A Grateful Nation Thanks You

As the end of life nears, veterans and their families need support. Caregivers must understand that veterans may grieve in a unique manner. Steps to ensure a dignified and honorable death for veterans begins with an assessment of grief with attention focused on the type of grief, reaction, influencing factors and the goals of care.

Current estimates suggest more than 1,800 veterans die every day. This number represents a quarter of all deaths in America. Most veterans still die in the community setting; only 4% of veteran deaths occur in VA facilities (National Hospice and Palliative Care Organization, n.d.). In order to ensure a dignified death for the veteran population, healthcare workers should understand the grieving process of veterans.

Veterans and Grieving

The grieving process may differ vastly from person to person. It is essential for caregivers to remember that grief can take on different appearances and approaches. As previously mentioned, many veterans maintain their military culture and identity until the very end of their lives. For this and other reasons, veterans may grieve in ways foreign to healthcare workers. Within the veteran culture, patterns or common features often exist. Examples of patterns may include the following:

  • Profound stoicism
  • Establishment of a trusting relationship may take longer than expected
  • Reluctance to admit pain for fear of being labeled as weak
  • Crying may be viewed as weakness
  • Sensing death is near may trigger or exacerbate PTSD
  • Many veterans seek to reconcile with their past, repair shattered relationships and seek forgiveness
  • Veterans may wish to die in isolation
  • Past experiences may surface and veterans may need to speak openly and honestly about them
  • Veterans may mourn their lost comrades from years ago
  • Anger/bitterness regarding their treatment by others may emerge

The veteran’s emotions and feelings may be intense during this time. Often, the healthcare provider may feel at a loss in providing support for the patient. One important element to remember is that respect for the individual’s humanity and dignity is paramount. Yet another element of importance is to appreciate the uniqueness of the individual’s life and their story; listed are a few suggestions for consideration.

  • Ensure the environment is physically and emotionally safe for the veteran, their family, visitors and healthcare providers
  • Affirm what the veteran is feeling
  • Remember stoicism may mask physical, emotional or spiritual pain
  • Listening is a powerful tool to assist an individual in their healing process
  • Remain non-judgmental at all times

Healthcare workers who never served in the military may have questions or curiosity regarding the veteran’s experience. While talking about experiences is viewed as a form of therapy, there are questions that should not be asked of veterans. Listed are questions that should be avoided when talking with veterans.

  • Did you kill anyone?
  • What was the nastiest or most disgusting thing you saw over there?
  • Do you feel guilty about what you did over there?
  • Do you want me to pray for you?
  • Do you think God could ever forgive you?
  • Did you see dead people?

Never tell a veteran you understand what they are going through. Do not ever, even in a joking manner, tell a veteran that they should be grateful they made it home alive, didn’t die, they need to get over it, they need to move on or they need to be happy.

Kubler-Ross (1969) identifies a series of stages individuals often experience upon grieving but cautions that strong emotions often cloud and prohibit healing. Service in combat may complicate the grieving process for veterans due to the presence of strong emotions that may complicate the grieving process. One of the proposed reasons for complicated mourning is that military members often do not have opportunity to grieve publicly and this may lead to disenfranchised grief. Disenfranchised grief may be thought of in terms of hidden/suppressed grief (Doka, 2002). Disenfranchised grief may occur for a number of reasons. Common reasons may include the following:

  • Inability to mourn a loss while in combat
  • The relationship of the deceased and the survivor do not take on traditional roles. Members of the military may not be friends or even family members but there is a sense of dependency on each other.
  • Loss that is not recognized or socially acceptable. An example is a veteran who returns home to celebration for his/her role in combat but days, months or even years later realizes that his/her actions caused the death of an enemy or, worse yet, a comrade.
  • As part of military training, killing is viewed as a central component. Survival becomes the central focus while death of an enemy may be considered an essential element of successfully completing a mission.

Additional points may include the circumstances surrounding the death and the manner that the individual grieves (Doka, 2002). For many veterans, especially those who served in Vietnam, they may be reluctant to discuss the circumstances of death because they may lack support and fear reprisal from listeners. Vietnam veterans suffered a great deal from the lack of support and negativity from many of their fellow Americans. Many veterans, upon returning home, were ridiculed, labeled as “baby killers,” and denied employment due to their military service. For these reasons, many Vietnam veterans never discuss their grief, loss and emotions. Healthcare providers may assist the veterans through this difficult period by recognizing unresolved grief that often contributes to disenfranchised grief.

For healthcare providers to assist veterans, they must remember that grief is expressed in different ways; some socially acceptable and others not acceptable. The role of the healthcare provider is to remain non-judgmental while acting as a support of the veteran and his/her family through the difficult time of disenfranchised grief.

Disenfranchised grief may be a very emotional time for the veteran, as well as the support system, as emotions may be enhanced and complicated. Many veterans feel they are undeserving, view themselves as a “bad person” or may feel their illness is a punishment for what they had done in combat. Such thoughts may lead to further unhealthy coping for the veteran. Researchers suggest that the lack of a funeral ritual may contribute to disenfranchised grief in veterans (Doka, 2002; Grossman, 2009). By providing time for some sort of ritual, veterans suffering from disenfranchised grief may recognize and express their grief and begin a healing process before their own death. Suggestions for the rituals may be visiting a war memorial, visiting the actual site of the battle if able or writing a note to the deceased enemy. However, those who were maimed or killed by the veteran are not the sole focus of mourning. Many veterans mourn the loss of their innocence, youth, idealism or former self (Lewis, 2006). Healthcare providers often hold the key to the successful transition from disenfranchised grief to healthy grieving. The time spent with the veteran may be short but the quality of this time will assist the individual and their support systems in resolving disenfranchised grief and assuring a dignified death for the veteran.

A Funeral With Full Military Honors

Much like the military itself, funerals for veterans are steeped in honor and tradition. To the bystander, witnessing a military funeral may cause emotions to emerge with much force.

Central to a military funeral is the flag-draped casket. The custom began during the Napoleonic wars when fallen soldiers were covered with a flag and placed on a gun caisson for removal from the battle field. In modern times, the blue field of the U.S. flag is placed at the head of the casket with the stars placed over the left shoulder of the deceased member of the military.

Graveside services for deceased members of the military may include the firing of three volleys each from seven members of the armed forces. Experts claim the source of this tradition came from an old battlefield custom. During battle, firing would stop for a time for the armies to remove their dead from the battlefield. The three rounds signaled the dead have been removed and battle could resume. Some claim the tradition of a 21-gun salute originated in the Anglo-Saxon empire. During this time, seven guns constituted a recognized naval salute, as most naval vessels had seven guns (Banusiewicz, 2004).

During some military funerals, especially at Arlington National Cemetery, horse drawn caissons carry the body. All of the horses are saddled but only those horses on the left have riders. This tradition came about when horses were the only way of moving ammunition and cannons from battlefield to battlefield. The horses with no riders carry supplies and ammunition.

Depending on the rank and branch of service of the deceased veteran, a single black rider-less horse, with boots turned backward in the stirrups, may follow directly behind the casket in the procession. This horse is called a “caparisoned horse” due to the ornamental coverings on the tack. Military order mandates that a member of the Army or Marine Corps who holds the rank of a colonel or higher be given this honor. The tradition of a caparisoned horse is believed by some to have begun during the reign of Genghis Khan. The rider-less horse symbolizes a warrior who will ride no more. Others interpret this custom as a final offering for the fallen leader to review his troops.

Perhaps one of the most emotional moments of a military funeral is the playing of “Taps.” The song was written during the Civil War by Brig. Gen. Daniel Butterfield. The tune gained popularity and became the symbolic bugle call signifying the commencing of eternal sleep of a fallen comrade.

With the birth of military aviation came another tradition. Upon the death of an aviator, a squadron of planes flies in a missing man formation. The missing-man formation usually consists of four aircraft flying overhead with number three aircraft either missing or performing a pull-up maneuver and leaving the formation near the site of the casket. This maneuver symbolizes a lost comrade.While many funerals for veterans may vary due to the prior request of the deceased or the wishes of the family, a standard order exists. An example of the standard order for a military funeral is listed below.

  1. The caisson or hearse arrives at the gravesite, military members are ordered to “present arms.”
  2. Casket team secures the casket, non-commissioned officer in charge (NCOIC), officer in charge (OIC) and chaplain salute.
  3. Chaplain leads the way to gravesite followed by casket team.
  4. Casket team sets down the casket and secures the flag.
  5. The NCOIC ensures the flag is stretched out, level and centered over the casket.
  6. NCOIC backs away and the chaplain, military or civilian will perform the service.
  7. At conclusion of interment service and before benediction, a gun salute is fired for those eligible (i.e., general officers).
  8. Chaplain concludes his service and backs away, NCOIC steps up to the casket.
  9. The NCOIC presents arms to initiate the rifle volley.
  10. Rifle volley complete, bugler plays “Taps.”
  11. Casket team leader starts to fold the flag.
  12. Flag fold complete, and the flag is passed to the NCOIC and OIC.
  13. Casket team leaves gravesite.
  14. NCOIC and OIC either present the flag to the next of kin, or if there is a military chaplain on-site, he will present the flag to the chaplain and then the chaplain will present to the next of kin.
  15. The only person remaining at the grave is one soldier, the vigil. The mission of this individual is to watch over the body until it is entered into the ground.

Tradition is included with the folding of the flag from the casket. Each fold represents something different. Symbols for the folds of the flag are listed below.

  1. The first fold of our flag is a symbol of life.
  2. The second fold is a symbol of our belief in eternal life.
  3. The third fold is made in honor and remembrance of the veteran departing our ranks, and who gave a portion of his or her life for the defense of our country to attain peace throughout the world.
  4. The fourth fold represents our weaker nature; as American citizens trusting in God, it is to Him we turn in times of peace, as well as in times of war, for His divine guidance.
  5. The fifth fold is a tribute to our country, for in the words of Stephen Decatur, “Our country, in dealing with other countries, may she always be right, but it is still our country, right or wrong.”
  6. The sixth fold is for where our hearts lie. It is with our heart that we pledge allegiance to the flag of the United States of America, and to the republic for which it stands, one nation under God, indivisible, with liberty and justice for all.
  7. The seventh fold is a tribute to our armed forces, for it is through the armed forces that we protect our country and our flag against all enemies, whether they are found within or without the boundaries of our republic.
  8. The eighth fold is a tribute to the one who entered into the valley of the shadow of death, that we might see the light of day, and to honor our mother, for whom it flies on Mother’s Day.
  9. The ninth fold is a tribute to womanhood, for it has been through their faith, love, loyalty and devotion that the characters of the men and women who have made this country great have been molded.
  10. The 10th fold is a tribute to father, for he, too, has given his sons and daughters for the defense of our country since he or she was first born.
  11. The 11th fold, in the eyes of Hebrew citizens, represents the lower portion of the seal of King David and King Solomon and glorifies, in their eyes, the God of Abraham, Isaac and Jacob.
  12. The 12th fold, in the eyes of a Christian citizen, represents an emblem of eternity and glorifies, in their eyes, God the Father, the Son and Holy Ghost.
  13. When the flag is completely folded, the stars are uppermost, reminding us of our national motto, “In God We Trust.”

After the flag is completely folded and tucked in, it has the appearance of a tri-cornered hat to remind us of the Continental soldiers who served under Gen. George Washington, as well as the sailors and Marines who served under Capt. John Paul Jones during our early fight for freedom. Once the flag has been properly folded, a few of the shells from the rifle volley may be inserted into the back fold before it is presented to the next of kin.