6 myths of veterinary palliative care

"They don't deserve to hurt." This serves well as a motto for caring for pets throughout their lives, particularly as they approach the end of their lives. Our obligation as veterinary healthcare providers is to advocate on behalf of beings that cannot advocate for themselves. Dr. Lloyd E. Davis once said of pain in animals that "[o]ne of the psychological curiosities of therapeutic decision-making is the withholding of analgesic drugs because the clinician is not absolutely certain that the animal is experiencing pain. Yet the same individual will administer antibiotics without documenting the presence of a bacterial infection. Pain and suffering constitute the only situation in which I believe that, if in doubt, one should go ahead and treat."1 When a pet develops a terminal disease and is approaching death, this obligation becomes even more important.

A common misconception both within veterinary medicine and among pet owners is that when a veterinarian renders a terminal diagnosis, all care options are exhausted. Often veterinarians advise immediate euthanasia because, as they will often state, "There is nothing we can do." In many cases this is wrong. While there are patients that present at the practice in distress that truly need the compassionate release of euthanasia as soon as a terminal diagnosis is rendered, these patients are in the minority. More commonly, the veterinarian discovers a situation that may require immediate treatment or intervention to relieve clinical signs but does not require immediate euthanasia. In the space between the diagnosis and death, the patient needs and deserves palliative care and hospice services.

A look at the team's role

Veterinary technicians and assistants can and should participate in delivering palliative care and hospice services. To be effective in this role, training is critical. This includes a team-wide understanding of pain pathophysiology and pain evaluation and examination techniques and a general understanding of how pain is treated. Even though diagnosis and prescribing medications are the veterinarian's responsibility, the technical team can serve as a critical link between the veterinarian, the palliative care or hospice patient, and the client.

Once a pet is deemed a palliative care or hospice patient, ongoing evaluation and fine-tuning of care focuses on managing signs rather than on curing a disease process. Palliative care embraces a wide scope of activities that can be accomplished in the home easily. The core competency of veterinary palliative care and hospice is appropriate, comprehensive pain management. Pet owners' biggest fear is that their pets will suffer. We can effectively prevent and relieve suffering. Clients need the veterinary team's support as they embark on this unique journey with their beloved companions.

Team training must include these skills:

• Performing a pain evaluation on both dogs and cats—and understanding differences between species

• Using a pain scoring system or scale

• Offering wound care

• Developing communication skills to enhance technician-client interactions

• Learning the delivery of medications and other home care techniques. (See the recommended resources at the end of this article.)

Common myths

Now that you know the value of pain management for terminal patients, let's dispel some common myths about veterinary palliative care and hospice.

1. "Palliative care and hospice merely delay or prolong the inevitable and are not fair to the pet."

Veterinary palliative care and hospice focus on the pet's comfort. Compassionate comfort care is the No. 1 priority. There is almost always time between rendering a terminal diagnosis and the need for humane euthanasia. The role of palliative care and hospice is to engage in an active dialogue among the client, the veterinarian, and the veterinary healthcare team and to provide ongoing patient assessments and fine-tuning of the management plans. The goal is not to prolong suffering. In fact, the goal is to prevent suffering and allow the pet to live well as long as possible, until death occurs or euthanasia is necessary.

2. "Palliative care and hospice is a substitution for euthanasia."

Veterinary palliative care and hospice principles are drawn from the human medical experience and practice. Unlike human medicine, however, veterinary medicine is able to provide a humane and compassionate end to suffering by performing euthanasia. For animal patients, palliative care and hospice techniques focus on sustaining comfort, relieving pain, and maintaining the family-pet relationship as long as possible. While the occasional animal patient dies on its own, far more often the veterinarian is called on to provide euthanasia.

3. "Just looking at an animal is enough to determine its comfort level."

This myth is similarly expressed as "Clients know when their pets are painful," or "Only veterinarians can appropriately assess patients for pain." Most pet owners are not well-equipped to understand when their pets are in pain. But with appropriate training and practice, technicians can effectively evaluate pain in palliative care and hospice patients that are seen at home. By using a standard pain assessment scoring system, a trained technician can easily convey his or her evaluation findings to the veterinarian so that the patient's pain management strategy may be fine-tuned. For example, a technician may stream video of the pain examination to the veterinarian from a smartphone, allowing the veterinarian to witness the reactions and responses of the pet. During a home visit, the technician will also review the medications that have been prescribed and confirm that they are being given appropriately. With the veterinarian's input, medications can be added, subtracted, or modified to respond to the patient's need. Technicians can also deliver other pain management modalities at home with the veterinarian's guidance.

The importance of ongoing, regular, and reciprocal communication among the veterinarian, the veterinary technician team, and the client cannot be overemphasized. It is only through ongoing dialogue and open, supportive conversation that the well-being of both the client and the patient can be adequately and appropriately assessed. For most clients, the time surrounding the impending death of a pet is uncharted territory. While it is an emotionally rewarding time, it can also be an emotionally stressful time. The veterinarian and the veterinary healthcare team have an obligation to support both the client or family and the patient during this special time of a pet's life.

To continue their education, veterinary technicians can pursue credentials as Certified Veterinary Pain Practitioners through the International Veterinary Academy of Pain Management. They can also become credentialed in canine physiotherapy and rehabilitation as well as canine medical massage. These credentials dramatically expand the positive effect the technician can have on the palliative care or hospice patient's quality of life.

4. "Clients can't—or won't—perform supportive medical treatments at home."

With a little guidance, most clients are delighted to take an active role in the day-to-day care of their pets. This is one area where the technician can play crucial supportive roles as a teacher, a coach, and an advocate for the hospice patient. The pet may benefit from the application of moist heat or cold therapy. The technician can demonstrate precisely how to accomplish this. Some palliative care and hospice patients develop chronic wounds that will not heal and must be kept clean and covered appropriately to prevent infection, pain, and discomfort. Technicians can teach and supervise wound care, and the client can help keep the veterinarian in the loop with transmitted images and the occasional practice visit.

The technician may also teach and coach clients about the delivery of injectable medications or subcutaneous fluids. Remember, we teach insulin administration to diabetic patients routinely. So injectable medications for end-of-life patients do not provide an insurmountable challenge.

5."It is difficult to adjust the home environment to accommodate a hospice pet."

The pet supply industry has exploded in recent years. If a pet needs something, chances are, someone has invented it. As a result, modifying home environments to accommodate a palliative care or hospice patient is generally pretty easy. Raised food and water dishes, steps up to the sofa or the bed, nonskid flooring squares, fabric slings, body vests with handles, and wheelchairs for two-legged or four-legged support are just some of the multitude of innovative items available. And baby gates can prevent unauthorized access to rooms or stairs. Clients can often create their own customized adaptations with a bit of guidance from the healthcare team.

6. "Palliative care and hospice patients can only be evaluated in the home."

This myth has a twin: "Palliative care and hospice patients can only be evaluated in the clinic." For dogs—and the occasional cat—that love nothing more than a ride in the car, periodic evaluations at the practice can be a welcome respite from uninterrupted time at home. Experts have guided veterinarians to do all they can to make visits to the practice as stress-free and enjoyable as possible for pets. The real pay-off for these efforts comes at the end of their lives, when pets need the most intensive care we provide. Palliative care and hospice patients can generally be evaluated both in the home environment and the clinic setting.

Technology has changed so many realities of veterinary medicine, and the delivery of palliative care and hospice is no exception. Now that smartphones are the rule rather than the exception, we can provide real-time, interactive information to veterinarians, team members, and pet owners outside the practice. This liberates pets that are uncomfortable in a clinic to have their evaluations in the comfort of their home environment. Video and still images can be transmitted to the veterinarian in the practice, allowing the veterinarian to guide care-giving from a remote location through the technician visiting the home.

As important as it is to recognize the need to offer palliative and hospice care for animal patients approaching their end of life, it is equally important to recognize that this approach is not a one-size-fits-all solution. Some clients may find the requirements of providing palliative or hospice care overwhelming or impossible in their particular circumstances. Clients should be encouraged to feel safe engaging in an open dialogue with the veterinarian and the veterinary team as they explore their concerns about providing palliative and hospice care for their pets.

Likewise, it is important that clients receive a clear message that at any point along the palliative care or hospice journey, humane euthanasia is available for their beloved pet. At no time should clients be left feeling that they are "bad" pet owners if they cannot provide palliative or hospice care for their pets. Neither should they worry that they cannot change their minds once palliative care has begun.

Veterinary medicine is best delivered using a team approach, and it becomes critical as the pet approaches its end of life. With appropriate training, practice, and ongoing guidance, technicians can play an active role in developing and delivering palliative care and hospice in primary care practices. Facilitating a pet's quality of life as it approaches the end of life is an amazingly rewarding experience. Our patients and clients deserve our attention to this emotionally delicate time, and they need our assistance as they negotiate this part of their beloved pets' lives.

Robin Downing, DVM, CVA, CCRP, DAAPM, is the hospital director for Windsor Veterinary Clinic and The Downing Center for Animal Pain Management. She has practiced veterinary palliative care for 25 years.

REFERENCE

1. Davis LE. Species differences in drug disposition as factors in alleviation of pain. In: Kitchell RL, Erickson HH, Carstens E, eds. Animal pain—perception and alleviation. Bethesda, Md: American Physiological Society, 1983:175.

RECOMMENDED READING

1. AAHA/AAFP Pain Management Guidelines Task Force. AAHA/AAFP pain management guidelines for dogs and cats. J Am Anim Hosp Assoc 2007;43(5):235-248.

2. Palliative medicine and hospice care. Vet Clin North Am Small Anim Pract 2011;41(3).

3. Villalobos A, Kaplan L. Quality of life scale. In: Canine and feline geriatric oncology: Honoring the human animal bond. Ames, Iowa: Blackwell Publishing; 2007;Table 10.1:304.