CHAPTER 31
CARE OF VETERANS
Elizabeth Bowers, APRN, ACHPN®,
Carma Erickson-Hurt, APRN, ACHPN®, LCDR, USN, RET
The Veteran population is a unique population with a vast amount of health specific issues associated with their military service branches as well as service era’s. Compared to the civilian population, veterans display increased rates of mental health disorders, post-traumatic stress, substance use disorders and traumatic brain injury
Health care professionals working with veterans should be educated on the various military branches as well as the risk factors associated with suicide. Eighteen to 22 American veterans commit suicide daily and young veterans aged 18–44 are most at risk. Regardless of age all Veterans should be screened for mental health issues, history of previous suicidal ideations and attempts as well as post-traumatic stress disorders.
Separation from military service and issues related to complex multiple deployments are among specifically identified veteran issues.
Approximately 49,933 American veterans are homeless and face the same difficulties as non-veterans in addition to service-related matters.
Successful veteran reintegration into civilian life rests upon providing veterans with training that builds on their military knowledge and skill, employment post-separation from service, homelessness prevention, and mental health programs that promote civilian transition. 27
I. DEMOGRAPHICS
A. One out of every four dying Americans is a Veteran.1
B. More than 1,800 Veterans die every day in the United States or about 54,000 per month.1
C. Although significant numbers of the dying population are Veterans; approximately 4% of Veterans die in a Veteran’s Health Administration inpatient facility, which is a division of the U.S. Department of Veterans Affairs (VA).1
D. Only 10-15% of all Veterans in the United States receive healthcare through the VA system.
E. Because the majority of dying Veterans are not served by the VA, it is essential that palliative APRNs understand their unique needs.
II. DEFINING THE VETERAN POPULATION
A. A Veteran is anyone who served any length of active duty, reserve, or guard service in the United States Navy, Marines, Army, Air Force, Coast Guard, Public Health Service, or National Oceanographic and Atmospheric Administration. Identifying a Veteran in the community is the initial step in providing Veteran centric care.
B. Different Types of Veteran Service
1. Active duty is determined by the amount of full time service a Veteran fulfilled in the military. This can vary from a few years to thirty years.
2. The Reserves are military personnel who chose to combine a civilian career with a military career. During drills (one weekend a month and approximately 2 weeks or more a year with a military unit on active duty), reservists perform mock military operations. Always on call, Reserves personnel could be ordered to enter active duty based upon the needs of their military branch. The current global war on terror utilizes the Reserves to support operations.
3. The Army and Air National Guard (National Guard) are similar to the Reserves. Again, these are military personnel who combine a civilian and military career. Historically the National Guards provide support to individual states to protect the life and property of the citizens of that state during times of emergencies such as natural disasters, riots, etc. However, The National Guards have also deployed troops in support of past and current wars and conflicts.
4. Retired military indicates that a person served at least 20 years of active duty service, but has retired from further service. Upon retirement, he/she is entitled to receive a pension and medical insurance benefits.
C. A Veteran’s discharge from military service form is known as a DD214 “Certificate of Release or Discharge from Active Duty.” The DD214 is issued upon a military member’s retirement, separation, or discharge from Active Duty military and serves as proof of military service. It is an essential element in the VA enrollment process and most Veterans will know what a DD214 is, but the family may not be aware of the need for this document. It is important to make sure the family is aware of the location of the DD214 or how to retrieve it.
a. The National Archives and Records Administration Military Personnel Records Center is the official repository for records of military personnel who have been discharged from the U.S. Air Force, Army, Marine Corps, Navy and coast Guard. One may also consult with their local Veteran’s Administration office or Veterans Service organization for assistance. 28.
a. The National Archives and Records Administration Military Personnel Records Center is the official repository for records of military personnel who have been discharged from the U.S. Air Force, Army, Marine Corps, Navy and coast Guard. One may also consult with their local Veteran’s Administration office or Veterans Service organization for assistance. 28.
https://www.archives.gov/veterans/military-service-records
III. THE MILITARY HISTORY CHECKLIST
A. It is impossible to treat a Veteran’s needs if his/her military status is unknown. All patients should be asked, “Did you ever serve in the military?” or “Are you a Veteran?”
1. If the answer to both questions is “yes,” then a military history checklist, relating to branch, period of service, perception of service experience, and military benefits, can serve as a guide to identify how military service has affected their life.
2. If the answer is yes to service in the military but no to a Veteran, it may be an indication the person had a dishonorable discharge from the military. They will not have access to care but will have the same experiences from service and the same healthcare issues.
B. Those men and women who have served in the military are part of a distinct culture with its own language, rituals and norms, and experiences. This culture can define the functioning of entire families; especially when there is a strong familial history of military service. Within this culture, there are significant subcultures based on—the era of service; combat versus noncombat service; voluntary entry into service or drafted into service; and whether the Veteran served as an officer or enlisted serviceman.
An enlisted serviceman undergoes a physical, standardized testing for their branch of service as well as meeting with a service liaison counselor to discuss details of enlistment agreement. They then take an oath to become a soldier.
In order to be commissioned as an officer, a minimum of a bachelor’s degree is first required. They are specifically trained to be leaders and supervisors of enlisted personnel.
C. Once a Veteran has been identified, he/she should be asked “Which branch of service were you in?” Each branch of service is distinct in its methods of training, instruction, and socialization. The focus of each branch also partially determines the likelihood of combat related trauma. For example, a Marine or Army Veteran is more likely to have seen combat than a Coast Guard Veteran.
D. The Veteran should then be asked “Which war era or period of service did you serve?” Each era of service and war has its own unique history and influences upon the Veteran. This can dramatically influence the outcome of the Veteran’s experience. Medical issues seen in the various eras and locations of service may be associated with presumptive disabilities.
E. Once the background information is gathered on the Veteran’s military service, the service man or woman can be asked, “Overall, how do you view your military service?” Understanding how the Veteran views his/her service, positively or negatively, may help the clinician gain insight into how the Veteran may perceive his/her serious or life-threatening condition, especially specially if the condition is related to his his/her military service
F. If hospice is involved in the care of the Veteran, they may ask, “If available, would you like a hospice staff member or volunteer with military experience?” The military Veteran culture, which is often able to span eras and theaters of service despite the previously mentioned differences, can be a powerful force even at the end of life. A volunteer or staff member who is part of the military culture can provide support in a unique way, helping to bridge the patient-provider relationship. It may also provide an outlet for the stories and experiences never previously communicated to family or others in the Veteran’s life.
Volunteer opportunities are often a path to healing war related trauma for the volunteer.
Veteran volunteers may benefit from education, training, and additional support when caring for fellow Veterans at the end of life, as their own trauma may also be re-triggered.
G. Finally the Veteran should be asked, “Are you enrolled in the VA?” All Veterans who were honorably discharged may be eligible for VA benefits. These vary from healthcare coverage to disability compensation. Eligibility for most VA benefits is based on honorable discharge from active military service.
.
1. Veterans must be enrolled in the VA in order to be considered for these benefits. If a Veteran is enrolled in the VA, it may be helpful to ask if they receive any benefits or if they have a service-connected condition.
2. Many Veterans may receive their medications through the VA. A Veteran enrolled in the VA for healthcare benefits may receive their medication from their VA primary care provider at a reduced rate. The name and contact information of the VA facility and provider should be obtained to promote collaboration, communication, and continuity of care. .
3. If the Veteran is enrolled in hospice, they would receive their medications related to their terminal diagnosis from the hospice and the medications not related to the terminal diagnosis from the VA.
H. Those who were dishonorably discharged are not eligible for VA benefits.
I. Only 10-15% of Veterans receive their healthcare at the VA.3 One cannot assume that because they are a Veteran they can use the VA. The majority of Veterans are not enrolled in the VA system, but instead may carry private insurance. Therefore, they are unfamiliar with the VA system and its healthcare facilities, because they receive their care elsewhere. Therefore, identification of Veterans in non-military healthcare settings is vital to helping the Veteran access benefits they may be missing
I. HONORING VETERANS
A. Once the military status is known, it is important to respect the Veteran’s service, feelings, and any suggestions they might offer. It may take longer for Veterans to build trusting relationships than other patients.
1. Patience and listening will build trust and rapport with the Veteran. Most Veterans will not share their entire story on the initial visit. Rather, pieces of the story may be revealed with time. The expectation and willingness to allow the sharing of information to occur over a period of time will help the APRN.
2. Veterans may have strong political feelings and/or positive or negative feelings about their military service. Allow them to express their feelings without being judgmental. Be supportive and validate their feelings and concerns.
3. Similar to any palliative care, it is best that the APRN avoid statements such as, “I understand how you feel,” as usually the clinician has not shared the same experience. Statements such as, “That must have been very hard for you,” validate the feelings the Veteran is expressing.
B. Simple acts of gratitude, particularly at the end of life, can make up for a lifetime of pain because some Veterans were never welcomed or thanked for their service. A general statement such as, “Thank you for your service,” may be appreciated. A specific statement such as, “Thank you for your service in Vietnam,” may be more authentic. Hospice and palliative care staff may provide the last opportunity for Veterans to feel that their service was not in vain, and they are appreciated. Additionally, showing appreciation to the family of the Veteran for their sacrifice is also important.
C. The National Hospice and Palliative Care Association (NHPCO) and the Department of Veterans Affairs have developed the We Honor Veterans program to assist hospice and palliative care providers in caring for the unique needs of Veterans.2
D. The Hospice and Palliative Nurses Association (HPNA—www.HPNA.org) and the End-of-Life Nursing Education Consortium
(ELNEC—ww
w.aacn.nche.edu/elnec) have developed education aimed at all levels of nursing about palliative care for Veterans.
II. CHARACTERISTICS OF PARTICULAR WAR ERAS
A. World War II (WW II) lasted from 1939-1945. There are over 2 million WWII Veterans living, all of whom are over 80 years old.3 WWII had a clear mission and these Veterans came home to a hero’s welcome. For the most part the country was supportive of the war efforts.
1. Many service personnel have a positive view about their military experience and felt they had a duty to serve their country. Veterans fought in several countries in extreme climates and conditions.
2. Those who served aboard ships may been exposed to asbestos. WWII Veterans may have also been exposed to infectious diseases, extreme temperatures, nuclear weapons, and chemical agents.
3. Although WWII ended triumphantly with soldiers viewed as heroes, some providers may not realize that these Veterans are still at risk for posttraumatic stress disorder (PTSD). However, PTSD had not yet been identified or accepted as a specific diagnosis. Thus, the term “shell shock” was applied to soldiers experiencing the traumatizing effects of war. These Veterans experienced disturbing events, such as multiple deaths of dying comrades in the field, and mangled injuries from various bombs. They relive these deaths once back in the United States. Those soldiers at highest risk for PTSD in this population included those engaged in high levels of combat, detained as prisoners of war, or were wounded in action.
B. The Korean conflict lasted from 1950 to 1953. Currently there are around 2.4 million living Korean Veterans.3 Because of the short duration and lack of media attention, the Korean conflict is sometimes termed “The Forgotten War.”
1. Because the war was overshadowed by WWII and Vietnam, soldiers’ efforts were minimized and traumas ignored.
2. Soldiers served in harsh weather conditions, with inadequate equipment exposing them to cold temperatures. Battlefield conditions, themselves, made treatment for cold injuries difficult.4 Injuries related to cold exposure often caused long-term sequelae, though delayed and worsen with age. The long- term effects of cold exposure included peripheral neuropathy, skin cancer in frostbitten areas such as the heels and earlobes, arthritis in injured areas, chronic tinea pedis, fallen arches, and stiff toes. Moreover, with aging, these soldiers developed conditions such as diabetes and peripheral vascular disease, placing them at risk for late amputations.4
3. Soldiers who experienced the traumatizing effects of war were diagnosed as having “combat fatigue.”
C. The Cold War lasted from 1945 until the fall of the former Soviet Union in the early 1990s. This period of tension between the United States and its allies and the Soviet bloc began after WWII.
1. Veterans of this era are often referred to as “Atomic Veterans” because of exposure to atomic weapons and radiation.4
2. A major fear of the Cold War era was nuclear war with associated health concerns about exposure to ionizing radiation. Service members during this time may have participated in nuclear weapons testing and cleanup. Exposure to radiation has been associated with leukemias and other cancers and cataracts.4
3. Atomic Veterans are eligible to participate in the VA’s Ionizing Radiation Program. This includes access to an Ionizing Radiation Registry Examination performed within the VA. In addition, there is special eligibility for treatment of conditions recognized by VA as potentially radiogenic, whether or not they have had a radiation compensation claim approved.4 See Appendix 31-A for the list of Presumptive Disability Benefits for Certain Groups of Veterans.
D. The Vietnam conflict began in 1962 and lasted until 1975. There are over 7.9 million Vietnam Veterans, comprising the largest number of combat Veterans.4 The proportion of Vietnam-era Veterans over the age of 65 continue to increase through 2014, when Vietnam Veterans will account for nearly 60% of all Veterans in that age group.5 Many soldiers who served in Vietnam were drafted—not serving in the military willingly. Because of the stigma associated with this unpopular war, many of these Veterans were personally attacked upon return home by their fellow citizens who opposed the war.
E. 1. Many Veterans may have negative or hidden feelings and attitudes toward their service. This situation magnified the trauma associated with their combat experiences.2 Contributing to the stress experienced by many Veterans was the lack of unit cohesiveness. Many soldiers were sent to Vietnam as individuals, not as units, and left upon completion of a year’s tour.2 Because they did not leave Vietnam with their fellow soldiers, many Vietnam Veterans did not have the opportunity to begin the closure process or sharing experiences.
2. Vietnam Veterans may have been exposed to an herbicide and defoliant chemical spray, called by the military code name Agent Orange. Extensive research identified the long-term health effects of exposure to Agent Orange. The government took many years to recognize the side effects of contact with this chemical. The VA assumes that all Vietnam Veterans who served in the Republic of Vietnam, from January 9, 1962 to May 7, 1975, were exposed to Agent Orange and now offers Veteran’s benefits related to Agent Orange exposure. (see Appendix 31-A)
a) Under VA Code of Federal Regulations, Veterans who served in Vietnam between
b) 1962 and 1975 (including those who even briefly visited Vietnam), and have a disease the VA recognizes as being associated with Agent Orange, are presumed to have been exposed to Agent Orange.6
c) b). Updates are now published every 2 years in reports issued by the Institutes of Medicine. Unfortunately, there is no concrete data to determine how much exposure to Agent Orange herbicide Vietnam Veterans experienced. Additionally, it has yet to be determined the amount of Agent Orange exposure resulted in various conditions or increased the risk of developing such conditions. Presumptive diseases related to Agent Orange exposure include E
d) Malignant diseases—non-Hodgkin’s lymphoma, Hodgkin’s, multiple myeloma, sarcoma, prostate and respiratory cancers, chronic lymphocytic leukemia, and hairy cell leukemia.
e) Nonmalignant diseases—birth defects in children of Vietnam Veterans, spinal bifida, type II diabetes, peripheral neuropathy, ischemic heart disease, and Parkinson’s disease
f) VA presumes Lou Gehrig's Disease (amyotrophic lateral sclerosis or ALS) diagnosed in all Veterans who had 90 days or more continuous active military service is related to their service, although ALS is not related to Agent Orange exposure. According to the ALS Association, Veterans are twice as likely to be diagnosed with ALS.
I. HONORING VETERANS
C. Once the military status is known, it is important to respect the Veteran’s service, feelings, and any suggestions they might offer. It may take longer for Veterans to build trusting relationships than other patients.
i. Patience and listening will build trust and rapport with the Veteran. Most Veterans will not share their entire story on the initial visit. Rather, pieces of the story may be revealed with time. The expectation and willingness to allow the sharing of information to occur over a period of time will help the APRN.
i. Veterans may have strong political feelings and/or positive or negative feelings about their military service. Allow them to express their feelings without being judgmental. Be supportive and validate their feelings and concerns.
i. Similar to any palliative care, it is best that the APRN avoid statements such as, “I understand how you feel,” as usually the clinician has not shared the same experience. Statements such as, “That must have been very hard for you,” validate the feelings the Veteran is expressing.
A. Simple acts of gratitude, particularly at the end of life, can make up for a lifetime of pain because some Veterans were never welcomed or thanked for their service. A general statement such as, “Thank you for your service,” may be appreciated. A specific statement such as, “Thank you for your service in Vietnam,” may be more authentic. Hospice and palliative care staff may provide the last opportunity for Veterans to feel that their service was not in vain, and they are appreciated. Additionally, showing appreciation to the family of the Veteran for their sacrifice is also important.
D. The National Hospice and Palliative Care Association (NHPCO) and the Department of Veterans Affairs have developed the We Honor Veterans program to assist hospice and palliative care providers in caring for the unique needs of Veterans.2
A. The Hospice and Palliative Nurses Association (HPNA—www.HPNA.org) and the End-of-Life Nursing Education Consortium
(ELNEC—ww
w.aacn.nche.edu/elnec) have developed education aimed at all levels of nursing about palliative care for Veterans.
I. CHARACTERISTICS OF PARTICULAR WAR ERAS
A. World War II (WW II) lasted from 1939-1945. There are over 2 million WWII Veterans living, all of whom are over 80 years old.3 WWII had a clear mission and these Veterans came home to a hero’s welcome. For the most part the country was supportive of the war efforts.
1. Many service personnel have a positive view about their military experience and felt they had a duty to serve their country. Veterans fought in several countries in extreme climates and conditions.
1. Those who served aboard ships may been exposed to asbestos. WWII Veterans may have also been exposed to infectious diseases, extreme temperatures, nuclear weapons, and chemical agents.
1. Although WWII ended triumphantly with soldiers viewed as heroes, some providers may not realize that these Veterans are still at risk for posttraumatic
stress disorder (PTSD). However, PTSD had not yet been identified or accepted as a specific diagnosis. Thus, the term “shell shock” was applied to soldiers experiencing the traumatizing effects of war. These Veterans experienced disturbing events, such as multiple deaths of dying comrades in the field, and mangled injuries from various bombs. They relive these deaths once back in the United States. Those soldiers at highest risk for PTSD in this population included those engaged in high levels of combat, detained as prisoners of war, or were wounded in action.
A. The Korean conflict lasted from 1950 to 1953. Currently there are around 2.4 million living Korean Veterans.3 Because of the short duration and lack of media attention, the Korean conflict is sometimes termed “The Forgotten War.”
1. Because the war was overshadowed by WWII and Vietnam, soldiers’ efforts were minimized and traumas ignored.
1. Soldiers served in harsh weather conditions, with inadequate equipment exposing them to cold temperatures. Battlefield conditions, themselves, made treatment for cold injuries difficult.4 Injuries related to cold exposure often caused long-term sequelae, though delayed and worsen with age. The long- term effects of cold exposure included peripheral neuropathy, skin cancer in frostbitten areas such as the heels and earlobes, arthritis in injured areas, chronic tinea pedis, fallen arches, and stiff toes. Moreover, with aging, these soldiers developed conditions such as diabetes and peripheral vascular disease, placing them at risk for late amputations.4
1. Soldiers who experienced the traumatizing effects of war were diagnosed as having “combat fatigue.”
A. The Cold War lasted from 1945 until the fall of the former Soviet Union in the early 1990s. This period of tension between the United States and its allies and the Soviet bloc began after WWII.
1. Veterans of this era are often referred to as “Atomic Veterans” because of exposure to atomic weapons and radiation.4
1. A major fear of the Cold War era was nuclear war with associated health concerns about exposure to ionizing radiation. Service members during this time may have participated in nuclear weapons testing and cleanup. Exposure to radiation has been associated with leukemias and other cancers and cataracts.4
1. Atomic Veterans are eligible to participate in the VA’s Ionizing Radiation Program. This includes access to an Ionizing Radiation Registry Examination performed within the VA. In addition, there is special eligibility for treatment of conditions recognized by VA as potentially radiogenic, whether or not they have had a radiation compensation claim approved.4 See Appendix 31-A for the list of Presumptive Disability Benefits for Certain Groups of Veterans.
A. The Vietnam conflict began in 1962 and lasted until 1975. There are over 7.9 million Vietnam Veterans, comprising the largest number of combat Veterans.4 The proportion of Vietnam-era Veterans over the age of 65 continue to increase through 2014, when Vietnam Veterans will account for nearly 60% of all Veterans in that age group.5 Many soldiers who served in Vietnam were drafted—not serving in the military willingly. Because of the stigma associated with this unpopular war, many of these Veterans were personally attacked upon return home by their fellow citizens who opposed the war.
1. Many Veterans may have negative or hidden feelings and attitudes toward their service. This situation magnified the trauma associated with their combat experiences.2 Contributing to the stress experienced by many Veterans was the lack of unit cohesiveness. Many soldiers were sent to Vietnam as individuals, not as units, and left upon completion of a year’s tour.2 Because they did not leave Vietnam with their fellow soldiers, many Vietnam Veterans did not have the opportunity to begin the closure process or sharing experiences.
1. Vietnam Veterans may have been exposed to an herbicide and defoliant chemical spray, called by the military code name Agent Orange. Extensive research identified the long-term health effects of exposure to Agent Orange. The government took many years to recognize the side effects of contact with this chemical. The VA assumes that all Vietnam Veterans who served in the Republic of Vietnam, from January 9, 1962 to May 7, 1975, were exposed to Agent Orange and now offers Veteran’s benefits related to Agent Orange exposure. (see Appendix 31-A)
a) Under VA Code of Federal Regulations, Veterans who served in Vietnam between 1962 and 1975 (including those who even briefly visited Vietnam), and have a disease the VA recognizes as being associated with Agent Orange, are presumed to have been exposed to Agent Orange.6
a) Updates are now published every 2 years in reports issued by the Institutes of Medicine. Unfortunately, there is no concrete data to determine how much exposure to Agent Orange herbicide Vietnam Veterans experienced. Additionally, it has yet to be determined the amount of Agent Orange exposure resulted in various conditions or increased the risk of developing such conditions. Presumptive diseases related to Agent Orange exposure include
i. Malignant diseases—non-Hodgkin’s lymphoma, Hodgkin’s, multiple myeloma, sarcoma, prostate and respiratory cancers, chronic lymphocytic leukemia, and hairy cell leukemia.
i. Nonmalignant diseases—birth defects in children of Vietnam Veterans, spinal bifida, type II diabetes, peripheral neuropathy, ischemic heart disease, and Parkinson’s disease.
ii. iii. VA presumes Lou Gehrig's Disease (amyotrophic lateral sclerosis or ALS) diagnosed in all Veterans who had 90 days or more continuous active military service is related to their service, although ALS is not related to Agent Orange exposure. According to the ALS Association, Veterans are twice as likely to be diagnosed with ALS.
3. Education is important as many Vietnam Veterans are unaware that their disease is related to military service that would qualify them for benefits. Or they may have been denied claims in the past by the VA, but now would be eligible. It is important to encourage Veterans to seek a VA evaluation.
b. The Gulf War lasted from 1990 to 1991. Currently approximately 5.7 million Gulf War era Veterans are living.3 The Gulf War was considered a brief and successful military operation with fewer injuries and deaths of American troops in comparison to other conflicts. Most Gulf War Veterans resumed their normal activities after returning from the war.
i. Troops were exposed to smoke from burning oil fields, various unknown chemical and biological agents, depleted uranium from weapons, and infections such as leishmaniasis. The effects of these exposures are still unknown.
ii. Many soldiers soon began reporting a variety of unexplained health problems they attributed to their participation in the Gulf War recognized by the VA as “Gulf War Syndrome.” The problems included chronic fatigue, muscle and joint pain, loss of concentration, forgetfulness, headache, rash, fibromyalgia, and irritable bowel syndrome. A registry was established for all Veterans for evaluation of complaints and symptoms. “Gulf War Syndrome” was later changed to “Gulf War Illness.” (see Appendix 31-A)
c. Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) began in 2003 with the wars in Iraq and Afghanistan. Most recently, Operation New Dawn (OND) was initiated. Similar to Gulf War Veterans, OIF/OEF/OND Veterans may experience complications from immunizations, chemical and biological agents, and infections. It is important to note that many OIF/OEF/OND Veterans have other health insurance plans after leaving the military and may not seek healthcare through the VA system. OIF/OEF/OND soldiers survived injuries that would have been fatal in previous conflicts. Due to advances in technology
i. Polytrauma is common in this group of Veterans. Polytrauma is defined as 2 or more injuries to physical regions or organ systems, one of which may be life-threatening, resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability.7 One particular polytrauma triad comprised of chronic pain, PTSD, and traumatic brain injury (TBI), presents a diagnostic and treatment challenge.7,8
ii. TBI is the hallmark injury of OIF/OEF/OND Veterans. TBI is the result of head injuries sustained when the head forcefully hits an object, when an object penetrates the skull, or when brain tissue undergoes sudden acceleration, deceleration, or both.9 There are almost 44,000 Veterans with TBI because military duties increase the risk of TBI.10 It is estimated that 10-20% of all soldiers returning from Iraq and Afghanistan have sustained some type of TBI.9
1. Blasts are a leading cause of TBI for military personnel in combat. Other causes of TBI in the military may include bullets or fragments, motor vehicle accidents, assaults, and falls.
2. TBI symptoms can appear immediately or can be delayed over time. These can include memory loss, decreased cognitive function, behavioral and personality changes, dementia, and PTSD. Neurological symptoms include seizures, headaches, impaired reflexes, nervous ticks, and post- concussive syndrome, which can manifest as dizziness, headaches, vertigo, nausea, insomnia, and depression.
3. A common complication of TBI is chronic pain syndromes. Therefore, an assessment of chronic pain is crucial.9 Some symptoms resolve within a month of injury while others persist for months or years.7
4. Long-term implications of TBI are not known; further research is needed to determine how to care for Veterans with TBI.
iii. OIF/OEF/OND combat Veterans can receive cost free medical care for any condition related to their service in the Iraq/Afghanistan Theater for five years after the date of their discharge or release. Other benefits may also be available. In order to take advantage of these benefits, OIF/OEF/OND Veterans need to enroll in the VA’s healthcare system.
iv. Often due to length of conflicts, service personnel participate in multiple tours of duty in which they have come back to the United States in-between being in the war zone. This may be seen as an accomplishment. However, the prolonged timeline of these conflicts has meant that military personnel and their families often endure multiple tours of combat duty.
4. WOMEN VETERANS
a. The role of women has evolved with each conflict. Thus, women in World War II had a much different role and military experience than today’s women Veterans. Identification of women’s Veteran status and military occupation can help to identify unique issues.
b. Women comprise approximately 14% of the U.S. Armed Forces.11 Women Veterans account for nearly 1 in 100 adult female patients in the United States.12 Most of today’s 1.7 million women Veterans obtain all or most of their healthcare outside of the VA system. It is common that a women’s Veteran status is unacknowledged when accessing a civilian healthcare system.8
d. However, the sequelae for women deployed to a combat area are still largely unknown.8 Many women, like their male counterparts, return from combat traumatized by the events they have experienced. Researchers and healthcare providers are beginning to recognize that gender plays a large role in how Veterans process the psychological trauma of war. The greatest hope for answers lies in the Women Veterans Cohort Study; a longitudinal study to identify gender- associated disparities in healthcare utilization among OIF/OEF/OND Veterans receiving care in the VA system. This may help to determine the healthcare needs of women Veterans.
5. HOMELESS VETERANS
a. Veterans comprise 23% of the homeless population.14 A large number of these are displaced and at-risk Veterans. They live with lingering effects of PTSD and substance abuse, compounded by a lack of family and social support networks.15 Since 1987, the VA has addressed the problems of homelessness among Veterans through the development of specialized programs geared to facilitate access to services and care.
i. The VA has a strategic initiative to end
Veteran homelessness by 2015[LTM3] .16 To accomplish this, the VA has established a range of specialized resources, services, and programs to promote easy access to programs and services for Veterans at risk for homelessness or attempting to exit homelessness. Programs and resources include prevention and early intervention services, a national call center, housing support services, treatment, employment and job training, benefits, and resources, all of which collaborate with community and national programs. The local VA Medical Center or Vet Center will have
information on the programs available to homeless Veterans.[LTM4]
ii. Most homeless Veterans will be able to access medical care through the VA system if they were honorably discharged from active military service. However, because of the complex process of obtaining eligibility for care from the VA, many Veterans may not have accessed care through the VA system. Few homeless Veterans are able to navigate the system assistance. Social workers can help connect the homeless Veteran with the VA system. Veteran Service Organizations (VSOs) such as the Veterans of Foreign Wars (VFW) or Disabled American Veterans (DAV) can provide free assistance navigating the VA system.
b. Many homeless Veterans may have issues with healthcare providers such as the VA, large institutions, or the government.17 Many Veterans also pride themselves in self-reliance and their ability to survive. This pride may result in a preference for sleeping out in the rough rather than staying in shelters. They may have experienced or heard about “red tape” bureaucracies and the lack of coordination of services. Many may feel resentful about not receiving services and benefits to which they feel entitled to. Efforts to promote outreach, collaboration, and access to services and care are essential to navigate the homeless Veteran to appropriate programs and resources available in the VA and community.
6. VETERAN (VET) CENTERS
a. The Veteran Centers or VET Centers are community based and part of the U.S. Department of Veterans Affairs. The VET centers are a VA program designed to provide readjustment counseling to Veterans exposed to the uniquely stressful conditions of military service in a combat theater of operations. The goal of a VET center program is to provide a broad range of counseling, outreach, and referral services to eligible combat Veterans in order to help them make a satisfying post- war readjustment to civilian life. The VET center program encourages early intervention to promote better readjustment and makes every effort to remove the stigma of seeking assistance. They provide services in a non-clinical environment without the stigma sometimes associated with some other mental health or readjustment care. Because many Veterans prefer to confidentially speak with a fellow Veteran regarding readjustment from military to civilian life following active service in a combat zone; the counseling staff at most VET centers are Veterans themselves.
b. The VET Centers are located within the community, with services tailored to the specific needs of the Veteran population within that community. VET center staff members are always available to welcome Veterans and family members, and to provide useful information about available services. Eligible Veterans have access to a wide range of services. These include professional readjustment counseling for war-related social and psychological readjustment problems, family military related readjustment services, substance abuse screening and referral, military sexual trauma counseling referral, bereavement counseling services, employment services, and multiple community-based support services such as preventative education, outreach, case management, and referral services.
c. To accommodate Veteran’s work schedules, VET centers maintain flexible schedules. VET centers have no waiting list. Veterans may be seen by a counselor the same day they stop by for an initial assessment. They can schedule subsequent appointments at their convenience.
d. VET Center Services include bereavement counseling to surviving parents, spouses, children, and siblings of service members who died while on active duty. Bereavement counseling includes a broad range of transition services including outreach, counseling by volunteers or a chaplain, and referral services for family members. Often counseling is available in the family’s home or where the family feels the most comfortable. There is no cost for VA bereavement counseling in the VET centers.
7. VETERAN SERVICE ORGANIZATIONS (VSO)
a. VSOs differ from VET centers in that VSOs are not part of the VA system. VSOs are located in every community. The larger VSOs have a national office with posts or chapters in communities across the United States. VSOs include, but are not limited to—the Veterans of Foreign Wars (VFW), American Legion, Disabled American Veterans (DAV), American Veterans (Am Vets) and Vietnam Veterans of America (VVA). These service organizations can provide information, support, and volunteers to assist Veterans in accessing benefits. They are non-profit community based organizations devoted to serving the interests of Veterans, usually supported by a Veteran membership base. Some VSOs have a Veteran’s advocate service officer who may legally represent and support Veterans on issues related to their Veteran status, including application for benefits, etc.
a. PTSD is an anxiety disorder that can occur after a traumatic
[LTM5] event, serious or life- threatening situation. Veterans are at higher risk than the general population of developing PTSD by the very nature of military service.4 Specific military situations that may cause PTSD for Veterans are—combat or military exposure; terrorist attacks; sexual, psychological or physical assault in military service; accidents in vehicles, planes, or boats; and participation in disaster relief or stabilization efforts related to hurricanes, tornadoes, floods, or earthquakes. However, not all Veterans have PTSD. (See Chapter 15,
Psychosocial Aspects)
i. Criterion A—stressor.18 The person has been exposed to a traumatic event in which both of the following have been present—the person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others; and the person's response involved intense fear, helplessness, or horror.18
ii. Criterion B—intrusive recollection.18 The traumatic event is persistently re- experienced in at least one of the following ways
1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions
2. Recurrent distressing dreams of the event
[LTM6]
3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes; including those that occur upon awakening or when intoxicated).
4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
5. Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
iii. Criterion C—avoidance/numbing.18 Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least 3 of the following
1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma
2. Efforts to avoid activities, places, or people that arouse recollections of the trauma
3. Inability to recall an important aspect of the trauma
4. Markedly diminished interest or participation in significant activities
5. Feeling of detachment or estrangement from others
6. Restricted range of affect (e.g., unable to have loving feelings)
7. Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
iv. Criterion D—hyper-arousal.18 Persistent symptoms of increasing arousal (not present before the trauma), indicated by at least two of the following
1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Hyper-vigilance
5. Exaggerated startle response
v. Criterion E—duration. Duration of the disturbance (symptoms in B, C, and D) is more than 1 month.
vi. Criterion F—functional significance. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.19
c. Despite its prevalence, PTSD often goes unrecognized and therefore untreated in Veterans. This is common because Veterans find it difficult talking about traumatic experiences. Veterans with PTSD may have experienced a traumatic event in which they witnessed something horrific or caused them to fear for their lives. The result is a feeling of helplessness because they could not change the course of events. It is theorized that strong emotions caused by the event create changes in the brain that may result in PTSD. Many Veterans who experience a traumatic event have some initial anxiety symptoms; yet only some will develop PTSD. The reason for this is not clear. Potential factors affecting whether a Veteran will develop PTSD include
i. The intensity or duration of the trauma, as the more severe trauma, the more likely the development of PTSD
ii. The death or injury of a close comrade or friend
iii. The physical proximity to a traumatic event—PTSD is worse the closer the soldier was to witness the event.
iv. The amount of control the Veteran had over the events—suffering may be worse if they felt they could have done more, or if they felt helpless to do anything.
v. The extent of the support the Veteran received after the event—Veterans of recent wars such as OIF/OEF/OND are benefitting from earlier PTSD screening and early interventions. Veterans from WWII, Korea, and Vietnam did not receive the same PTSD routine screening or intervention following their homecoming.
d. When speaking with a Veteran about PTSD, it is important to consider the era under which they served, because they may use terms other than PTSD. As stated before, PTSD known as “shell shock” in WWI and WWII, and “battle fatigue” in The Korean War.
e. Stigma may exist in the Veteran population regarding mental health services.20 Stoic attitudes are pervasive in the military culture. Many soldiers view seeking help as a sign of weakness. Often, Veterans experiencing PTSD fit the profile of the “difficult” patient; the one who is persistently confused, angry, depressed, abusing alcohol and other drugs, and/or otherwise emotionally dependent and demanding. He/she may have tried to cope alone without seeking treatment. The result is that they have yet to recover from the trauma and are in daily struggle to come to terms with what they witnessed or experienced.
f. PTSD symptoms often start soon after the traumatic event. However just as often, they may be delayed until months or years later. Symptoms may also wax and wane over many years. If the symptoms last longer than 4 weeks, they may cause great distress, or interfere with work or home life, the individual probably has PTSD.4
g. Many soldiers who develop PTSD improve. However, 1 out of 3 continue to experience PTSD symptoms. Treatment can help to prevent symptoms from interfering with everyday activities, work, and relationships. Types of PTSD symptoms may include
i. The presence of repetitive, disturbing memories, nightmares, flashbacks, and/or hallucinations is common. The Veteran may feel the same fear and horror as when the event originally took place. The Veteran may experience a flashback, including nightmares or the re-experience of the event itself. Sometimes a trigger, such as a sound or sight, causes the Veteran to relive the event. An example of such triggers may be the sound of a car backfiring reminding the Veteran of gunfire, or the sound and light of fireworks reminding him/her of a bomb dropping.
ii. Veterans may avoid thoughts, people, places, and activities that resemble the traumatic event. Additionally, Veterans may keep very busy to distract them from thinking or talking about the event. Or they may avoid seeking help so that they do not have to focus on the details of the trauma.
iii. Suppressing trauma related memories and emotions can lead to amnesia for aspects of the trauma or a sense of being emotionally “numb.”21 Even if the Veteran remembers aspects of the trauma, he/she may be unable to talk about them or they may find it difficult to express feelings about it. The Veteran may lack loving feelings toward others and have distress in relationships. Previously enjoyed activities may no longer be of interest.
iv. Symptoms of hyper-arousal, hyper-vigilance, irritability, heightened startle response, insomnia, attention difficulties or anger may be present.7 The feeling of always being on edge, constantly looking out for danger, a sense of being anxious or jitteriness, may manifest as sudden anger or irritation. Hyper-vigilance can amplify pain experiences.
v. Psychosocial issues such as depression, general anxiety, and survivor guilt are often present with PTSD.21 The Veteran may have concomitant substance abuse issues such as alcohol or drug problems. They may express feelings of hopelessness, shame or despair, and may have employment problems.
h. Brief, direct questions about trauma exposure and post-trauma symptoms as part of a routine assessment can quickly identify when traumatic experiences are continuing to have a significant impact on functioning. The following questions can be sure to screen for PTSD
- Have you ever had any experiences that were frightening, horrible, or upsetting in the past?
- Have you had nightmares about the event or thought about it when you did not want to?
- Have you tried hard not to think about it or went out of our way to avoid situations that reminded you of it?
- Are you constantly on guard, watchful, or easily startled?
- Do you feel numb or detached from others, activities, or your surroundings?
If the patient answers “yes” to any two of the above questions, it is a positive screen for PTSD.
i. Survivors of trauma may not complain directly of PTSD symptoms such as re- experiencing the trauma or avoidance of discussing the trauma. Instead, they may complain of sleeping disturbances or insomnia.
j. Questioning the Veteran, as well as his/her family members, co-workers, or friends improves the identification of PTSD. Therefore, the palliative APRN should consider asking specific questions about sleep problems, (e.g., flashbacks, nightmares), hyper-arousal (e.g., an exaggerated startle response or sleep disturbance), agitation, and/or depression and anxiety. In particular, the APRN should assess for signs of suicidal ideation.
k. The hospice/palliative APRN may need assistance in the diagnosis of PTSD. By detecting PTSD, the APRN can refer patients for further evaluation to mental health professional as appropriate. It is assumed that APRNs develop ongoing collaborative relationships with mental health professionals at the local VA clinic or hospital.
l. Treatment of PTSD may include both pharmacological and nonpharmacological modalities. Medications prescribed for PTSD symptoms act upon neurotransmitters related to the fear and anxiety circuitry of the brain including serotonin, norepinephrine, GABA, and dopamine to name a few. Most often, medications do not entirely eliminate the symptoms, but rather provide symptom reduction. As with other psychiatric diagnoses, medications are best used in conjunction with an ongoing program of trauma specific psychotherapy.6
ii. Antidepressants that work through other routes of neurotransmission in altering serotonin neurotransmission are also helpful in PTSD. Mirtazapine may be particularly helpful for treatment of insomnia in PTSD. Trazodone is also commonly used for insomnia in PTSD, even though there is little empirical evidence available for its use. Nefazodone carries a black box warning regarding liver failure, so liver function tests need to be monitored and precautions taken as recommended in the medication’s prescribing information.22
iii. Atypical antipsychotics may also be used in PTSD treatment. While originally developed for patients with a psychotic disorder, this class of medications is being used for patients with myriad psychiatric disorders including PTSD. These medications primarily act on the dopaminergic and serotonergic systems and relieve hyperarousal and re-experiencing symptoms. The evidence for their use as adjunctive therapy in PTSD for patients who have residual symptoms following the use of the first line agent such as SSRIs and venlafaxine is mixed.6 These medications must be used with caution and require monitoring for elevation of blood glucose and cholesterol levels. There is also a small risk of developing extrapyramidal side effects as well as tardive dyskinesia. A rarer side effect is neuroleptic malignant syndrome. Dosages vary widely for olanzapine and risperidone.
iv. There are a number of other medications that can be helpful for specific PTSD symptoms or used as second line agents.
One medication is prazosin for decreasing nightmares, although it has not been found to be effective for other PTSD symptoms at this time.[LTM7] Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) act on a number of neurotransmitters. Again, as second line treatment, TCAs are thought to alleviate intrusive symptoms as well as anxiety and depression.21 However, both have high side effect profiles. The TCAs have cardiac effects such as ventricular arrhythmias, especially in overdose.22 The MAOIs can cause potentially fatal reactions due to hypertensive crisis when taken with other medications or with certain foods rich in tyramine (e.g., aged cheeses, smoked fish, cured
[LTM8]
meats, some types of beer). MAOIs can also provoke the potentially fatal serotonin syndrome when used concurrently with SSRIs.6 While evidence supports their use, their use as second line therapy warrants judicious and attentive monitoring of safety and side effects.
v. Benzodiazepines such as clonazepam, alprazolam, and lorazepam act directly on the GABA system, which produces a calming effect on the nervous system. Studies have not shown them to be useful in
PTSD treatment because they seem to affect core PTSD symptoms.[LTM9] There is also the concerns of the potential addictive and disinhibition symptom necessitating their cautious use in PTSD.6
vi. Because of the delayed onset of effects of SSRIs and TCAs, patients with days or weeks to live may require medications with more rapid action. Short acting
benzodiazepines or neuroleptics [LTM10] may be the most effective relief for Veterans experiencing intense PTSD symptoms at the end of life.21
m. Nonpharmacological treatment of PTSD may include support groups with other Veterans suffering from PTSD, complementary and interventional therapy approaches that facilitate a relaxation response such as mindfulness, yoga, acupuncture, and/or massage, which can be adjunctive treatment of hyperarousal symptoms. Hypnotic techniques can be considered, especially for symptoms such as pain, anxiety, dissociation, and nightmares.6 Group therapy such as PTSD support groups may be very helpful. Veterans considering group therapy should agree to the underlying rationale of trauma work, and the willingness to participate in self-disclosure within the group work.
n. Spiritual support may be desired by the Veteran. The spiritual provider can explore PTSD as well as grief and loss in the areas of physical being, psychological stamina, and loss of future hopes and aspirations.
o. Maintaining an egalitarian stance with all patients is important, but even more so in the Veteran population who may be distrustful of the medical system. A Veteran may be more open to treatment when he/she feels an equal voice in their care. Emphasis should be placed on the Veteran’s control over decisions, allowing options and choices whenever possible.
p. A Veteran’s family should be educated about PTSD symptoms, including potential consequences of exposure to traumatic stress, practical ways of coping with symptoms, and potential treatments. When Veterans and their family members begin to understand that much of the distress and associated problems are connected to the war experiences and posttraumatic stress, there is often more willingness to reach to the many kinds of available help.
9. END-OF-LIFE PAIN AND SYMPTOM MANAGEMENT
a. Veterans experiencing chronic pain, particularly headache disorders and fibromyalgia (FM), associated with psychological traumas need a special management strategy.
i. Obtaining the clinical history of a traumatic event or diagnosing PTSD in chronic pain patients can guide treatment.
ii. Stoicism is valued in the military culture. While on active duty, service personnel may be less likely to report pain because of peer pressure, fear of being medically evaluated, and/or potential separation from fellow soldiers.9 Consequently, it is important to build trust with Veterans. They must be given
reassurance that it is not a sign of weakness to report pain or discomfort or take pain medication. Moreover, pain medication can improve activity and function.
b. Factors can influence how the Veteran experiences the dying process.
i. The threat to life from a terminal illness may mimic the threat to life experienced in military service, leading to significant distress.23 For some Veterans it may seem inconceivable that they survived a war only to die of something else.
ii. The process of life review, common at the end of life, can lead to anxiety, guilt, anger, and sadness. Allowing time and space for life review and facilitating the conversation on their military experience are both very important for all Veterans for closure. Encouraging the family to interact with the Veteran and listen to his/her stories may be helpful and healing.
iii. Avoidance behaviors, which are common in Veterans with PTSD, can manifest as non-adherence. The Veteran may cope by ignoring problems.
iv. Distrust can cause excessive questioning of medical personnel and possible refusal of care. Building trust takes time and dedication.
v. Isolation and avoidance behaviors may lead to broken relationships resulting in a lack of caregivers at the end of life due to the Veteran repeatedly pushing away family and friends.
vi. All of these factors can influence how the Veteran experiences the dying process, sometimes with more agitation and restlessness.
The Life-Sustaining Treatment Decisions Initiative (LSTDI) is a national VHA quality improvement project led by the National Center for Ethics in Health Care (NCEHC), whose aim is to promote personalized, proactive, patient-driven care for Veterans with serious illness by eliciting, documenting, and honoring their values, goals and preferences. Implementation will begin in 2018.This standardizes practices related to discussing and documenting goals of care and life sustaining treatment decisions. It provides the tools, resources, education and monitoring to support clinicians and facilities in making practice changes. (
https://www.ethics.va.gov/LST.asp[LTM11] )
10. CAREGIVERS
a. Caregiver support coordinators at each VA Medical Center are available to assist family caregivers in identifying benefits and series of enrolled Veterans. The Caregiver Support Coordinators are well versed in the VA programs and have information about other local public, private, and non-profit agency support series that are available to support Veterans and their family caregivers at home. There is education and training on the caregiver role including how to best meet the Veteran’s care needs, the importance of self-care when in a care-giving role. Caregivers for Veterans of all eras are eligible for respite care.
b. As of May 2011, wounded Veterans and their caregivers may apply for new benefits under the Caregivers and Veterans Omnibus Health Services Act of 2010.24 The law directs the Department of Veterans Affairs to assist caregivers of Veterans needing ongoing personal care services because of serious injury (including TBI and psychological trauma) incurred in the line of duty on or after September 11, 2001. These benefits include education and training for caregivers, in-home and community-based care, respite care, counseling, health insurance, and a monthly stipend. For a complete explanation of eligibility criteria and benefits, please refer to the VA Medical Center or VA website (www.va.gov). Additional supports for primary family caregivers of eligible post 9/11 Veterans and service members may include a stipend, mental health series, and access to
healthcare insurance, if they are not already entitled to care of services under a healthcare plan.[LTM12]
11. VA BENEFITS
a. A Veteran must be enrolled in the VA to receive healthcare benefits and other Veteran services. Eligibility for most VA benefits depends upon departure from active military, naval, or air service under honorable discharge. In addition, current and former members of the Reserves or National Guard, who were called to active duty by a federal order and completed the full period for which they were called or ordered to active duty, may be eligible for VA health benefits. If the Veteran is not enrolled in the VA, it may be possible to expedite enrollment by working with the nearest VA Medical Center, a county Veterans Service Officer, or a Veterans Service Organization.
b. Some benefits and services require that the Veteran have a service-connected disability, such as an injury or a disabling condition sustained during his/her time in the military. The VA will determine if the disability was incurred or aggravated in the line of active duty. The extent of an injury or disabling condition that has incapacitated a Veteran determines his/her level of service-connected disability. Service-connected disability ranges from 0-100%. A VA benefits specialist rates the Veterans’ percentage of service connection of the condition and reviews a Veteran’s service history to determine eligibility. There are conditions (e.g., amyotrophic lateral sclerosis) that are presumed to be service connected. See Appendix 31-A for the list of Presumptive Disability Benefits for Certain Groups of Veterans. Some, but not all, Veterans that are rated with a service-connected disability may receive a monthly monetary stipend. However, both types of Veterans are eligible for VA healthcare and services. Additionally, the survivors of a service-connected Veteran may be eligible for monetary benefits.
c. To qualify for using the VA system, a Veteran with an honorable discharge from active military, naval, or air under any condition may be eligible for some benefits. Service personnel with a dishonorable or bad conduct discharges issued by a general court martial are disqualified from VA benefits. However, prison inmate or parolee Veterans may be eligible for certain VA benefits. Local VA benefits offices can assist in determining eligibility.
12. THE VA HOSPICE AND PALLIATIVE CARE BENEFIT FOR ENROLLED VETERANS
a. Hospice and palliative care are included in the VA healthcare benefits for all enrolled Veterans. Veterans can receive both VA and community services concurrently. Under the Veterans’ Healthcare Eligibility Reform Act of 1996, the VA determines need and provides or purchases hospice and palliative care services for an enrolled Veteran.25 These can occur in either the home or VA inpatient setting.
b. VA provided hospice and palliative care
i. All VAs have interdisciplinary consult palliative care teams headed by a palliative care coordinator. These teams have been established throughout VA facilities serving both acute settings and outpatient clinics.
ii. Many VA facilities have inpatient hospice and palliative care beds. Inpatient hospice care is provided directly in VA acute care facilities and nursing homes (Community Living Centers [CLCs]). The latter is the preferred option for many Veterans.
b) Target population is all bereaved family members of Veterans who died as inpatients in any VA hospital nationwide.
c. For Veterans needing skilled care, the VA may purchase hospice care through a VA community contracted nursing home or State Veterans Home under some specific conditions.
d. There is collaboration with community hospices for out-of-VA referrals. The VA purchases hospice care from a community hospice provider.
i. This may be purchased from the community hospice provider if the VA physician and patient/family agree care is appropriate.
ii. The VA and the hospice have a written contract agreement
iii. Contracted hospice services mirror the Medicare hospice benefit with its comprehensive, per diem coverage, including home visits by professional and paraprofessional staff, medications, supplies, biological, durable medical equipment, and ancillary services as outlined in the plan of care. If a Veteran needs care unrelated to the terminal diagnosis stated in the admission paperwork, the Veteran is admitted to a VA hospital.
e. All Veterans enrolled in the VA are eligible for hospice care. If an individual is not currently enrolled in the VA, evidence of an honorable discharge and income verification will be needed to enroll. The process to enroll in the VA can be time consuming, so early assessment of enrollment status is essential. The DD214 form, which is used by all branches of service as proof of military service, is necessary for enrollment into the VA. The VA itself does not provide home hospice, but they contract and pay for hospice care to be provided by a community hospice.
f. To better serve the needs of Veterans and to ensure access, care coordination, and continuity of care, it is beneficial for community organizations to continue efforts to collaborate with the Veteran’s preferred VA Medical Center Palliative Care Consult team, social workers, and community health nurse coordinator.
13. TRICARE
a. TRICARE is a regionally managed healthcare program for the active duty and retired members of the uniformed services, their families, and survivors.
b. A military retiree or the spouse of a Veteran who was killed in action will always be a TRICARE beneficiary.
c. Veterans eligible for TRICARE can obtain care from military hospitals and clinics. Military hospitals and clinics are not the same as the VA system as military facilities are located on or near military installations.
d. It is important to note that TRICARE is not available to all Veterans—only Veterans who qualify based on service.
e. The TRICARE hospice benefit is very similar to most insurance coverage for hospice care.
14. BURIAL AND MEMORIAL BENEFITS
a. Veterans discharged from active duty under conditions other than dishonorable and service members who die while on active duty, or active or inactive training duty, as well as spouses and dependent children of Veterans may be eligible for VA burial and memorial benefits. It is recommended Veterans be asked in particular about their preferences regarding military honors at burial.
b. The Burial and Memorial Benefit is a guaranteed right to all Veterans who served honorably. Most funeral directors are aware of Veteran benefits.
c. Burial and Memorial benefits include the following
i. If a burial with full military honors is desired, it can be requested by the Veteran at no charge.
ii. A plot internment allowance and a small burial benefit may be available to some Veterans.
iii. The VA will provide a headstone marker with the branch of service and rank noted if desired. The spouse’s name can also be added to the headstone.
iv. Veterans may be buried in a Veteran’s cemetery, and if desired the spouse can be buried in the Veteran’s plot. There may be rules and regulations about cremated remains of a spouse of a retired service member being buried with the Veteran.
v. Veterans may elect to have a burial at sea. This can be arranged through the United States Navy Mortuary Affairs, the various branches of military, or the Maritime Funeral Directors. The rules vary for each of these organizations.
vi. A burial flag is provided along with a presidential memorial certificate signed by the current president of the United States.
15. CONCLUSION
a. The unique needs of Veterans and their families can best be met by providing a family and patient centered care approach to health and end-of-life care.
b. The palliative APRN should promote identification of a Veteran patient for military service.
c. With evaluation of the medical history of the Veteran, including the impact of the Veteran’s military service on how they view their disease, the APRN may understand how the military service affects the dying process of the Veteran. This can facilitate optimal care, with referral to and access of appropriate VA Services and Benefits.
d. The APRN can relieve suffering and promote healing with treatment of potential PTSD, and support for family.
e. Finally, by their presence and sensitivity to subsequent effects of military service, the APRN can promote respect for Veterans in honoring and acknowledging their service.
Appendix 31-A: “Presumptive” Disability Benefits for Certain Groups of Veterans26
What is “Presumptive” Service Connection?
VA presumes that specific disabilities diagnosed in certain Veterans were caused by their military service. VA does this because of the unique circumstances of their military service. If one of these conditions is diagnosed in a Veteran in one of these groups, VA presumes that the circumstances of his/her service caused the condition, and disability compensation can be awarded. For more information call 1-800-827-1000 or go t
o www.VA.gov.
What Conditions are “Presumed” to be caused by Military Service?
Veterans in the groups identified on the next page—Entitlement to disability compensation may be presumed under the circumstances described and for the conditions listed.
Veterans within one year of release from active duty—Veterans diagnosed with chronic diseases (such as arthritis, diabetes, or hypertension) are encouraged to apply for disability compensation.
Veterans with continuous service of 90 days or more—Veterans diagnosed with amyotrophic lateral sclerosis (ALS)/Lou Gehrig's disease at any time after discharge or release from qualifying active service is sufficient to establish service connection for the disease, if the Veteran had active, continuous service of 90 days or more.
Former Prisoners of War | Vietnam Veterans (Exposed to Agent Orange) | Atomic Veterans (Exposed to Ionizing Radiation) | Gulf War Veterans (Undiagnosed Illness) |
(1) Imprisoned for any length of time, and disability at least 10 percent disabling • Psychosis • Any of the anxiety states • Dysthymic disorder • Organic residuals of frostbite • Posttraumatic osteoarthritis • Heart disease or hypertensive vascular disease and their complications • Stroke and its residuals (2) Imprisoned for at least 30 days, and disability at least 10 percent disabling • Avitaminosis • Beriberi • Chronic dysentery • Helminthiasis • Malnutrition (including optic atrophy) • Pellagra • Any other nutritional deficiency • Irritable bowel syndrome • Peptic ulcer disease • Peripheral neuropathy • Cirrhosis of the liver | Served in the Republic of Vietnam between 1/9/62 and 5/7/75 • Acute and subacute peripheral neuropathy* • AL amyloidosis • B-cell leukemias • Chloracne or other acneform disease similar to chloracne* • Chronic lymphocytic leukemia • Diabetes type 2 • Hodgkin's disease • Ischemic heart disease • Multiple myeloma • Non-Hodgkin’s lymphoma • Parkinson's disease • Porphyria cutanea tarda* • Prostate cancer • Respiratory cancers (lung, bronchus, larynx, trachea) • Soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma or mesothelioma) *Must become manifest to a degree of 10 percent or more within a year after the last date on which the Veteran was exposed to an herbicide agent during active military, naval, or air service. | Participated in atmospheric nuclear testing; occupied or was a POW in Hiroshima or Nagasaki; service before 2/1/92 at a diffusion plant in Paducah, KY, Portsmouth, OH, or Oak Ridge, TN; or service before 1/1/74 at Amchitka Island, AK • All forms of leukemia (except for chronic lymphocytic leukemia) • Cancer of the thyroid, breast, pharynx, esophagus, stomach, small intestine, pancreas, bile ducts, gall bladder, salivary gland, urinary tract (kidneys, renal pelves, ureters, urinary bladder and urethra), brain, bone, lung, colon, ovary • Bronchiolo-alveolar carcinoma • Multiple myeloma • Lymphomas (other than Hodgkin’s disease) • Primary liver cancer (except if cirrhosis or hepatitis b is indicated) | Served in the Southwest Asia Theater of Operations during the Gulf War with condition at least 10 percent disabling by 12/31/11. Included are medically unexplained chronic multi-symptom illnesses defined by a cluster of signs or symptoms that have existed for six months or more, such as • Chronic fatigue syndrome • Fibromyalgia • Irritable bowel syndrome • Any diagnosed or undiagnosed illness that the Secretary of Veterans Affairs determines warrants a presumption of service connection Signs or symptoms of an undiagnosed illness include fatigue, skin symptoms, headaches, muscle pain, joint pain, neurological symptoms, respiratory symptoms, sleep disturbance, GI symptoms, cardiovascular symptoms, weight loss, menstrual disorders. |
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ADDITIONAL RESOURCES
Freeman SL, Berger AM. Nebraska Veteran’s preferences for end-of-life care. Clinical J Oncol Nurs.
2009;13(4):399-403.
Grassman DL. Peace at Last: Stories of Hope and Healing for Veterans and their Families. St. Petersburg, FL: Vandamere Press; 2009.
MacLean A, Edwards R. The pervasive role of rank in the health of U.S. Veterans. Armed Forces Soc.
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Pols H, Oak S. War and military mental health: the US psychiatric response in the 20th century. Am J Public Health. 2007;97(12):2132-2142.
Many community hospice providers have implemented an innovative model for serving Veterans at the end of life - the Veteran-to-Veteran (Vet-to-Vet) Volunteer Program. The Vet-to-Vet Volunteer Program aims to pair recruited Veteran Volunteers with hospice patients who have been identified as Veterans. Once paired with hospice patients who also have military experience, Veteran Volunteers have the unique ability to relate and connect with Veteran patients and their families. Establishing a Veteran-to-Veteran Volunteer Program is also a criterion for hospices accomplishing We Honor Veterans (WHV) Partner
Level Three. Veteran volunteers will benefit from education, training and additional support when caring for other Veterans at end of life. Volunteer opportunities are often a path to healing not only for the Veteran and family but also the Volunteer. 29.
a)
(https://www.publichealth.va.gov/exposures/agent orange)
[LTM2]Can you elaborate further?
[LTM3]Please edit/update this, was their goal accomplished?
[LTM5]Are there any other symptom management unique to the veteran patient? What about neuropathic pain s/t amputation?
[LTM6]Please put this in table format
Please include screening tools and how frequently this should be assessed
[LTM7]I believe this was disproven in an article published this year: Raskind MA, Peskind ER, Chow B, et al. Trial of prazosin for post-traumatic stress disorder in military veterans.
N Engl J Med. 2018 Feb 8;378(6).
doi: 10.1056/NEJMoa1507598.
[LTM8]Can this be put into a table with dosing recs?
[LTM10]Include drug name and dosing recs
[LTM13]Why is this red? Please fix spacing