Starting last year, more military veterans are passing away in hospice care than in all of VA trauma and ICU wards combined.
That's because the millions of Americans who served in Korea and World War II are reaching their 80s and 90s; Vietnam veterans are reaching their 70s. That means the U.S. Department of Veterans Affairs is focusing on how to make veterans comfortable in their final weeks and months.
"I think they call it end of life care. But whatever it is ... they treat you like gold," says 68-year-old Thomas O'Neil, a resident at St. Alban's VA in Queens, New York. "If you're going to be sick, this is the place to be."
O'Neil did a year in Vietnam, from 1966 to 1967, at a time when the war was killing more Americans in a year than the total casualties from Iraq and Afghanistan combined.
"The only good thing was the night time, because you knew another day closer to coming home," he says. "To be honest with you, I was a scared, I was very scared the whole year. And I don't think I was the only one."
When he came home he didn't talk to anyone about the war. O'Neil says he nearly drank himself into the grave. In 2011, he finally came to the VA to treat the PTSD he'd been enduring for 40 years. Last year he learned he has terminal cancer.
"They can tell you you got three months. They don't really know," he says. "I came to terms with this. I'm not happy with the diagnosis, but I came to terms with it."
Coming to terms with the end of life can be a bit different for veterans, says Dr. Alice Beal, who directs VA palliative care for most of New York City.
"If a veteran's been in combat, a veteran's likely to have killed," Beal says. "I think no matter what your culture is, when you meet your maker, even if it's been to save your buddy, to save your life to save your country, it's just a burden the rest of us haven't even thought of."
Sometimes that means vets want to tell their stories at the end of life, Beal says. Sometimes the stories come unbidden.
"If you've had blood on your hands it comes up," she says. "People who have PTSD, maybe have not had it unmasked their whole life, but as they're dying, all of a suddenly they get flashbacks."
Beal says the goal in hospice is to make life as good as it can be for as long as possible; that usually means focusing on relieving pain for the last weeks or months of life.
The hospice ward is a contradiction: it's brightly decorated, at the entrance there's a fish tank and an electric fire place. But there's usually a room recently vacated, with an American flag draped on the bed and a lantern on the night stand honoring a veteran who passed on.
"It's a real toss-up between respect and release. Around here we tend to be full of life," Beal says. "But you don't want to be too joy full in the presence of a family who is grieving."
All VA facilities now have a palliative care team, but only a fraction of veterans enter VA hospice, according to Scott Shreve, who directs VA hospice care nationwide.
Shreve says the vast majority prefer to stay in their communities near family instead. The VA and the National Hospice and Palliative Care Organization are collaborating on a project called We Honor Veterans, to help civilian hospice workers ask the right questions.
"Are you a vet? How did that military service impact your life and how can we help with some difficult and intrusive memories as you come to the end of your life?" Shreve says.
Volunteers with We Honor Veterans sometimes show up to find an elderly veteran who hasn't mentioned much about serving in the military to their family or community, like 92-year-old Florence Keliher, in Hallowell, Maine.
"I served during World War II in the Army Nurse Corps. I was on Tinian, the little island in the South Pacific," Keliher says. "We had a ward full of patients; airplane crashes and things like that. They flew from Tinian to Japan to bomb. Some had trouble taking off sometimes."
Keliher's son, Pat, who lives up the road, says he never heard much about his mother's time at war until a grandchild asked to type up some of Keliher's stories:
"The patients we nursed in the wards on afternoon duty broke our hearts. It sounds like a cliché, but they were so young. Malaria, horrible burns ... I was only 23 years old, but I felt much older than the patients I tended, some of whom called for their mothers in their distress."
Besides her kids and grandchildren nearby, Keliher gets regular visits from a volunteer with Beacon Hospice, part of the We Honor Veterans campaign. They play cribbage and swap stories.
Scott Shreve from the VA says only half the community hospices nationwide are taking advantage of the free We Honor Veterans program. He'd like to see that number increase, because the VA estimates half a million vets will be needing end of life care each year through 2020.
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