Advances in end-of-life care: updates on recent literature

Photo: Ben R/Adobe Stock

The veterinary literature about end-of-life care, animal hospice, and palliative care is growing as these areas of practice become more common. The goal of this type of research is to support the "human animal bond by providing best medicine and directing the industry," according to Kathleen Cooney, DVM, CHPV, DACAW resident, of the Companion Animal Euthanasia Training Academy. During a session at the recent Fetch dvm360® conference in Charlotte, North Carolina, Cooney reviewed some of the latest research in companion animal end of life care and key takeaways that can be used by veterinarians and their teams when engaging in end-of-life care.¹

Use of quality-of-life scales

Quality of life (QOL) scales are commonly used by palliative care and hospice veterinarians to provide a more objective way for pet families to monitor a pet’s QOL.² Cooney shared that only one scale has been validated (Vetmetrica, which is a paid system). However, the Lap of Love and H5M2 scales are commonly used and consider some of the social and emotional aspects as well as physical measures of quality of life. Cooney suggests adding the BEAP scale to assess pain to existing QOL scales. These assessments are most beneficial when completed by multiple family members.

Euthanasia communication

A 2019 paper by Matte et al. explored the impacts of euthanasia and end-of-life conversations on veterinarians.³ This survey-based study found that veterinarians understand the importance of providing a “good death” to their patients. In fact, the ability to provide a good death is directly linked to wellness, with those who are able to provide euthanasia that are “humane, peaceful, smooth, and quick,” having a large sense of accomplishment. However, when euthanasia goes poorly, there is a reduced sense of wellbeing and job satisfaction.

Additionally, this study found that one of the most difficult parts of the euthanasia process was navigating complex decisions with clients. Veterinarians often report feeling drained when multiple, long conversations are needed prior to the decision to euthanize. Overall, these conversations are more draining than performing euthanasia. Cooney notes that these types of conversations are an opportunity to involve veterinary social workers to help support both the client and veterinary team members through these difficult decisions.

Defining a good death

A 2022 study explored the opinions of pet owners on what defined a “good death.”⁴ The top 5 characteristics of a good death from a pet owner’s perspective included:

• Never separated from the pet and allowed to be with them through the entire process.
• Assistance with pre-planning, which includes opportunities to set expectations and minimize regrets by determining who will be present, where the euthanasia will take place, and what the aftercare will be.
• The pet is sleeping and comfortable, even if this takes time.
• Pet is anxiety- and pain-free.
• The client is offered in-home euthanasia.

Although some of these items, like pre-planning and home euthanasia, may not be feasible in an emergency situation, many of the others could be accomplished, especially with the use of pharmaceuticals to reduce pain and anxiety and provide heavy sedation. The results of this pet owner survey should be considered when determining how euthanasia is handled in the clinic.

Documentation of client conversations

Cooney noted that documenting details of conversations leading up to euthanasia is essential for protecting veterinarians in the event of a client complaint.^5,6 Detailed records also hold the team accountable. Cooney recommended clinics create practice guidelines for how euthanasia is handled, which will increase efficiency and ensure that all appropriate documentation occurs. Additionally, when euthanasia is declined or delayed, it is important to provide documented recommendations for palliative care, pain management, and emotional support for pet families.

Considerations for aftercare

Pet owners look to veterinarians and their teams not only for support in the decision to euthanize a pet but also in making decisions around aftercare.⁷ Although crematories are where the experts in pet memorialization work, they were lowest on the list of information sources for pet aftercare. Cooney recommended veterinarians tour crematory facilities on an annual basis and discuss what options they can provide to their clients. Connecting clients to the crematory to discuss all options for pet memorialization can improve the client’s perception of the aftercare process.

This study also found that owners have strong feelings about how their pet’s body is stored after death. Trash bags are unacceptable. Blankets/shrouds, designated cadaver bags, and caskets were acceptable ways to store pet bodies. Most owners expect their pet’s body to be moved from the veterinary office to the crematory or burial site within 24 hours of death.

Emerging Issue: pentobarbital and animal remains

Cooney concluded her lecture with a word of caution around pentobarbital use. Although commonly used for euthanasia, pentobarbital poses an environmental risk, especially for secondary poisoning to animals scavenging carcasses. In fact, there are federal fines for improper burial leading to relay toxicosis. Large animal practitioners are more likely to be aware of these risks and discuss them with clients than small animal practitioners.8 However, it is essential that veterinarians provide clients with safe burial guidelines. In order to protect access to pentobarbital, Cooney shared that the American Veterinary Medical Association is looking at ways to help improve awareness of this issue and the need for client education.⁸

The future of end-of-life research

End-of-life care continues to be an evolving area of veterinary practice, and research is ongoing in this field. Cooney encouraged veterinarians who are interested in exploring research in this area of medicine to contact her or the International Association of Animal Hospice and Palliative Care.

Dr. Boatright, a 2013 graduate of the University of Pennsylvania, is a practicing veterinarian and freelance speaker and author in western Pennsylvania. She is passionate about mentorship, education, and addressing common sources of stress for veterinary teams and recent graduates. Outside of clinical practice, Dr. Boatright is actively involved in organized veterinary medicine at the local, state, and national levels.

References

1. Cooney K. Updates on New Research in End-of-Life Topics. Presented at: Fetch dvm360 Conference; Charlotte, NC. March 25, 2023
2. Flavell S. The use of quality-of-life scales for hospice and end-of-life patients. The Veterinary Nurse. December 2019/January 2020. Vol 10, Number 10. P 534-537
3. Matte A, Coe J, Khosa D, et al. Impacts of the process of decision-making around companion animal euthanasia on veterinary wellbeing. Veterinary Record. 2019-10, Vol.185 (15), p.480-480
4. Cooney, K., Kogan, L. “How Pet Owners Define a ‘Good Death’: New Study Reveals Some Surprising Facts.” DVM360 magazine 2022. 53.8: 12 https://www.dvm360.com/view/how-pet-owners-define-a-good-death-
5. Gray C and Radford A. Using electronic health records to explore negotiations around euthanasia decision making for dogs and cats in the UK. Veterinary Record. 2022-02, Vol 190(9):https://doi.org/10.1002/vetr.1379.
6. Cooney KA. The importance of documenting euthanasia decision-making processes in patients’ medical records. Veterinary Record. 2022-05, Vol 190(9):364-366. https://doi.org/10.1002/vetr.1759
7. Cooney K, Kogan L, Brooks S, Ellis C. Pet Owners’ Expectations for Pet End-of-Life Support and After-Death Body Care: Exploration and Practical Applications. Topics in Companion Animal Medicine. Volume 43. 2021
8. Kollias NS, Hess WJ, Johnson CL, et al. A literature review on current practices, knowledge, and viewpoints on pentobarbital euthanasia performed by veterinarians and animal remains disposal in the United States. JAVMA 2023;261(5):733-738. DOI: 10.2460/javma.22.08.0373