By Jeannine Miesle MA, AAV
Part 1: History / Introduction
Part 2: Pain Perception and Signal Reception
Part 3: Pain Signal Transmission and Pain Pathways
Part 4: Types of Pain, Long-term effects, Referred Pain, and Pain Memory
Part 5: Pain, Stress, and the Body’s Physiological Response to Them
Part 6: Pain in the Avian Species
Part 7: Anesthesia and Analgesia, Chronic Pain
Part 8: Quality-of-Life Issues
Part 9: Pain Assessment in Birds / Quality of Life
Part 10: Hospice and Palliative Care for Pets, Strategy for Comprehensive Care, & Conclusion (Please scroll down)
Part 10: Hospice and Palliative Care for Pets
Many of the ideas in this final chapter will not pertain to birds, but some do. The reader will determine which is applicable to his situation.
Human beings grow old, and many require long-term care. A growing number of people are seeking the same type of care for their pets as is given to people in their end stage of life. The goal of palliative and hospice care in veterinary medicine is the same as it is in human medicine: to relieve suffering and enhance the quality of life for the pet and the family. Up until recently, euthanasia had been the only option in the treatment of advanced illness. Now, veterinarians realize they have another options in the treatment of the pet: palliative care and hospice. Due to the advances in veterinary medicine, pets are experiencing extended life and improved quality of life.
Hospice refers to a facility or program designed to provide a caring environment which provides for the physical and emotional needs of the terminally ill. Palliative care focuses on the relief of suffering in order to achieve the best quality of life for the patient, regardless of the disease outcome. The two services overlap as the patient approaches death.
Owners who are unprepared for the death of their pets tend to grieve longer and more intensely than those who are prepared due to the strength of the human-animal bond. Veterinarians who are aware of this will prepare their clients early in the disease process for the inevitable end of their pets’ lives. Failure to do so does their clients a disservice. However, it is important that care be taken not to discuss hospice and palliative care while the illness is still treatable. Only after diagnostic tests are performed, treatment is attempted and fails, and symptoms grow worse should the clinician discuss palliative care with the client. Accurate diagnostic and prognostic information will aid in the transition from curative treatment to supportive care, and then from palliative to hospice care. If the veterinarian is interested in provided such care for his patients, he will need to be a good listener, be patient, and be empathetic with the client. He will also need good time-management skills. Not every veterinarian is willing to provide such care; therefore, the client should ask about this possibility of it if this is what he wants for his pet in the end.
The following circumstances preclude the choice of administering palliative or hospice care:
- A decision not to pursue curative treatments
- Diagnosis of a terminal illness
- Diagnosis of a chronic illness
- Symptoms of a chronic illness that are interfering with the routine of the pet
- Disease process in which curative treatment was possible but failed
- Difficulties that require long-term intensive care
- Illnesses that are progressive
- Trauma or diseases that have health complications associated with them
Clients should be given the following information:
- Physical examination findings
- List of all complications
- Assessment of quality of life
Hospice and Palliative Care Protocols
The “Pet Hospice and Education Center” in Sunbury, Ohio has developed a Five-Step Strategy for Comprehensive Care.” It is important to have such a protocol to make sure all details of care are provided. Because every pet’s condition and family relationship is different, a protocol assists the veterinarian and the family when they share information and discuss the pet’s care.
Five-Step Strategy for Comprehensive Care
Evaluation of the pet owner’s needs, beliefs, and goals for the pet. For the program to be successful, the care given by the veterinarian must be consistent with the beliefs of the pet owner. The program needs to be individualized for each client and each pet; therefore, the foundation upon which the care is built rests upon the communication between client and practitioner. The client may not wish euthanasia, or may not want the pet to be hospitalized, so alternatives need to be provided. It is not unusual for pet owners to abandon their original palliative or hospice care plan and pursue additional treatment in the hope of a cure.
It is also not unusual for the client to change his mind about the course of treatment or the option of euthanasia. Should the owner choose to have the dying pet given extraordinary care, such as esophageal feeding tubes, he should be advised of the risks of such procedures. Most of the time, these efforts are futile and merely serve to prolong the pet’s discomfort. Does the owner wish to track the disease process with testing? Where will the pet spend its time, in the hospital or at home? Are there alternative therapies for this illness? Final event details should be discussed with the owner. Does the owner want the pet to die at home or at the office? What will be done with the body? There are several options for handling the remains, and the client should ask about this ahead of time.
Step 2: Education about the disease process
The veterinarian should be familiar with the disease process and share this information with the owner. The owner will need to be informed about life expectancy, symptoms of the disease, and common side effects. This will allow the owner to make better choices on his pet’s behalf. An accurate diagnosis is vital before initiating a hospice plan. He should also discuss the complications of any treatments provided. A discussion about the owner’s financial concerns is also in order. The owner should not be made to feel guilty if he cannot afford the long-term treatment or hospice care. The option of euthanasia should always be offered.
Step 3: Development of a personalized plan for the pet and pet owner.
This plan is based upon the previous discussion about the family’s beliefs and desires for the pet. The plan should take into account the management of the symptoms of the disease, the willingness of the pet to take medications, the ability of the owner to dispense the medications, and the pet’s reactions to the stress of hospital visits. As the pet’s condition deteriorates, there will be a transition into hospice care. For this to happen, the family must acknowledge that the pet is actually dying and showing no improvement or worsening, even with medical help.
The veterinarian my come across dilemmas regarding the treatment choices because of the side effects of some of the medications. Such interventions may have negative consequences. For example, a medication which will alleviate pain my also risk death because of respiratory depression, but the importance of controlling pain overrides the other concerns. Nutrition should be addressed. If the pet is not able to eat on its own, it might require feeding tubes. These options should be discussed with the pet owner. Another challenge the veterinarian faces is that of treatment of wounds. There is the pain of the wound itself and the pain associated with the caring for the wound. In these cases, pain medication should be given one to two hours before the wound treatment.
Many of the medications given during the hospice and palliative care experience produce unwanted side effects; in addition, many will react adversely with each other. The client needs to be aware of the possible side effects of these drugs.
Medication Side-effect List for Clients:
A rapid decline in condition, especially after starting a new medication
Restlessness, excitability, (salivation, licking of the lips for mammals), or trembling after administration of a medication
Lack of appetite or vomiting after being given medication
Change in bowel movement consistency, frequency, or color
Development of skin irritation or itching
Development of depression or disorientation of administration of a medication
Step 4: Application of Palliative or Hospice Care Techniques
The pet owner should be able to carry out any directives given for the care of the dying pet. A support team member for the owner should be available to contact when problems develop in carrying out the techniques.
The pet owner should be taught how to carry out the palliative techniques to provide comfort to the animal.
Techniques should be demonstrated by a professional then performed by the client under staff observation.
Compounded medications should be provided
A list of medication side effects should be given to the client.
Step 5: Emotional Support during the Care Process and After Death
End of life is defined as the period when death is imminent. Before and during this time, the pet owner needs to be able to interpret the pet’s quality of life. Veterinarians should have a system to evaluate the pet’s physical comfort as well as the emotional well-being of the pet owner in the decision process. The clinician needs to describe the dying process, whether by natural causes or by euthanasia, with the pet owner. (When euthanasia is chosen, it is a two-step process: First, a tranquilizer is given to put the pet to sleep, then the drug is given to stop the heart. The veterinarian should always use the stethoscope to make sure the heart has stopped completely before declaring the animal dead.)
If possible, an emotional support system for the owner should be implemented before the end of the pet’s life. It might mean calling on the services of medical advisors, clergy, psychologists, social workers, or volunteers who have training in human palliate and hospice care. This team approach ensures that every need of the client is met. There should also be a list of pet-loss support groups to which the pet owner can refer if need be. For many people, depression and grief can impact their lives for a long time.
Any veterinarian should be able to use this philosophy of palliative and hospice care. The role of the veterinarian and staff in the palliative and hospice care of the dying patient is extremely important. The client is in a vulnerable state and relies heavily on the clinician’s information and advice when making decisions about his pet’s care. A solid, relationship-centered plan will relieve the suffering of the pet and enhance its quality of life. It will also provide the needed emotional support system for the owner at this difficult time. Long after the death of the pet, the owner will remember the many kindnesses of the veterinary professional and his staff.
Shearer T. Hospice and Palliative Care. In: Handbook of Veterinary Pain Management, Ed. Gaynor J and Muir W III. Mosby, Inc. 2009.