1. Veterans, PTSD and End-of-Life MARGARET WALKOSZ, MS, GNP-BC NURSE PRACTITIONER HINES VA HOSPITAL PALLIATIVE CARE AND HOSPICE

2. VA MISSION: TO CARE FOR HIM WHO SHALL HAVE BORNE THE BATTLE, AND FOR HIS WIDOW, AND HIS ORPHAN – ABRAHAM LINCOLN – …BY SERVING AND HONORING THE MEN AND WOMEN WHO ARE AMERICA’S VETERANS. Veterans, PTSD and End-of-Life

3. Objectives: 1. Explain the influences that military culture and service exert on Veterans, and how these experiences impact end-of-life care. 2. Describe the components of Post Traumatic Stress Disorder (PTSD) in Veterans. 3. Outline how PTSD may impact the process of dying for Veterans. 4. Describe palliative care assessment and intervention for combat and non-combat Veterans.

4. America’s Veterans America’s Wars Total (1775 -1991) U.S. Military Service during Wartime almost 42 million Living Veterans (Periods of War & Peace) over 23 million Living War Veterans over 17 million Department of Veterans Affairs, Nov. 2007

5. World War II Era World War II (1941 – 1945) Total U.S. Service members (Worldwide) over 16 million Living Veterans 2 million Approximately 850 WWII Veterans die each day Department of Veterans Affairs, Nov. 2007

6. Korean War Era Korean War (1950-1953) Total U.S. Service members (Worldwide) almost 6 million Served in Korea 1.7 million Battle Deaths 33,741 Living Veterans 2.4 million Department of Veterans Affairs, Nov. 2007

7. Vietnam War Era Vietnam War (1964-1975) Total U.S. Service members (Worldwide) 8.7 million Living Veterans Vietnam Era 7.2 million Deployed to Southeast Asia 3.4 million Living Veterans who served in Vietnam less than 1 million Department of Veterans Affairs, Nov. 2007

8. Veteran Deaths Nearly 680,000 Veterans die each year (about 1800 each day) Less than 4% of Veterans die in VA facilities Approximately 96% of Veterans die in the community www.va.gov/vetdata

9. Influence of Military Culture Military training encourages courage, toughness, and denial of emotion: Big boys don’t cry. No pain, no gain. (Marine slogan: “Pain is weakness leaving the body”) Fear and pain are signs of weakness. Once a Marine, always a Marine. Stoicism: stubborn pride, control that conquers, fierce independence

10. Influence of Military Culture Biggest influence: COMBAT

11. Consequences of Combat Exposure Video Clip: WW II Veteran

12. Vietnam War The average infantryman in the South Pacific during World War II saw about 40 days of combat in four years. The average infantryman in Vietnam saw about 240 days of combat in one year thanks to the mobility of the helicopter. History.com

13. Exposure to Toxins Exposure to toxic substances has occurred in every war era: For example: Agent Orange is the name given to a blend of herbicides the U.S. military sprayed from 1961 to 1971 in Vietnam to remove foliage that provided enemy cover. Source of chronic and sometimes life-threatening illness and disability.

14. Coming Home: Era of Service World War II: Heroes * country worked together Korea: Ignored * forgotten war Vietnam: Shamed * country torn apart

15. Impact of Military Service on Families Whole family experience --authoritarian family dynamics --frequent moving Battlemind training -- inner strength to face fear and adversity with courage -- “no pain, no gain”, suppressing emotions

16. Impact of Military Service on Families Deployment and Combat --redefining identity role and purpose (war to peace) -- roller coaster for family Discharge or Retirement --transition to civilian life

17. Mental Illness Among Veterans Depression Anxiety Substance Abuse Schizophrenia PTSD

18. Disability from PTSD Number of Veterans Compensated for PTSD : 397,019 (as of 06/30/10) http://www1.va.gov/VETDATA

19. PTSD Estimated 30 to 50 % of Veterans who served in combat will exhibit some symptoms of PTSD. Other military experiences, such as military sexual trauma, can also contribute to PTSD.

20. DSM-IV-TR criteria for Post Traumatic Stress Disorder (PTSD) Diagnostic criteria for PTSD include o A history of exposure to a traumatic event experienced with fear, horror, or helplessness o Symptoms from each of three symptom clusters:  intrusive recollections,  avoidant/numbing symptoms  hyper-arousal symptom

21. PTSD How likely someone is to get PTSD depends on many things: How intense the trauma was or how long it lasted If someone close was lost or hurt Proximity to the event Strength of the reaction to the event How much the Veteran felt in control of events How much help and support the Veteran got after the event History of previous trauma

22. PTSD PTSD symptoms * typically start soon after the traumatic event * can be delayed by months or even years * may come and go over many years  If the symptoms last longer than 4 weeks, cause great distress, or interfere with work or home life, the individual probably has PTSD.

23. PTSD Symptoms 1. Reliving the event (also called re-experiencing symptoms):  Bad memories of the traumatic event can return at any time.  The Veteran may feel the same fear and horror as when the event took place.  He/she may have nightmares or may feel like he/she is going through the event again (flashback).  Unrelated events may trigger these symptoms (For example: Hearing a car backfire, which can bring back memories of gunfire and war for a combat Veteran. )

24. PTSD Symptoms 2. Avoiding situations that are reminders of the event: The Veteran may  try to avoid situations or people that trigger memories of the traumatic event  avoid talking or thinking about the event

25. PTSD Symptoms 3. Feeling numb: The Veteran may find it hard to express feelings. This is another way to avoid memories. He/she may not:  have positive or loving feelings toward other people and may stay away from relationships  be interested in previously enjoyed activities  be able to remember parts of the traumatic event or be able to talk about them

26. PTSD Symptoms 4. Feeling keyed up (also called hyper-arousal): The Veteran may be jittery, or always alert and on the lookout for danger. Hyper-arousal can cause:  Sudden anger or irritation  Difficulty sleeping and concentration  Fear for personal safety and a constant need to be on guard  Overreaction when something surprises him/her.

27. Other Common Problems with PTSD Drinking or drug problems Tobacco Feelings of hopelessness, shame, or despair Employment problems Relationship problems, including divorce and violence Physical symptoms

28. Coping with PTSD Video Clip: Vietnam Veteran

29. Military History Intake Assessment: Have you served in the military? If so, have you served in a Dangerous Duty assignment? (Encourage stories…..)

30. Screening for PTSD

31. Impact of Military Service on Veterans EOL experience Anticipate complications at End-of-Life, particularly for combat Veterans: Stoicism (pervasive in military culture) may present as resistance, non-compliance or mistrust of caregivers. Dying experience can trigger painful memories of comrades and (often traumatic) deaths, even in Veterans who were never diagnosed with PTSD. Co-morbidity (i.e. terminal illness along with addiction, mental illness, PTSD) can complicate care.

32. Interventions for PTSD Assess for underlying conditions that may be contributing to distress: pain urinary retention constipation hypoxia poly-pharmacy withdrawal from alcohol or tobacco terminal restlessness

33. Interventions for PTSD Create an environment that helps the Veteran feel safe.

34. Interventions for PTSD Understand, acknowledge and accept the Veteran’s pain, anger, shame, guilt, fear, and helplessness. Encourage forgiveness (of self, others, God). Educate the family on symptoms of PTSD. Offer support of Social Worker, Chaplain, Psychologist. Consider psychotropic medication to treat depression, anxiety, psychosis, delirium (trial and error due to variable response).

35. Interventions for PTSD No restraints, particularly for former POWs. If possible, avoid bed alarms and other loud noises. Don’t touch the Veteran without calling out his/her name or letting them see you first. Grounding in reality may not be effective at end of life. Create a safe space (for example, by entering the battlefield metaphor with the Veteran, “this is a special bomb proof room”).

36. Interventions: For All Veterans Affirm the feeling aspect of the death experience, the tears and fears (which the military culture taught them to disdain); encourage, but don’t force. Anticipate that Veterans might underreport physical and emotional pain. Anticipate that Veterans might underreport fear.

37. Interventions: For All Veterans Thank each Veteran for serving our country and giving us our freedom. Post a certificate of appreciation. Create personal ceremonies (American flag pin.) Educate Veterans and families about VA benefits. (ALL Veterans, regardless of service, have Hospice as a benefit, inpatient or outpatient.)

38. Recommended Reading Peace at Last Stories of Hope and Healing for Veterans and Their Families Deborah L. Grassman 2009 by Vandamere Press

39. Resources www.WeHonorVeterans.org Collaboration between VA and the National Hospice and Palliative Care Organization (NHPCO)

40. Thank a Veteran.