THE UNDEFEATABLE FOE:VETERANS FACING THE END OF LIFE

In 2009, veterans comprised approx. 25 percent of U.S. deaths

that year. Veterans: An Underserved Population, Deborah

Grassman, ARNP

Veteran Population in MichiganAs of 9/30/2013

Wartime Vets 483,963Peacetime Vets 176,810Female Vets 50,121Male Vets 610,652WWII 39,574Korean Conflict 72,421Viet Nam Era 247,859Gulf War 134,004Total 660,773U.S. Dept. Veteran Affairs NCVAS

Two major potential Psychosocial problems can develop for Vets in a

Hospice setting :

1. Difficulty accepting the terminal prognosis, possibly resulting in Clinical Depression.

2. Triggering of invasive and emotionally painful traumatic memories.

Conscious Mind

Subconscious

Mind

Defense Mechanisms protect usfrom unacceptable information

about ourselves and our world. Our

reactions canBe intense and the defenses

difficult topenetrate, especially when our

indoctrinationto a specific perception of reality has been intense and our belief

complete.

Two Essential Types of Defense

Mechanisms:Repression [Unconscious]Suppression [Conscious]Forms of Denial:Reaction Formation RationalizationProjection

Recognize the Power of Military Indoctrination:Tearing down individualism in boot camp.Build up with “Group Mind”.Stoicism is valued: prevents defeat and surrender.Death is the ultimate enemy; live to fight again.Death is a sacrifice made for a greater good.“It is a good day to die!” (Controlled sacrifice)Your body is your best weapon.

An emotional state will cause one’s consciousness to bridge back to other times

when a similaremotional state was being experienced.

These memories, or fragments of them, will then be pulled in to consciousness and must then be re-integrated back in to one’s core narrative. This is as true in grief as it is in

the experiencing of any trauma and is known as the “affective bridge”.

ExperientialElements (how the

event sounded, smelled, looked)

The meaning assigned to the memory

Emotions connected to the memory

How a Healthy Memory is Encoded and Stored

ExperientialElements (how the

event sounded, smelled, looked)

The meaning assigned to the memory

Emotions connected to the memory

Conscious Mind

Trauma Trigger

Unconscious

Mind

Unconscious Mind

Frequent Causes of Depression and Increased Suicide Risk

in Vets Facing Death• When they prepare themselves for it, it

doesn’t come fast enough. (lack of control)

• Feeling betrayed by their bodies for housing “the enemy”.

• The inability to re-define the meaning of death (not “surrender”, not weakness, not defeat or failure, not sacrifice for a greater good; just the end of life.)

• Wanting the unrelenting guilt and pain of unresolved traumatic memory to end.

*Please recognize Depression is a form of pain that may be treated. It is not an inevitable by-product of dying.

So how do you help your patient re-integrate their military experiences without ripping apart theirdefense mechanisms and re-traumatizing them?

How to Assist:Take a Military History:Begin with the straight-forward questions.However, keep in mind that you’ll only glean fullyconscious and well-rehearsed material with this method..

Augment the Military History with the opportunity for them to tell you stories that may lie at the edge of conscious memory by using generally themed pictures. This will access memories of importance to the individual in accordance with their readiness to remember specific details of their experiences. It helps to let them choose which images they wish to tell you about.Be careful to select images that are not overly graphicor violent.