Education in Palliative and End-of-life Care for Veterans is a collaborative effort between the Department of Veterans Affairs and EPEC

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Module 8 Psychosocial Issues in Veterans

Education in Palliative and End-of-life Care for
Veterans is a collaborative effort between the
Department of Veterans Affairs and EPEC
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Acknowledgement
The slides in this module were produced in
cooperation with the Veterans Advisory Council
and a committee of the National Hospice and
Palliative Care Organization.
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Objectives

• Summarize the basic characteristics of four
  important psychosocial issues in Veterans
• Assess these issues in Veterans
• Identify resources available to help manage these
  issues

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Clinical case
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Disclaimer
The problems discussed in this overview are
complex. It is beyond the scope of this
presentation to give you the skills to treat
them. Consultation with or referral to a
qualified mental health professional is the best
approach to addressing the needs of Veterans with
mental health problems at end of life.
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Post traumatic stress disorder (PTSD)
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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 disasters

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PTSD prevalence

• About 30 of men and women who spent time in war
  zones experience it
• An additional 20 to 25 experience symptoms
  sometime in their lives
• More than half of all male Vietnam Veterans and
  almost half of all female Vietnam Veterans have
  experienced "clinically serious stress reaction
  symptoms

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Consequences of PTSD

• Elevated mortality for Vietnam Veterans
• Increased rates of substance abuse
• Increased psychosocial problems

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Consequences of PTSD

• Increased medical diagnoses
• circulatory and musculoskeletal conditions
• poorer health quality of life
• Greater pain intensity and pain interference in
  functioning

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PTSD What to look for

• Three key symptom clusters
• reliving the event
• avoiding reminders of the trauma / feeling numb
• feeling anxious or keyed up
• Screening tools can be used to refer to a mental
  health professional

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Primary care PTSD screen . . .

• In your life, have you ever had any experience
  that was so frightening, horrible, or upsetting
  that, in the past month, you
• Have had nightmares about it or thought about it
  when you did not want to?YES / NO
• Tried hard not to think about it or went out of
  your way to avoid situations that reminded you of
  it ? YES / NO

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. . . Primary care PTSD screen

• Were you constantly on guard, watchful, or easily
  startled?
• YES / NO
• Felt numb or detached from others, activities, or
  your surroundings? YES / NO

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Death/illness as a PTSD activator

• How can PTSD impact EOL care?
• death / illness as a PTSD activator
• challenging social ties, incl. clinician- patient
• delirium or flashback
• medication issues
• Goals of care to include reduction in PTSD
  symptoms

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Military Sexual Trauma
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Definition

• Sexual assault or repeated, threatening acts of
  sexual harassment that occurred while in the
  military
• Includes any sexual activity where someone is
  involved against his or her will
• Both men and women experience MST

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Examples of MST

• Pressured into sexual activities
• e.g., threats of consequences for refusing to be
  sexually cooperative implied better treatment in
  exchange for sex
• Unable to consent to sexual activities
• e.g., intoxicated
• Physically forced into sexual activities

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More examples of MST

• Unwanted sexual touching or grabbing
• Threatening, offensive remarks about a persons
  body or sexual activities
• Threatening and unwelcome sexual advances

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MST facts

• Higher rates among women but are about equal
  numbers of male and female survivors due to
  male-female ratio within military
• Sexual trauma is more likely to result in
  symptoms of PTSD than are most types of trauma,
  including combat

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Implications of MST

• Interactions with healthcare providers can be
  complicated for Veterans who experienced MST
  because the clinician relationship can resemble
  some aspects of the victimperpetrator
  relationship
• e.g., power differential, being in physical pain,
  physical exposure and touching of intimate body
  parts, feeling a lack of control over the
  situation

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Implications of MST

• Exams and procedures are intrusive and can
  physically recreate some of the sensations a
  Veteran experienced at the time of the sexual
  trauma
• because of this, providers need to employ extra
  sensitivity and care when working with Veterans
  who experienced MST

Saxe and Frayne 2003
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Some psychological sequelae

• PTSD
• Depression
• Substance use disorders
• Panic disorder
• Generalized anxiety disorder
• Suicide
• Eating disorders

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Some physical sequelae

• Chronic pain
• low back pain
• headaches
• Gastrointestinal
• irritable bowel syndrome
• Gynecologic
• menstrual disorders
• pelvic pain

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Screening and connecting to care

• VA policy that all Veterans must be screened for
  experiences of MST using the one-time clinical
  reminder in CPRS
• Universal screening is good clinical practice
• many patients do not spontaneously disclose a
  trauma history. Asking about MST can be the
  first step in getting them the help they need
• understanding that a patient has a history of MST
  may provide context for his or her presenting
  problems
• knowing that a patient has experienced MST helps
  the provider adapt care appropriately

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Dont be afraid to ask

• Studies have shown that most sexual trauma
  survivors favor routine screening for sexual
  trauma and other forms of interpersonal violence
• However, its important to be sensitive to
  barriers to disclosure
• shame, especially for men
• anxiety about how others will view them,
  particularly if they have had previous negative
  experiences disclosing

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Examples of triggers

• Touch to chest, abdominal, groin, pelvis,
  buttock, back or neck
• Insertion of enemas, meds, thermometers, feeding
  / breathing apparatus
• Oral care
• Assisted transfers

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... Triggers

• Washing of the patients body by others
• Applying lotions or oils
• Soft or other restraints including chemical
  restraints

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Tips

• Patient education
• Asking permission and offering to stop if patient
  requests
• Language - use nonthreatening terms
• Anticipate and prepare

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Responding to disclosure

• Respond with empathy
• Im sorry that this happened to you
• I am here to listen to your story
• Ensure privacy
• Listen if you are able or find someone who can
• Know your limitations

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The role of VA

• All treatment for mental and physical health
  conditions related to the MST is provided free of
  charge
• Service connection or documentation are not
  necessary
• This may be true even if the Veteran is
  ineligible for other VA services

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Where to find help

• Contact the MST Coordinator at your local VA
  Medical Center or the MST Specialist at your
  local Vet Center
• To locate facilities online go to www.va.gov or
  www.vetcenter.va.gov
• Visit www.mentalhealth.va.gov/msthome.asp
• Call 1-800-827-1000 VAs general information
  hotline

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Substance use disorder
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Background ...

• Of Veterans who access VA health care system each
  year, approximately a ½ million are diagnosed
  with substance use disorders (SUD)
• Prevalence of heavy drinking and other substance
  use are at least as high among Veterans compared
  to non-Veterans

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... Background

• Pain, depression and other mental conditions are
  associated with increased likelihood of substance
  use
• Alcohol and other substance use can interfere
  with effective palliative care (e.g., adherence)

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SUD implications for end-of-life care

• Pain management becomes complex
• Potential high tolerance for pain medications
• Choose medications for palliation that minimize
  adverse drug-drug interactions

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How to help ...

• Ask about current substance use and implications
  for pain management
• Adopt a nonjudgmental approach to discussing
  substance use issues
• Collaborate with patient on goals regarding
  quality of life
• Develop an interdisciplinary treatment plan for
  end of life care which considers substance use

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... How to help

• Offer referral to SUD specialty care for patients
  who identify SUD recovery as an end-of-life goal
• Consult with a SUD specialist on a case-by-case
  basis to manage substance use behaviors
  consistent with providing effective palliative
  care

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Homelessness
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Definition

• Public law 100-77 The McKinney Act (1987)
• A homeless person is one who lacks a fixed,
  regular and adequate nighttime residence or by a
  primary nighttime residence that is
• a supervised a supervised publicly or privately
  operated shelter
• a temporary residence for individuals intended to
  be institutionalized
• a public or private place not ordinarily used as
  a regular sleeping accommodation

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Causes of Veteran homelessness

• Limited access to affordable housing, livable
  income, and health care
• Lingering effects of PTSD
• Substance abuse disorder
• Lack of family and social support networks

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Homeless Veterans facts

• 23 of the homeless population are Veterans
• 13 of all sheltered homeless adults are Veterans
  
• 47 of homeless Veterans served during the
  Vietnam Era
• 33 were stationed in a war zone

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Homeless Veterans facts

• 45 suffer from mental illness
• 70 suffer from substance abuse problems
• 58 have health / physical problems
• 46 are age 45 or older compared to 20 of
  non-Veteran homeless citizens

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VA homeless programs

• Every medical center has a homeless Veteran
  services coordinator
• Health Care for Homeless Veterans Program (HCHV)
• Project CHALENG
• Domiciliary Care for Homeless Veterans Program
  (DCHV)

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Summary