Hospice: A Way to Care for Terminal Pets
Veterinary medicine has remarkable diagnostics and therapeutics for disease, but practitioners are being asked to embrace the concept of pet hospice for both the patient and the client.ProfileRising economic hardships may preclude families from electing costly options for treatable diseases, including cancer. This situation makes pet hospice a viable and more affordable option that veterinarians can offer with professionalism and sincerity.
BenefitsClients can be introduced to pet hospice after diagnosis of a terminal disease in their pets, such as organ failure, advanced cancer, or senility, even if they are not dying at the moment. The objective of hospice is to help the family realize that the pet's condition is terminal and that palliative care, although not curative, may help increase the time between diagnosis and death.
If hospice care is offered with empathy for terminal patients, it may become a busy medical service that brings the hospital additional revenue and respect. Both specialists and generalists should offer hospice as an option to extensive treatment or euthanasia (if treatment is not affordable).
ConsiderationsPet hospice embraces end-of-life care for pets while maintaining quality of life. It has the potential to become a routine support service in everyday practice. The veterinarian needs to determine how much care a pet owner is willing to provide for a dying pet. A person who has a strong bond with a pet may feel no limits. Each pet's family has its own unique personal lifestyle and tolerance considerations.
Patient Selection & SignalmentThe following are potential candidates for hospice:• Older pets with some degree of gagging, coughing, wheezing, respiratory compromise, or weakness. Initial radiographs may depict widespread pulmonary metastatic disease, pleural effusion, or a globoid-shaped heart.• Older large-breed dogs that have collapsed with hemoabdomen and hypovolemic shock, most often due to ruptured splenic hemangiosarcoma, hepatocellular carcinoma, and adrenal carcinoma.Clinical and radiographic findings such as organomegaly, ascites, carcinomatosis, abdominal lymphadenopathy, and cardiomegaly necessitate abdominal and cardiac ultrasonography, with cytology or histopathology to determine the cause and extent of disease.• Older large- and giant-breed dogs with painful lameness exhibiting boney lysis on radiographs, typical of osteosarcoma. Although these patients may be considered terminal, they may survive for months.• Animals with severe cachexia, dehydration, anorexia, end-stage organ failure, depression, dementia, uncontrolled seizures, and central nervous system dysfunction.• Well animals with untreated progressive malignancies, untreated end-stage organ failure, or recurrent malignancies that are known to be unresponsive to further known therapy.• Well animals at risk for recurrence of malignancy, such as those that have had splenectomy for hemangiosarcoma, cats that have had mastectomy for metastatic mammary adenocarcinoma, and cats with 2 to 3 recurrences of vaccine-associated sarcoma.
Client EducationIt is best to advise clients to view their pet's illness in the context of prognosis: overtly terminal (grim prognosis), short-term terminal (very poor prognosis), or pending terminal (poor to guarded prognosis). On the basis of historical survival periods derived from disease stage and evidence-based medicine, it may be possible to offer clients a time frame, such as 4 months after splenectomy for dogs with hemangiosarcoma or 7 months' survival for dogs with untreated nasal cancer.
A supportive, coaching approach from the veterinarian helps clients address the needs of the hospice pet at home and decide when to end the pet's life. Families may seek continuous management for the failing pet and move into 24-hour pet hospice care facilities, which are becoming more widely available at veterinary teaching hospitals.Principles of CareWith education and counseling, clients who want to take terminally ill pets home should be allowed to do so. Caregivers are much more at ease with a pet's death if their personal preferences are honored.
Overtly terminal patients need special allowances from normal hospital procedure. The attending doctor can sign off patient responsibility and arrange for transdermal or injectable pain medications. This compassionate approach parallels the human hospice movement. Doing the same for pets creates a new perspective, especially at emergency and cancer care facilities.
Support the basic needs of patients as they decline toward end-stage failure. Try to palliate each problem by at least 30% to 50% to restore an acceptable quality of life. Follow-up evaluations for short-term and pending terminal hospice patients help monitor compliance and reevaluate existing therapy. Weekly or biweekly recheck examinations are required to monitor temperature, weight, body score, hydration, respiration, and pain.1 Routine periodic blood analysis to evaluate organ function and electrolytes is essential to improve palliative therapy. The Palliative Management Strategies table (pages 44-45) provides medication, supplement, diet, and other helpful suggestions for managing various diseases and types of cancer.
Basic Tools for HospiceThere are 5 major tools necessary to set up hospice service in your practice.
The HHHHHMM Quality of Life ScaleThis scale is the most important tool for attending doctors and nursing staff to use and share with hospice families. It helps to monitor issues by assessing Hurt, Hydration, Hunger, Hygiene, Happiness, Mobility, and having More good days than bad days. The criteria should be assessed weekly, daily, or hourly as needed because the patient may be deteriorating rapidly. You can download the scale at cliniciansbrief.com.
Expertise in Pain Assessment & ManagementPain control is essential for every pet hospice service. The most important rule is to presume that hospice pets have pain if the same condition would cause pain for a person. See Aids & Resources for a list of resources regarding pain management. In addition, see the Box for a list of Clinician's Brief articles discussing this topic.
Communication SkillsDepending on family situations, finances, and other psychosocial issues, pet owners may respond to pet loss with a wide range of emotions. Veterinarians and the veterinary staff need to support the emotional needs of hospice family members.
Several organizations provide information on understanding clients' attachment to their pets and ethical decision making. Communication between veterinary team members and clients will be regularly covered in Exceptional Veterinary Team, the first issue of which accompanies this issue of Clinician's Brief.
Immunonutrition & ChemopreventionImmunonutrition is a comprehensive nutritional strategy that helps restore the immune system by modulating or enhancing key physiologic processes, which are often compromised by poor nutrition, stress, internal disease, and senescence. Chemoprevention involves using natural or synthetic compounds that may reverse or suppress carcinogenesis, metastasis, and recurrence. It may be presented as palliative care for hospice patients.
Candidates for chemoprevention and immunonutrition include:• Animals that have undergone surgery, chemotherapy, or radiation therapy• Dogs with osteosarcoma, hemangiosarcoma, adenocarcinoma, and lymphoma• Cats with breast cancer, vaccine-associated sarcoma, lymphoma, irritable bowel disease, and FeLV and FIV infection.
When patients respond to immunonutrition and chemoprevention, quality of life may be enhanced significantly, despite their terminal condition.2-4
Daily Care & House CallsHospice pets often need daily supportive services at the hospital or via home visits. Services may include monitoring vital signs, adjusting medications, bathing and brushing the soiled pet, administering subcutaneous fluids, providing injections, and hand-feeding. These services may be the key to sustaining a high-quality hospice service for pet owners who work. Convenient drop-off and pick-up times may be prearranged. Ask your staff to be sensitive about hospice communications, such as when clients call for refills, information, updates, appointments, or emotional help. Keep a library or a list of helpful books for clients to read.5-9
The Ethics of Hospice CareVeterinarians have a loyalty to their dying patients that creates an ethical dilemma. On one hand, veterinarians have taken an oath to prevent suffering and have been advised not to discharge pets that cannot stand or function. On the other hand, when dealing with overtly terminal cases, veterinarians are being asked to rethink the situation and provide hospice care. The attending doctor must be loyal to the patient's physical needs during progression toward death, yet remain loyal to the client's emotional needs and honor the human-animal bond.
In overtly terminal situations, it is best to gain client consent for the transfer from hospital to home. Note in the chart that "The patient is terminal and/or incapacitated and is being taken home with proper pain control and limited supportive care at the bequest of the family for hospice and humane euthanasia when quality of life becomes inappropriate."
For additional information on ethical issues regarding euthanasia and hospice care, see Decision-Making Issues with Euthanasia (Clinician's Brief, May 2008).
Create Comfort & Relief for the EndAs the hospice philosophy becomes routine in veterinary hospitals, one examination room can be converted to a "comfort" room. Soft lighting, flowers, and candles help establish a setting for counseling, decision making, thoughtful and reverent euthanasia, and returning cremated remains with sensitivity.
Relief is a natural component of grief.9 Attending staff can help clients understand that it is acceptable to feel relief. Staff can also help clients accept their choice for humane euthanasia as the best decision under the circumstances. As a follow-up, consider sending the pet owner a sympathy card and a memorial gift, and call a week later. When an ideal hospice arrangement comes to an end, clients often come back with thank-you gifts and notes of appreciation for the care given to their pet as well as themselves.
PawspiceVeterinarians can create a unique, inclusive hospice service for terminal pets, such as Pawspice, which I established in Southern California. Pawspice is committed to the highest standard of compassionate cancer treatment and end-of-life palliative care, including expert pain management, for advanced disease stage and terminal pets. The Pawspice concept also involves emotional support for families. Our goal is to restore and maintain quality of life for animals with terminal disease so they may give their families an extended farewell.
A Few Helpful Hints for Hospice Care
• Create a daily calendar that specifies morning and evening times for medications and chemotherapy, amounts of fluid, feeding volumes, and supplements. This schedule helps clarify the day’s work order for home care.• If hematuria causes extreme blood loss, mix a 1% solution of formalin with a vial of topical ear solution that contains dimethyl sulfoxide (Synotic Otic; fortdodge.com). Instill into the bladder with a urinary catheter. Keep the mixture in the bladder for 10–15 minutes; then void and flush out the clots. This palliative procedure may reduce hematuria for 7–10 days.• For one desperate, low-budget hospice case, I dispensed injectable atropine to help a Great Dane suffering from relentless vomiting and salivation. Provide liquid tears Q 6 H if using atropine in this fashion, especially in breeds susceptible to keratoconjunctivitis sicca.
See full article link for Palliative Management Strategies table.
HOSPICE: A WAY TO CARE FOR TERMINAL PETS • Alice E. Villalobos
References
Understanding and recognizing cancer pain in dogs and cats, treating cancer pain in dogs and cats. De Lorimier LP, Fan TM. Vet Med 5:352-377, 2005.2. Immunonutrition. Satyaraj E. Nestle Purina Nutrition Forum, 2008.3. Chemoprevention. Bergman P. ACVIM Proc, 1999.4. Sensible supplements for cancer patients. Oncology outlook. Villalobos A. Veterinary Practice News, December 2004.5. Pets Living with Cancer: A Pet Owner’s Resource. Downing R—Lakewood, Colorado: AAHA Press, 2000.6. Help Your Dog Fight Cancer. Kaplan L—Briar Cliff, New York: JanGen Press, 2007.7. Angel Paw Prints: An Anthology of Pet Memorials. Hunt LE—Pasadena, California: Darrowby Press, 1998.8. Angel Whiskers: Reflections on Loving and Losing a Feline Companion. Hunt LE—New York: Hyperion Press, 2001.9. Canine and Feline Geriatric Oncology: Honoring the Human-Animal Bond. Villalobos A—New York: Blackwell, 2007.
ResourcesAAHA/AAFP Pain Management Guidelines for Dogs & Cats: aahanet.org/resources/guidelines.aspxAmerican Association of Human–Animal Bond Veterinarians: aah-abv.orgAssociation for Veterinary Family Practice: avfp.orgInternational Veterinary Academy of Pain Management: ivapm.orgSociety for Veterinary Medical Ethics: vetmed.wsu.edu/org_SVME