The Relationship of Post-traumatic Stress Disorder to End-of-life Care Received by Dying Veterans: a Secondary Data Analysis

Abstract

BACKGROUND: Post-traumatic stress disorder (PTSD) can be exacerbated by subsequent trauma, but it is unclear if symptoms are worsened by impending death. PTSD symptoms, including hyperarousal, negative mood and thoughts, and traumatic re-experiencing, can impact end-of-life symptoms, including pain, mood, and poor sleep. Thus, increased symptoms may lead to increased end-of-life healthcare utilization. OBJECTIVES: To determine if veterans with PTSD have increased end-of-life healthcare utilization or medication use and to examine predictors of medication administration. DESIGN: Secondary analysis of a stepped-wedge design implementation trial to improve end-of-life care for Veterans Affairs (VA) inpatients. Outcome variables were collected via direct chart review. Analyses included hierarchical, generalized estimating equation models, clustered by medical center. SUBJECTS: Veterans, inpatient at one of six VA facilities, dying between 2005 and 2011. MAIN MEASURES: Emergency room (ER) visits, hospitalizations, and medication administration in the last 7 days of life. KEY RESULTS: Of 5341 veterans, 468 (8.76%) had PTSD. Of those, 21.4% (100/468) had major depression and 36.5% (171/468) had anxiety. Veterans with PTSD were younger (mean age 65.4 PTSD, 70.5 no PTSD, p < 0.0001) and had more VA hospitalizations and ER visits in the last 12 months of life (admissions: PTSD 2.8, no PTSD 2.4, p < 0.0001; ER visits: 3.2 vs 2.5, p < 0.0001). PTSD was associated with antipsychotic administration (OR 1.52, 95% CI 1.06-2.18). Major depression (333/5341, 6.2%) was associated with opioid administration (OR 1.348, 95% CI 1.129-1.609) and benzodiazepines (OR 1.489, 95% CI 1.141-1.943). Anxiety disorders (778/5341, 14.6%) were only associated with benzodiazepines (OR 1.598,. CONCLUSIONS: PTSD's association with increased endof-life healthcare utilization and increased antipsychotic administration in the final days of life suggests increased symptom burden and potential for terminal delirium in individuals with PTSD. Understanding the burden of psychiatric illness and potential risks for delirium may facilitate the end-of-life care for these patients.

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

“…In the last days of life, individuals with PTSD might be more likely to receive symptom-relieving medications, particularly in the antipsychotic class, suggesting increased symptom burden. 18 More upstream, some have postulated that a life-limiting illness may mimic the original trauma. Additionally, those with PTSD might cope through avoidance, potentially making communication with the care team challenging.…”

A study of post‐traumatic stress disorder in schizophrenic patients 35 years after experiencing the Tangshan earthquake

“…However, PTSD is not the only diagnosis for those who have experienced a traumatic event (Auxemery, 2018). Other outcomes associated with trauma include anxiety, depression, dissociative experiences, and psychiatric symptoms (Auxéméry, 2015;Baryshnikova & Pham, 2019;Bickel et al, 2020;Lin et al, 2016;Roley et al, 2015;Wang et al, 2020).…”

“…However, PTSD is not the only diagnosis for those who have experienced a traumatic event (Auxemery, 2018). Other outcomes associated with trauma include anxiety, depression, dissociative experiences, and psychiatric symptoms (Auxéméry, 2015; Baryshnikova & Pham, 2019; Bickel et al., 2020; Lin et al., 2016; Roley et al., 2015; Wang et al., 2020). Therefore, it is essential to understand the relationship between these symptom clusters and mental distress to better treat those affected by traumatic events.…”

Trauma-informed palliative care is needed: A call for implementation and research

“…From a psychological perspective, the very real existential threats imposed by a life-limiting illness may trigger memories of prior traumatic events, thus exacerbating acute traumatic stress symptoms. 7 Indeed, up to 80% of people with advanced, recurrent cancer experience post-traumatic stress symptoms compared to 20% of patients with early-stage cancer. 8 People with life-limiting illnesses may also experience healthcare-induced trauma resulting from painful surgeries, procedures, medication adverse effects, ICU admissions and ER visits.…”

“…From a psychological perspective, the very real existential threats imposed by a life-limiting illness may trigger memories of prior traumatic events, thus exacerbating acute traumatic stress symptoms. 7 Indeed, up to 80% of people with advanced, recurrent…”