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We Honor Veterans: What does this mean? 1.Asking are you a Veteran? Are staff prepared to deal with the answer? 2.Military impact on end of life care?

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Presentation on theme: "We Honor Veterans: What does this mean? 1.Asking are you a Veteran? Are staff prepared to deal with the answer? 2.Military impact on end of life care?"— Presentation transcript:

1 We Honor Veterans: What does this mean? 1.Asking are you a Veteran? Are staff prepared to deal with the answer? 2.Military impact on end of life care? 3.Partnering with VA to improve care? 4.Measure the impact of our interventions?

2 We Honor Veterans Top 10 reasons to participate

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4 Community hospices are earning their stars! Provide Veteran-centric education Build organizational capacity Develop and strengthen relationships with VA Veteran-specific quality measures

5 Military History Checklist

6 Hospice and Palliative Care: We Honor Veterans Scott T. Shreve, DO National Director, Hospice and Palliative Care Department of Veterans Affairs Associate Professor of Clinical Medicine The Pennsylvania State University

7 End of Life Care and Military Hospice (End of Life) Dependency Reconnect with others Life review, reminisce, openly grieve Encourage self- determination and choice Military Interdependence Hierarchical organization Difficult memories Culture of stoicism; downplay suffering Give orders, follow orders

8 To honor Veterans preferences for care at the end of life 420,000 US servicemen and women died in WW II How many Veterans will die this year? a. 42,000 b.120,000 c.320,000 d.640,000

9 To honor Veterans preferences for care at the end of life 420,000 US servicemen and women died in WW II How many Veterans will die this year? a. 42,000 b.120,000 c.320,000 d.640,000 More Veterans will die this year than died in WW II 28% of all Americans who die this year ~21,000 will die as VA inpatients; 136,000 VA outpts

10 Demographic Imperative Only 4% of Veterans die in VA (~21,000) ~642,370 Veterans will die in 2012 PTF file and VetPop for 2012 MANY with advanced serious illness

11 Veterans Integrated Service Networks

12 VA Hospice & Palliative Care US Hospitals: 12% offered palliative care in 2000, now ~60% What % of VA hospitals offer palliative care? a.30% b.56% c.67% d.100%

13 VA Hospice & Palliative Care US Hospitals: 12% offered palliative care in 2000, now 60% What % of VA hospitals offer palliative care? a.30% b.56% c.67% d.100% (up from 38% in 2002)

14 Uniform Benefits Package Hospice and palliative care is a covered benefit - all enrolled veterans, all settings, 38 CFR and VA is both a provider (eg inpatient units) and purchaser (eg home hospice) of end of life care.

15 End-Of-Life Issues Impact All Systems of Care

16 When hospice is available, many will use it (absolute % change in inpatient deaths by venue nationally) ICUAcute Nursing Home Hospice Change6 %12 %13%31% FY1122%27%7%44% FY0428%39%20%13% Note, ~5060 veterans impacted despite declining overall inpt deaths

17 VA Hospice & Palliative Care What % of Veterans who die as VA inpatients receive care from a palliative care team? a.30% b.56% c.73% d.100%

18 VA Hospice & Palliative Care Unknown for US Hospitals What % of Veterans who die as VA inpatients receive palliative care? a.30% b.56% c.73% (up from 33% in 2004) d.100%

19 …early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival.

20 VA Trends Overview FY04 Inpt deaths 26,231 VA-paid hospice ADC 164 % VA deaths in hospice 12% % of inpt deaths with PC 33% FY11 21,606 1,105 44% 73% ADC- Average Daily Census, PC-Palliative Care

21 Video Clip

22 Case Example: Mr. R 65 y/o White, male, divorced x 1 Served in the Army, saw combat, vague history of PTSD Advancing lung cancer Family are buddies from Army, VFW. There is a son. Came to hospice when more difficult to live alone Conflicted family history Seemingly adjusted well to unit for ~month THEN: Refusing meds, angry outbursts at staff Vacillating between paranoia, anxiety and anger Pacing, fearful and exhausted

23 Mr. R., contd Differential diagnosis –Delirium? –Anxiety reaction with psychosis? –Adverse drug reaction? –PTSD? –Others? What do you want to do?

24 Im broken Im a horrible person Im a monster Father, friend, generosity Guilt I could have done more I shouldnt be alive I couldnt protect them I violated my own morals View of the World: Bad things happen to good people The world is unsafe The world is cruel View of the Others: No one understands me I cannot connect with anyone No one can be trusted Others wish me harm If people knew what I did, they would hate me Blame I caused this myself I should have seen this coming I could have prevented this TRAUMA Accomplishments

25 Post traumatic stress disorder (PTSD)

26 What is PTSD? An anxiety disorder that can occur after a traumatic event Examples of traumatic events include: combat or military exposure child sexual or physical abuse sexual or physical assault * serious accidents, such as a car wreck. natural disasters PSTD- Post traumatic Stress Disorder

27 PTSD: What to look for Three key symptom clusters 1)reliving the event 2)avoiding reminders of the trauma / feeling numb 3)feeling anxious or keyed up Screening tools can be used to refer to a mental health professional

28 Triggers: Environment Sensory experience Others Re-experience the event Nightmares Flashbacks Hallucinations Intrusive thoughts Avoidance Emotional numbing Detachment/isolation Avoid triggers & thoughts interests Sense of a foreshortened future Hyperarousal Hypervigilance Insomnia Difficulty concentrating Angry outbursts startle response Trauma Post traumatic stress disorder

29 WWII & Korean War Veterans Prevalence of PTSD largely unknown WWII and Korean War vets (community-dwelling) –<2% lifetime PTSD –Nearly 10% had symptoms consistent with partial-PTSD Dx Schnurr et al, 2002

30 PTSD background Lifetime prevalence of as high as 30% of Vietnam era Veterans Prevalence from Gulf War 12.1% What about end of life prevalence? What about almost PTSD? Lifetime prevalence among Americans ~6%

31 Consequences of PTSD … Elevated mortality for Vietnam Vets Increased rates of substance abuse Increased psychosocial problems National Vietnam Veteran Readjustment Study (1990)

32 … Consequences of PTSD Increased medical diagnoses circulatory and muscular-skeletal conditions poorer health quality of life Greater pain intensity and pain interference in functioning

33 PTSD and Veterans Terminal illness may be risk factor for re-emergence of symptoms in late-life (Feldman & Periyakoil, 2006) Normative changes in late-life can prompt reminiscence of combat exposure Increasingly more emotional about combat experiences Stronger reactions to daily stressors Veterans typically asymptomatic prior to changes (Davison et al, 2006)

34 Death/illness as a PTSD activator How can PTSD impact EOL care? death/illness as a PTSD activator challenging social ties, eg doctor - patient delirium or flashback medication issues Goals of care to include reduction in PTSD symptoms

35 Hospice and PTSD Hospice (end of life) Dependency Reconnect with others Reminisce; Life review Multiple checks by staff Legacy-building PTSD Need for control Isolation; family may not know about trauma May avoid reminiscing (possible triggers) Need predictability, privacy Wish to forget Difficulties with authority figures

36 PTSD at EOL: Themes Vulnerability and Safety –Inability to defend self from perceived threats –Increased sense of vulnerability (physical/cognitive decline) –Mr. R: Im not safe; Youre are trying to poison me. Difficulty with authority figures (staff; physicians) –Difficulty relinquishing control –Potential for non-adherence to medications (e.g., sedatives) –Mr. R: No one can be trusted, angry outbursts Potential triggers –Physical pain (especially if trauma-related injury) –Environmental triggers (sounds, sights, smells, people) –Mr. R: I dont want to suffer like he did.

37 Interpersonal Relationships Some families express concern about PTSD- related symptoms in pt during last month of life Palliative Care consults improved families perception of pt discomfort from PTSD symptoms. (Alici et al, 2010)

38 Practical Applications Anger: Disarm and empathize No mention of past trauma If pt begins to disclose, listen and empathize Pt is in charge of the pace and extent of disclosure Hypervigilance: Consistency/predictability is key Keep regular schedule with same staff Narrate actions so patient aware of what is happening Announce self upon entering to reduce potential startle response Make sure patient can hear you entering Remain in patients line of vision Position patient so (s)he can see the doorway

39 Video clip Link: ns/nightly_news/t/going-back-terrifying- place-where-young-man-grew-old/

40 VAs Bereaved Family Surveys Attempted for every VA inpatient death Over 23,000 completed surveys and 39,700 chart reviews in all VA facilities Response rate: 56% (No significant effect of nonresponse bias on facility or VISN scores) More than 3,400 families referred for additional support Casarett et al, 2011

41 % of Families Rating End of Life Care as Excellent in Acute Units vs. Palliative care vs. Inpatient Hospice Unit Settings p values < % 58% 66%

42 Shared Accountability Leadership engagement Community partners –More than hospice –Family Evaluation of Hospice Care (FEHC) –Recently released FEHC for Veterans Care of serious illness goes beyond palliative care National Quality Forum

43 We Honor Veterans 1.Asking are you a Veteran? Are staff prepared to deal with the answer? Consider committing to We Honor Veterans 2.Military impact on end of life care? Learn about the care needs of Veterans 3.Partnering with VA to improve care? Hospice- Veteran Partnerships 4.Measure the impact of our interventions? Satisfaction is one option


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