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Palliative Care for the Hospitalized Pet

Heather Troyer, DVM, DABVP (Canine & Feline), CVA, CVPP, Oradell Animal Hospital, Paramus, New Jersey

Ethics & Human-Animal Bond

|October 2015|Peer Reviewed|Web-Exclusive

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The delivery of palliative care can vary widely and depends on the goals of the practitioner, staff, hospital, and patient/client needs.1 Veterinarians often consider palliative care to be synonymous with hospice care, although neither is firmly defined in veterinary medicine. The World Health Organization defines palliative care as “an approach that improves the quality of life of patients and their families… through prevention and relief of suffering… by early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.”2 In veterinary medicine, palliative care embodies an individualized treatment philosophy that encourages a comforting, nonconfrontational treatment style. The existence of veterinary hospice is controversial, as many believe that suffering will accompany a pet’s natural death, despite all levels of intervention. The American Veterinary Medical Association defines veterinary hospice as “care that will allow a terminally ill animal to live comfortably at home or in a facility, and does not believe that such care precludes euthanasia.”3 The author would argue that euthanasia is the ultimate palliative measure, while hospice implies a scenario of natural death.

Related Article: Veterinary Hospice: Medicate, Meditate, Mitigate

Patient Evaluation

Palliative care for a hospitalized pet is largely intuitive but can be overlooked in a busy hospital setting. The first step toward improved bedside palliative care is for the practitioner and technician to identify patient problems that could exacerbate pain, stress, anxiety, poor hygiene, inability to move or eliminate, or inability to eat or obtain nourishment.

Applying the concept of “hurt, hydration, hunger, hygiene, happiness, mobility”4 to the evaluation of each hospitalized animal can help identify subtle problems. In addition, the practitioner must focus on the palliative philosophy of “comfort, do not confront” as a mantra that provides a treatment strategy designed to lower patient stress.

Characteristics of Pain & Stress

Identifying the individual characteristics of different types of pain and stress in a hospital setting is important to develop an effective palliative treatment plan. It is safe to say that most, if not all, animals experience some level of stress or discomfort at some point during their hospitalization (see Steps to Reduce Stress in the Hospitalized Patient1,5,6).

Figure 1. A male cat suffering from lower urinary tract disease receives low-level laser therapy to the bladder to help alleviate his discomfort.

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Subtle signs of pain (eg, stiffness, muscle atrophy from previous illness, increased nervousness, aggression, depression, loss of appetite) can easily be overlooked in a busy practice.7 In addition, neuropathic pain (ie, pain attributed to injury or disease that damages the axon or soma of a sensory neuron) can result in somatic or visceral pain or signs of centralized hypersensitivities and can present critical challenges in pain management.7,8 Sometimes these hypersensitivities can be misinterpreted as avoidance behaviors. In fact, neuropathic pain is often worsened by stimuli that evoke a sympathetic response, such as a startle response or emotional arousal during stressful situations.8 Avoidance behaviors, in addition to subtle signs of pain, are proper triggers for comfort care as an alternative to confrontation. Every animal gives a signal that, when recognized, could help the practitioner develop an individualized strategy that will encourage patient healing. 

Related Article: End-of-Life Care

Steps to Reduce Stress in the Hospitalized Pet

Environmental enrichmentPharmacologic intervention
  • Playing classical music may lower patient heart rates and decrease anxiety.4
  • Separate feline from canine wards.
  • Provide lighting to encourage normal sleep/wake cycles.
  • Supply warm, dry orthopedic bedding.
  • Provide consistent use of antistress pheromones.1
  • Institute low-stress physical or chemical restraint.6
  • Multimodal pain management approach
  • Antianxiety medications
  • Sedatives

Implementing a Structured Program

Physical medicine and rehabilitation also are important aspects of palliative care in any setting but are particularly important in the hospital environment because they encourage interaction between patient and staff. It is important to remember that hospitalized patients may have a history of maladaptive or neuropathic pain. In addition, surgery, patient positioning for images, sedation causing hind end weakness, slips and falls on hospital floors, and physical restraint can lead to soft tissue trauma in hospitalized patients.

Figure 2. A dog with end-stage arthritis undergoes a rehabilitation exercise program while in a quad cart with neck support.

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A critically ill patient that presents to an ICU after a prior state of inactivity may experience a heightened state of deconditioning, in which muscle strength is lost, endurance declines, and muscle contracture leads to decreased range of motion.7,8 For example, if a patient had difficulty walking before its episode of acute necrotizing pancreatitis, walking will be more difficult when confronted with additional pain and stress. However, a strategy for implementing physical medicine must be clear and defined, as often specially trained staff and/or equipment may be necessary, with treatments adding to the amount of staff labor and time devoted to patient care.9  

Emphasis on implementing a structured palliative care program can help all hospitals achieve higher standards for patient care. This can also improve the human–animal bond between patient and staff. Encouraging continuing education on basic concepts of establishing a low-stress environment, along with performing physical medicine and massage, are humane, cost-efficient, and overall valuable additions to any practice. 


HEATHER TROYER, DVM, DABVP , CVA, CVPP, graduated from The Ohio State University, after which she completed a 1-year internship at The Animal Medical Center in New York. She joined the staff at Oradell Animal Hospital in Paramus, New Jersey, and is board certified in Canine and Feline Medicine and Surgery through the American Board of Veterinary Practitioners. She has a strong interest in pain management and palliative care. In 2009, Dr. Troyer helped create the Oradell CARES program, designed to assist families and patients with hospice and caregiver support issues through both in-home evaluation and outpatient management. In addition, Dr. Troyer became certified in veterinary acupuncture by the Chi Institute of Chinese Medicine in Reddick, Florida. She is also certified through the International Veterinary Academy of Pain Management as a Certified Veterinary Pain Practitioner. Dr. Troyer uses integrative medicine, especially in cases when quality-of-life issues are paramount, and practices both outpatient and in-home pain management using Eastern and Western medicine techniques.

References

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