An introduction to the concept of veterinary hospice care (Proceedings)

Mention the word hospice and the term alone evokes varying degrees of emotion in people. If this is a service that you have had the opportunity to be involved with personally it can stir up some powerful emotions of loss. And, depending on the circumstances, it can either conjure up peaceful and grateful feelings or a negative and adverse reaction. Either way, the reaction is often strong. Hospice has been called the "final act of compassion" and finds its roots traced back a couple of hundred years ago to Europe. By definition, the word comes from the Latin word hospitum, to host or hospitality. Hospice is a philosophy of care that provides comprehensive, loving support for patients with terminal illnesses that have progressed beyond a doctor's expectation of cure. Hospice care helps the patient to live with dignity, in comfort and peace, surrounded by their loved ones, as they approach the end of their lives. The hospice care philosophy views death as a part of living, instead of something to always struggle against. Hospice neither hastens or postpones death and seeks to reduce the suffering involved in the dying process for both the dying patient and her or his loved ones. Having its foundation in religion, monks and nuns provided shelter and care for the poor, orphans, sick and dying and initially was seen as a place for the weary traveler to rest. In 1905a handful of Irish Sisters of Charity opened St. Joseph's Hospice in Hackney, East London. The mission of this facility was to care for the terminally ill. The modern hospice concept was defined and developed by Dame Cicely Saunders, a physician, R.N. and social worker, who began working with dying patients in the 1940's. In the 1960's Dame Saunders founded the first modern hospice, St. Christopher's Hospice in London, England. She was inspired by a dying patient who, at the end of life, requested words of comfort and acts of kindness and friendship. Dr. Saunders came to believe and to teach, "We do not have to cure to heal". The hospice movement in the United States has its roots in the pioneering work of Dr. Saunders. Also in the 1960's Dr. Elisabeth Kubler-Ross was bringing the subject of death and dying out in the open and her groundbreaking and best-selling book, On Death and Dying, published in 1969, was based on interviews with dying patients. Time Magazine said of her book, "It has brought death out of the darkness". Dr. Kubler-Ross identified five stages of grief: denial, anger, depression, bargaining and acceptance. Dr. Kubler-Ross's trailblazing work enhanced the hospice movement. The first hospice in the United States was the Connecticut Hospice opened in 1974. And, four years later, the U.S. Department of Health, Education and Welfare cited hospice as a viable concept of care for terminally ill people and their families that provides humane care at a reduced cost. In the early 1980's, Congress created legislation establishing Medicare coverage for hospice care. The Medicare Hospice Benefit was made permanent in 1986 and today most states also provide Medicaid coverage. This coverage allowed this movement to grow and more and more hospices were formed around the country. Hospices quickly went from volunteer-based into health care companies with paid staff and quality practices. Once people learned of the benefits of hospice care more chose this care for their loved ones or themselves.

The hospice movement in veterinary medicine

Eric Clough, VMD and his wife, Jane Clough, RN, BA, VNA presented "Helping Clients Say Good-bye:Hospice Care for Pets" at the AVMA Convention in Baltimore, MD in 1998. This was a landmark conference for many veterinary professionals who had been providing pet hospice care and didn't know it.

Dr. Clough, a New Hampshire based veterinarian, became interested in his wife, Jane's, work as a human hospice administrator. By the early 1990's, Clough noticed that by using the hospice focus on pain relief and comfort as well as home care, his clients were more satisfied with their experience – even though the end result was the same. Dr. Clough said, "Hospice care gives you the opportunity to say goodbye to your pet rather than take the animal to the vet and never see him or her again. The underlying philosophy is not about treatment, but to make the animal comfortable and provide them with a kind death." Soon the veterinary community began to see an emergence of the veterinary hospice care movement. In 2000, at the 137th AVMA Annual Convention in Salt Lake City, UT, Dr. Alice Villalobos, Hermosa Beach, California, led a talk about the emerging veterinary hospice movement she termed "Pawspice". Dr. Villalobos spoke about her many years' experience in veterinary oncology and the difference incorporating "Pawspice" care has made to her clients and the clients referred to her. Shortly after, in 2001, the AVMA established Veterinary Hospice Care Guidelines. They reviewed and kept them in 2007. The First International Symposium on Veterinary Hospice Care was held in 2008 at the UC Davis School of Veterinary Medicine. This was a first attempt at gathering professionals from different areas of healthcare to discuss this emerging new specialty of veterinary hospice. During that same year, Valarie Hajek Adams, a veterinary nurse (CVT) from Wisconsin, formed a 501c3 non-profit foundation, Healing Heart Foundation, Inc., to sponsor programs that honor the spirit of the human animal bond. The first program the HHFI launched, was Healing Heart Pet Hospice. This program is modeled after the human hospice standard in that veterinarians are in place as medical directors and veterinary nurses (CVT's) do home health care under their direction. Other professionals such as mental health counselors are consulted or called as necessary.

The principles: hospice and palliative care in veterinary medicine

Palliative care, (from the Latin palliare, to cloak), is a specialized area of healthcare that focuses on relieving and preventing the suffering of patients. Palliative medicine is appropriate for patients in all disease stages, including those undergoing treatment for curable illnesses and those living with chronic diseases. In hospice care, it is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness. Palliative care is comfort care that treats the whole patient – mind, body and spirit. Taken from the human model, palliative care is usually provided by a team of experts, including doctors, nurses and social workers. chaplains, various therapists, nutritionists, pharmacists and others may also be part of a palliative care team. Every hospice patient receives palliative care, but not every patient receiving palliative care is a hospice patient. The veterinary hospice care model is afforded different options for care. Hospice may be provided through hospitalization, but most frequently is provided in the pet's home. Like human hospice, pet hospice and palliative care is best provided with a team approach coordinating a plan of care that falls within the family's beliefs and goals for the pet. Dr. Alice Villalobos cautions the veterinary profession to be vigilant against owners going too far. Her Quality of Life Scale has set a standard that many veterinary hospices utilize in practice. The criteria for veterinary hospice care are closely modeled from human hospice in that:

     • The patient has a life expectancy of 6 months or less

     • Doctors feel further treatment is futile since the patient is not improving

     • Owners who have opted not to pursue treatment

Aggressive treatments/diagnostics vs. Palliative and hospice care

When deciding to pursue aggressive treatment or certain diagnostic testing for a terminally ill animal, the veterinary practitioner must ask themselves the following questions and consider the answers carefully before moving forward.

     • Will the treatment change the outcome?

     • Will the treatment cause pain or harm to the pet?

     • Will the treatment improve the quality of life for the pet?

     • Will knowing the test results make a difference in the outcome for the pet or family?

The benefits of veterinary hospice care

Palliation allows the terminally ill pet to function more comfortably so as to enjoy as much of their normal routine as possible, interacting with their family in their own surroundings. Life is just better when its pain free! The bond between owner and pet deepens and takes on new meaning during the hospice care journey. Owners and their families will benefit emotionally, perhaps spiritually and often physically from having veterinary support to assist on this journey. While euthanasia might be a consideration at some point, it often does not have to be the first choice for many terminally or chronically ill pets.

For the veterinary professional, providing veterinary palliative and hospice care to clients and their pets opens the door for economic and spiritual growth. Providing veterinary hospice services as an additional benefit will generate income and expand the client base of a practice. Offering this compassionate end of life care, dignifies the profession by further honoring the bond we share with our pets. Most importantly, the veterinary profession now has the ability to say to many families of terminal pets, "We now have another option for you" instead of having to say, "I'm sorry, there's nothing more that can be done".

Bibliography and References

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