Palliative medicine and hospice care, the third option
Article Outline
Palliative medicine and hospice care has become a new area of interest, expertise, and opportunity in companion animal practice. It is a philosophy of care that supports good quality of life for pets with life limiting diseases as they and their families face the challenges associated with their illness.
What happens when a veterinarian diagnoses a life-limiting disease in an elderly dog or cat and medical or surgical intervention is indicated, but the owner just cannot afford it, or for other reasons, the owner simply does not want it? Are veterinarians obligated to provide hospice and palliative care? Actually, social ethics and the American Veterinary Medical Association (AVMA) policy statements say yes. AVMA Guidelines for Veterinary Hospice Care states, “Veterinarians or veterinary hospitals that are unable to offer hospice care should be prepared to refer clients to another veterinarian who can offer these services. Referring this activity does not infer that excellent care is not being delivered by the referring veterinarian, but provides more options for the client desiring to access veterinary hospice.”1 Palliative medicine and hospice care is indeed a viable third option that should be offered to clients when neither premature euthanasia nor aggressive medical treatment is desired or wise.2
Planning
The program components will vary, reflecting each veterinarian's personal preferences, and foremost in importance is choosing which medical services to provide. Much of this care can take place through consultations or a house call practice so that the patient may remain at home. Full service hospitals offer more options for palliative medical or surgical interventions and advanced diagnostics, but it is difficult in hospitals to offer the relaxed environment of home. An existing space could be renovated to create a comfort room or a new facility could even be built (Fig. 1). Even options like daycare services for debilitated patients with working owners are possible. Referral may be necessary to offer acupuncture, chiropractic, rehabilitation, and advanced pain management. A veterinarian wanting to offer palliative and hospice care should never be restricted because of physical constraints or the inability to afford a facility. It is the philosophy of care that is important, and core concepts can be applied in any location or combination of locations.3
Figure 1.
Pet and owner benefit from a comfort room, and home nursing services provided by veterinary technicians are an essential component of animal hospice.
(Courtesy of Amir Shanan, DVM, Chicago, IL)
The hospice team consists of veterinarians, veterinary technicians, assistants, volunteers, social workers, clergy, and bereavement counselors. An interdisciplinary team is necessary as support and care must be available 24/7. The fee schedule should be based on the time invested by the veterinarian and staff in caring for the pet. Most pet insurance companies will honor claims for medical care.3 Seeing patients outside the office setting does add liability issues,3 but legal issues that arise in context of veterinary hospice are not much different than those that arise with other types of small animal practice.4
In terms of marketing strategy, the palliative team should meet with personnel from area emergency clinics, referral clinics, and local primary care practices to explain services and alert them that they are available. A press release could be used to announce to pet owners that palliative and hospice care exists in their community.3
Implementation
The following 5-step strategy for comprehensive palliative and hospice care will aid in insuring the provision of appropriate care.5
Evaluation of the pet owner's needs, beliefs, and goals for the pet
Past experiences with pets, people, and disease conditions typically influence these. The use of hospitalization, home care, or a combination of the 2 should be decided. Medical testing to track the disease is discussed at this time. Recommendations for outside professionals, such as oncologists, pain management specialists, rehabilitation practitioners, acupuncturists, nutritionists, and alternative medicine specialists, can be offered. Financial concerns are expressed at this point. The family's beliefs about death and dying and what they prefer for their own pet's death should be explored, i.e., euthanasia, natural death, and will they be present?5
Education about the disease process
Discussions concerning the disease trajectory and the specific disease, nutritional support, and how to recognize and manage clinical signs help with planning care and understanding the dying process associated with different illnesses. Death by this disease should be explained. Education and preparation for death and dying should start at the beginning of a palliative or hospice care plan.5
Development of a personalized plan for the pet and pet owner
Based on psychosocial beliefs of the family and the pet's daily activities, the veterinarian sets up a plan that preserves quality of life and lessens adverse effects of the disease. The veterinarian must consult the other team members, correctly balance care and adverse effects of treatment, and ascertain how much support the pet owner can contribute. Arrangements for 24-hour care are made, treatment options are chosen, and the home care environment is set up. Preparation for death includes close monitoring for evidence of suffering, respecting the owner's choice for natural death or euthanasia, and being ready to advocate for the pet if there is a failure in care.5
Application of palliative or hospice care techniques
The owner should be taught techniques by the support staff, and medications should be reviewed as to use, frequency, and adverse effects.5
Emotional support during the care process and after death
This is one of the most important steps in palliative and hospice care. It begins the moment a pet is diagnosed with a chronic or terminal illness and is carried out by veterinary staff, social workers, psychologists, and bereavement counselors.5
Quality-of-life assessment is integral to the successful delivery of palliative and hospice care and imperative to decision making. How do veterinarians and family members know when a pet's quality of life is good or bad? Dr. Alice Villalobos, veterinary oncologist and hospice authority, has designed the HHHHHMM Quality of Life Scale. It is scored on a scale of 1 to 10 and evaluates the following criterion: hurt, hunger, hydration, hygiene, happiness, mobility, and more good days than bad.2
Conclusion
Client interest in well-managed end-of-life care plans for their beloved pets is increasing, and practitioners should consider initiating a palliative and hospice care program to meet that need.
For information and guidance, consult these excellent resources:
References
- . Guidelines for veterinary hospice care. American Veterinary Medical Association Web site. (Online) April 2011. (Cited: July 17, 2011) . http://www.avma.org/issues/policy/hospice_care.asp
- . Quality-of-life Assessment Techniques for Veterinarians . Vet Clin N Am Small Anim Pract . May, 2011;41:519–530
- . Delivery systems of veterinary hospice and palliative care . Vet Clin North Am Small Anim Pract . May, 2011;41:499–506
- . Legal concerns with providing hospice and palliative care . Vet Clin North Am Small Anim Pract . May, 2011;41:661–676
- . Pet hospice and palliative care protocols . Vet Clin North Am Small Anim Pract . May, 2011;41:507–518
PII: S1041-7826(11)00174-5
doi:10.1016/j.asams.2011.12.001
© 2012 Elsevier Inc. All rights reserved.
