December 2009 Newsletter
Pet Hospice - Caring Until the End
Debbie De Louise and Marion S. Lane
Caring for a dying companion animal at home requires veterinary assistance and other types of support. The help that's needed is slowly becoming available.
In the wee hours of September 16, 2001, Christine Church's orange-and-white cat Taffy died of kidney disease in a Connecticut veterinary hospital. Church, who had been maintaining the cat at home for seven months by giving her fluids under the skin, had taken Taffy to the hospital two days earlier because the cat had stopped eating.
Church, who has nothing but praise for the veterinarians who care for her animals, is nevertheless filled with anguish. "I told the vet that I didn't want her dying in a hospital," Church recalls. "I asked if there was any way I could do her care at home. But the veterinarian said that Taffy needed IV fluids and round-the-clock monitoring that could only be done in the hospital."
Five years earlier, in March 1996, Kathryn Marocchino, Ph.D., a cat "parent" in Vallejo, CA, reluctantly agreed to euthanize her 13-year-old cat, Nikki, who was stricken with acute kidney failure. Maracchino, who had trained as a human hospice volunteer at a nearby medical facility, agreed to euthanasia only because she could find no alternative that would spare her cat substantial suffering. But before the year ended, Marocchino and her husband had founded the Nikki Hospice Foundation for Pets, a nonprofit, charitable clearinghouse of information about pet hospice for interested veterinarians and hospice professionals, and for pet owners who do not wish to choose euthanasia, or who wish to postpone it in favor of a natural dying process in the home. In late September 2001, NHFP launched a website that includes an expanding nationwide database of veterinary hospice care providers, training opportunities for veterinarians and mental health/hospice professionals and related services.
A Welcome Alternative
Veterinary hospice, as defined by the Denver, CO-based American Animal Hospital Association, "focuses on giving pets a safe, caring, intimate end-of-life experience in their familiar environment." Like human hospice, on which it is modeled, veterinary hospice is not geared toward curing disease. Its purpose is to alleviate the physical discomforts and emotional stresses of dying.
Hospice is described as a philosophy, not a physical place. Writing in Pets Living With Cancer: A Pet Owner's Resource, published by AAHA Press in 2000, Robin Downing, D.V.M., notes, "Hospice care is compassionate care that is administered to the animal patient prior to euthanasia [or natural death], but after control of the cancer becomes ineffective. When a cat or dog cannot recover from its cancer, time in the hospital takes away precious 'together time' from the pet and its family. Hospice returns this valuable time." Once hospice care is initiated, Downing explains, the emphasis shifts from trying to cure (treatment) to trying to comfort (palliative care), from procedures and medications that may actually compromise the pet's quality of life to such things as symptom relief, physical affection, favorite food treats and extra one-on-one time with family members.
Cathy Toft's 12-year-old collie, Kallie, has been a patient of Cheryl A. Scott, D.V.M., a veterinary hospice provider in Davis, CA, since November 1999-not the typical course for hospice, which, in Scott's practice, averages two months. At the time she became Scott's patient, Kallie was suffering from primary lung cancer and acute kidney failure. Though the cancer was not yet at an advanced stage, Toft wasn't sure if Kallie would rebound from the 10 days she had just spent in a veterinary hospital for treatment of her kidney condition. Like many dogs, Kallie became agitated at every visit to the veterinarian, and the recent extended stay had taken a heavy toll.
"I wanted to minimize her stress," Toft recalls. "I needed a veterinarian who understood management of terminal illnesses and who could treat Kallie at home. We had used hospice care for my father, and it was a true godsend to let him die at home, surrounded by family. I wanted the same experience for my terminally ill dog."
Scott, who has operated HomeVet Hospice since January 1998, was a nurse for 10 years before receiving her veterinary degree and practicing traditional, curative veterinary medicine in a hospital setting. She explains the circumstances that led her to specialize in hospice care. "Clients started asking me to come to their homes to perform euthanasia," she says. "It wasn't just one or two. It was happening every week." As she struggled to meet these requests by doing house calls after office hours, Scott began to realize that a great need was not being met. "I was thinking that somebody else had to do this, then I thought, 'Why don't do it...not only euthanasia, but hospice care?' It evolved from there."
In practical terms, veterinary hospice care is similar to human hospice care. In Kallie's case, Scott does physical exams and draws blood in the home, observes the dog's demeanor and listens to whatever concerns that Toft may have. She delivers medicines to the home, instructs Toft in how to do injections and subcutaneous fluids, and, as needed, consults with specialists in internal medicine, oncology and nutrition. Most consultations are handled by telephone, but if Kallie needs to go to a veterinary office for X rays or an ultrasound, Scott sets up these referrals. Should the time come when the dog needs to be on intravenous fluid therapy, that too will be set up in the home. "Dr. Scott assures me that we can do everything at home that could be done at a hospital," Toft says.
A Different Emphasis
The fact that Scott has a nursing background may be more than coincidence. "Hospice care is based on nursing practice, not the medical model," says Guy Hancock, D.V.M., M. Ed., the current president of the 325-member American Association of Human/Animal Bond Veterinarians (AAHABV), an organization formed in 1993 to promote awareness of the human/animal bond and explore the possibility of developing a veterinary specialty in that area. It's important for persons who are contemplating hospice care for their companion animals to realize that much of the in-home intensive nursing care will fall to them. The fact that so many pet owners are willing to take this on is precisely why veterinary hospice is being promoted within the AAHABV membership. "I've tried to make a case that vet hospice is a clinically relevant area of interest that would fit with our mission," says Hancock. "It could become a specialty some day. Palliative care is now a recognized specialty in human medicine."
Hancock envisions that pet hospice care-like human hospice-will be best provided through a team approach, with the team consisting of the pet owner and family members, the veterinarian and veterinary technicians, and individuals with cross-over credentials in psychosocial services and the human animal bond.
In Merrimack, NH, Eric Clough, D.V.M. and his wife, Janice, have been active in the pet hospice movement for more than five years. Clough, an acknowledged pioneer in the field, offers hospice service through his veterinary clinic, while Janice, a former human hospice nurse, now directs a hospice program in the state.
"We used to talk all the time about what I did and what he did," says Janice, "and he began to see that a lot of what I did could be applied to animals. At that time, nobody was doing veterinary hospice. The options for pets were to euthanize them or offer very aggressive treatment that was often futile and was always fabulously expensive." The Cloughs offer a third option: "aggressive comfort treatment."
Hospice is generally considered when there is nothing more that the arsenals of surgery and medicine can accomplish. "In hospice," says Clough, "We never say there's nothing more we can do. There's always something in the way of comfort. We can't do anything about the quantity [of life], but we can do a lot about the quality."
Although preemptive management of pain and symptom control are important components of veterinary hospice care as outlined by Eric Clough, choosing hospice does not necessarily rule out euthanasia-although a surprising number of pets in hospice do seem to die peacefully in their sleep. Dr. Cheryl Scott, who sees hospice as "promoting quality of life at the end of life," advises euthanasia when that quality is gone. Similarly, Dr. Robin Downing suggests that owners should decide what capabilities, i.e., elimination, eating and drinking, mobility, responsiveness to the owner, constitute a minimum acceptable quality of life for their pets before the need to consider euthanasia arises. She believes that this will reassure owners that they'll make the right decision when the time comes. Euthanasia at home, rather than in a hospital, would be the natural extension of hospice care.
"Hospice often ends in euthanasia," says Janice Clough, "but this last piece can still be meaningful and comfortable." She and her husband have found that pet owners who choose hospice feel very good about it. "These are not the people who say they're never getting another animal," she says.
Issues and Obstacles
Despite its many benefits for companion animals and their owners, pet hospice raises some questions within the veterinary community. Dr. James Harris is an Oakland, CA-based veterinarian who serves on the Human/Animal Bond Committee of the American Veterinary Medicine Association, which approved guidelines for veterinary hospice care in April 2001. Says Harris, "In California, you have licensed veterinarians and licensed veterinary technicians. By state law, technicians are allowed to do certain procedures under direct supervision, meaning a veterinarian has to be on the premises, and some under indirect supervision, meaning upon written order of a veterinarian." The current practice act in California stipulates that licensed veterinary technicians can only do their job at a licensed premise-a veterinary hospital. "A mobile clinic or van would be okay," Harris says, "but technicians can't legally function in someone's home." He notes that the California Board of Examiners understands the problem and wants to change the practice act to make it possible for home care by a veterinarian and his technicians. "This may be an issue in other states, as well," he says.
Prescribing controlled substances, such as opiate pain control medications, for use in a home environment is also a concern, as is the matter of time and cost. "Hospice is much more time consuming than euthanizing an animal," Harris says, citing travel time for the veterinarian and his technicians, telephone calls necessary for follow-up questions and emergencies, and the records that must be maintained on each pet. "It's more time consuming for the practitioner," he says, "and it's more expensive for the client."
Cathy Toft acknowledges that hospice care probably does cost more than outpatient care at a veterinary hospital, although much less than inpatient care. Toft, like the overwhelming majority of pet owners, has no pet health insurance. She decided against it because the polices she looked at excluded cancer. "The question is whether pet insurance covers not just in-home care, but the kinds of treatments required by most hospice patients," says Toft. "That's also an issue in human insurance, and it affected our decision about when to move my father's care to hospice."
Perhaps the greatest obstacle to the growth of veterinary hospice, however, is that it is not part of veterinary school curriculum. In fact, the longstanding emphasis on curative medicine requires the practicing veterinarian to shift gears and set a completely different goal for the hospice patient. To many veterinarians, and to many pet owners, this feels like quitting. Says Christine Church about her decision to hospitalize Taffy: "I think if I had just kept her home, or had her euthanized at home, I always would have wondered if there wasn't more that could have been done to save her." Eric Clough, howevers, holds a different perspective. "Death isn't losing the game," he says. "Death is unavoidable. If you make death a safe, loving, comfortable experience, then you've won the game."
As for the future of veterinary hospice, Janice Clough believes it depends on pet owners. "It will come from them, not from other veterinarians," she says.
This certainly was true in the case of Dr. Cheryl Scott, whose clients showed her their need for end-of-life care. "Vets tend to think hospice care is depressing and not something they want to spend their careers doing," Scott says. "And it is sad. But it also has benefits: wonderful clients, wonderful patients, people who totally adore their pets, and pets who have had wonderfully long lives. I would like to see it spread."
Debbie De Louise is a freelance writer in Hicksville, NY; Marion S. Lane is editor-in-chief of Animal Watch.
For More Information:
The Nikki Hospice Foundation for Pets
400 New Bedford Drive
Vallejo, CA 94591
Tel.: (707) 557-8595; Fax: (707) 557-5555
E-mail: marocchino@aol.com
http://www.csum.edu/pethospice
American Association of Human/Animal Bond Veterinarians
Sally Walshaw, V.M.D., Secretary
4550 Comanche Drive
Okemos, MI 48864
http://members.aol.com/guyh7/aahabv.htm
© 2001 ASPCA
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