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We Honor Veterans: What does this mean?

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1 We 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?

2 Top 10 reasons to participate
We Honor Veterans Top 10 reasons to participate

3 National Provider Awareness campaign
A commitment to honor Veterans by: Assessing current ability to serve Veterans Learning more about caring for Veterans Finding resources to support Veterans at the end of life Providing veteran-centric education for staff Measuring quality and outcomes 3

4 Community hospices are earning their stars!
Provide Veteran-centric education Build organizational capacity Scott’s opening comments then transition to slide Develop and strengthen relationships with VA Veteran-specific quality measures

5 Military 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

6 Hospice 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, 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) Military Dependency Reconnect with others Life review, reminisce, openly grieve Encourage self-determination and choice 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? 42,000 120,000 320,000 640,000 8

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? 42,000 120,000 320,000 640,000 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 9

10 Demographic Imperative
Only 4% of Veterans die in VA (~21,000) MANY with advanced serious illness Open with slide and then back to Scott when he begins to talk about the 642,370 Veteran deaths if 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 2012 PTF file and VetPop for 2012

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? 30% 56% 67% 100%

13 VA 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)

14 Uniform Benefits Package
Hospice and palliative care is a covered benefit - all enrolled veterans, all settings, 38 CFR and 17.38 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) ICU Acute Nursing Home Hospice Change 6 % 12 % 13% 31% FY11 22% 27% 7% 44% FY04 28% 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

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

18 VA Hospice & Palliative Care
Unknown for US Hospitals What % 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.”

20 VA Trends Overview Inpt deaths 26,231 VA-paid hospice ADC 164
FY04 Inpt deaths ,231 VA-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

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., 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?

24 Father, friend, generosity
Blame I caused this myself I should have seen this coming I could have prevented this View of the World: Bad things happen to good people The world is unsafe The world is cruel TRAUMA 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 I’m broken I’m a horrible person I’m a monster Trauma 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/partner Guilt I could have done more I shouldn’t be alive I couldn’t protect them I violated my own morals Father, friend, generosity 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 Post traumatic Stress Disorder (PTSD) is an anxiety disorder that can occur after an individual has experienced a traumatic event, such as the violence of war or a horrific accident. 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

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

28 Post traumatic stress disorder
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 Triggers 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 in complexity; none are diagnostic. The Primary Care PTSD Screen (PC-PTSD) is currently in use by VA and consists of 4 questions. Current research suggests that the 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 to a mental health provider with expertise in PTSD for a more complete diagnostic evaluation. More information about this screening tool can be found at:

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 among Americans ~6% 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”?

31 Consequences of PTSD … Elevated mortality for Vietnam Vets
Increased rates of substance abuse Increased psychosocial problems Comment that most of what we know about PTSD comes from study of Vietnam vets such as National 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 problems almost 50% of all male Vietnam Veterans currently suffering from PTSD have been 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 disorders Male: alcohol abuse/dependence, generalized anxiety disorder, antisocial personality disorder Female: Generalized anxiety disorder, depression, alcohol abuse/dependence PTSD 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 conditions poorer health quality of life Greater pain intensity and pain interference in functioning individuals with PTSD report greater intensity of pain, though it is unclear why this 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 to distressing reactions to pain;

33 PTSD 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 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 PTSD and use of medications at the end of life can be challenging for the clinicians for the 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 the medications 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 manage longstanding PTSD symptoms;  some Veterans with PTSD may feel more vulnerable with sedating medication meant to calm them and this can increase agitation as they are not “ready to defend” themselves if they need to; and Understand PTSD Provide psychoeducation Listen if pt wishes to reminisce/disclose trauma Symptom management PTSD” Skills training (e.g., mindfulness), grounding, practical problem solving; draw on past coping skills; forgiveness (trauma related guilt, moral killing, Pain management Refer out to mental health (if possible/needed)

35 Hospice and PTSD Hospice (end of life) 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 Dependency Reconnect with others Reminisce; Life review Multiple checks by staff Legacy-building

36 PTSD at EOL: Themes Vulnerability and Safety
Inability to defend self from perceived threats Increased 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 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 don’t 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 patient’s line of vision Position patient so (s)he can see the doorway

39 Video clip Link:

40 VA’s 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
% of Families Rating End of Life Care as “Excellent” in Acute Units vs. Palliative care vs. Inpatient Hospice Unit Settings 66% 58% 46% p values < 0.001

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

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

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