Every year, more than 180,000 Americans enlist in the United States armed forces. These brave men and women commit years of their lives to protecting our country, helping others, and lending humanitarian aid to those in need around the world.

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Throughout these years of service, however, the demand of military life can begin to take its toll, manifesting in unique physical, mental, emotional, and spiritual health issues that become especially evident as veterans approach the end of life.

With a veteran population of over 21.8 million, and with Americans age 65 and over becoming an increasingly larger portion of the country’s total population — estimated to climb from 43 million to 83 million by 2050 — our country’s need for quality end-of-life care for veterans is growing.

It’s now more important than ever that we, as family members and friends of aging veterans, understand the unique health challenges they face, the quality of care provided by hospice, and how to support our country’s veterans throughout the end of their life.

The Landscape of Hospice for Veterans: Veterans’ Use of Hospice Care Services

Historically, the use of hospice by veterans has lagged behind that of non-veterans. As of the United States Department of Veteran Affairs (VA) report in 2000, only 5% of the then veteran population was enrolled in some form of hospice care.

Since the publishing of these statistics, many hospice and palliative care organizations have worked closely with VA in a joint commitment to ensure that veterans and their families were made aware of the end-of-life care options available.

Most notable among these efforts is the We Honor Veterans initiative, developed by VA in partnership with the National Hospice and Palliative Care Association, where member hospices and palliative care organizations, including Crossroads Hospice, are committed to increasing veterans’ awareness of hospice and palliative care and continually improving the quality of care received.

Since the inception of We Honor Veterans and other programs like it, the use of hospice care by veterans has improved dramatically and so too have positive patient outcomes and overall satisfaction in care received at the end of life.

While these initiatives are net positives for increasing the use of hospice and palliative care services, it is vital for the sake of our aging population that this upward momentum continue. To do this as a community in support of our veterans, we must understand the unique physical, mental, emotional, social, and spiritual end-of-life challenges that many veterans face and how hospice care programs specifically address those challenges and provide quality care.

The Physical Issues that Veterans Face at the End of Life

While every veteran’s end-of-life care needs will vary, veterans as a whole tend to suffer from a unique array of physical challenges as a result of their service in the armed forces. These physical issues differ as a result of many factors, including age, location where they may have served when deployed, and the specific types of chemicals or physical hazards they were exposed to on the battlefield.

Chronic Pain Military service is extremely physically demanding. After years of service, many veterans enter their elder years with a history of severe musculoskeletal pain, particularly in the back and joints. In addition, veterans who showed symptoms of post-traumatic stress disorder (PTSD) or had a history of traumatic brain injury (TBI) more often reported chronic pain conditions than those without PTSD or TBI. Presumptive Diseases Presumptive diseases, as defined by VA, are diseases that are associated with exposure to chemicals like Agent Orange and other herbicides. Presumptive diseases can manifest into a wide array of symptoms and diseases, including various forms of cancer, hyperthyroidism, and Parkinson’s disease. Traumatic Brain Injuries Traumatic brain injuries are defined by the Brain Injury Association of America as “an alteration in the brain function, or other evidence of brain pathology, caused by an external force.” For those in the general population, this is often only a health risk during serious accidents such as falls, physical assaults, and motor vehicle accidents. For veterans, however, this is extended to the hazards of the battlefield, including grenades, mines, mortars, bullets, and improvised explosive devices (IEDs) While many of our nation’s elderly veterans have suffered from TBI, it has unfortunately become the “signature” injury for those serving in the armed forces during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), according to the National Association of State Head Injury Administrators. Source: Traumatic Brain Injury Among Veterans, Congressional Research Service

How Does Hospice Care for the Physical Issues that Veterans Face?

The primary goal of hospice is to ensure that a patient’s remaining time is spent living life to the fullest.

In pursuit of this, providing physical pain management in accordance with the patient’s wishes for their end-of-life care is a core focus of hospice care. To provide this comfort, hospice employs a range of pain management treatments — many of which can be administered wherever a patient calls home — including, but not limited to:

Pain Relief Medications Central to pain management is the use of pain relief medications. Unfortunately, one of the many myths surrounding hospice pain management is that its medications are administered to continuously and needlessly sedate patients. Above all, the goal of these medications and their administration is to provide relief from pain so that patients may enjoy life to its fullest — spending time with family and friends, engaging in cherished hobbies and activities, and embracing the experiences of life without pain. Hospice’s pain recognition and management protocols ensure that a patient’s hospice team continuously monitors and assesses: The potential risk of a medication’s use for a specific patient’s pain relief needs

The necessity of initial administration and continuing the use of specific medications

The dosage and administration schedule for all medications used

The secure storage and prevention of dangerous misused by a patient’s family and friends

When pain medication use should be discontinued for a patient The administration of pain relief medications in hospice, guided by these strict protocols, all serve one common goal: to support patients’ highest practicable levels of physical, mental, and psychosocial well-being at the end-of-life. Physical Therapy Physical therapists are licensed and highly-trained healthcare professionals that use a host of manual therapeutic techniques to improve mobility and reduce pain in the patients they treat. These therapeutic techniques include: Musculoskeletal Manipulation Physical therapists help patients relieve pain and restore mobility to key joints by applying precise pressure to the problem joint — with a speciality device or hand — and then using controlled force to reintroduce correct movement and flexibility. Therapeutic Massage Applying pressure to the body’s soft tissues and muscles, physical therapists massage using appropriate pressure to promote flexibility, relieve pain, and increase proper circulation. Mobilization Steady, precise movements are used to align joints and position bones in order to loosen tightened muscles that are inhibiting a patient’s flexibility and causing pain. Physical therapists also play a pivotal role in end-of-life care education by instructing both patients and caregivers how to prevent future injury, increase flexibility over time, and reduce overall physical pain. Occupational Therapy Though sharing a great deal of responsibilities with physical therapists, occupational therapists care for hospice patients by helping them increase independence and once again accomplish their activities of daily living (ADL), when appropriate and possible, by themselves. Occupational therapists further specialize by helping patients and family caregivers optimize their living spaces and work environments to promote greater ease of movement and an overall higher quality of life. Often, this space optimization includes training on how to use movement aid devices, such as wheelchairs, scooters, and crutches. Music Therapy Music has a long and storied history of use in the healthcare setting; however, since the 1940s, music therapy has been a valuable tool in promoting total well-being within hospice patients. Conducted by trained music therapists, sessions include listening to music performed by the therapist, songwriting, moving to music, singing, and insightful lyric discussion. Together, these exercises allow patients to relax and embrace the comforting presence of music. Multiple studies throughout the years have concluded that music therapy is profoundly effective in increasing both physical comfort and promoting relaxation, making it a viable and effective tool for providing therapeutic pain relief to hospice patients. Animal Therapy Animal therapy, also known as pet therapy, allows hospice patients to enjoy the unconditional love and companionship of dogs, cats, birds, rabbits, and a host of other friendly animals. Patients can enjoy animal therapy sessions either at home or by visiting specialized animal therapy locations, should their conditional allow. During these sessions, hospice patients can play fetch with the animals, teach their animal companions new tricks, or simply enjoy the loving presence of the animal — cuddling, hugging, and embracing them throughout their visit. Animal therapy, having continuously grown in popularity since its first uses in the 1800s, has become an established and proven tool for reducing pain and promoting overall wellness in hospice patients at the end of life.

The Emotional and Psychosocial Issues that Veterans Face at the End of Life

The demands placed upon a veteran’s body throughout their career of service are significant and many, and just as a veteran’s body has endured such stress and trial, so too have their hearts, minds, and relationships. For many veterans, some of the deepest scars they possess are the ones that we cannot see.

For veterans on the end-of-life journey, the emotional and psychosocial issues that they face are among the most difficult of challenges. In alignment with the holistic care philosophy that is hospice, hospice provides veterans and families with care specially designed to address the unique issues that veterans face, such as:

Post-traumatic Stress Disorder Post-traumatic stress disorder (PTSD) is an anxiety disorder that develops in individuals who have lived through a particularly dangerous or frightening event. For veterans suffering from PTSD, symptoms can include reliving the event, feeling continually on-edge, avoiding situations that remind them of the traumatic event, and a general increase in negativity and numbness toward themselves and others. Depression and Suicidal Ideation 11% of veterans age 65 and older suffer from depression — twice the overall national average. That percentage, however, is considered as likely inaccurate by VA, as many older veterans never receive an official diagnosis from a healthcare provider. Sadly, depression can lead to suicide — especially in older veterans. As of a 2016 mental health report from the VA Office of Suicide Prevention, about 65% of all veterans who died by suicide were ages 50 and older. If you are struggling with suicidal thoughts, please contact 1-800-273-TALK (8255) immediately. If you are deaf or hard of hearing, you can dial 1-800-799-4889. Please also visit the Suicide Prevention Lifeline Website for more assistance and to contact trained, supportive counselors who are here to help. Get Help Now 1-800-273-TALK (8255) 1-800-799-4889



Visit Suicide Prevention Lifeline's Website Survivor’s Guilt Often very closely connected with PTSD and depressive symptoms, veterans often experience survivor’s guilt. This type of guilt most often forms after situations where veterans were forced to take drastic action to ensure their own survival, or after the death of friends and fellow service members in the armed forces.

How Does Hospice Care for the Emotional and Psychosocial Issues that Veterans Face?

Veterans enrolled in hospice care receive compassionate emotional and psychosocial care from highly-trained professionals from a wide array of emotional and psychosocial healthcare disciplines.

Working together as a cohesive, multidisciplinary unit, hospice teams adapt a plan of mental and emotional care that specifically addresses the unique needs of veterans. While the plan of emotional and psychosocial treatment for each patient is varied according to his or her needs, hospice helps patients at the end of life by providing the following:

Professional and Compassionate Counseling Anger, grief, fear, and guilt are common emotions for veterans in hospice care. While in hospice care, veterans receive compassionate counsel from trained psychosocial professionals who help patients navigate the negative emotions commonly experienced at the end of life and work toward healing and an overall greater sense of peace. Assistance in Strengthening and Restoring Relationships Throughout life, relationships with family members and close friends can become challenging and strained, leading to a loss of connection that was once cherished and drawn upon as a source of support during difficult times. For veterans, especially those suffering from PTSD, social isolation is unfortunately all too common. Often feeling as though they have no one who can understand their experiences, or that they are a burden on others, veterans place themselves in a form of self-imposed social exile. To help veterans regain a sense of belonging and to instill within them the knowing that they are loved and valued, social workers and other trained psychosocial professionals help veterans reconnect and rekindle relationships with cherished loved ones and friends. These relationships become an invigorating source of support and comfort as veterans navigate the end-of-life journey.

The Spiritual Issues that Veterans Face at the End of Life

As terminally-ill patients near the end of life, they often contend with difficult spiritual questions. These challenges and questions, however, are often compounded for veterans — particularly those who engaged in combat with enemy forces, demanding the use of violence, making difficult sacrifices, and the taking of life.

Anger and Frustration with Life and God Veterans often express frustration with life as a whole and the higher powers that they might recognize. They question why they were selected to have this terminal illness and may begin to question the purpose of life, God, nature, and existence. Spiritual Isolation Throughout their adulthood, veterans may have fallen away from the religious faith of their youth. With so many years spent away from their faith, veterans often worry if God or other higher power will accept them should they attempt to pray and seek spiritual peace. Fear and Anxiety Surrounding Death Veterans, particularly those who have experienced heavy combat during their time in service, often express uncertainty and worry about their acceptance into an afterlife. With many American veterans hailing from traditional Christian backgrounds, they often express concern, asking whether or not their taking of life could ever be forgiven by God.

How Does Hospice Care for the Spiritual Issues that Veterans Face?

Just as hospice seeks to care for patients’ physical, emotional, and psychosocial needs, so too does the compassionate nature of hospice seek to provide comfort and care for patients’ spirits.

Hospice organizations understand the difficult and unique spiritual struggles that veterans face while on the end-of-life journey. To help veterans gain spiritual clarity and work toward achieving peace, quality hospice programs employ highly-trained spiritual care staff and use effective spiritual therapy techniques.

Undergoing Spiritual Counseling and Guidance with Chaplains Hospice chaplains provide spiritual counsel and guidance for hospice patients. Experts in all matters spiritual, chaplains can help patients gain understanding and perspective as to the meaning of their life and the positive impact their life has had on others. Journaling and Spiritual Exploration Therapy Providing patients with the tools and guidance to explore their memories and embrace their spirituality is central to providing holistic care. Through therapeutic exercises like journaling, patients are encouraged to reflect upon life, cherished memories, and the people, places, experiences that made their lives so very rich and rewarding. By mentally and spiritually traversing back through the years and fondly remembering each unique and enriching experience, patients can begin to see how much better they made the world by their being. Engaging in Religious and Cultural Rituals The end of life is a sacred time to nearly every religion and culture that exists. Expertly trained in the history and evolution of many religions and cultures, hospice chaplains help patients reconnect with their spiritual roots — engaging in song, dance, prayer, and other forms of reverence that pay tribute to the patient’s journey through life and forthcoming death. Hospice Ensures No Patient Dies Alone No one should be alone when they die. This belief is foundational to all quality hospice programs and is paramount to providing veterans with spiritual comfort. As patients enter the final stages of their illness, hospice ensures that a chaplain, nurse, compassionate volunteer, or other member of the hospice care team is beside the patient and providing a warm and continually supportive presence until the patient’s death.

How Hospice Helps the Family Caregivers of Veterans

As a veteran approaches the end of life, it’s common for a close and trusted family member to assume the role of caregiver. Whether feeding, bathing, picking up and administering medications, providing transportation to doctor's appointments, or performing any number of care tasks, family caregivers compassionately assume the majority of the care workload for their terminally-ill loved one.

Understanding the importance of the family caregiver role, and stress that comes with it, hospice organizations provide family caregivers with the tools and education they need to better service their loved one as well as services to help caregivers mentally, emotionally, and physically unwind from the demands of caregiving.

Caregiver Education Many caregivers come into their role as family caregiver unexpectedly, often as the result of simply being the first one to step forward in recognition of their loved one’s care needs. Understanding that family members assume the role of caregiver suddenly, hospice organizations take great care to ensure family caregivers are aware of their loved one’s needs, how to care for their loved one at home, and how to properly care for themselves during this time of great responsibility and effort. Assistance with Household Tasks and Errands When providing care for a terminally-ill loved one, priorities shift dramatically. Household tasks and minor errands like picking up the dry cleaning, finishing off the last load of dishes, and getting the laundry finished don’t quite measure up to the care needs of a loved one. To help caregivers maintain peace and comfort within the home, many hospice organizations offer the assistance of volunteers to help with light housework and errands, allowing caregivers the freedom to focus on the care needs of their loved one. Emotional and Spiritual Support Caregiving is a labor of love that heavily taxes not only the body, but the mind, spirit, and emotions as well. In light of this, hospice organizations provide caregivers with the counsel and support they need to bolster their emotional and spiritual fortitude. Respite Care Caregiver burnout is a very real occurrence in the lives of family caregivers. The continuous output of physical labor, combined with the ever-present stress and anxiety of being responsible for a loved one’s care, is taxing on every level. To combat caregiver burnout, hospice provides family caregivers with the respite care option. With respite care, caregivers can get the rest and relaxation they need — for a period up to three days — while their loved one is temporarily checked in to a care facility and cared for by professional healthcare staff.

How Hospice Helps the Families of Veterans

Whenever anyone is diagnosed with a terminal illness, the mental, emotional, and spiritual shock of such news is acutely felt by the patient’s network of family and friends.

Understanding the traumatic impact of a loved one’s terminal diagnosis, and the difficulties that lie ahead in the lives of these friends and family members as they support their loved one, hospice offers professional support and compassionate guidance to them throughout this journey.

Assistance in Strengthening and Restoring Relationships with the Veteran While old grudges and familial strife can separate loved ones for quite some time, the news of a terminal diagnosis often drive family and friends to reconnect with the patient. Unfortunately, with so much time having passed and with hurtful words potentially exchanged, it can be difficult for either party to know how to go about rekindling a long-lost relationship. To aid in reconnection, trained psychosocial professionals help everyone involved begin the work of re-establishing communication, understanding one another’s needs, and working toward achieving healing in the relationship. End-of-life Educational Resources Throughout a patient’s time in hospice care, the families and friends of the patient receive actionable information concerning the nature of their loved one’s terminal illness, how to support their loved one and the family caregiver, and what to expect as the disease progresses into its later stages. Bereavement Counseling For a period of up to 13 months after a patient’s death, hospice organizations provide bereavement counseling for families in order to provide them with the tools they need to process their loss and start the work toward healing.

How Veterans Qualify and Pay for Hospice Care

Similar to the qualification process for non-veteran patients, veterans must fulfill a series of requirements to clinically qualify for hospice care and receive financial coverage from VA.

1. Veterans must apply for enrollment in the VA Health Benefits program. Veterans can apply for the VA Health Benefits program by telephone at 1-877-222-VETS (8387), online, by mail, or in-person at one of the many local VA healthcare facilities. 2. Veterans must receive a certification of terminal illness from a physician. To meet the clinical qualifications for hospice service, a licensed physician must examine the patient and provide a written certification for terminal illness. This certification states a patient’s prognosis for life expectancy is 6 months or less should the terminal illness run its projected course. 3. Veterans must state their acceptance of hospice care. The veteran must state their acceptance of hospice care instead of seeking curative treatments for the terminal illness. In cases where the terminally-ill veteran is unable to speak for themselves, the veteran’s family or the person legally designated to speak on behalf of the veteran may state the acceptance of hospice care.

Should veterans seek financial coverage for hospice apart from VA, there are a multitude of options available through Medicare, Medicaid, and private insurance.

Quality Comfort and Care for Veterans at the End of Life

Our nation’s veterans give so much of themselves — physically, emotionally, mentally, socially, and spiritually — to protect our country and bring aid to those in need. Should the need for end-of-life care be a part of their life’s journey, they deserve quality, holistic care.

As friends and loved ones of veterans, we must work to make sure that those who so valiantly defended our freedoms are made knowledgeable of the end-of-life care options available to them. Together, we can ensure that veterans enjoy an end of life that is as pain free as possible, filled with love and compassion, and made richer through the presence of cherished family and friends.