What Palliative Care Teams Need to Know When Caring for a Veteran

When I see patients at the Atlanta VA Medical Center, I know they’re veterans who have served our country in uniform. I have some context for the experiences that may have affected their physical and mental health. And as part of the VA health care system, our hospital accounts for their particular needs.

But veterans’ needs are not often front-and-center in the “civilian” health care system, though they make up more than 6% of the nation’s population. Clinicians outside of the VA are not trained to work specifically with this patient population, nor is the system set up to cover the costs of their care and address their specific needs, including mental health concerns.

If you’re a member of a palliative care team in a civilian setting, you will likely have the opportunity to care for a veteran. It’s important to consider how to truly address their unique needs. Start by screening for veteran status, which is as simple as asking a new patient if they have a history of military service. (It may not be part of your organization’s initial assessment.)

Below, I share some key considerations for caring for veterans and ways to address them.

Any time you interact with a veteran, there’s a good chance that they have experienced symptoms of PTSD—or may be experiencing them in the present. According to the National Center for PTSD, the number of veterans with PTSD varies by service era. Experts estimate that as many as 30% of Vietnam-era veterans have experienced PTSD in their lifetimes. Twelve percent of Gulf War veterans experience PTSD in a given year, and 11 to 20% of veterans of Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) experience PTSD in this timeframe.

That said, it is a good idea to refresh your knowledge about PTSD. This includes reviewing the specific criteria for PTSD in the DSM-5 and learning more about symptoms and manifestations. You can also watch for common symptoms as you observe the patient. To open the door to a conversation, you can address:

Ask how they’re sleeping. Are they having any vivid nightmares—and how often? Some people experience flashbacks when they’re sleeping, so you might try asking about that, too.

Do they feel agitated or irritated frequently? Despondent or hopeless? Do they have regular negative thoughts or a lack of interest in their favorite activities? Veterans tell me that sometimes the smallest things will set them off. That can be rooted in PTSD, too.

Some veterans may not mind discussing their military service, but others may react very strongly to questions. This could be an indicator that they experienced or witnessed trauma.

It is also important to note many safety challenges that confront all adults—including veterans—as they age. This includes being at a greater risk for falling, so it is important to ensure their home is safe. This is a great opportunity for the team to talk with patients about potential tripping hazards (e.g., rugs). As the National Institute on Aging notes, some of the biggest potential hazards for older adults in the home include:

• Cluttered walkways
• Throw rugs and small area rugs
• Slippery floors
• Dim lighting
• Electrical cords
• Stairs without secure handrails on both sides

Other safety issues that you could raise for discussion with your veteran patients and their families include driving, dementia, and gun safety.

Research has shown that motor vehicle collisions are a leading cause of accidental death among military veterans. Per a 2019 study, there is additional concern that PTSD and mental health difficulties may increase a veteran’s risk of driving-related impairment. Additionally, your patient may have suffered recent injuries or illnesses that might not make it safe for them to drive—temporarily or permanently. These factors all make driving safety a very important topic to bring up.

People who experience PTSD are significantly more likely to develop dementia later in life. As a result, veterans are more likely than non-veterans to be diagnosed with dementia. As clinicians, we must be aware of this increased risk and watch for signs of potential cognitive impairment. If you notice any signs—or the patient’s caregivers mention any loss of memory or direction—you may want to suggest further evaluation.

According to the VA, firearm injuries are responsible for almost 7 out of 10 veteran deaths by suicide. If your patient has experienced injury or illness that has affected their physical or cognitive function (including dementia), unrestricted firearms access is a safety concern. It would then be time to talk about gun safety (e.g., secure storage).

Everyone should know about veterans’ payment rights for medical care. Most importantly, if a veteran receives care from or is admitted to your non-VA hospital or facility, the VA will still cover their expenses. But, very importantly, the VA will only cover the expenses if someone from the facility notifies the VA that a veteran is receiving care at a non-VA hospital—within 72 hours of the start of care. If that window is missed, the VA does not have to foot the bill; it would then be left to the patient. (There are specific steps clinicians need to follow, as outlined in this fact sheet.)

Does your hospital or team have a designated staff member who can notify the VA that a veteran is receiving care at your facility? My advice is to figure this out. If not, consult with your team to make sure that someone—perhaps the social worker or case manager—takes on that task so that your patient doesn’t receive a bill they weren’t expecting (and might not be able to afford). And don’t assume that the patient or their family will do this.

Another issue to consider is that your patient might not know what the VA covers. For example, the VA will pay for certain types of care, depending on the veteran’s service connection—that is, how their health is specifically affected by their military service. It will also pay for other types of care (e.g., home health care services for all veterans). While you don’t have to understand the specific details, it’s never a bad idea to make sure your patient understands their coverage.

You may become more attuned to the nuances as you become better acquainted with veteran-related issues. You or your colleagues may want to consider reaching out to your local VA with further questions about the best ways to care for a veteran, resources, and more.

Edited by Melissa Baron. Clinical review by Andrew Esch, MD, MBA.