Will hospice care become a standard part of practice?
Kath Dyson qualified from Glasgow in 1989. She then spent several years in small animal practice, going part time in 1996 due to ME. Eventually retiring from veterinary practice in 2009 she moved into human health and social care as a part time home care worker/home help.
In human healthcare, modern hospice and palliative care, pioneered here in the UK, is now mainstream, although it has taken several decades for this to happen. Care of the terminally ill and dying is a core subject in the medical curriculum, as well as being a recognised and evolving speciality. The work of charities like Marie Curie and Macmillan is well known. Tesco supported the ‘Help the Hospices’ campaign, and ‘Children’s Hospice’ has been on the TV. A 2008 poll of British Medical Journal readers asking ‘which project would make the greatest difference to healthcare’ (of all projects worldwide) found that ‘palliative care for all at the end of life’ received the most votes*. There is also high profile political support for better access to palliative care, for all who might benefit (probably most of us at some point).
In veterinary medicine, an increasing number of vets now offer this type of service, mainly in America but also more recently in the UK. Most do so by offering palliative and hospice care and euthanasia as a mobile service to people’s homes.
Kath Dyson
Over the last 25 years there has been a lot going on in the USA in the development of animal hospice care. The American Veterinary Medical Association Guidelines on Veterinary Hospice Care were first published in 2001 and renewed in 2007. The International Association for Animal Hospice and Palliative Care formed in 2009 and the ‘Veterinary Clinics of North America’ published a ‘Palliative Medicine and Hospice Care’ issue in 2011. There have been a number of symposia and conferences including, or, in the past decade, devoted to these subjects in the US, with more coming up all the time, and there are various resources and courses available including online webinars and chapters in various textbooks.
Here in the UK, the ‘BSAVA Manual of Canine and Feline Rehabilitation, Supportive and Palliative Care’ was published in 2010, and BSAVA Congress included a session on palliative care.
Despite the overlap between human and animal hospice there are some obvious differences. In animal hospice it is the pet’s owner who takes on all the financial, practical and emotional costs involved, whereas human patients have a lot more support available. Euthanasia is always an option in veterinary medicine, and indeed euthanasia of an animal can legally be carried out by anyone, so long as it is done humanely.
The aim of animal hospice is for the terminally ill patient to remain free of pain and distress and, when the time is right, for the animal to die peacefully whether by euthanasia or naturally, and it takes into account the needs of the whole family.
Regarding natural death and euthanasia, there is some debate within the animal hospice movement about these topics and various shades of opinion. Some regard euthanasia as more of a last resort, with hospice assisted natural death being seen as preferable and only a minority of patients requiring euthanasia. Others feel that euthanasia is more often likely to be the preferable outcome of a period of hospice care in the animal patient, even though they do not rule out a natural death. All these options would be fully discussed with the client in either case, and remain flexible depending on the changing situation of the patient.
The human surgeon and writer Atul Gawande describes the helplessness human doctors often feel when faced with incurable patients, and how palliative care can help. ‘These are patients with untreatable disease,’ he says ‘and yet palliative specialists have been remarkably successful at helping them. The key is simply that they take suffering seriously, as a problem in itself’**
Vets have always taken suffering seriously, and additional expertise in end of life care could help the profession to be even better able to provide truly lifelong care to all their animal patients.
*www.bmj.com/campaign/making-difference
**Atul Gawande ‘Complications- a surgeon’s notes on an imperfect science’ Profile books 2003 p143
Saying no to palliative medicine/animal hospice care is also saying yes to substandard care and compromised animal welfare – or premature euthanasia! Why not have it all and have better clinical outcomes and client satisfaction – ultimately reflected at the bottom line?
Excellent blog piece and topic of the month which diligently highlights the essential components of animal hospice and why attention to the end of life in the form of adopting lessons learned from the human hospice movement, can potentially improve animal welfare and widen client satisfaction when faced with yet a terminal pet situation. With animal hospice or palliative medicine (same thing depending on expected outcome) clients can be offered an actual compassionate, gentler alternative to either aggressive treatment or premature euthanasia – unlike now. As a UK practising in-home hospice vet I know very well after more than 5000 end of life consultations that offering a “third option” would be inclusive of the diverse client base and ensure a much more empowered, happy and not least returning client as they feel allowed to also make a fully informed and compassionate choice and not pressurised to choose only between “either or” solutions from opposite ends of the treatment spectrum – and if not wanting these sent home with nothing or at best a tub of Rimadyl and come back when “he is not happy” or when “it’s time” – as if clients are naturally equipped to maneuver such potentially complex parameters when left to their own devices – or worse by consulting “Dr Google”.
Palliative medicine or animal hospice basically hemp to bridge the wide gap between the two extremes and is a far more inclusive practice philosophy to better cater for the diverse client pool while increasing animal welfare – not the opposite.
Sadly, I find too many clients come to my hospice practice dissapointed that their own (trusted) vets didn’t offer more than the two options and thus many an otherwise loyal, satisfied client is “lost” in this way at the very end. We now know that 20% even deflect to a new “better” practice after this type of experience with their new pet (OnSwitch survey, 2014)
After many heartfelt conversations with thousands of clients, left at “the alter” at this seminal end stage, I truly believe that if we as a profession do not fully embrace palliative medicine (equal to animal hospice when outcome is terminal) and incorporate this as a valid, clinical option bridging the vast space between aggressive therapy and premature euthanasia, the outcome is poor animal welfare, client attrition, missed business opportunity and risk of substandard care at the end of life as owners “take their animals home” anyway but are left unassisted to fend for themselves.
We as the highly regarded profession we are, can do better and should take lessons from the hard earned hospice successes from our human counterparts and realise animal hospice IS also the way the “wind is blowing” as more and more pet owners want this for themselves, their relatives and therefore also for their furry family members – but thankfully we as vets also have the added bonus of the “gift of euthanasia” as the ultimate outcome once comfort is no longer possible – but not before! Let’s continue this debate to make this one last lasting memory a good one – for everybody!
Susan Gregersen, Hospice & Emergency Vet, Founder & MD Vets2Home – Peaceful Pet Goodbyes
Well said Susan! I was surprised that the majority of vets seem to have voted ‘no’ to the question of providing hospice-type care as standard. This makes absolutely no sense to me! On what grounds do vets object?
Margaret
I suspect part of the answer to your concerns as to why vets say no to formalised palliative care relates to their personality type.
It is a huge generalisation I know, but the profession has more than its fair share of type A personalities. And this type requires total control of a situation and is willing to assume responsibility for all the outcomes.
Type As are not necessarily perfectionists, but they do need to feel they are doing as much as they can for a case. And in this current climate of EBVM, giving treatments – either more and more surgery, or more and more drugs – has what EBVM measures as positive outcomes.
As yet, EBVM is unable to define and measure welfare – that remains overly subjective and falls into the “Art” rather than the “science” of VM.
Additionally, clients’ relationships with their pets is changing – many no longer regard their pet as an animal so much as a partner, or member of the family. This is partly facilitated by their abrogating responsibility for their pets’ welfare to the veterinary surgeon directly – expecting the vet to be the sole arbiter of how much and for how long, and then to finally take possession of the decision for euthanasia. For a vet to suggest palliative care maybe read (by the vet themselves) as a cop-out rather than a positive recommendation.