Mary Gardner and Dani McVety
Mary Gardner, DVM, and Dani McVety, DVM, have focused on geriatric medicine, hospice, and in-home euthanasia since 2010 and founded Lap of Love Veterinary Hospice, the nation’s largest group of veterinarians dedicated to end-of-life care. Lap of Love helps over 1500 families per month and has been featured on The Doctors and in the New York Times, USA Today, and the Associated Press, as well as numerous veterinary trade publications. Drs. Gardner and McVety speak frequently at national and international conferences and veterinary schools on many topics, including body language, communication techniques for doctors, and care of geriatric veterinary patients.Read Articles Written by Mary Gardner and Dani McVety
Almost every time the door opens, we are greeted by a crying client. Because we are veterinarians who limit our practice to in-home hospice and euthanasia, grief is something we anticipate and encounter daily with families. In those moments, we give a warm smile, a gentle handshake, and, in many cases, a big hug.
Dealing with end-of-life treatment is an emotionally fragile time for pet parents, but guiding them through this phase can be rewarding and also provides valuable medical care to the pet, while strengthening the bond your client has to your clinic. In the January/February 2016 issue of Today’s Veterinary Practice, the article, Handling Euthanasia in Your Practice, discussed how to provide the most comforting care to both pets and their owners during the euthanasia process.
While the majority of pet owners request our service for euthanasia, there is a growing demand for veterinary hospice care, both within our practice and in general practitioners’ offices. However, veterinary hospice is still misunderstood, even within our profession. We are often asked by clients, “What is veterinary hospice? Isn’t that prolonging the inevitable (or suffering)?”
Before we delve into defining veterinary hospice, it is important to first understand what hospice is not: It is not prolonging suffering, nor is it euthanasia or natural dying. Hospice is a medically supervised service dedicated to providing comfort and quality of life for the pet (and support for the owners) until euthanasia is elected or natural death occurs.
Hospice is most commonly a service for the advanced age pet suffering from disease, such as the 13-year-old Labrador retriever struggling with mobility issues or the 16-year-old cat with heart failure. However, hospice is not just for senior pets; it is for any pet facing the end of its life.
Hospice may be needed for the puppy with distemper, the 5-year-old cat with unmanageable diabetes, or the 6-year-old boxer with osteosarcoma. While the younger pet may be managing the signs of its disease satisfactorily and its quality of life may still be adequate, the family knows this precious time is limited. Regardless of the age or disease, when quality of life is decreased and euthanasia is being considered, hospice services are appropriate.
Hospice Services in Practice
When you have a client facing the end of his or her pet’s life, you should be able to discuss and offer hospice services within your clinic. Using the word hospice to describe this care helps families realize that their pets are at the end of their lives and long-term management or curative options are no longer being pursued. Many times just the use of the word hospice is a relief to pet owners.
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 blood analysis checked every 6 months (to evaluate long-term nonsteroidal anti-inflammatory drug [NSAID] administration), don’t threaten to cease medical treatment. Instead, take these measures to ensure the family feels supported, comforted, prepared, and not financially burdened:
- Educate the owner about potential NSAID side effects, highlighting the importance of presenting the pet for treatment if any adverse effects are noted.
- Have the owner sign a liability waiver refusing blood analysis in order to protect you and your practice.
- Help the owner plan a compassionate approach to end-of-life care for his or her pet.
Within your clinic, agree—among doctors and the support team—that, if a case is marked as “hospice,” the family can elect euthanasia at any time without the need to go through the pet’s entire medical history with the attending doctor. The clients should feel supported by the entire team without the requirement to defend the choice to say goodbye.
In the same manner that veterinary clinics provide pet owners with a puppy/kitten package at the beginning of a pet’s life, clinics should also make available detailed end-of-life information for clients. Some items to provide to pet owners include:
- Handouts about various diseases, with detailed information about the illness affecting the pet, including end-stage clinical signs. Some examples can be found at lapoflove.com, in the Education section.
- Daily diaries that describe appetite, thirst, urination, defecation, mobility, and clinical signs of disease, which are important details to monitor while a pet is in hospice care because these activities help determine overall quality of life.
- Quality of life scales, which give a measurable value to owners. 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 (see Assessing Quality of Life).
- Adjunctive services you support and trust (preferably mobile) in the area, such as acupuncture, massage, mobile grooming, and in-home pet sitting (which is also a great opportunity for technicians).
- Local pet loss groups or grief counselors (a local human hospice can be a valuable referral source).
- Emergency clinics in the local area if your clinic does not offer 24-hour emergency care.
- Information on natural death, specifically what occurs during the process (see Handling Euthanasia in Your Practice, Today’s Veterinary Practice, January/February 2016, available at tvpjournal.com).
- Specific euthanasia information, including:
- When and how to schedule euthanasia at your clinic, and 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. For example, “rescue” pain medication can be provided to help the pet through the night if emergency care is not available or possible.
- Aftercare information (owners need to plan ahead), including services your clinic provides and their prices.
- Local pet crematories or cemeteries, or services that can pick up the pet from the home after it has passed.
The most commonly requested hospice service is the consultation. Clients are often greatly appreciative for even 30 minutes with a veterinarian to discuss what to expect and how to manage his or her pet’s disease and its progression. Communication, preparation, and more communication are the hallmarks of a successful hospice case.
Many families wish to keep their pets alive for as long as possible, while also maintaining good quality of life, but simply don’t know how to manage this. They feel helpless. Sometimes a client calls our practice and says, “It’s not time for euthanasia yet, but I would like to be in your system or know what to expect.” We know this is a call for help and the perfect opportunity to offer a hospice consultation.
As veterinary hospice practitioners, we are able and willing to help extend life as long as pain and anxiety are controlled. These actions are always preceded by a lengthy discussion about the progression of the disease process and a clear “stop point,” which we and the clients agree is the ending of a good quality of life. Stop points are often specific to the pet and its past behavior; they can be used as individual points or combined to guide decision-making.
Following are some examples of stop points we have used with families:
- When a pet’s resting respiratory rate is more than 60 breaths per minute 3 times during the day.
- When the pet refuses a hamburger.
- When the pet does not try to attack the vacuum cleaner and has refused french fries in the same day.
The most important thing clients need to know is what they risk if they wait too long before choosing euthanasia, which is why education about their pet’s disease progression is crucial.
Hospice consultations almost always take longer than normal appointments, so be sure to schedule at least 30 minutes with the clients and charge appropriately. In a clinic, this consultation can be done with or without the pet present.
Assessing Quality of Life
“Doc, when is it time?”
This is a fair question, and deserves attention and time for discussion with your clients. The answer is not as simple as saying, “When he stops eating, it’s time,” or “She will give you ‘the look’ and you will know.” Although those can be good indications, sometimes they are not. Do we, as the veterinary team, know exactly when the time has come for euthanasia? Not specifically, so why would we expect our pet owners to just “know”?
Assessing quality of life, and teaching owners how to do so, are integral parts of hospice appointments. There are many tools available that can assist owners with evaluating the pet’s quality of life. Here are some websites with good information:
- Pawspice.com: Click on Services tab; then select Quality of Life Care and Quality of Life Scale
- Lapoflove.com: Click on Quality of Life tab
- Pethospicejournal.com: Free, interactive site.
Each of these websites provides a variety of tools that can help families subjectively and objectively gauge quality of life. These tools typically ask the owner questions that pertain to signs of the pet’s quality of life, such as appetite, hygiene, attitude, pain, and interaction with owners and other pets. The owner then assigns a score to each sign; the scores are tallied up and the total score determines if palliative care is appropriate or end-of-life options should be discussed.
When an owner fills out a scale daily or weekly, it is easier for them to identify changes in the pet’s well-being, and the scale provides a tangible number that serves as the stop point—the point at which the pet no longer has a good quality of life.
We also provide a list of questions that gauge the owner’s feelings toward end-of-life care (available at lapoflove.com), including what scares the owner and specific goals he or she has in mind, plus a variety of other questions that help us understand the impact that end-of-life decisions will make on the owner and family.
Examples of pet owner goals include helping the pet:
- Live comfortably until a certain date, such as the holidays or when a family member returns home
- Sleep comfortably for 4 or more hours per night, with 2 or less vomiting episodes per week
- Be as pain free as medically possible, while still enjoying life as a dog/cat.
Today’s Veterinary Practice : Pain Assessment & Management
Find these articles on pain at todaysveterinarypractice.com:
- Strategies for Managing Cancer Pain in Dogs & Cats (May/June 2015, Jan/Feb 2016)
- Acute Pain in Cats: Treatment with NSAIDs (May/June 2014)
- Assessment of Acute Pain in Cats (Jan/Feb 2014)
- Managing Chronic Pain in Dogs & Cats (Nov/Dec 2013, Sept/Oct 2014, Nov/Dec 2014)
- Assessing Chronic Pain in Dogs (Sept/Oct 2013)
Palliative care is a key component of hospice service. The 5 most common areas of palliative care are:
1. Pain Management
Providing adequate pain medication is vital, and evaluating its effectiveness is just as important. In our practice, we also equip owners with an “emergency intervention” that they can provide to their pets. For example, the client with a dog with osteosarcoma or severe degenerative joint disease should leave your clinic with a dose of injectable pain medication and instructions on administration in case of a pathologic fracture. That way, the pet can have some relief while the next steps are organized.
Teaching owners to recognize pain can be challenging. Colorado State University has validated pain scales to help assess both acute and chronic pain; to download these scales, visit todaysveterinarytechnician.com, click on Archives from the Issues tab drop-down menu, and then select the March/April 2016 issue of Today’s Veterinary Technician.
2. Anxiety Control
Many dogs that are painful or suffer from cognition issues are up all night panting and pacing, keeping their owners awake as well. Providing medications that help pets sleep through the night decreases their anxiety level and is appreciated by everyone in the home. In addition, anxiety and distress can change pain perception and the pain threshold, which may exacerbate the pet’s pain level and make pain management even more difficult.
If the anxiety is caused by pain, then pain should be addressed with appropriate pain control (see Today’s Veterinary Practice: Pain Assessment & Management). If the pet is anxious due to cognition issues and separation anxiety, the Table provides common starting protocols in our practice.
3. Hygiene & Infection Control
Urinary and fecal incontinence are often a problem for geriatric pets. Although incontinence may not affect quality of life drastically, some pets do become anxious when they have accidents in the house. The human–animal bond is tested, and infection or urine scalding can occur. The pet should be kept clean with sanitary grooming and/or shaving, baby wipes, diapers, waterproof bedding, low-sided litter boxes, and frequent walks.
4. Nutritional Support
Some diseases lead to decreased appetite. While appetite stimulants are useful at times, often their effectiveness decreases quickly. Many owners are willing to cook for their pets, so providing nutritious recipes with alternating protein sources can be helpful. However, many ill and/or senior pets have specific nutritional needs; therefore, consultation with a board-certified nutritionist is recommended when creating personalized diets for these pets.
5. Nausea Control
Pets dealing with certain illnesses or on some medications will become nauseated. It is best to control nausea proactively so that the pet does not stop eating, which may cause even more issues. More information about nausea and appropriate medications can be found in the article, GI Intervention: Approach to Diagnosis & Therapy of the Vomiting Patient (March/April 2013), at tvpjournal.com.
Once patients matriculate into your hospice program, do not let them slip through the cracks. Based on the pet’s disease process and current quality of life, you can often estimate the length of time the pet will spend in hospice.
In our practice, if we have a patient in the early stages of hospice, we request monthly updates via email or phone. However, if the pet’s decline is advanced, weekly or even daily updates are needed. This allows consistent monitoring of the effectiveness of treatment, progression of the disease, overall quality of life, and the owner’s wishes.
Once the initial hospice consultation has taken place, follow-up visits may be handled by a trained technician in your clinic who is:
- Educated on the end stages of disease
- Informed about the end-of-life care the owner has chosen, including the agreed upon stop point
- Comfortable providing advice and informed recommendations
- Confident communicating with the veterinarian about disease progression and patient quality of life.
In Your Practice
Creating a hospice package is a good starting place (see Hospice Handouts). Additional steps include:
- Educating your team on proper ways to assess quality of life
- Developing hospice protocols
- Marketing the services to your clients.
Hospice service demands a team approach, and everyone in the clinic needs to be involved and find ways to improve this avenue of care.
When dealing with hospice patients, or any geriatric pet, you may want to consider the following in your practice:
- Ensure visits are free from pain or distress: Practicing Fear Free techniques (see The Value of the Fear Free Initiative, January/February 2016, available at todaysveterinarypractice.com).
- Ensure owners feel safe to discuss their wishes: Marking the case as “hospice” means owners do not need to defend their choice of euthanasia to anyone at your clinic. They will feel safe to ask for help and not wait too long.
- Remember that geriatric or sick pets are fragile and brittle: Proper handling techniques are important. Be mindful of holding techniques, create a restraint policy, and set expectations for clients and the veterinary team.
- Provide a peaceful ambient environment: Ensure a minimal amount of noise, odors, and distractions.
- Ensure proper cage/kennel set up: Kennels should be comfortable with padding, slip-proof flooring, and something from home. For dogs experiencing incontinence, mesh sling beds that allow urine to drip through help keep the kennel clean.
- Encourage visiting hours: If an aging pet is in your hospital for treatment or boarding for more than a day, encourage visitation. The joy the pet and owner experience is priceless.
- Offer specialized boarding: Create a special boarding program for geriatric or hospice pets that includes specialized cage/kennel set up, visiting hours, twice daily pictures, and updates.
- Utilize a low rider stretcher: Use this stretcher for dogs with mobility issues when they go for walks to relieve themselves or get fresh air.
- Provide in-home technician visits and care: Seeing pets in their own environment is important, as they act differently in their home surroundings. More important, modifications can be made that may have been overlooked, and treatments can be done in the home without a distressing trip to your clinic.
While offering veterinary hospice may not provide the largest avenue of revenue, the long-term benefits are immeasurable. The satisfaction your clients will experience with the full circle of veterinary care at your clinic will be priceless. This positive experience will lead to word-of-mouth referrals and repeat business with other pets owned by that client. Most important, it is what is best for the pet.
When families have a better end-of-life experience with their pets, they heal more quickly from the debilitating emotional loss. Pet owners are better able to cope with their decisions and feel confident in their ability to care for their pets, encouraging them to open their homes and hearts to pet ownership again.
Iaahpc.org. Emerging group for all members of a pet hospice team.
Lapoflove.com/education/common-diseases. End-of-life information on common diseases seen in hospice practice.
Pethospicejournal.com. Free resource for clients to track progression of their pet’s condition.