Home care and end of life issues (Proceedings)

"The death we fear most is dying in pain, unnoticed, and isolated from loved ones. Concern about such an undignified and difficult death has engendered the debate over authorizing voluntary active euthanasia and physician-assisted suicide. Death is fundamental to the nature of being human." (Anon.)

It is the rare adult who does not have an emotional response to thoughts of dying. We are all inherently aware of our mortality and to that of those around us. No different from our clients, we fear the pain and suffering of friends and companions, human or non-human. Nor do we become elated when considering the probabilities of terminal illness and long-term nursing care.

What is aging? To paraphrase from Robbins1: Aging begins at the moment of conception, involves differentiation and maturation and, at some point, leads to the progressive loss of functional capacity characteristic of senescence ending in death. This occurs at an organismal level as well as at a cellular level. The former may be affected by genetics, social environment, nutrition, and the occurrence of age-related diseases. Cellular aging, on the other hand, includes progressive accumulation of sublethal injury (e.g., from free radical damage), resulting in either cell death or diminished capacity of the cell to repair itself.

Why consider this? Home care and end of life inherently encompasses matters of age-related and age-appropriate illnesses. In cats, these include most significantly renal insufficiency progressing to failure, hyperthyroidism, diabetes mellitus, degenerative joint disorders, neoplasia and chronic digestive disorders including inflammatory bowel disease, pancreatitis and cholangiohepatitis. In some cases, by addressing organ and cell function, we can impact well-being.

Just as we match nutritional and preventative medical recommendations to life-stage, so too can we match stages and types of care to the final stages in life.

1. 1-Support function

2. 2-Alleviate discomfort, optimize comfort

3. 3-Preparing for an ending; dying with dignity

4. 4-Caring for the caregivers

1-Support function of cells and organism

Hydration is of utmost importance and should be included in any home care program. Most clients are able to give fluids subcutaneously at home if the care team believes in their importance and that the client is capable. Fluids are a gift to make the kitty feel better. Dehydration at a cellular level results in headaches, sluggishness, inappetence, lethargy and constipation. When cells aren't getting enough fluid, they take it from urine and feces. This results in hard fecal balls rather than the normal log-shaped feces. Dehydrated cells aren't able to function adequately, can't transport toxins or nutrients well, aren't well oxygenated, suffer further damage and lethal changes.

Daily subcutaneous fluid requirements are determined just as intravenous requirements are, namely deficit (as a percentage of ideal body weight in kg), plus maintenance (60 ml/kg ideal weight/day) plus ongoing losses sustained by diarrhea or vomiting. If this volume is too large for administration at a single time, it may be divided into multiple treatments during the day. Warming the fluids may make the experience more pleasant for some cats. We prefer to administer the fluids as rapidly as possible using gravity feed and an 18G needle. A client hand out is included in the appendix.

Nutrition is essential providing calories from fat and protein, anti-oxidants and other micronutrients. Carbohydrates are less essential for cats as obligate carnivores, however, they can be a good source of energy as well. The goal is to have a cat eat 50 kcal/kg ideal weight/day on his/her own. Often illness interferes with meeting this goal, so we have to assist.

Pharmacological agents such as cyproheptadine (PeriactinTM) at 1 mg/cat PO q12h or mirtazapine (RemeronTM) at 3 mg/cat po q72h can be used. Discontinue cyproheptadine if ineffective after four doses. Mirtazapine has the added benefit of being an anti-emetic as well as an appetite stimulant. While diazepam (ValiumTM) is still an option, because it is sedating, has the possibility of inducing irreversible, life-threatening toxic hepatopathy and because it has the least likelihood of being effective, it cannot be recommended.

Pain may interfere with eating. There may be oral pain from periodontal disease, from an odontoclastic resorptive lesion or from a mass. Dental health should be optimized wherever possible. Musculoskeletal pain makes crouching or bending the neck uncomfortable. Shapes, sizes and placement of bowls may help. Nausea associated with uremic gastritis or renal disease may be lessened with famotidine (PepsidTM) 5 mg PO q24h. Declining senses may result in lack of awareness of food (hearing, vision, smell). Warming food to a freshly killed prey's temperature increases its palatability. Small, more frequent meals may suit the older patient better than two meals a day. The texture of the food may play an important role. Canned foods are preferable, should the cat like them, as they contain significantly more water. We often recommend feeding a prescription diet for a specific ailment. However, cats being the selective creatures they are, it is more important that they eat, than what they eat. And that they eat enough of it.

Feeding tubes save lives. They make administration of nutrients and medications less stressful for the client and for the patient. Naso-esophageal tubes can be used short-term and require a liquid diet, such as Clinicare FelineTM (1.0 kcal/ml). Human enteral diets are too low in protein for long-term use and have a high osmolarity resulting in diarrhea. Oral syringe feeding can be performed with minimal stress if several tips are considered. Face the cat away from you; small volume syringes are preferable as administration of more than one ml at a time is larger than the oral capacity of the kitty; place the tip of the syringe at the back of the mouth to make it harder for the cat to spit out the food; room or body temperature food is less unpleasant. A cat's stomach can hold up to 100 ml in health, so starting with 6 ml and increasing in 6 ml increments to 48 ml total per feeding is realistic with most cats.

Large bore tubes are preferable because a wider variety of diets can be used. The easiest one for home care is an esophagostomy tube. It requires only a brief anaesthetic and doesn't have post-op risks of peritonitis that a gastrotomy tube potentially does. These tubes allow the use of Hill's a/dTM (1.3 kcal/ml) or Eukanuba Maximum CalorieTM (2.1 kcal/ml). If the client wants to dilute the diet for ease of syringing, they should use ClinicareTM to prevent loss of caloric density. G-tubes must be aspirated before infusing food to determine residual gastric volume. Both types of tubes must be flushed with water following feeding to prevent clogging. More on this in the appendix.

Mobility often declines in older or ill cats. Over the past several years, numerous papers have been published regarding arthritis and degenerative joint disease in our feline patients.2-4 While estimates vary regarding the frequency of joint disorders, all agree that older cats have a greater incidence of joint problems that are clinically under-diagnosed, either because cats aren't an exercised species or because they hide their discomfort well. If specific questions are asked about movement, one can often determine that there is stiffness or discomfort. "Have you noticed: a change in how he jumps/climbs up? down? walks?" In one paper2, a startling 90% of cats over 12 years of age were found to have radiographic evidence of degenerative joint disease regardless of the reason that they were presented to the veterinary hospital. Many had lesions in the lumbosacral vertebral column with severe lesions found in 17% of the radiographed elbow joints. Thus, care of the older cat must include attention to mobility.

Manifestation of problems with movement include constipation, defecating outside of the litter box, falling when jumping onto or off of the bed, inability to climb stairs, inability to crouch to eat resulting in weight loss. Regular nail trimming helps by maintaining proper joint relationships. Ramps and steps onto favourite sleeping spots are thoughtful. The following website has steps and ramps for cats: www.cozycatfurniture.com Warm, soft, padded sleeping places for stiff, painful, possibly bony joints should be considered. Adding a litter box so that kitty doesn't have to walk as far may reduce accident as well as encourage regular voiding and defecation. Make sure that the rim of the box is not too high, nor the opening into the box too small. Scoop it several times a day and make sure that the litter isn't too deep or too sparse.

2-Alleviate discomfort, optimize comfort

Obviously, optimizing cell function may require medications and supplements. Compliance is best achieved through helping the client understand the kitty's illness and how the medication helps. In the appendix there are handouts on diabetes, renal insufficiency and hyperthyroidism. In Feline Oncology: a Comprehensive Guide to Compassionate Care by Drs. Greg Ogilvie and Antony Moore (VLS publications), there are excellent handouts regarding cancer terminology, treatment, and decision making.

Grooming may be neglected by the cat with stiffness or one who is simply elderly and possibly less attentive. Recently it has been found that cats with cognitive dysfunction have similar brain changes to humans with dementia5. Diligent, patient grooming may be necessary to help keep a cat's coat clean and healthy. Massage of stiff muscles may be appreciated. If not, warm soft padded places to lie may be.

A common complaint is night-time yowling. Differentials include: loss of special senses, hypertension, hyperthyroid agitation, pain, and cognitive dysfunction. The first may be discernable and alleviated by simply calling out to the kitty, so that he/she is able to locate where you are. Hypertension and hyperthyroidism are readily diagnosed and controlled medically. Pain may be difficult to assess. Often the best way to determine if pain is present is to administer pain relief and see if behaviour normalizes.

The Veterinarian's Oath states that: "I solemnly swear to use my scientific knowledge and skills for... the relief of animal suffering..." Above all else, clients have the right to expect that our focus is going to be on alleviating (and preventing) pain. Fortunately, over the past decade, cats have received more attention than they did previously in this regard, so that we now have a slightly wider menu to choose our analgesic protocols from. Use of a multi-modal approach is often preferable in order to minimize the potential adverse effects of a single agent by using lower doses of several agents. Often a narcotic (such as buprenorphine, hydromorphone, butorphanol or fentanyl) is combined with a non-steroidal anti-inflammatory (NSAID) like meloxicam or aspirin or, for single dose, ketoprofen or cartrophen. Topical and local analgesia may also be provided either with EMLA crème or a local block or acupuncture. Corticosteroids should not be combined with NSAIDs but can be used in conjunction with the other drugs.

Because of concern about possible effects on renal function, the general recommendation is to avoid NSAIDs in patients with renal disease. Having said this, at this stage of life, as long as the client has been fully informed about the risk, quality of life without arthritic pain may well be preferable to a painful, risk-free existence. As mentioned above, the clinical signs of arthritis include weight loss, anorexia, depression, urinating outside the litter box, poor grooming, and lameness. Having used it for over six years in older cats and given that most older cats have some degree of renal insufficiency, this author feels comfortable after describing the risks and possible signs of problems to dispense meloxicam (1 drop/cat every 2-3 days PO) for ongoing use. In addition to analgesics, nutraceuticals and chondroprotectants, such as glucosamine and chondroitin sulfate play a role in the management of degenerative joint disease.

For more information on these topics, you can refer to the International Veterinary Academy of Pain Management at: http://www.cvmbs.colostate.edu/ivapm/ and if you are interested in learning more about acupuncture, IVAS - The International Veterinary Acupuncture Society has their website at: www.ivas.org/

Many patients in the later stages of life require numerous medications. The number and frequency of administration is a source of stress for both the patient and the client. Thus, whenever possible, the importance of the particular agents should be prioritized to ensure that the most important ones are given diligently. If the less critical ones cannot be avoided perhaps they can be administered by a different, less psychologically invasive route. Feeding tubes are wonderful allowing most oral medications to be given without handling the patient. Many clients are comfortable giving injections subcutaneously of agents that can be administered in this fashion.

3-Preparing for an ending; dying with dignity

As we have the wonderful opportunity to know our patients from cradle to grave, we often know their people for a long time. As a feline companion reaches middle to late years, it is often a good idea to encourage clients to give consideration to introducing another companion, not only for themselves, but also for other critters who will be left alone. Should they want a kitten, a pair is better for the older cat to avoid some of the indignities of kitten behaviour! If they are considering adopting another single cat, then a young adult who has learned his/her manners is suitable.

Probably the most difficult thing clients fear is wondering how they will know "when it is the right time". Our aim has to be to not take time away from an individual's life or from the time that that cat and their people can spend together and balance that with trying to avoid going beyond the point that the kitty wishes to be alive.

I encourage the human caregivers to step inside their cat's skin and try to imagine what he/she is experiencing. Some people are very clear in their assessment of how kitty is doing: others less so. Using a scale of one through ten, with ten being the best day of their life and one being equivalent to agony and hopelessness, most of us live at around a six or seven. If they use this as a means to score a given day or part of a day, it allows them an objectivity that is an emotional buffer from the roller coaster of emotions they are living in. (Or, for those who are hiding or numb, it adds content to their cat's experience.) When the scores are mostly twos and threes, that is the time to consider helping kitty pass on. This is very helpful when a person is afraid that they allowed their last companion to suffer too long and also encourages the person who can't let their friend go that it is the right time.

Advice from Dr. Bernie Rollin is to ask a client to write a list, as long as possible, of the things their cat enjoys doing while the cat is still well and to put this list into a drawer as well as having it in the medical record. As the cat becomes more debilitated, they can review this list and see, with their own eyes what changes have occurred. This may help as a reality check, give a gauge of progression and reassurance that the decision to euthanize is appropriate. On the other hand, it will also help the individual who is unwilling or unable to see the changes that have occurred gradually.

Because this is such a difficult period, people like to feel that they have some control should their cat's condition deteriorates quickly. Make sure that they have appropriate phone numbers and know where the emergency facility is. Give them a photocopy of the most recent medical record and lab work to keep by their car keys in case they need to go to the emergency clinic. Clients often forget the names of medications and doses that they are giving when they are upset.

Let people know what euthanasia entails. Tom Ewing wrote in the June 2006 issue of CatWatchTM newsletter: "The term euthanasia is derived from two Greek words — eu, which means good, and thanatos, which means death. In a report published in 2001, the American Veterinary Medical Association (AVMA) defined this "good death" as follows: "Euthanasia is the act of inducing humane death in an animal. It is our responsibility as veterinarians and human beings to ensure that if an animal's life is to be taken, it is done with the highest degree of respect, and with an emphasis on making the death as painless and distress-free as possible.""

Reassure the client that the dose of barbiturate is painless. We place kitty on a nice thick towel on the client's lap and tell them that cats generally keep their eyes open and that because muscles relax, the cat may empty his/her bladder or bowels. Also let them know that some cats may still make breathing movements as the body shuts down. While intravenous administration is the most common route for euthanasia, unless a cat is agonal, I prefer to administer euthanasia solution intraperitoneally, just caudal to a kidney. This avoids restraint and the accompanying fear for the patient. Additionally, the transition from life to death is less sudden: it may take 2 minutes or 20 minutes. As soon as the cat is anaesthetized, should the client be wanting to "finish it", a vein can be accessed for an additional dose. In my experience, clients who have witnessed intravenous euthanasia, prefer the more natural passing with the IP route.

The time of waiting gives them a good opportunity to remember and cry and laugh. This helps me know that they are working through their grieving normally and are going to be okay.

4-Caring for the caregivers

Most people are able to cope with a loss if they know it is imminent and if they have a support network. Too often, in our modern life, the veterinary team may be the only support the client has. This is especially sad when friends and family don't appreciate the attachment the person has for their cat. Along with sending a personal card, it is usually greatly appreciated when we check in on the person after a few days. There is a lovely poem: Gone from my Sight in the appendix. If there is any concern about the client's emotional security and you are concerned that they might be suicidal, be sure to get help from the human health care system.

In general, however, it helps people to know that they may go through a whole range of emotions, from grief to guilt to anger to uncertainty and emptiness. This is normal and healthy. "It is even normal for these feelings to overwhelm you days or weeks after the death of a beloved companion. This reflects the unconscious mind working through things and letting go a little bit at a time. What is NOT normal or healthy is when you get stuck in one emotion." There are also instances in which the death of a cat companion is a reminder of unfinished grieving for another person or pet. There are also numerous wonderful grieving support networks via veterinary school telephone hotlines: www.vet.cornell.edu/public/petloss/other.htm. Some may prefer the electronic support group found at the Rainbow Bridge: www.petloss.com.

As mentioned in the previous section, if clients haven't already adopted a new friend, they should give thought to that. Everyone recognizes that the new kitty isn't a replacement for the one who has died, but by adopting, the newcomer receives a wonderful home and a heart to fill to ease grief and bring joy. When the time is right, that new cat will show up.

Finally there is the cost of caring. We, the care team, experience dying and recovering from it approximately five times as often as our human health care equivalents. "Compassion fatigue goes beyond just normal burnout. Compassion fatigue is a type of physical, emotional, and spiritual exhaustion that comes with frequent exposure to death and having to offer support to clients in highly emotional situations over long periods of time."8

Some of the issues that have been associated with compassion fatigue in veterinary medicine include8:

• Difficulty accepting that the patient's physical problems cannot always be controlled.

• Frustration at having invested large amounts of energy in caring for a patient who then dies, taking this investment with them.

• Disappointment if expectations for patients to die a "good death"- however this may be defined- are not met.

• Difficulty ending a life you once saved.

• Difficulty establishing realistic boundaries and expectations on veterinary care.

• Caring for an animal more than the owner does.

• Guilt arising from a cat's death.

Without risking the tragedy of arms-length detachment, it is possible to take care of yourself. Suggestions for dealing with and protecting your self proactively from compassion fatigue include8:

• Allowing yourself to be human.

• Acknowledging and honouring your own grief and emotions.

• Embrace your personal life away from work.

• Allowing time to debrief and support other team members.

• Saying your own private "good-bye" to your patients.

• Believing in your ability to provide comfort and love to your patients.

• Re-defining death: not as a failure but as an inevitable part of the life cycle.

• After euthanasia, knowing that the individual is no longer suffering.

• Thinking of euthanasia as a gift that owners want and appreciate.

• With euthanasia, realizing that you are providing a loving and caring time for your patients and clients.

References

Cellular injury and cellular death In Cotran RS, Kumar V, Robbins SL (eds): Robbins: Pathologic basis of disease, W B Saunders, Philadelphia, 5th ed, 1994, p32-33.

Hardie EM, Roe SC, Martin FR: Radiographic evidence of degenerative joint disease in geriatric cats: 100 cases (1994-1997). J Am Vet Med Assoc. March 2002; 220(5): 628-32.

Clarke SP, Mellor D, Clements DN, et al: Prevalence of radiographic signs of degenerative joint disease in a hospital population of cats. Vet Rec. December 2005; 157(25): 793-9.

Godfrey DR: Osteoarthritis in cats: a retrospective radiological study. J Small Anim Pract. September 2005; 46(9): 425-9.

Gunn-Moore DA, McVee J, Bradshaw JM, et al: Ageing changes in cat brains demonstrated by beta-amyloid and AT8-immunoreactive phosphorylated tau deposits. J Fel Med Surg. August 2006; 8(4): 234-42.

Hardie EM: Management of osteoarthritis in cats. Vet Clin North Am Small Anim Pract. July 1997; 27(4): 945-53.

Beale BS: Use of nutraceuticals and chondroprotectants in osteoarthritic dogs and cats. Vet Clin North Am Small Anim Pract. January 2004; 34(1): 271-89, viii.

Durrance D: Compassion Fatigue. Proceedings of the 2005 Western Veterinary Conference

Thayer V, Monroe P, Smith R: AAFP Position Statement: Veterinary hospice care for cats. J Fel Med Surg September 2010; 12 (9):728-730