ELNEC- For Veterans
End-of-Life Nursing Education Consortium
Palliative Care For Veterans
Module 1:
Introduction to
Palliative Nursing
Care
Veterans Affairs Motto
“…to bind up the nation’s
wounds, to care for him
who shall have borne the
battle and for his widow,
and his orphan, to do all
which may achieve and
cherish a just and lasting
peace among ourselves and
with all nations.”
President Abraham Lincoln
2nd Inaugural Address
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Mission of the Department of Veterans
Affairs Hospice and Palliative Care
Program
“To honor
Veterans’
preferences for
care at end
of life.”
Department of Veterans Affairs Office of Geriatrics
and Extended Care http://www.va.gov
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Demographics of Veterans
•Projected
–Over 5,000,000 Veterans cared
for at a VA facility/year
–US Veterans: 23,442,000
–Deaths of WW II Veterans/day:
900
–% of Veterans over the age of
65: 39.4%
National Center for Veterans Analysis and
Statistics, 2009; Casarett et al., 2008a
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The Facts About Veteran Deaths
• More than 50,000 Veterans die a month
(600,000/year)
–23,000 die in VA inpatient
settings/year
• Veteran deaths account for almost 28%
of all deaths in the US
• Approximately 85% do not receive
care in a VA facility
• Only 4% die in a VA facility
NHPCO, 2010
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Veterans in the Community
• Nearly 40% of enrolled
Veterans live in rural
communities
• 121,000 Veterans are
without shelter or
healthcare, hence no
access to
hospice/palliative care
NHPCO, 2010
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Nurses Caring for Veterans at the End of
Life Must Understand the Culture
• Enrolled Veterans
–Social isolation
–Lack of family support
–Low income
• Military camaraderie
• Culture of stoicism
US Department of VA Affairs, VA Health Administration, 2005
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Characteristics of VHA and
Unique Characteristics of Enrolled
Veterans
•The largest integrated healthcare
system in the US
•Multi-layered benefits system
•Large elderly population
•Higher percent of homelessness
than in general population
•Multiple co-morbidities
Back et al., 2005; Casarett et al., 2008a; Finlay et al., 2008
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Various Experiences Can Affect a
Veterans Dying
• What branch of service?
• Enlisted? Drafted? Rank?
• Age?
• Combat and/or POW
experience?
• PTSD (assess for social isolation,
alcohol abuse, anxieties)?
• Stoicism
Department of Veterans Affairs, VA Health Administration & Office of
Geriatrics and Extended Care, 2005
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We Do Not Always Die the
Way We Would Prefer
•Care at home
•Fear of pain
•Financial burden
•Invasive, painful treatments
•Dependence on others
•Role changes
•Elderly caring for the sick
Boni-Saenz et al., 2005; Egan-City & Labyak, 2010
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Hospice and Palliative Care
• HOSPICE
• PALLIATIVE CARE
– Most intense form of
palliative care
– Less than 6 months to
live
– Agrees to enroll in
hospice
– Chooses not to receive
aggressive care
– Ideally begins at the time
of diagnosis
– Can be used to
complement
treatments
NCP, 2009
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Hospice and Palliative Care
cont.
• BOTH
– Interdisciplinary care
– Provide pain and symptom
management
– Physical, emotional, social
and spiritual care
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Palliative Care
NCP, 2009
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Death and Dying in America:
Today
• Over 4700 hospice programs in the US
• Average length of stay in hospice is 69 days (median=21 days)
• In 2007: 1,560,000 patients received hospice services and 41.6% of
all deaths in the US were under the care of a hospice program
• Patients with chronic illnesses make up the majority of hospice
patients (i.e. heart disease, dementia, etc)
NHPCO, 2005 & 2010a
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Barriers to Quality Care at End of
Life
• Failure to acknowledge limits of medicine
• Lack of training for healthcare providers
• Hospice/palliative care services are misunderstood
• Many rules and regulations
• Denial of death
Glare et al., 2003
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History of Palliative Care in VA
• 1992: Policy— “All Veterans should be provided access to a
hospice program…”
• 1998-2000: VA Faculty Leaders Project for Improved Care
at the End of Life
• 2001: Training and Program Assessment for Palliative Care
(TAPC)
• 2001-2003: TAPC launched the VA Hospice & Palliative
Care Initiative (VAHPC)
– VAHPC Launched Hospice-Veteran Partnership (HVP)
NHPCO, 2010b
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History of Palliative Care in the
VA (cont.)
• 2003-Present: Palliative Care
Consultative Team (PCCT) and
Accelerated Administration & Clinical
Training (AACT)
• 2009- Comprehensive End of Life Care
Initiative (CELC)
– PROMISE
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Palliative Care in the VA Today
• VA provides palliative care consultation services at
– ALL of its medical centers
– Many Community Living Centers (CLC)
– And contracts with community-based hospice programs
to enhance VA’s ability to meet the end-of-life services
of its Veterans
• Over 60% of all Veterans who die in VA facilities receive
care from a palliative care team
Department of Veteran Affairs, VA Public Affairs, 2008
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Benefits of Palliative Care Consultation
Teams (PCCT) in VA
• Veteran’s goals of care are identified
• Less likely to be admitted to ICU
• Laboratory and technological tests
decreased
• Communication between PCCT and
Veteran allow goals to be honored
Penrod et al., 2006
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Differences in Cause of Chronic
Illness and Death by Wars
•
•
•
•
•
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World War II
Korean War
Vietnam
Gulf War
Operation Enduring
Freedom/Operation
Iraqi Freedom
Eligibility for VA Hospice Benefit
• Included in the Medical Benefits Package
(both inpatient or home settings)
• Eligible for both VA and Medicare may
elect to have hospice paid for under
Medicare Hospice Benefit
Department of Veterans Affairs, VA Health Administration & Office of
Geriatrics and Extended Care, 2005
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Providing Hospice Services to a
Veteran who Becomes an Inpatient
• GENERALLY, VA provides needed
inpatient hospice care at a VA
facility (preferred option)
• VA may utilize Community Nursing
Home (CNH) contracts
• VA may purchase inpatient hospice
services from a community provider
Department of Veterans Affairs, VA Health Administration & Office of
Geriatrics and Extended Care, 2005
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Prognostication: May Be Used to
Establish Goals of Care
• Performance status
–ECOG and Karnofsky are
poor indicators
• Multiple symptoms
• Biological markers
–Albumin, etc.
• “Would I be surprised if
this Veteran died within
the next 6 months?”
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Glare et al., 2010; Lamont & Christakis,
2007; Lynn et al., 2000
Two Palliative Care Frameworks
for Assessing Patients
• Making Promises
Document:
–Begin by envisioning what a
better care system would
look like
• Quality of Life Model:
–Identify physical,
psychological, social, and
spiritual aspects of care
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Making PROMISES:
Changing Systems of Care
• Good Medical Treatment
• Never Overwhelmed by Symptoms
• Continuity, Coordination, & Comprehensiveness
• Well Prepared, No Surprises
• Customized Care, Reflecting Your Preferences
• Consideration for Patient and Family Resources
• Make the Best of Every Day
Lynn et al., 2000
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QUALITY OF LIFE MODEL: Addressing Four
Dimensions of Care
Physical
Psychological
Functional Ability
Strength/Fatigue
Sleep & Rest
Nausea
Appetite
Constipation
Pain
Anxiety
Depression
Enjoyment/Leisure
Pain Distress
Happiness
Fear
Cognition/Attention
Quality of Life
Social
Spiritual
Financial Burden
Caregiver Burden
Roles and Relationships
Affection/Sexual Function
Appearance
Hope
Suffering
Meaning of Pain
Religiosity
Transcendence
Adapted
Adapted from
from Ferrell
Ferrell et
et al.,
al., 1991
1991
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Role of the Nurse in Improving
Palliative Care for All Patients
• More time at the bedside than
other healthcare providers
• Some things cannot be “fixed”
• Use of therapeutic
presence
• Maintain a realistic
perspective
• Keep Veteran’s goals first in
all communication with the
team
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Maintaining Hope in the Midst of
Death
• Experiential processes
• Spiritual processes
• Relational processes
• Rational thought
processes
Ersek & Cotter, 2010
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Extending Palliative Care for
Veterans Across Various
Settings
• Nurses are the constant
caregivers
– In-patient settings
– Clinics
– Community living centers
• Expand the concept of healing
• Become well-educated
• Willing to be a “change agent”
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Final Thoughts
• Quality palliative care
addresses quality of life
for ALL patients
• Increased nursing
knowledge is essential
• “Being with”
• Interdisciplinary care is
vital
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Consider…….
What steps do you need to
take to improve palliative
care at your institution so
that you and other
members of the team are
prepared to “care for
him who shall have borne
the battle…?”
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