Veteran’s Building a Bridge to Healing: “Side Effects of War”

Rhonda Copeland RN BSN MSAHospice of Helping Hands, Inc.

rcopeland@hospiceofhelpinghands.com

Objectives

• Describe the We Honor Veteran’s Program and its relation to best practice for hospice programs.

• Identify the potential physical, psychological and spiritual illnesses related to each period of war.

• Discuss strategies to effectively treat the identified side effects of each period of war.

• A veteran is someone who, at one point in his/her life, wrote a check made payable to “the United States of America,” for an amount of “up to and including my life.”

Who is a Veteran?

• A veteran means a person who served in the active military, naval or air service and who was discharged or released under conditions other than dishonorable.

• Army, Navy, Marines, Air Force or Coast Guard• A veteran may have served during war or

peace time.• DD214

Veteran’s

• Reservists and National Guard members may qualify for VA benefits if they were called to active duty by a Federal order and completed the full period for which they were called or ordered to active duty.

• “Veterans who enlisted after Sept. 7, 1980, or who entered active duty after Oct. 16, 1981, must have served 24 continuous months or the full period for which they were called to active duty to be eligible.”

Department of Veterans Affairs

We Honor Veteran Program

• Partner Levels– Military History Checklist– FEHC-V

• www.wehonorsveterans.org• Hospice Education Network (HEN)– ELNEC for Veteran Curriculum

Demographics of Veterans

• 8.92 M veterans enrolled in VA Health Care System• US Veterans: 21,973,000• Deaths of WWII Veterans/day: 413– (as of 9/2013: living 1, 246, 000)

• % of Veterans over the age of 65y/o: 44.19%• Veterans receiving VA disability: 3.79M– 100% disabled (403,342)

National Center for Veteran Analysis and Statistics, 2013

Veterans in the Community

• Only 4% of veterans die in a VA facility• Nearly 40% of enrolled Veterans live in rural

communities• 121,000 Veterans are without shelter or

healthcare (no access to hospice/palliative care)

Michigan Stats

• Veterans 660,773• Wartime: 483,963• Gulf War: 134,004• Vietnam: 247,859• Korean: 72,421• WWII: 39,574• Peacetime: 176,810– Female 50,121– Male 610,652– www.va.gov/ncvas as of 9/30/13

Characteristics of Enrolled Veterans in the VA Medical System

• The largest integrated healthcare system in the US

• Multi-layered benefits system • Large elderly population• Multiple co-morbidities• Higher percent of homelessness than in general

population

ELNEC-V 2008

Eligibility for Hospice Benefit

• Included in the Medical Benefits Package (both inpatient or home settings)

• Eligible for both VA and Medicare hospice benefit– (**Need to be enrolled in the VA system)

What Affects Veterans Dying?

• Branch of service• Enlisted, drafted• Rank• Combat and/or POW• PTSD• Stoicism

War Periods

• WWII• Korean Conflict• Cold War• Vietnam War• Gulf War• Operation Enduring Freedom/Operation Iraqi

Freedom

WWII1941-1946

Health Risks• Infectious diseases• Mustard Gas Testing• Exposure to nuclear

testing• Nuclear clean-up• Long range cardiac

diseases

Morbidity• TB• Rheumatic fever • Hepatitis

Cold Warend of WWII until 1990’s

• Exposure to ionizing radiation– Leukemia– Cancers (ex. Thyroid/lung

brain)

– Cataract• “Atomic Veterans”

• Linde Ceramic Workers – Private companies

• Largest number of veterans exposed to nuclear weapons testing from 1945 to 1962

Korean Conflict “Forgotten War”1950-1955

• “Cold” Injuries– Frostbite– Immersion (Trench) Foot

• Complications from “Cold” Injuries– Peripheral neuropathy– Peripheral vascular disease– Skin cancers (location specific)– Arthritis– Fallen arches and stiff toes– Nocturnal pain

Vietnam War1964-1975 (**2/1061 who served in Vietnam before 8/5/64)

Health Issues• PTSD, depression• Hepatitis C• Growing list of service

connected illnesses• Substance abuse

Environmental Hazards• Agent Orange (spraying

and touching)• Tropical country• Bacterial and fungal

infections• Skin diseases

AGENT ORANGE

• 20 million gallons of herbicides were used in Vietnam between 1962 to 1971

• Used to “protect” US troops• Herbicide was used to kill unwanted plants

and to remove leaves from trees that otherwise provided cover for the enemy

Agent Orange

• Under Section 102, Public Law 104-262, the Veterans’ Health Care Eligibility Reform Act of 1996, VA shall furnish hospital care, medical services and may furnish nursing home care to Veterans exposed to herbicides in Vietnam

Nursing Home Care

• National Programs– VA-owned and operated Community Living

Centers– State Veteran Homes– Community nursing home program (contracted)• Requirements for benefit:

– Service connected disability– >70% service-connected disability– Veterans with a rating of total disability based on individual

employability

Diseases Associated with Agent Orange Exposure

Fourteen illnesses are presumed by VA to be service-connected:

• Chloracne or other acneform disease consistent with chloracne• Amyloidosis• Type 2 diabetes• Hodgkin's disease• Chronic B-cell leukemia's• Multiple myeloma• Non-Hodgkin’s lymphoma• Acute and subacute peripheral neuropathy• Prostate Cancer• Respiratory cancers (lung, bronchus, larynx, or trachea)• Soft-tissue sarcoma• Ischemic heart disease• Parkinson’s disease• Porphyria cutanea tarda (heme)

Related to Korean and Vietnam Veterans

• Birth Defects Spina bifida– Benefits to children born to veterans who served from • Korean demilitarized zone Sept. 1, 1967 to Aug. 31,

1971• Vietnam January 9, 1962 to May 7, 1975Children of women Vietnam veterans may be eligible for benefits who have birth defects that resulted in permanent physical or mental disability

Federal Benefits for Veterans 2011 edition

1st Gulf War (Operation Desert Storm)1990-1991

• Multiple vaccinations• Undiagnosed illnesses or unexplained chronic multisystem

– Example: Chronic fatigue/fibromyalgia/IBS• Environmental

– 605 oil well fires burning over the period of the war– Chemical warfare use???– Depleted Uranium (“deadly dust”)

• Infectious diseases– Dead animals all over the desert

• Living conditions– desert

Operation Desert Storm

• Chronic fatigue• Muscle and joint pain• Loss of concentration• Forgetfulness• Headache• Rash• Infectious diseases (nine specific)• Stomach issues (Radiation exposure?)• Respiratory (asthma)• ALS

ALS

• On September 23, 2008, Veteran’s Affairs Secretary, Dr. James Peake, announced that ALS will become a compensable illness of all Veterans with 90 days or more of continuously active service in the military.

• *Gulf War Veterans are twice as likely to develop ALS than those who did not serve in the war. (alsa.org)

Operation Enduring Freedom/Operation Iraqi Freedom

Afghanistan 2001-present Iraq 2003-2011

• Psychological toll• PTSD• Prolonged exposure to combat stress• Increasing incidence of suicide/attempts• Depression• Traumatic Brain Injuries

Health Risks

• Infectious diseases• Cold Injury• High Altitude Illnesses• Exposure to sewage• Exposure to agricultural/industrial contamination of

food and water• Air pollution• Severe sand and dust storms

www.va.gov/oaa/pocketcard

Additional Risks

• Blast Injuries – (as of 9/2013 Number of amputees---1,642)

• Traumatic brain and spinal cord injury• Vision loss• Traumatic amputation• Sand-fly-transmitted infection of the skin• *Depleted uranium• Mental health issues

Status of Pain Specific to Veterans Serving in Recent Conflicts

Pain is one of the most frequently reported symptoms since the Gulf War

Headaches 54%Joint Pain 45%Back Pain 44%Muscle Pain 33%Abdominal Pain 23%

John Hopkins Medicine 10/13/2011ELNEC-Veterans

Veterans at Risk for Under-Treatment of Pain

• Elderly• Non-verbal or cognitively impaired• Those who deny pain due to stoicism• Uninsured/underserved• History of addiction• PTSD

Influences: Military Culture

• “Big Boys don’t Cry”• No pain, no gain• The more it hurts, the better• Fear/Pain is a sign of weakness• “Few good men”• Once a marine, always a marine

Treatment of Pain with Addictive Disease

• IDT development of POC– Consider contract/lock box

• Educate on tolerance vs. Addiction• Prevent withdrawal• Anticipate they are drinking alcohol – “double” the amount they may report – seizures potential

Non-pharmacologic Techniques

• Exercise• Relaxation• Reiki/Tai Chi/Yoga• Distraction• Essential Oils• Massage• Acupuncture

PTSD(Post Traumatic Stress Disorder)

• PTSD is an anxiety disorder that can occur following the experience or witnessing of a traumatic event

• A traumatic event is a life-threatening event such as military combat, natural disasters, terrorist incidents, serious accidents or physical/sexual assault in childhood or adult life.

• Not everyone who witnesses/experiences at traumatic event will develop PTSD

PTSD History

• PTSD was first recognized in the Vietnam War Era– As of 6/30/2010

• Formal diagnosis in 1980• **Recently identified that second hand

experiences can also cause PTSD

*http://www1.va/gov/VETDATA** Nursing 2011, September

Civilian vs. Military PTSD

• Military personnel are at greater risk for PTSD secondary to exposure to traumatic events.– Increased risks for PTSD:• Duration of exposure to trauma• Repeated exposure• War zone exposure (leading factor associated

with PTSD)

Medscape 1/26/2012

Symptoms of PTSD

• Reliving the trauma in some way such as becoming upset when confronted with a traumatic reminder or thinking about the trauma when doing something else—”flashback”

• Staying away from places or people that remind you of the trauma, isolating from other people or feeling numb

• Felling on guard, irritable, or startling easily (loud bang)

Diagnosing PTSD

• Symptoms may start soon after the event• Delayed months or years• May come and go over many years

• If symptoms last longer than 4 weeks probably PTSD– (less than 4 weeks—likely acute stress disorder)

Criteria for Diagnosis

• Exposure to traumatic stress– Re-experiencing symptoms (relive the event)– Avoidance or emotional numbing– Impaired function in social, work or other areas– Hyper-arousal

Re-experiencing

• Memories of the trauma may reoccur at any time

• Feel fear and horror as when event took place• Nightmares• Unrelated events trigger (fireworks/backfire

of a car– Unable to close curtains or tuck in sheets

Avoidance

• Avoid situations or people that trigger memories of the event

• Avoid talking or thinking about event– (social gatherings, weddings/parties)

Impaired Function: Numb

• Hard to express feelings– Stays away from people/relationships– No interest in previous enjoyed activities– Unable to remember parts of the traumatic event

Hyper-arousal

• Always alert, jittery, on the lookout for danger– Sudden burst of anger– Difficulty sleeping or concentrating– Fear for personal safety “on-guard”• Bed on floor• No restraints

– Overreaction when surprised/startled

Treatment of PTSD

• Therapy– Individual– Group– Anger management

Treatment of PTSD

• Medications– SSRI

• Zoloft/Prozac/Celexa/Paxil

– Buspirone (Buspar) for anxiety– Trazodone (Desyrel) for insomnia– Nightmares

• Off label use of prazosin (Minipress)

– Essential Oils• Lavender/Peace and Calming/Orange/Ylang-Ylang

– Avoid use of Benzodiazepines (paradoxical effect)• Use Haloperidol • Chlorpromazine (SE: sedating/orthostatic hypotension)

Responding to a “Flashback”

• Remain calm and focused• Safe place• Breathing and muscle relaxation• Prevent:– Music– Distraction– Meditation“Stop before you pop”

PTSD Resurfacing at EOL

• Difficult sleep patterns• Irritability or outbursts of anger• Difficulty concentrating• Hyper-vigilance• Exaggerated startle response• Suspicion or mistrust of caregivers

PTSD at EOL

• Recognize confusion/agitation for the PTSD that it might be (not terminal restlessness)

• Be aware of possible paradoxical reactions with benzodiazepines (opposite effect)

• Enter metaphor with them (battles)• Put mattress on floor if enemy soldiers are under the

bed• NO restraints (especially POW’s)• Approach the patient from the front—do not startle• Avoid caregivers of same race as wartime enemies

EOL and PTSD

• “Did I do the right thing?”• “Am I going to heaven?”• Fight to survive• Distrust of authority• Lack of caregivers• Live review• Religious rituals (confession and sacraments)• Forgiveness (self, others, GOD)

Wounded and Healing: Spiritual Healing

• Interventions:– Unconditional acceptance of the veteran– Active listening– Not judging – Not abandoning– Making a connection

Remember the Caregiver

• Our veterans experiences may have been displayed in positive and negative actions towards family and friends

• Might have anger/bitterness toward how their loved treated them or how they were treated

• Spouse/child killed in war• Support the caregiver and engage them in life review• NO “roots” (career military with numerous moves)• Military pensions (potential loss of income)

Veteran-Veteran Volunteers

• Formal training for veteran volunteers

References and Resources• Grassman, D.L. (2009). Peace at Last: Stories of hope and healing for

veterans and families. Vandermere Press: St. Petersburg, Fl.• Grassman, D.L. (2012). The Hero Within: Redeeming the Destiny We

Were Born to Fulfill. Vandermere Press: St. Petersburg, FL.• hospiceonline.com-- Hospice Education Network—ELNEC- Veteran

curriculum.• Federal Benefits for Veterans: Dependents and Survivors. (2013).

Department of Veterans Affairs. Washington, DC: US Government Printing Office.

• Cohen, S. (2011). Headaches in Troops Returning from Iraq and Afghanistan. Retrieved November 4, 2011, from http://www.hopkinsmedicines.org

• National Center for Veterans Analysis and statistics. 2013 www.va.gov

References and Resources

• www.alsa.org ALS in the military: Unexpected consequences of military service. May 2013.

• Lavin, J. (2011, September). Surviving posttraumatic stress disorder. Nursing 2011, 41(9), 41-44.

• Serdahely, W. (2012) Wounded and Healing: A dynamic for the spiritual healing of hospice patients. Volume 17, Number 4, 7-9.

• Essential Oils Desk Reference (2009). Essential science publishing: USA www.essentialscience.net