| Veterinary Hospice Concepts and Applications |
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The first difficulty to be faced by veterinarians is making a prognosis that the patient is terminal. The human hospice guideline of a life expectancy of 6 months or less is probably too long for many veterinary situations. Using the ratio of average human years to dog years, 6 months is equivalent to approximately 1 month. While hospice care would certainly be appropriate during the final month of life, it may be appropriate for much longer in some cases. The veterinarian must first recognize that the patient is terminal and that hospice care is a better alternative then further heroic attempts at cure. This step is complicated by the veterinarian's emotional investment in the case's good outcome, which may make it more difficult to admit the true circumstances as early as is optimal. In addition to determining the appropriate time to make a switch to hospice care, a second problem is that there is no veterinary hospice to which a referral can be made. The same veterinarian must re-evaluate the patient care plan from an entirely different perspective. Once the veterinarian determines that hospice care should be considered, the primary caregivers (owners) must then be informed about the choice. In some cases this will come as a relief to clients who have already recognized the impending death of their pet. Other clients may not yet be ready to face reality or give up hope for a cure. Helping reluctant clients choose between ever intensifying medical treatment, hospice care or euthanasia is a difficult task calling for much sensitivity and care. It is important to thoroughly explore with the client all the options and their medical and financial consequences as a part of this preparation. It may be necessary to give the client time to think about the options and discuss them with family members before making a decision. A particularly useful idea is to have the client think through the issues and describe their preferences long before they are faced with the real decision. This might be termed "pre-need" counseling, and veterinarians might encourage clients to complete a form similar to the advanced directive now required at human hospital admission. In terms of providing comprehensive hospice care, the veterinarian is most prepared to fill the role of medical director. Pain management and relief of signs are the major emphasis. Hospice care is becoming a specialty in human medicine, which indicates the potential for advancement and new knowledge about treatment techniques. The veterinarian, veterinary technician and clients should jointly develop a plan of care to address relief of pain and management of signs. Clients should be made aware of various techniques which might be employed, and their limitations. They should be advised of signs indicating pain, side effects of the medical conditions and treatments, and anticipated complications as the patient's condition declines. Clients may need to decide if euthanasia is still an option, how the pet's remains will be treated after death, and other details of care and memorialization. Home nursing care and respite care can be provided by veterinary technicians and hospital personnel, but veterinarians are probably not the best providers for the other aspects of hospice care. Psychosocial services to the immediate family should be provided by people with credentials in that field. An ideal veterinary hospice care team would include employees and volunteers from the local human hospice. Spiritual counseling is another critical aspect of hospice care, and should be available to a veterinary hospice patient's family members. The unexpected death of a much beloved pet can cause intense personal grief and could precipitate a spiritual crisis as well. There are two cautions to consider: first, the care must be provided by a team that is well coordinated and has good communication. Secondly, the spiritual and psychosocial counselors on the team need to be selected for both their professional competence and also their sensitivity to the human animal bond. A blind referral to an insensitive counselor could do more harm than good. Guy Hancock, DVM, MEd |
