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2011 ppe disclosure statement

2011 PPEDisclosure Statement

It is the policy of the Oregon Hospice Association's (OHA) Continuing Medical Education Program to insure balance, independence, objectivity, and scientific rigor in all its educational programs. All faculty participating in any OHA-sponsored programs are expected to disclose to the program audience any real or apparent affiliation(s) that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker from making a presentation. It is merely intended that any relationships should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts.

This presenter has no significant relationships with companies relevant to this presentation to disclose.

we honor veterans what does this mean
We Honor Veterans:What does this mean?
  • “Are you a Veteran?” and is your staff prepared for to deal with the answer?
  • How can partnering with VA improve care?
  • How can we extend our “reach” to improve care and access?
  • How can we measure the impact of our interventions?
  • Veteran-specific
  • Building capacity
  • Strategic partnerships
  • Cultural Humility
hospice and palliative care we honor veterans

Hospice and Palliative Care:We Honor Veterans

Scott T. Shreve, DO

National Director, Hospice and Palliative Care

Department of Veterans Affairs

Associate Professor of Clinical Medicine

The Pennsylvania State University

uniform benefits package
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.

to honor veterans preferences for care at the end of life
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?





to honor veterans preferences for care at the end of life1
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?





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

Source: Vetpro


Annual Veteran Deaths

-21,000 deaths in VA facilities (4%)

-136,000 enrolled Veteran outpt deaths

Of 2.4 million deaths in USA, 660,000 are Veterans

Who cares for Veterans dying outside VA?


NHPCO Congratulates 'We Honor

Veterans' Grant Recipients for 2011

ALEXANDRIA, Va., Jan. 25, 2011 /PRNewswire-USNewswire/ -- Five hospice organizations from

across the nation have been chosen as grant recipients in the third year of the National Hospice and

Palliative Care Organization's Reaching Out grants program.  The grantees are:

  • Hope Hospice & Palliative Care – Medford, Wisconsin
  • Hospice of Central Iowa – West Des Moines
  • Mercy Hospice – Roseburg, Oregon
  • Guardian Hospice – Franklin, Tennessee
  • Mountain Hospice – Belington, West Virginia

Funded through a contract with the Department of Veterans Affairs, the Reaching Out grants were

created to support innovative programs committed to increasing access to hospice and palliative care

or rural and homeless Veterans.

"These grants serve a two-fold purpose," said J. Donald Schumacher, NHPCO president and CEO.

"They support specific, community-based programs and the lessons learned will help the VA in

discovering new ways to reach veterans who are homeless or living in rural areas and in need of

quality care as they near the end of life."

global vision award
Global Vision Award

The Veterans Health Administration was awarded the Global Vision Award from the National Hospice Foundation on April 8, 2011.

Global Vision Awardees demonstrate an extraordinary vision for caring that has a far-reaching impact and creates a lasting change in communities. The Department of Veterans Affairs, in collaboration with the National Hospice and Palliative Care Organization, launched We Honor Veterans in September 2010.

va hospice palliative care
VA Hospice & Palliative Care
  • US Hospitals: 12% offered palliative care in 2000, now ~60%
  • What % of VA hospitals offer palliative care?
    • 30%
    • 56%
    • 67%
    • 100%
va hospice palliative care1
VA Hospice & Palliative Care
  • US Hospitals: 12% offered palliative care in 2000, now 60%
  • What % of VA hospitals offer palliative care?
    • 30%
    • 56%
    • 67%
    • 100% (up from 38% in 2002)
va hospice palliative care2
VA Hospice & Palliative Care

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

  • 30%
  • 56%
  • 73%
  • 100%
va hospice palliative care3
VA Hospice & Palliative Care
  • Unknown for US Hospitals
  • What % of Veterans who die as VA inpatients receive palliative care?
    • 30%
    • 56%
    • 73% (up from 33% in 2004)
    • 100%

Hospice and Palliative Care Units

New & Established

57 New Units

40 Established Units


New Unit

New Unit Not Funded

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

Note, ~5060 veterans impacted despite declining overall inpt deaths

va trends overview
VA Trends Overview


Inpt deaths 26,231

VA-paid hospice ADC 164

% VA deaths in hospice 13%

% of inpt deaths with PC 33%






ADC- Average Daily Census, PC-Palliative Care

case example mr s
Case Example: Mr. S
  • 65 y/o White, male, divorced (1x)
  • 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:
case example mr s1
…Case Example: Mr. S
  • Refusing meds, angry outbursts at staff
  • Vacillating between paranoia, anxiety and anger
  • Pacing, fearful and exhausted
mr s cont d
Mr. S, cont’d
  • Differential diagnosis
    • Delirium?
    • Anxiety reaction with psychosis?
    • Adverse drug reaction?
    • PTSD?
    • Others?
  • What do you want to do?


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


I’m broken

I’m a horrible person

I’m a monster

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

Father, friend, generosity


what is 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 disasters

PSTD- Post traumatic Stress Disorder

ptsd background
PTSD background
  • 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”
projected vietnam era veteran deaths
Projected Vietnam Era Veteran Deaths

Fiscal year 2010- 105,049

Fiscal year 2020-



consequences of ptsd
Consequences of PTSD …
  • Elevated mortality for Vietnam Vets
  • Increased rates of substance abuse
  • Increased psychosocial problems
consequences of ptsd1
… Consequences of PTSD
  • Increased medical diagnoses
    • circulatory and muscular-skeletal conditions
    • poorer health quality of life
  • Greater pain intensity and pain interference in functioning

Post traumatic stress disorder


  • 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
ptsd and veterans
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 exposure

Increasingly 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
Death/illness as a PTSD activator
  • How can PTSD impact EOL care?

death/illness as a PTSD activator

challenging social ties, inc. doc - patient

delirium or flashback

medication issues

  • Goals of care to include reduction in PTSD symptoms
hospice and military
Hospice and Military




Hierarchical organization

Culture of stoicism; downplay suffering

Give orders, follow orders

  • Dependency
  • Reconnect with others
  • Life review, reminisce, openly grieve
  • Encourage self-determination and choice
hospice and ptsd
Hospice and 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

  • Dependency
  • Reconnect with others
  • Reminisce; Life review
  • Multiple checks by staff
  • Legacy-building
ptsd at eol themes
PTSD at EOL: Themes
  • Vulnerability and Safety
    • Inability to defend self from perceived threats
    • Increased sense of vulnerability (physical/cognitive decline)
    • Mr. S: “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. S: No one can be trusted, angry outbursts
  • Potential triggers
    • Physical pain (especially if trauma-related injury)
    • Environmental triggers (sounds, sights, smells, people)
    • Mr. S: “I don’t want to suffer like he did.”
interpersonal relationships
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
Practical Applications
  • Anger: Disarm and empathize

No mention of past trauma

If 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 happening

Announce self upon entering to reduce potential startle response

Make sure patient can hear you entering

Remain in patient’s line of vision

Position patient so (s)he can see the doorway

video clip
Video clip




“…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.”

percent improvement in family perceptions with palliative care
Percent Improvement in Family Perceptions with Palliative Care
  • Palliative care consult-19%

Emotional support-20%

Spiritual support- 22%

  • If Veteran died in an HPC unit-13%
  • Bereavement contact-16%

All with p< 0.001, 2800 Bereaved Family Surveys;

HPC= Hospice and Palliative Care

% of Families Rating End of Life Care as “Excellent” in Acute Units vs. Palliative care vs. Inpatient Hospice Unit Settings
meaningful outcomes
Meaningful Outcomes
  • Veterans module to the Family Evaluation of Hospice Care (FEHC) is a key opportunity.
  • There are others.
we honor veterans what does this mean1
We Honor Veterans:What does this mean?
  • “Are you a Veteran?” and is your staff prepared for to deal with the answer?
  • How can partnering with VA improve care?
  • How can we extend our “reach” to improve care and access?
  • How can we measure the impact of our interventions?
next steps
Next Steps

Expertise Dissemination

  • EPEC for Veterans (Education in Palliative & End of Life Care)
  • ELNEC for Veterans (End of Life Nursing Education Consortium)
  • PCNA training program (Palliative Care Nursing Assistants)

Veteran-centered care= Family satisfaction

  • Survey results drive quality

We Honor Veterans Campaign

  • Community hospices aware of Veterans’ care needs

CELC=Comprehensive End of Life Care

PACT= Patient Aligned Care Teams

we honor veterans
We Honor Veterans

For those who are not participating, why?

Given the demographics of dying Veterans in America, shouldn’t we be acting now?