Veterans, PTSD and End-of-Life

MARGARET WALKOSZ, MS, GNP-BCNURSE PRACTITIONER

HINES VA HOSPITALPALLIATIVE CARE AND HOSPICE

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

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.

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

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

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

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

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

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

Influence of Military Culture

Biggest influence:

COMBAT

Consequences of Combat Exposure

Video Clip: WW II Veteran

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

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.

Coming Home: Era of Service

World War II: Heroes * country worked

together

Korea: Ignored * forgotten war

Vietnam: Shamed * country torn apart

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

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

Mental Illness Among Veterans

DepressionAnxiety

Substance Abuse

SchizophreniaPTSD

Disability from PTSD

Number of Veterans Compensated for

PTSD : 397,019

(as of 06/30/10)http://www1.va.gov/VETDATA

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.

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

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

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.

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. )

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

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

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.

Other Common Problems with PTSD

Drinking or drug problems TobaccoFeelings of hopelessness, shame, or despair Employment problems Relationship problems, including divorce and

violence Physical symptoms

Coping with PTSD

Video Clip: Vietnam Veteran

Military History

Intake Assessment:

Have you served in the military?

If so, have you served in a Dangerous Duty assignment?

(Encourage stories…..)

Screening for PTSD

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.

Interventions for PTSD

Assess for underlying conditions that may be contributing to distress:

painurinary retentionconstipation hypoxia poly-pharmacywithdrawal from alcohol or tobaccoterminal restlessness

Interventions for PTSD

Create an environment that helps the Veteran feel safe.

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).

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”).

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.

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.)

Recommended Reading

Peace at LastStories of Hope and Healing for

Veterans and Their Families

Deborah L. Grassman2009 by Vandamere Press

Resources

www.WeHonorVeterans.org

Collaboration between

VA and the

National Hospice and Palliative Care Organization (NHPCO)

Thank a Veteran.