As Vietnam Veterans Age, Hospices Aim to Meet Their Needs

When Timothy Hellrung was told he had aggressive cancer this past June and had only days or weeks to live, he knew where he wanted to die.

Mr. Hellrung, a 73-year-old veteran of the Vietnam War disabled by Agent Orange, spent his last 10 days in hospice care at the community living center of the V.A. Ann Arbor Healthcare System in Michigan. The staff provided him with a roomy suite. A social worker wheeled in a bed for his wife of 44 years, Brenda, and gave her pajamas so she could be comfortable spending every night with him.

“The V.A. became family to us,” Ms. Hellrung said. On his first day in hospice, a roomful of veterans honored Mr. Hellrung by placing a pin on his clothing with the American flag and the words “thank you for your service.”

When her husband was nearing the end and put his hand in hers, Ms. Hellrung said, “I sensed he was in complete peace. I don’t think he would have been if he had not been in the place where he wanted to be: At the V.A.”

Mr. Hellrung is one of the roughly 28,000 veterans who spent their final days this year in a V.A. hospice care program that provides a unique way of honoring their dignity at the end of their lives. The Department of Veterans Affairs’ hospice program for this population is designed to specifically address the complexities they face as memories of the traumas of war surface — in many cases, for the first time.

Each veteran receives care from a multidisciplinary team, including social workers, physicians, nurses and spiritual leaders addressing not only physical but emotional, social and spiritual needs. Veterans tend to be more chronically ill compared to the general population, with high rates of disability, intricate psychiatric issues, post-traumatic stress disorder and depression.

“When you have complex needs, you really need the whole team,” said Dr. Robert Hogikyan, medical director of the community living center that cared for Mr. Hellrung.

The wave of veterans entering hospice care now includes many Vietnam veterans whose experience of these issues is particularly profound, according to a findings of a pilot program underway by We Honor Vets — a joint initiative of the National Hospice and Palliative Care Organization and the V.A.

Unlike their predecessors from World War II who were welcomed home as heroes, Vietnam veterans “were often spit on in the streets,” said Dr. Scott Shreve, national director of palliative and hospice care for the V.A. Edo Banach, president and chief executive of the National Hospice and Palliative Care Organization, said this led many of them to disassociate from the V.A., wary of receiving help from the government.

A decade from now, there will be an estimated 500,000 vets dying each year, with an increasing percentage of them Vietnam veterans, Dr. Shreve said. “It’s a whole new framework for us in hospice care to be prepared for, and that’s what we’re trying to do.”

As the V.A. has come under fire for perilously long wait times to see a provider, it is holding up the hospice program as a point of pride: The department’s policy requires that hospice services be provided without delay to enrolled veterans who seek them.

“V.A. senior leadership has made it clear there is to be no wait list for these services,” Dr. Shreve said.

[Read more about the efforts to expand veterans’ health care under the Mission Act.]

As of June of this year, 63 percent of patients in V.A. medical centers chose hospice care, nearly twice as many as a decade ago. Yet experts say it is still underused.

Hospice care is available to everyone under Medicare with a life expectancy of six months or less. But for veterans to receive the services through the V.A., they have to register, something only a third of the 22 million veterans in the United States have done. Dr. Shreve encourages vets to register early to avoid any delays when they are in need of hospice care. The V.A. hospice care program is offered at 170 V.A. hospitals, and the agency has more than 1,000 outpatient facilities that can make referrals, connecting veterans with other hospice providers. Veterans may be eligible for a broad array of benefits that Medicare doesn’t offer, such as compensation for burial costs and a survivors’ pension.

Mr. Banach said obstacles to using hospice services include a general lack of awareness and the stoicism of some veterans. “There’s a misconception about hospice that it means giving up,” he said. And this is a population that has found it difficult to ask for help. The V.A. hospice program aims to normalize the process and renew the vets’ faith in the system. In addition to care providers, there are veterans who volunteer to discuss shared experiences and “act as a gateway to accepting more help from more people,” Mr. Banach said.

At Vitas Healthcare based in Miami, Nancy Auster is a registered nurse who started her career serving in the Air Force 38 years ago. She serves as a liaison between vets and the V.A. who has helped veterans with challenges like retrieving lost medals. After telling a Vietnam veteran with no family, “Sir, we want to welcome you home,” she recalls he replied in a faint voice, “I’ve waited 48 years to hear this.”

Deborah Grassman, who has cared for 10,000 dying vets as a hospice nurse practitioner at the V.A. for 30 years and now runs Opus Peace, a nonprofit that provides educational materials for health care providers, originated the pinning ceremony that Mr. Hellrung experienced. She says, “honoring vets isn’t enough” and that hospice workers are trained to deal with the guilt and shame that many vets live with if they have killed people. “We help them unburden themselves and their family members,” creating “a safe emotional space where that stoic wall can come down and the pain can come forth.”

Courtney Butler, assistant vice president of hospice at Amedisys, a Baton Rouge-based company that is one of the nation’s largest hospice providers, said it takes a special set of communication skills to work with the many vets who have P.T.S.D. “You need to be careful in how you approach them so you don’t startle them. You shouldn’t stand over them to intimidate them.”

Since veterans often have fractured family situations, with few or any loved ones present at the end of their lives, hospice care can help them feel less lonely, said Dr. Sanjay Saint, chief of medicine for the V.A. Ann Arbor Healthcare System, where Mr. Hellrung was treated. He said that about 70 percent of his typical hospital patients had visitors, but only 10 percent of those at the V.A. did. “That’s another reason hospice care can be so comforting,” he said.

He recalled one veteran who was acutely ill but wanted to leave the hospital because he had no one to care for his dog. “That dog was his source of love,” Dr. Saint said. One of the staff members helped him contact a neighbor to feed the dog.

Ms. Hellrung continues to marvel at the way the V.A. hospice staff honored her husband after his service in an unpopular war. After his death on June 26, Mr. Hellrung was transported to the morgue in a coffin draped with the American flag. Everyone in the hallway saluted as “Taps” was played. “I knew my Timothy would have loved that,” Ms. Hellrung said. “He was a military man.”

How to Get Help

Make sure the patient has a DD214 Military Separation Paper, which documents service in the military. This can be requested through the National Archives Service Records Request website.

The Veterans Affairs site can help vets determine their eligibility and apply for health care.

We Honor Veterans assesses qualifications of participating hospice care facilities based on levels of care from one to five; each level indicates a degree of education and training of staff.

Many organizations offer guidance on choosing a hospice provider, such as this work sheet from the National Hospice and Palliative Care Organization.

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