Veterans at the End of Life: An Essential Salute

Veterans Day: "Some gave all, all gave some."

Source

In the United States, Veterans Day is a federal holiday, observed annually on November 11th. Not to be confused with Memorial Day (remembrance of fallen soldiers,) this is an occasion to recognize the service of men and women who have served in the armed forces. Their service was in a wide variety of capacities, in locations near and far. Some soldiers never used a weapon after basic training, and some rarely put theirs down.

War has shaken the world and mankind, innumerable times, so it is no surprise that Veterans Day coincides with other nations' Armistice Day and Remembrance Day, as well as being the anniversary of the end of World War I. And I use the word SHAKEN, deliberately.

I will never forget my vigiling experiences at the deathbeds of some veterans, who shake in their final hours. Agitation is a common occurrence in the labor of dying; Barbara Karnes, RN notes that "restlessness can be from a lack of oxygen but more than likely it is fear."  Support is frequently dispensed with medication, comfort care and calming words. But when a dying veteran experiences agitation, we can and should offer specialized support.

Scott Field, IL circa.1942. Library of Congress

Discharged from duty

 This summer, along with other hospice volunteers, I attended the Hospice Foundation of America video program, "Improving Care for Veterans Facing Illness and Death." It is important to recognize that not all veterans carry "emotional baggage" or bear a stoic, "battle ready" sensibility. Your patient or loved one's branch of service, rank, and job(s) may or may not impact their unconscious mind. One of the program panelists, Deborah Grassman, ARNP, shared great insights from her career as a hospice nurse at the Department of Veterans Affairs. I encourage readers to follow this link to Grassman's excellent essay, Wounded Warriors: Their Last Battle. She includes a long list of questions suited to end of life counseling when it seems necessary to discharge the veteran from the troubling demons of unfinished duty or guilt. But Grassman cautions professionals and companions:

"don't keep pushing; plant a seed."

"Golden Wings" by Suzy St. John

 Bedside basics

Some of the best bedside skills during an end of life vigil revolve around silence--though soothing or "favorite" music is appropriate at times; calmness in the room and gentle touch also promote a peaceful death. But when the person you are companioning is struggling with agitation (symptoms may include shaking, thrashing, groans or other distressed vocalizations,) beneficial intervention can go beyond medical options.

• If your loved one is conscious, gently ask him or her to share a thought or feeling. 
• Showing one or two service-era photos can prompt expression.
• Symbols touch and access our deepest selves; this is true even when dementia is present. Expressing gratitude and recognition of service through the use of ceremony and symbol is significant. 
• A hospice or veterans organization may be able to conduct a brief Honors presentation "on behalf of a grateful nation." But don't hesitate to step up with your own veteran tribute:  say a few words, play a patriotic or branch-of-service song, and attach a flag pin to their shirt. 
• Often, as death nears (this could be days, hours or minutes) the person is unconscious or 'nonresponsive' (despite movement or talking) and yet, these bedside basics can have a profound impact. I would encourage the Honors tribute even at this stage because the sense of hearing is still active.
• One of the most powerful interventions for agitation, advocated by Deborah Grassman, is the Hand-Heart-Connection: 
• Put your hand on the person's chest,
• take their hand and hold it on your chest, 
• breathe calmly and deeply.

"We are called to be strong companions and clear mirrors to one another, to seek those who reflect with compassion and a keen eye how we are doing, whether we seem centered or off course ... we need the nourishing company of others to create the circle needed for growth, freedom and healing."

- Wayne Muller

Thank you for caring!
Read more about my vigiling experience in Silent Night Holy Night: Sacred Dying is another reason to write condolence

Climbing Out of Deep Space: through and beyond grief

My friend, artist Suzy St. John recently posted some new images on her blog. The group is titled:

Throwback to High School Ceramics:  Pinch Pot Figures

Suzy shared her thoughts about them:

"The pinch pot was and still is my favorite work of art. I was a high school student and it came from those angst ridden feelings most teenagers experience. I still relate to that piece!"

Each pot creates a very deep well of space. 

Is it a place to hide and feel safe? Is it a dark place--where you may feel lost? I think that space (like silence) is something that many in western culture are uncomfortable with. Like the figures, we are more at ease outside, surrounded by active people, stuff, sounds, structures. did you notice my use of the term 'active people'?  I recently wrote about our culture's unease with people during their grief and re-adjustment. In Stop Pushing the Bereaved, I suggested that after a death, taking a break from life's typical vibrancy is a sane response to a sudden deep well of space. 

Caregiving during a loved one's end of life "fills the pot" of each day. 

When caregiving ends, the tasks that fill the pot abate. But you are different. You do not bounce back like a rubber band released. Honoring the changes is an important step. 

The Compassionate Friends, an international support network for parents who have lost a child, share a message with newly bereaved moms and dads. Finding The New Me, explains that grief is work that takes time. It is not a straight line on a map. 

"You will learn coping skills from other bereaved parents who, like you, never thought they'd survive." 

Coping skills develop over time.

Learning what feels okay, how to manage when it doesn't feel okay, and how to tackle a new (scary) experience, involve trial and error, courage and cowering, agony and the flutter of recognition that you managed to do something you had dreaded. In this last pinch pot image, Suzy's figures are experimenting:

• Will my grip on this edge hold?
• Can I lift my leg that high?
• Do I have the strength to support my partner?
• Is it okay to enjoy this moment?

Pinch Pot Figures by Suzy St. John
Used with permission

Do you know someone climbing out of deep space? 

The Condolence Coach suggests the following ideas to encourage or assist them:

• Be lavish with confidence boosters. Whenever an opportunity arises, offer positive reinforcement. It doesn't have to be a big deal, but spot something and express: 
• You do that so well... 
• You were so patient when... 
• Would you show me how to... 
• You have a remarkable... 
• Thanks for telling me about... 
• Turn off your urge to criticize or advise. Even if your friend describes stresses or struggles, you are most valuable as a listener, acknowledging the matter with simple phrases: 
• What a bummer... 
• That stuff is confusing... 
• You'll find a way... 
• That's not easy to talk about, thank you for trusting me... 
• Would a hug help? 
• Keep talking about the deceased loved one. Freely bring up stories, anecdotes, admiring comments. You are not causing pain! The loved one will always live in the heart and memory. 
• Give your friend the gift of judgement-free time. 
• Take time off for yourself, too. 
• Let intuition guide you on when to be present and encouraging. Remember, your friend's grief work and healing are not your "mission". It's not "all up to you."

For some fresh reflections and insights on grief and time, read:

"You Didn't Waste Any Time" and other reactions

Thank you for caring!