Potential Elements of Hospice Care

No universally accepted definition exists for the term veterinary hospice.^5,6 However, hospice care overlaps with the issues and techniques described as palliative care, end-of-life care, and thanatology.⁷ Some key elements of hospice care are common to the end-of-life care currently offered by most veterinary practices. However, the movement to client-driven hospice care is associated with a wider variety of options related to the management of the animal's care. This typically will include 24-hour availability of the primary veterinarian, extended appointments involving supported decision making and counseling, in-home care, and a wide variety of palliative and euthanasia options tailored to the needs of the client. A more important but less tangible feature of hospice care is a strong and overt emphasis on maintaining a veterinarian-client-patient relationship that is supportive on the personal (eg, emotional, spiritual, and ethical) and medical levels. A focus on hospice care often requires veterinarians to develop working relationships with other, nonveterinary members of the hospice team, such as counselors, care-givers, and alternative practitioners. Veterinary practices should decide which elements of hospice care they are prepared to offer their clients.

At-home care—Unlike human hospice, veterinary hospice almost always involves caring for the patient in the home rather than in a dedicated facility, although residential hospice care is not unknown. However, this requires that the animal's owners be able to carry out necessary palliative care and recognize and respond to changes in the animal's condition.⁸ At-home hospice care gives family members more time to spend with the animal and may increase the animal's comfort and reduce any anxiety associated with being in the hospital. Veterinary practices should determine whether they can provide the necessary support for at-home hospice care and, if so, designate who will visit the animal's home for monitoring and providing treatments. Staff members sent to perform these activities must be qualified to do so if the practice is to meet the standard of care and avoid liability.

Euthanasia—Veterinary hospice includes diverse perspectives on and approaches to the issue of euthanasia. Some programs provide pet loss support assistance for owners after euthanasia, others provide structured support for family members as they recognize the need for euthanasia and make appropriate plans. Some programs support the family until death occurs without euthanasia, which may be at the client's request or a provision of the particular hospice program.⁶ The position that euthanasia should never or should only rarely be provided is particularly controversial. The AVMA Guidelines for Veterinary Hospice Care⁹ state, “Euthanasia service should be available if the client and veterinarian at any time believe this service is appropriate.” Most veterinarians consider timely euthanasia a part of hospice care. However, some favor natural death in most cases.

Residential hospice—Residential hospice programs offer hospice care to client-owned animals transferred permanently to the hospice center, whether a veterinary clinic or some other facility. However, having an animal cared for in an unfamiliar setting is a potential source of stress both for the animal and for the family. Residential programs may also take in unwanted, surrendered, wild, or feral animals and other animals outside of a traditional animal-owner relationship.^a

Potential Client Needs

Because the term hospice is used to refer to various types of end-of-life care, effective communication must take place to ensure that the needs of the client and patient are harmonious with the hospice philosophies and practices of the veterinarian.

Mitigation of animal suffering—A client's main concern may be that his or her animal is as comfortable as possible prior to euthanasia or natural death. The veterinarian has a responsibility to provide the best possible medical management of pain, nausea, and other conditions causing discomfort until death occurs.

Prior planning—Most clients should make important decisions about care and euthanasia prior to the onset of stressful disease conditions, whether prior to the diagnosis if possible or in the early stage of the disease. This would include decisions about how to care for a seriously ill animal, when to euthanize, and how to handle the remains. Given that most owners will eventually need to face the illness and death of their pets, veterinarians can make end-of-life decisions easier and less distressing by encouraging advance planning.^9,10

Support for informed decision making—After making a diagnosis of a serious or terminal disease, the veterinarian has a responsibility to provide comprehensive information about feasible treatment and care options and likely outcomes and, ultimately, to support the owner in making a plan for palliative care and euthanasia. Both clients and members of the veterinary team may want to continue aggressive treatment because of a strong bond with the animal or an unwillingness to admit failure.¹¹ The veterinarian should help the owner fully consider the animal's quality of life and how much it may be suffering¹² to ensure the most humane care for the animal can be pursued.

Veterinarians should develop a method for ensuring transparency and accord between the client's needs and the veterinarian's services. Clough¹³ has created a list of questions a client might consider when requesting hospice care to gain a realistic view of what to expect and whether the veterinary care team can meet the client's needs:

• • Do I accept that this is a dying animal and no more efforts will be made to cure its illness?

• • Have I discussed with my veterinarian my pet's medications and their effects?

• • Do I have enough time in my schedule to spend the necessary hours looking after my pet?

• • Does my family realize what home hospice care will entail?

• • Can I cover the projected costs of hospice care?

• • Are there sufficient veterinary staff personnel to support me and my family throughout my pet's disease course?

• • Will someone be available 24 hours a day if my pet's condition changes?

• • What is the expected outcome, how might death occur, and what arrangements will I make following my pet's death?

Grief support—Grief processes begin with the initial anticipation that the animal's death is imminent. An involved veterinarian may be able to detect severe grief—potentially complicated by other trauma, guilt, or depression—and provide or refer clients to appropriate aid. Grief counseling training for veterinary team members is advisable, especially if a practice plans to provide hospice care, in that even well-intentioned remarks can sometimes have an adverse effect on grieving family members. Practices not equipped to provide grief support should refer clients to pet loss support hotlines or local grief counselors.

Controversial Issues

Because the term hospice encompasses an increasing variety of end-of-life care philosophies and protocols, some veterinarians may find certain aspects of it controversial or problematic.

Natural death—Some individuals and groups in the hospice movement believe that animals should not be euthanized¹⁴ or should be euthanized very rarely and will actively support a choice to not euthanize an animal if the client wishes.¹⁵ Thus, veterinarians and clients must reach a shared understanding beforehand about the use of euthanasia, and veterinarians should decide in advance how to respectfully educate or refer clients and refuse treatment, as appropriate, when irreconcilable disagreements arise. Clients may not understand or may have an unrealistic view of the death process, so providing education about what to expect if and when natural death occurs is important.

Animal hoarding—A residential hospice program can potentially conceal or be used as a front for the hoarding of animals and an excuse for the poor condition of hoarded animals. When the hospice owner does not believe in the use of euthanasia, the division between philosophical differences and outright animal abuse can blur.¹⁶ In a true hoarding situation, the animals may receive inadequate hygiene, pain control, or nutrition. Instances of suspected neglect or abuse should be well documented in medical records and reported to the appropriate authorities.

Nonveterinary care providers—Some hospice programs are run and staffed entirely by individuals who are not veterinarians, which can create concerns about appropriate levels of training and care. Hospice programs based in veterinary practices may make extensive use of nonveterinary personnel to make residential and in-home hospice programs more affordable. Clients typically take a much more active role in caring for animals in hospice programs, including giving injections and expressing the bladder. Adequate training must be provided, and potential liability issues should be addressed in advance. When establishing a hospice program, legal advice should be sought regarding risk factors and insurance coverage for staff members, particularly staff members who travel to clients' homes.

Complementary and alternative therapies—Hospice care may be more popular among those interested in alternative and complementary therapies. Thus, veterinarians engaged in hospice care should be comfortable working alongside individuals offering these therapies and be aware of the potential for conflicts and deleterious interactions between these therapies and conventional medical treatments.

The Veterinarian's Role

Veterinarians should develop effective methods of assisting clients and patients during end-of-life care. An increasing proportion of clients are adopting hospice as part of their care philosophy for their pets and wish to involve veterinarians as part of a multidisciplinary approach. Currently, many veterinarians are perceived as unfamiliar with hospice as a concept or practice,⁹ and the variety of uses of this word may compound this misapprehension. Veterinarians and their support staff should be able to discuss hospice in such a way that they come to understand their clients' wishes. Veterinarians must consciously choose the extent to which they embrace the hospice approach and how and when they will participate in hospice care.

In recent years, 2 international symposia on veterinary hospice care organized by the Nikki Hospice Foundation for Pets and the Assisi International Animal Institute have begun to galvanize the veterinary profession on this issue. Future progress might include development of a veterinary hospice association to promote the role and enhance the expertise of the veterinary profession in hospice programs. Such an association could enhance the transfer of knowledge from hospice specialists to veterinarians serving clients across the country in general practice.