- Email: [email protected]
Spiritual Warfare: Moral Distress (777)
574
Schedule with Abstracts
influence symptom control, advance care planning, and subject-perceived quality of care. III. Methods. Prospective case-control study of subjects seen by CCS (cases) and control group matched by age, gender, service of admission, and comorbidity scores (validated instruments). IV. Results. N = 110. 53 case-subjects and 57 control subjects. Subjects’ mean age was 75 years. Ethnicity: 57% white, 42% Hispanic, 9% black. 77% of subjects seen by CCS completed AD vs. 47% not seen (P = .001). After consultation (intervention), 50% of subjects seen by CCS had marked improvement of delirium (P < .0001). 94% of subjects seen by CCS had improved function (P < .0001). 33% of subjects seen by CCS had improvement in pain control (P < .0001). V. Conclusions. Combined geriatric/palliative care consult services are effective at improving symptom control, management of geriatric syndromes, and completion of AD. Significant results are seen in completion of advance directives, improvement in pain, management of geriatric syndromes (including delirium and functional status). VI. Implications for research, policy, or practice. Combining the expertise of geriatrics and palliative care into CCS is a practical way for hospitals to improve patient care and should improve length of stay and discharge disposition planning as well. A larger, multi-center, randomized trial is needed further elucidate the advantages of CCS.
Families’ Perceptions of Distress Due to Posttraumatic Stress Disorder at the End-of-Life Among Veterans (776) Yesne Alici, MD, Central Regional Hospital, Butner, NC; Hien Lu, BA, University of Pennsylvania, Philadelphia, PA; Dawn Smith, MS, Philadelphia VAMC, Philadelphia, PA; David Casarett, MD MA FAAHPM, University of Pennsylvania, Philadelphia, PA Objectives 1. Define the frequency of PTSD-related symptoms near the end of life among veterans and the impact of those symptoms on the families. 2. Compare the level of discomfort caused by PTSD-related symptoms to discomfort due to pain and dyspnea at the end of life among veterans. I. Background. It is important to understand how PTSD symptoms affect veterans’ end-of-life care. If they are a frequent cause of distress for
Vol. 37 No.3 March 2009
patients and their families, then the impact on end-of-life care may be substantial. II. Research Objectives. To define the frequency of PTSD-related symptoms near the end of life among veterans and to describe the impact that these symptoms have on patients and their families. III. Methods. This project was conducted in five VA medical centers. Patients were included if they had received care from a VA facility in the last month of life. One family member per patient was selected. Family members then completed a telephone survey, The Family Assessment of Treatment at End-of-life (FATE), that assessed their perceptions of the quality of the care that the patients and they themselves received during the patients’ last month of life and after the patients’ deaths. IV. Results. Seventeen percent (n = 89) of patients were reported by family members to have had PTSD-related symptoms in the last month of life. Families reported that these symptoms made the patient uncomfortable more often than dyspnea did (mean severity score 1.79 vs. 1.73; Wilcoxon sign rank test, P < .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 = .007). Family members of patients with PTSD-related symptoms reported less satisfaction overall with the care the patient received (mean score, 0.52 vs. 0.61; rank sum test, P = .005). V. Conclusions. This study highlights the need to consider PTSD in the differential diagnoses of psychological distress in the terminally ill. VI. Implications for research, policy, or practice. Further research is needed to better define the characteristics of PTSD in this population and to uncover mechanisms of pathogenesis. Nevertheless, these data suggest that these symptoms are both common and distressing in a veteran population, and should be a part of palliative evaluation and management.
Spiritual Warfare: Moral Distress (777) Jennifer Gentry, MSN APRN BC, Duke University Medical Center, Durham, NC; Anthony N. Galanos, MD, Duke University Medical Center, Durham, NC; Toni Cutson, MD MHS, Durham VA Medical Center, Rougemont, NC; Leslie J. Bryan, MD, Durham Veterans Administration Medical Center, Sanford, NC
Vol. 37 No.3 March 2009
Schedule with Abstracts
Objectives 1. Describe ways that palliative care teams can provide optimal spiritual care. 2. Describe ways that palliative care teams can support staff experiencing moral distress. I. Background. Honoring patient values and caring for the human spirit is central to the work of palliative care teams. When deeply held spiritual beliefs, patient values, and the healthcare system collide, conflict is a common outcome, as in the case of a 51-year-old African-American woman with advanced ovarian cancer. II. Case Description. Facing insurmountable odds for survival at the time of diagnosis, this woman pursued aggressive curative care and shunned any mention of defeat, death, and “negative talk” throughout the course of her illness. With “expect a miracle” as a literal and figurative banner during hospitalization, her faith would not allow for discussion of prognosis, decline, or death. During
575
the last 11 weeks of her life, spent in an ICU, her dedicated family upheld these desires for aggressive care. Nothing illustrated this commitment more than when family, dressed in combat fatigues for a bedside vigil, prepared for “battle with the devil.” III. Conclusion. Moral distress is a common occurrence when we, as providers, are compelled to offer care that conflicts with our own values and is perceived as increasing the suffering and distress of patients. Nursing staff often referred to this patient’s room as “the torture chamber.” The work of the palliative care team, illustrated with this case, was in large part, to support the ICU staff while supporting the family coping and spiritual needs.
Schedule with Abstracts
influence symptom control, advance care planning, and subject-perceived quality of care. III. Methods. Prospective case-control study of subjects seen by CCS (cases) and control group matched by age, gender, service of admission, and comorbidity scores (validated instruments). IV. Results. N = 110. 53 case-subjects and 57 control subjects. Subjects’ mean age was 75 years. Ethnicity: 57% white, 42% Hispanic, 9% black. 77% of subjects seen by CCS completed AD vs. 47% not seen (P = .001). After consultation (intervention), 50% of subjects seen by CCS had marked improvement of delirium (P < .0001). 94% of subjects seen by CCS had improved function (P < .0001). 33% of subjects seen by CCS had improvement in pain control (P < .0001). V. Conclusions. Combined geriatric/palliative care consult services are effective at improving symptom control, management of geriatric syndromes, and completion of AD. Significant results are seen in completion of advance directives, improvement in pain, management of geriatric syndromes (including delirium and functional status). VI. Implications for research, policy, or practice. Combining the expertise of geriatrics and palliative care into CCS is a practical way for hospitals to improve patient care and should improve length of stay and discharge disposition planning as well. A larger, multi-center, randomized trial is needed further elucidate the advantages of CCS.
Families’ Perceptions of Distress Due to Posttraumatic Stress Disorder at the End-of-Life Among Veterans (776) Yesne Alici, MD, Central Regional Hospital, Butner, NC; Hien Lu, BA, University of Pennsylvania, Philadelphia, PA; Dawn Smith, MS, Philadelphia VAMC, Philadelphia, PA; David Casarett, MD MA FAAHPM, University of Pennsylvania, Philadelphia, PA Objectives 1. Define the frequency of PTSD-related symptoms near the end of life among veterans and the impact of those symptoms on the families. 2. Compare the level of discomfort caused by PTSD-related symptoms to discomfort due to pain and dyspnea at the end of life among veterans. I. Background. It is important to understand how PTSD symptoms affect veterans’ end-of-life care. If they are a frequent cause of distress for
Vol. 37 No.3 March 2009
patients and their families, then the impact on end-of-life care may be substantial. II. Research Objectives. To define the frequency of PTSD-related symptoms near the end of life among veterans and to describe the impact that these symptoms have on patients and their families. III. Methods. This project was conducted in five VA medical centers. Patients were included if they had received care from a VA facility in the last month of life. One family member per patient was selected. Family members then completed a telephone survey, The Family Assessment of Treatment at End-of-life (FATE), that assessed their perceptions of the quality of the care that the patients and they themselves received during the patients’ last month of life and after the patients’ deaths. IV. Results. Seventeen percent (n = 89) of patients were reported by family members to have had PTSD-related symptoms in the last month of life. Families reported that these symptoms made the patient uncomfortable more often than dyspnea did (mean severity score 1.79 vs. 1.73; Wilcoxon sign rank test, P < .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 = .007). Family members of patients with PTSD-related symptoms reported less satisfaction overall with the care the patient received (mean score, 0.52 vs. 0.61; rank sum test, P = .005). V. Conclusions. This study highlights the need to consider PTSD in the differential diagnoses of psychological distress in the terminally ill. VI. Implications for research, policy, or practice. Further research is needed to better define the characteristics of PTSD in this population and to uncover mechanisms of pathogenesis. Nevertheless, these data suggest that these symptoms are both common and distressing in a veteran population, and should be a part of palliative evaluation and management.
Spiritual Warfare: Moral Distress (777) Jennifer Gentry, MSN APRN BC, Duke University Medical Center, Durham, NC; Anthony N. Galanos, MD, Duke University Medical Center, Durham, NC; Toni Cutson, MD MHS, Durham VA Medical Center, Rougemont, NC; Leslie J. Bryan, MD, Durham Veterans Administration Medical Center, Sanford, NC
Vol. 37 No.3 March 2009
Schedule with Abstracts
Objectives 1. Describe ways that palliative care teams can provide optimal spiritual care. 2. Describe ways that palliative care teams can support staff experiencing moral distress. I. Background. Honoring patient values and caring for the human spirit is central to the work of palliative care teams. When deeply held spiritual beliefs, patient values, and the healthcare system collide, conflict is a common outcome, as in the case of a 51-year-old African-American woman with advanced ovarian cancer. II. Case Description. Facing insurmountable odds for survival at the time of diagnosis, this woman pursued aggressive curative care and shunned any mention of defeat, death, and “negative talk” throughout the course of her illness. With “expect a miracle” as a literal and figurative banner during hospitalization, her faith would not allow for discussion of prognosis, decline, or death. During
575
the last 11 weeks of her life, spent in an ICU, her dedicated family upheld these desires for aggressive care. Nothing illustrated this commitment more than when family, dressed in combat fatigues for a bedside vigil, prepared for “battle with the devil.” III. Conclusion. Moral distress is a common occurrence when we, as providers, are compelled to offer care that conflicts with our own values and is perceived as increasing the suffering and distress of patients. Nursing staff often referred to this patient’s room as “the torture chamber.” The work of the palliative care team, illustrated with this case, was in large part, to support the ICU staff while supporting the family coping and spiritual needs.