Stripping Away the Battle Armor A Panel Discussion LuAnn Carraher, RN, CHPN Clinical Coordinator with Health Connect at Home in Grand Island. Kerri Denell, MSW Social worker with Hospice of Tabitha in Lincoln. Dr. Jennifer King Serves as the medical director of the Grand Island Veteran s Home. Vicki Lamb Is a volunteer with Hospice of Tabitha in Lincoln. Stephen Rallis, DDS Hospice Chaplain, Bereavement and Volunteer Coordinator with St. Joseph Villa Homecare and Hospice in Omaha. 1
Shane Van Dorin, M. Div. Chaplain of the Hospice and Palliative Care Team for the Omaha VA Hospital. Format of Discussion Spirituality/Cultural Diversity Refresher Introduce Case Study Interdisciplinary Discussion Veteran s Final Hours Q & A Session Objectives of Panel Discussion Define the concept of Spirituality Define the concept of Cultural Diversity. Recognize how the concepts of spirituality and cultural diversity apply to the practice of hospice and palliative care. Spirituality Model Connection through relationship with: God Self Others Spirituality Model The essence of spirituality for the health care professional is understanding the process of how patients can connect with their own spirit, the spirit of others, and the spirit of their higher power. Spiritual Assets Relationship with God/H.P.: Hope Peace Guidance/Direction 2
Spiritual Assets Relationship with Self: Self Awareness Self Assessment Self Determination Spiritual Assets Relationship with Others: Learning Accountability Service Spiritual Injury Relationship with God/H.P.: Hopelessness No hope beyond self. Anger Angry due to unjust acts. Guilt Feeling unforgiven. Purposelessness Lack of meaning in life. Spiritual Injury Relationship with Self: Denial Refusal to acknowledge painful emotions. Anxiety Inability to find rest. Fear Frightened by consequences of circumstances. Complicated Grief Dealing with loss. Spiritual Injury Relationship with Others: Isolation Lack of trust. Frustration Loss of control. Shame Acceptance of negative personal insight. Non-compliant Unteachable,, rebellious; unwilling to be held accountable. Culture Defined A system of shared symbols Provides security, integrity, belonging Constantly evolving Making meaning of illness Not limited to race or ethnicity 3
Components within Culture Ethnicity Race Gender Age Religion and Spirituality Sexual Orientation Components within Culture (Cont.) Differing abilities Financial status Place of residency Employment Education level Cause of death Cultural Diversity Defined Acknowledging an endless variety of cultural components in the context of observing particular people groups. Challenges in Veteran Sub-culture Higher prevalence of than other subcultures: Suicide (especially combat veterans) Homelessness Substance Abuse Severe health issues at younger ages. Post Traumatic Stress Disorder Components of Cultural Assessment Patient/family/community Birthplace Ethnic identity, community Decision making Language and communication Components of Cultural Assessment Religion Food preferences/prohibitions Economic situation Health beliefs regarding death, grief, pain, traditional therapies, care of the body, organ donation 4
Battle armor is a metaphor for spiritual/cultural barriers, common with many veterans, that might prohibit the healing processes for veterans and/or family members at end of life. Possible Battle Armor Issues: Lack of trust Fear of losing control Emotional expression is a sign of weakness. Bitterness/Hatred is embraced Idea of battle armor is to protect military personel in physical hostility; however, the hope is to return veterans to a safe place where battle armor is no longer needed. WARNING: Removing battle armor can cause a veteran to feel threatened because they become vulnerable. Stripping away the battle armor is an exercise in awareness of spiritual/cultural dynamics that can hinder the healing process at end of life. Case Study 59 yrs old transsexual pt who is a Veteran and has a medical dx of squamous cell carcinoma, wearing a non rebreather mask to keep sats up to 90%, has medical history of PTSD, mood disorder, GERD, bipolar effective disorder, COPD, wt loss, chronic hepatitis C and smokes. Pt comes to the hsp with recent work up of the cancer dx and is indecisive re code status / intubation in light of his medical diagnosis s. Case Study Pt does not wish to transfer back to larger VA system for medical care / treatment due to distance from his family and hardships to them to be present. Pt is unable to transfer to local care facility due to high needs of non re-breather requirements (15L) to keep oxygen levels up that the local facility was unable to accommodate. The pt has a wife and adult children of which they remain interactive and supportive. The pt was in the marine corp while in the service as well as practiced Wiccan belief systems and some of the family was of Christian faith. 5
Case Study The pt remained with us for 9 days with the initial days being in ICU, then transferred to the medical floor where the pt made the decision to have more supportive / comfort care until this pts death. PANEL DISCUSSION Veteran s Final Hours The day before this pts death SWS attempted to try to see if we could coordinate Hospice / Palliative Care at receiving Veterans facility. We were unable to do this due to pts requirements for oxygenation / comfort. Early afternoon of this day pt / family agree to allow us to try continuous IV analgesia for comfort / dyspnea. Order received to titrate up hourly per her comfort. This pt visited briefly w her primary MD the next a.m. and voiced understanding of poor prognosis and desire for comfort care. Veteran s Final Hours By mid morning family expresses to Palliative Care that they sense a change in her overall condition and preparing for the final hours. Mid hour of this day we note more physical changes that reinforce we were entering into sacred time for this pt and her family. Family asked to perform cleansing of her hair and some personal cares which they desired to do as a family in preparation of what was to come and as an act of providing for her needs. They were all by her beside, washing her hair, stroking her face, scalp and touching her and conversing with her and each other, as she laid there limp and in their total care. She was very peaceful and a sense of calm seemed to surround the room from this time on. Veteran s Final Hours Palliative care came back an hour later and found the pts S.O and some of her children had left the room but the oldest daughter was by her bedside as this pt drew in her last breath and released her spirit. The eldest daughter embraced the pt and cried out in the room for her daddy and shared with the nurse present that she the pt, was a good dad and how she was daddy s little girl who always did everything with him when she was little. She also expressed how glad she was that she got to spend one very special last time with her dad that she viewed this as his gift back to her. The daughter did not reference her, the pt, as dad again, then the remaining family entered and they all embraced the lifeless body of this pt and supported each other in a silent understanding of their united struggles, that those of us on the outside could not fully understand. Q & A 6