Feelings of Survivor's Guilt
The young soldier's first tour of duty in World War II was clearing bodies from the beaches at Normandy. Now, at the end of his life, he looks back on 30 years of active military duty, including combat in three wars. At night he relives the Invasion of Normandy and other horrors he's seen-and committed. During the day he ducks for cover at loud noises and worries about how he'll "meet his maker" with so much on his conscience.
Facing the end of life for many veterans means coming to terms with what they did-and witnessed-during combat. Feelings of "survivor's guilt" rise to the surface as they remember lost buddies. The trauma of war can manifest itself in chronic physical and psychological conditions. All these things make caring for a veteran near the end of life a complex endeavor for hospice.
Recognizing the Unique Needs of Veterans
According to the US Census Bureau, there are an estimated 22 million veterans living in the United States.¹ Veterans make up one-fourth of all deaths today; that’s 617,000 per year.²
The harsh toll of war includes diseases, disabilities and illnesses that can complicate end-of-life care. Depending on the war, veterans may have been exposed to ionizing radiation, Agent Orange, open-air burn pits, battlefield transfusions, below freezing temperatures and infectious diseases. These exposures put them at a higher risk for a variety of cancers, type 2 diabetes, kidney disease, heart disease, hepatitis C, respiratory illnesses, malaria, TB and more.
Veterans can also suffer from what medical professionals refer to as "co-morbidities" or the simultaneous presence of two or more chronic conditions. Post-traumatic stress disorder (PTSD), depression, alcoholism, drug addiction and mental illness are common conditions that can accompany the terminal disease of the veteran.³
In addition to physical and psychological conditions, emotional concerns may arise, such as feeling the need to purge themselves of memories by discussing their military experience with family members, sometimes for the first time. Veterans also have concerns about their families and how they will manage after the veteran dies.
PTSD: Facing the Enemy Within
Experiencing or witnessing a terrifying or life-threatening event causes PTSD; soldiers who have been in combat are one of the most prevalent groups affected by the disorder.
In wars prior to Vietnam, the condition was known as “battle fatigue” or “shell shock.” In 1980 it officially became known as Post-Traumatic Stress Disorder. “Roughly 30% of Vietnam veterans developed PTSD. The disorder also has been detected in as many as 10% of Gulf War (Desert Storm) veterans, about 6%–11% of veterans of the Afghanistan War and about 12%–20% of veterans of the Iraq War,” according to one study.4
Veterans experiencing PTSD often exhibit such symptoms as recurring nightmares, loss of interest in their surroundings, confusion, isolation, anger and irritability not long after they return from combat duty. For others, these symptoms can lie dormant for years as the veteran denies and buries his or her memories and feelings. The shock of a terminal diagnosis can trigger these memories and cause PTSD symptoms to appear.
Guilt and Shame
Combat veterans nearing the end of life often have feelings of guilt. It could be the guilt of having taken a life, of not having been able to save a buddy, or the survivor's guilt of questioning why he or she made it home and others did not.
For veterans who did not face combat, there is sometimes shame, feelings of failure and the belief that they are not truly veterans at all.
How VITAS Cares for Veterans
Veterans are identified at the time of admission to VITAS. Each veteran patient has an interdisciplinary care team that includes a physician, nurse, hospice aide, social worker, chaplain, volunteer and a veteran liaison, all of whom listen to the veteran to determine how VITAS can best meet his or her needs and whether additional referrals should be made. According to Carole Quackenbush, a VITAS veteran liaison in Ohio, listening is key.
"So many of our veterans have horrendous memories that we can't take away. We want to give them the ability to talk about those memories and to forgive themselves for their actions in combat," she says. "That's why it's so important to listen to them when they do start to talk about the past. We don't ever dismiss what the vet is saying."
Whenever possible, the 義工 on the veteran patient's team is also a veteran. This helps patients feel more comfortable talking about military experiences. The volunteer may suggest conducting a life review with the veteran patient, which not only looks back at military service but also helps the veteran remember happier memories throughout in his or her life.
Other duties performed by veteran volunteers include recovering lost medals and helping the family complete the necessary documents to receive VA benefits or arrange for a military funeral.
VITAS offers each veteran a recognition ceremony honoring his or her military service. Sometimes it happens quietly right at the bedside. Other times it's held in a facility with other residents and family in attendance. "We help provide a sense of pride for our veterans by presenting them with certificates of appreciation for serving their nation and by pinning an American flag lapel pin on them," says Wayne Rioux, a VITAS veteran liaison in Connecticut. "At VITAS, we believe all veterans need to be honored and shown respect for their service, commitment and duty. And it's never more important than at the end of life."