Ben diverts his eyes and wipes away tears, his typical stoicism and iron-willed suppression of emotion giving way to a sea of churning thoughts, feelings and memories. While visiting as his hospice social worker, we’d been talking about his impending death, walking it through in our minds from the time the funeral home arrived until he’s planted in the ground. We’d talked about death before, and he’d always been cool as steel. But this time something is different.

Reading his face, his wife Patsy leaves us alone. I wait for him to speak.

“It’s not right,” he whispers, staring into space.

“What’s not right?” I ask.

He shakes his head as if gauging how much to say. I’m not surprised when the Vietnam War comes up again. There’s something about dying and the way it invites us to look back on the life we have lived that often frees repressed and unspoken images of war. I’ve worked with many dying veterans who, even among those who expressed pride and who found meaning and friendships amidst the terrors of combat, have shared heartbreaking sadness and painful memories which had long been unspoken.

In some ways dying — facing a mortal threat, losing control, feeling unsafe, sudden shifts in assumptions about the future — can mirror distant experiences of those who once went to war. Moreover, terminal illness and medical care are replete with potential triggers and trauma reminders — physical pain, shortness of breath, feeling states like fear and anger — that can intensify and bring to the surface symptoms of posttraumatic stress, undigested grief as well as hidden moral, spiritual and existential pain.

“It’s not right,” Ben continues, “that I’ve had a long life and get a fancy send-off when so many of my buddies got killed when they were kids and had what was left of their bodies packed into bags and shipped home in cargo holds.”

His hands are shaking. Suspecting there’s more, I let him know I’m listening and wait.

“War turns people mean,” he says as if speaking in a trance, making no eye contact. “It turns good men on both sides into sadists, animals.”

His respirations are quick and shallow, forehead beading sweat, signs of a ramped up nervous system. I ask if he wants to say more, making it clear the ball is in his court. No pressure. When he nods, I encourage him to take it slow, in small pieces.

He tells me about things forever seared into his mind: The smell of burning human flesh; the sound of a friend screaming for help just before dying; corpses of women and children bleeding into a packed dirt trail; the image of a young Vietnamese soldier whose dead body he had desecrated in a fit of rage-fueled revenge.

“Why do I get a funeral when all that poor Viet Cong soldier got was,” he searches for words and finds none.

Some have attempted to find language for the deep wounds that can occur to one’s moral identity when faced with the kind of horrors Ben was describing and the personal responsibility he felt. In his book on working with Vietnam combat veterans, “War and the Soul,” Ed Tick goes so far as to assert that such pain undergirds all combat-related posttraumatic stress disorder (PTSD).

According to him, “PTSD is not best understood or treated as a stress disorder, as it is now characterized. Rather, it is best understood as an identity disorder and soul wound.” Deborah Grassman, who specializes in working with terminally ill veterans, has found that this kind of pain often emerges at the end of life as big questions arise amidst the gathering twilight. “The source of soul injury,” she believes, “is unmourned grief and unforgiven guilt and shame over things we think we should or should not have done.”

Having worked with hundreds of combat veterans — including the much vaunted survivors of World War II, many of whom were traumatized in ways only immediate family would ever know — I’ve learned not to use platitudes like quickly thanking a veteran for his or her “service,” or using words like “heroes” or “freedom.” For patients like Ben, such euphemisms and automatic phrases can ring hollow and may telegraph that we are not interested in letting them define for themselves the meaning and truth of their experience.

Such phrases may convey that we are not prepared to hear things which collide with simplistic, morally sanitized preconceptions we may have about the nature of war. Clinically, they often shut down the difficult but potentially therapeutic conversation Ben and I were having. And such conversations may be the last chance to move in the direction of healing or forgiveness before death.

Ben looks out the window and talks in a far-away voice. “I’ve been seeing that Vietnamese soldier. He visits me.”

“You talking about in dreams, nightmares?”

“No, I mean when I’m wide awake. I see him clear as day.” Ben looks me hard in the eye. “Started happening after I got sick. You think I’m crazy?”

“No.” Inwardly, prepare myself for a long visit. It takes however long it takes.

We sit in silence for a while. Ben fidgets with his oxygen cannula and clears his throat. I ask if the soldier has a message for him and he shakes his head.

“What does he do when he comes?”

Tears well in the corners of Ben’s eyes, “He just stares at me, asking the same question over and over. ‘Why?’”

Scott Janssen is a social worker.

Image credit: Shutterstock.com