In human medicine, there's an increasing focus on palliative and hospice care aimed at making the end of life more comfortable for the dying. Different countries and cultures have, of course, always viewed death differently from one another; America, for a long time, has swung heavily into length of life over quality of life. The proliferation of medical dramas showing miraculous recoveries – and downplaying the brutality of some life-prolonging procedures – encouraged the idea.
More and more, though, people are recognizing that the quality of a few more weeks stuck in a hospital bed, breathing through a machine, isn't worth it for themselves or their loved ones. Thus, increasing attention is being paid to end-of-life care through hospice care.
Make no mistake, though; palliative and hospice care are not just for human medicine. We all love our pets and beloved animals, and we want them to have comfortable lives as well. When a pet suffers from a chronic illness, they may have few options, and the best choice may be either palliative care or hospice care.
The Difference Between Palliative and Hospice Care
First, let's talk briefly about what palliative care means, what hospice care means, and how they differ.
Both of these kinds of care come up most for those nearing the end of their lives, and it's no different for animals. A critical detail is that "the end of their lives" doesn't mean the end of a natural lifespan but can also include chronic, incurable diseases and other issues that have a high likelihood of fatality. It's still end-of-life care for a dog that's 16 years old with systemic organ failure or a dog that's three years old with an aggressive cancer.
Since both palliative and hospice care deal with the end of life and the comfort of the patient, what's the difference between them?
Put simply, palliative care is care that promotes comfort and quality of life while still potentially seeking a cure for what ails the patient. In contrast, hospice care is care that promotes comfort and quality of life while acknowledging that there's no cure for whatever is happening to the patient.
"The National Hospice and Palliative Care Organization (NHPCO) describes palliative care as "treatment that enhances comfort and improves the quality of an individual's life during the last phase of life." Likewise, the NHPCO defines hospice as "support and care for persons in the last phases of an incurable disease so that they may live as fully and as comfortably as possible." These definitions are simple and straightforward when it comes to offering guidance for palliative care and hospice for pets approaching the end of their lives." – VCA Animal Hospitals.
To use a common example, consider a dog with cancer. This cancer has metastasized and is not curable with surgery alone. Palliative care might skip any surgery and focus solely on chemotherapy, immunotherapy, or simple pain management to help keep the dog happy and comfortable. If the treatments work and the cancer shrinks or goes into remission, the client can then consider additional treatments like surgery for a primary tumor or treatments for other related diseases, like kidney disease caused by damage from a tumor.
In contrast, if initial attempts at chemotherapy don't work and the cancer doesn't respond to them, hospice care may be the way to go. Hospice care will forego any treatment meant to be curative if it hinders the quality of life of the patient. Instead, treatments will focus on prolonging the quality of life through pain management and whatever minor issues need to be addressed to keep the patient going, like addressing nausea.
Traditionally, palliative care begins early in the process, and hospice kicks in when a point is reached such that hopes of a cure are no longer viable.
How to Provide Effective Palliative and Hospice Care
As a vet, your primary goal is always to care for the animals brought to you to the best of your abilities.
Sometimes, that means acknowledging that you don't have the knowledge or experience to handle their issues and referring them to a specialist. Sometimes, it means recognizing that further treatment is futile and that quality of life should be the preference. In all cases, it means treating any case with gravity, respect, and care. Emotions are always going to run high, and it's never an easy decision for a pet owner to make.
To provide the best possible palliative care, you have to follow a process.
Begin by working for a thorough diagnosis. This isn't just a diagnosis of one specific issue but a holistic review of all issues a pet might be facing. Especially for older animals, many issues can crop up at once; an animal with diabetes, kidney failure, cardiovascular issues, and arthritis might be able to keep going on treatment for a while, but their quality of life may be suspect. Examining and treating each issue individually may not be the most effective method, but looking at the entire animal overall can reveal the trend.
As a more specific example, kidney failure may be forestalled through IV fluids, but if kidney failure is rapidly approaching, the best that IV treatment can do is forestall it. Since the animal would be confined to the veterinary hospital – a stressful, unfamiliar, and uncomforting environment – it may not be the best option. Instead, allowing the animal to go home with what treatment they can get may be the more humane option. It allows the animal to be more comfortable, surrounded by loved ones, and able to spend precious final moments with family.
It's notable that this isn't a death sentence! For issues like kidney failure, fluids can be delivered subcutaneously by a family member in a noninvasive way to sustain kidney function for at least a little longer. Cancer, similarly, can be forestalled through oral chemotherapy, and side effects like nausea and gastrointestinal problems can be handled through antacids and other medications.
A complete diagnosis allows you to evaluate and decide which of four options is most relevant:
The patient has some ailment that can be addressed, treated, and cured in your practice.
The patient has an ailment that can be addressed and potentially cured, just not by you; a referral can send them to the right vet to handle the task.
The patient has an ailment that may be treatable on a long shot; prioritizing comfort while attempting a cure is an acceptable outcome. This is palliative care.
The patient has an ailment that has progressed beyond being curable. Priority is now on comfort for their remaining life. This is hospice care.
Once you determine how to handle the patient, you can proceed to the next step: administering appropriate care. Obviously, what you do depends on the specifics of the case and your expertise, resources, and the ability of the client to handle the burden.
Palliative care is more than just painkillers and bed rest.
"Palliative care can be as easy or complex as necessary to meet the needs of the pet and human family. Some palliative care patients benefit from massage, therapeutic laser, temperature therapy (heating or cooling devices), acupuncture, chiropractic, and physical rehabilitation techniques." – VCA Animal Hospitals.
It is, again, all about a holistic review of the pet. Some therapies may not be curative but can be comforting; others can be both. There's no such thing as a single palliative care plan. Instead, you need to develop a set of resources for care, different tools, medicines, methodologies, and treatments that can combine into an enhancement of quality of life.
On top of the above, it's also not entirely your responsibility to administer this care. We all recognize when compassion fatigue becomes an issue, as well as the burden of difficult clients, heightened emotions, emotional resonance, and more. This is why building a care team of various practitioners can be an important part of both palliative and hospice care.
The Transition from Palliative to Hospice Care
One of the most difficult decisions for both a vet and a pet owner to make is where to draw the line. When does the progression of a disease reach the point where it is no longer curable? At what point do further attempts to do so risk damaging quality of life for a long shot?
In human healthcare, this is a difficult task because we as a culture have a taboo around euthanasia and medically-assisted intentional death. In veterinary medicine, however, euthanasia is a much more acceptable consideration. In fact, vast numbers of pets reaching their end of life are humanely euthanized rather than allowing their suffering to continue. This may be an in-clinic euthanasia or even in-home euthanasia.
"While euthanasia itself remains a procedure to end intractable suffering, it is advised to avoid using it as a first-line treatment for pain, or as a substitute for compassionate, state of the art palliative care. Veterinarians are encouraged to be cautious with the message, "There is nothing more we can do for your animal." Veterinarians have an obligation to advise clients about the range of palliative options available. Alternatively, veterinarians can offer a referral to animal hospice providers who will discuss all available options. When a veterinarian also recognizes that caregivers cannot effectively provide animal hospice care, euthanasia may need to be advocated for to prevent further suffering." – IAAHPC Guidelines.
The decision when to transition from palliative to hospice care is dependent upon the progression of illness and the quality of life. If the prognosis is poor, and the remaining life is measured in days or weeks, hospice care is appropriate. If there's a chance at a cure with reasonable means, palliative care is much more appropriate.
Are Palliative and Hospice Care Regulated?
The concepts of formalized palliative and hospice care are not entirely well-defined or controlled in veterinary medicine.
In part, this is because veterinary medicine is changing rapidly. Diseases that were incurable just a few years ago now have much better prognoses; advanced technology, genetic testing, and new medications are pushing the envelope of what we thought was even possible. To formalize an "end point" of traditional care and a transition to palliative or hospice care would be to do everyone a disservice.
On top of that, veterinary care is often uneven. Rural clinics might not have access to the same medications, tools, resources, and procedures that urban facilities do. Setting standards that could be well under the capabilities of some practices and above the capacity of others would be likely.
That said, there are organizations looking into creating guidelines for ethical treatment and use of palliative and hospice care. For example, the International Association of Animal Hospice and Palliative Care, or IAAHPC, publishes this document of guidelines. Their goals are to create plans of care, shift the way of thinking about animal end of life, and improve the mental health of caregivers. There's a lot to consider – the guidelines document is 51 pages long – but it's a good read to get a feel for what the current state of thinking is surrounding veterinary end-of-life care.
It's important to acknowledge that, just as medical care for animals is evolving rapidly, so too are the outlooks, ways of thinking, and considerations surrounding end-of-life care for those animals. Ethics, legal questions, responsibility, the burden of assessing the condition of an animal, and more are all under consideration, and there are a lot of difficult choices that have to be made.
"Animal hospice and palliative care are emerging fields. Veterinarians and other professional animal care providers are seeking ways to provide end of life care in an ethical and humane manner that serves the needs of animal patients as well as their human caregivers. Applying insights and knowledge from bioethics will expedite the development of evidence-based best practices in these emerging fields." – IAAHPC Guidelines.
At the end of the day, the most any of us can do is our best. As such, one of the best things we can all do is work together. At Hope Vet, our priority is helping ensure that you're making the best decisions you can. That's why we've built our team of consultants and experienced vets in a variety of specialties who can offer their opinions on your cases. Whether it's in dermatology, neurology, critical care, internal medicine, oncology, or another form of care, simply request a consultation, and we'll do what we can to help you.