Our nation’s veterans are no strangers to difficulty. As they near the end of their lives, they continue to face unique challenges, both old and new.
Every veteran has different end-of-life treatment needs. These needs depend on several factors, including:
- Age when they served
- Branch of service and rank
- Which conflict(s) they served in
- Location(s) where they served
- If they have struggled with post-traumatic stress disorder (PTSD)
- If they were ever a prisoner of war
- Whether they were exposed to combat vs. noncombat situations
- Whether they enlisted or were drafted
LEARN ABOUT WE HONOR VETERANS PROGRAMS AT AMEDISYS
“We ask every new patient if they are a veteran,” says John DaSilva, an Opus Peace ambassador and Amedisys hospice bereavement coordinator in East Providence, RI. “If they are, we may need to look at their care in a different way. We talk to the patient and family differently. We learn as much as we can about their background and priorities so we can tailor our services to their needs and honor them in a way that is meaningful to them.”
Here are some of the challenges veterans face at the end of life and the ways veterans hospice programs can help:
Challenge: Post-Traumatic Stress Disorder
The deepest wounds of war are often the ones we cannot see. Frightening, dangerous or life-threatening experiences such as combat or military sexual trauma can lead to post-traumatic stress disorder. Veterans with PTSD may relive terrifying events, feel unfocused or constantly on edge, avoid people and situations that remind them of the traumatic event, and feel irritable, angry or numb. Nightmares, insomnia and loss of interest in usual activities are other common PTSD symptoms.
According to VA statistics, the prevalence of PTSD in veterans varies by time of service:
- Vietnam War: 10%
- Gulf War: 21%
- Operations Iraqi Freedom and Enduring Freedom: 29%
- WWII and Korean War: 3%
There are several unique considerations when providing hospice care for veterans with PTSD:
- Some symptoms of terminal illnesses can trigger or worsen PTSD symptoms. For example, pain, loss of control and breathlessness might trigger flashbacks or nightmares.
- Opioid medications used to treat pain can make PTSD symptoms worse.
- The intimate personal care that may be necessary near the end of life may trigger traumatic memories for some veterans.
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How Hospice Care Helps:
- A safe, nonjudgmental therapeutic environment to share difficult feelings or experiences
- A calming setting to ease unsettled behaviors
- Professional support, education and guidance for family members and loved ones helping to care for a veteran with PTSD
- Medication management with a nurse and physician
- Counseling with a social worker
- Connection with veteran volunteers to feel understood and supported
“If a veteran has PTSD, we know we have to work to earn their trust,” says DaSilva. “We take extra time to sit and explain who we are and what we plan to do. We train staff to avoid making sudden moves or approaching the veteran from the side. We may announce ourselves at the door and speak slowly and calmly. After all they’ve been through, our veterans need reassurance that they will be cared for and honored.”
Challenge: Chronic Pain
The physical demands of military service can continue to take a toll decades later. More than half of veterans receiving care at VA facilities have chronic pain, often due to musculoskeletal damage, traumatic brain injury or PTSD. Soldiers in the Korean War may experience more pain near the end of their lives because of their exposure to extreme cold and other elements.
Veterans are trained to endure pain and hardship without showing their feelings. Stoicism serves them well during active duty but can make it difficult for them to accept help for physical, emotional or spiritual pain in end-of-life treatment. They may see admitting pain as a sign of weakness.
How Hospice Care Helps:
- A safe, nonjudgmental environment where asking for and accepting help are encouraged
- Connection with veteran volunteers who share similar experiences
- Ongoing monitoring and pain assessment
- Pain-relieving medications and devices
- Coping skills practice with a social worker, counselor or clergy
- Relaxation and comfort through music, art and other tools
Challenge: Depression
VA statistics show that 11% of veterans over 65 have been diagnosed with major depressive disorder. This rate is more than double the rate in the general 65+ population. Veterans also have a suicide rate that is 22% higher than non-veterans. Sadly, only half of veterans who need mental health treatment receive it.
How Hospice Care Helps:
- Counseling and spiritual support
- Medication, as needed
- Help with household tasks and errands from hospice volunteers
- Personal care from a home health aide
- Connection with veteran volunteers who share similar experiences
“Many veterans feel agitated near the end of life,” says DaSilva. “We carefully monitor medications that could increase agitation and provide an open, safe person who is willing to hear their experiences. This gives them the opportunity to die with the peace of letting go of the stuff they’ve been carrying around their whole lives.”
Challenge: Traumatic Grief/Survivor Guilt
It’s important for veterans to grieve the loss of comrades. If grief goes unresolved, veterans may experience sadness, anger, shock, emptiness, distrust and guilt. Intense symptoms, similar to the feelings grieving spouses and parents have six months after a loss, can persist for decades among veterans. Experiencing sudden loss (traumatic grief) or multiple losses complicate the grieving process, as do self-blame and survivor guilt (feeling they have done something wrong by surviving when others did not).
How Hospice Care Helps:
- Counseling with a social worker
- A safe, nonjudgmental therapeutic environment to share difficult feelings or experiences
- Professional support, education and guidance for family members
- Connection with veteran volunteers to feel understood and supported
“A lot of veterans are worried about everyone else, not themselves. It’s how they’re conditioned in the military,” says Nicole Finitsis, an Amedisys hospice volunteer coordinator in Portsmouth, NH. “But at end-of-life, they’re looking for forgiveness – for the things they’ve done in service to our country, as well as things they couldn’t do like being present for their families or saving fallen comrades. They can work through these issues with a hospice social worker, nurse or volunteer.”
Challenge: Substance Abuse/Addiction Recovery
Veterans struggle with substance abuse at higher rates than the general population. A 2013 survey showed that one in 15 veterans had a substance use disorder in the past year, compared to 1 in 11 non-veterans. Many abuse drugs or alcohol in an attempt to cope with trauma from their military service and other mental health disorders. Others may inadvertently become addicted to prescription drugs used to treat pain.
Many of the medications used in hospice and palliative care are related to drugs that may have been abused by veterans. Prescription opiates, for example, are chemically similar to heroin. Benzodiazepines, often used to treat anxiety, are related to alcohol. Veterans may have unique concerns about using these medications.
How Hospice Care Helps:
- Consulting about alternative medication options for veterans with substance abuse concerns
- Counseling with a social worker
- Veteran volunteers to provide companionship and emotional support
Challenge: Service-Related Diseases
Veterans may be at higher risk of several illnesses that are linked to exposure to chemical warfare agents, Agent Orange (Vietnam War) or nuclear weapons. These diseases can lead to other issues such as cancer and Parkinson’s disease.
How Hospice Care Helps:
- Pain management through medication and therapies
- Medical check-ins with a hospice nurse
- Spiritual care with a chaplain
Challenge: Traumatic Brain Injuries
Traumatic brain injuries may result from military combat and exposure to mortars, mines, improvised explosive devices (IEDs) and other devices. Members of the armed forces who served during Operation Iraqi Freedom and Operation Enduring Freedom have particularly high incidences of traumatic brain injury.
How Hospice Care Helps:
- Pain management through medication and therapies
- Medical check-ins with a hospice nurse
- Spiritual care with a chaplain
- End-of-life treatment education for patient and family
Challenge: Spiritual Uncertainty
End-of-life is a time when spiritual questions arise for most people. Veterans may question their faith or feel uncertain about how their higher power will view their military service, especially if they were in combat. Concerns over forgiveness and acceptance are common.
How Hospice Care Helps:
- Spiritual exploration and counseling with a chaplain
- Journaling and other exercises that encourage reflection
- Connection with veteran volunteers to share memories and gain perspective on their contributions and purpose
“Near the end of life, we want to reflect,” says DaSilva. “But veterans may have spent many years pushing down memories. When the walls come down, they need to release their memories to an objective person. That’s where we hospice workers come in – to help patients and their families come to terms with what they went through.”
“In hospice, we’re their last chance to tell their true story,” says Karen Powell, an Amedisys hospice volunteer coordinator in Methuen, MA. “Veterans can choose any place to die, but when they come to a hospice program they’re looking for someone who will help them through this journey. It’s a humbling experience to be there for them at this critical time.”
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