Over the course of a lifetime, most people will experience at least one potentially traumatizing event. Some will develop posttraumatic stress disorder (PTSD); others will experience lingering after-effects, such as situational anxiety, hypervigilance, or patterns of avoidance. Underlying posttraumatic stress can accrue and be intensified by issues associated with aging, medical care, and terminal illness. Social workers working with such patients in geriatric, hospice, and palliative care settings may encounter challenges for patients that run counter to conventional end-of-life goals, such as effective symptom management, good communication, and a peaceful death.

 

Identifying such patients can be difficult. Symptoms of posttraumatic stress are often misattributed to personality or disease-related factors. Patients may be unaware that they are experiencing posttraumatic stress or may be reluctant to disclose this because of the fear of stigma, stoicism, or a preference to avoid painful memories. Limited energy and cognitive changes may hamper a patient’s ability to provide information. Symptom management concerns or other end-of-life goals may take priority. Although information may emerge during conversations about concerns or coping, there may be issues related to privacy or trust that render assessment through direct inquiry problematic.

 

Standard PTSD assessment tools may send the wrong message to some patients who are sensitive to psychiatric labels or perceived inferences that they are being judged as having a psychiatric disorder. Social workers familiar with the many validated measures of assessing for PTSD may be able to adapt these with patients who are receptive, but what about patients with cognitive impairment, high levels of distrust, or who prefer to avoid the topic?

 

In such cases, the best approach may be a blend of trauma-sensitive observation and inquiry within the larger context of ongoing end-of-life care. Such an approach includes an awareness of patients whose life experiences place them at elevated risk for trauma exposure, identifying behaviors and symptoms suggestive of PTSD, recognizing trauma triggers and elevated nervous system responses, and the potential assessment-related uses of life review.

 

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