Veterinary hospice care guidelines (Proceedings)

Many of the hospice and palliative care principles that have been successfully adopted in human hospice for decades are now being embraced to provide end of life care for terminal pets and their families by veterinary professionals. Steve Miles, M.D. said, "Death is not a medical event. It is a personal and family story of profound choices, of momentous words and telling silences." While death has remained a constant over the course of history the process of dying has changed for humans as well as companion animals. Medical advances have changed death, frequently, from a sudden event into an often long journey with many events. We have increased the lifespan of our pets, created complex medical choices and shaped a new population of pets with chronic illnesses.

End of life care is 'patient centered' medicine and, some postulate, should be, at the very least, offered for those who have a limited life expectancy. The term palliative care is frequently used when discussing end of life care. The word 'palliative' means to abate or reduce the intensity. The concept of palliative care is based on the provision of comfort and relief. Palliative care is care of the 'whole patient'. This includes the body, mind, heart and spirit. The goal of palliative care is to make life the best it can be when individuals are living with declining health. Palliative care can be delivered in the absence of hospice care, but hospice care is not delivered in the absence of palliative care. Having euthanasia as an option has assured those in veterinary medicine that the vow they take to not allow animal suffering is somewhat guaranteed. Therefore, hospice care is a paradigm shift for many in veterinary medicine. The emergence of veterinary hospice and palliative care is being explored as a comprehensive healthcare option delivered by cohesive veterinary teams trained in end of life care to bring comfort, dignity and choice to terminal pets and their families. As an example, newer chemotherapy options have allowed pets to live much longer than in the past. But, not all families want to pursue treatment for disease, or they've sought treatment and now the pet is out of remission, or, perhaps finances or personal beliefs are preventing a family from pursuing treatment. Hospice care is not emergent care. Many pets coming into hospice care are pets that have had chronic health issues and are now at a time where curative measures are no longer seen as an option. It is the hope of the trained veterinary hospice team to help their patients live quality lives to the fullest while supporting the family that loves them for whatever time they have left. The following is standard hospice criteria to determine if this type of care is an appropriate option:

     › A poor prognosis has been given and treatment is not being pursued

     › Treatment has been pursued, but the patient is now out of remission and is not expected to recover

     › The patient has a 6 months or less prognosis

     › Euthanasia is being offered as an option, but the patient is not emergent

Medical conditions that benefit from hospice care

Not surprisingly, cancer is the most common condition seen in end of life and palliative care. Cancers such as Osteosarcoma, Mast Cell, Lymphoma and genitourinary tumors are but a few of the conditions that potentially have a wide range of palliative care options that may be offered to a family exploring end of life care. Renal failure, Cardiac failure and CNS conditions such as brain tumors and spinal cord tumors may also be good candidates for end of life care. Other conditions, such as FCE, neuropathies and polyneuropathies that may not be terminal but, hospice care may provide benefit to the family and pet by providing supportive home care to afford them the time to make further decisions regarding euthanasia or management are certainly to be considered in this type of care.

Circle of care

The human hospice care model utilizes a comprehensive healthcare team consisting of a physician, registered nurse, social worker, clergy, nursing assistant and trained volunteers as well as other professionals to assist in an individualized manner. Taken from the AVMA Guidelines for Veterinary Hospice Care, "The veterinary hospice team consists of the veterinarian and trained staff who provide expertise in palliative care and pain control for such terminally ill animals." And, in addition, "A team approach, encompassing professionals in veterinary medicine and psychosocial care is the ideal. The veterinary hospice team should be prepared to recommend that clients contact licensed mental health professionals who are trained and experienced in grief and bereavement." Other ancillary services such as physical therapists and alternative healthcare providers can also be extremely helpful, but there is no doubt that veterinarians and veterinary nurses should be at the helm delivering this end of life care.

Stepping into the 21st century

The obstacles facing veterinary hospice and palliative care are largely due, in fact, to misconceptions about this type of care and it's transference to veterinary medicine as well as a lack of definition of end of life care in veterinary medicine. As Dr. Amir Shanan has stated, "Many animal owners don't know enough about these services to seek them out. In addition, many veterinarians don't know enough about the benefits hospice care can offer their patients and clients and, therefore, don't provide hospice services or information about them." A factor contributing to this is that students of veterinary medicine, doctors and technicians alike, receive very little training to prepare them for this side of medicine. The topic of euthanasia may be briefly touched upon in schools, but the idea that we, too, can offer and deliver a type of care that can assist our patients to enhance their quality of life through intense palliative care at the end of life and support their families emotionally with an interdisciplinary team approach isn't being addressed. The industry's academic structure is mostly based in preventative health care and treatment of illness and disease. The exception to this is CSU's Argus Institute, whose pet hospice program is wonderfully structured and hands on learning for veterinary students. According to Gail Bishop, Clinical Coordinator for Argus Institute, students in their junior year are taught the following concerning end of life issues: quality of life conversations, euthanasia planning, explaining the euthanasia protocol to clients, euthanasia role-play and supporting the grieving client. A significant number of hours within their fall and spring semesters are spent learning this subject in preparation for what they will encounter in veterinary practice. By integrating hospice and palliative care principles at the academic level we can start to cultivate an area of care that is keeping in step with the advances in medicine being offered to pet families.

Myths and misconceptions

Proponents of veterinary hospice care are continually finding themselves dispelling myths and giving definition to this option of care. It is not unusual to find a population of veterinary professionals as well as pet parents that believe that hospice is prolonging life 'at any cost'. There are also groups that believe veterinary hospice is simply a 'home euthanasia' service. Neither is true. When we explore some of these misconceptions we find that hospice neither hastens nor postpones death. Hospice affirms life and regards dying as a normal process. Hospice emphasizes quality rather than quantity of life. The dying are comforted and their families are supported and guided through this process by professionals trained in this type of care. Another misconception that plagues veterinary hospice, as well as human hospice, is the belief that a patient must be near death before they enter a hospice program or that to be in hospice services means the family is 'giving up'. Nothing could be further from the truth. The intention of hospice care is to turn bad days into better days and extend those good days through concentrated and compassionate comprehensive care. All too often we hear, "She/he isn't ready for hospice because she/he still feels good." This is PRECISELY when it will be most beneficial for the family and the pet alike to bring a patient into hospice care. With this timely entry into hospice care the hospice team can use a palliative care focus to aid the dying pet and, additionally, enrich and strengthen the human animal bond, which in many cases, brings greater peace to the family after loss.

According to the Hospice Foundation of America, a hospice should be several things:

     › It should be an agent for learning in the community, especially the medical community.

     › It should be an agent for change, especially in the health care community.

     › It should be humble about the work it is privileged to do.

     › It should be respectful of the lifestyles of all it serves.

     › It should serve people (families and pets) regardless of race, religion and economic or social status.

The added benefit of adding these services as an option means we can eliminate the phrase, "There's nothing more that we can do". Palliative care offers many options to a family seeking this support. The only way to dispel myths and misconceptions is through education and awareness. This education must include the veterinary community as well as the public so as to give a true and accurate picture of what this type of care has to offer. Veterinary professionals working in end of life care will continue to develop ways of educating and creating awareness so that pet families know they have options that do not always have to include complex treatments or immediate euthanasia.

In conclusion

By the AVMA definition, the human animal bond is a mutually beneficial and dynamic relationship between people and other animals that is influenced by behaviors that are essential to the health and well-being of both. This includes, but is not limited to, emotional, psychological, and physical interactions of people, other animals and the environment. The veterinarian's role in the human animal bond is to maximize the potentials of this relationship between people and other animals. According to CSU guidelines, a 'Bond Centered Practice' supports and responds to the emotional needs created by the bond. Some veterinary professionals would make the claim that if we are able to offer the advanced medicine we have available now, we are obligated to offer end of life care as a specialty should it be available. In addition, if this type of care is offered it should be provided by trained veterinary professionals who have sought out particular education so as to preserve the standards of care we, in veterinary care, strive for. Hospice care is not about waving a white flag or giving up hope. It may, however, mean redefining hope to include a kinder, gentler death with more good days than bad toward the end of time here on earth and hope that the days before death can be filled with rich and memorable experiences guided and assisted by a caring team of end of life professionals.

References available upon request.