Veterans Issues at the End of Life

Objectives of Training

At the end of the training, you will be able to: •  Describe why it is important to improve our

knowledge and understanding of Veteran’s needs

•  Describe how we can best meet the needs of Veterans and their loved ones

•  List four unique issues that Veterans may face at the end of life

Veteran Populations •  The 26 million veterans that are alive today

served our country during times of both peace and war. The breakdown of surviving veterans is as follows: – Peacetime veterans - 6,142,000 – WWII veterans - 3,151,000 – Korea war veterans - 3,086,000 – Vietnam war veterans - 7,956,000 – Gulf War veterans from 1990 forward number

more than 4,646,527

Additional Facts About Veterans

•  One in four adult men is a Veteran, with a median age of 58 years old.

•  More than 1,800 Veterans die each day •  The Veterans Administration (VA) cares for

less than 4% of veterans at the end of life •  96% of veterans die in the community

Veteran’s Unique Needs

America’s veterans and their loved ones may have unique needs

These needs are influenced by: •  Combat or non-combat experience •  Which war they served in •  If they were Prisoner’s of War (POW’s) •  If they had Post Traumatic Stress Disorder (PTSD) •  Their branch of service and their rank •  Whether they enlisted in the military or were drafted

Influences on Veteran’s Needs

•  Both combat and non-combat experiences influence a Veteran’s needs.

•  Since every Veterans experience is different, it is unrealistic to assume that: – Non-combat Veterans have little to no needs – Combat Veterans have more extensive unique

needs

•  The magnitude and time spent in a specific war is a major factor in determining needs of Veterans.

•  It is likely that Prisoners of War (POW’s) experienced a higher level of trauma from their war experiences, which would increase their unique needs.

•  Those Veterans who struggle with PTSD may also require more extensive support.

Influence’s Continued…

•  Depending on the specific war or conflict, one branch of service may have suffered more casualties during the war

•  Be aware that the needs of enlisted Veterans might differ from the needs of drafted Veterans. –  Drafted Veterans may be bitter about their forced

military service. –  This may make it more difficult to support that Veteran

as well.

Influence’s on Unique Needs continued….

War Experience + Non-Combat Dangerous Duty Assignments •  World War II •  Korean “Conflict” •  Vietnam War •  Gulf War •  Iraq/Afghanistan •  Other “conflicts” around the world •  Peacetime

Peacetime and Non-Combat Dangerous Duty Assignments

•  Do not assume that service was easy for the Veteran if it was provided during peacetime.

•  Soldiers serve on many highly dangerous assignments during Peacetime

•  The message is the same: “We own you. We can send you anywhere we want.”

War’s Consequences

“The outcome of any armed conflict holds

not just the promise of peace but also dark, terrible revelations, questions of

justice over the vanquished, and, for far too many, the confronting of personal loss.”

Veterans History Project: Forever a Soldier: Unforgettable Stories of Wartime Service

Military Cultural Norms

Some “Norms” of Military Culture influence end-of-life experiences because...

• Stoicism was promoted • Fear and admitting pain was seen as a sign of weakness. Slogans include:

–  “Big boys don’t cry” –  “No pain no gain” –  “Few good men” –  “Once a Marine always a Marine”

Possible Outcomes from Combat Experience

•  Some Veterans are able to integrate experience into their lives, especially if they…

– Are naturally resilient – Have good family and social support – Had a positive war outcome – Talked about their war experiences

Growth After Traumatic Experiences

•  After a traumatic event, individuals may experience growth. This growth is a positive psychological result due to the traumatic experience.

•  Growth can occur because of new revelations that are realized by the person experiencing the traumatic event. For example: –  A soldier narrowly escapes death on the battlefield; he or

she may find new beauty in the smallest things that life has to offer.

–  The individual may learn to cherish things that were once taken for granted.

Signs That Post Traumatic Growth Has Occurred

Signs that Post Traumatic Growth occurred include:

•  Relating well to others •  Being open to new possibilities •  Personal strength •  Spiritual changes •  Appreciation of life

Traumatic Combat Memories Can Cause Problems for the Veteran As Well

The following slides will examine some of these potential problems

Traumatic Combat Memories Can Cause

•  Alcohol or drug abuse •  Social isolation •  Anxiety •  Outbursts of anger •  Difficulty concentrating •  Post Traumatic Stress Disorder (PTSD)

What Is Post Traumatic Stress Disorder (PTSD)?

•  Exposure to a traumatic event •  Persistently re-experienced through:

–  Recollections/flashbacks –  Nightmares –  Sensory distress cues

•  Individual persistently avoids associated traumatic stimuli, such as: –  Thoughts, feelings, conversations about trauma –  Situations that trigger sensory distress cues

•  Other persistent symptoms

Post Traumatic Stress Disorder (PTSD)

•  The onset of PTSD can be acute, chronic or delayed

•  How it will manifest, and who it will affect, is unpredictable

•  Immediate treatment and ongoing support helps

•  Deborah Grassman, of the VA Hospice in Bay Pines, FL identifies three main responses to War Trauma: –  Integrated Response to Trauma: The trauma has

been processed, healing occurs and life goes on. –  Incomplete integration of trauma: This occurs when

PTSD is prolonged. –  Apparent integration of trauma: The trauma is locked

in the unconscious mind and everything seems to go on. The effects of the war trauma linger. PTSD is undiagnosed or has a delayed onset.

Types of Response to War Trauma

Integrated Response to Trauma

Integrated Response to Trauma •  Some examples of Integrated Response to

Trauma include the following statements:

– “I’ve faced death before…I’m not afraid anymore...I’m not afraid now.”

– “I’ve faced death before and survived…Every day since then has been a gift.”

•  These statements show that the trauma has been processed, healing has occurred and life has gone on.

Integrated Response to Trauma, continued

How you can help:

•  Listen carefully •  Invite them to tell their stories •  Express sincere appreciation for their service to

our country, and •  Celebrate their accomplishments with them •  Affirm the wisdom they have gained, and be

aware that it may impact your own life

Incomplete Integrated Response to Trauma

Incomplete Integrated Response to Trauma

•  There are many indications of a Veteran with incomplete integrated response to trauma. Some indications include: –  PTSD –  History of alcohol and/or drug abuse –  Estranged relationships –  Unfulfilled longings –  Suspicion & lack of trust –  Anxiety and agitation or acting out of the trauma –  Nightmares –  Sleeping “on guard”

Incomplete Integrated Response to Trauma

•  Statements that indicate incomplete integration of trauma include:

“I lost my soul in Vietnam.”

“If I’d just …..he’d still be here today.” “Most of my brothers stayed over there.” “My son’s never been the same.”

“I didn’t know the person who came back to me.”

•  If you hear this type of statement or notice the previously listed symptoms, discuss with the Interdisciplinary team as quickly as possible

How to Respond to Incompletely Integrated Trauma

•  Remember that their behavior is related to the trauma and not personal.

•  Use open ended statements such as, “Some Veterans tell me they experienced horrific things in war. Did anything like that happen with you?”

•  After asking a question about war, sit quietly and wait for an answer.

•  Sometimes, medication may help; consult with the nurse and/or physician as appropriate

How to Respond to Incompletely Integrated Trauma (cont.)

•  Don’t touch the person unexpectedly •  Speak to the person first, and avoid

sudden movements. •  Keep in mind that sudden loud noises or

sudden sporadic movements can re-stimulate trauma.

Apparent Integration of Trauma

Apparent Integration of Trauma

•  Indicators that a Veteran may have Apparent Integration of Trauma include:

–  Acting out behaviors –  They may have been a workaholic or had other

addictive behaviors –  “White Knuckle Syndrome”-Veteran appears hollow or

aloof

•  These Veterans should receive the same interventions and care as listed above for Veterans with Incomplete Integrated Trauma.

Apparent Integration of Trauma (c0ntinued)

•  Some examples of statements that may indicate Apparent Integration of Trauma include the following:

“I don’t want to talk about it.” “What good will it do anyway?”

•  These statements may indicate that the

effects of the war trauma linger.

Facilitating Communication •  Keep the focus on the veteran, not on you •  This is especially important if you are also a

veteran •  Remember, the veterans experience may be

very different from yours •  Open the door to communication, but never

push

Recommended Interventions with ALL Veterans

•  It’s important to create safe emotional spaces for tears and fears by validating feelings

•  Affirm the feeling aspect of their conversation. For example: –  “It’s only normal that you might feel sad right now.

It’s okay to cry.” –  “Most veterans tell me that they feel a little afraid

at a time like this.”

Recommended Interventions with All Veterans, continued…

•  Recognize women Veterans: – Thank older women Veterans for paving the way,

if appropriate – Be aware that military nurses saw trauma and

mutilation –  Look for signs of PTSD in women – Realize that women Veterans may have been

sexually assaulted in the military

The Effects of Stoicism

•  Remember that stoicism might interfere with the Veterans ability to acknowledge physical, emotional or spiritual pain.

Responding to Guilt

•  Combat veterans may feel guilty about acts committed during war.

•  It’s important to create a safe emotional space through listening

37  

Responding to Guilt: Hear It & Help

Veterans may feel guilt for:

•  Themselves –  Killing during combat –  Not killing, not dying, or “friendly fire”

•  The *ENEMY*. They may blame: –  Government for using or betraying them –  The world - for being like it is –  God - for allowing the world to be like it is

•  DON’T dismiss guilt with platitudes.

Listen and refer the patient to other members of the IDT, such as the hospice chaplain for help

is

healing of the heart

needed

What is

•  Non-combat veterans may have served on dangerous assignments

•  Combat era veterans may have served in “safe” areas

•  Avoid making assumptions •  Realize that not all people who have

suffered trauma will experience PTSD

Additional Considerations

Veteran Staff and Volunteers who work with Veterans in Hospice •  Some of our staff members and volunteers have served

in the military. As a result, they may: –  Bring their military training and history to their hospice work –  Offer patients unique opportunities that support life review and

healing –  Be able to share a common language, regardless of branch/era

of service •  Because they share codes of conduct and honor, a

cultural bond exists that opens doors of trust, dissolving barriers of stoicism and secrecy. This is especially true for combat veterans.

Veteran Staff and Volunteers, continued

A word of caution, •  While staff and volunteers have a very important

advantage in dealing with Veterans, the decision to share that experience with patients is a personal and private choice.

•  It’s important to respect staff and volunteers who may not be comfortable sharing their military experience.

Veteran Volunteers

Our Veteran Volunteers have received special training to work with Veteran patients. These volunteers may: •  Visit and listen as the patient reminisces •  Assist the patient to create a legacy video •  Provide telephone assurance calls •  Provide respite for family members/ caregivers •  Attend and participate in Pinning Ceremonies

Recognizing Veteran Volunteers

•  Acknowledge your Veteran volunteers for their service and for the work they are doing with our Veteran patients

•  Thank them for both their volunteer service and

their service to the country. Any amount of support and recognition will aid in helping the Veteran volunteer to feel that their service was worthwhile.

Supporting Veteran Volunteers

•  Be aware of signs that a Veteran volunteer may be having negative reactions or experiences to the We Honor Veterans program

•  Reactions could be: –  Withdrawal from the patient or other team members – without

knowing why –  Sadness or even depression –  Re - living their own experience while hearing the patient

reminisce about their experiences –  Flashbacks or increased emotional reaction or arousal

•  Be sure to notify the Volunteer Coordinator immediately of any concerns.

May each of us here have the GRIT, the GRACE, the HUMILITY, the LOVE to heal our war-ravaged soldiers and our broken nation. May we be the link that connects the circle so they feel connected to HUMANITY once again. May we not miss the opportunity to help these veterans’ souls from Iraq Desert Storm Vietnam Korea Nazi Germany and various other parts of the world where they served so they can have peace…at last. May we help them know that the circle goes on, joining them to you and me. Our people, our nation, our God would be ever so grateful. - DEBORAH GRASSMAN

In Closing: