October 31, 2012
Veterinary hospice movement growing
End-of-life care addresses emotional bonds
By: Phyllis DeGioia
For The VIN News Service
Next to the bed of the 15-year-old chow, the dog’s owner has placed an inflatable mattress so he can sleep by her side and shepherd his friend through whatever time she has left.
Photo by Janell Osborn
Dr. Kathleen Cooney, with her dogs Guber and Daisy, sits in her Pet Euthanasia Center. The homelike atmosphere is designed to provide a peaceful alternative setting to euthanizing at home or in a regular clinic.
The owner set up the tender sleeping arrangement after a three-hour house call visit and consultation with Dr. Maren Bell Jones, owner of a mobile veterinary practice in Columbia, Mo., whose services include palliative medicine and end-of-life care.
Their long discussion delved into quality-of-life issues, treatment options for the aging chow and practical ways the owner could keep his pet safe and comfortable. Besides sleeping on the ground, the owner has barricaded the top of the stairs so the blind dog doesn’t fall down or enter the kitchen where she's apt to slip on the uncarpeted floor.
"It's rewarding to him," Jones said. "He can get as much (emotional benefit) from the relationship while maintaining some level of dignity for her. It's pretty amazing what people will do for their pets."
The regard people have for their pets as members of the family is fueling a movement in veterinary medicine to provide hospice services. Veterinary hospice shares the philosophy of human hospice in attending to terminally ill patients with compassionate care that includes pain management and emotional and spiritual support for the patient’s family and loved ones. The goal is to maintain the patient’s comfort and dignity as he or she approaches death.
For human patients, the hospice concept originated more than 50 years ago, according to the National Hospice and Palliative Care Organization. In 1982, hospice became an established part of American medical practice as a benefit available under Medicare.
A few key elements distinguish human hospice from veterinary hospice. Most notable is that the option of ending the patient’s life through euthanasia is part of veterinary hospice only.
On the human side, the Centers for Medicare and Medicaid provide regulatory oversight. Veterinary hospice has no such oversight — only professional guidelines, such as those developed by the American Veterinary Medical Association.
The veterinary hospice movement is considerably younger than human hospice, but some signs suggest it’s growing apace.
The International Association for Animal Hospice and Palliative Care (IAAHPC) was founded in 2010 and currently has 130 members. One item on the association’s to-do list is to promote development of a veterinary hospice certification program, according to Dr. Kathleen Cooney, a board member and education chair.
In May 2011, the journal Veterinary Clinics of North America: Small Animal Practice devoted an entire issue to the topic of palliative medicine and hospice care.
Cooney, owner of an in-home veterinary hospice and euthanasia service called Home to Heaven in Loveland, Colo., credits the IAAHPC with propelling the movement. “There couldn't be a bigger time in this field,” she said. “It's been trying to take off since the ’80s. There were a few lectures peppered around at conferences, but it was slow to pick up until groups like IAAHPC (were established).”
IAAHPC spokeswoman Coleen Ellis said that while veterinary hospice isn’t uniquely American, it is more common in the United States than in other countries.
"While there are bubbles of activity in the (United Kingdom) and Australia, there is no teaching or formality like the IAAHPC represents," Ellis said.
Photo by Bob Thompson
Dr. Dani McVety founded a network of pet hospice providers. She believes that hospice care lessens a pet owner's anxiety and benefits the patient.
In many ways, hospice is not a new concept to veterinary medicine but an extension of traditional practice. For example, a growing number of practitioners are willing to perform euthanasia in the patient’s home, judging from the lengthening list of clinics in an online directory. Cooney, who created the nationwide directory in 2009, said entries are added every week.
But hospice is more than enabling a patient to die at home. Part of the IAAHPC’s goal is to help animal patients to die neither too soon nor too late. Its mission statement reads in part: “IAAHPC promotes hospice/palliative care for animal companions as an alternative to premature euthanasia and as an alternative to prolonged suffering, which can result either from isolating an animal in intensive care or from inadequately treating the animal at home.”
Cooney said it is gratifying to be able to offer owners of pets with terminal disease options other than immediate euthanasia. “A family can call me and say, ‘My dog has bone cancer, and they told us to euthanize but we don't want to,’ ” she said. “ ‘Can you provide us with pain management, can you help us modify our home to what he needs, (can you provide) comfort drugs ... until he dies naturally or euthanasia is needed?’ ”
Some veterinary hospice providers say they conduct their operations as on-call, round-the-clock services. Dr. Dani McVety of Tampa, Fla, founder of a hospice network called Lap of Love, is an example.
“I can be there within one to three hours,” McVety said. “Not every vet who does hospice can do that, but I am full time on this. I think it's very important. If you can't be there, you can at least talk to the family. I've been at homes at 2, 3, or 4 in the morning.”
McVety, who used to volunteer in the human hospice field, sees the approach as a way to prepare mentally for what is a natural progression in life. Even as a student in veterinary school, she was struck by the sense that clients needed to know about the bridge between curing disease and death.
"Sometimes clients want to hear it's OK to not go on, to stop tests and procedures," McVety said. "At some point, we have to give up the battle and say, ‘Let's just keep the pet comfortable, as quality of life is more important.’ "
Photo by Roberta Knauf
Coleen Ellis travels the country teaching certification courses in pet loss and grief.
Ellis, the IAAHC spokeswoman, brought 18 years of experience in the human funeral business into the founding of what she calls the nation’s first stand-alone pet-only funeral home — Pet Angel Memorial Center in the Indianapolis area. Ellis also serves as a consultant in the area of pet grief and works with people who wish to provide in their communities what she terms “death care services."
Ellis said she has found that the decision to euthanize leaves 99 percent of her personal pet bereavement clients feeling guilty because they don't want to play God. The word euthanasia derives from the Greek term for “good death,” but Ellis said very few people who request euthanasia for their pets feel as though they are doing a kindness.
Hospice care, she said, can relieve that guilt and anxiety. "Hospice allows us to know we did everything we could,” Ellis said.
Added McVety: “Hospice lessens the possibility of surprises and gives them ownership of the situation. It's a relief to them to have a plan."
Jones, the Missouri veterinarian with a mobile practice, estimates that one out of 10 calls from potential clients is about end-of-life care.
"The biggest thing is reading people's goals for their animal. It's very personalized as to what these goals are,” Jones said. “Some people don't want to euthanize. They don't want to make that decision, whereas some people (say), 'Fluffy is getting old. Let's put her to sleep,' without considering what (else) we could do.”
Jones sees her job as presenting options to pet owners. Her approach is to meet the client “in the middle,” she said, “without judging that person or (person's) pocketbook." She said many owners choose hospice because they can't afford diagnostics and treatment.
At the same time, hospice is not necessarily low-cost. Prices vary by geographic area and provider but are in the neighborhood of $180 to $200, plus medications and/or fluids, for an in-home visit. In-home euthanasia services tend to run about $230 to $250 (about $50 more for night and weekend visits).
Although palliative medicine and hospice may be extensions of conventional practice, not all veterinarians are supporters. Dr. Alice Villalobos of Hermosa Beach, Calif., believes that some practitioners consider palliative medicine and hospice equal to giving up.
She disagrees. A veterinary oncologist since 1972, Villalobos has developed an approach that integrates cancer treatment, palliative care and hospice. She calls the service Pawspice (rhyming with hospice).
Villalobos describes Pawspice’s three phases this way: First is “entry,” in which palliative care is given along with standard treatment but using what she calls “kinder, gentler care,” especially for geriatrics. In the middle phase, a patient may feel better because his or her symptoms are treated. If the cancer goes into remission, the patient gains weight, redevelops an appetite and has less or no pain. At last comes the process of dying and death.
Photo by Haley Harrington
Veterinary oncologist Dr. Alice Villalobos created a program she calls Pawspice that combines palliative care with "kinder, gentler" treatment.
Villalobos’s main tenet is to not make pets sicker with treatment.
"For 16-year-old dogs, there is no good evidence-based medicine," Villalobos said. "I'm trying to avoid over-treatment .... Often an animal is treated for a primary problem, but we're not taking care of the rest of the body.
“My older and advanced-stage cancer patients live longer than the norm because we don't stress them, we don't give them unnecessary CTs or MRIs, standard radiation or radical surgery, which requires anesthesia, if it is not going to be (clearly) beneficial. We can finesse a diagnosis using ultrasound and fine needle aspiration cytology without exploratory surgery. We’re talking about fragile and aged patients. I've helped a lot of animals escape unhelpful surgery.”
Villalobos said she believes that at the end their lives, her patients should be treated as outpatients and allowed to remain at home "until the gift of euthanasia is needed to help them escape unnecessary and futile pain."
Cooney has found that practicing hospice benefits not only the patient and client, but her own emotional health.
Before her mobile practice provided hospice services in addition to in-home euthanasia, Cooney found herself burning out. She wondered if the suffering she saw surrounding end-of-life issues was the cause.
"I saw the human-animal bond breaking down,” she said. “People begin resenting their animals ... (due to) the sleepless nights, the anxiety that comes with watching a loved one die, the loss of financial reserves to pay for treatment, etc.”
The answer, she found, was for her to be involved earlier in the process and to add hospice. She found reward in giving families support before a crisis.
Cooney said veterinary medicine's traditional end-of-life philosophy is "better a month too early than too late," but that may lead a pet's family to feel pressured to request euthanasia before they're ready. "We never talked (before) about supporting a pet longer with better home care 24/7,” she said.
When the time for euthanasia does come, Cooney believes it's best done at home. But for clients for whom that's not feasible, she offers this option: coming to her 35-acre farm in Colorado. There, she has built a center she calls "a peaceful alternative to hospital-based euthanasia." Very different from a standard clinical setting, the two rooms set aside for the procedure look like living rooms.
Said Cooney: "I think pets prefer to be in their home, but this center is the next best option."
VIN News Service commentaries are opinion pieces presenting insights, personal experiences and/or perspectives on topical issues by members of the veterinary community. To submit a commentary for consideration, email email@example.com.
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