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