We Honor Veterans:What does this mean?

1. Asking are you a Veteran? Are staff prepared to deal with the answer?

2. Military impact on end of life care? 3. Partnering with VA to improve care?4. Measure the impact of our interventions?

We Honor Veterans

Top 10 reasons to participate

Community hospices are earning Community hospices are earning their stars!their stars!

Provide Veteran-centric education

Build organizational capacity

Develop and strengthen relationships with VA

Veteran-specific quality measures

www.wehonorveterans.org

Military History Checklist

Hospice and Palliative Care:

We Honor Veterans

Scott T. Shreve, DO

National Director, Hospice and Palliative CareDepartment of Veterans Affairs

Associate Professor of Clinical MedicineThe Pennsylvania State University

End of Life Care and Military

Hospice (End of Life)

• Dependency• Reconnect with others• Life review, reminisce,

openly grieve• Encourage self-

determination and choice

Military

• Interdependence• Hierarchical

organization• Difficult memories• Culture of stoicism;

downplay suffering• Give orders, follow

orders

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?

a. 42,000b.120,000c. 320,000d.640,000

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?

a. 42,000b. 120,000c. 320,000d.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

Demographic Imperative

Only 4% of Veterans die in VA (~21,000)

~642,370 Veterans will die in 2012

PTF file and VetPop for 2012

MANY with advanced MANY with advanced serious illnessserious illness

Veterans Integrated Service Networks

VA Hospice & Palliative Care• US Hospitals: 12% offered palliative care in

2000, now ~60%

• What % of VA hospitals offer palliative care?a. 30%b. 56%c. 67%d. 100%

VA Hospice & Palliative Care

• US Hospitals: 12% offered palliative care in 2000, now 60%

• What % of VA hospitals offer palliative care?a. 30%b. 56%c. 67%d. 100% (up from 38% in 2002)

Uniform Benefits Package

Hospice and palliative care is a covered benefit - all enrolled veterans, all settings, 38 CFR 17.36 and 17.38

VA is both a provider (eg inpatient units) and purchaser (eg home hospice) of end of life care.

End-Of-Life Issues Impact All End-Of-Life Issues Impact All Systems of CareSystems of Care

When hospice is available, many will use it(absolute % change in inpatient deaths by venue nationally)

ICU AcuteNursing Home

Hospice

Change 6 % 12 % 13% 31%

FY11 22% 27% 7% 44%

FY04 28% 39% 20% 13%

Note, ~5060 veterans impacted despite declining overall inpt deaths

VA Hospice & Palliative Care

What % of Veterans who die as VA inpatients receive care from a palliative care team?a. 30%

b. 56%

c. 73%

d. 100%

VA Hospice & Palliative Care• Unknown for US Hospitals

• What % of Veterans who die as VA inpatients receive palliative care?a. 30%

b. 56%

c. 73% (up from 33% in 2004)d. 100%

“…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.”

VA Trends Overview FY04

Inpt deaths 26,231

VA-paid hospice ADC 164

% VA deaths in hospice 12%

% of inpt deaths with PC 33%

FY11

21,606

1,105

44%

73%

ADC- Average Daily Census, PC-Palliative Care

Video Clip

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 staffVacillating between paranoia, anxiety and angerPacing, fearful and exhausted

Mr. R., cont’d

• Differential diagnosis– Delirium?– Anxiety reaction with psychosis?– Adverse drug reaction?– PTSD?– Others?

What do you want to do?

I’m broken I’m a horrible

personI’m a monster

Father, friend,

generosity

Guilt•I could have done more•I shouldn’t be alive•I couldn’t protect them•I violated my own morals

View of the World: •Bad things happen to good people

•The world is unsafe•The world is cruel

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

Blame•I caused this myself• I should have seen this coming•I could have prevented this

TRAUMA

Accomplishments

Post traumatic stress disorder (PTSD)

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 disastersPSTD- Post traumatic Stress Disorder

PTSD: What to look for

Three key symptom clusters

1) reliving the event

2) avoiding reminders of the trauma / feeling numb

3) feeling anxious or “keyed up”

Screening tools can be used to refer to a mental health professional

http://www.ptsd.va.gov/professional/pages/assessments/pc-ptsd.asp

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

Trauma

Post traumatic stress disorder

WWII & Korean War Veterans

• Prevalence of PTSD largely unknown

• WWII and Korean War vets (community-dwelling)– <2% lifetime PTSD – Nearly 10% had symptomsconsistent with partial-PTSD Dx

PTSD background

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”?

http://www.ptsd.va.gov/professional/pages/fslist_ptsd_overview.asp

Lifetime prevalence among Americans ~6%

Consequences of PTSD …

Elevated mortality for Vietnam Vets

Increased rates of substance abuse

Increased psychosocial problems

National Vietnam Veteran Readjustment Study (1990)

… Consequences of PTSD

Increased medical diagnosescirculatory and muscular-skeletal conditions

poorer health quality of life

Greater pain intensity and pain interference in functioning

PTSD and Veterans• 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 experiences Stronger reactions to daily stressors Veterans typically asymptomatic prior to changes

(Davison et al, 2006)

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

Hospice and PTSDHospice (end of life)

• Dependency• Reconnect with others

• Reminisce; Life review

• Multiple checks by staff• Legacy-building

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

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.”

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)

Practical Applications• Anger: Disarm and empathize

No mention of past traumaIf 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 happeningAnnounce self upon entering to reduce potential startle

responseMake sure patient can hear you entering Remain in patient’s line of vision Position patient so (s)he can see the doorway

Video clip

Link:

http://www.msnbc.msn.com/id/43142267/ns/nightly_news/t/going-back-terrifying-place-where-young-man-grew-old/

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

% of Families Rating End of Life Care as “Excellent” in Acute Units vs. Palliative care vs. Inpatient Hospice Unit Settings

N=3163 N=4706 N=3296N= 2,884 N=4,696 N=4,1640%

10%

20%

30%

40%

50%

60%

70%

Acute Units Palliative care Inpatient Hospice Unit

FY2010 FY2011

p values < 0.001

46%

58%

66%

Shared Accountability

• Leadership engagement

• Community partners– More than hospice – Family Evaluation of Hospice Care (FEHC) – Recently released FEHC for Veterans

Care of serious illness goes beyond palliative care

National Quality Forum

We Honor Veterans1. Asking are you a Veteran? Are staff prepared to deal

with the answer? Consider committing to We Honor Veterans

2. Military impact on end of life care? Learn about the care needs of Veterans

3. Partnering with VA to improve care? Hospice-Veteran Partnerships

4. Measure the impact of our interventions? Satisfaction is one option