Intentional Care for a Dying Veteran

Intentional Care for a Dying Veteran

World War II veterans are dying each day. Experts suggest by the year 2020 heroes from our nation's greatest generation will no longer live among us. Soon a single white cross will be etched with the name of the last remaining patriot from this war. Soldiers from the Korean War and Vietnam War begin a new era of caring for dying soldiers. New end of life issues have and will emerge as these theaters of War bring new challenges for the soldiers who fought in them. Behavioral health will become more prevalent and caregivers will need to be intentional in their approach to these veterans in order to reach the outcomes desired by the patient, family and caregivers alike.

I have a belief that the experiences these veterans have been exposed to creates a unique path in the dying process and the ability to gain trust and expertly navigate the psyche of a soldier will dictate a skill set that we have yet to develop. As a soldier who served in a wartime setting, I have been exposed to the brother and sisterhood binds that are developed during moments of life and death. I have seen death on the battlefield and have sat with my team decompressing after transporting patients clinging to life during medivac missions all night long. Only a soldier knows the stress on the mind of enduring hours of extreme boredom sprinkled in with moments of uncontrolled adrenaline rushes. 

Breaking through, building trust and having a plan will be key to creating the experience desired.  Intention is the first step. One must intentionally approach care differently in order to provide care differently. Sounds simple, but how or where do we start? I think the starting point lies within the care plan. Intentionally assessing and addressing Veteran specific issues in the care plan will change our approach and therefore change our results. 

I propose four key elements to be integrated in to every veteran's care plan:

           1) Assess and plan for Post Traumatic Stress Disorder.

           2) Plan for assessing pain and other symptoms.

           3) Reconciliation plan.

           4) Military rituals.

PTSD: The Veteran's Administration is looking at its behavior health programs and gearing up for the anticipation of the growing needs of our veterans. As hospice providers, we must be more aware of behavior and environmental triggers that impact our patients as well. An intentional approach to assessing for PTSD and putting a plan in place could be the difference of the team causing an episode of PTSD, or even worse, sending a patient to a Geri-psych program because we did not understand the behavior, versus expertly managing the environment to reduce the likelihood of an event.

Building a PTSD care plan should include identifying the "event" that caused the PTSD to develop. It could be as broad as being in an active battle zone, to specifically seeing death or even causing death of another human. Next identify what typically triggers an episode. The family may be great historians in defining triggers and you may hear that a family never had balloons in the house for fear of one unexpectedly popping, or that crowded places with no identifiable escape route causes severe panic. Clearly describing the behavior while an episode is present will help the team know and understand what is occurring. Finally listing the identified techniques to bring the soldier to a sense of normalcy will be necessary and using proven methods to bring clarity to the soldier are important.

PLANNING AND ASSESSING FOR PAIN AND OTHER SYMPTOMS: A "good" soldier will not complain. From day one they are taught to focus on the goal rather than on their own discomfort. This mentality has won many a battles in our history and is now the enemy of the caregiver.  Proper assessment of pain and symptoms allows the caregiver to appropriately address the issues and alleviate discomfort. 

An intentional difference in your approach to the assessment could be the difference. For instance, approaching a veteran directly with, "Are you in pain?", could result in a nonspecific, "Nah, I'm fine.", response from a soldier. Consider in your conversation with the solider to mention that you noticed they seemed uncomfortable the last time you were visiting and then ask if their pain or symptom is greater or worse than the last time you were there. You will find the answer to be more definite and improve your ability to address the pain or symptom. You may find the opposite to be true as a question about pain could result in an overstatement of such in an attempt to garner higher doses of pain medications. History may reveal this was a coping mechanism for PTSD that has presented itself before.

The pain and symptom management care plan should address an identified way to approach each soldier individually in probing for severity and stating the plan to appropriately address. The follow up may then be typical as it is for other patients or continue with an intentional approach.

RECONCILIATION PLAN: I have written a previous blog entitled  A Peaceful Reconciliation where I address providing an opportunity for a soldier who was faced with making choices either during a wartime setting or afterwards as a way to cope, that may haunt them still today. The reconciliation plan allows for an opportunity to make this right and helps the team to act in a way that facilitates reconciliation.

The approach is simplistic, yet very powerful. While having a conversation about the veteran's military history ask them this question, "If you had a do-over, what would it be?" Be prepared to listen without judgment and do not diminish the strength of their feelings regarding this issue. Attempting to give a pass by saying that was such a long time ago, don't worry about it will not address the reconciliation needed and allow the soldier to move on. The team should work together to develop a plan that is meaningful to the Veteran. 

MILITARY RITUALS: Once a Marine, always a Marine. The same can be said about all service members. There are hard driven core values that may play into daily life that, if left out, could cause anxiety and distress. Ask about any rituals that are important such as raising the flag daily or getting up at a certain time. Does the arrangement of the room matter or the placement of a chair or bed matter? Does acknowledging rank matter, or to be called "Sir" or not calling them "Sir" for the non-enlisted soldiers who view themselves as the ones who really worked for a living in the military matter? What are their desires for a military funeral or flag draping at the time of death? Identification of these details can be significant to building trust and easing tensions during the course of care.

For all veterans, acknowledging their service is important. Many times these patriots are humbled by the acknowledgment and you might be surprised how many have not been thanked for their service. I have been taught to welcome them home as this particular era of soldiers have yet to be acknowledged and welcomed home from their service to our country in many cases.

An intentional approach to caring for a dying Veteran is the least we can do for our heroes. Using the care plan as a driver of care creating an awareness for care providers to understand the nuances of care will change the world for those who protected and served ours. Some soldiers may not present all of these four elements, nonetheless, by intentionally probing, we will set up the right plan for each soldier. Implementing an intentional approach will build new skills that every patient on Hospice could benefit from. Many of these same techniques are transferable to any patent. Make an intention to make a difference for those we serve.

Gary W. Walker

Vice President of Hospice Operations - West

Kindred Healthcare

Kindred At Home

March 2, 2017