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.