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Posts by dwensel

Palliative Care for Veterans with PTSD by Kehrle, Steckart, Moran

Starting with Dr. Kehrle this started as a research project during training. Case 1 63 yo male sent to radiology for test and became agitated. He was confrontational with staff. He had been a Vietnam Veteran and shared that he had flashbacks when placed on the table for test. He also shared that he was a POW and could not stand to be flat on his back due to pain.

Overview:PTSD, Treatment options, signs and symptoms with special needs of Vets.

PTSD first reports published in 600bc diagnosis of exhaustion in 1800’s, WWII 10% of mobilized men hospitalized between 1942-45. Civil War diagnosis of shell shocked and railway spine. How common is PTSD? 50-90% of people encounter trauma world wide. Lifetime prevalence for Vietnam is 27% female and 35% male.

PTSD classified in DSM 4 as anxiety disorder, develops in some people after extreme trauma. Re-live the event, avoid anything that reminds them of it. Diagnosis is made when all criteria are met in DSM. 6 total expose to trauma, re-experiencing event, persistent avoidance and emotional numbing, Persistant arousal, duration >1month, significant impairment.

Avoidance and numbing: avoid stimuli of trauma, places, behaviors, people that lead to distress. decreased involvement in life activities.

Primary Care PTSD screening: How do we find them before it happens? 4 item screen with yes no answers: do you have nightmares, try hard not to think about it or went out of way to avoid, are consistently on guard, felt numb.

Neuroanatomy: Hippocampus gets stimulated and then awakens with memories, Left amygdala is also involved with feeling at time of trauma.

Neuroendocxrinology: studies have shown decrease levels of glucocorticoid levels with up reg of receptors. Increase central norepinephrine and down reg of receptors. Plasma cortisol levels have been correlated with PTSD, so lower cortisol and PTSD is worse. enhanced HPA axis with negative feedback.

Genetics: increased risk in identical twins, but studies were very small in number.

If you know a vet in crisis 1-800-273-TALK

Treatment options: long term treatment is needed, combined medication and psychotherapy is best, early treatment is better. Psychotherapy is difficult in hospice with vets due to lack of experience with PTSD. Identify mental heatlh professionals with experience to help. Contact VA for help will post how later.

CBT: most well researched approach, gradual reexposure to memories and replace them with healthier thoughts

Stress Management: Cognitive and behavior components, breathing control and relaxation, positive self talk.

Eye Movement desensitization and reprocessing (EMDR) can reduce symptoms in PTSD

VA use CBT and EMDR as first line treatments.

Is PTSD preventable? Pharmacological, Alpha-adrenergic agonist, Bets Blockers, Glucocorticoids, Opiates. These have all been studied in different settings with some results. Vets who received morphine just after event suffered less PTSD.

SSRI’s are most studied class and considered first line with strong evidence for use. SNRI’s have not been studied. Only paroxetine and sertraline have been FDA approved.

TCA’s they decrease flashbacks and nightmares. Generally less tolerated than SSRI’s so not used as first line.

Antipsychotics: possible benefit as adjunct in chronic PTSD. Current large multi-site trial with resperidone. None are approved currently.

Anticonvulsants: effective in restoring emotional stability but none are FDA approved for PTSD.

Benzo’s only 1 study comparing alprazolam with placebo showed small benefit but no evidence they are useful in PTSD and they may be contraindicated in use with CBT.

Future research, NMDA receptor antagonist proposed as possible treatment for distress and depression. Neuropeptide Y signaling may be reduced in PTSD subjects.

2008 20% of vets diagnosed with PTSD from middle east conflicts.

Now back to case study. Patient had suspicious behavior, anxious, nervous and triggered by memories. Could it be delirium? PTSD and dying where the threat to life may mimic original trauma. This can be triggered by life review and lead to poor communication between patient and provider. 1 small study found that 17% of patients treated at VA at end-of-life had PTSD.

1 out of 4 dying Americans are veterans. Currently 23.4 mil Veterans with 5.5 million receiving care at the VA. Must ask to get information because they are there. Veterans are reluctant to disclose PTSD symptoms due to fear and stigmatization. Look for anxiety, substance abuse, avoidance, and attempts to distract with work or activity. Consider using Military History Checklist, “Are you a Veteran?”, provide them opportunity to tell their stories, and THANK THEM FOR THEIR SERVICE! (We live free because they served)

Consider bringing another veteran with you when caring for a Veteran. Try to avoid loud noises, restraints, confining positions, and movies/TV showing war scenes. Goals of care should be to reduce PTSD symptoms.

Family members of patients with PTSD reported overall less satisfaction with care of loved one.

www.ncptsd.va.gov www.va.gov www.ptsdalliance.org all good resources to look at.

I wish that this information had been better known in past as my grandfather had PTSD from serving in WWII but it was not well understood. I only learned long after he died that he served and was wounded in WWII. Great talk and advocacy for Veterans and recognizing PTSD earlier to help them as they die. Without screening for PTSD we will not find it and the Veterans may suffer.

David Wensel

Facing Death:A Journey Through Pictures, Prose, Poetry, and Plainsong

Session by Lawrence Wolfe MD

Demon is failure to acknowledge that patient’s are suffering and dying and leads to Burnout, sec trauma, moral distress, hostility, and structured violence. Most of us view death as a horrible thing and we are often not available to those who are dying.

Story about demons and priest to overcome fear.

Wallace Stevens: Death is the mother of beauty

Mitch Alboms Tuesdays with Morrie

Lets Meet death in picture. Showing a picture of tomb of a child then telling story of mother asking for healing of child who died.

Bonds of ritual that help to help with grief. 23 psalm as an example of strength and beauty. Water is a precious commodity and that water is a depth symbol where we may find order from grief. What is shadow? The sun is still there but will the clouds pass? The mourner must walk through the shadow.

It is a complete mystery when we die. We see the symbols of angels and demons but what do we believe? Picture of the death of Mary shown and very moving. Aging is natural even though we do not believe it.

Picture of Socrates taking hemlock while surrounded by his students.

You only live twice, once when you are born and once when you face death. Death does not extinguish the light it is completing the dawn.

Now showing a series of images and art that is very moving. The Vigil no one is touching the person in the bed and all sitting around the room.

Freddy the Leaf story about a leaf growing, learning, purpose and reason for being, watching, transformation, differences. Everything dies after their journey. Everyone is afraid to die and we are all a part of life. What is the reason for being here? It is about the sun and the moon, the warmth and the cold. Freddy was the last leaf left on his tree and as he fell he saw the whole tree for the first time. Closed his eyes and feel asleep. He did not know that he would join the ground and start again.

Poem about leaves falling. Do we see something others do not in this work we do?

When a great whale dies it falls to the ocean floor and feeds life for centuries. Giving birth to new life forms.

Reading aloud the 9 contemplations: a weather report warning us of a storm. We must prepare now and not wait.

1. All will die sooner or later.

2. My life span is ever decreasing. Each breath brings us closer.

3. Death comes weather or not I am prepared.

4. My life span is not fixed. Death can come at any time.

5. Death has many causes.

6. My body is fragile and vulnerable. My life hangs by a single breath.

7. My material resources will be of no use to me at the time of my death.

8. My loved ones can not save me. They can not keep us from death.

9. My own body can not help me when death comes. It will be lost at the moment of my death.

Story: There is no Death light house and ship watching for her to come.

Plainsong: chosen by patients and families. My immortal great choice for reading the lyrics. Where can my baby be with pictures to accompany sound. Sorry, I will remember You, Go on, No More Tears in Heaven.

The music combined with the pictures, art and images was very powerful and moving. Many tears in the room and then a video of Evenescence to get our energy back up. Overall this session was wonderful and attended by many. I hope we continue to provide this type of education and presentation for our souls.

David Wensel

Rage against the Dying of the Light: Geriatrics, Palliative Care, and Dementia

Case based discussion dementia is a chronic illness but not recognized as a terminal illness.

There are really not any good secondary prevention measures. Most people with dementia have symptoms if we look for them.

Treating depression may reverse some of the cognitive decline.

Tertiary Prevention: intensive case management can make a big difference in rate of decline.

Frail elderly have an atypical presentation for many medical problems and delirium can be many things. Need to know the patient’s baseline to make a better assessment.

Older drivers per mile driven have more accidents than younger drivers.

No great tool for assessing driving, can refer for testing but most will not go. Only 9 states have mandatory reporting for driving impairment. Most states have no reporting at all.

Florida is God’s waiting room? I am only reporting what I hear so don’t take it out on me.

Dementia trajectory is gradual slow decline and many of the patients will follow all the trajectories.

Study showing that dementia is a terminal illness and increases mortality from all other causes.

Barriers to good end of life care for dementia: 1. View it as a terminal illness and trajectory is slow over 4-8 years, hospice criteria is not very helpful. 2. Treatment of co-morbid conditions is harder, when do they forgo treatments. 3. Pain management is very hard.

Advanced care planing needs to be done while the patient still has cognitive ability. Health Care proxy more likely to choose aggressive care if they understand it is a terminal illness.

Decision-making capacity should be related to specific decisions, can be determined by any physician and is not the same as competence.

Patients with dementia can make a contribution to decisions about their care.

Advanced directives are not always useful or easy to find. More helpful when families have the discussions before the emergency.

Asking dementia about pain while they are moving is better and use behavioral pain scales.

Palliative care as the restraint police. That is a great analogy.

Take home points: Frank discussion of prognosis can make a big difference in end-of-life care.

Hope this was helpful found it to be fun!