some of those war stories that they had experienced," Grassman said.
By contrast, the Korean War is often called the "forgotten war" and was officially only a "conflict" or a "police action," she said. "I think those labels reflect how we often tend to minimize . . . what our Korean War veterans have gone through," Grassman explained.
In Vietnam, due to television coverage, Americans "were no longer shielded from the brutality of war," said Grassman, noting that it was "a very political war" about which the country was divided. Therefore, when Vietnam veterans returned, it was to quite a different reception than World War II vets received.
"You think about how our soldiers from Vietnam were being treated," Grassman said. "How did we meet and greet them when they came back?" Sometimes they were greeted as "baby killers" or simply as "murderers" by war protesters.
Although all wars involve brutality, one of the challenges with any veterans' death is complicated by whether they have caused harm, in addition to whether they have been harmed, she said. The fighting in Vietnam was more face-to-face, and the enemy was hard to determine.
Grassman said that as a result, it is easy to understand that a Vietnam veteran's memories like this "can sometimes complicate their peaceful dying."
Post-traumatic stress syndrome
Post-traumatic stress syndrome (PTSD) can be diagnosed in anyone who has had exposure to a traumatic event that is experienced with fear, horror, or a sense of helplessness, Grassman said. Bad memories of war often lead veterans to do "what most of us would do, which is to avoid any thought, any memory, any trigger that . . . would cause them to have these memories," she said.
According to the Diagnostic and Statistical Manual (DSM-IV), there are many criteria, or symptoms, of PTSD. The three major categories are:
The "traumatic is persistently re-experienced."
The person avoids associated trauma. For example, a veteran hears a balloon pop at a party, which reminds him or her of the war, so that individual never goes to parties again.
There are persistent symptoms of increased arousal, such as irritability or outbursts of anger, difficulty concentrating, etc.
According to Grassman's presentation, "some resources say that the single most influential risk [factor for PTSD] is having killed. This complicates EOL care."
"You see, it is one thing to have witnessed trauma; it is another thing to have caused trauma," she said. "That is a deeper level of traumatization . . . That is the injury that sometimes surfaces as people come to the end of their lives."
Some research suggests that one-third of Vietnam veterans suffer from PTSD, but 60% do not report it, Grassman said.
"PTSD is a mental, emotional, social, spiritual, moral, familial, intergenerational injury," Grassman writes in her presentation. "Healing requires interventions that address all dimensions of suffering."
With all the veterans that Grassman has dealt with in her years with the VA, she told the audience that they tend to "sort out" into three combat response trajectories:
integration (healing from the war);
apparent integration (delayed-onset PTSD; subclinical PTSD; latent PTSD);
incomplete integration (PTSD).
With trajectory one, the combat trauma is "successfully integrated." Among the comments she has heard from veterans who fall into this category are:
"I've faced death before in the war. I'm not afraid of death anymore."
"I must have been spared for a purpose."
"I faced death before, and every day since has been a gift."
With the third trajectory, Grassman says that she has heard the following comments from veterans or family members of veterans:
"Most of my brother remained in Vietnam."
"I didn't know the person who came back."
"I lost my soul in Vietnam."
"90% of me died in that war."
According to Grassman's presentation, one of the main criteria for PTSD is "estrangement from others," along with suspicion and lack of trust; alcohol use; anxiety; agitation; unfulfilled longing for the life not lived."
Don't push for stories
Grassman suggests that in working with patients at the end of life, it is "very important that we do not push people to tell their stories."
She noted that providers can inadvertently "do damage when we don't know" how to respond with an appropriate emotional environment.
Regarding intervention, Grassman suggested not asking someone, "Are you a veteran?" "The reason I don't want you to ask it that way, there are some veterans who don't think they're veterans. They think veterans are only people who have been in combat [or] only those [who] have used the VA," she told the audience. "Ask the question instead, 'Have you ever served in the military?'"
Another step is to identify those among volunteers at a particular hospice or other facility who might be veterans themselves, and assign those volunteers to the patients who are veterans. "There is a camaraderie that forms very, very quickly," she said.
"We need to affirm the feeling aspect of their death experience, especially the tears and the fears, which the military culture taught them to disdain," she said. "We need to anticipate that they might under-report their physical and emotional pain and fear. We need to thank them for serving our country and giving us our freedom. And there are a lot of ways you can do that."It's not unusual for soldiers who have returned from war never to discuss the war with their families or friends, which creates an aura of mystery or a sense that their loved ones somehow cannot fully understand them now that they have returned to civilian life.
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