1. Our Veterans: Spiritual Issues at the End of life
Healthcare Chaplaincy Network
New Orleans, April 23, 2018
Penny V. Phillips, MA, MDiv, BCC
Palo Alto VA Hospice & Palliative Care Center
x65746

2. From Thich Nhat Hanh: Veterans are the light at the tip of the candle, illuminating the way for the whole nation. If Veterans can achieve awareness, transformation, understanding, and peace, they can share with the rest of society the realities of war. And they can teach us how to make peace with ourselves and each other, so we never have to use violence to resolve a conflict again.

3. Objectives Identify three distinct US Military cultures
List 4 categories of Spiritual distress for Veterans
Define and contrast Post Traumatic Stress
and Moral Injury

4. Military Culture
Military service is an acquired cultural experience that continues long after discharge.
The cultural context of Veterans can have positive and negative impacts on their end-of-life care. It can be a source of strength and a source of conflict.
‘Culture’ refers to integrated patterns of human behavior that include the language, thoughts, communication, actions, customs, beliefs, values and institutions of racial, ethnic, religious or social groups.
Most new recruits are young, fresh out of high school
Some search for adventure
Better economic circumstances
Search for community
Some to escape difficult circumstances

5. Basic Training Turns soldiers into squads
Discipline, Privilege, duty, connectedness
Initiation into warrior class
Unique language, ‘battle mind’ training
One for all/all for one
Buddies = family/community
Stoicism promoted; ‘no pain, no gain’
Admitting fear, pain seen as sign of weakness

6. Veterans’ Unique Characteristics
>>Combat or non-combat experience
>>War or era they served
>>POW’s
>>PTSD [Note: Most soldiers are able to integrate the experience into their lives as naturally resilient people. VA is studying this group in depth.]
>>Branch of service and their rank; Special Forces (ie., Green Berets, Navy Seals
>>Enlisted or drafted
>>Family history of serving in military; current geographical (rural vs. urban)
Resiliency handout

7. Culture Comments
Each era of service has its own unique culture which can influence the outcome of a soldier’s experience. WW2 Vets are more likely to have had areas of ‘safe haven’ than VN Vets who were often in immediate and constant physical danger. This resulted in a higher incidence of stress-related disorder. Korean Vets were often told not to discuss their military service and are sometimes overlooked in the discussion regarding the needs of Vets. A significant number of Korean Vets were POWs held by the Chinese, and subjected to torture and other mistreatment. So asking and understanding the military history of Vets is important

8. World War II Almost all WW2 Vets >80 years of age
Many died or were wounded
Pride in American victory over fascism
No TV coverage so public shielded from brutality
Entire country supported war; came home as heroes; definite end to the war; “glories” of war
Segregation
Many have injuries from combat or environmental exposure --Radiation, mustard gas

9. Cold War 1950’s Arms race Every VA has a registry physician for
Radiation exposure to above ground nuclear testing
Anger/mistrust of gov’t, including VA
Every VA has a registry physician for
Agent Orange, Gulf War Syndrome, and
Ionizing radiation

10. Korean Conflict Unfamiliar to most Americans, never declared a war
No clear victory
Some feel service unappreciated; Korean trauma largely forgotten
Environmental exposure
Injuries from extreme heat and cold
Cold sensitivity
Vets may minimize experiences
Many relive experiences

11. Viet Nam War….. Source of much angst for USA
Extensive television coverage; war was “in our living rooms”
Draft forced many into war they opposed
Soldiers required to on only one-year tours
Controversial
Distrust of political leadership
First guerilla war
Had to separate combatants and civilians, soldiers could never let guard down
Hard to have sense of completion,
sense of accomplishment

12. …Viet Nam Great physical, emotional, existential trauma
Severely wounded more likely to survive
Reintegration difficult
Alcohol/substance abuse
Many mental health issues, PTSD
Agent Orange
Hepatitis C
Traumatic Brain Injury, Polytrauma Injuries

13. Gulf War (early 1990’s) Many exposed to environmental toxins
burning oil fields
Depleted uranium, etc.
Multiple vaccinations
Gulf War Syndrome
Memory loss
Fibromyalgia symptoms
Two conditions correlate with service
ALS
Respiratory problems
Asthma, exposure to high levels of smoke
Young age means few need palliative care now
Will change as population/Veterans get older!
[8,000 people turning 65 EVERY DAY.]

14. OEF/OIF/OND
Early evidence suggests psychological toll will be worse than physical toll
Prolonged exposure to combat stress over multiple rotations
Several (inside and outside VA) groups already reviewing care
Increasing incidence of suicide/attempts, SI
Depression
PTSD
Traumatic Brain Injury
Operation Enduring Freedom Operation Iraqi fredoom Operation New Dawn

15. Culture Clashes
Veterans generational cultural clashes have occurred and will continue to occur due to the very nature of military service at this time in history. Some WW2 Vets have a difficult time comprehending the Vietnam experience. Some saw these soldiers as ‘wimps’ who lost the war. The Veterans of Foreign Wars use to not allow Korean or Vietnam Veterans to join because neither of those wars were officially declared ‘war’. This is no longer the case.
Despite best efforts, clashes will occur. The key is to continue attempts to understand each perspective and take time to understand your own reactions. Failure to take the culture seriously means we choose to place our own values over those of differing backgrounds. Stereotyping, disregarding personal rights, etc, are examples of not respecting another’s culture.
Not all Veterans get along together. Know your own reactions to various Veteran cultures.

16. Women Veterans 10% of all Veterans 15% of all active duty military
18% of all National Guard and REserve
240,000 sought care at VA facilities (2006)
6% of Department of Veterans Affairs (VA) health care users.
Top three diagnoses: Post Traumatic Stress
Hypertension
Depression
Higher rate of minority women serving in the military than minority men
Handouts

17. What do you think might be spiritual issues that a Veteran deals with or will deal with?

18. Categories of Spiritual Distress
Spiritual Pain
Why is this happening to me?
What does all of this mean?
God doesn’t seem to be listening.
Spiritual Alienation
God just seems so far away.
Where is God when I need Him most?
I don’t need any help from God, I can it myself!
Spiritual Anxiety
I think God is punishing me. Why else would I have this cancer?
I’ve been so far from God; I don’t think he’s going to help me now.
I’m afraid of dying.
Spiritual Guilt – Moral Injury Moral Distress, Soul Injury
I don’t think God is very pleased with me. I haven’t exactly led a ‘good’ life.
I should have lived my life better.
Spiritual Anger
I want nothing to do with God. He has nothing to offer.
If God is good and loving, why is he allowing this to happen?
Spiritual Loss
I don’t think God loves me .
I don’t feel God’s love anymore.
Spiritual Despair/Hopelessness
What hope do I have? God doesn’t care.
I stopped praying. God is not listening.
Experience of hope! Changing nature of hope. Moral distress (often for caring staff) Handout
Soul Injury handout

19. Moral Injury
“Moral injury is present when (1) there has been a betrayal of what is morally correct; (2) by someone who holds legitimate authority; and (3) in a high-stakes situation.” (Shay, 2013)
“Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” (Litz et al., 2009)
“the key precondition of moral injury is an act of transgression, which shatters moral and ethical expectations that are rooted in religious or spiritual beliefs, or other culture-based organizational, and group based rules about fairness, the value of life, and so forth.” (Maguen, 2011)
Moral Injury is disruption in an individual’s confidence and expectations about her or her own moral behavior or others’ capacity to behave in a just and ethical manner.

20. Post Traumatic Stress History of exposure to a traumatic event that meets two criteria: 1. 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 2. Response involved intense fear, helplessness or horror. AND Symptoms from each of these symptom clusters >> intrusive recollections >> avoidant/numbing symptoms hyper-arousal symptoms DSM IV criteria PTS disrupts relationship to world when it becomes unreliable.

21. What is the #1 question
from Vets in hospice at the end of life?
What are other questions from
Vets in hospice at the end of life?

22. Special challenges (with possible spiritual connections) serving Vets and their families:
PTSD, TBI, Polytrauma injuries
Military sexual trauma
Agent Orange (making claim)
Grief at all levels and stages
Guilt; Moral Injury
Distance from/in church after serving (people change but sometimes churches cannot change)
Financial distress; family dynamics
Loneliness and isolation
PTS not inevitable. Moral Killing new term to deal with Vet issues about actually killing people when their faith has always said that killing is wrong.

23. Do Vets have different end-of-life spiritual issues?
Yes and No. Some issues may be more intense– others just the same as they have always been. Just because you are dying does not mean the all of a sudden you will talk about your military expeirence.

24. Interventions for all Vets
Create safety to build trust, rapport, relationship.
Thank Vet for his/her service! This may invite dialogue (or not). Some are quite shy about it; others will stand up taller and prouder. Many are still healing from their experience, regardless of how long ago their service was.
Affirm the difficult feelings aspect of your dialogue.
Remember that stoicism might interfere with acknowledging emotional or spiritual or physical pain. Some Vets have varied drug use history.
Go slow, and listen for what is not being said.
Get to know your local VA Hospital, and local VA programs. [CBOCs, Vet Centers]
On line resources for Veteran programs and assistance.
Some say combat Vets only share with other combat Vets. Not true. Thanks Veteran but don’t expect any big return.

25. Invitation Invitation to do a self-assessment:
How do your own values/beliefs influence your attitudes toward WW2 Vets vs. Iraq/Afghanistan Vets?
We must become aware of our own cultural beliefs and attitudes in order to be culturally competent for our Veterans.
Seek to understand; never assume.

26. A few resources….
Chang, et al. “Spiritual Needs and Spiritual Care for Veterans at End of Life”. American Journal of Hospice & Palliative Medicine. 29 (8)
Deborah Grassman. Peace at last: Stories of Hope and Healing for Veterans and their Families , Vandamere Press.
Sebastian Junger. Tribe: On Homecoming and Belonging , 4th Estate, London.
Joshua Phillips. None of Us Were Like This Before: American Soldiers and Torture. 2010, Verso Press, London.
Justine Sharrock. Torture: When Good Soldiers do Bad Things. 2010, Wiley & Sons, Inc., New Jersey.
Resource handout.

27. President Obama, Veterans Day, 2016 “Whenever the world makes you cynical, whenever you doubt that courage and goodness and selflessness is possible, then stop and look to a Veteran. On Veterans Day, we acknowledge humbly that we can never serve our Veterans in quite the same way that they served us, but we can try. We can practice kindness, we can pay it forward, we can volunteer, we can respect one another, we can always get each other’s backs.”
Thank you!!