Serving those who served: Growing need for quality geriatric palliative care for Veterans

 

The Veteran population is rapidly aging  with 9.2 million veterans who are 65 years of age and older (See Table 1 below). 1.4 million Veterans are “old-old” i.e. 85 years or older. Like the late Mr. Martin Wise (US Coast Guard Veteran) shown in the video, most of the illness burdens borne by Veterans are due to chronic illnesses like cancer, heart disease, lung disease, stroke and Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s disease).  Due to exposure to toxins like  Agent Orange, Veterans are at high risk for diseases like  ALS and Prostate Cancer.

 

Older Adult Veterans by State and Age Group

State 65-69 yrs 70-74 yrs 75-79 yrs 80-84 yrs 85+ yrs

Grand Total

Alabama 42,691 34,677 34,139 26,796 21,594 159,897
Alaska 6,114 3,507 2,555 1,742 1,471 15,389
Arizona 57,353 46,788 46,194 37,235 33,250 220,822
Arkansas 27,539 21,921 21,090 16,008 14,301 100,860
California 200,461 153,322 151,438 132,768 142,545 780,535
Colorado 41,257 28,728 27,685 22,992 21,331 141,993
Connecticut 28,067 23,507 23,507 20,059 19,621 114,762
D.C. 3,084 2,608 3,030 2,638 2,462 13,823
Delaware 9,433 7,093 7,034 5,219 4,067 32,846
Florida 167,871 134,731 138,584 120,443 116,685 678,314
Georgia 77,418 55,384 51,146 38,346 29,718 252,012
Hawaii 11,318 8,420 7,779 6,552 5,810 39,879
Idaho 13,977 11,046 9,798 7,662 7,786 50,269
Illinois 92,166 73,155 75,328 60,450 52,591 353,691
Indiana 56,696 42,911 43,033 33,731 27,035 203,406
Iowa 27,952 21,443 23,189 17,738 15,623 105,945
Kansas 24,380 17,819 19,164 16,429 15,017 92,808
Kentucky 38,144 27,978 28,235 21,295 17,247 132,899
Louisiana 34,590 26,008 25,210 21,027 17,983 124,819
Maine 15,180 11,779 12,039 9,194 8,496 56,688
Maryland 44,069 33,598 32,913 28,178 25,604 164,361
Massachusetts 48,082 41,253 43,062 36,057 36,839 205,294
Michigan 90,741 69,927 67,984 49,159 40,026 317,837
Minnesota 44,417 33,157 32,540 26,399 25,062 161,575
Mississippi 22,428 18,916 18,108 14,108 11,708 85,267
Missouri 58,631 43,440 44,088 34,836 31,853 212,848
Montana 11,834 9,202 7,485 6,172 5,541 40,235
Nebraska 15,115 11,665 12,212 10,032 9,413 58,438
Nevada 25,799 20,207 17,289 13,299 10,038 86,633
New Hampshire 13,910 10,039 9,649 7,570 6,846 48,014
New Jersey 58,842 48,904 51,981 42,063 38,771 240,561
New Mexico 18,117 13,386 12,795 10,088 9,410 63,795
New York 110,664 92,539 95,638 81,260 79,643 459,744
North Carolina 79,733 60,526 59,650 46,021 38,246 284,176
North Dakota 5,599 4,304 4,085 3,440 2,990 20,418
Ohio 110,650 84,232 84,258 65,273 52,930 397,343
Oklahoma 38,473 27,572 26,956 20,999 18,617 132,618
Oregon 41,601 30,455 26,088 21,510 23,170 142,825
Pennsylvania 123,253 100,551 102,053 85,234 78,714 489,805
Rhode Island 8,735 6,984 7,078 6,172 6,295 35,265
South Carolina 44,087 33,523 31,595 23,934 19,572 152,710
South Dakota 7,783 6,103 6,004 4,598 4,238 28,726
Tennessee 58,995 46,088 42,324 32,327 26,155 205,888
Texas 170,536 120,989 117,982 95,285 85,826 590,618
Utah 15,221 11,177 12,376 10,920 9,829 59,523
Vermont 6,189 4,847 4,484 3,525 3,460 22,505
Virginia 68,320 49,520 48,792 39,549 32,516 238,697
Washington 65,515 45,661 39,815 32,749 33,694 217,434
West Virginia 20,658 15,921 15,064 12,251 10,008 73,902
Wisconsin 50,740 41,556 39,784 30,230 26,771 189,081
Wyoming 5,698 4,155 3,451 2,678 2,441 18,422
Puerto Rico 12,653 11,673 11,934 9,134 7,954 53,348
Is. Areas & Foreign 11,250 8,615 6,576 6,335 11,736 44,512
Grand Total 2,484,033 1,913,506 1,886,271 1,529,711 1,400,551 9,214,073

Source: Dept. of Veterans Affairs.

The Veteran population is becoming very diverse. The population of minority veterans is projected to increase significantly over the next few decades ( see figure below). The women Veteran population, which is currently estimated to be about 9% is expected to almost double in the next few decades.

Minority Veteran Population is on the Rise

Minority Veteran Population is on the Rise

 

In additional to the cultural needs based on ethnic background, there are specific behaviors more common in Veterans due to the training and experiences related to serving in the armed forces which can manifest with specific behaviors like battlemind, for example.

       Battlemind is defined as a soldier’s inner strength to face fear and adversity during combat, with courage. It is the will to persevere and win. When on a tour of duty, a person is expected to be strong and fully operational at all times. There is a strong stigma associated with any show of weakness. They cannot back away from the war front.

When faced with physical threats due to serious illness, Veterans often work hard to meet the illness related challenges with courage and stoicism. Data show that Veterans, as a cultural group, are at a higher risk for post traumatic stress disorder, depression, and substance abuse. The cluster of these experiences will likely influence how pain, illness and end of life issues are experienced and interpreted.

As we prepare to care for the changing Veteran population and as they become increasingly older and are living with various chronic illnesses, there is a great need for high quality geriatric and palliative care that is tailored to the culture of veterans of diverse backgrounds and their families. System based strategies need to be further developed to promote early palliative care to all Veterans with serious illness.  In a recent study analyzing indicators of care quality in Veterans with advanced cancer, addressing pain, non-pain symptoms, and  advance care planning,  only 17.7% of veterans had goals of care addressed in the month after a diagnosis of advanced cancer, and 63.7% had timely discussion of goals following intensive care unit admission. Most decedents (86.4%) were referred to palliative care or hospice before death.

Much work that needs to be done in order to provide high quality, culturally tailored geriatric palliative care to all Veterans with serious illness.  The good news is that the VA is leading the way nationally and serving as a best practice for what can be accomplished when there is strategic and tactical planning and strong partnerships between line staff caring for patients and the leaders who are designing and resourcing care in the local facilities as well as the national office in Washington DC.

 

Resources: What to do

a. If you are a Veteran or a family member looking for geriatric and palliative care services, a good place to start is the VA Geriatrics Portal 

b. Call the VA facility closest to you and enroll first ( if you are not already enrolled). Next ask to make an appointment with a primary care provider.

c. Ask your doctor to refer you to palliative care specialists if you have a serious illness.

d. Other questions? : Post your question below this post using the comments feature and we will do our best to find you some answers.

 

Serving those who served: Veterans Day 2014

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  • Charlie Antoni

    Thank you Dr. VJ for opening the discussion on Veterans and their Palliative Care needs and giving Kudos to the VA for their leadership role in the areas of innovation and integration of Palliative Care ranging form PACT (Primary Care) to ICU (Intensive Care) and thanks to all those that have served, their families, and the staff at VA Medical Centers around the Country and Puerto Rico.
    Charlie Antoni, ACHP.
    Palliative Care Coordinator
    Orlando VA Medical Center

    • Charlie Antoni, ACHP-SW

      It is important for all tax payers to realize when they see the budget that the VA’s portion is going to care for those who have served without question. Their service both those in combat and many others in non-combat assignments have led to injury, illness, sacrifice and hardship that carries on beyond their time in service and often results in complicated illness that requires strong Palliative skills and sensitive EOL that recognizes and honors both the Veteran and the family/support system that have often times care for them for decades and stand with them now. Don’t just look at a budget number ….see compassionately beyond to the suffering that occurred in your name American.

  • Firstly, thanks Charlie for your service as a veteran. I agree with you that the Dept of Veterans Affairs has led the way in palliative care by a combination of top down (support from the program office in Washington DC) as well as grassroots efforts in all the VA facilities.