The goal of this webinar was to equip healthcare professionals with an understanding of military veterans’ unique medical, emotional, and spiritual needs as they near the end of life.

1. Veterans Nearing the
End of Life: Distinct Needs,
Specialized Care

2. VITAS Healthcare programs are provided CE credits for their Nurses/Social Workers and
Nursing Home Administrators through: VITAS Healthcare Corporation of Florida, Inc./CE
Broker Number: 50-2135. Approved By: Florida Board of Nursing/Florida Board of
Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and
Family Therapy & Mental Health Counseling.
VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home
Administrators and Respiratory Therapists through: VITAS Healthcare Corporation of
Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number:
139000207/RT CE Provider Number: 195000028/Approved By the Illinois Division of
Profession Regulation for: Licensed Nursing Home Administrators and Illinois
Respiratory Care Practitioner.
VITAS Healthcare, #1222, is approved to offer social work continuing education by
the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE)
program. Organizations, not individual courses, are approved as ACE providers.
State and provincial regulatory boards have the final authority to determine whether
an individual course may be accepted for continuing education credit. VITAS Healthcare
maintains responsibility for this course. ACE provider approval period: 06/06/2018 –
06/06/2021. Social workers completing this course receive 1.0 ethics continuing
education credits.
VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine,
CA 92602. Provider approved by the California Board of Registered Nursing,
Provider Number 10517, expiring 01/31/2023.
Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No
NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA: No NHAs,
TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only
receive CE Credit in Illinois
CE Provider
Information

3. Goal
This presentation equips the
healthcare professional with a
multi-faceted understanding of
the unique needs of the veteran
patient nearing the end of life.
The goal is to provide the highest
quality care and dignified treatment
that the veteran who selflessly
provided service to our
nation deserves.

4. Objectives
• Discuss pertinent statistics regarding ill and aging
US veterans.
• Highlight why it is important for non-VA healthcare
entities to develop Veteran Cultural Competency.
• Describe military cultural values that may influence
both the veteran’s help-seeking behaviors and
his/her end-of-life experience.
• Discern factors that might explain differences in
how combat veterans integrate their war experience
as they transition from soldier to civilian.
• Describe how attending to the combat veteran
through the lens of Trauma-Informed Care
supports empathic, effective, quality healthcare.
• Describe the major components of post-traumatic
stress disorder (PTSD) and ways to mitigate symptoms
that may appear as a veteran nears the end of life.
• Define moral injury and describe evidence-based
treatment methods for easing moral or “soul” injury.

5. US Veteran
Statistics
• 240,329 WWII veterans are
alive today
• 1,800 veterans die every day (234 are WWII
Vets)
• Only 4% of veterans receive hospice care
through the VA
• 48% of veterans are enrolled in the VA
Healthcare system
• Hospices are now caring
for mostly Vietnam and
Korean War vets
Planning, O. of P. (2010). Veterans Affairs. https://www.va.gov/vetdata/quick_facts.asp

6. Each
Veteran
Is Unique
• How they adjust to civilian life
• How they cope with life stressors
• Whether they enlist help
• How they experience the
end of life

7. • Which war they served in
• Whether they had PTSD and
whether it was treated
• Combat vs. Non-Combat
• How they’ve integrated trauma
• Branch of Service (“A Few Good Men”
“Once a Marine, Always a Marine”
• Officer vs. Non-Officer
• Drafted or Enlisted
• Age
Factors
That
Influence
Veteran
Experience

8. Military
Cultural
Values
• “Big Boys Don’t Cry”
• “No Pain, No Gain”
• “The more it hurts, the better”
• Fear/Pain is a sign of weakness
• Stoicism
• Military Males – Double Dose of Macho!
• Alcohol encouraged environment

9. • Being in control
• Deference to authority
• Death as the enemy
– “Fight to the bitter end.”
• Support your own
– “The few. The proud. The brave”
• No soldier dies alone
Military
Cultural
Values

10. Military values essential for the battlefield might be
contraindicated when the veteran is nearing the end of life.
Stoicism, the need for control, trusting “we” and
not “them,” and putting others before yourself may
shape the way our veterans experience their physical,
emotional, and spiritual symptoms as they near the
end of life and their attitudes about seeking help.

11. Combat vs.
Non-Combat
Veterans
Non-combat:
• Fewer psychological and
social obstacles transitioning
to civilian life
Combat:
• More psychological adjustments,
physical ailments, and
social adjustments

12. • Country united behind war effort
• Men lied about their ages to join the war
effort
• Degree of safety behind enemy lines
• War was glamorized
– No TV coverage of atrocities
• Veterans came back heroes;
we won the war
• Victory Gardens & Letter Writing
Campaigns
• Woman more involved than ever
World War II
1941-1946

13. Korean War
1950-1955
• “Police Action” - limited war
• No formal declaration of war from Congress
• Korean vets felt ignored, forgotten;
their experiences were minimized
• WWII & Vietnam
• M*A*S*H

14. • Soldiers were young, many
were drafted
• US involvement was unclear
• War was unpopular; massive
protests at home
• No safety behind enemy lines
• More civilian causalities
• Brutality portrayed on TV
• America lost the war
– “We sacrificed ourselves and
our buddies in vain.”
• Veterans wanted to forget the war
Vietnam War
1964-1975

15. • Societal support was split
• Success and failure were/are
hard to measure
• Extensive vivid media coverage
• More traumatic injuries
• High potential for terrorist
attacks and roadside bombs kept
veterans constantly on alert
Gulf War
1990-Present

16. Vietnam veterans:
• Chemical warfare (Agent Orange)
• Presumptive Conditions & Diseases
Gulf and Afghanistan veterans:
• Explosive-related injuries –TBI
• Burn Pits – Respiratory Diseases
• Gulf War Syndrome
Combat:
Physical
Ailments and
Injuries

17. • Expands and extends eligibility for VA
health care for Veterans with toxic
exposures and Veterans of the Vietnam,
Gulf War, and post-9/11 eras
• Camp Lejeune Justice Act
• Adds more than 20 new presumptive
conditions for burn pits and other toxic
exposures
• We are morally obligated to inform veterans
of their benefits
Grassman, D. (2007). Wounded warriors: Their last battle. Home Health Nurse, 25(5), 299-304.
The PACT
Act

18. • Integrated response to trauma
• No integration of trauma
• Apparent integration of trauma
Grassman, D. (2007). Wounded warriors: Their last battle. Home Health Nurse, 25(5), 299-304.
Integration
of Trauma

19. • Personality and resiliency
• Social, familial support
• Financial stability
• Physical health
• Faith support
• Ability to openly discuss
war experience
• Societal acceptance of the conflict
Factors
Influencing
Integration
of Trauma

20. Ganzel, B. (2018). Trauma-Informed Hospice and Palliative Care. The Gerontologist, 58(3), 409-419.
Trauma-informed care recognizes the nature of terminal illness,
the effects of aging, and the knowledge that many individuals,
including veterans, have experienced lifetime trauma.
Trauma-informed care is provided by first assessing signs or
symptoms of trauma, and then by developing intervention
strategies in ways that prevent reactivation or exacerbation
of possible trauma symptoms.

21. • Military History Checklist
• Assess & Plan for PTSD
• Assess for Pain – May Under Report
• Assess for Moral Injury
• Identify Military Rituals
• Identify Suicide Risk - Weapons – Provide
Gun Locks
Care Planning
Guide for
Veterans

22. Veteran
Suicide
Rates in
the US
• 16.8 suicides per day (9.7% decrease from
2018; first time since 2006)
• Suicide rate is almost double than non-
veterans
• Second Leading Cause of Death for Vets 45
years of age and younger
• 38.6% > age 55-74 in 2019
• More likely to act on
suicidal plan

23. Veterans
Crisis Line
• Dial 988 then Press 1
• Chat Online – veteranscrisisline.net
• Text 838255

24. A: Stressor* Exposed to death, threatened
death, actual/threatened serious injury, sexual
violence. Direct exposure, indirect exposure
B: Intrusion symptoms* Traumatic event
persistently re-experienced via upsetting
memories, nightmares, flashbacks; emotional
distress or physical reactivity after exposure
to traumatic reminders
C: Avoidance* Of trauma-related stimuli,
thoughts or feelings, external reminders
D: Negative alterations in cognitions and mood**
Inability to recall key trauma features, overly
negative thoughts about self/the world, exaggerated
blame of self/others, negative affect, decreased
interest in activities, isolation, difficulty being positive
Trauma- and Stressor-Related Disorders. (2013). DSM-5.
*One symptom from the list **Two symptoms from the list
Post-
Traumatic
Stress
Disorder
(PTSD)

25. E: Alterations in arousal and reactivity
Irritability or aggression, risky or destructive
behavior, hypervigilance, heightened startle
reaction, difficulty concentrating,
difficulty sleeping
F: Symptoms last for more than 1 month
G: Symptoms create distress or functional
impairment (e.g., social, occupational)
Trauma- and Stressor-Related Disorders. (2013). DSM-5.
Post-
Traumatic
Stress
Disorder
(PTSD)
(cont.)

26. Most
Prevalent
Mental
Disorders
in Veterans:
PTSD
• Depression, anxiety, adjustment problems,
distrust authority, survivor’s guilt, adverse
family consequences
• Flashbacks, vivid dreams, hypervigilance,
especially debilitating
• 52% males, 28% females with PTSD
meet lifetime criteria for alcohol
abuse/dependence
• 35% males, 27% females with PTSD
meet criteria for drug abuse
Kessler, R., et al. (2005) Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the
National Comorbidity Survey Replication (2005). Archives of General Psychiatry, 62(6), 593-602.

27. • 23% women reported sexual assault
• 55% women reported sexual harassment
• More than half of veterans with military
sexual trauma are men
Symptoms:
• Disturbing memories or nightmares
• Difficulty feeling safe
• Depression or numbness
• Alcohol/drug issues
• Feeling isolated
• Anger, irritability
• Sleep disturbances
• Health problems
“Military Sexual Trauma,” retrieved from US Department of Veteran Affairs
https://www.mentalhealth.va.gov/mentalhealth/msthome/index.asp
Military
Sexual
Trauma

28. Guilt
Commission or Omission of Actions
• Killing; for not killing
• Failing to perform one’s duty or
to act during trauma
• Being unable to save fellow
service members
• Feeling a rush or enjoyment
during trauma
• Disproportionate violence
inflicted on others
• Witnessing or perpetrating
violence on civilians, children
Williamson, V., et al. (2019). Moral injury in UK armed forces veterans: a qualitative study.
European Journal of Psychotraumatology, 10(1), 1562842.

29. Guilt
(cont.)
Feel guilty for:
• Surviving…
• What other comrades did
• Seeing others volunteer
• Life and death decisions
• What families went through
– 54% - lifetime post-traumatic guilt
– 41% - current post-traumatic guilt
– 35% - moderate to extreme guilt
Miller M., et al. (2012). The prevalence and latent structure of proposed DSM-5 posttraumatic stress
disorder symptoms in U.S. Psychological Trauma: Theory, Research, Practice, and Policy.

30. What is
Moral Injury?
• “Perpetrating, failing to prevent, or bearing
witness to acts that ultimately transgress
one’s deeply held moral beliefs,”
creating dissonance
• Emphasizes the psychological, social,
cultural, and spiritual aspects of trauma
Litz B., et al. (2009). Moral injury and moral repair in war veterans: A preliminary model and
intervention strategy. Clinical Psychology Review, 29:695–706.

31. • Social problems (e.g., isolation, aggression)
• Trust and intimacy issues
• Loss of faith
• Existential issues (e.g., fatalism, sorrow)
• Intrusive thoughts
• Intense negative appraisals (e.g., shame,
guilt, disgust)
• Self-deprecating emotions
Drescher, K. D., et al. (2011). An exploration of the viability and usefulness of the construct
of moral injury in war veterans. Traumatology, 17(1), 8-13.
Moral Injury

32. What is
“Soul”
Injury?
• Disruption of fundamental identity
• Sense of betrayal (self, others,
organization, faith)
• Emptiness; meaninglessness
caused by disconnection
from self
• Unmourned grief
• Unforgiven guilt
Grassman, D. Retrieved from Opus Peace www.opuspeace.org

33. • Understand what the veteran has
experienced and what they prefer
to experience in this moment
• Help reconcile ideals and values
with past and present
• Look for opportunities to use
ideals and core values to help
them make peace
• Care Planning is Essential!!!
Community Hospices: Suicide Prevention for Vietnam Veterans. Sponsored by the Empowering Community Hospices Initiative.
Retrieved from: https://www.wehonorveterans.org/wp-content/uploads/Hospice__Suicide_Prevention-2.pdf
Military
Cultural
Competency

34. • Pharmacological management of
anxiety and depression
• Cognitive behavioral techniques
– Cognitive processing therapy (CPT)
– Prolonged exposure (PE)
– Trauma-Informed Guilt Reduction
(TrIGR) therapy
– Mindfulness meditation
• Group therapy
Diefenbach, T.M. (2018). Improving the integration of psychoeducation, prolonged exposure, and psychopharmacological
trreatments of combat-related PTSD: A descriptive phenomenological study. (Doctoral dissertation, Northcentral University).
Treatment
for PTSD

35. Treatment
for Moral
Injury
• Trauma Informed Guilt Reduction (TrIGR)
• Adaptive disclosure (AD)
• Impact of Killing Treatment Program (IOK)
• Life review-based exposure
• Spiritually oriented counseling
• Complementary/alternative therapies
Litz, B., et al. (2015). Adaptive disclosure: A new treatment for military trauma, loss, and moral injury. Guilford Publications.
Maguen, S., et al. (2017). Impact of killing in war: A randomized, controlled pilot trial. Journal of Clinical Psychology, 73(9), 997-1012.
Steenkamp, M., et al. (2011). A brief exposure-based intervention for service members with PTSD. Cognitive and Behavioral Practice, 18(1), 98–107.

36. • “Re-own and re-home” part of
the self that carries pain and guilt
Treatment involves:
• Grief work
• Unifying the fragmented self
• Learning to forgive
• Complementary therapies – Very useful;
especially music therapy
Grassman, D. Retrieved from Opus Peace www.opuspeace.org
Treatment
for Soul
Injury

37. • Advanced illness can be traumatic
• For the veteran, both can rekindle
wartime memories, survivor’s guilt,
unresolved grief
• Can be hard for veteran to “let go”
• May be socially isolated
• May ignore or under-report symptoms
• May be distrustful of helping professionals
The Veteran
Nearing the
End of Life

38. • Trauma treatment options determined by:
– Nature and intensity of symptoms
– Length of expected survival
– Physical, cognitive, and
emotional energy
• Care does not include probing deeply
into trauma history
Care for
Veterans
Nearing the
End of Life

39. • Establish rapport in a helpful,
respectful manner
• Manage symptoms pharmacologically
• Restore and support a sense of safety
• Calm and orient distressed individuals
• Connect veteran to sources of
social support
Veterans
With
Advanced
Illness

40. • Distinguish between PTSD and
“terminal restlessness”
• Assess for environmental triggers
– Loud noises, bed alarms,
violent TV shows
– Avoid restraints
– Avoid noxious stimuli
• Avoid startle response: call out their name,
let them see you first
• Approach patient calmly and slowly,
especially before touching them
Grassman, D. (2007). Wounded warriors: Their last battle. Home Health Nurse, 25(5), 299-304.
Trauma
Informed
Physical
Care

41. • Position patient so he/she is not “boxed in”
• Introduce battlefield metaphors:
– “This is a special bomb-proof room” or
“bomb shelter.”
– If “enemy soldiers are under the bed,”
put mattress on the floor
– Suggest you’re the sentry posted
to keep them safe
• Providers of Asian ethnicity may trigger
veterans of Vietnam/Korean Wars
• Those of German descent may trigger
WWII veterans
Grassman, D. (2007). Wounded warriors: Their last battle. Home Health Nurse, 25(5), 299-304.
Trauma
Informed
Physical
Care (cont.)

42. • Offer permission to accept declining
health, allow support from others
• Suggest that emotional control and
tolerating pain ⏤ once critical for
battle ⏤ are not helpful now
• Allow as much control as possible
• Help translate their lifetime values
into positive present actions
“What have you done in the past to make
yourself better when things got difficult?”
“Can you think of things that would help
you to feel better?”
Enhancing
Coping Skills

43. Supporting
Spiritual
Growth
• Help construct a “trauma narrative”
with room for personal strengths,
positive relationships, spiritual change,
appreciation for life
• Examine where values have contributed
to strengths and suffering
• Use rituals, confession, pastoral care,
letter-writing, and role-playing to
release guilt, find reassurance
• Help redefine usefulness, purposefulness
at the end of life

44. Forgiveness:
Cornerstone
of Healing
• Forgiveness of the enemy, For killing or not
killing, the U.S. government and God or
higher power
• Allows a letting-go of trauma and guilt
• Can alter relationship with the past
• Wanting to forgive is essential
– We do not rush it prematurely
– We accept if the veteran
cannot forgive

45. • Memories remain vivid
for the veteran
• Externalizing stories
is cathartic
• Both provide
self-acknowledgement,
self-forgiveness,
acceptance, and
reconciliation
“Beholding is more than
listening to stories with our ears.
It involves the spiritual dimension.
We must listen with our
deeper selves.”
—Deborah Grassman

46. “Listen
with all
your might
and do
not judge.”
—Deborah Grassman
Do:
• Take your lead from veteran
• Validate their experience
• Thank them for their story and
their service
Do Not:
• Give advice
• Quiz for many details
• Suggest they should NOT feel guilty
• Ask highly personal questions
• Share your political views

47. Recognition
Engenders psychological and spiritual
congruence between personal
values and motivation for enlisting,
vis-a-vis their war actions.
• Leaving a “legacy” is critical
at end of life
– Freedom of speech
– Peace (absence of war)
– Respect for all people
– Patriotism
– Tolerance

48. United States
of America
Vietnam War
Commemo-
ration
• Commemorative Partner
• Welcome Home Ceremonies
• Commemorative Pin & Certificate
• March 29, Vietnam Veterans Day

49. Minorities &
Women
Veterans
• Minority veterans fought on “two fronts – at
the home front and with the enemy on the
front lines
• Tuskegee Airmen & Montford Point Marines
• Medallion of Strength – Celebrates woman
veterans (Center for Women Veterans)
• June 12, Women’s Veterans Day
• Rosie the Riveters – Congressional Gold
Medal Authorization

50. Gratitude
• Thank them for:
– Serving our country
– Giving us our freedom
– Putting their life on hold
• Celebrate accomplishments
with them
• Provide ceremonies of recognition

51. Appreciation
• “You are the peacemakers of today.”
• “It’s because of your service that
we are free today.”
• “We’ll always remember the sacrifices
you and other service members
have made.”
• “This country is great today because
of your service.”
• “The world is a better place today
because of you.”

52. • Acknowledge their sacrifices
• Assess for secondary trauma
• Facilitate an understanding
of how military experience
may affect the present
• Provide psychoeducation re:
moral injury and PTSD
• Facilitate connection,
unfinished business
• Suggest that the veteran
share his/her war experience,
if they’ve not done so
Treating
the Veteran
Family

53. Open-ended Life Review Questions
Some open-ended questions that
elicit storytelling might include:
• What branch of service were
you in? Why did you choose
that one?
• What inspired you to join?
• What was your job? What was
the most rewarding part of it?
• What is the most important
thing you learned from service?
• What made you most proud
of being in uniform?
Life Review
Questions

54. Advanced questions might include:
• What surprised you most about being
overseas or deployed?
• What did you do in your free time
when you were deployed?
• How did the United States change
while you were gone?
• Do you think you were changed
as a result of being in the military?
Please describe the changes.
• What was your homecoming like?
• Do you keep in touch with
your war buddies?
Life Review
Questions
(cont.)

55. In closing…
Let’s not allow the soldier dying in our midst be
unknown any longer… Let us BEHOLD and
FEEL BEHOLDEN!
—Deborah Grassman
(VA Mission)

56. Hospice Care
• Interdisciplinary team-oriented approach to EOL care
– Patient- and family-centered care
– Goals of care/shared decision-making
• Aggressive care near the end of life: medical care, pain and
symptom management, and emotional and spiritual support
• Provided in any setting
• 4 different levels of care, based on each patient’s clinical needs

57. Medicare Hospice Benefit
These services are mandated by the Medicare hospice benefit.
Interdisciplinary
Team of Hospice
Professionals
Home Medical
Equipment
Medication Bereavement
Support
Continuous
Care
Respite Care
Routine
Home Care
Inpatient Care

58. Continuous Care
Higher level of care
• Acute symptom management
• Patient’s bedside/preferred care setting
• VITAS RN/LPN/LVN/aide
• Temporary shifts of 8-24 hours until
symptoms stabilize
• Prevents ED visits/hospital readmissions
Respite Care**
• Provides temporary break (caregiver
burnout, travel, work, etc.)
• Up to 5 days and nights of 24-hour
patient care
• Medicare-certified hospital, hospice
facility, or long-term care facility
Routine Care
• Most common level of hospice care
• More robust and comprehensive
compared to home health care services
• Patient’s preferred setting
• Proactive clinical approach helps
prevent ED visits/hospital readmissions
Four Levels of Care
*Per Medicare guidelines, these 2 levels of care are provided on a temporary basis
until the symptom(s) is optimally managed.**Usually not offered more than monthly
General Inpatient (GIP) Care*
• Higher level of care (GIP/VITAS IPU)
• Acute symptoms can no longer be
managed in patient’s preferred setting
• VITAS RN/MD/psychosocial team
• Temporary until symptoms stabilize
• Prevents ED visits/hospital readmissions

59. Patient and
Family
Volunteers
Physicians
Spiritual
Counselors
Social
Workers
Bereavement
Counselors
Hospice
Aides
Therapists
Nurses
Hospice Interdisciplinary Team

60. How VITAS Can Help
Services VITAS Home Health
Nurse 24-Hours a Day ✓ Variable
Nurse Frequency of Visits Unlimited Diagnosis Driven
Palliative Care Physician Support ✓ X
Medications Included ✓ X
Equipment Included ✓ X
Levels of Care
Home, Inpatient,
Respite, Continuous
Home
Bereavement Support ✓ X
Primary Care/Specialty Visits ✓ ✓
Targeted CHF Program ✓ Variable
Care Plan Review Weekly Variable

61. www.vetcenter.va.gov Veteran Centers provide counseling free of charge
www.va.gov US Department of Veteran Affairs
http://www.vba.va.gov/ Veterans Benefits Administration Home Page
http://www.va.gov/vso Veteran Service Organizations
https://www.ptsd.va.gov/ VA National Center for PTSD
VA/DOD Clinical Practice Guideline For the Management of PTSD and
Acute Stress Disorder
https://www.loc.gov/vets/ Veteran History Project (Library of Congress)
https://www.wehonorveterans.org/ the National Hospice and
Palliative Care Organization
VA
Resources

62. Questions

63. References
American Psychiatric Association. (2013) Diagnostic and statistical manual
of mental disorders, (5th ed.). Washington, DC.
Barno, D., et al. How to Talk to a Veteran, School of International Service
at American University. Retrieved from warontherocks.com
Community Hospices: Suicide Prevention for Vietnam Veterans.
Sponsored by the Empowering Community Hospices Initiative. Retrieved from:
https://www.wehonorveterans.org/wp-content/uploads/Hospice__Suicide_
Prevention-2.pdf
Diefenbach, T. (2018). Improving the integration of psychoeducation,
prolonged exposure, and psychopharmacological treatments of combat-related
PTSD: A descriptive phenomenological study. (Doctoral dissertation,
Northcentral University).
Drescher, K., et al. (2011). An exploration of the viability and usefulness
of the construct of moral injury in war veterans. Traumatology, 17(1), 8-13.
Feldman, D., et al. (2014). Treatment of posttraumatic stress disorder at the
end-of-life: Application of the stepwise psychosocial palliative care model.
Palliative & supportive care,12(3), 233-243.
Ganzel, B. (2018). Trauma-Informed Hospice and Palliative Care.
The Gerontologist, 58(3), 409-419.
Grassman, D. Retrieved from Opus Peace www.opuspeace.org
Grassman, D. (2007). Wounded warriors: Their last battle.
Home Health Nurse, 25(5), 299-304.
Haiken, M. (2013). Suicide Rate Among Vets and Active Duty Military
Jumps - Now 22 A Day. Forbes.

64. References
Hoge, C., et al. (2004) Combat Duty in Iraq and Afghanistan, Mental Health
Problems, and Barriers to Care. New England Journal of Medicine, 351, 13-22.
Kaiman, C. (2003) PTSD in the World War II combat veteran.
The American Journal of Nursing, 103(11), 32-41.
Kessler, R., et al. (2005) Lifetime prevalence and age-of-onset distributions
of DSM-IV disorders in the National Comorbidity Survey Replication (2005).
Archives of General Psychiatry. Jun;62(6), 593-602.
Kubany, E., et al. (1995). Initial examination of a multidimensional model of
trauma-related guilt: Applications to combat veterans and battered women.
Journal of Psychopathology and Behavioral Assessment, 17, 353–376.
Litz, B., et al. (2009). Moral injury and moral repair in war veterans: A preliminary
model and intervention strategy. Clinical Psychology Review, 29, 695-706.
Litz, B., et al. (2015). Adaptive disclosure: A new treatment for military trauma,
loss, and moral injury. Guilford Publications.
Maguen, S., et al. (2012). Moral injury in veterans of war. PTSD Research
Quarterly, 23(1).
Maguen, S., et al. (2017). Impact of killing in war: A randomized, controlled pilot
trial. Journal of Clinical Psychology, 73(9), 997-1012.
Marma, C., et al. (2015). Course of posttraumatic stress disorder 40 years after
the Vietnam War: Findings from the National Vietnam Veterans Longitudinal
Study. JAMA Psychiatry, 72(9), 875-81.
Miller M., et al. (2012). The prevalence and latent structure of proposed
DSM-5 posttraumatic stress disorder symptoms in U.S. Psychological Trauma:
Theory, Research, Practice, and Policy.

65. “Military Sexual Trauma,” retrieved from US Department of Veteran
Affairs https://www.mentalhealth.va.gov/mentalhealth/msthome/index.asp
Nash, W., et al. (2013). Moral injury: A mechanism for war-related
psychological trauma in military family members. Clinical Child & Family
Psychology Review, 6, 365-375.
National Center for Veterans Analysis and Statistics.
https://www.va.gov/vetdata/quick_facts.asp
National Child Traumatic Stress Network (NCTSN), & National Center for
Posttraumatic Stress Disorder (NCPTSD). (2006) Psychological First Aid:
Field operations guide, second edition. Retrieved from http://www.nctsn.org
National Vietnam Veterans Readjustment Study (NVVRS) www.ptsd.va.gov ›
articles › article-pdf › nvvrs_vol1.
Norman, S., et al. (2014) Trauma Iand Behavioral informed Guilt Reduction
Therapy with Combat Veterans. Cognitive Practice, 21(1), 78–88.
Olenick, M., et al. (2015). US veterans and their unique issues: enhancing
health care professional awareness. Advances in Medical Education and
Practice, 6, 635.
Shay, J. Moral injury. (2014); Psychoanalytic Psychology, 31, 182–191
(quoted PsychiatryOnline.org).
Sher, L., et al. Posttraumatic stress disorder, depression, and suicide
in veterans. Cleveland Clinic Journal of Medicine, 79(2), 2 92-97.
Steenkamp, M., et al. (2015). Psychotherapy for military-related PTSD:
A review of randomized clinical trial. Journal of the American Medical
Association, 314(5), 489-500.
References

66. Steenkamp, M., et al. (2011). A brief exposure-based intervention for service
members with PTSD. Cognitive and Behavioral Practice, 18(1), 98–107.
Suicide Among Veterans and Other Americans 2001-2014. (2019).
National Veteran Suicide Prevention Annual Report. Office of Mental
Health and Suicide Prevention. Retrieved from: Mentalhealth.va.gov
Tick, E. (2005). War and the soul: Healing our nation’s veterans from post
traumatic stress disorder. Quest Books.
Tick, E. (2014). The Warriors Return. Boulder, CO: Sounds True Inc.
Trauma-and Stressor-Related Disorders. (2013). DSM-5.
U.S. Department of Veterans Affairs. (2014). PTSD: National Center for
PTSD: Acts of Violence, Terrorism, or War: Triggers for Veterans. Retrieved from:
http://www.ptsd.va.gov/public/types/war/terrorism-war-affect-vets.asp
U.S. Department of Veterans Affairs. (2014). Statistics at a Glance. Retrieved from:
http://www.va.gov/vetdata/docs/Quickfacts/Homepage_slideshow_3_31_14.pdf
U.S. Department of Veterans Affairs. Veteran Health Concerns. Retrieved from:
www.va.gov/oaa/pocketcard/unique.asp
Williamson, V., et al. (2019). Moral injury in UK armed forces veterans:
a qualitative study. European Journal of Psychotraumatology, 10(1), 1562842.
2019 National Veteran Suicide Prevention Annual Report. Office of Mental
Health and Suicide Prevention.
References

67. Veterans Nearing the
End of Life: Distinct Needs,
Specialized Care