Starting the Conversation With Veterans Dr. Ritamarie Moscola, MD, MPH, Manchester VA Medical Center Peter Cassell, Volunteer, Central New Hampshire VNA and Hospice
Veterans Statistics An average of 1,800 Veterans die daily 900 of the 1,800 are WW II Veterans Veterans are approximately 25% of all deaths in the U.S. Most males over 65 have served in the military due to the draft
Veterans Statistics There are approximately 22,340,000 Veterans living today; most have served in times of war Approximately 1/3 (8,340,000) of Veterans are enrolled in the VA Approximately 4% of Veterans die in VA facilities; the rest die in local community facilities or at home
Former Prisoners of War (POWs) Since WW I, over 142,000, including 8 women, have been captured and interned as POWs Nearly 30%, or 29,500, POWs since WW I are still alive More than 90% of living POWs are from WW II The VA has, for the last 30 years, had special care for former POWs They may suffer from PTSD
WW II, 7 Dec 1941 31 Dec 1946 U.S. Served - 1,800,000 U.S. Battle Deaths - 291,557 U.S. Wounded - 671,846 U.S. Medals of Honor - 433 Diseases typical to this group include COPD, CHF, cancers, liver failure Psychological illnesses shell shock (PTSD)
Korean Conflict, 25 June 1950 27 July 1953 The forgotten war U.S. Battle Deaths - 33,741 U.S. Other In-theater Deaths - 2,833 U.S. Wounded - 103,284 U.S. Medals of Honor - 131 Long-term delayed symptoms; these may worsen as Veterans age Arthritis Diabetes Peripheral vascular disease These put some Veterans at higher risk for amputations later in life
Cold War, 1945 1990s 12 different actions Bay of Pigs, Beirut, Grenada, Panama U.S. Battle Deaths - 440 U.S. Wounded - 978 Health Issues Normal chronic illnesses, i.e., cancers, COPD, CHF PTSD
Vietnam, 4 Aug 1964 27 Jan 1973 U.S. Served in Vietnam Era 7,900,000 U.S. Served in Southeast Asia 3,403,000 U.S. Served in Vietnam - 2,700,000 U.S. Battle Deaths - 47,424 U.S. Other In-theater Deaths - 10,785 U.S. Wounded - 153,303 U.S. Medals of Honor - 238 The first war in which the U.S. failed to meet its objectives
Vietnam (cont d) The first time America failed to welcome its Veterans home as heroes By 2014 60% of Veterans over 65 will be Vietnam-era Veterans Environmental Hazards Pesticides/herbicides approximately 20,000 gallons used; most well-known is Agent Orange
Vietnam (cont d) The VA now recognizes the following conditions related to service in Vietnam for the purposes of establishing service connection Soft-tissue carcinoma Non-Hodgkins lymphoma Hodgkin s disease Respiratory cancers Multiple myeloma Prostate cancer
Vietnam (cont d) Hepatitis C Virus (HCV) 63% of VA-enrolled Veterans testing positive for HCV are Vietnam-era Veterans Hepatocellular carcinomas Psychological illnesses PTSD Anxiety Depression Substance abuse
Gulf War, August 1990 June 1991 (Operations Desert Shield/Desert Storm) U.S. Battle Deaths - 149 U.S. Wounded - 449 Health Issues Gulf War Syndrome exposure to chemical, biological agents Pulmonary problems from exposure to smoke from oil field fires ALS Gulf War Veterans are twice as likely to develop ALS as other Veterans PTSD
OEF (Afghanistan) and OIF (Iraq) OEF 7 Oct 2001 now (ongoing) OIF 20 Mar 2003 31 Dec 2011 (?) U.S. Battle Deaths - 5,281 U.S. Wounded - 50,897 U.S. Missing - 3 Health Issues Combined penetrating and blunt trauma, burn injuries (blast injuries) Traumatic brain injury (TBI) or spinal cord injury Vision loss Traumatic amputation Mental health issues, including PTSD
The Conversation Military Service Referred to as a hidden variable May have important influence on current behavior Formative period of young adulthood May be searching for identity, meaning and purpose in life Transformative experience that can have both positive and negative effects
Military History Useful tool in bridging the silence that often surrounds the war experience Need to establish an environment of trust and respect Not all veterans will want to speak with you about the details of their war experience A discussion of combat experiences can reactivate deeply buried issues
Respectful Inquiry Listen non-judgmentally Offer caring presence, conveying warmth and acceptance of the person, their journey and struggles Do not offer platitudes or prematurely assuage feelings of guilt
Types of Response to War Trauma Integrated response trauma has been processed, healing occurs, life goes on Incomplete integration of trauma PTSD Apparent integration of trauma delayed onset; partially mediated by appraisals of the desirable and undesirable effects of military service Losses in career or relationships, health problems
PTSD Triggers in Serious Illness Experiencing illness and death of loved ones Losing key avoidance strategy(ies) with personal illness Being in physical pain Feeling vulnerable power differential, dependency, being touched, startle response, being in noisy areas, being confined to small places
Potential Issues in Patients with PTSD Avoidance symptoms High levels of anxiety Stoicism Stoic values Distrust of authority or anger at government (including the VA) Sedating medications can increase sense of vulnerability Flashbacks or agitated delirium?
More Potential Issues Life review intense anxiety, sadness, guilt, anger Spiritual distress Impact of struggle with PTSD on loved ones
Special Issues at End of Life I am a warrior. I am supposed to take it. What about this pain and loss? Can I let down a lifetime of defenses? I have never spoken of the war. Can I now? Was the war right or wrong, moral or immoral? Was I a good and just soldier? Did I do right or wrong? Did my service mean anything? Did it do any good?
How do I reconcile with my country s treatment, neglect and/or betrayal of me? PTSD and its related war imagery often intensifies during the terminal process. I am at war again. How did the war impact my relationships with others? Do I need to make any amends? Death is an old friend. How can I meet him? Will I meet old friends or foes? What am I leaving behind? The foxhole creates atheists. If there was a God, this would not have happened.
Veteran s Prayer (Universal Version) As I begin my walk out of the darkness and turmoil of conflict, may I find the strength to find a lasting and gentle existence May I treat all living creatures with respect May I do no harm for the remaining days of my life May I accept who I am now not who I have been in the past. Help me to remember and to dim not forget the tragic past May I take my experiences and use them to understand others wherever I go to ban fear, hate and violence from my thinking May I understand how one person can make the world a better place May I discover the reasons I am still here and what I am to do May I find the strength to face the time I have left here to reconnect with humanity to feel and give love Spirit of Life, make me whole again. Amen.
DISCUSSION
Some slides created and provided by: Dr. Julie Phillips, Hospice and Palliative Care Physician, Albany VA Medical Center Dr. Edward Tick, Executive Director, Soldier s Heart and author, War and the Soul, and Warrior s Return: Restoring the Soul After War