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2011 PPE Disclosure Statement

2011 PPE Disclosure Statement.

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2011 PPE Disclosure Statement

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  1. 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.

  2. 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?

  3. Themes • Veteran-specific • Building capacity • Strategic partnerships • Cultural Humility

  4. 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

  5. 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.

  6. 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? 42,000 120,000 320,000 660,000

  7. 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? 42,000 120,000 320,000 660,000 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

  8. 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?

  9. 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."

  10. 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.

  11. 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%

  12. 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)

  13. VA Hospice & Palliative Care What % of Veterans who die as VA inpatients receive care from a palliative care team? • 30% • 56% • 73% • 100%

  14. 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%

  15. Hospice and Palliative Care Units New & Established 57 New Units 40 Established Units Established New Unit New Unit Not Funded

  16. 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

  17. End-Of-Life Issues Impact All Systems of Care

  18. VA Trends Overview FY04 Inpt deaths 26,231 VA-paid hospice ADC 164 % VA deaths in hospice 13% % of inpt deaths with PC 33% FY11Q3 ~21,000/yr 1090 43% 73% ADC- Average Daily Census, PC-Palliative Care

  19. 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:

  20. …Case Example: Mr. S • Refusing meds, angry outbursts at staff • Vacillating between paranoia, anxiety and anger • Pacing, fearful and exhausted

  21. Mr. S, cont’d • Differential diagnosis • Delirium? • Anxiety reaction with psychosis? • Adverse drug reaction? • PTSD? • Others? • What do you want to do?

  22. Blame • 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 TRAUMA 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 Accomplishments

  23. Post traumatic stress disorder (PTSD)

  24. 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

  25. 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”

  26. Projected Vietnam Era Veteran Deaths Fiscal year 2010- 105,049 Fiscal year 2020- 197,593 Vetpro

  27. Consequences of PTSD … • Elevated mortality for Vietnam Vets • Increased rates of substance abuse • Increased psychosocial problems

  28. … Consequences of PTSD • Increased medical diagnoses • circulatory and muscular-skeletal conditions • poorer health quality of life • Greater pain intensity and pain interference in functioning

  29. Post traumatic stress disorder Trauma • 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

  30. 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)

  31. 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

  32. Hospice and Military Hospice Military Interdependence 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

  33. Hospice and PTSD Hospice 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

  34. 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.”

  35. 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)

  36. 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

  37. Video clip Link: http://www.msnbc.msn.com/id/43142267/ns/nightly_news/t/going-back-terrifying-place-where-young-man-grew-old/

  38. Military History Checklist

  39. “…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.”

  40. 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

  41. % of Families Rating End of Life Care as “Excellent” in Acute Units vs. Palliative care vs. Inpatient Hospice Unit Settings

  42. Meaningful Outcomes • Veterans module to the Family Evaluation of Hospice Care (FEHC) is a key opportunity. • There are others.

  43. 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?

  44. 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

  45. We Honor Veterans For those who are not participating, why? Given the demographics of dying Veterans in America, shouldn’t we be acting now?

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