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Veterinary Hospice: Medicate, Meditate, Mitigate

Dani McVety, DVM Lap of Love Veterinary Hospice

Ethics & Human-Animal Bond

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February 2012
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Peer Reviewed

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Veterinary Hospice: Medicate, Meditate, Mitigate

Hospice has taken many forms throughout history—from places of respite for the sick or dying to rest stops for travelers and pilgrims. Hospice started to take today’s meaning when care for the terminally ill began evolving in the mid-19th century, with The Lancet and British Medical Journal publishing articles pointing to the need for good care and sanitary conditions for the impoverished.1 By the turn of the 20th century, dedicated facilities provided sanitary conditions for patients with tuberculosis and other terminal illnesses.­ These facilities helped shape the hospice movement that exploded in the 1980s.

Hospice: Veterinary & Human
For humans, hospice care is available in hospitals, nursing homes, and dedicated hospice facilities but is usually provided in the home with a family member as the caretaker. The home is where people are generally most comfortable, a point that applies even more strongly to hospital-phobic pets.

Veterinary hospice is a “family-centered service dedicated to maintaining comfort and quality-of-life for the terminally ill pet until natural death is achieved or the family elects euthanasia.”2 In human medicine, terminally ill is generally used to refer to patients who are given about 6 to 12 months to live or who have a condition that is deemed life-limiting. In small animal medicine, we could argue that the phrase terminally ill is appropriate when the pet’s life expectancy is considered to be 1 month or less. For the sake of emotional, physical, and medical preparation, however, veterinarians should use hospice for any pet that could reasonably have 3 months or less before quality-of-life, not imminent death, becomes a serious concern.

Veterinary hospice is distinctly different from human hospice because veterinarians have the ability to perform humane euthanasia on animals when medication is no longer adequate and quality-of-life is questionable. This distinction should be made when a family is faced with a terminally ill or senescent pet, regardless of life expectancy.

Related Article: Hospice: A Way to Care for Terminal Pets

Veterinary Hospice Services
Just as a bed of hay for the backyard dog has been replaced with orthopedic memory foam for the indoor pampered pet, so do clients continue to seek more personalized and human-like medical care for their pets. As a result of the exceedingly positive experiences families have had with human hospice, owners are actively searching for similar care for their aging and/or terminally ill pets.

Although hospice care can be provided as both a stationary and mobile service, few veterinarians dedicate their practice strictly to hospice care. The frequently incurable nature of cancer, coupled with highly attentive clients seeking specialized treatment, commonly places the task of palliative care in the hands of oncologists.

General practitioners forget, however, that they routinely provide some level of hospice or palliative care for their elderly or terminally ill patients. We have the unique privilege of treating our patients from cradle to grave, and we need to nurture the end of this spectrum as much as the beginning. Just as there are “puppy packages,” there should be “hospice handouts.”

Our knowledge of disease processes and progression of signs places us in the role of advocate. A detailed explanation of the disease process, including the possible mechanism of death, is information that clients likely desire most during hospice discussions. Although we cannot predict with certainty when or how a patient may die, we can offer a “perhaps” scenario of what the end-of-life experience may be.

Quality-of-life and planning are essential hospice topics to discuss in order to help pet owners decide whether to medicate (provide palliative medical care), meditate (make an educated decision about what is best for the pet), or mitigate (end the pet’s suffering).

Clinician's Brief
Medicate
The veterinarian’s role is to provide palliative care, which is designed to relieve or reduce the intensity of uncomfortable signs but not to produce a cure.3 It is our duty to identify signs of discomfort and treat patients appropriately while predicting and preventing further stress or suffering.

Pet owners may not realize that dribbling urine, nocturnal panting or pacing, or decreased appetite can be managed with simple medications. Phenylpropanolamine, mirtazapine, gabapentin, tramadol, amantadine, amitriptyline, alprazolam, and other tricyclic antidepressants are routinely prescribed when appropriate. Nutraceuticals, such as omega-3 fatty acids, S-adenosyl methionine (SAMe), glucosamine, selenium, and vitamins E and C, can be beneficial and should be started early in the course of hospice care.

Many adjunctive pain management and other services can help support patients and pet owners during the hospice period, often provided on a mobile basis to prevent additional stress to the pet. These include:

  • Acupuncture
  • Laser therapy
  • Massage
  • Grooming
  • In-home pet sitting
  • Support groups or “old-dog play dates”

Assisting clients in the transition to hospice care includes having them sign an NSAID release (ie, no more blood work required before providing NSAID refills), having 5 to 7 days of pain medication when the pet needs pain relief, and having a plan in place for crises, such as providing injectable pain medication if owners are comfortable administering it or reconstituting medication to a transdermal or transmucosal formulation.

In many cases, a single professional can perform certain procedures in the home environment, especially for senior or incapacitated patients, with minimal sedation as needed. These include:

  • Administering SC fluids, short-term IV fluids, and/or injectable medication (if the owner prefers not to give injections)
  • Performing therapeutic centesis (eg, thora-
    centesis, abdominocentesis, cystocentesis)
  • Delivering dietetic and nutritional support
  • Explaining current and future pain management protocols to the client

Supporting pet owners so they can enjoy the time they have left with their pet is of high importance.

Meditate
The primary role of hospice veterinarians is to impart tools that fully prepare families to handle a terminally ill pet. Educating clients about their pet’s condition and teaching them how to provide certain types of care in the home increases their confidence and sense of control, thereby allowing them to better evaluate their pet’s condition, especially under stressful conditions, and empowering them to take appropriate action to mitigate pain and suffering.

When caring for a terminally ill pet, owners are usually confronted with 3 budgets: time, emotional, and financial. Although it is the veterinarian’s duty to present all possible care options, it is also essential to discuss each client’s concerns and limitations.

Mitigate
One aspect of hospice care is ensuring that owners are mentally and physically prepared for any situation that may arise as the pet’s condition deteriorates. Owners should know the steps to take in case their pet suddenly becomes uncomfortable, begins to suffer, or dies. They should know the specific warning signs for each scenario based on the individual pet’s medical condition, the general signs of pain and suffering in animals, and the next course of action.

As the availability of hospice services continues to grow, pet owners will elect to have certain comfort-oriented procedures (including euthanasia) performed in their home, particularly as end-of-life nears. Paramount to the success of any hospice program is acknowledging, suggesting, and assisting clients toward that end.

Closing Remarks
The tremendous success of human hospice has fueled a positive reaction to providing this service for pets, and the availability of mobile veterinary services has opened the door to providing hospice care in the ideal atmosphere—the home.

Veterinarians who provide hospice services realize quickly that a change in the philosophy of care is all the client truly desires. A shift in focus from diagnostics and prolonging life to pain management and maintaining quality-of-life speaks volumes and assures owners that their pet’s well-being is important. We must embrace the fact that hospice is a medical model that begins with the patient–client–veterinarian triad. Implementation and nurturing of both in-hospital and mobile hospice services can ensure that clients and doctors have the same goal in mind: the comfort of the pet.

Laying the Foundation for Veterinary Hospice

Perhaps the most notable figure in the veterinary hospice movement is Alice E. Villalobos, DVM, whose “Pawspice” philosophy has encouraged veterinarians to hold quality-of-life and the human–animal bond higher than the actual treatment of the disease. Pawspice’s values for compassionate end-of-life palliative care for advanced-stage and terminal pets can be described in 4 main points:

1. The patient’s needs are always the primary focus of concern.
2. The best outcomes are realized through the partnership of staff, patient families, and referring veterinarians.
3. We are never complacent. We continually strive to ensure that we are doing everything possible in the best interest of our patients and their families.
4. Treatment is conducted in compliance with the highest ethical standards.

Benefits of Mobile Hospice

Mobile veterinary hospice care can have advantages over in-hospital care because mobile care works with patients in their natural surroundings. Companion animals are much more relaxed in their home environment, allowing more comprehensive evaluation of their level of pain and anxiety. Daily habits are also more easily evaluated, and small changes (eg, nonslip surfaces, slings, proximity to food and water, limiting interaction with rambunctious pets) to their environment become important for ensuring quality-of-life.

What to Charge?

Determining what to charge for hospice-related services can be an obstacle.* The challenge is to properly introduce both the medical aspects of hospice care and the adjunctive services that make the human equivalent successful while also earning a profit.

Establishing charges for hospice-type services is simple in stationary clinics, but for mobile services the “bread and butter” remains in-home euthanasia. In-home hospice consultations and examinations take twice as much time as traditional appointments, and it’s difficult to charge for services that need to be repeated—especially ones that only a veterinarian can perform (eg, thoracentesis).

Successful mobile programs use veterinary technicians in conjunction with one or more veterinarians who oversee patient care.

* As of this writing, charges for in-home care were $30–$40 an hour for technician time and $100–$150 an hour for doctor time.


VETERINARY HOSPICE: MEDICATE, MEDITATE, MITIGATE • Dani McVety

References

1. Medicine and Care of the Dying: A Modern History. Lewis MJ—New York: Oxford University Press, 2007, p 21.
2. Pet hospice: A new idea and a new service in veterinary practice. McVety D, Gardner M. NAVC Conf Proc: 2012.
3. Mosby’s Medical Dictionary, ed 8—Philadelphia: Elsevier, 2009.

Suggested Reading

Animals in Translation. Grandin T, Johnson C—New York: Scribner, 2005.
Canine and Feline Geriatric Oncology: Honoring the Human-Animal Bond. Villalobos A, Kaplan L—Ames, IA: Wiley-Blackwell, 2007.
Guidelines for Veterinary Hospice Care. American Veterinary Medical Association. Revised Nov 2011; avma.org/issues/policy/hospice_care.asp; accessed Jan 2012.
Palliative medicine and hospice care. Sherer TS. Vet Clin North Am Small Anim Pract 41:1069, 2011.

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