For 25 years, Deborah L. Grassman has been caring for veterans at Bay Pines VA Medical Center in St. Petersburg. As director of the hospice and palliative care program, she has come to know veterans from both world wars, Korea and Vietnam, as well as those who have served in other dangerous duty assignments and during peacetime. Over the years, the nurse practitioner realized that her hospice patients faced struggles unlike others at the end of life. She has shared what she has learned in a new book, Peace at Last: Stories of Hope and Healing for Veterans and Their Families.
While the spotlight is on the veterans, the book also offers personal glimpses at the author's willingness to grieve loss — and celebrate life — with veterans and their families. Grassman, who recently shared the story of her own mother's death with Perspective readers, spoke with Times health and medicine editor Charlotte Sutton:
What makes veterans' end-of-life experiences different from anybody else's? What makes them similar?
In our culture, many of us are imbued with a "pull yourself up by your own bootstraps'' mentality. But with our military, on top of that they really get this value of stoicism that is indoctrinated in all their training, and necessarily so. You need stoicism on a battlefield. But sometimes when these very stoic veterans are dying, they underreport their physical pain and their emotional pain. They've got to keep this facade on to be a good soldier. Now the facade is interfering with their having a peaceful death and getting their needs met. That's rather pervasive with all military, no matter when they served.
We live at a time when veterans are celebrated, unlike during the Vietnam era. So what do you mean when you write "we need to do more than just remember our veterans; we need to re-member veterans into society.''
Thank God that our current soldiers don't have to go through what our Vietnam vets went through. I can't help but wonder what our Vietnam vets' experience would have been if they'd had more bumper stickers welcoming them home.
At the same time, just saying "Thank you for serving; welcome home'' isn't enough. Just as they needed six weeks of basic training so they could become soldiers, it's important also to have some way to re-member them as civilians when the war is over and when soldiers are discharged from service. I think the military is heading in that direction. If more had been done then for soldiers, I'd be seeing less of what I see as they die.
You write about several veterans who hadn't talked much about wartime experiences until they got to hospice.
Some veterans nearing death say they need forgiveness for the people they've killed. It's one thing to have witnessed trauma; it's another to have caused it. Some vets have told me they've tried to tell people about what they did, and it gets dismissed with "Oh, you were just being a good soldier.'' What we're really saying is: "Don't tell me about it. Swallow it.'' Sometimes what's really needed is just to have the opportunity to express how sorry they are. For me, our role is to hear it without judgment.
There's been a lot written lately about the pitfalls of "positive thinking.'' Sounds like you've seen that too.
I don't think there's anything wrong with positive thinking in itself. However, when it's used to deny what we're feeling, then the vitality of our feeling has no place to go, and we have to put on this facade of "everything's okay.'' To me, thinking positively is: "It's okay to open up to my fears. It might hurt, but I can handle it."
That's affirming. It says a person can not only survive the feelings that they're having of helplessness or guilt or whatever it is, but they can grow through them and heal.
You tell the stories of veterans who come to terms with their wartime traumatic experiences decades after the war, at the end of their lives. Why does that happen?
If they don't come to peace with the trauma they've had, it surfaces at the end of life when the conscious mind gets weaker and the unconscious mind gets stronger.
Just yesterday I saw a patient who was 98 years old. He died today. His daughter said he was very tight-lipped about his World War II experience until five years ago when he started having little strokes. He would start crying, and when she asked what was the matter, the story would come out about the things he'd seen in the war. Then he'd recover from the stroke, and be close-lipped until his next stroke.
It sounds in your book as if some veterans didn't even realize they had posttraumatic stress disorder until they were dying. Is PTSD a generational thing?
PTSD only became a diagnosis in 1980, but it really happens across all wars. Civil War veterans called it soldier's heart, and World War II veterans called it combat fatigue. Now, with the current war, there's a lot of talk of PTSD.
I always remind audiences when I'm speaking that PTSD isn't just associated with veterans. Anyone who's been victim of crime, abuse, natural disaster might experience these things.
I'm not an expert on PTSD, but there are no experts on PTSD at the end of life, because the experts have not followed patients to their deaths. It's why the observation is coming out of the hospice arena instead of the PTSD arena.
You've nursed more than 5,000 hospice veterans. Yet it sounds like you get emotionally involved with so many of them.
Our whole society, our media, is geared to teach us how to be a winner. But where do we learn how to be a loser — a gracious loser? How do we learn to let go? That goes against our American culture.
I'm not just talking about death. Any change requires that you let go of one thing in order to accept something else.
I really feel like in our training (as health care professionals in general), rather than teaching us how to open up to a patient and let go, we just say, don't get attached to begin with. Stay objective. But when you enter into hospice work, you learn if you want a peaceful death you have to learn to let go. That's the great gift of hospice; it shows us how to let go of our fears, what we don't want to look at. It shows us how to grieve.
I thought health care professionals needed to maintain some distance for their own well-being. How do you cope?
There's a wonderful saying in hospice: "Those who grieve well, heal well.'' The truth behind that is that people who grieve well know how to let go. Grieving is just the outward expression of the inward letting go.
So yes, I openheartedly join into a patient and family system. I cry with them. At the same time, the paradox almost always is that in doing that there is great joy and much laughter. Because the depth of our laughter and joy is related to our ability to touch our grief. I do everything I can to help give patients the tools to die healed; but I recognize it's their journey. I can't do it for them.
Tell us what you mean by "warrior wisdom."
These veterans have struggled with their suffering and so they have lessons the rest of us need to know. Many have a peace that is beyond our worldly understanding. Sometimes, I think it's because, paradoxically, war has taught them to yearn for peace and so their soul finds it. These lessons are important for all of us. We all need peace in our lives.