Bridging the Gap Between Terminal Illness and Euthanasia
Mary Gardner, DVM, and Dani McVety, DVM
With the increasing number of positive experiences families have with human hospice, they are open to similar care for their aging and/or terminally ill companion animals. The veterinary team may not be able to cure such a pet, but they can help the owner maintain the animal’s quality of life, which is not only important for the welfare of the pet but also the human—animal bond.
Although veterinarians and the veterinary team may not be able to cure a pet dying due to terminal disease or old age, they can certainly help the owner keep the pet comfortable, clean, and happy, which is important, not only for the welfare of the pet, but for the human—animal bond.
With the increasing number of positive experiences families have with human hospice, clients are open to similar care for their aging or terminally ill companion animals. The challenges the veterinary team face when implementing this beneficial (and profitable) service are how to properly introduce the:
- Medical aspects of companion animal hospice care
- Ancillary services that complement medical care and improve quality of life.
We define hospice care as: A family-centered, medically supervised, and team-oriented service dedicated to maintaining comfort and quality of life for the terminally ill pet until a natural death occurs or the family elects euthanasia.
It’s important to note that natural death is not the goal for veterinary hospice, it is simply a reality for many terminally ill pets whether they are in hospice care or not. The main purpose is comfort of the pet before death, whether from natural death or euthanasia. This care can take place in the clinic or home: the home is often preferred because it is where pets are most comfortable; however, education and medical direction begins at the clinic.
Using the word hospice to describe this care will help families realize that their pets are at the end of their lives and unable to be cured. Many times just the use of this word is a relief to pet owners. This terminology also illustrates that comfort and quality of life are the most important goals for these pets.
When describing hospice care, it’s helpful to use the MMM approach: medicate, meditate, mitigate.
- Medicate includes assisting the client in identifying, predicting, and treating pain and anxiety in his or her pet during hospice care.
- Meditate encompasses the discussions and education the owner will receive during the difficult time leading up to natural death or euthanasia.
- Mitigate refers to death or “end of suffering.” Presenting it to clients in the latter way helps them realize that end of life also means an end to severe pain and poor quality of life.
COMMON REASONS FOR HOSPICE
Lack of mobility is one of the most common reasons clients seek hospice care from veterinarians in our organization. Making the pet comfortable is a priority and the veterinarian can provide many therapeutic and environmental options, including:
- Medical therapy (NSAIDs and other pain medications)
- Physical therapy (heat therapy, massage)
- Complementary medicine (acupuncture)
- Household and handling improvements (nonstick flooring and slings).
Owners need to understand that there is no cure for certain disease conditions and, at some point, they will be faced with either comprehensive nursing care of their pets or mitigation of suffering.
Cancer (of all types) is another common reason hospice patients require our care. The terms oncology and chemotherapy can cause pet owners to feel anxiety and uncertainty. The veterinary team needs to encourage owners to consult an oncologist to determine whether their pets may benefit from chemotherapy.
The most common elements of hospice care for cancer patients include:
- Pet owner education and discussion about:
- Type of cancer, associated signs and conditions, and disease progression
- Therapeutic options and prognosis
- Pain assessment and provision of appropriate pain management
- Proper nutrition.
- Assistance with therapy once a treatment plan has been developed.
- Administration of gastrointestinal protectants (for patients receiving chemotherapy), appetite stimulants, and any other medications needed to treat secondary clinical signs.
Renal failure is another common ailment seen in pets requiring hospice care.
Although not typically considered painful, renal failure is uncomfortable and can lead to severe nausea, vomiting, diarrhea, dehydration, anorexia, and anemia. Pain medications, especially those given transmucosally, such as buprenorphine, can be of great benefit in some patients.
Hospice therapy should also include:
- Diet changes
- Fluid therapy
- Appetite stimulants
- Client education about disease progression.
THE FOURTH LIFE STAGE
Historically, veterinarians have been taught the 3 life stages of cats and dogs: kitten/puppy, adult, and senior. However, there are actually 4 life stages; the fourth being the geriatric stage.
The Senior stage (end of adult life) commonly describes pets that have simply grown old but remain active, eat well, and have a good quality of life. However, this stage is also when pets typically develop debilitating diseases, and the clinical approach is to diagnose, treat and, if possible, cure the disease. Both the veterinary team and pet owner want to extend this stage as long as possible.
The Geriatric stage usually finds the pet experiencing some kind of ailment associated with old age. These patients are generally frail and more likely to suffer a cascade of diseases instead of a single one and, therefore, are also on one or more medications for management/treatment of these conditions. The veterinary team and pet owner are no longer trying to cure diseases but, instead, keep them from causing quality-of-life concerns.
Both medical therapy and client communication/education are different when the pet reaches the geriatric life stage.
- Therapy: The main focus of medical therapy is comfort of the pet.
- Education: Clients need information on their pets’ long-term prognoses and disease progression in order to understand what to expect when the final stages occur.
- Support: Veterinary teams need to be sensitive to clients’ wishes with regard to medical care for their pets. Some clients cannot afford and/or do not want to put their teenage pets through extensive medical workups and/or invasive treatment, but they do want them comfortable.
- Preparation: Clients need to prepare themselves emotionally, physically, and financially for the care their pets require and the end-of-life decisions that will be faced.
Note that, while this discussion is focused on senior/geriatric patients, younger pets may also require hospice care. The points discussed above apply to all hospice patients, no matter what age.
Hospice services and treatments can be provided on an outpatient basis or in the client’s home.
- Specific treatment for disease process
- Supportive medical therapy, including pain and antianxiety medications and subcutaneous or intravenous fluids
- Nutritional support, including appetite stimulants and alternative feeding strategies (eg, tube feeding)
- Physical therapy, including moist heat therapy, massage, and laser therapy
- Complementary medicine (eg, acupuncture)
- Client education, including how to administer medications and fluid therapy and foods to feed when pet’s appetite is waning
- In-home evaluation: Provide suggestions for reorganizing the household for senior pet mobility/safety, such as:
- Barricading stairs
- Moving food bowls
- Using nonslip surfaces
- Improving traction by shaving hair between pads or using traction booties
- Diapers or chux pads (“puppy pads”)
- Waterproof bedding (baby mattresses are an alternative to expensive waterproof dog beds)
- Baby powder, waterless shampoo, and shaving hair around the perineal area help keep pets clean and comfortable.
- Life enrichment: Keeping the pet’s mind active and alert can make a huge difference in quality of life. Owners can simply change typical pet games:
- Instead of tossing the ball in the back yard, roll the ball to the dog while he is in bed.
- Long walks can be replaced with an inside activity, such as “hide and seek,” a game many dogs enjoy.
- Pets with a high food-drive may love a Kong toy (kongcompany.com) filled with their favorite treats or unique bowls (aikiou.com) that encourage them to seek out food in compartments.
Many pet owners do not take vacations or leave town because they worry their pets won’t receive appropriate care or may pass while they are gone and also do not want to burden the interim caretakers. Offering senior/geriatric boarding can alleviate these fears and can include:
- Putting nonslip mats in cages
- Locating pet in the main treatment room so the veterinary team can monitor the pet carefully
- Using slings for walks and making sure pet gets walked often (if pet is mobile enough)
- Providing daily updates (phone/email/text) to owner and sending pictures.
The American Veterinary Medical Association (AVMA) recommends that if a veterinary clinic is not able to provide hospice care, that the clinic should refer the pet owner to a veterinarian or veterinary service that offers hospice options.
The AVMA views veterinary hospice as care that will allow a terminally ill animal to live comfortably at home or in a facility, and does not believe that such care precludes euthanasia.
- The comfort of the animal must always be considered when veterinary hospice care is provided.
- As is the case in human hospice programs, patients must have a terminal illness with a short life expectancy.
- The veterinary hospice team consists of the veterinarian and trained staff who provide expertise in palliative care and pain control for terminally ill animals.
REACHING OUT TO CLIENTS
Don’t be afraid to discuss hospice and end-of-life options with clients. Owners are usually anxious and distressed when confronted with an aging pet and impending loss. The veterinary team can help these clients by asking about their expectations and fears as well as explaining the hospice process. It is important for owners to feel at peace when remembering the last few months of their pets’ lives.
Targeting Geriatric Patients
While veterinary clinics usually have a standard of care developed for patients 6 years and older (blood analysis, preventive procedures, etc), geriatric patients have different needs. In order to implement the geriatric/hospice care described in this article, the veterinary team needs to target these patients. This can be as easy as determining which patients are over the age of 12; and if these patients have not been to the clinic in the past year, calling the owner to discuss what care may be needed.
Keeping It Simple
Many pet owners with geriatric pets want to avoid stressing their pets as much as possible and may also have financial concerns. This includes avoiding unnecessary clinic visits and procedures. Therefore, an open discussion about the pet’s disease, appropriate medical therapy, and ancillary services, with the emphasis on quality of life, is one of the first steps in beginning hospice care.
It is important to avoid making pet owners feel guilty if they choose to cease treatment or decide against it. For example, if an owner decides against having his or her pet’s bloodwork checked every 6 months (to evaluate long-term NSAID administration), don’t threaten to cease medical treatment. Instead:
- Educate the owner on potential side effects, highlighting the importance of presenting the pet for treatment if any adverse effects are noted.
- Have the owner sign a liability waiver to protect you and your practice.
- Help the owner plan a compassionate approach to end-of-life care for his or her pet.
In the same manner that veterinary clinics provide pet owners with a puppy/kitten package, detailed end-of-life information for patients should also be available. Some things to include are:
- Disease sheets with detailed information about the illness affecting the pet, including end-stage clinical signs
- Daily diaries that describe appetite, thirst, urination, defecation, mobility, and clinical signs of disease, which are important things to monitor while a pet is in hospice care as they help determine overall quality of life.
- Quality of life scales help determine quality of life; the pet can be evaluated daily or weekly and ideally by more than one person in the family, which provides a more accurate evaluation of the pet. Make sure to teach the owner(s) how to accurately use the scale.
- Adjunctive services (preferably mobile) in the local area, such as acupuncture, massage, mobile grooming, in-home pet sitting
- Local pet loss groups
- In-home hospice and euthanasia services (if clinic does not provide these services), such as in-home evaluation, rechecks, diagnostics, fluid therapy, bandage changes, and prescribing/administering medication.
- Emergency clinics in the local area, if clinic does not offer 24-hour emergency care
- Euthanasia information, including:
- When and how to schedule euthanasia at your clinic
- If your clinic offers euthanasia in the home
- How to handle an emergency situation, such as nights or weekends, when a veterinarian may not be available
- Aftercare information, including services your clinic provides (and prices), local pet crematories or cemeteries, services that will pick up the pet at the home after it has passed, etc
Explaining the euthanasia process to pet owners ahead of time is extraordinarily important. Many people are very worried about making this decision. Careful planning and discussion of this challenging issue before their pet reaches this stage helps prevent miscommunication when the family is emotional.
- Open the conversation with “Do you have any questions about the euthanasia process?” or “Have you ever witnessed a euthanasia?”
- Discuss the medications that are used and what the owner should expect during the process.
- Explain that it is not ideal to wait until an emergency situation occurs to decide to euthanize.
- Instead, develop a plan that evaluates the patient’s health and quality of life regularly to help the veterinarian and client determine when it is time for euthanasia (or natural death).
Promoting open discussion about this difficult topic helps pet owners realize that euthanasia is not as dreaded as they may have imagined.
When providing hospice care, the veterinarian’s role is to properly evaluate the patient and educate the owner, all while remaining objective and nonjudgmental (within boundaries) of the desires and wishes of the family. The family or owner knows his or her pet best and will most likely have better insight into the animal’s quality of life. By approaching the hospice phase thoroughly and thoughtfully, the veterinary team will solidify their roles as animal advocators and compassionate individuals.
NSAID = nonsteroidal anti-inflammatory drug