Veterinary hospice: a compassionate option at the end of a pet's life?

The hospice philosophy

The term ‘hospice’ can be traced back to medieval times and refers to a place of refuge for weary and ill travellers returning from a long journey (Lutz, 2011); the term hospice was applied to the specialised care of terminal ill patients in 1967 by Dame Cecily Saunders who is regarded as the pioneer of the modern concept of hospice care (Marocchino, 2011; Harrison and Connor, 2016). Hospice reflects a philosophy of care that recognises death as a natural and inevitable process and provides palliative support and care for the terminally ill patient and loved ones through the prevention of physical and mental suffering rather than curative treatment (Marocchino, 2011; Cooney, 2015). A study by Hong et al (2016) found that individuals would prefer to die at home in familiar surroundings with family and friends, with deaths at home being considered to be a good death and perceived by individuals to be more favourable than deaths away from home. Similarly, Brumley et al (2007) found that there was increased satisfaction for individuals who received in-home palliative care, although the limitations of the study were that the researchers relied on death at home as a measurement of patient preference when a better measurement would have been death in the individual's preferred location. As many owners consider companion animals to be part of the family, pet owners are expecting more varied options when a pet approaches the end of their life, and the delivery of home-hospice for a terminally ill patient is now a possibility (Hewson, 2015), Downing et al (2011), Villalobos (2011a), Teachout (2012); Gregerson (2016b) suggested that when early euthanasia or aggressive medical treatment is not desired or is not in the best interest of the companion pet, palliative and hospice care should be available and offered to the owner as a third option (Figure 2). If the veterinary clinic is unable to provide such services, owners who opt for hospice care as an alternative should be referred to a veterinary surgeon that can (American Veterinary Medical Association, 2017). Although hospice care is a rapidly growing speciality in the USA (Gregerson, 2016b), 56% of participants in a poll by Veterinary Futures (Dyson, 2015) were against the idea of hospice care becoming a standard component in veterinary practice; however the poll may not be representative as it is unclear if the participants, that were self-selected, were veterinary professionals (Hewson, 2015). Hewson (2015) suggested that hospice-assisted natural death is not always the ultimate outcome for terminally ill patients receiving end-of-life care in the hospice environment, often clients are provided with sufficient time and support to accept the inevitable impending death and the benefit of an assisted peaceful death by euthanasia (Gregerson, 2016a). Hewson (2015) reported that 98% of animals are euthanased in hospice care, although it is unclear where or how this result was obtained. A similar claim by Bittell (2012) found that 67% of patients receiving hospice care had died without euthanasia and had been allowed to die under close veterinary supervision to ensure adequate pain relief and comfort was achieved; it is unclear, however, how many patients were receiving hospice care at the time of obtaining the results.

The gift and guilt of euthanasia

Verdon (2006) described euthanasia as a selfless gift and humane way to cease an animal's suffering, however, it is a gift that is usually painful for the owners and often wrought with feelings of guilt (Morris, 2012; Dickinson, 2014). Hewson (2015) and Cooney (2015) suggested that as many veterinary professionals value euthanasia as a gift, the option of a hospice assisted natural death is one of the concerns that veterinary professionals hold regarding hospice care. The American Animal Hospital Association/International Association for Animal Hospice and Palliative Care (2016) outlined that it is the veterinary surgeon's responsibility to recommend euthanasia when palliation no longer relieves an animal's suffering; if euthanasia is not an acceptable option for the owners a combination of a high-dose palliative sedation with appropriate analgesia is an ethical option.

Delivery of end-of-life care

Due to the emerging demand for veterinary hospice care the American Veterinary Medical Association (AVMA) have published guidelines that act as a reference guide for veterinary surgeons wishing to deliver appropriate veterinary hospice care for terminally ill patients (Bishop et al, 2008). The AVMA guidelines addressed several issues for the delivery of appropriate hospice care to ensure quality of life is achieved for the patient, through the provision of adequate pain management, regular monitoring and review of the patient, and the availability of emotional and supportive resources for the client (AVMA, 2017). The Office for National Statistics (2016) found that quality of care, being treated with respect and dignity and pain management were all best achieved in a hospice setting; the Cicely Saunders International Report (2013) highlighted that the key aim for hospice care is to provide quality end-of-life care and assist patients to be cared for and die in the preferred place of care. For human patients, hospice is a programme of end-of-life care and support for terminally ill patients who have less than 6 months left to live (Joyce and Lau, 2012, Graaf et al, 2016); in human medicine, end-of-life palliative and hospice care can be provided at inpatient hospices, in the acute hospital setting, in nursing homes or in the community, but mainly in the patient's home (Department of Health, 2008, Graaf et al, 2016). Early veterinary hospice care is delivered when a patient is diagnosed with a life-limiting illness and death is expected within 2 to 3 months (Cooney, 2016). Usually hospice for the terminally ill companion pet is delivered in the home setting (Bishop et al, 2008; Kerrigan, 2014; Gregerson, 2016b).

The role of the registered veterinary nurse (RVN) in providing end-of-life care

Broadshaw (1996) claimed that care of the dying is the quintessential expression of nursing, where caring for the patient is most fundamental. In human medicine, an interdisciplinary team delivers palliative and hospice care of which nurses play a pivotal role (Dickinson et al, 2008; Kennedy et al, 2015), acting as advocates for patients and families (Dickinson et al, 2008; Brown, 2013; Dobrina et al, 2014), and spending the most time taking care of and interacting with patients and family members directly (Dickinson et al, 2008; Ramjan et al, 2010). Nurses also play an essential role in several aspects of pain management, which include, pain assessment, development and implementation of a patientcentred treatment plan, correct administration of analgesia and reporting to the doctor if the treatment plan is not effective (Brown, 2013). Goldberg (2016) suggested that veterinary nurses are a currently underused resource for the development of the emerging animal hospice movement, which can provide the veterinary nursing profession with an opportunity for personal growth and the development of specialist skills in palliative and hospice care to provide individualised, high standards of end-of-life care for terminally ill patients (Hewson, 2015; Gregerson, 2016a).

Education and training in end-of-life care

Cooney (2016) suggested that as the hospice field is still a relatively new and emerging speciality in the UK some veterinary surgeons are reluctant to extend veterinary services into the field of hospice care due to lack of knowledge and experience in advanced end-of-life care, with minimal end-of-life education opportunities available. Lewis et al (2016) stated that when medical personnel are uncomfortable providing end-of-life care, an increased distance between medical staff and the patient may arise which can directly impact on the quality of care that the patient receives at the end of life. The Colorado State University Pet Hospice programme, developed in 2003, was the first academic programme to recognise the growing needs and demand of end-of-life care for terminally ill pets and was designed to meet those needs through supporting terminally ill pets, owners and veterinary surgeons, and by providing end-of-life education to veterinary students (Bishop et al, 2008). However there has been minimal progress in the integration of hospice and palliative care programmes into veterinary teaching institutions (Goldberg, 2016). Fogle and Abrahamson (1990) found that 96% of veterinary surgeons had no formal training in how to explain a terminal diagnosis to a client, with 72% suggesting that such training would be useful; a more recent survey by Dickinson et al (2011) found that 75% of veterinary surgeons surveyed stated that veterinary schools should place more emphasis on communication skills with clients who owned terminally ill pets. A survey conducted by Dickinson and Paul (2014) found that six of the seven veterinary schools in the UK offered end-of-life teaching with approximately 20.5 hours devoted to the topic dispersed randomly within the curriculum. With an average of 7.53 animals euthanised per month by veterinary surgeons, Dickinson and Paul (2014) suggested a need for more workshops in veterinary schools' curriculum on end-of-life issues to further prepare veterinary surgeons for euthanasia of animals, communication with clients of terminally ill and dying pets, and bereavement issues. A study by Dickinson et al (2008) found that an average of 45 hours was devoted to palliative and end-of-life care teaching in nursing programmes in the UK, however, to the author's knowledge there appears to be no research into the integration of end-of-life education for veterinary nursing programmes. As many studies have focused on end-of-life teaching for veterinary surgeons it may be beneficial for further research to focus on the integration of end-of-life education for veterinary nursing programmes, although many of the top up degree and advanced nursing programmes now offer palliative care modules as part of the programme. Although such studies are not directly focused on palliative and hospice practice, the core qualities of palliative and hospice care are proficient end-of-life communication and grief and bereavement support and it is essential that veterinary professionals are educated in these areas (Goldberg, 2016).

Cure or care?

Heinle et al (2014) suggested that one of the reasons why palliative patients often receive inadequate care is because of the medical philosophy, which places great emphasis on curing disease and prolonging life rather than on relieving suffering and improving a patient's quality of life (Morrison and Meier, 2004). Shanan (2011) suggested that doing everything medically possible for a terminally ill companion animal to prevent death is not always in the best interest of the patient, this is also supported by Dunlay et al (2015) who suggested that end-of-life discussions should go beyond the narrowly focused consideration of resuscitation and should include quality of life assessments, goals of care and the social support availability for palliative patients, as prolonging survival is not the main objective. The veterinary nursing philosophy has evolved, much like the human nursing profession, to become more holistic and provide individual, patient-based veterinary nursing care for companion animals (Nelson and Welsh, 2015). End-of-life care encompasses palliative care and allows a patient to receive a death that is private and dignified, focused on adequate pain and symptom control, quality of care in surroundings that are comfortable (Figure 3) and the provision of support for the patient and those closest to the patient (General Medical Council, 2010). In a health system designed towards prolonging life and keeping patients alive, dealing with death can be challenging, emotional and representative of failure (Dickinson et al, 1999; Sawyer, 2016); it has been recommended by the Department of Health (2008) that within the healthcare profession, a cultural shift towards end-of-life care is required as death is inevitable and should not constitute a failure of care.

Consideration of the owners' role and responsibilities in the delivery of hospice care

The Department of Health (2008) recognised the critical role that family members play as co-workers within the hospice care team in providing physical, emotional, financial and social support for the terminally ill patient (Grande et al, 2009; Roulston et al, 2017). Gregerson (2016a) identified that often the pet's owners take on the role of carers in the home hospice environment and under the guidance of end-of-life veterinary professionals deliver the daily handson care for the terminally ill patient. Cooney (2015) suggested that while some veterinary personnel may feel uneasy about relying heavily on owners to deliver the level of care required to keep a terminally ill patient comfortable, an interdisciplinary team approach to veterinary hospice may alleviate these concerns. Villalobos (2011b) and Cooney (2015) suggested that all team members, including the family members of a terminally ill pet, should be educated on how to assess a patient's quality of life to prevent unnecessary pain and suffering; quality of life assessments can also act as a guide to develop and deliver individualised care for the patient (Mullan, 2015; Tottey and Sheridan, 2016) and help owners to consider difficult issues that previously they may have been in denial about (Villalobos, 2011b).

Emotional care and support for the bereaved owner

A survey by Adams et al (2000) found that 30% of participants whose pets had died experienced severe grief; the hospice philosophy is an integrative approach that not only aims to deliver individualised palliative care for the patient but also provides emotional and personal support for the owner and family members (Downing et al, 2011; Shearer 2011a; Hewson, 2015). A number of studies have found that hospice care has positively benefitted family members of the terminally ill patient by supporting and preparing family members emotionally for the impending bereavement (Jack et al, 2015; Morris et al, 2015; Jack et al, 2016). Veterinary surgeons can impact greatly on an owner's ability to grieve and how owners experience the loss of a companion animal (Adams et al, 1999; Adams et al, 2000; Ptacek et al, 2004; Bishop et al, 2008); 33% of individuals in a study by Fernandez-Mehler et al (2013) indicated that the veterinary surgeon was the best person to provide support during the mourning process. A study by Gallagher and Krawczyx (2013) found that for family members of palliative care patients, an important source for family members' emotional care, communication and support were nurses, which had a positive impact on family member satisfaction with the end-of-life care provided by the healthcare team. Limitations of the study were that the sample size was too small for the authors to make causal arguments and there was a high margin of error of 9%. In addition, Donohue (2005) suggested that in some cases the only source of support that an owner of a bereaved companion animal can access are the veterinary team with owners feeling that veterinary personnel are the only people to talk to regarding the loss and bereavement of a pet. Although veterinary staff are not trained counsellors and are not expected to fulfil that role, there is much that the veterinary team can do to provide compassionate support for bereaved clients (Foote, 2017). The provision of high quality end-of-life care to patients and bereavement support for family members is a nurse's responsibility (Davis, 2011; Johnson, 2015).

A survey by Compassion Understood (2015) indicated that 16–19% of pet owners that had lost a pet failed to return to the same practice with a new pet; similarly, Fernandez-Mehler et al (2013) found that 14% of clients changed to a different veterinary practice following the loss of a pet. While the reasons for client attrition are multifactorial, communication and management of the owner during this difficult period influenced clients' decisions not to return to the practice with any subsequent pets (Tottey and Sheridan, 2016). Providing exceptional client care through proactive planning and support for the owner can make a difference to this outcome (Fernandez-Mehler et al 2013).

Recommendations for future studies

Veterinary hospice care is a rapidly growing speciality in America. As it is a relatively recent concept, there is a limited amount of scholarly research into the delivery of palliative and hospice care for companion animals and the benefits, if any, for both the companion animal and the owner. Research conducted in human medicine has included studying family members' perceptions of end-of-life care and the impact of a hospice at home service; as the veterinary hospice movement continues to grow hopefully such research will be conducted and will contribute to the limited amount of literature that already exists.

Although a poll conducted by Dyson (2015) found that 56% of participants were against the idea of hospice care becoming a standard component in veterinary practice, a poll representative of veterinary professionals' opinions may be a valuable contribution to the limited research available on palliative and hospice care for companion animals.

As research conducted by Dickinson and Paul (2014) focused on end-of-life teaching for veterinary surgeons, it may be beneficial for further research to focus on the integration of end-of-life education for veterinary nursing programmes so that veterinary nurses are educated in end-of-life communication, grief and bereavement support.

Conclusion

Veterinary palliative and hospice care are emerging specialities that provide owners with a comfort-orientated, alternative option to premature euthanasia for terminally ill pets (Gregerson, 2016b), through the provision of palliative support and care for both the patient and family members (Marocchino, 2011). Hong et al (2016) suggested that individuals would prefer to die at home in familiar surroundings with family and friends; to want this for a family member is unsurprising, and as many owners consider companion animals as integral family members, veterinary palliative and hospice care may be a desirable third option for some owners (Hewson, 2015). Hewson (2015) and Cooney (2015) suggested that there is a reluctance to embrace the emerging palliative and hospice speciality within the UK veterinary profession for various reasons, one being that veterinary professionals value euthanasia as a gift and equate hospice care as being incompatible with euthanasia, with the belief that a natural death is synonymous with suffering. It has been suggested that palliative patients often receive inadequate care because of the medical philosophy which places great emphasis on curing a disease and doing everything possible to prevent death, thus perceiving death as a failure of care (Department of Health, 2008). Hospice reflects a philosophy of care that recognises death as a natural and inevitable process with the primary goal to maintain the terminally ill patient's wellbeing and dignity and to preserve quality of life (Cooney, 2015) through the prevention of physical and mental suffering rather than curative treatment (Marocchino, 2011). The aim is for the patient to die peacefully and free of pain and distress when the time is right, either by euthanasia or naturally (Hewson, 2015). Broadshaw (1996) claimed that care of the dying is the quintessential expression of nursing; in human medicine, palliative and hospice care is delivered by an interdisciplinary team of which nurses play a pivotal role. The development of the emerging hospice movement in the veterinary profession provide the veterinary nursing profession with an opportunity for professional growth and the development of specialist skills in palliative and hospice care so that terminally ill patients may receive high standards of individualised end-of-life care.

It has also been suggested that the reluctance to extend veterinary services into the field of hospice care is due to a lack of knowledge and experience into advanced end-of-life care (Cooney, 2016), with research showing that there has been minimal progress in the integration of palliative and end-of-life care into veterinary teaching (Fogle and Abrahamson, 1990, Dickinson et al, 2011, Dickinson and Paul, 2014). Companion animals are now living longer and this has resulted in an increase in pets with age-related conditions and co-morbidities being presented in practice (Villalobos, 2011a). Many owners no longer accept that the only option is that of early clinical euthanasia (Villalobos, 2011a; Gregerson, 2016b); as the expectations for high quality end-of-life care increases, further research into veterinary palliative and hospice care and increased end-of-life care training for veterinary professionals will hopefully lead to high quality end-of-life care provision for companion animals and owners. The human nursing profession contributed significantly to the development of hospice for people and the emerging veterinary hospice movement offers an exciting opportunity for the veterinary nurse profession to lead the way for veterinary hospice. Veterinary nurses can remind the veterinary profession that death is not representative of failure but is a natural and inevitable part of life and to help animals achieve a good death is the act of a caring and compassionate profession.

Key points