Advancing Trauma-Informed Care Education for Hospice and Palliative Staff: Development and Evaluation of Educational Videos.

Nurses play an essential role in managing mental health conditions, such as posttraumatic stress disorder (PTSD), especially in rural areas where access to mental health care is limited. Posttraumatic stress disorder may emerge at the end of life and complicate health care and is a particular concern for aging Vietnam veterans. We describe the development of 3 videos that illustrate how to recognize PTSD, respond to trauma disclosures, and manage PTSD in cognitive impairment during an in-home hospice nurse visit. Through problem identification and needs assessment, we identified 6 goals and 28 specific content objectives presented through cinematic action with flashbacks or voice-over narration with graphics. Videos were evaluated through a survey (N = 155) and analysis of "chat" responses (N = 186) to targeted questions during a webinar presentation to clinicians (N = 345). Approximately 75% rated videos as "very much" relevant to needs, having helped learn something new, and realistic. Analysis of chat responses showed videos conveyed most content objectives (92%). In addition, participants stated videos were helpful in demonstrating nursing skills of listening, responding, and displaying empathy, as well as showing case presentations involving cognitive impairment and the patient experience. Participants expressed a desire for longer videos/more information including a wider range of PTSD presentations and comorbidities.

Guardianship Before and Following Hospitalization.

When ethics committees are consulted about patients who have or need court-appointed guardians, they lack empirical evidence about several common issues, including the relationship between guardianship and prolonged, potentially medically unnecessary hospitalizations for patients. To provide information about this issue, we conducted quantitative and qualitative analyses using a retrospective cohort from Veterans Healthcare Administration. To examine the relationship between guardianship appointment and hospital length of stay, we first compared 116 persons hospitalized prior to guardianship appointment to a comparison group (n = 348) 3:1 matched for age, diagnosis, date of admission, and comorbidity. We then compared 91 persons hospitalized in the year following guardianship appointment to a second matched comparison group (n = 273). Mean length of stay was 30.75 days (SD = 46.70) amongst those admitted prior to guardianship, which was higher than the comparison group (M = 7.74, SD = 9.71, F = 20.75, p < .001). Length of stay was lower following guardianship appointment (11.65, SD = 12.02, t = 15.16, p < .001); while higher than the comparison group (M = 7.60, SD = 8.46), differences were not associated with guardianship status. In a separate analysis involving 35 individuals who were hospitalized both prior to and following guardianship, length of stay was longer in the year prior (M = 23.00, SD = 37.55) versus after guardianship (M = 10.37, SD = 10.89, F = 4.35, p = .045). In qualitative analyses, four themes associated with lengths of stay exceeding 45 days prior to guardianship appointment were: administrative issues, family conflict, neuropsychiatric comorbidity, and medical complications. Our results suggest that persons who are admitted to hospitals, and subsequently require a guardian, experience extended lengths of stay for multiple complex reasons. Once a guardian has been appointed, however, differences in hospital lengths of stay between patients with and without guardians are reduced.

Trauma re-engagement and PTSD in older medically ill veterans: implications for trauma-informed care.

OBJECTIVES: We characterize rates and correlates of PTSD and of trauma re-engagement without PTSD in medically ill older Veterans, as well as supportive strategies, with the goal of advancing trauma-informed care. METHODS: We interviewed medically ill older Veterans (N = 88, M age 75.13, SD = 6.14) with primary care screening measures for PTSD and trauma re-engagement, and open-ended questions to assess supportive strategies. RESULTS: One-fifth (20.5%) presented with probable PTSD, associated with greater trauma exposures (r=.57, p<.001), whereas two-fifths (43.2%) reported re-engagement with military memories without PTSD, associated with having a spouse/partner (t = 2.27, p=.028). Of those who experienced trauma, half reported thinking more about the trauma recently and becoming more emotional on certain days. In response to the question 'What gives you strength as you think about the future with your illness' Veterans described support of family, healthcare, worldview, personal control, acceptance, and health behaviors. CONCLUSION: Memories of trauma are common with medical illness. Age-friendly trauma-informed care could consider factors that patients describe as sources of strength with illness.

Assessing What Matters Most in Older Adults With Multicomplexity.

BACKGROUND AND OBJECTIVES: Abilities and activities that are often simultaneously valued may not be simultaneously achievable for older adults with multicomplexity. Because of this, the Geriatrics 5Ms framework prioritizes care on "what matters most." This study aimed to evaluate and refine the What Matters Most-Structured Tool (WMM-ST). RESEARCH DESIGN AND METHODS: About 105 older adults with an average of 4 chronic conditions completed the WMM-ST along with open-ended questions from the Serious Illness Conversation Guide. Participants also provided demographic and social information, completed cognitive screening with the Telephone-Montreal Cognitive Assessment-Short and frailty screening with the Frail scale. Quantitative and qualitative analyses aimed to (a) describe values; (b) evaluate the association of patient characteristics with values; and (c) assess validity via the tool's acceptability, educational bias, and content accuracy. RESULTS: Older adults varied in what matters most. Ratings demonstrated modest associations with social support, religiosity, cognition, and frailty, but not with age or education. The WMM-ST was rated as understandable (86%) and applicable to their current situation (61%) independent of education. Qualitative analyses supported the content validity of WMM-ST, while revealing additional content. DISCUSSION AND IMPLICATIONS: It is possible to assess what matters most to older adults with multicomplexity using a structured tool. Such tools may be useful in making an abstract process clearer but require further validation in diverse samples.

Enhancing Access to Yoga for Older Male Veterans After Cancer: Examining Beliefs About Yoga.

BACKGROUND: Yoga is an effective clinical intervention for cancer survivors. Most studies of the positive effects of yoga on cancer patients report on predominantly middle-aged women with breast cancer. Less is known about the use of yoga in older adults, veterans, and those from diverse racial or ethnic backgrounds. METHODS: We examined strategies to enhance access to yoga in older veterans after cancer, focusing on education (study 1) and intervention (study 2). Study 1 included 110 participants with a median (SD) age of 64.9 (9.4) years who were mostly male (99%) cancer survivors who were interviewed 12 months after their cancer diagnosis. Study 2 included 28 participants with a median (SD) age of 69.2 (10.9) years who were mostly male (96%) cancer survivors who participated in a yoga program within 3 years of their cancer diagnosis. Standardized interviews assessed interest in and barriers to yoga while self-reporting assessed health-related quality of life and beliefs about yoga. RESULTS: In study 1, interest in yoga increased from 5.5 to 31.8% (χ 2 = 22.25, P < .001) following education. In open-ended questions 4 themes related to negative beliefs or barriers emerged: lack of knowledge or skepticism, disinterest or dislike, physical health barriers, and logistical barriers. In study 2, beliefs were more positive following intervention for expected benefits (t = 4.44, P < .001), discomfort (t = 4.92, P < .001), and social norms (t = 4.38, P < .001) related to yoga. Physical function improved after participation in a yoga class, especially for those with higher beliefs in yoga prior to class. Age was not associated with beliefs about yoga in either sample. CONCLUSIONS: A portion of older veterans who are cancer survivors were interested in yoga but faced access barriers. Implications for practice and research include increasing knowledge about yoga benefits and addressing physical health and logistical barriers to enhance access to yoga for older veterans.

End-of-Life Care for Persons Under Guardianship.

CONTEXT: Guardians are surrogate decision makers appointed by a court when other health care decision-makers are unable, unwilling, or unavailable to make decisions. Prior studies suggest that persons under guardianship may experience delays in transitions of care. OBJECTIVES: To compare quality of end-of-life care for persons under guardianship to a matched group on objective indicators and to identify narrative themes characterizing potential obstacles to quality end-of-life care. METHODS: One hundred sixty-seven persons under guardianship who died between 2003 and 2019 within the Veterans Healthcare Administration in Massachusetts and Connecticut matched on a 1:1 basis to persons without guardians. The groups were compared on treatment specialty at death, days of hospice and intensive care unit care, and receipt of palliative care consultation. Additionally, patient narratives for those under guardianship with extended lengths in intensive care unit were subjected to qualitative analysis. RESULTS: Overall, <1% were under guardianship. Within this sample of persons who died within the Veterans Health Administration, persons under guardianship were as likely as patients in the comparison group to receive palliative care consultation (odds ratio [CI] = 0.93 [.590-1.46], P = .359), but were more likely to have ethics consultation (odds ratio [CI] = 0.25 [0.66-0.92], P = .036) and have longer lengths of ICU admission (ß = -.34, t = -2.70, P = .009). Qualitative findings suggest that issues related to family conflict, fluctuating medical course, and limitations in guardian authority may underlie extended lengths of stay. CONCLUSION: Guardianship appears to be rare, and as a rule, those under guardianship have equal access to hospice and palliative care within Veterans Health Administration. Guardianship may be associated with health-care challenges in a small number of cases, and this may drive perceptions of adverse outcomes.