- What is hospice or End-of-Life care?
- Why should this interest the AAH-ABV?
- The History of Hospice
- Veterinary Hospice Concepts and Applications
What is hospice or End-of-Life care?
Hospice is a system which provides compassionate comfort care to patients at the end of their lives and also supports their families in the bereavement process. It includes comprehensive nursing care as well as psychosocial and spiritual care for the patient and family. Hospice is built on the nursing model, in contrast to the medical model of care. Hospice is not about heroic medical interventions that prevent quality of life in a pointless attempt to prolong it.
Why should this interest the AAH-ABV?
Back to topThe striking similarity is in hospice’s respect for the patient’s quality of life and the AAH-ABV’s interest in the human-animal bond. At the end of a pet’s life the quality time with the family is precious to them, and helps them cope with the approaching death of their pet.
In addition, hospice care for animals is a welcome additional option at the end of life. It is an alternative to premature euthanasia. It is also an alternative to prolonged suffering either in the isolation of intensive care or at home without treatment.
The History of Hospice
Back to topThe modern human hospice movement began in the early 1970’s as an alternative for terminally ill patients dying in hospital intensive care undergoing heroic but hopeless treatment. A brief description will help veterinarians unfamiliar with hospice understand the rationale and major guiding principles.
Hospice care for terminally ill patients is characterized by recognition that the life expectancy is less than 6 months. Approximately 50-70% of hospice patients have cancer. Staging of cancers and statistics on large numbers of patients contribute to making semi-accurate predictions of life expectancy. The focus of care is on sustaining the highest quality of life for whatever time remains. A majority of patients remain at home with family, pets and familiar surroundings instead of being hospitalized.
Hospice care encompasses the family and patient, unlike traditional medicine which focuses on the patient and the disease in isolation from considerations about family and friends. Hospice services provided to family members include psychosocial counseling, spiritual counseling, respite care to give primary caregivers time to rest and recharge, and bereavement counseling and support groups for survivors after the patient’s death.
Hospice care is provided by a multi-disciplinary team, not a single professional. A team includes nurses, psychosocial counselors, home health aides, a medical director, a chaplain, and volunteers. Each member of the team is called in as needed and patient assistance is available 24 hours per day. Coordination and communication among the team members is a vital operational requirement.
Hospice care includes significant emphasis on pain management as well as other supportive medical care, with the goal of providing comfort care (opposed to cure). The patient’s condition may continue to be treated, but heroic measures causing significant loss of quality of life are avoided. The patient often signs “do not resuscitate” orders so that emergency medical personnel are not obligated to attempt resuscitation.
Patients are frequently referred to hospice by their primary physician when the physician recognizes that the life expectancy is less than 6 months.
- The hospice philosophy is to have the patient and family acknowledge the immanence of death. The patient and family then begin to make realistic plans for maintaining the highest quality of life for whatever time remains.
- The second aspect of hospice philosophy is expert medical care. The medical director uses every resource to keep the patient free of pain and minimize side effects. Hospice nurses and staff carry out the prescribed care and nursing interventions.
- A third key concept is that the unit of care is the family. Psychosocial counseling and support are an important element of hospice care, and this care for the family continues up to a year after the patient’s death.
In conclusion, providing hospice care for veterinary patients improves the quality of their final days and is also a great support to the client family as they face the loss of their pet. The challenge to veterinary medicine is to adapt the techniques developed in human medicine and learn to skillfully apply them in the appropriate setting.
Veterinary Hospice Concepts and Applications
Back to topThe first difficulty to be faced by veterinarians is making a prognosis that the patient is terminal. The human hospice guideline of a life expectancy of 6 months or less is probably too long for many veterinary situations. Using the ratio of average human years to dog years, 6 months is equivalent to approximately 1 month. While hospice care would certainly be appropriate during the final month of life, it may be appropriate for much longer in some cases.
The veterinarian must first recognize that the patient is terminal and that hospice care is a better alternative then further heroic attempts at cure. This step is complicated by the veterinarian’s emotional investment in the case’s good outcome, which may make it more difficult to admit the true circumstances as early as is optimal. In addition to determining the appropriate time to make a switch to hospice care, a second problem is that there is no veterinary hospice to which a referral can be made. The same veterinarian must re-evaluate the patient care plan from an entirely different perspective.
Once the veterinarian determines that hospice care should be considered, the primary caregivers (owners) must then be informed about the choice. In some cases this will come as a relief to clients who have already recognized the impending death of their pet. Other clients may not yet be ready to face reality or give up hope for a cure.
Helping reluctant clients choose between ever intensifying medical treatment, hospice care or euthanasia is a difficult task calling for much sensitivity and care. It is important to thoroughly explore with the client all the options and their medical and financial consequences as a part of this preparation. It may be necessary to give the client time to think about the options and discuss them with family members before making a decision.
A particularly useful idea is to have the client think through the issues and describe their preferences long before they are faced with the real decision. This might be termed “pre-need” counseling, and veterinarians might encourage clients to complete a form similar to the advanced directive now required at human hospital admission.
In terms of providing comprehensive hospice care, the veterinarian is most prepared to fill the role of medical director. Pain management and relief of signs are the major emphasis. Hospice care is becoming a specialty in human medicine, which indicates the potential for advancement and new knowledge about treatment techniques.
The veterinarian, veterinary technician and clients should jointly develop a plan of care to address relief of pain and management of signs. Clients should be made aware of various techniques which might be employed, and their limitations. They should be advised of signs indicating pain, side effects of the medical conditions and treatments, and anticipated complications as the patient’s condition declines. Clients may need to decide if euthanasia is still an option, how the pet’s remains will be treated after death, and other details of care and memorialization.
Home nursing care and respite care can be provided by veterinary technicians and hospital personnel, but veterinarians are probably not the best providers for the other aspects of hospice care. Psychosocial services to the immediate family should be provided by people with credentials in that field. An ideal veterinary hospice care team would include employees and volunteers from the local human hospice. Spiritual counseling is another critical aspect of hospice care, and should be available to a veterinary hospice patient’s family members. The unexpected death of a much beloved pet can cause intense personal grief and could precipitate a spiritual crisis as well. There are two cautions to consider: first, the care must be provided by a team that is well coordinated and has good communication. Secondly, the spiritual and psychosocial counselors on the team need to be selected for both their professional competence and also their sensitivity to the human animal bond. A blind referral to an insensitive counselor could do more harm than good.
Back to topGuy Hancock, DVM, MEd