Care of the Dying Patient: Maximizing Compassionate Care on the Battlefield

Palliative care is a philosophy of treatment that focuses on relieving suffering while aligning care with a patient's goals. This treatment modality has proven benefits for civilian patients of all ages with both traumatic injuries and non-traumatic disease states. It results in the reduction of distressing symptoms and improved patient satisfaction, as well as reducing painful, ultimately futile interventions. Palliative care has also been employed throughout history on the battlefield and is a vital component of compassionate care for dying patients. Unfortunately, its use on the battlefield is an unpalatable topic with little formal documentation. As the U.S. military transitions from the counter-insurgency/counter-terrorism operations of the Global War on Terror (GWOT), with its historically low casualty rates, to large scale combat operations (LSCO) in which the number of casualties is anticipated to be much higher and resources significantly limited, it becomes crucial to discuss and plan for the care of dying patients in the operational environment. Experience documented in Ukraine demonstrates that LSCO produces much larger numbers of casualties than were seen during GWOT and that logistics and evacuation are significantly compromised. Therefore, it is crucial that military medical providers, from combat-life-saver-trained soldiers to physicians, be adequately prepared and trained to manage large numbers of expectant casualties with suboptimal and/or constrained resources. In that setting, there will be patients who will die that could have been saved in prior conflicts with greater resources. We must prepare now to reduce the pain and suffering of dying patients on the battlefield and potentially mitigate the degree of moral injury sustained by the personnel managing those casualties. Consider a soldier in a far forward area who suffered a traumatic amputation, a penetrating traumatic brain injury, and a blast overpressure injury to the lung at 9.00 am during LSCO; his evacuation will not occur until sunset. A single combat medic, carrying one unit of blood, manages his developing hypotension and hypoxia in addition to treating multiple other severely injured soldiers. Two hundred kilometers away, a general surgeon with a minimal store of blood and no chance of patient evacuation or resupply for at least 12 hours, makes triage decisions for 5 urgent surgical patients injured in a drone strike. How should this medic and this surgeon, facing the same problem of inadequate resources, prioritize the care of critically injured patients? Should these soldiers be treated as expectant casualties? Should they receive only comfort-directed end-of-life care? Can civilian palliative care principles inform the decisions and actions of resource-constrained military medical personnel? What principles, if any, does the lung cancer patient with brain metastases, making decisions with his family about palliative care at home, bring to informing end-of-life care decisions in an LSCO scenario? Or can the ethical considerations of a 20-year-old pedestrian, in a persistent vegetative state since being struck by a car 4 months ago, guide LSCO comfort-directed end-of-life care?