THE NHFP (Nikki Hospice Foundation for Pets)
GUIDELINES FOR VETERINARY HOSPICE CARE

PREAMBLE

Veterinary medicine is a field that is constantly undergoing new and exciting changes, very much like human medicine, and it can often benefit from concepts and modalities which have been shown to have great validity for both human and non-human animals. Such is the case with veterinary hospice care, a term indicating the provision of end-of-life services to terminally ill or dying companion animals, thereby allowing clients to spend more quality time with them during a period which may either precede a euthanasia decision or take its place. These guidelines reflect the new and emerging status of veterinary hospice care as it is envisioned by The NHFP within the parameters of veterinary medicine in order to provide a more comprehensive and compassionate approach to dealing with the impending death of non-human animals.

The use of veterinary hospice care is to be considered as constituting good veterinary medicine in that it allows for a “good death” for the pet and consequently, “good” grieving for the client. This service must be offered in the context of a valid veterinarian/client/patient relationship, and it is recommended that appropriate client consent be obtained for all facets of veterinary hospice care. Training seminars will be available through The NHFP at various locations for those veterinarians wishing to learn more about veterinary hospice care, and it is incumbent upon animal health care practitioners who may be new to this field to pursue such education in order to learn how it can best be applied to their own practice.

Those board and advisory board members of The NHFP who have been practicing veterinary hospice care for some time, and who are actively involved in offering training seminars, all bring their expertise and their proven experience to this new field. Although no AVMA board certification currently exists for veterinary hospice care, The NHFP hopes that this will soon become a reality. For now, it should be kept in consideration that because the emergence and development of veterinary hospice care is an evolving process, especially in regards to current pharmacological protocols, this information may need to be modified from time to time.

GUIDELINES

Veterinary hospice care provides end-of-life palliative care to terminally ill or dying companion animals, and is modeled very closely on the concept of human hospice. As such, it represents a breakthrough in veterinary medicine in that it provides clients with an option that was previously unavailable to them. In the past, traditional veterinary medicine evaluated and aggressively treated animals who were terminally ill or declined to treat them if the condition was deemed hopeless. But in all cases, the end result was almost always euthanasia. Veterinary hospice care, on the other hand, allows the pet to spend quality time at home with the caregiver, under adequate sedation for pain control, until such time as the caregiver decides to euthanize or until death occurs.

When considering veterinary hospice care, the attending veterinarian should carefully assess the animal’s physical condition in order to determine if it qualifies as a “hospice” patient, based on the following: a) it has been given six months or less to live; b) it has a limited prognosis and a progressive disease with quality of life issues to consider; c) it has evidence of clinical decline such as multiple visits to the veterinarian, multiple or extended hospitalizations, a decline in functional status evidenced in three out of four ADLs (self-grooming, feeding, locating, ability to control urine or stool, righting, or ability to ambulate), impaired nutritional status, fluid retention or dehydration, weight loss or anemia, is symptomatic of pain, has dyspnea at rest, is unable to vocalize or vocalizes abnormally, or has lost the ability to smile or greet the caregiver or other family members. In many cases, hospice status may be applicable when the caregiver has decided not to pursue curative treatment and the caregiver, family members, the veterinarian and the veterinary staff have all been consulted and informed about the above.

In providing veterinary hospice care, veterinarians are offering benefits to the pets themselves, to their caregivers and families, and even to the veterinary staff as a whole. It is nonetheless imperative for everyone involved in the process to clearly understand the expected outcome, the time frame involved (what is the prognosis for the pet and the anticipated disease progression), how the palliative approach differs from the curative approach, when to expect the symptomatic and terminal phase of the chronic illness to begin manifesting itself, and what tasks the caregivers and their families will be facing.

As far as the pet is concerned, the veterinarian will have to deal with pain and symptom control, wound care, problems with incontinence and other aesthetics, and changes in behavior patterns. Special attention must be given to the caregiver’s perceptions of the pet’s comfort or discomfort (which are very similar to the perceptions encountered in the nurturance of a child) as well as the caregiver’s perceived ability to alleviate discomfort and feel a sense of satisfaction in his or her attempts to make the animal comfortable.

The veterinarian’s participation, knowledge, experience and open-mindedness are all of crucial importance. Both doctor and staff should be available at all times and be able to provide ready access to medications when needed. Being able to anticipate oncoming symptoms in the animal and routinely administer analgesics to minimize pain, as well as educate the caregiver in adequate home pain control, are all essential duties. As pain and suffering are both physical and metaphysical—with both the pet and the caregiver partaking in the experience—defining, assessing and interpreting pain adequately is an important step in veterinary hospice care.

Pain may be opiate dependent and therefore atypical (in bones, nerves, or muscles) or require an analgesic (non-opioid, weak opioid or strong opioid). Veterinarians are encouraged to begin administering these kinds of analgesics slowly, increasing them at a moderate rate so as to avoid side effects (which should always be anticipated and fully explained to the caregiver), to constantly evaluate the compounds being used and their efficacy in reaching the desired effect.

Symptoms which should always be defined, assessed, interpreted for the caregiver, and ultimately treated are dyspnea, coughing, sneezing, nausea, vomiting, constipation, seizures, fever, hemorrhages, agitation, restlessness, avoidance, vocalizing, pain and urinary retention, among others. Veterinarians should always work toward prevention, if possible, and recognize that these problems can be a source of great stress for the caregiver, especially if the animal begins exhibiting personality or behavioral changes. Often, the caregiver will need to maintain a “bedside” vigil and will require encouragement, understanding, and assistance in doing so.

The caregiver should be instructed in how to administer medications to the pet, as well as in how to dress and cleanse wounds and control minor hemorrhages, should these occur when the veterinary staff is not present. Medications should always be administered by a primary caregiver in order to minimize stress to the animal and the possibility of overmedicating the pet. Caregivers who wish to take on these tasks during their pet’s hospice experience must be able to rely on pre-prepared emergency kits (for both anticipated and unanticipated events) that can be safely used at home. These generally contain injectables which must deliver medication in an efficacious manner, often under conditions of questionable absorption, and may typically consist of zip-lock bags with pre-loaded syringes of the necessary medication(s).

Caregivers also need to know what to do when death occurs and who to call. During what can be a very difficult time of grieving and loss, caregivers must be able to locate someone on the staff (preferably a licensed grief therapist or mental health professional) who can provide them with adequate counseling. Ultimately, veterinary hospice care provides for “safe passage” for the pet in the comfort of the caregiver’s home and allows “growth” to occur at the end of life--ideally for both pet and client. For all involved, it is a unique learning experience and represents an opportunity for clients and their families to come together and share the lessons learned with the veterinary hospice team through cooperation, reconciliation and bonding. When clients return with a new pet, the trust and confidence they will have gained during the hospice experience will be renewed through the continuum of care, and the cycle truly comes full circle.

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