Posttraumatic stress disorder at the end of life

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.

Clinical Education: Addressing Prior Trauma and Its Impacts in Medical Settings

Prior trauma exposure significantly increases the risk of developing PTSD following medical stressors and may contribute to the development of medically induced PTSD. However, healthcare systems often overlook the interaction between prior trauma and current medical stressors, contributing to negative psychosocial and health-related outcomes for patients. Integration of both trauma-informed and trauma-focused practices into psychosocial programming in medical settings may be key to effectively addressing the needs of trauma-exposed patients. Yet, there is a lack of practical guidance on how clinical psychologists in medical settings can respond to trauma's effects in routine clinical practice. This paper aims to provide an overview of trauma-focused theory, assessment, and treatment considerations within medical settings, emphasizing the importance of incorporating trauma-focused intervention into integrated psychosocial programming to address prior trauma and its impacts on care in order to improve patient outcomes.

Trauma-Informed Care for Inpatient Palliative Care Social Work: Applying Existing Models at the Bedside

Coexisting serious illness and posttraumatic stress place hospitalized individuals at risk for complex pain, anxiety, and retraumatization. Hospital palliative care social workers increasingly recognize the value of trauma-informed care (TIC) for reducing harm in the inpatient setting. Despite this recognition, there is limited operationalization of TIC principles for inpatient interventions. This paper integrates each TIC principle with inpatient psychosocial interventions to advance trauma-informed competencies among inpatient palliative care social workers and to provide a foundation for future TIC implementation research.

Total pain and social suffering: marginalised Greenlanders' end-of-life in Denmark

With a focus on socially marginalised Greenlanders in Denmark, this study explores the significance of the concept of social suffering for the concept of total pain. Greenland is a former Danish colony and Greenlanders retain the right to Danish citizenship with all the benefits of access to the resources of Denmark as any other Danish citizen. However, Greenlanders are overrepresented amongst the most socially disadvantaged in Denmark. They have a disproportionately high risk of early death, often undiagnosed and untreated. This study reports on research conducted with socially marginalised Greenlanders and some of the professionals who work with them. It interrogates the concept of total pain as developed by Cicely Saunders, the founder of modern palliative care. Saunders noted that pain at the end-of-life was not adequately explained by symptoms of a disease process because it was more like a situation that engulfed every aspect of the patient and those close to them; it included physical, psychological, spiritual, and social dimensions. We agree with other scholars that the social dimension of the total pain experience is underexplored. By drawing on the theoretical and methodological lens of intersectionality, our work with marginalised Greenlanders has enabled us to describe the multiple and intersecting social forces that create social suffering for this group. This leads us to conclude that social suffering is not entirely an individual experience but a product of social harm and disadvantage, poverty, inequality, and the various legacies of colonialism, which combine to place some citizens in a harmed condition. Our findings also draw us into a discussion with the concept of total pain and its neglect of the socially constructed nature of social suffering. We conclude by indicating ways in which the concept of total pain can be informed by a more thoroughgoing concept of social suffering. We conclude, with others, that there is a problem of inequity in the way that end-of-life care is currently distributed. Finally, we point to ways in which an understanding of social suffering can help to address the exclusion of some of the most vulnerable citizens from appropriate end-of-life care.

Lived Experience: A Case-Based Review of Trauma-Informed Hospice and Palliative Care at a Veterans Affairs Medical Center

Many individuals who present for hospice or palliative care might have experienced trauma during their lives, with some progressing to post-traumatic stress disorder. As these individuals face life-limiting illness, trauma might resurface. Consequently, physical and emotional health might suffer due to exacerbation of trauma-related symptoms, such as anxiety, irritability, or flashbacks. Providing trauma-informed care can help mitigate the effects of trauma for those facing life-limiting illness who might not be able to tolerate formal trauma treatment due to limited prognosis, fatigue, or lack of willingness to engage in treatment. The goal of this narrative review is to describe how aging and the end-of-life experience can lead to a re-engagement with previous traumatic experiences and, using case-based examples, provide recommendations for all members of the interprofessional hospice or palliative care team on how to elicit and respond to a history of trauma to minimize the potential negative impact of trauma at end-of-life.

Patient-Reported Quality Measures for Palliative Care: The Time is now

CONTEXT

While progress has been made in the ability to measure the quality of hospice and specialty palliative care, there are notable gaps. A recent analysis conducted by Center for Medicare and Medicaid Services (CMS) revealed a paucity of patient-reported measures, particularly in palliative care domains such as symptom management and communication.

OBJECTIVES

The research team, consisting of quality measure and survey developers, psychometricians, and palliative care clinicians, used established state-of-the art methods for developing and testing patient-reported measures.

METHODS

We applied a patient-centered, patient-engaged approach throughout the development and testing process. This sequential process included 1) an information gathering phase; 2) a pre-testing phase; 3) a testing phase; and 4) an endorsement phase.

RESULTS

To fill quality measure gaps identified during the information gathering phase, we selected two draft measures ("Feeling Heard and Understood" and "Receiving Desired Help for Pain") for testing with patients receiving palliative care in clinic-based settings. In the pre-testing phase, we used an iterative process of cognitive interviews to refine draft items and corresponding response options for the proposed measures. The alpha pilot test supported establishment of protocols for the national beta field test. Measures met conventional criteria for reliability, had strong face and construct validity, and there was diversity in program level scores. The measures received National Quality Forum (NQF) endorsement.

CONCLUSION

These measures highlight the key role of patient voices in palliative care and fill a much-needed gap for patient-reported experience measures in our field.

End-of-life care for people with severe mental illness: mixed methods systematic review and thematic synthesis of published case studies (the MENLOC study)

OBJECTIVES

People with severe mental illness (SMI) have significant comorbidities and reduced life expectancy. The objective of the review reported in this paper was to synthesise material from case studies relating to the organisation, provision and receipt of care for people with SMI who have an end-of-life (EoL) diagnosis.

DESIGN

Systematic review and thematic synthesis.

DATA SOURCES

MEDLINE, PsycINFO, EMBASE, HMIC, AMED, CINAHL, CENTRAL, ASSIA, DARE and Web of Science from inception to December 2019. Supplementary searching for additional material including grey literature along with 62 organisational websites.

RESULTS

Of the 11 904 citations retrieved, 42 papers reporting 51 case studies were identified and are reported here. Twenty-five of the forty-two case study papers met seven, or more quality criteria, with eight meeting half or less. Attributes of case study subjects included that just over half were men, had a mean age of 55 years, psychotic illnesses dominated and the EoL condition was in most cases a cancer. Analysis generated themes as follows diagnostic delay and overshadowing, decision capacity and dilemmas, medical futility, individuals and their networks, care provision.

CONCLUSIONS

In the absence of high-quality intervention studies, this evidence synthesis indicates that cross disciplinary care is supported within the context of established therapeutic relationships. Attention to potential delay and diagnostic overshadowing is required in care provision. The values and preferences of individuals with severe mental illness experiencing an end-of-life condition should be recognised.

PROSPERO REGISTRATION NUMBER

CRD42018108988.

Practice Considerations for Trauma-Informed Care at End of Life

Trauma is widespread, and its symptoms can adversely impact wellbeing at end of life, a time when hospice seeks to maximize quality of life. This article reviews research on trauma at end of life, provides an overview of trauma-informed principles, and explores possibilities for applying trauma-informed care through an illustrative case study of a patient at end of life. The case discussion applies findings from the literature using Feldman's Stepwise Psychosocial Palliative Care model as a roadmap. As shown in the case study, trauma-related symptoms may complicate care, making it an important subject of clinical attention for interdisciplinary hospice team members. As part of this team, social workers are particularly well suited to provide more targeted interventions where indicated, though all members of the team should take a trauma-informed approach. Lastly, this article reflects on the need for organizations to take a systems-level approach when implementing trauma-informed care and suggests implications for practice through a universal approach to trauma and the need for trauma-specific assessments and interventions at end-of-life, along with areas for future research.

Psychological Distress after a Diagnosis of Malignant Mesothelioma in a Group of Patients and Caregivers at the National Priority Contaminated Site of Casale Monferrato

BACKGROUND

Patients of malignant mesothelioma (MM) and their caregivers face significant physical and psychological challenges. The purpose of the present study is to examine the emotional impact after the diagnosis of MM in a group of patients and familial caregivers in a National Priority Contaminated Site (NPCS).

METHODS

A sample of 108 patients and 94 caregivers received a sociodemographic/clinical questionnaire, the Beck Depression Inventory II, the Davidson Trauma Scale, the Coping Orientation to the Problems Experienced-New Italian Version, and the Defense style questionnaire. The risk of depressive and post-traumatic stress disorder (PTSD) symptoms in relation to the strategies of coping and defense mechanisms was estimated in patients and caregivers separately by logistic regression models.

RESULTS

For patients, a high risk of depression was associated with high usage of Defense Style Questionnaire (DSQ) Isolation (OR: 53.33; 95% CI: 3.22-882.30; p = 0.01) and DSQ Somatization (OR: 16.97; 95% CI: 1.04-275.90; p = 0.05). Other significant risks emerged for some coping strategies and some defenses regarding both depression and trauma in patients and caregivers.

CONCLUSIONS

This research suggests that for both patients and caregivers unconscious adaptive processes have a central role in dealing with overwhelming feelings related to the disease.

Posttraumatic Stress Disorder in Older Adults: A Conceptual Review

Objectives: We provide a review of the literature on posttraumatic stress disorder (PTSD) in older adults, focusing largely on older U.S. military veterans in two primary areas: 1) assessment and diagnosis and 2) non-pharmacological treatment of PTSD in late life. Methods: We performed a search using PubMed and Academic Search Premier (EBSCO) databases and reviewed reference sections of selected papers. We also drew on our own clinical perspectives and reflections of seven expert mental health practitioners. Results: Rates of PTSD are lower in older compared with younger adults. The presence of sub-syndromal/partial PTSD is important and may impact patient functioning. Assessment requires awareness and adaptation for potential differences in PTSD experience and expression in older adults. Psychotherapies for late-life PTSD appear safe, acceptable and efficacious with cognitively intact older adults, although there are relatively few controlled studies. Treatment adaptations are likely warranted for older adults with PTSD and co-morbidities (e.g., chronic illness, pain, sensory, or cognitive changes). Conclusions: PTSD is an important clinical consideration in older adults, although the empirical database, particularly regarding psychotherapy, is limited. Clinical Implications: Assessment for trauma history and PTSD symptoms in older adults is essential, and may lead to increased recognition and treatment.

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.

Assessment and Treatment Considerations for Post Traumatic Stress Disorder at End of Life

Post traumatic stress disorder (PTSD) may first emerge, reemerge, or worsen as individuals approach end of life and may complicate the dying process. Unfortunately, lack of awareness of the occurrence and/or manifestation of PTSD at end of life can lead to PTSD going unaddressed. Even if PTSD is properly diagnosed, traditional evidence-based trauma-focused treatments may not be feasible or advisable with this group as many patients at end of life often lack the physical and mental stamina to participate in traditional psychotherapy. This article reviews the clinical and empirical literature on PTSD at end of life, as well as discusses assessment and psychotherapy treatment issues with this neglected population. In addition, it expands on the current reviews of this literature1-3 by extrapolating results from nontraditional treatment approaches with other patient populations. Elements of these approaches with patients sharing similar characteristics and/or comorbidities with patients with PTSD at end of life may provide additional benefits for the latter population. Clinical implications and suggestions for interdisciplinary care providers are provided.

End-of-Life Care for WW II, Korea, and Vietnam-Era Veterans

Military Veterans have made many sacrifices for our country and deserve high-quality care at end of life. The purpose of this article is to discuss the WW II, Korean and Vietnam Veteran population, and common concerns at the end of life. Areas of focus include spiritual and emotional needs, posttraumatic stress disorder, and pain management. Understanding of military/Veteran culture, the stoic mindset, and moral injury may provide foundational knowledge for nonmilitary home care and hospice clinicians to understand Veteran patients and their families. In addition, resources and other references are offered to enhance the knowledge of Veteran-related care.

Stepwise Psychosocial Palliative Care: A New Approach to the Treatment of Posttraumatic Stress Disorder at the End of Life

Although evidence-based therapies for Posttraumatic Stress Disorder (PTSD) exist for physically healthy populations, these often do not adequately address PTSD in dying patients. Particularly because these interventions require 8-16 weekly sessions, and the median stay in U.S. hospices is 17.5 days (National Hospice and Palliative Care Organization [NHPCO], 2015 ), there is a potentially serious timing mismatch. Moreover, these treatments may temporarily increase trauma symptoms (Nishith, Resick, & Griffin, 2002 ), resulting in some patients dying in greater distress than had they not received care. The Stepwise Psychosocial Palliative Care (SPPC) model presented in this article compensates for these difficulties by embracing a palliative care approach to PTSD. Although it utilizes techniques drawn from existing PTSD interventions, these are re-ordered and utilized in a time-responsive, patient-centered manner that takes into account prognosis, fatigue, and logistical concerns. The SPPC approach is further considered with respect to existing social work palliative care competencies (Gwyther et al., 2005 ) and a case study is used to demonstrate its application.

Person-centered older military veteran care when there are consequences

The consequences of each war present themselves in many ways and differently within a veteran's lifetime. For civilian nurses to give applicable, vital care to the older veteran, they need to deeply appreciate the military culture, the strength of the ethos, as well as the various health concerns connected with the individual war/conflict. Attentiveness to the evolving health issues of older veterans are a priority at a time when many personal developmental changes are also creating life stressors for the Vietnam veterans and they are often presenting to civilian health facilities for their care. This article explores the controversial war within Vietnam (1955-1973), and the use of the universal question of "Have you ever served in the military?" An incremental veteran health assessment is discussed in order to care for the specific, prior-era physical/behavioral issues of post-traumatic stress disorder, Agent Orange, military sexual trauma, hepatitis C, and homelessness that are discussed for these men and women veterans, along with a rationale for their long-term presence, which is still evident today. Other relevant nursing interventions for veterans are suggested such as reminiscing, and art/animal-assisted therapy to supplement their medical care.

Medication Needs Vary for Terminally Ill Vietnam Era Veterans With and Without a Diagnosis of PTSD

This retrospective pilot study aims to evaluate the clinical impact of palliative care in the treatment of terminally ill Vietnam Veterans with a history of posttraumatic stress disorder (PTSD) versus those without PTSD, as it pertains to medications for symptom control at the end of life (EOL). Active prescriptions for benzodiazepines, hypnotics, antidepressants, and antipsychotic medications at the EOL were recorded. During EOL care, 28 (72%) participants with PTSD used these medications versus 55 (40%) of the non-PTSD participants (P = .0005). There was significant correlation between a lifetime diagnosis of PTSD with antidepressant use (P = .0002) and hypnotics (P = .0085) during EOL care but not with benzodiazepines or antipsychotics. The higher utilization of certain medication classes among participants with PTSD may indicate that PTSD treatment should continue at the EOL to improve care.

Treatment of posttraumatic stress disorder at the end-of-life: Application of the stepwise psychosocial palliative care model

Objectives:

Feldman (2011) has proposed a new approach to the treatment of posttraumatic stress disorder (PTSD) in individuals at the end-of-life known as Stepwise Psychosocial Palliative Care (SPPC). This approach helps to compensate for the disadvantages of existing PTSD interventions with regard to treating patients with life-limiting and terminal illnesses by employing a palliative care philosophy. The model relies on cognitive and behavioral techniques drawn from evidence-based approaches to PTSD, deploying them in a stage-wise manner designed to allow for interventions to track with patents’ needs and prognoses. Because this model is relatively new, we seek to explore issues related to its implementation in the complex settings in which providers encounter patients at the end-of-life. We also seek to provide concrete guidance to providers regarding the management of PTSD at the end-of-life in diverse palliative care settings.

Methods:

We examine three specific cases in which the SPPC model was utilized, highlighting particular treatment challenges and strategies. These case studies provide information regarding the SPPC model's application to patients in two distinct palliative care settings—a palliative care consult team and an inpatient palliative care unit.

Results:

The SPPC model's stage-wise approach allows for its flexible use given a variety of constraints related to setting and patient issues.

Significance of results:

The SPPC model provides an alternative to existing psychosocial treatments for PTSD that may be more appropriate for patients at the end of life.

One hospice's project to honor and care for veterans

This article explains Hospice of Dayton's program to care for veterans at end-of-life using 2 case studies as examples. Instructions, opportunities, and the unique challenges for support and care of this population at end-of-life are illustrated.

Posttraumatic stress disorder at the end of life: extant research and proposed psychosocial treatment approach

According to some estimates, 84% of people experience a traumatic event during their lives (Vrana & Lauterbach, 1994), and 15% to 24% then develop posttraumatic stress disorder (PTSD). Many carry with them lasting effects of trauma as they age and enter the last phase of life. PTSD manifests in unique ways at the end of life, possibly disrupting factors associated with a positive dying process, including social support, medical communication, life review, and acceptance of death. Terminally ill people with PTSD may suffer more emotional distress, lower quality of life, and poorer medical prognosis than those without PTSD. Unfortunately, healthcare providers may not be trained to address this issue. This article reviews the literature concerning how PTSD may affect the end of life and proposes an intervention model based on a palliative care philosophy.

Families' perceptions of veterans' distress due to post-traumatic stress disorder-related symptoms at the end of life

OBJECTIVES

To define the frequency of post-traumatic stress disorder (PTSD)-related symptoms among veterans who are near the end of life and to describe the impact that these symptoms have on patients and their families.

METHODS

Patients had received inpatient or outpatient care from a participating VA facility in the last month of life, and one family member per patient was selected using predefined eligibility criteria. Family members then completed a telephone survey, The Family Assessment of Treatment at End-of-Life, which assessed their perceptions of the quality of the care that the patients and they themselves received during the patients' last month of life.

RESULTS

Seventeen percent of patients (89 of 524) were reported to have had PTSD-related symptoms in the last month of life. PTSD-related symptoms caused discomfort less often than pain did (mean frequency score 1.79 vs. 1.93; Wilcoxon sign rank test, P<0.001) but more often than dyspnea did (mean severity score 1.79 vs. 1.73; Wilcoxon sign rank test, P<0.001). Family members of patients with PTSD-related symptoms reported less satisfaction overall with the care the patient received (mean score 48 vs. 62; rank sum test, P<0.001). Patients who received a palliative care consult (n=49) had lower ratings of discomfort attributed to PTSD-related symptoms (mean 1.55 vs. 2.07; rank sum test, P=0.007).

CONCLUSION

PTSD-related symptoms may be common and severe among veterans near the end of life and may have a negative effect on families' perceptions of the quality of care that the veteran received.

Palliative care for people with severe persistent mental illness: a review of the literature

A systematic overview of the literature on palliative care for people with severe persistent mental illness (SPMI) was conducted to inform clinical practice, research, and education. Empirical studies and nonempirical papers were included. Few empirical studies exist. There is even less information about the palliative care needs of, or the nature of palliative care provided to, people with SPMI. Mental health, primary care, and palliative care providers need to partner with people who have SPMI in developing and providing palliative care. The field of palliative care for people with SPMI is wide open and in need of methodologically sound studies that will help define the issues that exist for this vulnerable population. Recognizing the similarities between mental health and palliative care should lead to collaborative ventures and discussions in an attempt to address common and parallel issues.