How can we best serve the unique end-of-life care needs of our veterans? Through my involvement with the Palliative Care Rural Initiative project in Veterans Integrated Service Network (VISN) 23 over the past year, I learned that one out of every four dying Americans is a veteran, yet 96 percent of veterans are cared for outside of the Veterans Affairs (VA) health care network, according to the National Hospice and Palliative Care Organization. This means that the majority of veterans are cared for by hospice and health care professionals in their hometown.
As health care providers, we work diligently to assess each patient as an individual and deliver high-quality, customized care. No time is more crucial to provide this level of customized service than hospice, where treatment is designed to relieve symptoms and provide comfort and support to individuals with life-limiting illnesses.
It has been pointed out time and again that when people reach the last chapter of their life journey, there is a natural tendency to reminisce, resolve issues, and reference previous experiences of emotional intensity—which, for veterans, includes their history in the military.
Both research and evidence-based practice have demonstrated that a person’s military history can exacerbate physical, psychological, social, and spiritual symptoms toward the end of life. The Department of Veterans Affairs notes, for example, that Vietnam veterans may still suffer from “trench foot,” a fungal infection of the feet from walking in wet conditions; that symptoms of posttraumatic stress disorder may surface; that social isolation and distrust of authority may develop (or redevelop) in veterans who have felt a lack of support in the adjustment from military to civilian life; and that spiritual questions may arise as individuals encounter death outside of the battlefield.
The VA also cites the following contributing factors that may influence a veteran’s behavior and responses to end-of-life issues:
· Entry status: enlisted or drafted- drafted veterans may experience higher levels of distrust of authority than veterans who enlisted.
· Branch of service and rank- Each branch of service has its own distinct culture. Veterans do not always share their rank with friends and loved ones yet sometimes reactions to life events are better understood when this status is revealed. Regardless of rank, each veteran carries a responsibility for fellow soldiers although they cannot ensure their well-being and safe return.
· Combat or noncombat experience- veterans who were directly exposed to the effects of combat may experience elevated levels of anxiety and posttraumatic stress disorder but noncombat veterans can experience these symptoms as well.
· Type of war or time served- each war or conflict carried its own significant burdens which may be re-experienced by veterans at the end of their lives.
· Prisoner of war experience- we cannot begin to imagine what our POW veterans have experienced physically, mentally, and emotionally. At the end of life, these experiences may be the ones that color their memories.
For health care providers, being aware of an individual’s military history and the elements to which the veteran was exposed can assist in proper diagnosis and intervention. Establishing a process to inquire about an individual’s military history has proven successful for numerous health care providers. The VA, in collaboration with the National Hospice and Palliative Care Organization, has developed a simple Military History Checklist that reviews the above factors for each patient to enable providers to best serve Veterans’ unique health care needs. The Military History Checklist is available online at www.wehonorveterans.org and through numerous electronic health record platforms.
In addition, it is important to invite veterans approaching the end of life to tell their stories, to celebrate their accomplishments, and to express appreciation for their service to our county. Thank you veterans, for your service to our country.
Contact Kami Norland for more information about how the National Rural Health Resource Center is involved in honoring veterans end-of-life care needs.
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