The Unique Needs of Veterans at the End of Life

The Unique Needs of Veterans at the End of Life Trisha OLeary, MSW, LCSWGretchen Fairweather, MSW, CAPSWNicole Keedy, PhD.Nancy Krueger, PhD.Presentation OverviewVA benefits: Resources, access, and eligibility

Effects of military culture and combat on the end of life experience

Mental health and PTSD in Veterans at the end of life

Access to the VAIt is important to ask each hospice patient if they are a veteran, as this will have an impact on the care plan.

If the patient is a veteran, the next step would be to find out the veterans enrollment status in the VA. In order for a veteran to receive hospice benefits, he/she must be in the system.

Are you enrolled with the VA?If yes, then ask what clinic they are in and who their Primary Care MD is. The VA has divided the primary care clinics by color. Each clinic has a social worker assigned to it. This clinic would be a link to additional resources, if needed by the veteran. The clinic could also assist with getting into a VA contract nursing home or the palliative care unit.If not enrolled then..If the veteran has not enrolled in the VA system, then it would be appropriate to ask the veteran if he would like to enroll.In order to get in the system the veteran must complete form 10-10EZR, which is located on the internet and provide a copy of his DD214. The DD214 is a one page form that describes when the veteran served, dates of service and type of discharge. Sometimes these are stored in county courthouses, or the VA could try to obtain a copy.(https://www.1010ez.med.va.gov/sec/vha/1010ez/)

Eligibility for the VANot all veterans are eligible for care.The admissions department determines eligibility based on income, assets, service time and current medical expenses.Veterans are always encouraged to apply.The quicker we can get the needed forms, the sooner the veteran can get registered.

Options available to enrolled VeteransThe palliative care unitVA contract nursing home careHome hospice careContinued aggressive treatmentsBurial benefits

This is a 24 bed inpatient unit that serves veterans with a limited life expectancy, days to weeks, and those needing radiation/chemo treatments.This is a free benefit to the veteranAdmission hours are Monday-Friday, 8:00AM-3:30 PMCannot guarantee admission same day as veteran is referredContact the palliative care unit directly for admission. #414-384-2000 ext. 46742 or 42483The Palliative Care UnitVA Contract Nursing HomesVA contracts with several skilled nursing facilities in the area.Veterans in need of hospice care, but can no longer reside at home are eligible for care in a contract home with VA paying the room and board. If VA was paying the hospice care, this would continue in the nursing home.Contact primary care clinic for assistance with this process or the palliative care unit.Home Hospice CareVA does not provide home hospice care, we depend on community agencies to provide this.The VA will pay for this care, if there is a provider agreement in place. If the veteran chooses to use another payer source (Medicare/Medicaid) then the requirement for a provider agreement is not needed. VA will pay the hospice agency the Medicare per diem rate.

Continuation of Aggressive TreatmentVeterans are not always ready to terminate treatment completely and not all hospices offer open access care.Since the VA does not bill Medicare, the veteran can continue to come to the VA for what would be considered aggressive treatment, if part of the care plan.Some examples include: blood transfusions, palliative radiation treatment and oral chemo.Burial BenefitsThese are dependent upon veterans location of death and if the VA was paying for the hospice.

Always encourage family to call the VA Regional Office at #1-800-827-1000 to learn about death/burial benefits.

GOING HOMEIS THE END OF LIFE JOURNEY DIFFERENT FOR VETS?Gretchen Fairweather, CAPSW1800 vets die each day in U.S.Only 4% die in VA facilities Greatest percentage of vets will be served by community hospiceNeed for collaboration between community hospice agencies and VA

(statistics retrieved from www4.va.gov/oaa/archive/hvp_toolkit3.pdf)What makes end of life (EOL) needs of vets different? Military culture promotes stoicismShowing fear or pain considered weaknessBasic training often demoralizingVets may have trust or guilt issuesHigh instance of substance abuse

(Grassman, D. L., 2009)Combat Experience Biggest InfluenceVeterans may have complex needs resulting from combat or Prisoner of War experienceMay have already faced death as dramatic eventCoping with unresolved grief or guiltMay have survivor guilt Why did my buddy die and I didnt? I should have saved himPerhaps witnessed traumatic events causing PTSDDifferent War Different MemoriesVeterans of different wars had different experiencesSense of important mission or purposeGeography and climate effectsStyle of engagement: Who was the enemy?Wars result Was there a clear victory?Support from those back homeReception upon returnEach war had a unique culture which influenced returning veterans

WWII had a clear mission1941-1945Supported by virtually everyoneFought in several countries in extreme climates and circumstancesAmerican public shielded from much of the horrorSoldiers came home to heros welcomeNation wanted stories of victory soldiers needed to give voice to atrocities of war

Korean War 1950-1953Military conflict often called The Forgotten WarSoldiers fought in extreme weather conditions frostbite was prevalentEnded in stalemateSoldiers efforts minimized, traumas ignored

Vietnam 1964-1975Unpopular warExtensive TV coverage of brutality of warAnti-war sentiments back homeDraftees and enlistees turned into cynics by uncertainty of missionGuerrilla war tactics-enemy could be anyoneA war without a victorySoldiers felt disrespected, shamed, disregarded

Vietnam (cont.)Soldiers buried their storiesEmotional baggagePTSDSurvivor guiltDepressionSuicidal ideationEffects of Agent OrangeMalaria

Desert Shield/Desert StormOEF/OIFHospices may be treating soldiers of recent warsRecently acknowledged that some veterans serving in the military have experienced MST (Military Sexual Trauma)Is now a recognized treatment focus as well as results of PTSD and TBI (Traumatic Brain Injury)Many women now serving in combat zones will have own special needs at end of life

Understanding a combat veteran facing EOLImportant for those serving vets to have appreciation and understanding of experiences known only to a combat soldier

VA is in unique position to assist hospices in developing best-practice strategies to help vets on their final journeysMental Health in Veterans at End of LifeNancy Krueger, Ph.D.Nicole H. Keedy, Ph.D.OBJECTIVESOverview of how the military shapes attitudes about death and dyingUnderstand special mental health needs of Veterans at end of lifeLearn strategies to help the veteran cope at end of life with psychological issues, especially PTSD

Special EOL Considerations in VeteransSuicidalityHighest prevalence in White, older, malesAlso higher prevalence in Veterans than non-VeteransFirearms Increased comfort and knowledge about themPotential lethal means for suicideLocks (available to Veterans through the VA)

Posttraumatic Stress Disorder - PrevalenceUp to 84% of people experience trauma in their life and it is thought that 25% of these individuals experience PTSD (Feldman & Periyakoil, 2006)Some people who did not previously have symptoms may experience delayed onset at the end of lifeThe end of life experience may trigger emotions and memories from their trauma

TraumaCombat is one type of traumaOther types includeSexual assault (and military sexual trauma)Motor vehicle accidentsSeeing someone harmedOther threats to oneself or othersMilitary combat may be different than other traumasRepeated traumaOne person may be both victim and perpetratorPotential PTSD Triggers at EOLPainDecreased functional capacityHelplessnessFear and AnxietyMedication side-effectsIn some people who are accustomed to feeling tense, the sensation of relaxation may paradoxically create discomfort and anxiety

PTSD - AssessmentPTSD diagnoses requires the experience of a traumatic event in addition to symptoms that can be described in three clusters:Re-experiencing symptoms (repetitive disturbing memories, nightmares, and hallucination-like flashbacks)Avoidance symptoms (attempts to avoid reminders of traumaobjects, places, people)Hyperarousal symptoms (hypervigilance, irritability, exaggerated startle response, and insomnia)American Psychiatric Association (DSM-IV-TR), 2000PTSD - AssessmentOther conditions have similar features:DeliriumParanoiaSuspicionAgitationFearHallucinationsConfrontationAnxietyAgitationWorry

Potential effects of PTSDDifficulty sleeping due to nightmaresDisturbing thoughts and memories that patient has difficulty avoidingMild paranoiaVivid hallucinationsIntense anxiety (Fight/Flight/Freeze) alternating with "no feelings at all" (emotional numbing).Distrust of othersPotential Effects of PTSDThreat to life can mimic the original trauma, and exacerbate previously mild symptomsThe normal process of life review can lead to intense anxiety, sadness, guilt, angerAvoidance as a coping mechanism may lead to poor medical adherence or poor communication with medical staffDistrust in authority can lead to excessive questioning of providers' actions and refusal of carePatients with PTSD may lack caregivers because of a history of social isolation and avoidance

Family Dynamics of PTSDFamily reactions are complex and each situation is uniqueEmotional numbing may create distance with loved onesVeterans with PTSD may be irritable much of the timeVeterans may engage in routines or behaviors such as checking the perimeter and avoiding public placesVeterans may attempt to control family and situations to the extent of control required in battleTreatment of PTSDDrugs to reduce intensity of symptoms (TCA, SSRI, Benzos)Psychotherapy (often not possible during brief admissions)Group therapyPsychosocial symptom management (helpful for brief admissions)

Psychosocial Management of PTSDAdopt a patient-centered approachEgalitarian communication style despite patient's hostility and avoidanceStaff must increase awareness of their own reactions to patient. Staff may feel:Sympathy for patient's sufferingAnger at patient's behaviorGuilt or sense of responsibility for patients distress

Psychosocial Management of PTSDConsider ways in which one's approach with the patient may trigger fear, startle, avoidance, or other reactions, and work toward altering one's approachAsk patient about behaviors that may trigger PTSDShoutingPointing TouchingEntering room unannouncedOrdering them what to do rather than providing optionsAsk patient about behaviors that may helpProviding nightlightAwaken patients by stating their name rather than touchingIncrease privacyNormalize the patients experience some Veterans may not know about PTSD

Possible QuestionsIn what branch of the military did you serve?When and where did you serve?Did you see combat, enemy fire, or casualties?Were you wounded or hospitalized?Do you have nightmares or feel like you are back in combat sometimes?Do you try to avoid thinking about it?Are you easily startled or constantly on guard?

Possible ResponsesListen patiently and warmly, and allow them to stop when they are readyAvoid attempts to comfort that actually serve to stifle the topic (Its ok, Dont cry, That was a long time ago, etc.)Inform them that it is very normal to have these memories and to feel distressed by them, especially near the EOLIs there anyone to whom you would like to speak about these concerns? A chaplain? A social worker?Possible Responses, cont.Signs a Veteran may be having a flashback Behaving as if in warfareLooking extremely fearfulFreezing and staring into spaceMaking statements such as look out or I see the enemyEngage in verbal grounding, while maintaining physical space for safetyMr. _____, were in your bedroom, in your home in Milwaukee, and my name is _____.Questions?

References and ResourcesAmerican Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, (Revised 4th ed.). Washington, DC: Author.

Feldman D.B., &Periyakoil, V.S. (2006). Posttraumatic stress disorder at the end of life. Journal of Palliative Medicine, 9, 213-218.

Grassman, D.L., (2009). Peace at last: Stories of hope and healing for veterans and families. Vandemere Press: St. Petersburg, FL

http://en.wikipedia.org/wiki/Korean_War

http://www4.va.gov/oaa/archive/hvp_toolkit3.pdf

Seahorn, J. J., & Seahorn, A.H. (2008). Tears of a Warrior: A Family's Story of Combat and Living with PTSD. Fort Collins, CO: Team Pursuits.

http://www.tearsofawarrior.com