In-home hospice provision — a viable option for veterinary palliative care?

Ethics of hospice care

Veterinary personnel have a loyalty to their dying patients which creates an ethical dilemma. Villalobos (2009) stated that veterinary surgeons have taken an oath to prevent suffering and been advised not to discharge pets that cannot stand or function. However, when dealing with terminal cases, veterinary staff are being asked to rethink the situation and provide in-home hospice provision. This situation requires loyalty to the patient's physical needs during progression towards death, but also loyalty to the client's emotional needs and respect for the human–animal bond.

Villalobos (2009) suggested that with education and counselling, clients who wish to take their terminally ill pets home should be allowed to do so. Clients are often much more at ease with a pet's death if their personal preferences are honoured.

Special allowances from normal practice protocols will be required for overtly terminally ill patients. Consent must be gained from the client for the transfer from the veterinary practice to the home (Villalobos, 2009). The client's record should be updated to state that the patient is terminal and/or incapacitated and is being taken home with appropriate analgesia and limited supportive care at the bequest of the family for hospice care and euthanasia once quality of life becomes inappropriate (Villalobos, 2009). Such a compassionate approach to care parallels the human hospice movement.

Shearer (2011) developed a five-step strategy for comprehensive veterinary palliative and hospice care that can be utilised as a starting point in developing a practice protocol and allowing veterinary personnel to feel confident that in implementing a home-care programme, no process of care has been neglected (Table 2).

Considering hospice care at home

Before an owner can commit to in-home hospice care, they should be fully aware of the disease condition and how it may progress. A thorough understanding of the disease process and anticipation of clinical signs will enable the pet owner to make an informed decision regarding their pet's care (Figure 2).

Shearer (2011) stated that the information shared should be based on the pet owner's need to know but should include information about the disease and its trajectory. An illness trajectory can be defined as a generalised pattern that a group of diseases follow (Murray et al, 2005). Thinking in terms of a disease trajectory provides a broad time frame and patterns of probable need that can, conceptually at least, be mapped out towards death (Murray et al, 2005). A pet owner's goals and priorities may vary and transform as the disease progresses, therefore, they should be made aware that if they commit to a home-care hospice programme, the situation will be closely monitored and if at any point management becomes difficult the situation will be reviewed.

A supportive, coaching approach from the veterinary team is essential to help clients address the needs of their terminally ill pet at home. The development of an individualised care plan for both the pet and family members is essential and should include consideration of stage one of Shearer's (2011) five-step approach to hospice care, evaluation of the pet owner's needs, beliefs and goal for their pet. The veterinary team must be respectful of such beliefs and facilitate them wherever possible, however the prime responsibilities are to preserve quality of life by limiting side effects of the disease and implementing a plan that works for both the pet and family. It is essential that all family members who will be involved with the care of the pet are consulted, as there may be differing views on the pet's care amongst family members, which should be taken into account when developing the plan (Shearer, 2011). The development of the care plan should not be rushed and it must be clearly ascertained how much the pet owner can contribute to the level of care required, this will dictate how much external care is required and if, in fact, a home-care programme is a viable option for this pet and owner. Clients should be clearly informed of their responsibilities as well as the services to be provided by the veterinary practice. Optimally, veterinary care should be available at all times and may include after-hours referral for emergency care, advice or euthanasia. The situations or times of the day/week that would require that a client be referred should be explained to the client at the onset of a hospice home-care plan, and at any point during the care if they should change (American Veterinary Medical Association, 2014). Provision of such a service can place huge demands on a busy veterinary practice and may require additional, specialised staff to meet demand.

The treatment options included in the care plan need to match the beliefs and values of the owner while remaining in the best interest of the pet. When developing a care plan, Shearer (2011) stated that owners must be made aware that it is important to treat all processes that interfere with quality of life. For example, the veterinary surgeon should treat otitis, even in a terminally ill patient, to prevent additional discomfort from the painful ear.

The veterinary team should take all steps to ensure that owners are both mentally and physically prepared to cope with any situation that may arise as their pet's condition deteriorates. McVety (2012) suggested owners should know the steps to take in case their pet suddenly becomes uncomfortable, begins to suffer, or dies.

Setting up a home-care environment

Assessment of the home environment is desirable in the development of an individualised care plan and such an assessment may be undertaken by a qualified veterinary nurse. Confinement to a restricted area of the house will likely prove necessary as most terminally ill pets are going to have compromised mobility and reduced mentation in the final days of their life.

Consideration of the type of flooring will need to be given to patients with compromised mobility; good traction will be essential to minimise the risk of falls. Stairways will also need to be blocked off for pets that are unsteady on their feet. Rugs with rubber backing may be suggested for use on slippery surfaces; the rubber backing, while preventing slippage, will also protect the underlying floor if the pet is incontinent. Incontinence is an issue that should be discussed with the family members as many terminally ill patients will develop urinary and/or faecal incontinence. Owners must be educated regarding the prevention of urine and faecal scald along with the basics of good hygiene practices. The veterinary nurse can offer advice regarding the wearing of personal protective equipment and appropriate disposal of soiled materials along with safe disposal of any sharps used. These are important considerations about which pet owners must be thoroughly informed prior to committing to a home-care hospice programme (Figure 3).

Ideally a social location within the home should be selected as the pet's designated area; this will enable the pet to be part of the normal family activities, especially if this is what it has been used to. The issue of incontinence will however have to be considered again here. It should be noted however that some terminally ill pets may prefer to be in a more peaceful location which is more conducive to rest; this should be facilitated where possible.

All areas in which the pet will reside must have access to drinking water in order that the animal does not have to physically move to another location to get a drink; such a strategy will help to minimise the risk of dehydration (Shearer, 2011).

Application of home-care hospice techniques

Provision of home-hospice care will require the owner, and possibly other family members, to provide medication and care techniques detailed in the care plan. Subject to the provisions of the Veterinary Surgeons Act (1966), the veterinary team should be prepared to train clients in the administration of medications and other necessary routine care. Shearer (2011) recommended that clients are shown how to perform a technique, and then be required to demonstrate the technique back. For example, a veterinary nurse could demonstrate how to administer a subcutaneous injection; the pet owner would then demonstrate the technique back to the veterinary nurse in order that their level of competency may be assessed. Written instructions should also be provided to the client for clarification and review. Dependent on the pet's disease and the individual care plan in place, owners may need to be shown such techniques as how to manually express the bladder, increase fluid intake/hydration status or methods to assist with mobility. Educating clients regarding their pet's condition and teaching them how to provide certain types of care in the home increases their confidence and sense of control, thereby allowing them to better evaluate their pet's condition, particularly during stressful circumstances, and empowers them to take appropriate action to minimise pain and suffering (McVety, 2012). If, however, owners are not comfortable in the administration of medication or certain techniques this need not mean that in-home hospice care is not a viable option for the care of their pet. The veterinary practice could consider offering a district nursing service where qualified personnel could, under veterinary direction, visit the owner and their pet to assess quality of life, perform appropriate nursing interventions and provide encouragement and support during this difficult period.

Management of pain is an important consideration in the terminally ill patient. For pets that are difficult to medicate, oral medications may be compounded into a more palatable medication or administered subcutaneously if owners are comfortable and competent with the procedure; it may also be possible to reconstitute medication to a transdermal or transmucosal formulation (McVety, 2012). What must be of paramount concern here is that the patient's level of analgesia is not severely compromised because it is being cared for in the home environment.

A pain assessment should be performed and it is essential that this involves more than simple observation of the patient. There must be interaction with the pet and the evaluator must have some knowledge of the pet's normal behaviours to have a context within which to place the pain assessment parameters (Downing, 2011). Various pain scoring systems and pain scales may be employed here, it is not so important which pain scale is chosen as it is to choose one. All personnel caring for the pet must then be fully briefed and trained in its use. Downing (2011) however, raised the interesting point that cancer pain, which is common amongst hospice patients, often possesses characteristics associated with both acute and chronic pain. This may pose a challenge therefore, unless a pain scale appropriate for assessing acute pain and a pain scale best suited for chronic pain is applied. Through a combination of regular physical evaluation, with open and honest dialogue with the client regarding their pet's day-to-day reality, veterinary personnel can work with the pet owner to anticipate, prevent, locate and relieve pain in the in-home hospice patient.

All medications should be reviewed and the owner must understand the role and frequency of each drug prescribed. Downing et al (2011) stated that the veterinary team have an ethical and moral obligation to the patient and pet owner to assist in the appropriate delivery of prescribed medications. Appropriate delivery may be as simple as providing a pill container such as those used by human patients, with compartments for day and time and/or blank spread sheets that clients can customise, complete and post in a central location. Such memory aids can encourage the regular delivery of medication to the pet and help prevent over dosing. Strict records must be kept and maintained by the practice surrounding all medications and supplies dispensed.

It is essential that the veterinary team recognise that caring for a terminally ill pet is an emotional and stressful time for the whole family and, despite training by qualified personnel, clients may not be able to perform necessary medical treatments in the home setting. Good communication and regular visits will enable veterinary personnel to assess how well clients are coping with treatment protocols. Accurate records of all interactions with patients and clients, including visits, telephone conversations, patient observations, treatments and instructions must be kept (AVMA, 2014).

Emotional support during the care process and after death of the pet

It is important to remember that the family can be suffering even if the patient is not (Loseth, 2002). Owners may need help in discussing the questions and conflicts they are experiencing because of their pet's illness. In addition to veterinary staff, clients may need support from external services such as a trained counsellor or pet bereavement support group. Contact numbers for such services should be readily available to clients both in preparing for and coping after euthanasia.

Further considerations

Hospice patients are likely to need daily supportive services at the veterinary practice or via home visits. Such services are the key to sustaining a high-quality hospice service for pet owners, particularly those who are employed (Villalobos, 2009); these will however incur additional costs. As with any service, fees should be discussed and agreed on before hospice care is provided (AVMA, 2014). Financial concerns of the family should be addressed but should not alter the sharing of treatment options for the pet. It is not unusual for pet owners with little means to find the resources to get the best care for their pets; however any financial constraints must be respected when designing the individual care plan (Shearer, 2011).

Determining what to charge for hospice-related services can, however, prove problematic. Establishing fees is easier in stationary practices, but difficult for in-home hospice provision. In-home hospice consultations and examinations take much more time than traditional appointments, with McVety (2012) stating it is difficult to charge for services that need to be repeated, especially in the case of services only a veterinary surgeon can perform, for example, thoracocentesis. It may be necessary to have two tiers of fees in place, one for veterinary nurse time and one for veterinary surgeon time.

A practice vehicle will be required in order to make home visits; besides the initial financial outlay of this, running costs, fuel and insurance will all need to be factored into the overall cost of the programme.

Safety of veterinary personnel involved in the delivery of home-hospice care programmes is an important factor which must not be overlooked. Downing et al (2011) suggested a written practice protocol should be in place detailing such things as having two staff members attend a visit wherever possible, ensuring at least one other team member knows the details and timing of the proposed visit, and staff always carrying a mobile telephone.

The emotional wellbeing of veterinary personnel who deliver hospice care is also important, as the role is emotionally and physically demanding. In order to specialise as a Macmillan nurse, NHS nurses must have a minimum of 5 years’ post registration clinical experience, with at least 2 of these within an oncology or palliative care setting. It is essential, therefore, that veterinary personnel who elect to pursue such a role in veterinary practice are provided with the necessary training and support network.

The future

A small number of mobile veterinary hospice and palliative care services do currently operate successfully within the UK, creating individualised home-care plans for terminally ill patients and home-based euthanasia and client support — interested parties are directed to www.vets2home.co.uk and www.dignified-departures.co.uk for further information. The author hopes that the success of such programmes both in the US and now in the UK will drive more veterinary practices to either implement such a service themselves or offer referral to a dedicated service, resulting in increased continuing professional development for veterinary personnel and further opportunities to specialise within this rewarding field of veterinary care.

Conclusion

Palliative and end-of-life issues are almost everyday occurrences for veterinary personnel, however these are typically not everyday concerns for pet owners.

Veterinary personnel therefore have an obligation to effectively coordinate and communicate details to clients to ensure they are fully informed of the disease trajectory and nursing care required prior to committing to a home-hospice care programme for their terminally ill pet. The process can be made more efficient by applying the five-step strategy for comprehensive palliative and hospice care (Shearer, 2011). This, combined with an individualised care plan and regular review meetings, should reassure both the client and American Veterinary Medical the veterinary team that no aspect of care is being neglected.