Looking after the end-of-life patient: four case studies

This article aims to give a brief but holistic look at end-of-life management, including some case studies which use an end-of-life framework.

There are thought to be four life stages (young, adult, senior, geriatric). However, it has been proposed that there should be a shift in thinking towards how life stages are classified (Gregersen, 2016a). There should be another life stage: ‘end-of-life’, which can occur after ‘geriatric’, or at any point during a pet's lifetime. Most owners value quality over quantity of life for their pet (Oyama et al, 2008). This study also revealed that owners were highly concerned about detection of perceived suffering in their pet. However, there is a profound mismatch between what owners expect from their veterinary practice in terms of their pet's care at the end-of-life, and what they receive (Gregersen, 2018). Euthanasia, for instance, has been in the top six of RCVS complaints every year, for over a decade (Gregersen 2016b). Historically, veterinary professionals have neglected this ‘fifth life stage’ in companion animals (Hewson, 2018). This lack of support and guidance may result in fear and anxiety for pet owners; and this fear and anxiety may lead to premature euthanasia, or delaying euthanasia, resulting in unnecessary suffering (Gregersen, 2016a).

An interesting survey by Heuberger et al (2016) showed that pet owners rate quality of life, end-of-life care, and pain management in their elderly pets as very important, but had little or no knowledge about the options available to them about any of these things. They also were unaware of, or had unrealistic expectations about cost. The survey also showed that, overwhelmingly, most pet owners would like to have their pet euthanased at home.

There may be differing opinions between veterinary professionals as to how end-of-life pets, with their unique problems, should be managed. A significant proportion of the pet keeping population will expect appropriate care for their pets, similar to that received by their human loved ones, through this stage and to the end.

Recognising that there is a gap in knowledge and caring for the veterinary end-of-life patient has led to emerging hospice and palliative care services.

Managing the end-of-life patient

Caring for a terminally or chronically ill pet is a challenging time for the caregivers and family. There is often a strong feeling from owners wanting to provide for their pet by ensuring their comfort, that they are not in pain, and that they are loved (Shanan, 2015). ‘Hospice’ care fulfils this role, and rather than focusing on fixing and curing, hospice care starts when there is recognition that a pet is seriously ill or no more investigations or cures are sought. The priorities and perspectives shift from constantly trying to get the individual to live, to instead helping the individual to have a peaceful, comfortable and dignified journey and passing (Shanan, 2015). Delivering this care considers the needs of the carers as well as the pet, and one of the aims is that the carer (or the pet's family) are well informed and have a feeling of control over their pet's wellbeing. This feeling of control reduces fear and anxiety in owners about looking after their pet at this stage. The aim is to ensure little or no regrets over the course of the journey.

The aim of managing the end-of-life patient is to:

• Minimise patient suffering — by alleviating pain and discomfort at all times
• Minimise care-giver suffering — by providing support, offered by regular communication by visits, phone calls and emails
• Chart a path of least regret — enabling caregivers to spend as much quality time as possible with their pets in peaceful, familiar surroundings with support and guidance where needed
• Create a profound and beautiful end-of-life experience offering supportive care during the last hours, days, weeks or months of the animals' life, to ensure a peaceful and dignified journey and passing (Shanan, 2015).

In general, there is a framework that, similarly to a nursing care plan, gives a complete consideration of these patients' requirements, and can be easily utilised in a hospital setting (Figure 1).

How can nurses help with end-of-life patients?

There is an opportunity for nurses to expand their role and be more involved with end-of-life patients, and their carers. Nurses can help implement plans for these patients (Figure 2), visit the patient at home for a nurse check, injection or simply be available to listen to the worries of pet owners and provide reassurance and advice. Nurses can advise owners on how to make lifestyle and environmental modifications for the pet at home to maximise comfort. For some examples, see Managing pain in common end-of-life conditions (Malik, 2019).

While the aim of hospice care is to manage the end-of-life patient at home, it is obvious that many of these patients, whether intended, ideal or not, spend their last days in hospital.

The framework in Figure 1 can be incorporated into veterinary practice, and there are four examples (two home cases, and two hospital cases) that utilise the framework in order to attempt a good level of care for an end-of-life patient. However, it must be noted that this particular framework focuses on the patient and does not involve the carer.

Case one (in hospital)

This patient (white and black) was a 6-year-old female entire rabbit with a 2 week history of a right sided head tilt (Figure 3). On examination she also had the following:

• Chronic bilateral corneal ulcers
• Tongue lesions
• Dental disease
• Dermatitis under her chin
• Pododermatitis
• Gut stasis
• Recumbency
• Ataxia.

Blood tests revealed a positive immunoglobulin G (IgG) titre for Encephalitozoon cuniculi, dehydration, and mild anaemia, which can be due to inflammation (Dettweiler et al, 2012). The following day she was sedated and a computed tomography (CT) scan of her head revealed moderate to severe dental disease, possible lysis of the maxillary and mandibular arcade, and normal ear canals.

With the extent of her problems, the decision was made after a few days to euthanase her.

Physical

• Pain levels were assessed by:
• Physiological parameters (temperature, pulse, respiration), gut sounds)
• Demeanour
• Behaviour
• Palpation of her head/jaw
• Movement/mobility
• The Rabbit Grimace Scale (RGS) (see https://www.nc3rs.org.uk/rabbit-grimace-scale).

Her physiological parameters were normal except for reduced/absent gut sounds, slightly pale mucous membranes, and slight hypothermia. Her demeanour was quiet, and behaviour was ‘inactive’. Inactivity is a very frequently cited (but unspecific) indicator of pain described in rabbits. She had difficulty mobilising, which may have been attributed to her head tilt and visual problems, however as her CT scan was only of her head, there is a likelihood (given her age and the presence of pododermatitis), for osteoarthritis, but this was not considered.

She scored 7/10 on the RGS on arrival in the evening and was started on buprenorphine at 0.03 mg/kg every 8 hours. Her overall pain score had improved slightly by the following morning, but the RGS score was 5/10 (which is still fairly high) and likely a result of painful corneal ulceration causing her to squint. She was quiet on admission and not eating or defecating. There was no reaction to palpation of her head and jaw, although rabbits do not always react to palpation. She was started on meloxicam 0.6 mg/kg twice daily (BID) by subcutaneous (SC) injection, following rehydration.

• Managing clinical signs: her treatment plan included ranitidine, syringe feeding and fluid therapy for gut stasis management. She was prescribed chloramphenicol and lubricant for her corneal ulcers, fenbendazole for E. cuniculi, and prochlorperazine (stemetil) to help with any nausea associated with the head tilt. She was rehydrated with warmed Hartmann's containing 20% Duphalyte™ (a protein/amino acid additive) to a total of 100 ml/kg/24 hour, which is maintenance in rabbits (Mitchell 2009). In addition, she was syringe fed a complete liquid convalescent diet for rabbits at 10 ml/kg, 4 hourly, which initially was Emeraid Herbivore™ due to its elemental properties which enable easier digestion in compromised individuals, then later on in the course of her stay this was gradually changed to Oxbow™.
• Hygiene: she received cleaning and treatment for her chin area area and pododermatitis, was groomed, and was able to groom herself after a few days.
• Nutrition: she received syringe feeding and assisted/tempting to eat. She began eating for herself after 2 days.
• Mobility: she was kept in a comfortable padded environment due to the ataxia and head tilt causing mobility issues.
• Safety and environment: she was kept in a padded kennel and received gentle slow handling to minimise the risk of her rolling or panicking. She was in an isolation ward away from other rabbits but with her companion, due to her E. cuniculi status.

Emotional

• Preserve dignity: she was treated, as far as possible in a busy department, respectfully and as an autonomous individual. Sanitation and hygiene were maintained.
• Preserve the pet's household role: she was a pet rabbit and she was treated as such in hospital.
• Maintain the will to live: she was housed with her companion and her behaviour was monitored for depression, withdrawal or deterioration. It is sometimes difficult to assess emotional state in ill or sick rabbits, but she responded to human and companion attention, and her demeanour and clinical signs improved during her hospital stay.
• Stress reduction: she received time to rest outside of treatment times and was housed in a ward away from predators. She did not appear to be overtly stressed with the head tilt.

Social

• Engagement with family: received one visit from owners (apart from pre-euthanasia).
• Engagement with pets: housed with her companion. Their behaviour was monitored, they both appeared to benefit from being with each other, and there were no obvious problems. The companion was often observed grooming her.
• Mental stimulation: it is sometimes difficult to ensure mental stimulation in hospital and the requirement depends on the condition of the patient. She received an appropriate and varied diet to reduce boredom, and social interaction from staff. She was seen engaging in social behaviour with her companion.

Reflective

• Given the degree of dental disease and corneal ulceration, the potential of undiagnosed osteoarthritis, and the likelihood of head tilt causing musculoskeletal (i.e. neck or spinal) pain, it may have been more appropriate to have started her on a full agonist opioid initially, rather than buprenorphine.
• Unfortunately, pain assessment was not continued after meloxicam was started, but she did gradually improve in demeanour, clinical signs and behaviour.
• It may have been more ideal for her to have had initial stabilisation in hospital, then hospice care and euthanasia at home.

Case two (in hospital)

This patient was a 33-year-old African Grey parrot (Figure 4) presenting with dyspnoea and lethargy. On arrival he received some first aid treatments (SC fluids, warmth, oxygen) and was later started on medication to cover suspected cardiac, respiratory and liver disease. The plan was to place an intravenous (IV) catheter and perform diagnostics under general anaesthetic once he was more stable. The following day he had a therapeutic coleocentesis (equivalent to an abdomenocentesis) and 9 ml of fluid was drained from his coelom (‘abdomen’). He was in hospital for 3 days.

Physical

• Pain: it is difficult to assess pain in birds, although research in this area is growing and a number of researchers have described avian pain behaviours (for a basic overview, see Malik and Valentine, 2018). His condition meant it was difficult to assess him specifically for pain; but his condition also made pain a potential factor.

He was therefore prescribed analgesia by:

• Anology (i.e. we know cardio – respiratory conditions and abdominal effusion can cause discomfort in humans, cats and dogs)
• Giving the benefit of the doubt (Cracknell, 2007; National Research Council, 2009).

In this instance, he was prescribed tramadol. There was also a likely potential for osteoarthritis, given his age, although this was not considered at the time.

• Managing clinical signs: his treatment plan included cardiac, liver medication, antibiotics, and antifungals to manage any signs that may be associated with the coleomic effusion and resulting dyspnoea. He received three furosemide doses based on respiratory assessment. He was on SC fluid therapy (warmed Hartmann's, containing 20% duphalyte) every 4 hours. He received low doses of intranasal midazolam sedation to manage dyspnoea.
• Hygiene: he was recumbent most of the time, therefore it was ensured that his vent and beak were kept clean and he had regular bed changes.
• Nutrition: he was eating small amounts for himself and was tempted to eat with fruit and vegetables. Bowls were kept accessible to him. He was crop fed a liquid omnivore diet (Emeraid Omnivore™) every 4 hours during the day to maintain nutrition.
• Mobility: he was kept in sternal recumbency in a donutringed towel on a padded bed. He was handled every 4 hours, therefore his position was altered slightly each time, to reduce risk of pressure sores or numbness.
• Safety and environment: his low perch was removed after recognising that when sedated he was unable to perch. He was kept in a separate air space to other birds.

Social

• Engagement with family: he received one visit from his family.
• Engagement with other pets: he was the only pet.
• Mental stimulation: he was generally lightly sedated so this was non-applicable, but he was talked to (and he often talked back). He received social interaction from staff when not receiving treatment or medication.

Emotional

• Preserve dignity: he was treated, as much as possible in a busy hospital, respectfully as an autonomous individual. Sanitation and hygiene were maintained.
• Preserve pet's household role: he was a pet parrot and treated as such in hospital.
• Maintain the will to live: he was monitored for signs of depression and withdrawal. In this case, the owners had filled in a questionnaire about their pet's care, and his normal demeanour at home was described as ‘interactive, friendly and talkative’. Although it is difficult to tell in the condition he was in, he was always (although weakly) interactive, friendly and talkative when roused from his sedation.
• Stress reduction: he was kept on a low dose of sedation to manage stress and anxiety associated with dyspnoea. He was in a quiet ward away from predators and received gentle quiet handling.

Reflective

• Diagnostics should have been done following stabilisation, to be able to know what the problem was in order to treat it.
• It would have been ideal for him to have had hospice care and euthanasia at home following a diagnosis and initial hospital stabilisation. However, given the severity of his condition it was entirely appropriate to have kept him in hospital.

Case three (at home)

A feline domestic shorthair presented to the practice 5 days after being adopted as a geriatric stray, with an estimated age of 15–20 years old (Figure 5). He had the following issues:

• Emaciation
• Undiagnosed neurological problem (likely partial intervertebral disc extrusion/protrusion from an old injury) causing hindlimb ataxia and muscle wastage
• Constipation
• Dental disease
• Deafness
• Hyperaesthesia over the thoracic area of the body, minor occasional facial twitch
• Mildmoderate cognitive dysfunction.

On arrival after settling in he had a ‘Vets2Home'Quality of Life Score which scored 7 (needs intervention). He had veterinary examination and a blood pressure reading (which was normal), and blood tests which revealed early renal failure. He required dental treatment and an enema. For his anaesthetic procedure, prior to premedication, he was administered IV fluid therapy prior, peri and post-operatively, and was incubator warmed pre- and post-operatively. Anaesthesia was monitored by a qualified and registered veterinary nurse and included multi-parameter use with capnography, electrocardiography (ECG), peripheral capillary oxygen saturation (SPO₂), temperature, and non-invasive oscillometric blood pressure, alongside normal human monitoring. He required four extractions and had a lidocaine dental block in order to reduce pain, reduce isofluorane levels, and minimise the requirement for meloxicam during a potentially hypotensive period under anaesthesia. He did initially have hypotension which responded well to a half dose of IV atropine. He received meloxicam at 0.2 mg/kg SC once normotensive, normothermic and fully conscious. Post-operatively his medication plan included 0.05 mg/kg meloxicam once daily (SID), 10 mg/kg gabapentin BID, lactulose 1–3 ml BID, a joint supplement (YuMove™, Lintbells), a supplement for brain-related ageing (Aktivait™, VetPlus), a supplement to help reduce cognitive dysfunction-related anxiety (Zylkene™, Vetoquinol), and a dietary fibre supplement (Profibre™, Protexin), and renal diet.

Following stabilisation and treatment he was re-scored on the ‘Vets2Home’ Quality of Life Score and scored 9.5, which indicated that no interventions were needed.

Physical

• Pain levels were assessed by:
• Stiffness and gait
• Movement and mobility
• Range of movements
• Palpation
• Demeanour
• Behaviour
• The Feline Musculoskeletal Pain Index, but this had some limitations regarding his neurological dysfunction.

Prior to starting analgesia he had a crouched posture, stiffness in forelimb gait and resented extension of his hindlimbs. He occasionally fell over when posturing to use his tray. He did not use any surfaces such as tables or chairs.

The above pain parameters measured improved on meloxicam and gabapentin. He started jumping down from surfaces, climbing up onto surfaces and he was able to position himself better to use his tray, and ceased to fall over when toiletting. His forelimb gait remained occasionally stiff. He was started on a joint supplement which led to a further improvement. His standing and lying postures improved.

His chronic pain was frequently monitored. He occasionally flinched on spinal palpation and lip licked on palpation of his abdomen, therefore gabapentin frequency was increased from 10 mg/kg BID to three times a day (TID) which resolved this behaviour. He had an orthopaedic bed and a heat pad at night to help any pain-related issues and reduce any hypothermia that may occur due to his poor body condition. He was started on physiotherapy (Figure 6) and laser therapy (Figure 7), and there is potential to consider other alternative pharmaceuticals such as amitryptilline, amantadine, or buprenorphine. At the time of writing he is starting acupuncture. Hydrotherapy is also an option in suitable candidates for his condition. It is generally accepted now that patient quality of life is more important than any future impact of medication. Studies have shown that cats with stable renal failure and concurrent chronic pain can be well managed on meloxicam with regular monitoring. This does not affect longevity (Gowan et al 2011, 2012). A plan in advance was made for his endpoint, which would be in the event of deterioration of quality of life, once a pre-determined limit to interventions had been reached. The plan would be to administer analgesia and anti-emetics if indicated (given his spinal condition and renal disease), place an IV cannula, and euthanase him at home.

• Managing clinical signs: he received regular weight, blood pressure and urinalysis checks alongside blood tests that were initially senior profiles, but later testing specifically for renal function. He was later started on benazepril at 1.25 mg once daily to help treat borderline hypertension and proteinuria. A combination of lactulose and a dietary fibre supplement (Profibre™, Protexin) successfully managed his constipation.
• Hygiene: he had difficulty using his litter tray therefore a mesh tray/step was made to catch urine and minimise soiling. He had a reduced ability to clean himself, therefore his owners ensured he was kept clean. Following treatment, his ability to use his litter tray improved.
• Nutrition: he always ate well and was on a wet renal diet, on a plan for weight gain.
• Mobility: he was unable to jump up, therefore he had a step and ramps to access his bed, tray or the back door. He had raised bowls. He enjoyed his physiotherapy session and had regular garden walks on a harness.
• Safety and environment: he required frequent regular monitoring and supervision, due to being a fall risk.

Emotional

• Preserve dignity: as much as possible, he was treated respectfully as an autonomous individual. Sanitation and hygiene were maintained.
• Preserve current role: he was thought to be a companion cat and was expected to continue this role.
• Maintain the will to live: he was monitored for signs of anxiety, depression and withdrawal, and was a valued member of the family. Following treatment and settling in it became apparent that his favourite pastimes included: trying to get inside the dishwasher; watching people cook food and food begging; and raiding the bin. He gradually and occasionally started exhibiting normal cat behaviour, such as grooming himself, exploring new surroundings, and scratching the sofa.
• Stress reduction: he was introduced to new things gradually, kept to a stable and familiar routine, and supervised constantly when out in the garden. He had a pheromone diffuser and was started on a dietary supplement to reduce anxiety, to help mild cognitive dysfunction-related anxiety in the evenings. Patients with cognitive dysfunction are at risk from stress such as fear, phobias and anxiety (Landsberg et al, 2012).

Social

• Engagement with family: he was treated as a member of the family, which was suspected to be his role before.
• Mental stimulation: he received regular fuss, and slight changes to walking routine and terrain each day, to maintain interest. He received dry food or treats in puzzle feeders and balls to maintain interest and brain function.

Reflective

• It may have been appropriate to have done further imaging such as an magnetic resonance imaging (MRI)/CT or radiographs under anaesthetic, as a second priority after having an enema and dental treatment, in order to determine the neurological issue and location of arthritic changes.

There were limitations such as: cost; the pros and cons of doing surgery (if he were a surgical case); the fact he was a hypotension and hypothermia risk under anaesthetic; and his age. A risk–benefit analysis may have indicated giving him benefit of the doubt and forgoing exact diagnostics, but treating for the high likelihood of a possible old traumatic intervertebral disc issue. However there is no one best course of action.

Case 4 (at home)

This patient was a 13-year-old female German Shepherd cross (Figure 8), presented to palliative care veterinary surgeon for at-home hospice care. Her main issue was advanced osteoarthritis.

She was rescued as a puppy, found abandoned with two open femoral fractures. Due to complications, she had chronic thickening and decreased mobility in her right stifle, decreased mobility in both hips, and an uneven gait. She was diagnosed with hip dysplasia and osteoarthritis in both hips and was on and off non-steroidal anti-inflammatory drugs (NSAIDs) from middle age onwards. She went onto NSAIDs long-term, aged 9 years. She had congestive heart failure which appeared to be well controlled on pimobendan, and a previous vestibular episode. On presentation during initial consultation, there were the following findings:

• Good condition, bright, alert and responsive
• Some bronchial sounds, and a positive tracheal pinch
• A grade five heart murmur, but no coughing or breathlessness
• Advanced osteoarthritis involving the hips, stifles and elbows
• Decreased mobility and uneven gait
• Infected sore spot on her hind limb due to licking, which was painful to touch.

She was fed once daily on dry senior diet, and was only able to walk for 10 minutes slowly, once daily for exercise. She was a friendly and inquisitive dog, eager to please her family. Her family reported restlessness and panting in the evenings, which may have been attributed to an end of dose failure, as she was on meloxicam SID. She lived with two young dogs, two young children, and the mother and father (the carers). The aim for her hospice care was to improve her comfort, mobility and her quality of life.

A plan was also made for her endpoint. The family agreed in advance that she would be euthanased at home if she was unable to get up, or if she had a recurrence of vestibular syndrome. They all wanted to be present to say goodbye. It was planned that she would be sedated prior to being put to sleep, and have an IV cannula placed.

The author implemented a five-step hospice plan (see Figure 2). The plan has been adapted into its constituent parts here, to fit the basic framework used in the other cases.

Physical

• Pain was assessed by:
• Behaviour
• Demeanour
• Movement/mobility
• Range of movement
• Palpation.

This patient was on long-term meloxicam (0.1 mg/kg SID), but this was insufficient for her pain levels. She resented manipulation of both hind limbs, had stiffness in both elbows, and an uneven gait resulting in scuffed nails on her right hind foot. She managed to get up and down from sitting or lying down fairly easily, but looked uncomfortable when getting up and was limited in her ability to walk far. She was licking an area on her hind limb, and was panting and restless in the evenings, which may have been attributed to when her meloxicam was due. The decision was to add in tramadol at 100 mg BID, and after a few weeks her pain control still seemed inadequate, so gabapentin at 150 mg twice daily (after a gradual dose increase) was prescribed.

This seemed to alleviate her pain. Her panting and restlessness in the evenings were reduced.

• Managing clinical signs: in addition, she was administered a chondroprotectant (1010 mg glucosamine HCL, 800 mg chondroitin sulphate, 80 mg vitamin C and 150 mg Boswellia extract) on a loading dose for 6 weeks. Then the dose was halved. Her heart disease was already well managed on pimobendan 5 mg BID. She required antibiotics for the infected area on her leg.
• Hygiene: she was able to maintain hygiene.
• Nutrition: she was transitioned from senior dry diet SID to Hills Joint Diet, BID, for its joint support properties. She had a good appetite and body condition.
• Mobility: on presentation she scored low on ‘mobility’ in the quality of life scales. In addition to the analgesia and supplements, she was started on acupuncture and hydrotherapy sessions. She was recommended an orthopaedic dog bed to rest on if she needed to sleep away from the other dogs, non-slip matting, a ramp to go outside if the need arose, and a boot for her right hind foot if the scuffing became worse. She was started on walks twice daily. After treatment was initiated, the owners reported that she was keen to go on walks, but still only able to walk for 10 minutes each time.
• Safety and environment: it was recommended to place a stairgate at the bottom of the stairs to eliminate the possibility of her falling, along with non-slip matting on laminate floors and raised bowls to help with her elbow pain.

Emotional

• Preserve dignity: she was assumed to be treated as she was before, which was respectfully, as a member of the family.
• Preserve the pet's household role: she was a member of the family and companion/pet, and it was assumed she continued this role.
• Maintain the will to live: she was monitored closely for signs of depression and withdrawal. She was scored regularly on two different quality of life (QoL) scales. She initially scored low on ‘doing her favourite things’ (which was chewing bones and toys in the garden), and the owners had reported a recent reduction in these activities. The total QoL scores began to increase as she improved on the care plan.
• Stress reduction: it was advised that she was given a separate area to rest and time away from the two younger dogs, for a small part of the day.

Social

• Engagement with family: on initial presentation she was scoring low on ‘interacting with the family’. The total QoL scores began to increase as she improved on the care plan. She was encouraged to interact with the family in the evenings when they were all there.
• Engagement with pets: she lived with two other dogs, and they all slept together in one place. There was no report of any adverse interactions between them.
• Mental stimulation: she was provided with safe chews and hide bones when away from the other dogs, and advised to have time to relax in the garden or on walks.

Reflective

• The veterinary surgeon in charge of this case may not have chosen tramadol had she been aware of how few studies there were. This patient disliked her acupuncture sessions, so the veterinary surgeon in charge of this case believes it may have been fairer to discontinue them, but at the time it seemed important to the owner to continue them. The family were provided with a comfort kit, which was an injection of acepromazine and buprenorphine to administer intramuscular (IM), in an urgent situation (under veterinary direction via a phone call). However, the veterinary surgeon in charge of this case now believes that fentanyl would have been more appropriate to manage breakthrough pain.

QoL scales

In human medicine, there has been a shift from using terms in disease prognosis such as ‘survival times,’ to considering quality of life (‘quality adjusted years’). Some human QoL scales independently predict mortality in some disease states; other human QoL scales have been shown to be a better predictor of survival than tumour size in some cancers (Mullan, 2015).

There are several quality of life scales available for pets, which can be used for assessment and on-going monitoring (HHHHHMM scale: https://my.vetmatrix.com/0033049/storage/app/media/5c2145cb7e460_Qual-ityofLifeScale.pdf; Vets2Home Scale: http://www.peacefulpetgoodbyes.uk/wp-content/uploads/2018/05/QOL-Checker-for-website.pdf). Some QoL scales are specific to certain conditions. However, it is worth remembering that there is no ‘one size fits all’ and, similarly to pain scales, there are often some flaws and drawbacks to all of them.

A note on cognitive dysfunction

It is important to recognise that cognitive dysfunction is a common and undiagnosed condition in older pets that needs thoroughly ‘working up’, in order to rule out medical disorders or pain conditions, prior to making a diagnosis. A full discussion is beyond the scope of this article. A useful paper discussing cases in cats is Gunn-Moore (2011), and dogs is Druce (2014) and Stott (2018). The authors were not able to find any research on cognitive dysfunction in exotics. Once a diagnosis has been reached, there are numerous lifestyle, environmental and pharmaceutical agents that can greatly benefit pets with this condition (Warnes, 2015).

Conclusion

When veterinary staff are presented with an elderly or geriatric patient in clinic, whether it is a dog, cat, guinea pig, rat, tortoise or chicken, by communicating compassionately with the owner, they should determine whether the patient is senior or geriatric, or in fact an end-of-life patient (i.e. fifth life stage). In addition, it is worth remembering that often in these end-of-life situations, pet owners are not interested in how much you know but in how much you care (Fox, 2014).

It has been suggested that ‘put to sleep’ can also stand for ‘preparation, time and support’ and by considering these three factors, the best and most consistent outcome is achieved for everyone involved — the pet, the owner, and the veterinary team (Gregersen, (2016a/b). Veterinary nurses have an important role in supporting the owner and pet through this difficult but potentially rewarding time. How owners first acquired their pet, and how they lost them, are often the two biggest memories they will hold on to (Gregersen, 2016b).

It is important to remember that inappropriate palliative or hospice care can prolong suffering (Nolen, 2007); and that as much as welfare science researches into the feelings and emotions of animals to give us evidence for positive and negative welfare states, we will never really know what animal patients are going through (Dawkins, 2012). However, we can only do the ‘best’ we can, and it is beginning to be accepted that there is a gap in the care provided for end-of-life animals, which needs addressing.

The authors believe the future of planned ‘euthanasia’ will no longer be in rushed 10 minute appointment called in from a busy waiting area, on a cold steel table in a consultation room, but instead in the peace and comfort of the pet's own home, under sedation if necessary, with the pet's family present.

Veterinary nurses may spend more time with patients facing death than any other member of the team. Nurses are an advocate for their patient's wellbeing. It is important that they approach end-of-life care as professionals, by educating themselves. Recognising a patient's pain, respiratory distress, hunger, thirst, fatigue, anxiety, depression or agitation, will ensure that the dying process is as peaceful and pain-free as it can be (Shanan, 2015), and that a euthanasia decision may be chosen at the ‘right time’; not too soon, nor too late. And what could be a complicated, difficult and fraught time for owners, pets and veterinary professionals alike, can instead be a well–planned, peaceful, dignified, and comfortable period of time for the pet, spent loved by its family ‘until the last good day’ (Downing, 2017).

KEY POINTS

• There is a fifth life stage at any stage, not just after geriatric: ‘end-of-life’ can be at any point in a pet's life.
• End-of-life patients are vulnerable, needing extra care and often have multiple problems.
• These problems, with careful consideration, on-going assessment, evaluation and effective communication with the owner, can be very effectively managed.