More than 400,000 Americans died in World War II alone. Across every conflict since the Revolution, hundreds of thousands more never came home. This weekend, we recognize those who didn’t return and remember the millions of families right now who are navigating past service that remains ever present. 

We spoke with Dr. Gary Hsin, Chief of Palliative Medicine at the VA Palo Alto Health Care System and Clinical Professor at Stanford Medicine about what end-of-life care support looks like for veterans and their caregivers.

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The term ‘warrior mentality’ came up often in our conversation with Dr. Hsin as we discussed veterans facing serious illness and end-of-life while struggling to accept care.

Without judgment and rooted in respect, Dr. Hsin acknowledged it’s the reality of what some of his patients carry and it’s one of the hardest things to work with in a clinical setting.

“How do you shift that fighting mentality?” he said. “It’s not that you just tell people to give up the fight. It’s how do you shift what’s still worth fighting for?” 

Hsin is Chief of Palliative Medicine at the VA Palo Alto Health Care System and a Clinical Professor at Stanford Medicine, where he has spent more than two decades caring for veterans at the end-of-life. He’s also a certified Compassion Cultivation Training instructor through Stanford’s Center for Compassion and Altruism Research and Education.

For caregivers of veterans, especially those living with advancing illnesses like Alzheimer’s, ALS, or cancer, accepting assistance is difficult and it can’t be understood in isolation. For many veterans the era they served in profoundly shapes how they relate to institutions, to help, and to the very idea of being cared for. 

When Hsin started at the VA more than two decades ago, the wards were full of World War II veterans. Men who came home to a country that celebrated them.

Vietnam changed that. Veterans who returned from Southeast Asia came home to a country that was less open to talking about what they’d done or what they’d seen. Many struggled for years before receiving any recognition or any meaningful support. Some of those men are now in their seventies and eighties, facing the end-of-life with decades of unprocessed grief, anger, and undiagnosed PTSD. 

And then there’s the post-9/11 generation. The Iraq and Afghanistan veterans who are now middle-aged, many of them dealing with injuries, physical and psychological, sustained in wars whose justifications have since been questioned. 

A veteran’s willingness to accept palliative care, to consider hospice or to let their adult kid help, may have less to do with their current condition and more to do with their service history. Understanding that doesn’t fix anything, rather informs the conversation. 

Dr. Hsin offers advice for caregivers who might be struggling with helping their veteran Dad accept help: don’t push so hard you lose the relationship entirely. He suggests allowing the palliative care and hospice team to have the hard conversations alongside you. 

“This may be the only thing he has control over,” Dr. Hsin stated compassionately. “He has no control of his illness. His only control is to say no to us and I respect that.”

His approach is to gently leave the door open, and check back. “If it’s okay with you, without being too naggy, can I check back with you in a couple weeks? And if you’re going to tell me no again, you won’t hurt my feelings.” 

For Dr. Hsin, supporting the entire system surrounding veterans with dignity, agency, and respect is paramount. Here’s what he wants caregivers to know about what the VA offers:

You’re entitled to an interdisciplinary team. By VA mandate, palliative care teams are supposed to be interdisciplinary, meaning not just a doctor or nurse, but psychologists, social workers, mental health providers, and chaplains, are all part of the program. This support is meant to extend to the whole family, not just the veteran. 

Veterans can be what’s called ‘dually eligible’. This means veterans can access VA benefits and Medicare (or private insurance) at the same time. Hsin gave the example of immunotherapy: a treatment a community hospice agency might not cover, but the VA will. For veterans who aren’t yet Medicare-eligible, the VA will also step in and pay for home hospice directly. The key, he said, is to start the conversation at the VA level. 

After a veteran passes away, support still exists. If a veteran dies while enrolled in a VA hospice program, bereavement counseling is available to the family, the same way it would be through community hospice. That benefit is tied specifically to hospice enrollment. Surviving spouses may also qualify for continued financial benefits through the Veterans Benefits Administration, depending on the veteran’s service connection. It’s not automatic, and there’s complexity involved but a VA social worker or a Veterans Service Organization (VSO) representative can help navigate it. And if burial is a concern, the National Cemetery Administration provides options, including for spouses.

Additional resources for veterans and their caregivers:

VA Hospice and Palliative Care: The VA offers palliative care consultations at every medical center and hospice care in many of its facilities, with the option to contract community-based hospice programs. 

The National Veterans Foundation: NVF offers vet-to-vet support. 

VA Caregiver Support Line: A dedicated toll-free line for family caregivers of veterans.

We Honor Veterans: A national program run by the National Alliance for Care at Home in collaboration with the VA, designed to help community hospice providers give veteran-specific end-of-life care. 

National Cemetery Administration: Eligible veterans and their spouses may qualify for burial in a national cemetery, including a flag ceremony, at no cost to the family.

You can’t fail this one. Answers and another quiz drop next week.

You said it. This week’s submissions.

"I think I have to make the decision to put my dad in a care home sooner than I wanted."

"Little win - traveled for work this week and didn't receive any panicked calls from my Mom."

"Omg...this is the worst, there are no resources, the struggle is real."

"Mom had an aide while I was away. Then she got mad that the aide talked to the neighbors."

"I don't think Mom can drive anymore after driving on a flat tire for days."