Death and other client kindnesses

Rather than treating death as an afterthought or an unfortunate consequence of treatment failure, it's time we do better by our clients and empower them to implement a plan that offers comfort, peace and reassurance. (Shutterstock.com)“Never turn down the leftover bowls and medications.”

This advice, passed down by sage colleagues with years of experience in end-of-life care for pets, has served me well over the years. After a euthanasia, heartbroken owners who don't want the reminders of a life now passed offer half-empty dog food bags, careworn beds and near-full bottles of medication in the hope that someone might be able to use them. Even though I can't do anything with most of the items, I always take them, if for no other reason than to spare the owner having to deal with the items themselves.

It's the medications that strike me the most: how many of them are barely touched, how little time has passed between the time of the prescription and the time of euthanasia, and how few of them are the currently recommended palliative drugs. Many are drugs intended to cure, intended for aggressive treatment, and the fact that they sit unused in my medication graveyard is the true indicator of how much good they're doing.

When a patient receives a life-limiting diagnosis, we jump right to the treatment plan-it's what we're trained to do, whether we're a veterinarian or an MD. Gold treatment, silver treatment, bronze treatment. We ask a few questions to help us get to the point: What can you afford, and how aggressive do you want to be? But this line of questioning makes a big assumption-that everyone views “gold treatment” the same way.

Death and the road to ‘One Health'

Click here to read about why Dr. Vogelsang says better veterinary hospice and euthanasia client communication could help people in their regular lives too.

You can't define a best plan without knowing the desired outcome, and talking to a patient's family about goals is the key element. I learned this the hard way. When my mother was diagnosed with grade IV glioblastoma, the process went like this: The neurosurgeon told us the diagnosis. The radiation oncologist laid out the course of daily radiation. The medical oncologist told us what chemotherapy she would be having. My mother knew what she wanted from the moment she heard the diagnosis: hospice care. The only problem was, no one asked her opinion until after they set her down a course she didn't want. Extricating her from unwanted interventions took a Herculean effort that should have been unnecessary.

When we're overwhelmed, it takes a great deal of effort to get off the track we're set on by our doctors, so most of the time, we don't. I will never forget the oncologist rolling his eyes at me when I told him my mother was declining treatment. He spoke to us as if we were daft, unaware that both of us were medical professionals. He couldn't understand why my mother was turning down the opportunity to live an extra three months. He assumed that is what anyone would want, but she was more than willing to trade that time to be free of daily hospital visits and chemotherapy, and enjoy a quiet spring at home watching "Harry Potter" movies on repeat. Her gold standard was very different from his, and once given the microphone, she expressed it with clear-eyed certainty. I learned a lot from that experience.

Ask, ‘What's best for the pet and the family?'

Medicine has been evolving from a paternal to a patient-centered model of decision making for several decades, but clearly it's still a work in progress. As we develop better communication strategies for families navigating end-of-life decisions for pets, we must make discussion of client goals an essential part of the consultation. Fortunately for us, hospice veterinarians like Shea Cox, DVM, of Bridge Veterinary Services are leading the charge. (Full disclosure: I work with Paws into Grace doing this kind of work.)

Shea Cox, DVMCox is an expert when it comes to end-of-life care. She's a certified hospice and palliative care veterinarian, certified veterinary pain practitioner, certified pet loss professional and the president-elect of the International Association of Animal Hospice and Palliative Care (IAAHPC). Before entering the veterinary field, she was a registered nurse in human hospice and home health care. And for Cox, excellent end-of-life care all comes down to time.

“My ‘aha' moment … happened in my 10th year working as an emergency veterinarian,” Cox says. At the time she often received patients in the ER that were declining from complications of their primary disease process. Even though they'd just been seen by a veterinarian or veterinary specialist, their owners often felt lost or overwhelmed with regards to the pet's diagnosis and care, Cox says.

Take a patient that's just seen a veterinary oncologist, for example. The oncologist “has one hour to discuss diagnosis, prognosis, treatment options and costs of care,” Cox says. “Because of the vast amount of information that needs to be shared in a short time, conversations are often one-sided until the last few minutes, when the doctor asks, ‘Do you have any questions?'”

Yes, the oncologist can deliver all of that in a compassionate way, Cox says, but clients still struggle in the moment to process all those details at the same time as their emotions are hijacking their brains. The result is they go home with very little understanding of what just took place.

In her hospice practice, Cox sets the stage for better client understanding by leading a guided discussion with families during their initial consultation. In addition to information about disease and treatment, she covers such issues as:

family goals

relationships and beliefs

challenges in the delivery of care

past experiences with care

quality of life for the family as well as the pet

preparation for death and the euthanasia process.

Adapting intake forms from human hospice, Cox has created a four-page checklist to remind her to touch on all the necessary topics. She schedules three-hour new-client appointments at the pet owner's home, with both a veterinarian and a veterinary technician, and she's learned (surprisingly) that the medicine is the easiest part of the discussion.

“About 20 percent of the conversation centers around a client's understanding of the medicine,” she says, “while I spend 80 percent getting an understanding of the pet owners' needs and goals and helping them determine the ‘lines in the sand' to know when the time is right for euthanasia.”

Dealing with the “when is it time?” question is one of the most essential parts of Cox's hospice work. She says many clients express angst when their veterinarian tells them they'll “know when he's ready” and to come back for euthanasia “when it's time.”

Euthanasia: Too soon? Not soon enough?

Click here for more advice from CVC educator Mary Gardner, DVM, on helping clients through the process.

Cox says this places a heavy burden on families when, more often than not, they have no idea when their pet is at the right point for euthanasia. “When they don't know but feel that they should know, they become burdened with feelings of guilt and that they're not doing right by their pets,” she says.

So Cox has adopted an alternative expression: “I say, ‘When you begin to feel that your pet is not experiencing joy or quality of life, let's talk more about what that may mean to both of you.'” The emphasis is on noticing changes, not making a final determination on the spot. 

Too much to talk about, too little time = Do you need help?

Cox recently worked with four practices to interview 100 clients about their pets' end-of-life experiences. The two biggest themes? Not enough time to discuss end-of-life issues with the veterinarian during a normal appointment, and not enough “easy access” to the veterinarian when it was time to review quality of life or possible euthanasia. That's regrettable but understandable, Cox says.

“Current practice business models only allow for 15- to 30-minute appointments at best,” she says. “This just isn't enough time to provide the level of care needed, especially when one considers the emotional complexities involved with end-of-life communication and the many needs of a geriatric pet with multiple comorbidities. It all comes back to time.”

4 steps to improve your end-of-life care for families

1. Use your technicians. Invest in training a licensed veterinary technician who has a strong interest in end-of-life care and who can work closely with a veterinarian in creating end-of-life care plans.

2. Review the End of Life Guidelinesfrom AAHA and the International Association for Animal Hospice and Palliative Care (IAAHPC).

3. Grab the latest textbooks. Two hospice-specific textbooks were released recently by Wiley: Hospice and Palliative Care for Companion Animals: Principles and Practice and Treatment and Care of the Geriatric Veterinary Patient (Cox is a contributing author).

4. Get certified. For a truly in-depth experience, enroll in the IAAHPC's Animal Hospice and Palliative Care Certification Program. This brand-new, 100-hour, RACE-approved program is available to veterinarians and licensed veterinary technicians for certification in hospice and palliative care.

One way to get past this hurdle is a multidisciplinary team that includes a doctor and technician dedicated to the lengthy at-home visits that can be time-consuming, emotional and complicated.

Is an outside hospice veterinarian the answer? Cox's business model is built on “yes,” and she emphasizes that while it can be hard for general practitioners to include another veterinarian in a cherished client's care, it can result in better outcomes. This model is also consistent with human medicine, where multidisciplinary care is increasingly being embraced by hospitals and patients alike.

In fact, Cox finds that the referring veterinarians often benefit from the referral almost as much as the families.

“A hospice-medicine relationship does not replace the relationship the family has with their lifelong veterinarian,” Cox says. “It's a collaborative relationship. We're not just there for the pet and client but the veterinarian as well. Part of our role is to lighten the load of care by being an additional layer of support in a veterinarian's busy day.”

End-of-life clients often require more frequent, in-depth conversations than other clients, and a hospice veterinarian is well equipped to offer that emotional support and presence. If a hospice veterinarian isn't available in a particular area, or if a general practice wants to make end-of-life care more of an emphasis, a doctor-and-technician team can take the lead on developing this service for its clients (see “4 steps to improve your end-of-life care for families” on this page).

Whether you're focused on improving your own patient care and client communication about end-of-life issues or seeking out third-party help to support your hospice care, the adage that “you don't know what you don't know” has never been more relevant. When clients are given clear choices and options with end-of-life care, they often make choices we never would have anticipated. But if we don't let them know what's possible, they'll never get there. Rather than treating death as an afterthought or an unfortunate consequence of treatment failure, it's time we do better by our clients and empower them to implement a plan that offers comfort, peace and reassurance.

Dr. Jessica Vogelsang is a certified veterinary journalist, a regular contributing writer for a number of publications, author of the memoir All Dogs Go to Kevin, and creator of the popular blog Pawcurious.com.