Shortly after qualifying as a vet, Kathleen Cooney had to say goodbye to her family's labrador so she understood why some pet owners like to say goodbye to their pet at home. She later set up an at-home euthanasia service and a hospice and euthanasia centre, and is currently president of the International Association for Animal Hospice and Palliative Care Veterinarians in the USA
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VETS are regularly faced with the predicament of how to treat patients during the time that falls between the diagnosis of the final condition and death, particularly when aggressive treatment has been declined or is no longer in the best interests of the patient. Hospice care may be the answer.
Hospices provide a philosophy of care or a framework for decision-making by focusing on a patient's comfort rather than treatment when a cure is no longer expected. The goal is to maintain the animal's wellbeing and dignity at the end of its life. In a hospice, preserving quality-of-life takes precedence over extending life; it is not denial of treatment.
Human hospices recognise dying as a normal process, whether or not resulting from disease, and believe that patients in the last phase of life deserve care so that they might live as fully and comfortably as possible. Through appropriate care in a community that is sensitive to their needs, patients and their families may gain a degree of mental and spiritual preparation for death that is satisfactory to them. The patient's condition may continue to be addressed, but heroic measures are avoided.
Animal hospices also address the needs of the pet's caregivers and family members. By supporting the patient and family, the human-animal bond remains strong throughout the dying process. The vet's role as a patient advocate is vital at the end of an animal's life.
The services provided through animal hospice are case-dependent but can include a range of care (see box).
The International Association for Animal Hospice and Palliative Care Veterinarians believes that animal hospices can provide an alternative to premature euthanasia and to the prolonged suffering that may result either from isolating an animal in intensive care or from inadequate treatment.
Hospices are an under used tool in veterinary medicine. Until recently, end-of-life care was limited in its scope. After diagnosis of a life-threatening condition, caregivers have typically had to pick between three options: aggressive treatment; euthanasia; or limited palliative care followed by euthanasia once quality-of-life is no longer acceptable.
Few veterinary staff have experience in advanced end-of-life care and are uncertain about how to proceed. Educational opportunities in animal hospice have been few and far between but this is beginning to change.
Due to its all-encompassing nature, providing hospice services can also appear overwhelming. Human providers deal with this by taking a team approach and animal hospices may do the same. An animal hospice team might include: veterinarians (traditional and complementary providers); veterinary nurses; pharmacists; social workers; grief counsellors; pet loss support hotlines; chaplains/clergy; workers from the field of human hospice; pet sitters; volunteers; and the animal patient's human family members and friends.
For all but the largest veterinary hospitals, having people on staff who are trained to perform all of these services is untenable. However, making use of community members trained in aspects of animal hospice (eg, mental health or nursing support) allows vets, VNs and veterinary support staff to focus on the services they are best able to offer while ensuring the patient's and client's needs are met.
The team approach to animal hospice can alleviate the unease that some vets feel about relying heavily on families to provide the level of care needed to keep a terminally ill animal comfortable. All team members should learn how to assess key quality of life parameters and bring any concerns to the attention of the caregiver and the vet.
Animal hospice providers are becoming increasingly available in the USA. As of 2013, 200 services were listed in a directory of in home euthanasia providers, many of which offer home hospice care as well. When the attending vet is unable or disinclined to provide hospice services, referring the case to a local colleague who focuses on end-of-life care may be considered.
Another concern that can prevent some veterinarians from providing or referring patients for hospice care is the mistaken idea that pets in hospice cannot be euthanased when their quality of life becomes unacceptable. Euthanasia services should be available if the client and vet believe this humane act is appropriate.
The decision to enrol a patient in animal hospice should not be reached without proper understanding of its obligations. Everyone involved assumes responsibility for the animal's and family's wellbeing. Caregivers must provide superior care, and many clients will have limitations that make animal hospice too much of a burden. In these cases, euthanasia is appropriate when an animal's suffering cannot be relieved in any other way.
Client education is also vital. Caregivers need detailed information about the expected course of their pet's disease, how the palliative approach differs from the curative approach, and what services can be provided by vets already involved in the case and which are available via referral.
Increased emphasis on the use of teams is critical. The veterinary profession needs to reach out to social workers, chaplains, human hospice providers, and other knowledgeable individuals. The more stakeholders involved in animal hospice provision, the greater its reach and influence will be. With more community involvement, though, vets should remain the team's medical guide at all times.
Research into how to best care for animals nearing the ends of their lives is sparse. Recognising ‘end-of-life’ as an official life stage would help focus attention on the needs of this population. When the veterinary profession classifies patients as ‘dying’, it is all too easy to discount the value of their lives and fail to provide for their needs. In truth, our patients are living and may suffer as death nears.
According to the Nikki Hospice Foundation for Pets (www.pethospice.org): ‘The use of veterinary hospice care is to be considered as constituting good veterinary medicine in that it allows for a “good death” for the pet and consequently, “good” grieving for the client’.
This is a time of evolution and momentum within the animal hospice field. Lasting change will take time, but, by working together, we have the opportunity to improve the level of care a pet receives from the time it develops life-limiting disease to the moment the family says goodbye.
▪ Dr Cooney will be speaking on this subject at the London Vet Show in November.
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