Presentation on theme: "We Honor Veterans: What does this mean?"— Presentation transcript:
1We Honor Veterans: What does this mean? Asking are you a Veteran? Are staff prepared to deal with the answer?Military impact on end of life care?Partnering with VA to improve care?Measure the impact of our interventions?
2Top 10 reasons to participate We Honor VeteransTop 10 reasons to participate
3National Provider Awareness campaign A commitment to honor Veterans by:Assessing current ability to serve VeteransLearning more about caring for VeteransFinding resources to support Veterans at the end of lifeProviding veteran-centric education for staffMeasuring quality and outcomes3
4Community hospices are earning their stars! Provide Veteran-centric educationBuild organizational capacityScott’s opening comments then transition to slideDevelop and strengthen relationships with VAVeteran-specific quality measures
5Military History Checklist The Military History Checklist is designed to help VA staff and community hospices identify their Veteran patients, evaluate the impact of the military experience and determine if there are benefits to which the Veteran and surviving dependents may be entitled.There is a Military History Checklist Guide located in the resources section of the Military History Toolkit that provides a quick overview of the questions and implications for each. In addition there are three PowerPoint slide sets that provide information on Veterans’ benefits, service-related issues, and homelessness.5
6Hospice and Palliative Care: We Honor Veterans Welcome! This is a precious gathering of VA staff that care for Veterans with life-limiting illness and their families.Scott T. Shreve, DONational Director, Hospice and Palliative CareDepartment of Veterans AffairsAssociate Professor of Clinical MedicineThe Pennsylvania State University
7End of Life Care and Military Hospice (End of Life)MilitaryDependencyReconnect with othersLife review, reminisce, openly grieveEncourage self-determination and choiceInterdependenceHierarchical organizationDifficult memoriesCulture of stoicism; downplay sufferingGive orders, follow orders
8To honor Veterans’ preferences for care at the end of life 420,000 US servicemen and women died in WW IIHow many Veterans will die this year?42,000120,000320,000640,0008
9To honor Veterans’ preferences for care at the end of life 420,000 US servicemen and women died in WW IIHow many Veterans will die this year?42,000120,000320,000640,000More Veterans will die this year than died in WW II28% of all Americans who die this year~21,000 will die as VA inpatients; 136,000 VA outpts9
10Demographic Imperative Only 4% of Veterans die in VA (~21,000)MANY with advanced serious illnessOpen with slide and then back to Scott when he begins to talk about the 642,370 Veteran deathsif you use Almanac to identify Veterans with just 4 serious illnesses, CHF, CRF, COPD and XX, you’ll get more a figure of more than 800,000 Veterans suffering from these illnesses. This is before we even add in ANY Veterans with serious cancers which likely numbers in the 100,000s as well. I applaud all the advances in coordinating cancer care. Many of these concepts, such as being evidence based, matching goals of care to appropriate services and improved care coordination are equally applicable to the care of non-cancer serious illness.~642,370 Veterans will die in 2012PTF file and VetPop for 2012
12VA Hospice & Palliative Care US Hospitals: 12% offered palliative care in 2000, now ~60%What % of VA hospitals offer palliative care?30%56%67%100%
13VA Hospice & Palliative Care US Hospitals: 12% offered palliative care in 2000, now 60%What % of VA hospitals offer palliative care?30%56%67%100% (up from 38% in 2002)
14Uniform Benefits Package Hospice and palliative care is a covered benefit - all enrolled veterans, all settings, 38 CFR and 17.38VA is both a provider (eg inpatient units) and purchaser (eg home hospice) of end of life care.
16When hospice is available, many will use it (absolute % change in inpatient deaths by venue nationally)ICUAcuteNursing HomeHospiceChange6 %12 %13%31%FY1122%27%7%44%FY0428%39%20%With the increased availability and awareness of hospice and palliative care beds, Veterans are choosing to receive end of life care in these specialized units. More Veterans die in hospice and palliative care units than in VA Intensive Care Units and the growth in this venue of death is expected to continue. For many Veterans, VA inpatient hospice is often needed because these Veterans lack a spouse (56% of the 21,000 inpatient deaths in FY09) or the option of Medicare Hospice (26% of FY09 inpatient deaths were < 65 years old).Note, ~5060 veterans impacted despite declining overall inpt deaths
17VA Hospice & Palliative Care What % of Veterans who die as VA inpatients receive care from a palliative care team?30%56%73%100%
18VA Hospice & Palliative Care Unknown for US HospitalsWhat % of Veterans who die as VA inpatients receive palliative care?30%56%73% (up from 33% in 2004)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.”This recent article from the NEJM prospectively looked at comparing standard care for metastatic non-small cell lung cancer versus standard care with early palliative care involvement at the time of diagnosis. While this is a single site study and more research is needed these findings are consistent with others in the literature (Connor et al, Journal Pall Med, 2007).The intervention group here received referral to an interdisciplinary palliative care team at the time of diagnosis and on average had 4 visits, as an outpatient, with the palliative care team. The authors share their conclusion that “…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.”
20VA Trends Overview Inpt deaths 26,231 VA-paid hospice ADC 164 FY04Inpt deaths ,231VA-paid hospice ADC% VA deaths in hospice %% of inpt deaths with PC %FY11 21,606 1,105 44% 73%ADC- Average Daily Census, PC-Palliative Care
22Case Example: Mr. R 65 y/o White, male, divorced x 1 Served in the Army, saw combat, vague history of PTSDAdvancing lung cancer“Family” are buddies from Army, VFW. There is a son.Came to hospice when more difficult to live aloneConflicted family historySeemingly adjusted well to unit for ~month THEN:Refusing meds, angry outbursts at staffVacillating between paranoia, anxiety and angerPacing, fearful and exhausted
23Mr. R., cont’d Differential diagnosis What do you want to do? Delirium?Anxiety reaction with psychosis?Adverse drug reaction?PTSD?Others?What do you want to do?
24Father, friend, generosity BlameI caused this myselfI should have seen this comingI could have prevented thisView of the World:Bad things happen to good peopleThe world is unsafeThe world is cruelTRAUMAView of the Others:No one understands meI cannot connect with anyoneNo one can be trustedOthers wish me harmIf people knew what I did,they would hate meI’m brokenI’m a horrible personI’m a monsterTrauma touches and affects multiple aspects of person’s sense of self and world view.Trauma also tends to overshadow other parts of person’s identity (roles/ accomplishments) that existed prior to trauma(s) – ex: father (mother), son (sister; bro; sis), spouse/partnerGuiltI could have done moreI shouldn’t be aliveI couldn’t protect themI violated my own moralsFather, friend, generosityAccomplishments
26What is PTSD?An anxiety disorder that can occur after a traumatic eventExamples of traumatic events include:combat or military exposurechild sexual or physical abusesexual or physical assault *serious accidents, such as a car wreck.natural disastersPost traumatic Stress Disorder (PTSD) is an anxiety disorder that can occur after anindividual has experienced a traumatic event, such as the violence of war or a horrificaccident. While combat exposure is often the trauma that leads to PTSD in Veterans,there are other types of trauma that Veterans and non-Veterans may experience including sexual trauma and natural disasters.To meet DSM-IV-TR criteria for PTSD, the individual must have experienced, witnessed, or been confronted with an event involving actual or threatened death or serious injury, or a threat to the physical integrity of the individual or others.Additionally, the individual’s response to the traumatic event must involve intense fear, helplessness or horror. Diagnostic features of PTSD fall into three categories: intrusive recollections of the trauma, avoidant behaviors and numbing of general responsiveness, and hyperarousal.The duration of symptoms must be at least 4 weeks, and onset of symptoms can occur quickly after the trauma or be delayed for 6 months or more.1 These symptoms often disrupt life, making it hard to continue with daily activities. Anyone who has gone through a life-threatening or horrific event can develop PTSD.PSTD- Post traumatic Stress Disorder
27PTSD: What to look for Three key symptom clusters reliving the event avoiding reminders of the trauma / feeling numbfeeling anxious or “keyed up”Screening tools can be used to refer to a mental health professionalRecurring memories of the traumatic event may intrude at any time. Recurring dreams or nightmares about the trauma may occur. Individuals experience intense psychological distress when exposed to cues that resemble an aspect of the trauma, and individuals experience physiologic reactivity such as an increased pulse or sweating when exposed to cues that resemble the trauma, i.e., the fight or flight response. Flashbacks, or acting and feeling as if the trauma is recurring in the present, can be particularly intense. During such episodes, the Veteran often mistakes the perceived reality of the flashback for reality and may incorporate people and objects as part of the flashback. This might include confusing the clinician for an enemy combatant. Sights, Sounds, and other environmental cues can trigger flashbacks.An individual may experience a pervasive sense of emotional numbness. This may be evidenced in a variety of behaviors, such as losing interest and not participating in activities that were once enjoyable; being unable to form close personal relationships; preferring to be isolated; or being unable to experience deep emotions such as love. Some individuals express a sense of foreshortened future, not expecting to live long or have meaningful careers, marriages or family life. When faced with new trauma, such as terminal illness and decline at the end of life the Veteran may experience overwhelming emotional distress and suffering. Unfortunately, as a result of some of the symptoms described above, a Veteran with PTSD may have strained relationships with family and friends and can have very limited social support during such difficult times.A state of hyperarousal may be manifested by behaviors such as: suddenly becoming angry or irritable; having a hard time sleeping; having trouble concentrating;fearing for their safety and always feeling on guard (sometimes referred to as hypervigilance); and being excessively startled when someone surprises them.
28Post traumatic stress disorder Triggers:EnvironmentSensory experienceOthersRe-experiencethe eventNightmaresFlashbacksHallucinationsIntrusive thoughtsAvoidanceEmotional numbingDetachment/isolationAvoid triggers &thoughts interestsSense of aforeshortened futureHyperarousalHypervigilanceInsomniaDifficultyconcentratingAngry outbursts startle responseTriggers for PTSD symptoms can be visual, auditory, other sensory (heat, pain, shortness of breath), situational (dates/anniversaries) or emotional (anxiety, anger, fear and other intense emotions) can activate PTSD symptoms.Several brief screening tools for PTSD have been devised. They vary incomplexity; none are diagnostic. The Primary Care PTSD Screen (PC-PTSD) iscurrently in use by VA and consists of 4 questions. Current research suggests thatthe results of the PC-PTSD should be considered positive if a Veteran answers"yes" to any three items.14,15 Any Veteran who has a positive screen is referred toa mental health provider with expertise in PTSD for a more complete diagnosticevaluation. More information about this screening tool can be found at:
29WWII & Korean War Veterans Prevalence of PTSD largely unknownWWII and Korean War vets(community-dwelling)<2% lifetime PTSDNearly 10% had symptomsconsistent with partial-PTSD DxSchnurr et al, 2002
30PTSD backgroundLifetime prevalence among Americans ~6%Lifetime prevalence of as high as 30% of Vietnam era VeteransPrevalence from Gulf War 12.1%What about end of life prevalence?What about “almost PTSD”?
31Consequences of PTSD … Elevated mortality for Vietnam Vets Increased rates of substance abuseIncreased psychosocial problemsComment that most of what we know about PTSD comes from study of Vietnam vets such asNational Vietnam Veteran Readjustment Survey (1990) which reported a number of consequences of trauma, including the following: 14.1% report high levels of marital problems, and 23.1% have high levels of parenting problemsalmost 50% of all male Vietnam Veterans currently suffering from PTSD havebeen arrested or in jail at least once; 34.2% more than once; 11.5% had been convicted of a felony; lifetime prevalence of alcohol abuse/dependence: 39.2%; and 40% percent of male Vietnam Veterans have been divorced at least once (10%had two or more divorces).the presence of PTSD is often correlated with some of the following problems:: feelings of hopelessness, shame, or despair; employment problems; and relationship problems including divorce and violence.; anger management difficulties; an elevated risk for suicide among Vietnam Veterans with PTSD.Prevalent Lifetime disordersMale: alcohol abuse/dependence, generalized anxiety disorder, antisocial personality disorder Female: Generalized anxiety disorder, depression, alcohol abuse/dependencePTSD linked with poorer physical health, particularly heart-disease mortality (Boscarino, 2008)National Vietnam Veteran Readjustment Study (1990)
32… Consequences of PTSD Increased medical diagnoses circulatory and muscular-skeletal conditionspoorer health quality of lifeGreater pain intensity and pain interference in functioningindividuals with PTSD report greater intensity of pain, though it is unclear whythis may be the case; it may relate to the hyperarousal of the nervous system,associated with PTSD or due to high levels of anxiety that contribute todistressing reactions to pain;
33PTSD and Veterans (Davison et al, 2006) 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 exposureIncreasingly more emotional about combat experiencesStronger reactions to daily stressorsVeterans typically asymptomatic prior to changes(Davison et al, 2006)
34Death/illness as a PTSD activator How can PTSD impact EOL care?death/illness as a PTSD activatorchallenging social ties, eg doctor - patientdelirium or flashbackmedication issuesGoals of care to include reduction in PTSD symptomsPTSD and use of medications at the end of life can be challenging for the clinicians forthe following reasons: many of the medications used to treat PTSD often take time for full effect (SSRIs,tricyclic anti-depressants). Veterans at the end of life may not have time for themedications to be adjusted to the best effect; Veterans may reject pain medication due to a need to be a “strong soldier”; Veterans may misuse medication to self-medicate PTSD symptoms; it is important to continue psychiatric medications at end of life to help managelongstanding PTSD symptoms; some Veterans with PTSD may feel more vulnerable with sedating medicationmeant to calm them and this can increase agitation as they are not “ready todefend” themselves if they need to; andUnderstand PTSDProvide psychoeducationListen if pt wishes to reminisce/disclose traumaSymptom managementPTSD” Skills training (e.g., mindfulness), grounding, practical problem solving; draw on past coping skills; forgiveness (trauma related guilt, moral killing,Pain managementRefer out to mental health (if possible/needed)
35Hospice and PTSD Hospice (end of life) PTSD Need for control Isolation; family may not know about traumaMay avoid reminiscing (possible triggers)Need predictability, privacyWish to forgetDifficulties with authority figuresDependencyReconnect with othersReminisce; Life reviewMultiple checks by staffLegacy-building
36PTSD at EOL: Themes Vulnerability and Safety Inability to defend self from perceived threatsIncreased sense of vulnerability (physical/cognitive decline)Mr. R: “I’m not safe; You’re are trying to poison me.”Difficulty with authority figures (staff; physicians)Difficulty relinquishing controlPotential for non-adherence to medications (e.g., sedatives)Mr. R: No one can be trusted, angry outburstsPotential triggersPhysical pain (especially if trauma-related injury)Environmental triggers (sounds, sights, smells, people)Mr. R: “I don’t want to suffer like he did.”
37Interpersonal Relationships Some families express concern about PTSD-related symptoms in pt during last month of lifePalliative Care consults improved families perception of pt discomfort from PTSD symptoms.(Alici et al, 2010)
38Practical Applications Anger: Disarm and empathizeNo mention of past traumaIf pt begins to disclose, listen and empathizePt is in charge of the pace and extent of disclosureHypervigilance: Consistency/predictability is keyKeep regular schedule with same staffNarrate actions so patient aware of what is happeningAnnounce self upon entering to reduce potential startle responseMake sure patient can hear you enteringRemain in patient’s line of visionPosition patient so (s)he can see the doorway
40VA’s Bereaved Family Surveys Attempted for every VA inpatient deathOver 23,000 completed surveys and 39,700 chart reviews in all VA facilitiesResponse rate: 56% (No significant effect of nonresponse bias on facility or VISN scores)More than 3,400 families referred for additional supportCasarett et al, 2011
41% of Families Rating End of Life Care as “Excellent” in Acute Units vs % of Families Rating End of Life Care as “Excellent” in Acute Units vs. Palliative care vs. Inpatient Hospice Unit Settings66%58%46%p values < 0.001
42Shared Accountability Care of serious illness goes beyond palliative careLeadership engagementCommunity partnersMore than hospiceFamily Evaluation of Hospice Care (FEHC)Recently released FEHC for VeteransNational Quality Forum
43We Honor VeteransAsking are you a Veteran? Are staff prepared to deal with the answer? Consider committing to We Honor VeteransMilitary impact on end of life care? Learn about the care needs of VeteransPartnering with VA to improve care? Hospice- Veteran PartnershipsMeasure the impact of our interventions? Satisfaction is one option