1. Conard, Patricia L. PhD, RN
  2. Keller, Michael J. PhD, RN, FACHE
  3. Armstrong, Myrna L. EdD, RN, ANEF, FAAN


More than 600,000 U.S. Veterans die from illness each year. Clinicians in civilian settings are increasingly providing care to Veterans at end of life. Veteran care should be distinctive and individualized to meet their unique needs. There is limited information to guide civilian clinicians in providing care to Veterans at end of life. This article provides bio-psycho-social information to holistically guide Veteran healthcare and assist them with solace, respect, and serenity at end of life. Various options for end-of-life care are discussed, as well as specific concerns of women, lesbian, gay, bisexual, and transgender Veterans. Some end-of-life entitlements for all Veterans and sometimes their spouses/children are included.


Article Content

"End-of-life care is a choice, and not every Veteran chooses it . . . [but] by tailoring end-of-life care to what is appropriate for Veterans, we're better serving those who do. . . our goal is to help them be all that they can be until the moment they pass away." Dr. James Hallenbeck, Associate Chief of Staff for Extended Care, VA Palo Alto HCS, as cited in Doyle, 2018.

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There are 18 million U.S. Veterans and more than 600,000 die from illness each year (Plys et al., 2020). This figure does not include deaths by suicide. These Veteran deaths are mainly men (98%), over 60 years of age (88%), with less than 7% dying in Veteran Health Administration (VHA) facilities. There is limited information about end-of-life (EOL) care for Veterans in civilian healthcare systems (Chargualaf et al., 2021). With growing access by Veterans to community-based healthcare afforded by the 2018 Veteran's Administration MISSION Act legislation, civilian clinicians will be increasingly called upon to address and manage Veteran care at EOL (Chargualaf et al., 2021; Varilek & Isaacson, 2021). The purpose of this article is to provide bio-psycho-social information to civilian clinicians so they can assist Veterans in non-VHA settings find solace, respect, and serenity at EOL. Specific EOL-focused care for women and lesbian, gay, bisexual, and transgender (LGBT) Veterans and those affected by homelessness and rurality is also included. Lastly, we list some Veterans Administration benefits accorded to all Veterans (and sometimes family) upon death.


Military Veterans

About 1 in 8 adult men and 1 in 100 adult women have served in the U.S. military; their ages range from 18 to over 100 years (Vespa, 2020). They have served in wartime and peace and include over 10 million noncombat Veterans who admirably served and supported those in combat (Conard et al., 2021). Veteran demographics are unique in gender (84% male) and age, with currently almost half (45%) of all male Veterans being over the age of 65 (Way et al., 2019).


Veterans are Distinctive

Individual military service experiences influence beliefs and behavior. The environment is atypical, hierarchical, and filled with masculine traits of "powerfulness, toughness, self-reliance, restricted emotionality, and aggression" (Plys et al., 2020, p. 120). Military ethos of honor, sacrifice, and camaraderie have been instilled in this culture, as well as stoicism and strong self-control, especially in those deployed to combat zones. With many harrowing experiences during their service time, Veterans have likely thought through and/or faced the pain and suffering of encountering death. Almost half of those in combat (48%) are estimated to have experienced near-death encounters (Goza et al., 2014), so it is not surprising that most Veterans find comfort with "highly ceremonial rituals. . . burials, and commemorations" surrounding a comrade's death (Petrova et al., 2021, p. 86).


Individual differences among Veterans may vary by service experiences and whether in wartime or peacetime. A high percentage of those who served during the Vietnam, Korean, or World War II eras (median ages 71-93) were drafted for mandatory duty (Vespa, 2020). This created different circumstances, experiences, and stress depending on which specific wartime era they served, the nation's response to that conflict, and later the health, financial, and educational benefits they received from the Department of Veteran Affairs (Keller et al., 2021).


In 1974, the United States began an all-volunteer system for entry into the military. The Veterans of the Afghanistan and Iraq wars (2001-2021, median age 45 years) represent some of the youngest (Keller et al., 2021). This cohort is more likely to have histories of early childhood/adolescent trauma leading to intensified behavioral health issues as Veterans (Calkins, 2018). In addition, physical and behavioral health injuries sustained in the Afghanistan and Iraq wars were as horrific as in other wars; however, the survival rates were greater due to faster evacuation from the battlefield and advanced medical care. The medical recovery successes have led to an increased number of Veterans (38.8%) exhibiting severe physical and behavioral service-connected disabilities. Subsequently, compared with prior-era wars, these Veterans have more decades of life and care before them, with many being seriously ill and often needing earlier EOL services (Vespa, 2020).


Need for Identification

Excluding the COVID-19 pandemic, one of every four American deaths is a Veteran, and identifying Veteran status in the civilian healthcare sector is imperative (U.S. Veterans Administration, 2019). Unless the question, "Have you ever served in the military?" is asked, their status may remain unknown (Way et al., 2019, p. 712). Clinicians should ask every patient about military service, then proceed respectfully to ask if additional information about their service experience would help providers to better understand their current health status and needs (Miller et al., 2017; U.S. Department of Veteran Affairs, 2019b). The VHA Military Health History card is a valuable tool for clinicians in gathering information and is available at Awareness and recognition of Veteran status can lead to meaningful communication, which can build trust, confidence, and adaptation during EOL.


Physical and Behavioral Health Issues

Physical Health

Military encounters and exposures such as burn pits, herbicides, radiation, chemicals, and even contaminated drinking water are known to have affected Veteran health (Conard et al., 2021). Subsequently, type 2 diabetes, heart disease, Parkinson's disease, amyotrophic lateral sclerosis, chronic obstructive pulmonary disease, and cancers could have been identified as service-related illnesses (McVeigh et al., 2019; Way et al., 2019).


Posttraumatic Stress Disorder

The actual diagnosis of posttraumatic stress disorder (PTSD) was not confirmed until 1980, and the criteria and conditions continue to be debated (Palmer et al., 2019). Before that, it was called with different names such as shell shock, and Veterans received little or no acknowledgment. Frequently, the treatment was a prompt return to duty (Palmer et al., 2019). Later, even as these Veterans led functional lives, the presence of this service-associated behavioral health issue can intensify with increasing worries about advanced age, along with physical, neurocognitive (Alzheimer's or dementia) disease, and social changes (Doyle, 2018). One of the most common examples of PTSD intensification during EOL is when the Veteran experiences nightmares/flashbacks, hyperarousal, emotional numbing, and social avoidance (Antoni et al., 2012; Elliott, 2017; Prince-Paul et al., 2016).


Veterans of recent conflicts have a PTSD diagnosis rate of >20%, even with better preventive education and treatment (Hoyt & Holtz, 2020). As Veterans with PTSD may experience poor sleep, irritability, hypervigilance, and dissociation during EOL, the use of Later-Adulthood Trauma Reengagement might be implemented. This therapy is an intervention designed to acknowledge wartime memories that had been inadequately recognized over the years and hopefully produce some relief from what they have historically experienced (Novotney, 2020).


Moral Injury

Veterans with moral injury are consumed with shame and guilt resulting from incidents that violated their ethical/core values and principles (Way et al., 2019). With unresolved self-forgiveness, perhaps for not effectively helping, or leaving their fellow comrade behind (survivor's guilt), Veterans with moral injury symptomology can experience health problems, decreased psychosocial functioning, and significant distress near EOL (Elliott, 2017; Prince-Paul et al., 2016). These factors can lead to anxiety, limited social relationships, and increased barriers to effective symptom control after start of EOL care (Shamas & Gillespie-Heyman, 2018).



The literature does not specify a direct relationship between suicide and EOL, although when associated factors are reviewed for suicide (insomnia, depression, anxiety, sexual victimization, gun ownership, substance use disorders, coping with aging, and lingering effects from their military service), there is substantial reason to continue Veteran suicide risk assessments during EOL (Novotney, 2020). This appears to have a specific application for untreated behavioral health issues in older male Veterans (Plys et al., 2020). Veterans who have had a near-death experience can encounter more of these events, feel increasingly isolated, and become uncomfortable sharing these memories. Suicide can become an outlet for their stress (Personal Communication Dr. D. Corcoran [COL Ret.], April 20, 2021). Inquire about firearm availability and safe storage/restriction. Almost 70% of Veterans use guns as a lethal means of suicide, compared with 50% of the general population (Hoyt & Holtz, 2020).


Veteran EOL Delivery Care Options

Numerous studies have documented a higher quality of life, complemented by a greater longevity when Veterans receive EOL care (Haverhals et al., 2019; Institute of Medicine, 2015). According to Varilek and Isaacson (2021), the greatest satisfaction with EOL care occurs when admission to hospice is started 1 to 3 months before projected death. Relevant information about EOL can affect the planning of appropriate care, anticipating and documenting the individual's wishes, improving communication between patients and health providers, and promoting shared decision-making. Depending on eligibility, Veterans could have different options for EOL care.


Veteran Health Administration (VHA) System Supported EOL

VHA EOL care is provided for almost 10 million enrolled beneficiaries at $50 billion per year through interdisciplinary consultation teams in 140 VHA facilities and their affiliated outpatient clinics (Doyle, 2018; Way et al., 2019). To qualify for EOL care within the VHA, the Veteran must be enrolled in the VHA healthcare system through either a service-connected disability or by meeting financial eligibility. Those with Medicare coverage can obtain information from the VHA about the differences in coverage and care. Veterans and their family can discuss the feasibility of EOL services, whether in the home, nursing home, VHA or private sector hospice (Antoni et al., 2012). Table 1 provides a summation of requirements, services, and financial support for EOL care that can be provided by either the VHA or the private sector under Medicare (Doyle, 2018).

Table 1 - Click to enlarge in new windowTable 1. Comparison of Medicare and VHA Services

Although there are several distinct differences, Veterans may continue to receive curative, concurrent treatments (palliative care), including radiation and chemotherapy with the VHA option (Haverhals et al., 2019). Ideally, palliative care is decided by the Veteran at a time when death is not projected for at least 6 months. This palliative EOL approach is currently not reimbursed by Medicare and most state Medicaid programs, but it is incorporated in the VHA to entice Veterans to enroll earlier in EOL care rather than closer to the time of death (Miller et al., 2017).


Veteran EOL Care with Other Hospice Services

For Medicare EOL eligibility, a terminal illness, certification, and a life expectancy of 6 months or less is needed. Hospice care coverage can continue after 6 months for two 90-day periods, or an unlimited number of 60-day periods provided the hospice provider recertifies that the patient is terminally ill (, n.d.). If the Veteran does not meet the qualifications for VHA enrollment or is ineligible for Medicare, any other health insurance plans should be reviewed for EOL services so a timely referral can be completed.


Veteran End-of-Life Care Considerations for Clinical Practice

Many Veterans do not identify their "core identity" as being from their military experiences, although it is often described as being influential (Prince-Paul et al., 2016, p. 222). Thus, the essence of Veteran EOL care should be whatever is needed to help adapt to EOL. Knowledge of military experiences such as the era of service, degree of military enculturation, responsibilities/occupation, exposure to toxins or events, service injuries, and any other subsequent medical conditions is important (Chargualaf et al., 2021; Petrova et al., 2021). Pain, coping, and family roles are other major concerns that should be assessed.


Pain Management

Pain response may present in an expressive way, whereas others may be stoic, withdraw and/or show little expression related to pain (Elliott, 2017). Awareness of the individual pain response is important, especially in the context of the military values of stoicism associated with service-related injuries (Antoni et al., 2012). Some research suggests Veteran, especially those who are older, may refuse assistance and/or medical care (Plys et al., 2020).



Veterans' thoughts about illness, death, anxiety, and problem solving can vary. In one EOL study of older male Veterans, humor ranked high as a coping mechanism, especially when they could share stories with other same-era Veterans (Plys et al., 2020). When healthcare providers deliver the truth to Veterans about their illness and prognosis, they feel valued and often start coping with the situation, just as they did in combat (Butler et al., 2015). Assessing Veterans' understanding of their illness is valuable as sometimes denial of their situation might be related to health literacy (Plys et al., 2020). Other military-associated factors that could adversely impact timely and proper EOL care include:


* Difficulty accepting EOL care as their military enculturation emphasized putting up a strong fight against any serious health issues. Veterans might consider EOL as giving in to their last battle for life (McVeigh et al., 2019),


* Finding out their illness is connected to their military service creating a "myriad of emotions - anger, sadness, regret, or difficulty processing the diagnosis and its implication" (Shamas & Gillespie-Heyman, 2018, p. 790),


* Experiencing a range of challenging emotions related to current events (bombings or end of a war) reminding the Veteran of military or homecoming events (U.S. Veterans Administration, 2019).



Family Roles

Proactively include family members so they can help navigate and support their Veteran (Butler et al., 2015). Be aware of fluctuating family relationships that could include limited support and decreased interactions because of various moves, deployments, injuries, occupational responsibilities, and civilian reintegration (Elliott, 2017; Plys et al., 2020). Other factors could include:


* Exhibiting "poor relationships, mistrust of providers, avoidant communication styles, and non-help-seeking behaviors because they .... they don't need anyone's assistance" (Plys et al., 2020, p. 121),


* Presenting with underlying psychosocial family issues, including premilitary adverse childhood/adolescent concerns, leading to strained relationships, dysfunctional situations, and/or divorces within Veteran's families and/or instead to "families of choice" (a composite of other Veterans and/or causal friends; Way et al., 2019).



Veteran Subgroups

Women Veterans

Currently, over two million women Veterans have served the United States (Varilek & Isaacson, 2021). The military women of the Vietnam, Korea, and World War II eras were trailblazers who received little or no recognition for their value and service, especially with military benefits (Koblinsky et al., 2017). If they experienced military sexual trauma (MST), it was not acknowledged, nor was there accessibility to VHA care until after 1988. These women Veterans (age 55-64+) are now coming forward for healthcare (Koblinsky et al., 2017). Military women of the later war eras are now serving the nation with their highest enrollment: Active Duty (>16%), Reserves (23.7%), and National Guard (14%). They are younger (90% are younger than 65 years) and more diverse (Gaffey et al., 2021; U.S. Department of Veteran Affairs, 2019a).


EOL care for female Veterans may be similar to males or may be gender-specific. Specialized conditions include cardiac valvular disease, asthma, sarcoidosis, multiple sclerosis, dementia, and specific breast and thyroid cancers (Varilek & Isaacson, 2021). In most key behavioral health concerns, women Veterans do not differ from their male counterparts. The one exception is that 40% of women Veterans experience MST (Burkhart & Hogan, 2015), compared with less than 2% of male Veterans. Women Veterans who experienced MST are up to nine times more likely to have more intense PTSD symptomatology than their unaffected male counterparts (Way et al., 2019). Some women Veterans with MST describe their service time as menial and humiliating (Burkhart & Hogan, 2015). At EOL, MST survivors may suffer alone-feeling ashamed, disconnected, and unable to talk with anyone about their experience. It is encouraging and comforting for them to feel heard, validated, and supported (Koblinsky et al., 2017). Peer assistance from female Veterans' groups could promote meaningful discussions surrounding sensitive issues without fear that others would misjudge them.


Being in a male-dominated environment (sometimes a ratio of 15 men to 1 woman) during military service could create other issues at EOL (Burkhart & Hogan, 2015). Some women have remorse, wondering if they had done their best and may feel their military service went unnoticed and unvalued. Other women Veterans who felt the need to prove themselves during deployment now wonder if they are worthy to receive Veteran-acknowledged care, or if they should give up their EOL care to someone more deserving (Koblinsky et al., 2017). Although anger helped them cope with military stress and defend themselves in the masculine warrior culture, anger could produce barriers to a peaceful EOL (Burkhart & Hogan, 2015).


Varilek and Isaacson (2021) reported a lack of research exploring women Veterans and EOL experiences. Women Veterans of color cited increased stress from their documented difficulty receiving treatment, disability ratings, and benefits for their behavioral health issues (Redd et al., 2020). Another recent cohort study examining Black women Veterans and cardiovascular disease noted increased depression, raising the possibility of intensity and incidence of health risks during EOL (Gaffey et al., 2021).


LGBT Veterans

Although there is sparse specific demographic information about LGBT Veterans, their national prevalence estimates are approximately one million (Disabled American Veterans, 2020). LGBT Veterans served admirably (86% Honorable Discharge), even though they were exposed to increased harassment and frequently changing military entry and retention policies (Keller et al., 2021). Regarding healthcare (military or civilian), LGBT encounters with the gendered health system and their mistreatment, stigmatization, discrimination, and victimization have left multiple invisible scars (Stein et al., 2020). Therefore, their Veteran identification, and secondly their LGBT status, becomes something they often guard until they feel comfortable and accepted by health providers (Keller et al., 2021).


Address individualized sexual orientation and gender identity concerns with sensitivity, compassion, and empathy (Keller et al., 2021). Unique issues include properly identified medical records, accessible advance care planning, acknowledgment of their families of choice, pertinent support systems, and attentive selection of military burial/headstone identification (Stein et al., 2020).


Rurality and Veterans Who are Homeless

Economics and residence often affect the accessibility of Veteran healthcare. Veterans comprise 38% to 49% of the population of people experiencing homelessness and at least 30% are African American (Hutt et al., 2018). Without stable housing, Veterans rapidly age, appearing older by 10 to 20 years and dying earlier at 34 to 47 years of age (Hutt et al., 2018). The three million Veterans living in rural areas are often older and have more difficulty accessing necessary care services (We Honor Veterans, 2021b). Care for both rural and Veterans experiencing homelessness will be complex so advocacy and sensitivity for individualized and humanistic care planning will be essential at EOL (Keller et al., 2021).


Educational Resources

Familiarity with the variety of newly published educational resources available for civilian clinicians who deliver Veteran EOL care is important (Chargualaf et al., 2021). Applicable Veteran care competencies, assessments, and interventions related to Veteran care are discussed in the following references and can greatly improve EOL care and family support (Champlin & Linck, 2021; Elliott, 2017; Shamas & Gillespie-Heyman, 2018). Integrated within these care competencies are VHA resources and benefits, including information about the Hospice-Veteran partnership toolkit (Prince-Paul et al., 2016). Other specific Veteran EOL educational collaboratives include:


We Honor Veterans. This program is a partnership between the VHA and the National Hospice and Palliative Care Organization to address the unique needs of Veterans and guide them to a peaceful EOL ending through respectful inquiry, compassionate listening, and grateful acknowledgment (We Honor Veterans, 2021a).


End of Life Nursing Education Consortium. This consortium is a collaborative effort between the City of Hope and the American Association of Colleges of Nursing (AACN) to provide student and health provider training on palliative care (AACN, 2020). A specific course for Veteran EOL care has been designed to meet their unique needs.


Entitlements for U.S. Veterans upon EOL

All Veterans are eligible for a variety of services for their military time. Table 2 provides a list of some available EOL and death benefits for Veterans, and sometimes these services extend to their family and caregivers. Burial entitlements provided by the Department of Veteran Affairs are not affected by the cause of death and may extend to spouses and dependent children. When the cause of death has resulted from a service-connected disability, the surviving spouse may continue to receive a portion of the Veteran's disability entitlement and other VHA benefits (Way et al., 2019).

Table 2 - Click to enlarge in new windowTable 2. End of Life Benefits All Military Veterans Qualified to Receive From the Department of Veterans Affairs (VA)


Civilian health providers are increasingly caring for Veterans at EOL. It is important that civilian clinicians be familiar with clinically appropriate, comprehensive, and individualized EOL care to properly serve the unique needs of Veterans. LGBT Veterans and women Veterans have additional service-related experiences that should be considered with sensitivity, compassion, and empathy at EOL. Educational resources are available such as We Honor Veterans and End of Life Nursing Education Consortium, as well as professional publications. EOL entitlements for all Veterans (and some spouses/children) upon death were described.




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