Confronting Mortality: Narratives of Military Veterans Enrolled in Home Hospice Care

Barriers to perioperative palliative care across Veterans Health Administration hospitals: A qualitative evaluation

BACKGROUND

Palliative care remains widely underused for surgical patients, despite a clear benefit for patients with life-limiting illness or nearing the end-of-life.

METHODS

Interviews exploring end-of-life care among critically-ill surgical patients were conducted with providers from 14 pre-specified Veterans Affairs (VA) hospitals. Data were analyzed iteratively through steps informed by inductive and deductive descriptive content analysis.

RESULTS

Six major domains were identified. At the patient and family level, barriers included managing expectations and goal-discordant care. At the provider-level, knowledge of and attitudes towards palliative care and provider role and identity were frequently cited barriers. At the system-level, participants identified institutional resources and culture as significant barriers.

CONCLUSIONS

While providers recognize the importance of palliative care and end-of-life care, obstacles to its use exist at various levels. Identification of these barriers highlights areas to focus future efforts to improve the quality of palliative and end-of-life care for Veterans.

Re-living trauma near death: an integrative review using Grounded Theory narrative analysis

Background

Symptoms of emotional and physical stress near death may be related to previous experiences of trauma.

Objective

To investigate current evidence regarding the following: (1) Is previous trauma identified in people who are dying, and if so, how? (2) How is previous trauma associated with the experience of death/dying in people with or without cognitive impairment? and (3) What palliative care interventions are available to people with previous trauma at the end of life?

Design

This integrative review was conducted per Whittemore and Knafl's guidelines, which involves a stepped approach, specifically (1) problem identification, (2) literature search, (3) data evaluation, (4) data analysis and (5) presentation.

Methods

This integrative review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Electronic databases were searched in August 2021 and updated in August 2023. The articles were quality appraised, and narrative data were analysed using Grounded Theory (GT).

Results

Of 1310 studies screened, 11 met the inclusion criteria (four qualitative and seven quantitative) conducted in Australia, Canada, Japan and the United States; and American studies accounted for 7/11 studies. Eight were focused on war veterans. Descriptive studies accounted for the majority, with only two publications testing interventions. Re-living trauma near death has additional features to a diagnosis of post-traumatic stress disorder alone, such as physical symptoms of uncontrolled, unexplained acute pain and this distress was reported in the last weeks of life.

Conclusion

This study proposes that re-living trauma near death is a recognisable phenomenon with physical and psychological impacts that can be ameliorated with improved clinical knowledge and appropriate management as a new GT. Further research is needed to enable past trauma identification at the end of life, and trauma-informed safe interventions at the end of life are an urgent need.

Advancing Trauma-Informed Care Education for Hospice and Palliative Staff: Development and Evaluation of Educational Videos

Nurses play an essential role in managing mental health conditions, such as posttraumatic stress disorder (PTSD), especially in rural areas where access to mental health care is limited. Posttraumatic stress disorder may emerge at the end of life and complicate health care and is a particular concern for aging Vietnam veterans. We describe the development of 3 videos that illustrate how to recognize PTSD, respond to trauma disclosures, and manage PTSD in cognitive impairment during an in-home hospice nurse visit. Through problem identification and needs assessment, we identified 6 goals and 28 specific content objectives presented through cinematic action with flashbacks or voice-over narration with graphics. Videos were evaluated through a survey (N = 155) and analysis of "chat" responses (N = 186) to targeted questions during a webinar presentation to clinicians (N = 345). Approximately 75% rated videos as "very much" relevant to needs, having helped learn something new, and realistic. Analysis of chat responses showed videos conveyed most content objectives (92%). In addition, participants stated videos were helpful in demonstrating nursing skills of listening, responding, and displaying empathy, as well as showing case presentations involving cognitive impairment and the patient experience. Participants expressed a desire for longer videos/more information including a wider range of PTSD presentations and comorbidities.

Perspectives on a good death: A comparative study of veterans and civilians

This study aimed to identify any differences between veterans and non-veterans in the importance of domains of the Good Death Inventory. Participants were recruited from Amazon Mechanical Turk to complete a Qualtrics survey on the importance of the 18 domains of the Good Death Inventory scale. Logistic regression models were then used to analyze any differences between veterans (n = 241) and nonveterans (n = 1151). Results showed that veterans (mostly aged 31-50, men, and White) were more likely to indicate that pursuing all treatment possible and maintaining their pride were important aspects of a good death. The results support other studies that have found military culture to be a significant factor in the way veterans view preferences at the end of life. Interventions may include increasing access to palliative care and hospice services for military members and veterans and providing education/training on end-of-life care for healthcare providers who work with this population.

Military Veterans' End of Life: Supporting Them in Their Last Deployment

More than 600,000 U.S. Veterans die from illness each year. Clinicians in civilian settings are increasingly providing care to Veterans at end of life. Veteran care should be distinctive and individualized to meet their unique needs. There is limited information to guide civilian clinicians in providing care to Veterans at end of life. This article provides bio-psycho-social information to holistically guide Veteran healthcare and assist them with solace, respect, and serenity at end of life. Various options for end-of-life care are discussed, as well as specific concerns of women, lesbian, gay, bisexual, and transgender Veterans. Some end-of-life entitlements for all Veterans and sometimes their spouses/children are included.

Female Veteran Use of Palliative and Hospice Care: A Scoping Review

INTRODUCTION

The number of female veterans in the USA in the age range of 55-64 years increased 7-fold from 2000 to 2015. Female veterans are more likely to suffer from certain mental health disorders, respiratory diseases, neurologic diseases, and some forms of cancer when compared to their male counterparts. Veterans Affairs (VA) healthcare providers need to be prepared to care for this growth of female veterans with serious illness. These serious illnesses require appropriate medical management, which often includes palliative care. It is imperative to determine how VA healthcare providers integrate palliative and hospice care for this population. The purpose of our scoping review was to explore the palliative and hospice care literature specific to female veterans to learn: (1) what evidence is available regarding female veterans' use of palliative and hospice care? (2) To meet the needs of this growing population, what gaps exist specific to female veterans' use of palliative and hospice care?

METHODS

A scoping review methodology was employed following the nine-step process described by the Joanna Briggs Institute for conducting scoping reviews.

RESULTS

Nineteen articles met the inclusion criteria. Fourteen quantitative articles were included which comprised 10 retrospective chart reviews, one randomized controlled trial, one correlation, one quality improvement, and one cross-sectional. The remaining five were qualitative studies. The sample populations within the articles were overwhelmingly male and white. Content analysis of the articles revealed three themes: quality of end of life care, distress, and palliative care consult.

CONCLUSIONS

The female veteran population is increasing and becoming more ethnically diverse. Female veterans are not well represented in the literature. Our review also uncovered a significant gap in the study methodologies. We found that retrospective chart reviews dominated the palliative and hospice care literature specific to veterans. More prospective study designs are needed that explore the veteran and family experience while receiving end of life care. With the rising number of older female veterans and their risk for serious illness, it is imperative that research studies purposefully recruit, retain, analyze, and report female veteran statistics along with their male counterparts. We can no longer afford to disregard the value of the female veterans' perspective.

Masculinity and Military Culture in VA Hospice and Palliative Care: A Narrative Review With Clinical Recommendations

This article examines the intersection between masculinity, military culture, and hospice and palliative care (HPC). The authors conducted a narrative literature review, supplemented with clinical annotations, to identify the impact of masculinity and military culture on the following topics salient to end-of-life care with older male veterans: pain management, mental health, coping, communication, autonomy and respect, and family roles. Findings suggest that traits associated with masculinity and military culture have an influence on the end-of-life process and HPC for older male veterans. Specifically, results suggest that older male veterans may deny or minimize physical pain, decline mental health treatment, utilize maladaptive coping strategies, avoid emotional conversations, struggle to manage perceived shifts in autonomy, and experience challenges negotiating changing family roles. The authors provide clinical recommendations for providers across various disciplines to address the aforementioned concerns with older male veterans in HPC. Overall, information presented in this article may be an important contribution to the literature for building cultural competencies with older male veterans and has the potential to improve the delivery of HPC for veterans and their families.