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Clinical Assessment and Care Planning for Vietnam Veterans€¦ · Psychosocial assessment • Vietnam veterans experienced a lack of post-combat treatment. • Direct combat trauma

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  • Bernard Lee, MD, US Army Veteran

    MJHS Hospice and Palliative Care

    Director of Palliative Provider Services

    Joseph Vitti, MBA-HCM, US Army Veteran

    VNSNY Hospice and Palliative Care

    Veterans Programs Director

    Enrique Aguilar, RN, CHPN, US Army Veteran

    MJHS Hospice and Palliative Care

    On Call Service Manager

    July 22, 2020

    Clinical Assessment and Care Planning for

    Vietnam Veterans

  • Acknowledgement

    VNSNY Hospice and Palliative Care

    MJHS Hospice and Palliative Care

    Hospice and Palliative Care Association of New York State (HPCANYS)

    National Hospice & Palliative Care Organization (NHPCO)

    We Honor Veteran Program

  • Objectives

    • Provide a basic understanding of military culture

    • Review historical data of the Vietnam War

    • Review Vietnam related presumptive illnesses and

    service related injuries.

    • Discuss challenges faced by service members returning

    from Vietnam war.

    • Review a physical and psychosocial assessment focused

    on special needs of Vietnam Veterans

  • U.S. Military Culture • Not just a job, but a way of life.

    • Reason for joining the military

    • Military Mission

    • Military branches

    • Military status

    • Military rank structure

    • Military occupation

    • Civilian vs. military structure.

    • Military core values

    • Soldier’s creed

  • 15 THINGS VETERANS WANT YOU TO KNOW

    • Reinforces the identity of being a veteran

    • Differences in culture and personal identity from

    being in specific branches (i.e. being called a

    Marine vs. Soldier)

    • Influence on personalities from being certain ranks

    and years of service delegating to subordinates

    • How MOS can influence this

    • Different war/service eras and it’s influences on

    one’s perspectives/thoughts

    • How to break the stereotypes of veterans

    • Hardship of being caregivers/family members

    within community

    • The conversations and struggles to discuss intense

    and intimate experiences

    • Psych Armor Institute on 15 Things Veterans Want

    You to Know

    https://psycharmor.org/courses/15-things-veterans-want-you-to-know/

  • 1960S AND 1970S AMERICAN CULTURAL SHIFT IN SOCIETY

    • Civil unrest

    • Increasingly vocal younger generation

    • Black Americans and women seeking equal rights

    • Changing attitudes about sexuality and drug use

    • Technology

    .

    Phillips, J., & Daratsos, L. (2017, August 15). Caring for Vietnam Veterans with Serious Illness. Lecture presented at Albany, New York.

  • • 1945 Vietnam declaration of independence from France.

    • 1959 North Vietnam invaded Laos and Cambodia. Created the Ho Chi Minh Trail, a

    network of roads to support the National Liberation Front (NLF) AKA Viet Cong.

    • 1960-1976 NLF led a guerrilla warfare against South Vietnam, U.S. and it’s allies.

    • USA was concerned communism would spread to South Vietnam and the rest of Asia.

    • 1964 Gulf of Tonkin incident. Confrontation between U.S. Destroyer USS Maddox

    and North Vietnamese Navy torpedo boats.

    • August 10, 1964 US Congress passed the Gulf of Tonkin Resolution, which granted

    president Lyndon B. Johnson authority to deploy military forces.

    • In 1965, the first US troops arrive in Vietnam

    • In 1968 the Tet Offensive occurred which drew much US public criticism and

    questioning of their involvement in the war

    • In 1973 the US negotiated a cease-fire that ended in the infamous 1975 withdrawal of

    US troops and embassy from Saigon (Fall of Saigon).

    VIETNAM WAR TIMELINE

  • VIETNAM

    • Tropical country

    • High temperatures, high humidity

    • Monsoon season; unable to get dry for days effecting one’s mental/physical health

    • Infrequent opportunities for bathing

    • Skin hygiene poor

    • Bacterial and foot infections common

    • Malaria

    • Agent Orange exposure

    • Increased survival rate b/c availability of rapid evacuation, whole blood and well-established semi permanent hospitals

    • Lack of social support services (VA and VSOs) to assist with service-connected conditions

    Phillips, J., & Daratsos, L. (2017, August 15). Caring for Vietnam Veterans with Serious Illness. Lecture presented at Albany, New York.

  • VIETNAM WAR

    • First televised war

    • Volunteer vs. Draft

    • 4GW (4th Generation Warfare) – First time encountered for military forces

    • Did not deploy and return as a unit nor have a supportive military exiting process

    • American society was experiencing political, economic, and social turmoil

    • The war did not have a national and unified understanding of its purpose and intent

    • Veterans returned suddenly to a confused and divided society at times conveying their aggravations at the individual veteran

    • Unwelcomed return home for veterans

    • VA and VSOs did not accept Vietnam veterans

    • Vietnam veterans have highest rates of divorce, unemployment, imprisonment, and substance abuse versus other veteran generation

  • VIETNAM COMBAT EXPERIENCE

    • Drafted for 1-year tour

    • Did not train and get deployed in companies

    • fragmented, eroded sense of camaraderie

    • Air travel meant active combatant one day and Veteran returning to

    hostile civilian environment the next

    • Sense of gratitude was often lacking from the Vietnamese due to lack

    of winning the peoples’ Hearts and Minds (harder to have a sense of

    accomplishment)

    • 70% of WWII Veteran sample felt appreciated upon their return to

    this country and to civilian life vs. < 25% of Vietnam Veterans

    • The average infantryman:

    • In the WWII S. Pacific saw ~ 40 days of combat in 4 yrs

    • In Vietnam ~ 240 days of combat in 1 year

    Phillips, J., & Daratsos, L. (2017, August 15). Caring for Vietnam Veterans with Serious Illness. Lecture presented at Albany, New York.

  • PRESUMPTIVE CONDITIONS,SERVICE RELATED ILLNESSES AND

    INJURIES

    • Infectious Diseases

    • Environmental Hazards

    • Psychiatric/Behavioral Health

    • Chronic Pain

    • Addiction

    • ALS

  • INFECTIOUS DISEASES

    • Poor Hygiene

    • Fungal

    • Bacterial

    • Skin Diseases

    • Hepatitis C

    • Malaria

  • ENVIRONMENTAL HAZARDS

    • High Temperatures

    • High Humidity

    • Monsoon Climate

    • Agent Orange

  • AGENT ORANGE

    • Herbicide

    • Dioxin - TCDD

    • Veteran’s Health Care Eligibility Reform Act of 1996

    • No Specific test to prove AO exposure

    • VA presumes AO exposure for Vietnam Veterans

  • Presumptive Illnesses Associated with

    Exposure to Agent Orange

    Malignant Diseases:

    • Lung Cancer Chronic B-cell Leukemia

    • Sarcomas Hodgkin’s Lymphoma

    • Prostate Cancer Non-Hodgkin’s Lymphoma

    • Multiple Myeloma

    Non-Malignant Diseases:

    • Amyloidosis Porphyria Cutanea Tarda

    • Ischemic Heart Disease Peripheral Neuropathy

    • Diabetes Mellitus Type 2 Parkinson’s Disease

    • Birth defects (Spina bifida) Chloracne

  • MENTAL HEALTH DISORDERS

    • PTSD

    • LATR – Later Adulthood Trauma Reengagement

    • Moral Injury

    • Depression

    • Sleep Disturbance

    • Addiction

  • Patient’s experience

    • “After Vietnam, I could not adjust to civilian life.

    I had trouble with drugs and alcohol. My spouse

    filed for divorce. I tried school, but I could not

    meet college requirements and dropped out. I

    couldn’t sleep or concentrate. I found myself

    daydreaming a lot. I got into many fights, often

    for meaningless reasons. I got fired from many

    jobs. Years later, I developed heart disease,

    breathing problems and chronic pain. I have lost

    hope and sometimes, I think life is not worth

    living”.

  • Clinical Assessment

    • Vietnam veterans are among the largest veteran groups receiving Social

    Security and Medicare benefits.

    • Great likelihood of civilian clinicians rendering care for Vietnam veterans.

    • Veterans are trained to listen to authority and observe discipline and structure

    • Veterans may have difficulty establishing trust. Promote empathy, hope,

    optimism, truth, education.

    • Involve the veteran in the assessment and care planning. Provide security and

    allows control.

    • Avoid making assumptions about their experiences or asking sensitive

    questions.

    • Every veteran’s experience is unique.

  • Physical Assessment

    • Introduce yourself and explain your role

    • Provide a welcoming environment conducive to comfort and privacy

    • Display empathy, validation and true concern to establish trust and

    credibility

    • Be honest

    • Be conscious of body posture and tone of voice

    • Provide active listening and be patient/lenient.

    • Explain every procedure and encourage active participation.

    • Assess for deployment-related exposure to prophylactic medications,

    chemical/biological/radiation agents, pesticides, bodily fluids, air pollution,

    insects.

    • Assess for combat physical trauma and its sequela.

    • Assess for Chronic pain. Vietnam veterans may be stoic about pain and

    other symptoms.

    • Assess for functional limitations including use of assistive devises and

    hearing aids.

    • Assessment 6Ws; Who, where, when, how, what, why

    • Ensure a safe home environment.

  • Psychosocial assessment

    • Vietnam veterans experienced a lack of post-combat treatment.

    • Direct combat trauma and POW experiences may require additional support.

    • Honor, respect and celebrate the service of Vietnam veterans.

    • “No event in American history is more misunderstood than the Vietnam war.

    It was misreported then, and it is misremembered now’ President Richard

    Nixon.

    • Psychological; PTSD, depression, sleep disturbances, substance abuse, moral

    injury, survivor’s guilt, military sexual trauma, physical abuse, sexuality and

    intimacy, suicide, later-adulthood trauma reengagement.

    • Veteran’s experiences have a significant impact on their families and society.

    • Assess for existential and spiritual concerns

  • We Honor Veterans Care Planning Guide

    https://www.wehonorveterans.org/wp-content/uploads/2020/02/Care_Planning_Guide_for_Veterans.pdf

  • Care Planning

    • Provide an interdisciplinary approach to address physical and psychosocial

    needs.

    • Identify service connection; Direct, Secondary, Aggravated, Presumptive

    • Ensure Veterans have current information, and assistance to access benefits and

    resources

    • Veterans Health Administration (VHA). Largest integrated health care system

    in U.S. (844-698-2311)

    • Veterans benefit Administration (VBA). Compensation, pension, loans,

    education, life insurance (800-827-1000)

    • Educate about specific registries and programs that provide additional

    resources for possible long-term health programs.

    • Assist with advance Care Planning; Health care proxy, MOLST, DNR/DNI

    orders, power of attorney, living will

  • CARE PLANNING GUIDE FOR VETERANS

    • Adaptable to each hospice organization as a guidance/reference in order to ensure quality healthcare delivery

    • Assists with interventions specific to PTSD, assessment for pain and other symptoms, Moral Injury, and Military Rituals

    • Provides cultural sensitivity and awareness regarding veteran patient population

    We Honor Veterans Care Planning Guide

    https://www.wehonorveterans.org/wp-content/uploads/2020/02/Care_Planning_Guide_for_Veterans.pdf

  • SUMMARY

    • Useful tool in bridging the silence that often surrounds the war experience

    • Need to establish an environment of trust and respect

    • Not all veterans will want to speak with you about the details of their war experience nor will all have PTSD (Thousand yard stare)

    • A discussion of combat experiences can reactivate deeply buried issues

    • Listen non-judgmentally

    • Offer caring presence, conveying warmth and acceptance of the person, their journey and struggles

    • Do not offer platitudes or prematurely assuage feelings of guilt

    https://www.mypcnow.org/blank-v6bdf

    GOAL: Evaluate the impact of their military experience(s)

    Phillips, J., & Daratsos, L. (2017, August 15). Caring for Vietnam Veterans with Serious Illness. Lecture presented at Albany, New York.

  • Thank You!!! Q&A