CONCEPTUALIZED HOSPICE FOR PET’S LAST DAYS: PET “PAWSPICE“
Alice E. Villalobos, D.V.M., VCA Coast Animal Hospital and Cancer Center,
Hermosa Beach, CA, 90254
As pets get older, the bond between them and their human caregivers grows stronger. In this millennium, cancer will touch one in every three people and over half of their senior pets. Organ failure will claim the lives of the other half of senior pets. It is time to rethink how the profession will help pet owners face the final days with a terminally ill best friend. Most pet owners have preconceived notions about cancer and its treatment. Obvious biases and ingrained feelings regarding cancer may cause a negative approach towards its treatment in geriatric pets. Case by case, veterinarians and their professional staff must overcome the defeatist attitude about cancer therapy by dispelling negative notions, one by one.
If the pet’s illness can’t be treated due to financial constraints or a logistical problem, it is still a matter of good professional service to compassionately provide advice and home care giving instructions. When a treated pet’s cancer has recurred, if it is resistant to further treatment or if the pet is in the terminal stages of cancer, in home hospice care is a wonderful next step that keeps pet and caregiver comfortably close to their nest. A well conceptualized, creative, palliative pet hospice (Pawspice) for pet owners may be the very best care that medicine can offer to support the people pet bond. Veterinarians and their staff can kindly and respectfully help sustain a quality life for the terminal pet during the last days of the people-pet bond
When a pet is injured, gets sick, gets old, or has arthritis the question of home care comes up. How much care is a pet owner willing to provide to an ailing pet? From this author’s personal experience with treating cancer patients in California for 30 years, it can be stated with authority that the answer to this question is very personal and it may have no limits. Each pet owner has unique personal life style and tolerance considerations. After an initial consultation with the primary veterinarian and a thorough consultation with a specialist regarding options for curative treatment or palliation, the owner will struggle with finances, logistics, love, guilt and grief. Then they either accept the challenge to treat their pet’s illness or decline therapy. It is crucial that veterinarians refrain from being judgmental at this touchy time. It is kind to continue educating and offering options that may be more palatable for the owner to incorporate into their routine. It is also important to refrain from suggesting or insisting on euthanasia as the next best option if the pet is not treated as initially recommended. Let the pet owner know that pain relief and ways to make the pet more comfortable is available while they are trying to make a decision regarding therapy. Many clients have complained that the initial veterinarian was too quick to recommend euthanasia, or that the veterinarian seemed to insist things be done as an “all or none” method because the pet’s prognosis was poor for recovery or it was suffering or its disease was incurable.
Some pet owners feel that they would be unable to handle the thought of giving daily injections of insulin to a diabetic pet or giving a daily injection of fluids under the skin to a pet with failing kidneys. The idea of using a feeding tube for nutrition during recovery from lipidosis, or after an oral surgery or during radiation treatments to the oral cavity may sound like heroics to one person and make perfect sense to another. It is truly important to always speak to the caregiver in a tender, unhurried fashion as that person is most likely under a tremendous amount of personal, financial and emotional stress.
Home care for a pet that can’t walk or eliminate is a task certain pet owners have chosen to tackle with the help of Pampers, pet wheel chairs, egg crate mattresses and ramps. Families will even acquire portable oxygen tanks for pets with compromised respiration. Some people react with fear of medical procedures and needles. Others have great interest in learning how to administer to their pets for convenience and needed financial savings. The most important ingredient to look for in oneself, in the staff and in the pet owner is willingness. Hold a staff meeting and ask the question if being a compassionate veterinary care giving facility is truly O.K. with the nursing staff. Put one special staff member as the appointed support person for a certain pet and its owner. Ask the client to direct phone calls and concerns to their designated staff member or support team. Staff can handle most of the home care problems and the doctor can see the pet on regular rechecks to answer major questions such as changes in prescription medications.
The nation is very impressed with the concern and care that the Hospice across America program has provided for people who are dying. Veterinarians can win the loyalty of their clients by emulating the philosophy of the Hospice in honor of that special bond that connects people to their pets. This may help keep our profession more celebrated in the eyes of the public. Unlike the Hospice Movement for people, the veterinary profession won’t be able to send in technicians with free bereavement counselors, hospital beds, oxygen, free meals and wheel chairs. However; from exam room consultations, veterinarians and staff can gracefully provide the education needed for the efficient home care of ailing pets. Education that facilitates the control of pain and the art of providing good nutritional and hydration support gives the caregiver ability to care with expertise. They have more time to let go slowly and carefully. Many tender private moments of quiet emotion and sweet conversation are shared between the caregiver and the dying pet.
The most important factors to educate home caregivers to confidently monitor are: quality of life, minimal pain, adequate nutrition, hydration and respiration and detection of sepsis. With training from the veterinary staff, home care may be almost like being in the hospital. Ask the question, “If this pet owner were trained to take the pet’s temperature, administer subcutaneous fluids and provide the proper medications and sufficient food , can this pet have some well being and live longer at home?” If the owner is instructed to create some frequent, routine fun (doing the pet’s favorite things), the pet may even cheer up and look forward to the events. Ask the pet owner if he/she is satisfied with the arrangement. It is also important to determine with oneself and the staff if it feels rewarding or at least satisfactory to help preserve the bond between this person and this pet. If these ingredients are present, then pet hospice (Pawspice) is a good experience for all involved.
Ask the pet owner if they have experienced the amazing help that the American home hospice care movement has provided for a terminally ill friend or family member.
Despite the lack of financial support from national fund raising campaigns, the veterinary profession can emulate the concern and care exemplified by the hospice concept. Veterinarians can win client loyalty by respecting and preserving the special bond that connects clients to their pets and keeps this profession so celebrated. If the veterinary team helps peacefully to control pain and to provide nutrition in a hospice way, client-caregivers gain confidence. They also gain courage for themselves.
PRACTICAL IDEAS FOR SOME SPECIFIC DISEASE CONDITIONS
Renal failure patients fed special modified diets such as Hill’s K/D or Select Balance, Modified Diet, may survive well if supplemented with educated home care which includes: subcutaneous fluids, Tumil-K, Pepcid, Amphogel, tissue salts, vitamins, fatty acids (safflower oil or fish oils). Regularly scheduled recheck profiles can monitor renal function, acidosis and anemia. Epogen may be used to bring low PCV levels back up to normal. One cat in this author’s practice survived six happy years at home on daily subcutaneous fluids passing away at age 22.
Diabetic pets who belong to reluctant, needle-shy owners need the option of their veterinarian feeling comfortable about offering oral hypoglycemic medication. One can expect good clinical results with oral medication in one third of diabetics that have no ketones in the urine. Clients feel that their veterinarian is trying to help the pet while prioritizing their own concerns. If hyperglycemia is not controlled with oral medication, the owner may be more inclined to try injectable insulin as a second choice.
Anorectic pets often need to be hand fed. People need to learn the proper technique to best hand feed their ill pet. Cats like their food warmed to body temperature. Squamous cell carcinoma of the tongue in cats renders the tongue stiff and useless and causes early starvation despite efforts to eat. When a pet can’t or won’t eat, the placement of a percutaneous esophageal feeding tube may be performed under a short anesthetic with minimal risk. The procedure has been described by Rawlings, JAAHA, 1993, 29: 562-530. After the esophagosotmy feeding tube is in place, the pet needs to be fed successfully a few times in the hospital. It is essential that a discharge appointment be scheduled for a demonstration on how and what to feed the pet. If a helpful nurse, whom the owner may call for further instructions, gives this demonstration, the client is more at ease during the first few days with the feeding tube. The diet and supplements for feeding must be spelled out to avoid clogging the tube and to ensure the pet is getting enough calories and liquid to maintain body weight. If the tube gets clogged, instruct the owner to use Coca-Cola to dissolve the clog. Create a schedule that spells out the morning and evening times for medications, chemotherapy, amounts of fluid, feeding volumes and supplements on a written daily calendar. This written schedule helps to clarify the day’s work order for the home caregiver.
Nasal cancer patients with facial deformity and night stridor may be palliated with combinations of NSAIDS such as piroxicam or carprofen and evening sedation with burtorphanol.
Osteosarcoma cases that are not amputated can be palliated with walking casts to prevent pathological fractures, ramps to get in and out of the car, into the house and on the bed. The use of piroxicam at 0.3mg/Kg once daily for pain control may actually yield a rare remission on a sporadic basis as shown by Knapp and workers at Perdue. Carprofen with caution about hepatotoxiciy in debilitated dogs may also help control pain. The cautious use of Fentanyl patches may also be very helpful for in home end of life pain control.
Degenerative myelopathy or paralysis often includes a wide range of resourceful home care items such as the above mentioned ramps along with slings, chest and rump lifts, canvass suspension hammocks, wheel carts, etc. Foot covers that are made with cloth or canvas help to prevent abnormal wearing and ulcers of the metatarsals, pads and metacarpals.
Decubital ulcers are avoided in recumbent animals if thoughtful planning ahead includes pads, waterbeds and egg crate mattresses, all with washable covers. Frequent and complete cleaning of the pet’s coat and skin is important if the pet is soiling itself with urine or feces. If the pet is out doors, extreme caution must be taken to prevent fly strike and maggots especially for the long hair breeds.
Transitional cell carcinoma cases will live many months on therapy. It helps to put diapers or Pampers when the pet is in the house and keep the bed close to the doggie door. This helps the family to endure the problems of stranguria and pollakiuria. If the hematuria is severe enough to cause extreme blood loss, measures to control the blood loss are in order. Mix a 1% solution of formalin with a vial of the topical ear solution, Synotic, which contains DMSO, and instill into the bladder with a urinary catheter. Keep the mixture in the bladder for 10 to 15 minutes and then void and flush out the clots. This palliative procedure may reduce the hematuria for 7-10 days and it may be repeated as needed.
Brain tumor patients that are having seizures may be able to stay at home with confidence and with fewer emergency visits if given instructions to use injectable diazepam introduced into the rectum as a suppository for seizure control.
Severe vomiting may be controlled with Zofran injections. On one rare occasion, this author dispensed injectable atropine to help a Great Dane that had unresponsive vomiting and salivation and a low budget owner. Care should be taken to provide liquid tears while using atropine in this fashion, especially in breeds susceptible to KCS.
Severe pain may be controlled with injectable nalbuphine. This drug offers pain control without the typical sedation effects that accompany most powerful pain medications. Nalbuphine doses range from 0.5-1mg/kg SQ. every 3-4 hours in dogs and 0.2-0.5mg/kg in cats SQ. every 3-6 hours as needed. This pain medication is not under the controlled substance regulations and may be of great value in pain control at home for end of life care patients.
“Chemoprevention” may be presented as palliative care for pawspice candidates. According to Dr. Philip Bergman of M.D. Anderson Memorial Cancer Center, chemoprevention involves the use of natural or synthetic compounds that may reverse or suppress the process of carcinogenesis, metastasis and recurrence. Nutritional advice and a nutraceutical supplementation program that underscores cancer prevention for treated, untreated or terminally ill cases may be professionally supervised. This service creates further client confidence that the primary care veterinarian is helping as much as possible. Animals that have received surgery or chemotherapy or radiation therapy that are still considered to be at great risk for recurrence are definite candidates for the pawspice concept because they are actually expected to die from their disease within 4-12 months. Dogs with osteosarcoma, hemangiosarcoma, adenocarcinoma, lymphoma and cats with breast cancer, vaccine associated sarcoma, lymphoma, IBD, FeLV and FIV all fall into this category.
Technician house calls may be set up for those who are unable to deal with administering injections and fluids to the ill pet. The reception staff can be made aware of which pets are on Pawspice programs so as to be sensitive to the owner’s calls.
Pet Loss Group Sessions can be very helpful for the most affected individuals.
We recommend that the family read the new AAHA book, PETS LIVING WITH CANCER: A PET OWNER’S GUIDE by Robin Downing, D.V.M.
Networking is also a big help. Give the phone number of another client who is providing the same type of Pawspice care so they can have the opportunity to share their experience with the newcomer. Dr. Kathleen Carson and Christine Grey, both from this author’s facility, actively participate in a Chat Room for Chronic Renal Failure cats on AOL (America on Line). This informative chat room opens every Sunday evening at 5:00 p.m. Pacific Standard Time. Tell clients to look for the private chat room, “CRF”.
This type of net working is very helpful and is a staff time saver.
Day care for ill pets can be provided by the primary care veterinarian. This service may be the key to sustaining a Pawspice for the working pet owner. Convenient delivery and pickup times that revolve around the owner’s schedule may be prearranged.
EUTHANASIA FOR THE PAWSPICE PET
Many pet owners want their beloved pet to pass away at home. Unfortunately for them, the slow decline of a sick pet may be too difficult for the family to accompany all the way to the end of the pet’s life.
There are many questions such as, “How will I know when the time comes?” The answer to this question rests with the pet. Advise the family that their pet will give a sign such as unrelenting vomiting, diarrhea, crying, a moribund state or more bad days than good days. When the time approaches for the pet to be humanely euthanized, the emotional pain for the family may be softened if they know that the procedure can be performed at any time of the day or night. Arrangements must be made that cover the patient’s care 24 hours a day. Referrals for house calls, night calls and after hour emergency room facilities need to be set so that the decision time for euthanasia is made on behalf of the pet, not the doctor’s office hours. When the time comes for the emotional pain of euthanasia, caregivers who are in a Pawspice program are enabled to make the best decision for the pet. If they are going to bring the dying pet to a facility for euthanasia, instruct them to bring the pet’s favorite blanket and a candle and family or friends and other pets to share in the final goodbye. It helps create a gentle atmosphere if the overhead lights can be softened. One suggestion is to turn off overhead lights and leave the x-ray viewer lights on in the exam room. The candles can also be lighted at this time.
The next step is to sedate the pet in the presence of the owner. This lets people relax while the pet gently falls into sedation. A deep intramuscular injection of dormacetin or butorphanol-ace in the presence of the owner is given. This allows that big first step to be an easy step for the family to see their beloved pet falling into a relaxed sleep. At this time it is kind to ask if each person in the room wants to stay for the final injection. Many families are content to leave their pet in the sedated state with complete trust that the next step is painless and fast. If family members are present towel may be placed over the pet’s body covering the chest area up to the neck. At this time it is this author’s preference to give the final euthanasia solution I.C. while the family lovingly strokes the pet’s head. Many institutions prefer I.V. euthanasia with I.V. catheters preplaced. However, it seems somewhat traumatic to take near death pets away from their grief stricken owners into the backroom in order to place indwelling catheters, which may involve a struggle. Most near death pets are often anemic, hypovolemic or hypotensive. If catheter placement causes any struggle or discomfort in the last few minutes of life for the near death pet, it is honestly too difficult for this author, let alone caring staff members, to repeatedly witness, even if the owner is not present.
After the family members are gently assured that their pet’s heart has stopped beating, it is appropriate and thoughtful to encourage them to stay and view the deceased pet. Compare this special time to the custom of having a little wake as they do for human family members. This author feels that there is not enough reverence, service, ceremony or support offered to the family on the occasion of death of the family pet by the veterinary profession in general. As recognition of the overriding importance of the bond that holds clients to veterinarians becomes common place across the country, more hospitals will set aside softly lighted rooms for pet wakes upon the occasion of a pet’s passing. This is the time to read poems and talk compassionately about how important and sweet this dear beloved pet was. It is highly recommend that the caregiver and children write a few words about who this pet was and what was their special relationship all about. Often a small lock of hair can be placed it in a windowed envelope with the date and the pet’s name and given to the family as a souvenir. This author likes to read Rainbow Bridge and a few poems from ANGEL PAWPRINTS, the wonderful anthology of pet memorials edited by Laurel E. Hunt, available from Darrowby Press, 3510 Thorndale Rd., Pasadena, CA, 91107. This book can be left in the room so the family may have private time to read poems and grieve alone with their deceased pet. Every five or ten minutes, it is wise to check in on the family and see if they need any assistance. We again recommend that writing a story or a few paragraphs about the pet would be helpful in the grieving and closure process. This is also the time for making a plaster imprint of the pet’s paw (available from the Argus Center at CSU).
POST EUTHANASIA FOLLOWUP
We send one or two sympathy cards with staff notes and signatures. It makes sense to ask for pictures of the pet and encourage the bereaved clients to get back into the love cycle again and adopt a homeless pet. A genuine invitation for the pet owners to come back and visit with cookies and pictures is extended.
A call to the family a week later to ask how things are going help the bereft family. If they are troubled, a very helpful tip can be given that encourages tears and grief feelings to be limited to 30 minutes a day preferably in the morning or the evening. It is good to tell person that they are missed and to encourage them to hurry back into the people-pet bond and adopt another loveable pet as soon as they feel up to it.
SIR WALTER SCOTT: ON A PET’S LIFE SPAN
A favorite short poem by Sir Walter Scott can be read to caregivers when they start a “Doggie Pawspice.” It is taken from Laurel Hunt’s book. With one changed word it can include cats and other species of pets.
“I have sometimes thought of the final cause of dogs (pets) having such short lives and I am quite satisfied it is in compassion to the human race; for if we suffer so much in loving a dog (pet) after an acquaintance of ten or twelve years, what would it be if they were to live double that time?”
Bergman, P., Chemoprevention, Proceedings of the 1999 ACVIM Forum in Chicago.
Choen, S. P. and C. E. Fudin, eds. “Animal Illness and Human Emotion.” Problems in Veterinary Medicine, 3, No. 1 (March 1991).
Downing, R., Pets Living With Cancer: a Pet Owner’s Resource, AAHA Press, April 2000.
Hoskins, J., Feline ‘Triad Disease” Poses Triple Threat, D.V.M. Newsmagazine, February 2000, p.4S-7S.
Hunt, L.E., Angel Paw Prints: An Anthology of Pet Memorials, Darrowby Press, 1998.
Lagoni, L., Morehead, D., Butler, C., The Bond-Centered Practice: The Future of Veterinary Care, Proceedings of the 1999 ACVIM Forum in Chicago.
Ogilvie, G.K., Hospice and Bond Centered Practice: The Future of Veterinary Care, Proceedings of the 1999 ACVIM Forum in Chicago.
Ogilvie, G.K., Moore, A.S., Managing the Veterinary Cancer Patient: A Practice Manual, Veterinary Learning Systems, 1995.
Rawlings, JAAHA, 1993, 29: 562-530, Percutaneous Placement of a Midcervical Esophagostomy Tube: New Technique and Representative Cases.
Villalobos, A. E., Oncology Outlook, Those Stubborn Cats That Won’t Eat, August 1999.
Villalobos, A. E., Oncology Outlook, Pet Hospice Nurses the Bond, VPN, September 1999.
Villalobos, A. E., Oncology Outlook, On Bladder and Prostate Cancer, VPN,January 2000.
Villalobos, A. E., Oncology Outlook, Chemoprevention: Can Food Fight Cancer? VPN, March 2000, p. 48.