Veteran’s Building a
Bridge to Healing:
“Side Effects of War”
Rhonda Copeland RN BSN MSA
Hospice 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
WWII
1941-1946
Health Risks
• Infectious diseases
• Mustard Gas Testing
• Exposure to nuclear
testing
• Nuclear clean-up
• Long range cardiac
diseases
Morbidity
• TB
• Rheumatic fever
• Hepatitis
Cold War
end 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 War
1964-1975 (**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, 1975
Children 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 10/13/2011
ELNEC-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