Hospice Care for Veterans

Continuing Education—August 2011

Hospice Care for Veterans

(material adapted from For further information, please visit their website.)

It is estimated that today 1 in 4 dying Americans is a Veteran. It is likely, therefore, that someday you may work with a Veteran and his or her family. If you are not a Veteran yourself or if your military service was at a different time than your patient’s, you may appreciate some information and resources to help you personalize your care of the patient and family. Your patient may or may not be interested in talking with you about serving in the military, but if you see medals or photographs that indicate military service, you might initiate conversation with questions such as: When and where did you serve? What did you do while in the service? How has military service affected you? Sometimes experiences that were unspeakable for decades need an airing in the days and weeks near death. Your willingness to listen compassionately and non-judgmentally would be a remarkable gift. This article includes some background on the health (physical and psychological) concerns affecting many of our Veterans.

Unique Health Issues for Veterans

WWII: WWII Veterans today are all over 80 years old and subject to all the diseases of aging: cardiovascular diseases, cancer, dementias, etc. However, in the early 1940s, they were among the nation's fittest and participated in modern warfare that coincided with major advances in modern medicine.The U.S. entered the war in December 1941 following the attack on Pearl Harbor. Before it was over, Americans had fought on the continents of Europe, Asia, and Africa and in the Atlantic and Pacific Oceans. At various times, their service was carried out under severe winter conditions, in the harshest of deserts, and in the hottest, most humid tropical climes. Those who joined up or were drafted were in the military for the duration, however long that might be.

WW II Veterans also were the first to serve in the nuclear age and American POWs were employed in the clean-up of Hiroshima and Nagasaki, thus becoming the first "atomic vets." Over 350,000 women served with a peak strength of 271,000 representing 2% of the personnel in uniform (compared to c. 15% now in the military). Women, mostly nurses, were taken prisoners of war by the Japanese when Bataan and Corregidor fell and were interned in the Philippines for four years.

Besides infectious diseases and wounds, other health risks of WWII included:

Frostbite / Cold Injury

Cold injuries may result in long-term health problems, including the following (at the site of exposure):

• Changes in muscle, skin, nails, ligaments and bones
• Skin cancer in frostbite scars
• Neurologic injury (bouts of pain in the extremities, hot or cold tingling sensations, and numbness, etc.)
• Vascular injury with Reynaud’s phenomenon ( extremities becoming painful and white or discolored when cold)

Exposure to Nuclear Weapons
WWII Veterans may have participated in atmospheric nuclear weapons tests, which were conducted primarily in Nevada and the Pacific Ocean between 1945 and 1962.

Mustard Gas Testing

In the 1940s, the Department of Defense recruited "volunteer soldier" subjects for experiments using mustard agents to evaluate clothing, ointments and equipment to protect American troops from mustard agent attacks.

• Nearly 60,000 military personnel were involved in a wide range of exposures, most of them participating in mild exposures (a drop of agent on the arm in “patch” tests).
• Approximately 4,000 soldiers were subjected to severe, full-body exposures carried out in gas chamber trials or as a part of field exercises over contaminated ground.

Nuclear Cleanup
Veterans who were involved in the occupation of Hiroshima and Nagasaki between August 6, 1945, and July 1, 1946, and Veterans who were prisoners of war in Japan during World War II may have participated in nuclear cleanup.

Korea: The Korean War is often called the “Forgotten War” because it was largely overshadowed by WWII and Vietnam. The importance of this war in the history of the United States and the world is vastly understated; this conflict marked the first clear battle of the Cold War. Tensions were already high between the Communist East and the Democratic West, and the Korean War certainly exacerbated the mistrust between the two sides. While this war is often forgotten, it is important that the Veterans who fought in this conflict are not also forgotten.

Cold injuries including frostbite and immersion (trench) foot constituted a major medical problem for U.S. service personnel during the Korean War. Veterans of the Battle of the Chosin Reservoir suffered especially high rates of severe cold injuries. Cold accounted for 16% of Army non-battle injuries requiring admission and over 5000 U.S. casualties of cold injury required evacuation from Korea during the winter of 1950-1951. In many instances U.S. service members did not seek or were unable to obtain medical care caused by cold injuries because of battlefield conditions.

Exposure to nuclear weapons
Korean War Veterans may have participated in atmospheric nuclear weapons tests which were conducted primarily in Nevada and the Pacific Ocean between 1945 and 1962.

Vietnam: The Vietnam War was the longest (to that point) and most unpopular war in which Americans ever fought. The first combat troops arrived in 1965 and fought the war until the cease-fire of January 1973. For many of the American Veterans of the war, the wounds of Vietnam will never heal.Approximately 2,700,000 American men and women served in Vietnam and it was the first war in which the US failed to meet its objectives. It was also the first time America failed to welcome its Veterans back as heroes. Many Veterans were attacked personally by their fellow countrymen who opposed the war. This situation magnified the stress associated with their combat experiences.

Also contributing to the stress many Veterans experienced was the lack of unit cohesiveness because many were sent to Vietnam as individuals and left when their year's tour was completed. They often traveled to and from Vietnam by air, being an active combatant one day and a Veteran returning to a hostile civilian environment the next. They reported being spat upon as they disembarked at the airport and being uncomfortable wearing their uniform in public. Following the war, Veterans experienced many readjustment problems and adverse health effects, many of the latter attributed to Agent Orange.

Environmental Hazards

In addition to the risks inherent to combat, troops experience many environmental hazards. Pesticide and herbicide spraying was commonplace. In addition, Vietnam is a tropical country with high temperatures, high humidity and a monsoon climate. Approximately 20 million gallons of herbicides were used in Vietnam between 1962 and 1971 to remove unwanted plant life and leaves which otherwise provided cover for enemy forces.

Infections and Diseases
Many troops were unable to get dry for days, opportunities for bathing were infrequent, and skin hygiene was poor. Bacterial and fungal infections of the feet were a major cause of temporary disability. Skin disease was a leading cause of outpatient visits and hospitalization.

Tropical diseases were frequent. Malaria was the most important. Over 40,000 cases of Malaria were reported in Army troops alone between 1965 and 1970 with 78 deaths.

Throughout the war, disease accounted for 70.6% of all admissions with the remaining approximately equally divided between battle casualties (15.6%) and non-battle injury (13.8%). Increased survival rates were attributed to rapid evacuation, the ready availability of whole blood and well-established semi-permanent hospitals.

Agent Orange

The name “Agent Orange” came from the orange stripe on the 55-gallon drums in which the herbicide was stored. Shortly following their military service in Vietnam, some Veterans reported a variety of health problems and concerns which some of them attributed to exposure to Agent Orange or other herbicides. The VA now recognizes eight conditions which are presumed to be related to service in Vietnam: soft tissue sarcoma, non-Hodgkins lymphoma, Hodgkin's disease, chloracne, porphyriacutaneatarda, respiratory cancers, multiple myeloma, prostate cancer, acute periperal neuropathy, and spina bifida in offspring.

Hepatitis C Virus (HCV)

Hepatitis C Virus is the most common infection carried by blood in the United States and 63% of enrolled Veterans testing positive for HCV are Vietnam Era Veterans. HCV infection is a major public health problem in the United States (U.S.) because of its potential to lead to cirrhosis, hepatocellular carcinoma, and other life-threatening conditions.

Post Traumatic Stress Disorder (PTSD)
Deployment places Veterans at increased risk for symptoms of psychiatric illnesses, particularly post traumatic stress disorder (PTSD), anxiety, depression and substance abuse.

Additional Resources:

Post Traumatic Stress Disorder:

Depression:

Spiritual Support:

Grief:

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