Veterinary hospice care in practice (Proceedings)

Implementing a prosperous and successful pet hospice care program in a veterinary practice is, unquestionably, beneficial to the terminally ill pet, the caregiver and veterinary staff. Palliation is the component to hospice care that allows the terminally ill pet to function more comfortably. Having hospice to assist allows the patient to enjoy as much normal routine as possible as well as interacting with family in familiar surroundings. Life is just better when it is pain free! The bond between family and pet takes on a different dimension at end of life, deepening and becoming more meaningful. Our pets can be our teachers when it comes to living in the moment and staying in the present and it is at end of life that pet families can learn this also with the assistance of hospice care. Hospice care supports a family emotionally, physically and often spiritually with this end of life journey with a pet. An important consideration for a practitioner when considering implementing a pet hospice program is that while euthanasia might be considered at some point it often does not have to be the first choice for many terminally ill or chronically ill pets. These compassionate services offer both direct and indirect benefit to the veterinary practice as well as expand the roles for some staff members. Services such as extended office consultations, telephone consultations, medications and possibly house call services are but a few ways of the monetary benefits. Providing house call services can be done by the veterinarian or the veterinary nurse depending on the veterinary professional's licensing state's practice act. This may be a new frontier for the veterinary nurse. If providing house call services is permissible, these services can include nursing care, respite for the caregiver, euthanasia and care of the pet's remains. Once the word gets out that a practice offers pet hospice care new clients will begin showing up. Pet hospice care does not necessarily generate high expenses for the pet owner. By the time a pet comes into pet hospice, all the expensive diagnostics have been completed. Going forward, the pet owner will be paying for medications, exams and perhaps nursing visits. The veterinary practice does not necessarily have to hire more staff. Starting a pet hospice program can be done slowly over time, one case at a time. Traveling the end of life journey with a client is the highest level of bonding and it is very rewarding for the veterinary staff to help a client during the final phase of their life. Ideally, end of life care should be done in the pet's home. If that isn't possible then the practice may be able to provide in hospital pet hospice care. Offering in hospital pet hospice care is preferred as a respite option only for the owner. Pets just do better at home in their familiar surroundings.

It takes a team approach when providing end of life care. Commitment to the pet hospice idea is essential. The hospice care team member must be a good listener and be able to empathize with the client. Choosing a licensed veterinary nurse as the hospice care team leader is a perfect fit. This person must have excellent time management skills and will serve as the medical liaison between the veterinarian and pet owner. It is important to know that pet hospice isn't for every pet, owner, or family nor is developing a hospice care plan a "one size fits all". Each pet's hospice care plan is developed individually taking into consideration the pet's disease and the owner's needs, belief system, and goals for their pet. The veterinary professional needs to know what the owner's feelings are regarding euthanasia and the care of the pet's remains. Some of these topics are very difficult to discuss but they need to occur. Further training in communication skills may be necessary for both the veterinarian and staff. This will serve the staff well as they will be offering telephone support to the owner. The caregiver must have a clear understanding about their pet's disease so they know what to expect as the animal declines. It is a good idea to explain the euthanasia process and the circumstances that may arise indicating its necessity. The more information provided to the caregiver, the better. Communication amongst the veterinary hospice team is essential. Having regular staff meeting to discuss pet hospice cases will keep everyone informed and is a great way for staff to share their own feelings and concerns. This will create a supportive environment of kinship and understanding. The veterinary professional must be prepared to walk this emotional journey with the pet caregiver from the beginning to the end and afterwards. Since the pet hospice movement is rooted in human hospice, it is recommended that the veterinary staff receive human hospice training.

Managing pain and pet palliation (comfort)

Managing pain is a pet hospice care must! The veterinary hospice care professional must be able to understand, assess and manage the pain of their patients. Developing a pain management plan is based on the individual's illness and pain management needs. While pain is generally managed through the use of pharmaceuticals, other modalities such as rehabilitation techniques, message, Reiki, and veterinary chiropractics may bring comfort to the pet as well. The veterinary professional can gain confidence in pain management through education and interacting with other veterinary pain management experts.

Providing pet palliation, or comfort care, encompasses many things ranging from assisting with mobility and eating issues to grooming, administering medications, nutrition and cooking special foods for the animal. The veterinary nurse will be instrumental in training the caregiver in pet palliation techniques. It is important to provide the caregiver with a list of side effects for all pet's medication. For example, if an owner knows that vomiting or diarrhea may occur with their pet's medication then they can better anticipate the needs of their pet should those side effects occur. Many pharmaceutical companies will provide written information for owners. The more written information a veterinarian or veterinary nurse can provide the client the better. This will empower the owner and reduce the number of phone calls to the practice by confused owners. Encouraging a client to keep a journal of their pet's condition will assist the owner with remembering the details of their pet's ever changing condition. The client can refer to their journal when updating the veterinary staff as to the pet's condition. The more accurate information the veterinary professional has the better to make medical recommendations. Creating a lending library for clients with information about grief and healing, pet hospice, as well as providing resources for products for special needs pets is an excellent way to support and educate clients.

Emotions experienced by the caregiver

Caregivers often experience grief or anticipatory loss prior to their pet's death. This grief can weigh heavily on the owner interfering with their ability to live in the moment and enjoying the time left with their beloved companion. The pet caregiver as well as the veterinary professional experience Compassion Fatigue. Compassion fatigue is internal emotional depletion or exhaustion. It is natural and understandable. For the owner, it stems from caring for an ill pet. For the veterinary professional, compassion fatigue comes from caring and feeling responsible for patients and sharing the hardships of their caregivers. The physical signs of compassion fatigue include:

     • Headaches, blurred vision, GI upset, sweating

     • Trouble sleeping, depression, anxiety, feeling frustrated

Tips to remedy the situation and restore balance include:

     • Take a break

     • For owners, seek respite care to allow a break from caring

     • Switch up your routine

     • Be kind to yourself: do things you love

     • Celebrate and enjoy all the healthy pets you care for

     • Talk about it your feelings

     • Laugh!

Monitoring the hospice pet's quality of life is essential in determine whether or not to continue hospice care. Dr. Alice Villalobos, a veterinary oncologist from Hermosa Beach, California, developed the Quality of Life Scale. This scale is an excellent tool for the caregiver and veterinary professional. The scale assesses how the animal is coping with Hurt, Hunger, Hydration, Hygiene, Happiness, Mobility, and More good days than bad. Defined as:

     • Hurt -Adequate pain control, including breathing ability is foremost on the scale. Is oxygen necessary?

     • Hunger- Is patient eating enough? Will hand feeding help? Is a feeding tube needed?

     • Hydration- Is animal hydrated? If patient not drinking enough use SQ's SID or BID

     • Hygiene- Patient should be cleaned especially after eliminating, brushed and all wounds treated, avoid pressure sores.

     • Happiness- Is pet joyful and interested in family, toys and surroundings? Is pet depressed, lonely, anxious, bored or afraid? Move pet's bed to area where the family is to avoid isolation.

     • Mobility- Can pet get around? Does she need human or mechanical (cart) help to get up and move? Does she want to go for a walk? Is she or he having seizures or stumbling?

     • More Good Days Than Bad- When there are too many bad days in a row then quality of life is compromised. When a healthy human-animal bond is no longer possible then the caregiver must be made aware that the end is near. The decision needs to be made if the pet is suffering. If death comes peacefully and painlessly, that is okay.

Every pet hospice program should strive to satisfy each of these factors. Each parameter is measured from 1 to 10 (10 being the best). A score of at least 5 on each parameter is acceptable for a decision to begin or continue a pet hospice program. A score of 35 or greater, the pet caregiver is justified in continuing Pawspice (pet hospice). Careful monitoring of each parameter by veterinarian and caregiver is essential. If the parameters are not met to continue pet hospice care, the owner and veterinary professional must discuss euthanasia and or the probability that the pet will die peacefully on their own, unassisted, without struggle or distress. It is helpful to inform the owner about what they will see when their animal begins their transition into a natural death. For example, the owner may see the following things associated with their pet's dying process:

     • Seeking cold- In nature, dying animals look for a cool place. Animals know that death will come faster if the body is cool

     • Restless- May not want welcome the owner's touch, in nature, animals die alone.

     • Eyes become vacant

     • Mouth may be open

     • Respiration - panting, then slows down

     • Gasping or gagging

     • Body movements

     • No movement or violent movement

     • Comatose

     • Flinching, flailing

     • Gulping

     • Urination, defecation or bleeding

     • Stretching out of legs as they pass

Dr. Alice Villalobos cautions the veterinary community to be watchful of owners going too far. Euthanasia is often warranted and can be the final act of compassion that we can offer our pets. Ideally, euthanasia should be done in the owner's home so the pet can be in familiar surroundings with their family close by providing reassurance and comfort. Owners prefer this as well as it is very difficult and painful for them to pack up their beloved pet and travel to the veterinary clinic for their final good bye. Either way, the pet owner should be apprised of what to expect when their pet is euthanized. Additionally the pet should be given a strong sedative prior to euthanasia. This allows the pet to relax as well as the owner. If the euthanasia takes place in the home, the veterinary professional should be prepared to take care of the pet's remains if necessary. This is another valuable service that can be provided to the grieving client. Often owners are often distressed and offering to take care of their pet's remains can be a gift of kindness. If a veterinary practice cannot provide home euthanasia then the client should be referred to a house call veterinary service when possible. If the owner must bring their pet to the veterinary practice for euthanasia, the practice should be able to provide a comfortable, private space for the pet and family to say good-bye. If a separate "quiet room" cannot be dedicated for euthanasias, then an exam room can be converted over to a comfortable space by adding a dimmer switch to lower the lights, having comfortable chairs and a soft blanket on the table. Wickless candles and soft music can add tranquility to the room. Preparing the staff and room ahead of time is very helpful for the ease of the process. The veterinary staff should be trained in grief and support techniques. This not only helps the client but also is beneficial in the staff's grieving process. Rotating the staff members who assist in euthanasia is recommended especially if the staff member was close to the pet hospice case. Provide grief support information to the client including a list of support groups and contact information for a mental healthcare professional. After the pet's passing, the veterinary practice must always acknowledge the client's loss. This can be accomplished by sending out a condolence card with a personal note, making a donation in the pet's name to a local animal shelter, humane society, or veterinary school. Remember to keep in touch with the client by following up with phone calls to see how the family is doing. The veterinary professional pledges to care for pets from the "cradle to the grave" and always welcomes new beginnings for pet owners. Providing veterinary hospice care for a client's pet will give the practice a client for life.

Bibliography and references

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