This chapter describes characteristics of the Veterans Administration Health System and then considers characteristics of veterans from different war eras. It describes two specific problems that veterans receiving palliative care may have faced in their history: posttraumatic stress disorder (PTSD) and military sexual trauma. Similar considerations may apply to the military from other countries, but for manageability this chapter focuses only on the U.S. military.
In the United States, the term veteran refers to men and women who have served in the armed services in the past and are now separated from the military. Veterans comprise up to 20% of the Americans who die in any given year. This is in part because of the large number of men and women who served in the military during World War II and the Korean conflict who are now aging into their 70s, 80s, and 90s. Their illnesses, declines in health status, and, ultimately, deaths are usually not directly related to their military service. However, their military experiences during their years of service as young adults may have profound effects on how they cope with pain and suffering, interact with family and professional caregivers, and manifest emotional and spiritual distress. It is important for clinicians outside the Department of Veterans Affairs (VA) system to ask patients if they are a veteran as part of the social history, because many veterans receive their care outside the VA system. For many patients, it is important to explore the impact of their military service on the current situation; from a practical point of view, many veterans are eligible for additional benefits that could help support both them and their family at the end of life. In collaboration with the National Hospice and Palliative Care Organization (NHPCO), the VA has established the We Honor Veterans campaign to help connect Veterans with existing hospice services.
Military service has long been a defining experience for many Americans as they transitioned from youth to young adulthood. For the most part, military recruits are young, ages 18 to 21, just out of high school or with a General Equivalency Degree (GED). Veterans share the cultural diversity of our country; however, they also share a common bond of military service to their country.
The process of basic training, common to each branch of service, is an intense experience designed to transform distinct individuals into uniformed and uniform soldiers who are bound to each other as a group. This is a remarkable experience that goes against much of the individualism and personal freedom that are valued in the larger American culture. Anthropologically and psychologically, this is an initiation into a select group; with this selection comes privileges, duty, and a connectedness that for many will continue for the rest of their lives, both in the military and after discharge as a veteran. The impact of military service has both positive and negative effects on the veteran and invariably impacts how the veteran will cope with the grief, loss, and suffering that are often experienced in the setting of serious illness.
Structure of the Department of Veterans Affairs
The Department of Veterans Affairs is a cabinet level department of the federal government tasked with provision of a wide range of benefits and services to veterans. The nascent formulation of the VA can be traced to President Lincoln’s promise “to care for him who shall have borne the battle, and for his widow and his orphan,” which greets visitors to the Department of Veterans Affairs offices in Washington, DC. The VA continues to grow and adapt to meet the changing needs of veterans and their families. The VA has three major programmatic charges—namely, to provide the following:
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Pensions and benefits
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Health care services
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National military cemeteries and memorials
The VA health care (VAH) system is the most visible manifestation of the VA to the general public and to many veterans. VAH has 153 Veterans Administration Medical Centers (VAMCs) located throughout the United States that provide care for more than 5.5 million veterans annually. These VAMCs provide acute hospital care, ambulatory primary and specialty care, long-term residential care, and home care programs. In addition, more than 800 Community Based Outpatient Care (CBOC) Clinics provide general primary and preventive care in local communities. The CBOC structure is supported by linkages to VAMC for referral for specialty or inpatient care. Other affiliated organizations, such as the National Association of State Veterans Homes (NASVH), are state, as opposed to federal, organizations.
Palliative care and hospice services are part of the required benefit package for veterans. The VAH recognizes that some of the veterans most in need have complex health and social problems, such as substance use disorder, homelessness, depression, and PTSD, that must be addressed to adequately and effectively provide health care services, including hospice and palliative care.
The VA has been a leader in hospice care in the United States. Some of the first and oldest inpatient hospice programs were started within the VA. In 2000, the VA began to evaluate the programmatic status of hospice and palliative care through the entire VAH system. This research revealed that there were a number of centers of excellence in hospice and palliative care but that variability was considerable. Major deficiencies included linkage to home hospice programs in the communities where veterans live and fiscal support of home hospice care by purchase of contracted services. The result of these findings led to the development of Palliative Care Consult services, with interdisciplinary teams in every VAMC, and a corresponding rapid increase in the number of consults provided and veterans given these services.
In addition, it has become apparent that designated hospice and palliative care beds, staffed with trained providers, is a key to the provision of quality end-of-life care. The VA has embarked on an ambitious program to expand services, training and improve quality of care of veterans at end-of-life. The VA is striving to move palliative care upstream by integration of palliative care services with symptom management using an “open access” model that does not require veterans to choose between palliative care and disease-modifying treatment, but to individually combine services that best meet the needs and preferences of individual veterans.
At the same time that the VA has been working to increase institutional capacity to deliver palliative care, the VA has also been committed to increasing noninstitutional care in the home and community to honor veterans’ preferences for type and location of care when appropriate. Although the VA has an extensive infrastructure to provide for residential, domiciliary, and nursing home care on VAMC campuses, many veterans would benefit from and prefer care in their own community. The types of home care assistance programs may include home-based primary care, home health aides and homemaker services, and attendant payments, support for durable medical supplies, and the purchase of contracted community-based care such as home hospice, home health, and nursing home care. These programs are allowing more veterans to be supported in their homes and community even when they have increasing debility near the end of life.
Impact of Veterans’ Experiences on Response to Suffering at Life’s End
Almost every society has a “warrior” class. The warrior may choose this identity or have it thrust upon him or her by the circumstances of war and necessity. The first step to becoming a warrior is initiation, which is a process to “break down” individual citizens and reconstruct them as soldiers. The training is meant to prepare soldiers with the bravery to face hardship and danger and to win battles.
One of the major aspects of this training is the development of stoicism. Stoicism is the ability to tamp down the emotions and outwardly seem indifferent to hardship, pain, and grief. This is an important trait during military service, but this effective coping mechanism in a time of service or battle can have unanticipated and perhaps adverse, affects on how people deal with pain, grief, suffering, and even joy and pleasure at the end of life. Veterans as a group have been known to show incredible stoicism in the face of devastating injury and illness. This can lead some to underreport and minimize pain and other forms of physical suffering, which can complicate pain and symptom control at the end of life. This attitude is sometimes articulated by veterans with phrases like “Big boys don’t cry” or “No pain, no gain.” Or it may be more subtly manifested by a veteran not reporting pain and other symptoms of suffering.
Although the majority (61%) of veterans were not in combat situations, all veterans were prepared for the possibility of combat as part of their training. For those who were in combat situations, many were physically wounded and some left with lifelong physical disability. However, almost all veterans carry away some emotional, social, or existential suffering from the experience of battle. Those closest to the battle or in the fighting the longest are most likely to experience profound effects. Even those involved in support positions, such as nurses and physicians who cared for the wounded or those who maintained and repaired the equipment used in war are affected by the loss and suffering not only of comrades but also of the people in whose country the war took place. Some veterans have learned to cope well, whereas others have been unable to accommodate their profound responses. Wherever they fall on this spectrum, all veterans need to be cared for in a way that respects the life-changing experiences they had during their military service. These things must be taken into consideration to provide culturally competent hospice and palliative care to America’s veterans.
Different Cohorts of Veterans
The time, location, branch of service, rank and mission during military service often lead to some common, shared health issues. This section discusses some of the unique issues related to service in particular war eras. It considers the experience of veterans who served during WWII, the Korean Conflict, Vietnam, Gulf War, and most recently, the wars in Afghanistan and Iraq (Operation Enduring Freedom/Operation Iraqi Freedom—OEF/OIF).
World War II
World War II began nearly 70 years ago. This aging cohort of veterans is rapidly decreasing in number. At this time, almost all World War II (WWII) veterans are more than 80 years old and many are in their 90s.
WWII veterans are almost uniformly proud of their military service and see their contribution to winning this war as an important part of their legacy at the end of life. However, although African Americans served, at that time the military was racially segregated. This is still a painful memory for many African-American WWII veterans, who felt the sting of discrimination and rightly believed that their contributions were and still are underappreciated. This reality is sometimes neglected as the triumphs of some activities, such as the actions of the Tuskegee Airmen and the Navajo code writers, are rightly celebrated. It is important to express gratitude and appreciation to all who served, but special effort should be made to recognize the contributions of African Americans, Native Americans, Hispanics, and other minorities that fought for our freedom as a country while their own freedom was not fully realized.
At the end of life, veterans of WWII may have complications related to injuries suffered during service. Combat injuries and environmental exposures such as cold injury, mustard gas exposure, and exposure to radiation due the use of atomic bombs in Japan at the end of WWII resulted in long-term consequences to veterans. The dangers of radiation exposure were not truly appreciated and exposure often occurred, such as during nuclear cleanup in Japan and during the early years of the Cold War caused by above-ground testing in remote islands in the Pacific. WWII veterans also may have had traumatic experiences that manifest themselves in nightmares or as part of delirium, which is a common occurrence at the very end of life. These can occur in the absence of a diagnosis of PTSD.
Korean Conflict
The Korean War is sometimes referred to as a “conflict” or a “police action” because there was never a formal declaration of war. Nearly half a million Americans served in Korea and more than 33,000 died there. For veterans who served in Korea, there was no clear victory as there was with WWII. This often leaves Korean War veterans feeling that their service and the deaths of their comrades were not appreciated. The same source of pride that came from winning WWII may be missing for those veterans who served in Korea.
Korean War veterans often suffered from exposure to extremes of heat and cold. Often supplied with inadequate equipment to protect themselves from the elements, they struggled to survive the dual enemies of humans and the environment. Veterans certainly may re-live some of these experiences during times of stress or delirium. Uniquely, veterans may experience cold sensitivity that is associated with their experience of injury resulting from frostbite, including amputations. Some veterans feel painfully cold even when in a warm room. Special attention to extremities, using warm packs, careful range of motion, and positioning to reduce pain and prevent skin breakdown, should be incorporated into to overall hospice and palliative care for these veterans.
Vietnam War
The Vietnam War has been and is a source of much angst for the United States. The Vietnam War was the first televised war, and the immediacy and violence of the fighting was a shock to the country. Although war reporting goes back to Homer and Herodotus, television brought immediacy that stripped the war of the glamour it may have once had. Furthermore, because of the large number of personnel required and the existence of the draft for much of the war, a large percentage of the men entering the services possessed baccalaureate and higher degrees. At the conclusion of the war, many in the United States came to question the authority and veracity of some of the institutions of government.
The Vietnam War was the first U.S. guerilla war. For the personnel, the landscape, language, and culture were very different from the United States. In WWII and in Korea, the enemy had been in a defined uniform and the battle lines were clear. In Vietnam, it was often not possible to identify and separate combatants from civilians. As a result, soldiers could never let their guard down or feel safe. Soldiers did not generally feel any sense of gratitude from the Vietnamese, whom they were supposed to be there defending and helping. This new style of war, especially with its civilian casualties, made it hard for solders to have a sense of accomplishment.
For Vietnam veterans, the physical, emotional, and existential trauma was great. Improvements in medical and surgical trauma therapy, coupled with an enemy strategy to injure but not necessarily kill, meant that wounded soldiers were more likely to survive; but they survived with severe and disabling injuries that would make reintegration into society difficult. The emotional and existential trauma resulting from the war was significant. During the war, alcohol and substance use was common among service personnel in Vietnam. For some, this would become substance addiction that they would bring home with them. The hypervigilance of guerrilla warfare still seems to have lead to a high prevalence of PTSD.
Vietnam veterans at the end of life often have struggled with mental health, addiction, or other social reintegration issues. Even for those who seem to have successfully transitioned to civilian life, there may be a resurgence of PTSD symptoms near the end of life, and especially during any episodes of delirium. Broken marriages and other relationships may also serve to reduce a veteran’s social capital and make home care more difficult, increasing the need for institutional care.
Examples of physical issues that cause complications near the end of life include hepatitis C infection caused by intravenous drug use or complications related to Agent Orange exposure. The physical manifestations of hepatitis C exposure include cirrhosis, liver failure, and hepatocellular cancer. Although the data regarding physical sequelae of Agent Orange exposure are controversial, they include soft tissue sarcomas, non-Hodgkin’s lymphoma, chronic leukemia, multiple solid organ cancers, Parkinson’s disease, and ischemic heart disease. In addition, Agent Orange exposure may create a sense that the veteran was duped and suffered needlessly. It is important to discuss exposure with Vietnam veterans and refer and assist them and their families in making claims as appropriate. At the time of death, it is important to include Agent Orange exposure on the death certificate so as to aid families in obtaining important VA benefits. Providing veterans with the peace of mind that can come from knowing they have access to all available benefits can be an important part of the psychosocial care plan at the end of life.
The Newest Veterans
Since the beginning of the Afghan and Iraq wars, approximately 1.64 million U.S. troops have been deployed for Operation Enduring Freedom (Afghanistan, OEF) and Operation Iraqi Freedom (Iraq, OIF). There are some early data to suggest that the psychological morbidity and traumatic brain injury from these deployments may be higher than the other physical injuries of combat. Specifically, there is a high prevalence of PTSD and traumatic brain injury (TBI) among these veterans. There is also an increasing incidence of suicide and suicide attempts among returning veterans.
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