Exposure to death in large-scale combat operations leadership’s role in addressing stress, grief and moral injury

Large-scale combat operations (LSCO) represent sustained, high-intensity warfare with near-peer adversaries involving massive casualty volumes. Military projections suggest 3000 casualties per day, approaching World War II intensity levels. LSCO will expose military personnel to continuous confrontation with death, producing psychological effects that threaten force preservation and mission continuity. Traditional centralized behavioral-health systems will be unable to sustain operations effectively under conditions of continuous exposure, contested evacuation, and specialist unavailability. Leadership emerges as the primary mechanism for force preservation, with influence increasing precisely when followers face the greatest threat. This narrative review examines three areas: (1) psychological consequences (stress reactions, grief, moral injury); (2) vulnerable populations (infantry, junior leaders, medics); and (3) leadership interventions including transformational leadership and grief-informed command practices. In contrast to centralized models, we propose a three-level operational framework: immediate unit-level peer support, embedded resource utilization through medics, chaplains, and behavioral health officers, and delayed professional intervention when feasible. This model positions leadership as the central mechanism for sustaining the fighting force amid continuous death exposure.