Situation Often Worse for Rural Veterans in Community Care
A palliative care/hospice room at the VA Boston Healthcare System. The dying process can be more difficult for veterans with PTSD but is better if hospice care is delivered within the VA system, according to a new report. Photo from VA Boston Healthcare System
BOSTON – Most veterans with post-traumatic stress disorder don’t just age out of it. At their end of life, veterans with PTSD often frequently exhibit irritability with their caregivers, sleep problems, nightmares, anxiety, guilt, lack of acceptance and restlessness, according to recent research.
Researchers from the National Center for PTSD at the VA Boston Healthcare System and Boston University School of Medicine pointed out that, at the end of life, veterans might relive earlier trauma as they reflect on life experiences and confront their mortality. That can worsen the quality of the death experience.
Their study, published in the journal Progress in Palliative Care, noted that the issue is especially of concern with military veterans, who tend to have more trauma exposures and higher rates of PTSD. It can be even more of a concern for veterans receiving care in rural areas where access to PTSD specialty services is limited.1
“When PTSD and serious illness co-occur, PTSD may impact care, coping and common end-of-life symptoms,” explains corresponding author Anica Pless Kaiser, PhD, clinical research psychologist at the National Center for PTSD and a research assistant professor of psychiatry at Boston University School of Medicine.
The study advised that PTSD patients tend to be more likely to experience chronic pain and pain may exacerbate PTSD symptoms. Those veterans also often use dysfunctional coping mechanisms, leading to increased distress with co-existing chronic medical conditions and dementia.
“Some providers may not recognize PTSD or be trained in how to appropriately assess and respond,” Pless Kaiser suggested. “Existing therapeutic approaches to treating PTSD may need to be modified to address the moral, spiritual and existential concerns that are often encountered as death nears.”
The study sought to better understand the issue, conducting 10 focus groups with clinicians serving veterans in rural communities in Florida, Vermont, Kentucky, Minnesota, and Michigan. It also used data from 157 respondents to the National Hospice and Palliative Care Organization survey.
The goal was to answer two questions:
- Do hospice and palliative care providers/staff observe PTSD symptoms in veterans at the end of life?
- If so, how are symptoms similar to and different from existing DSM-5 criteria for PTSD?
Researchers noted that descriptions from veterans revealed specific issues related to the end-of-life setting such as resistance to care, agitation, restlessness, and effects of delirium. Family dynamics also played a role, they said, although recollections of the past varied. Some veterans expressed pride in service and openness to discussing military experiences.
Hospice and palliative care clinicians reported observing many symptoms and behaviors in the aging veteran population in line with re-experiencing of traumatic events. Those included:
- intrusive memories,
- dreams/nightmares,
- flashbacks or
- dissociative reactions, and psychological distress in response to trauma reminders and cues.
- The symptoms sometimes occurred with dementia or delirium, they said.
Many veterans are or likely will be affected, according to the study. About 85% of military veterans have been exposed to traumatic events, which puts them at elevated risk — ranging from one to 22% depending on the conflict era – for PTSD.
Rural Veterans Fare Worse
In addition, according to a previous study, about a fourth of all veterans live in rural communities and make up more than a third of patients receiving VA healthcare. A 2017 study in the Journal of Rural Mental Health pointed out that, compared to their urban counterparts, rural veterans have more severe PTSD symptoms and higher rates of suicide and substance use disorders. At the same time, rural areas face shortages of mental health providers and less access to specialty mental health care. It added that, because most rural veterans live far from VAMCs, end-of-life care is more likely to occur outside of a VA facility.2
Ultimately, according to the authors, the goal is to better train healthcare providers to care for veterans with PTSD during the dying process. For example, they said, veterans might fare better if they have opportunities to talk about traumatic experiences, find meaning in them and reconcile the good with the bad.
The VA’s Rural Health Resource Center already has some initiatives in place, suggesting that rural health providers often need more training in assessing PTSD symptoms and knowing how to respond when a veteran discloses trauma and trauma-related emotions or negative beliefs
The group said on its website that it is developing educational resources and materials about end-of-life PTSD symptoms to distribute to rural hospice and palliative care providers. It also will continue to investigate the end-of-life experiences of rural Veterans and their families, and the needs of rural hospice and palliative care providers caring for veterans, as well as assess family members’ and veterans’ educational needs regarding end-of-life PTSD.
- Kaiser AP, O’Malley K, Moye J, Etchin AG, et. al. (2021) Hospice and palliative care clinicians’ perceptions of posttraumatic stress disorder at end-of-life in military veterans, Progress in Palliative Care, DOI: 10.1080/09699260.2021.1980649
- Bumgarner, D. J., Polinsky, E. J., Herman, K. G., Fordiani, J. M., Lewis, C. P., Hansen, S. K., … & Cardin, S. A. (2017). Mental health care for rural veterans: A systematic literature review, descriptive analysis, and future directions. Journal of Rural Mental Health, 41(3), 222-233.
