Transcript Veterans, PTSD and End-of-Life - IL-HPCO

Veterans, PTSD and End-of-Life
MARGARET WALKOSZ, MS, GNP-BC
NURSE PRACTITIONER
HINES VA HOSPITAL
PALLIATIVE CARE AND HOSPICE
Veterans, PTSD and End-of-Life
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.
Objectives:
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.
1.
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
 Depression
 Anxiety
 Substance Abuse
 Schizophrenia
 PTSD
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
 Tobacco
 Feelings 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:
 pain
 urinary retention
 constipation
 hypoxia
 poly-pharmacy
 withdrawal from alcohol or tobacco
 terminal 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 Last
Stories of Hope and Healing for
Veterans and Their Families
Deborah L. Grassman
2009 by Vandamere Press
Resources
www.WeHonorVeterans.org
Collaboration between
VA and the
National Hospice and
Palliative Care
Organization (NHPCO)
Thank a Veteran.