The end of an era

As our country says good-bye to the last of the survivors of WWII, we are challenged going forward to focus on the needs of heroes from later eras of war. Each veteran carries both common and unique experiences and challenges. These become even more apparent at end of life, often manifested by anxiety and restlessness. Because of this, it is crucial for all hospice professionals to have an in-depth understanding of what veterans experienced during their military service, how this experience has, or has not been integrated in their life, and most importantly how it can affect a peaceful death.

We will be looking at ways to help veterans come to terms with wartime experience, accept forgiveness, and regain a sense of self. We will learn how to be good witnesses for veterans and their families, lessening the impact of feelings of helplessness that accompany end of life.

The battle

Early in my hospice career, I met a sweet, mild-mannered, yet distinguished man who I immediately recognized as a World War II veteran. It was impossible not to because he always wore his branch cap with pride. He was a joy to serve, loved by his nursing staff, family, and hospice team. A few months later I met another veteran. This veteran lived alone in his home in a rural area. When I met him he was disheveled, wouldn’t make eye contact and was gruff and distant. He had never been married and very rarely left his home. He could not stand to hear dogs barking, cars backfiring or fireworks on Independence Day. He was suspicious of me, and my role as a hospice social worker. It took a great deal of time to gain a level of trust.

These two veterans had military service in common but their experiences during the war, and after were very different. The first veteran served in a war that was clearly defined as a battle against evil. The return home for him was a great celebration. He was greeted with a true hero’s welcome. This veteran easily shared details of his time in the military. The second veteran was barely 18 when he was drafted to serve in Vietnam. He had been a high school athlete in his small town, had a steady girlfriend and had aspirations of one day becoming an architect. Vietnam changed all of that. When he arrived in Vietnam he immediately began to question the purpose for being there. He reported a lack of direction and guidance from his leaders. He also reported, “the drugs and alcohol flowed like the river”. He began to use both heroin and alcohol. It didn’t take long for him to become addicted. When he and his buddies returned home, they were not greeted as heroes. Because of the controversy and opposition to United States’ involvement in Vietnam, they were treated rudely, with disdain. This treatment compounded the trauma and pain that accompanied these veterans home.

Why do I share the stories of these men?

Why is it important for our hospice work at end of life?  It is often said that we die like we live. Even though both of these men were veterans, one experienced a much greater level of trauma. This was due both to his active duty and the way he was treated when he returned home. His homecoming actually re-traumatized him. We have all experienced some type of traumatic event in our lives but there is no other population who has experienced more trauma as a group, that the veteran population (Opus Peace). To best serve the veteran population, we must have an understanding of why trauma often goes undetected until end of life, differs based on era of service and how we can assist in acknowledging trauma to allow a veteran a peaceful death.

The struggle

It didn’t take long in my hospice career for me to witness a patient struggling significantly with restlessness and agitation. The patient could not tolerate lying still. He adamantly insisted on sitting up, seeing what was going on, feeling like he had to do something. This was a hard thing to watch. I felt exhausted. I can’t imagine how the patient and family felt. In hospice, we call this behavior terminal delirium or terminal restlessness. Deborah Grassman with Opus Peace Foundation refers to this type of agitation as “a hospice emergency.” Although anyone can demonstrate this type of behavior, Deborah believes that it is experienced more often by individuals who have unresolved feelings of remorse, regret, guilt or need to forgive or be forgiven (Opus Peace). Veterans are at higher risk for these feelings because of things they have witnessed or have been asked to do. Human beings were simply not created to inflict and experience the level of pain and destruction that military duty can require. This coupled with a veteran’s young age, often younger than twenty years, and separation from family, makes a veteran vulnerable. In addition, veterans often do not share details of negative experiences with family or friends. A veteran often believes that anyone outside the military could not understand the experience, or that hearing about trauma would only upset a loved one. So one of the most powerful tools to combat the traumatic experience, listening, is never provided to the hurting veteran, and the feelings are pushed away or denied. This can create what Grassman calls a Soul Injury.  Grassman identifies two types of soul injuries: one resulting from a single episode or event, and insidious, which is an acquired injury over time as hurts and disappointment build up over time. The Vietnam veteran who was spit on and ridiculed is at risk for an insidious soul injury. After witnessing trauma directly related to combat, they were reinjured by not having that trauma validated. Instead of speaking about the trauma, they quickly learned instead to bury the feelings deep within.

What can be done to help the veteran before he reaches the end of life?

One of the most important things someone can do is to become educated on the branch and era in which a veteran served. Each military branch has unique rituals and traditions, and as stated earlier, each era produced its own challenges. For example, WWII veterans were better supported than Vietnam veterans, but they were much more isolated from family. With the absence of Facetime or Skype, a WWII veteran may not see a son or daughter until his return and there was no way to keep up on events happening within his family. A family left behind could only pray for safety and return because communication was limited.

“I’ve seen how bitterness and addictions sometimes squeeze life from traumatized souls until they become shells, hardened and lifeless, dead in bodies that are alive.” – Deborah Grassman

How do we become educated?

Of course, we can Google and read countless articles on the dynamics of veterans, but the best way is to simply listen. Grassman refers to nonjudgmental listening as, “bearing witness”. Bearing witness to another person’s sorrow and hurts can lessen the power of those hurts. Giving voice to things once thought to be unspeakable can provide a veteran an opportunity to forgive themself and others. I worked with one veteran who spent his time overseas worrying about his father, who was left to run the farm without his “right-hand man.”  This was on his mind the entire time he was away. At age 84, he still felt guilty over this.  The Opus Peace Foundation also offers a tool created specifically to help veterans discern their feelings of guilt. This tool allows them to see the role other people or circumstances played in the situation. For example, a veteran who carried the guilt of killing an enemy during combat can be helped to see how others helped influence the situation:  the government, the political realm, squad leaders, etc. One veteran saw his “percentage of responsibility” decrease from 100% to 35% based on the tool criteria. This one tool helped him relook at his perceived responsibility for the act that he has carried the weight of for so many years.

Even when veterans are given opportunities to give voice to their injuries and trauma, terminal restlessness and anxiety at the very end of life do sometimes occur. We can’t say that this is always directly related to loss, trauma or guilt, but we do know that unresolved issues do come to the surface when the conscious brain gets weaker. Also, veterans have historically had to be vigilant protectors. Their job was often to help the helpless and protect the weak. As a veteran dies, he or she becomes weaker and helpless, needing help and protection rather than providing it. This feeling is new to them and often uncomfortable. During active combat, letting down your guard or failing to be alert to surroundings often meant death to self or others. So when this new feeling of helplessness is felt near death, a veteran often fights against it. A common intervention then is to give a relaxant, such as Ativan. This can work in reverse for a person who has not had the luxury of allowing his body to relax. As he feels the body relax, he may actually become more anxious and restless-the opposite result. Being aware of these things can make the difference between a good death and an unsettling one. Our heroes who have seen much death and destruction deserve to have an end of life filled with peace.

 

Additional Resources:

I Need A Witness: Deborah Grassman Author, Peace at Last & The Hero Within

We Honor Veterans: Soul Injury and Opus Peace Tools with Deborah Grassman

This link offers many resources and tips on helping veterans as well a soul injury self-assessment tool to determine if one suffers from soul injury.

References:

Opus Peace – Home. (n.d.). Retrieved from https://opuspeace.org/