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2008 Ontario VMA Conference
February 1, 2008 2:30PM-3:30 PM
Dr. Alice Villalobos
Ask the family if they have experienced the amazing help that the American home hospice care movement has provided for a terminally ill friend or family member. They may be interested to know that the hospice movement in America emerged from nurses and caregivers rather than doctors. Despite the lack of financial support from national fund raising campaigns, the veterinary profession can emulate the concern and care exemplified by the hospice concept. Veterinarians can win client loyalty by respecting and preserving the special bond that connects clients to their pets and keeps our profession so celebrated. If the veterinary team helps to control pain and provide nutrition in a peaceful hospice way, client-caregivers gain confidence. They also gain courage for themselves and will look back at the pawspice experience with satisfaction.
Satisfaction: An Important Ingredient for Pawspice Care.
Periodically it is important to ask members of the family if they are satisfied with the pawspice arrangement. At times, there is conflict in the family about how attached the main care giver is to the pet. Some family members feel inconvenienced with the soiling, the odors, the sacrifice, the sadness or the diverted attention and devotion of the caregiver. This issue of disapproval creates a double-edged sword for the patient’s main caregiver to deal with on a daily basis. I like to address this issue directly with the family so they can come to a supportive consensus. If this issue goes beyond your personal counseling ability, definitely suggest a family counselor and provide a referral card.
Determine within yourself, as the doctor, and with your professional staff, if it feels rewarding to help preserve the bond between this person and this pet. If these positive ingredients are present, then Pawspice is a good experience for all involved.
Hospice Programs Around the Country
End of life care is being taught in many veterinary schools now, as an active part of patient care. The pet hospice program at CSU is staffed and run by veterinary students, and supported by faculty advisors in the College of Veterinary Medicine. Animal hospitals in the greater Ft Collins area refer terminal patients to the Veterinary Teaching Hospital Hospice Program. Every patient and caregiver is required to have a relationship with a local DVM, and that veterinarian is constantly updated about the health status of the animal and the emotional needs of the owners. The referring veterinarian also ensures that the Hospice Case Managers understand the patient’s medical needs. Many local veterinarians who work with the CSU Hospice Program will perform home euthanasia.
The goal of the CSU hospice is to create the best end-of-life experience for both patient and family in their home, assuming that the pet can be made comfortable at home. They teach their students that when a terminal pet's medical needs can be met at home, that's where the pet should be. If the family feels they need extra time to say goodbye, or if an animal is diagnosed with a terminal illness, but has good general health, hospice can help by visiting the home and making sure the pet's needs are met in that environment. Student participant, Christie C. Long Professional Veterinary Medicine Class of 2007 says, “We find ourselves in many situations providing extensive emotional support to owners, especially in helping them determine when it's time to euthanize their animals.”
Many house call practitioners tell me that a significant percentage of their practices is supportive of animals with end of life care needs. Dr. Tami Shearer has set up a nonprofit Pet Hospice Practice in the Columbus Ohio area. She provides second opinions, pain control and rehabilitation services for patients along with instruction and workshops for caregivers. Dr. Shearer set up a five-step hospice protocol to help organize the process of educating pet caregivers and to teach other veterinarians expanded end of life hospice care ideas for their needy patients and their families.
Pet Hospice Center 5-Step Strategy for Comprehensive Care
1. Evaluation of the pet owner’s needs, beliefs, and goals for the pet.
2. Education about the disease process, aging and pain management.
3. Development of a personalized plan for the pet and pet owner.
4. Application of hospice care techniques.
5. Emotional support during and after the process.
Dr. Shearer uses a talented team to accomplish hospice care. The hospice team consists of a full veterinary staff, human hospice medical advisors, an ethicist, clergy, psychologists, social workers, and volunteers. Dr. Shearer said, “The center is a place where pet owner's come with their pets to be educated. They return home to continue the pet's care. We rarely have pets and pet owners stay at the facility even though it could accommodate them.”
Practical Ideas for Some Specific Disease Conditions
CRF: Renal failure patients fed special modified diets such as Hill’s K/D or Select Balance, Modified Diet, may survive with a better quality of life if they are supported with educated home care which includes: subcutaneous fluids, Tumil-K, Pepcid, Amphogel, vitamins, and fatty acids (safflower oil or fish oils). Regularly scheduled recheck exams and laboratory profiles and CBC’s can monitor renal function, acidosis and anemia. Erythropoietin may be used to bring low PCV levels back up to normal. One cat in this author’s practice survived six happy years at home on daily subcutaneous fluids, finally passing away at age 22.
Feline Triad Disease: Senior cats with “Feline Triad Disease” which is the inflammatory condition of having concurrent hepatic, pancreatic and intestinal inflammatory disease. It may be palliated with fluids and oral potassium gluconate, vitamin E, prednisolone, metronidazole, Actigall, pancreatic enzymes, l-carnitine, glutathione, lactulose, S-Adenosylmethionine (Sam-e) and SQ vitamin K-1, according to Dr. Johnny Hoskins. Animals with severe liver failure may be helped with Hill’s liver diet L/D, Actigall, vitamin K-1 and milk thistle. Some products contain a combination of supplements to assist hepatic function.
Diabetes: Diabetic pets belonging to reluctant, needle-shy owners need options. Their veterinarian needs to feel comfortable about offering these clients the option of oral hypoglycemic medication for their diabetic cats. One can expect good clinical results with oral medication in one third of diabetics that have no ketones in the urine. Clients feel that their veterinarian is trying to help the pet while prioritizing their own concerns. If hyperglycemia is not controlled with oral medication, the owner may be more inclined to try injectable insulin as a second choice.
Anorexia: Patients with inappetence often need to be hand or forced fed to maintain a proper nutritional status. People need to learn the proper technique to best hand feed their ill pet. If the patient has anorexia, cancer cachexia or has a feeding tube, we use high quality glutamine and whey protein powders such as Glut Immune™ and ImmunoPro™ from HYPERLINK "http://www.genomicwhey.com/" www.genomicWhey.com. Glutamine supports intestinal health, helps prevent muscle breakdown, promotes healing and is a precursor in the synthesis of glutathione. ImmuoPro contains undenatured whey proteins such as lactoferrin, immunoglobulins and active peptides that can benefit Pawspice patients.
Anorectic cats may prefer their food warmed to body temperature. Squamous cell carcinoma of the tongue in cats renders the tongue stiff and useless and causes early starvation despite efforts to eat. When a pet can’t or won’t eat, the placement of a percutaneous esophageal feeding tube may be performed under a short anesthetic with minimal risk. The procedure has been described by Rawlings, JAAHA, 1993, 29: 562-530. After the esophagostomy feeding tube is in place, the pet needs to be fed successfully a few times in the hospital.
It is essential that a discharge appointment be scheduled for a demonstration on how and what to feed the pet. If a helpful nurse, whom the owner may call for further instructions, gives this demonstration, the client is more at ease during the first few days with the feeding tube. The diet and supplements for feeding must be spelled out to avoid clogging the tube and to ensure that the pet is getting enough calories and liquid to maintain body weight. If the tube gets clogged, instruct the owner to use Coca-Cola to dissolve the clog. Create a schedule that spells out the morning and evening times for medications, chemotherapy, amounts of fluid, feeding volumes and supplements on a written daily calendar. This written schedule helps to clarify the day’s work order for the home caregiver.
Nasal Cancer: Dogs with facial deformity and stridor may be palliated with combinations of NSAIDS such as piroxicam or carprofen, deracoxib, etc. Most dogs with nasal tumors have little to no trouble with stridor while they are awake and panting. But they have trouble sleeping at night. Most end of life nasal cancer patients will sleep more comfortably and with less stridor if they are given evening sedation with butorphanol or valium or a combination. Mr. Shelton, an engineer, devised a plan to help his 12 year-old Lab, BJ, breathe more peacefully at night. BJ had trouble sleeping due to stridor and obstruction of her nasal passages. She loved to play ball and chew on bones. Mr. Shelton punched holes in a tennis ball for air passage. He taught BJ to sleep with the ball in her mouth. BJ got similar relief when she fell asleep with a large rawhide bone or any object that was big enough to keep her mouth open. This simple adjustment was a joy for Mr. Shelton as a caregiver because it provided so much palliation for BJ. Be sure to keep this concept in mind for the next case you see like BJ. Most caregivers can train their dog to sleep with a toy, ball, or bone to keep the mouth open, to allow air to flow freely in and out of the trachea.
Osteosarcoma patients, not receiving amputation are in great pain and at risk for pathological fracture. These patients can be palliated with pain alleviation and if necessary, walking casts to prevent pathological fractures. Their quality of life is benefited with the use of ramps to get in and out of the car, the house and on and off the bed. The use of piroxicam at 0.3mg/Kg once daily not only palliates bone cancer pain but in addition, it may actually yield a rare remission on a sporadic basis as shown by Knapp and workers at Perdue. Carprofen, deracoxib, meloxicam, firocoxib and other newer selective NSAIDs may also be used for bone cancer pain palliation with this optimistic goal in mind. All NSAID’s need to be used with great caution to avoid vomiting, gastric ulceration, hemorrhage, nephrotoxicity and hepatotoxicity in geriatric, frail, debilitated or dehydrated patients. Tramadol, a synthetic opioid is very helpful when combined with NSAID’s for palliation of bone cancer pain. Fentanyl (Duragesic™) transdermal opioid pain patches are very helpful in combination with NSAID’s for bone pain palliation.
You will need to use the highest level of combinations of pain control drugs suggested by the World Health Organization pain control ladder to treat bone cancer pain. Adjunctive drugs such as gabapentin may be needed to provide adequate ongoing pain control.
Degenerative myelopathy or paresis/paralysis cases benefit from a wide range of resourceful home care items such as runner rugs for a slippery floor, ramps for the stairs, bed and car, slings for assistance while walking, chest and rump lifts to help larger dogs stand up, canvass suspension hammocks, wheel carts, soft bedding etc. Physical therapy pools, massage, acupuncture, chiropractic and rehabilitation techniques may be very helpful to palliate these special patients. Recommend foot covers made from fleece or canvas to prevent scraping and ulceration of the metatarsals, metacarpals and toe pads.
Decubital ulcers must be intentionally avoided for recumbent animals with thoughtful planning. Make sure you instruct caregivers to think ahead and shop for items such as soft bedding, foam rubber pads, and egg crate mattresses and doughnut pads, and waterbeds all with washable covers. Frequent inspection of pressure sites and complete cleaning of the cancer patient’s coat and skin is important. If the patient is soiled with urine or feces, it is important to completely bathe the contaminated are for maximum hygiene. If the pet needs or likes to be situated out doors, extreme caution must be taken to prevent fly strike and maggots. Patients with long hair may need to be shaved to allow more convenient bathing and inspection of the skin and orifices.
Transitional Cell Carcinoma: Patients with TCC often survive for many months with conventional chemotherapy using mitoxantrone and NSAIDs. It can be a tremendous help for the family if you suggest diapers for those patients with pollakiuria and incontinence while the pet is in the house. You can also suggest more frequent opportunities for the patient to void out doors. Instruct clients to keep the pet’s day bed close to the doggie door and helps the family endure the frustrating problems associated with house soiling.
Severe hematuria may be palliated to avoid extreme blood loss, mix a 1% solution of formalin with a vial of the topical ear solution, Synotic™ (which contains DMSO). Instill this solution into the bladder with a urinary catheter. Keep the solution in the bladder for 10 to 15 minutes. Then void the bladder and flush out the blood clots. This palliative procedure may reduce the hematuria for 7-10 days and may be repeated as needed. Some TCC cases develop tumor obstruction of urine outflow at the trigone or in the urethra. Prostatic carcinoma patients may develop obstruction of urine outflow due to extension of malignant tissue into the prostatic urethra. Some patients may benefit from placement of a permanent urinary catheter. Unfortunately the patient can easily remove these catheters. Cancer patients can be surgically palliated with the placement of a prepubic low-profile cystostomy tube (Stiffler et al, 2003). Caregivers are instructed to void the patient’s bladder four times a day.
The stoma provides immediate life saving palliation by diversion of urine and bypassing the obstruction caused by the tumor. Cystostomy may reduce hydronephrosis and allow the TCC patient to maintain a good quality of life for a variable time period. Stiffler et al reported on 3 dogs with TCC that lived for 3, 13, and 30 weeks and one dog with uterine carcinoma that lived 4 weeks following cystostomy. I had an elderly cat that lived one year following cystostomy for prostate cancer. Stiffler et al stated that quality of life was an important objective for pet owners who wanted their cancer patient dogs to be able to participate in as many of their normal activities as possible. The low-profile cystostomy tubes required no bandaging, gave patients unhindered mobility and lacked signs of discomfort. “Owners of the dogs began their grieving process during the period of cystostomy tube placement, and their confidence in the quality of life provided by the low-profile cystostomy tube was key to their emotional comfort with their treatment decision.”
Brain Tumors: Pets with brain tumors that experience periodic seizures may be palliated at home with confidence and fewer emergency visits. Caregivers can be instructed to squirt injectable diazepam into the nasal passages or into the rectum for seizure control. Steroids, lomustine, OM-3 fatty acids and fish oils are reasonable palliative care program for with brain tumors. If seizures are not under control with medication, the pet’s Quality of Life is ruined and the pet owner must yield to hospitalization for IV anesthesia. After 2-3 days with IV medications, if the patient were unable to be stabilized, then the kindest option would be to provide the pet the relief of euthanasia.
Refractory Vomiting: Pet owners experience great anxiety and frustration when their pets are nauseated and exhibit refractory vomiting. If the normal first line antiemetics fail to control vomiting, then use drugs that control the chemotherapy trigger zone. The patient may need to be hospitalized and given IV Zofran or Anzamet. For home care, large dogs (60-90 pounds) may be given one half of a 1mg Kytril tablet crushed and dissolved in salty water. The solution can be gently dripped on the pet’s lips. Zofran injectable solution may also be given orally or mixed in yogurt. Anzamet can also be given orally. On one rare occasion, this author dispensed injectable atropine to help a Great Dane that had unresponsive vomiting and salivation due to pressure exerted by a tumor. The tearful pet owner had a very exhausted budget and could not afford the more costly antiemetics. He was absolutely not ready to make the decision for euthanasia for his big dog; he just wanted me to stop the vomiting on his super slim budget. He was very thankful for the relief from vomiting that his dear dog received with the inexpensive injections of atropine. Care should be taken to provide liquid tears while using atropine in this fashion, especially in breeds susceptible to kerato conjunctivitis sicca.
Pain: Patients in Pawspice care should ideally experience no pain! Severe pain may be controlled with injectable nalbuphine. This inexpensive generic drug offers pain control without the typical sedation effects that accompany most of the powerful analgesics. Nalbuphine doses range from 0.5-1mg/kg SQ. every 3-4 hours in dogs and 0.2-0.5mg/kg in cats S.Q. every 3-6 hours as needed. This pain medication is not registered under the controlled substance regulations and may be of great value in pain control at home for end of life pawspice care patients.
Managing Soft and Loose Stools
Terminal pets in Pawspice care are often plagued with soft, lose stools. Abnormal stools may result from illness itself, the treatment, and an imbalance of intestinal flora or from eating whatever seems palatable from one day to the next. Many Pawspice patients have a diminished appetite and need to be coaxed and hand fed. This variable appetite and food intake may cause soft or loose stools and irregular elimination times. It is difficult for some caregivers to manage their pet’s loose eliminations. The soiling problem is magnified for recumbent patients unable to get up and use their normal toilet area.
Practical suggestions make a big difference. Instruct caregivers to feed the patient tasty bland food. They can feed a prepared diet or use barley, millet, rice, potato or pasta cooked with chicken broth, garlic, parmesan cheese and hickory for flavor). Adding more fiber to the diet is helpful. Clients can use canned pumpkin, metamucil, Benefiber™ powder, oatmeal, oat bran and high fiber bread as sources for fiber. Symptomatic treatment with Flagyl, Azulfidine or Tyolsin powder may also help. For bland protein, we recommend yogurt, egg, cottage cheese, broccoli, spinach, kale, ground chicken or turkey cooked in broth and flavors.
You and your staff should give caregivers all the comfort and encouragement they need. Offer them a supply of hospital towels for frequent bed changes. Help them establish good hygiene for the patient and encourage frequent bathing . If each one of the patient’s problems can be addressed and improved by at least 50%, the Pawspice patient’s quality of life situation improves greatly.
Hospital Day Care
Some Pawspice pets benefit from day care services provided by the primary care veterinarian’s facility while the owners are at work. This service may include taking the pet’s temperature and weight, bathing and brushing the soiled pet, SQ fluids, injections and hand feedings. This service can be the key to sustaining a quality Pawspice for the working pet owner. Convenient monthly billing and drop off and pickup times that revolve around the owner’s schedule may be prearranged with attending staff members before and after routine receiving hours.
Technician house calls may be set up for those who are unable to deal with administering injections and fluids to the pawspice pet. The reception staff can be made aware of which pets are on Pawspice programs so they can be sensitive when family members call in for information, updates, appointments or emotional help.
Immunonutrition and Chemoprevention as Palliative Care
Carefully selected supplements have a major role as palliative care for pawspice candidates. This feature of supporting the whole patient has added quite a bit more to my practice than I ever dreamed could be possible. According to Dr. Philip Bergman of M.D. Anderson Memorial Cancer Center, chemoprevention involves the use of natural or synthetic compounds that may reverse or suppress the process of carcinogenesis, metastasis and recurrence. Nutritional advice and a nutraceuticals supplementation program that underscores cancer prevention for treated untreated or terminally ill companion animals may be professionally and sensibly supervised by your clinic. This service creates further client confidence that the primary care veterinarian is helping to address the pet’s immune system and support the pet’s organ function as much as possible.
Most geriatric cancer patients that undergo surgery or chemotherapy or radiation therapy are considered to be at a moderate to great risk for recurrence of their cancer. These older cancer patients are definite candidates for palliative Pawspice. The expectancy rate for recurrence and death from metastases or complications is 50-90% within 4-12 months. Dogs with osteosarcoma, hemangiosarcoma, adenocarcinoma, and lymphoma as well as cats with breast cancer, vaccine associated sarcoma, oral tumors and lymphoma are also at very high risk. Cats with IBD, chronic gingivitis, stomatitis, inflammatory disease and feline triad disease are at greater risk of developing illness or cancer. Cats infected with FeLV and FIV are at risk for retroviral-associated neoplasia. Cats exposed to cigarette smoke and dogs exposed to agricultural herbicides and pesticides are also at greater risk for cancer. When these at risk conditions are addressed with immunonutrition and chemoprevention, the pet may derive an advantage.
Pet Loss Group Sessions can be very helpful for the most affected individuals.
We held weekly pet loss group meetings at our hospital on Saturdays. Pet owners found it very rewarding because they could share their feelings with others. Locate a pet loss support group that you can refer your clients to if they need extra help with coping.
The UC Davis Veterinary Teaching Hospital has a pet loss support line that is covered by students who have been trained to answer questions about end of life grief. The phone number is 1-800-565-1525.
Networking: Help clients share their problems with others who have pets in similar situations either by phone or on the Internet can be very helpful. Give caregivers the phone number or the e-mail address of another client who is providing a similar type of Pawspice care for their pet. The experienced caregiver has the opportunity to share their knowledge with the newcomer. Dr. Kathleen Carson participates in a chat room for patients with chronic renal failure every Sunday evening at 5:00 p.m. Pacific Standard Time. Instruct clients to look for the private chat room, “CRF”. There are chat rooms for dogs with cancer, dogs with lymphoma, feline vaccine associated sarcoma and other types of cancer. I was a guest consultant recently for a Friday night chat room for dogs with cancer. Online net working is very helpful for pet caregivers to get detailed information and for mutual support. Helping clients to Network with other pet caregivers who have similar diseases or are in Pawspice will bring them comfort and companionship. We find that those who use on line chat rooms for comfort and information are less needy of our staff.
One Doctor Can Make a Difference
Dr. Tami Shearer started practicing pet hospice care via her house call practice in 1987. She founded The Pet Hospice and Education Center in 2003 in Columbus, Ohio. Dr. Shearer said, “In 2004, our Hospice and Education Center became a non-profit organization. The goal of our Center is to educate pet owners and the general public about all aspects of pet care for the long-term benefit of society to preserve the relationship between pets and people. Emphasis is placed on but not limited to hospice care and children's programs. The hospice aspect of the Center applies hospice guidelines adopted from human hospice to prevent unnecessary suffering and to help pet owners cope with the upcoming loss of their loved one. The goal is to provide comfort without prolonging suffering. The Pet Hospice and Education Center abides by the guidelines put forth by the American Veterinary Medical Association.”
One RVT Can Make a Difference
RVT, Val wrote me about setting up Pawspice at her busy practice. She has 35 years of experience and for the past 11 years she has been working in a large emergency and specialty clinic that has 24 veterinarians. She wanted to do more for the E-clinic clients. She wanted to give options to pet owners caught in the drama of the E-clinic scenario of “Make a $2-4,000 deposit or your pet will die.” in other words, Val wants to give the client more time to say goodbye to their beloved pets via a Pawspice program. The doctors at her clinic are enthusiastic to be able to offer clients Pawspice (end of life care) as an option rather than the standard “either or” E-medicine model that is prevalent in this country. Val read my book from cover to cover and spent a few days with me to observe.
I envision that she will walk into her E-clinic every morning and ask, “Which ones are my Pawspice patients?”
I have been asked by a number of veterinarians to offer franchises and set up Pawspice care programs in hospitals all over the country. Pawspice resonates with the public and within our hearts. Most of us have been providing some aspect of this service all along. Does a formal Pawspice program have the potential of being a national movement? Pawspice is certainly a natural way to help our companion animals when age, disease and cancer has stricken them with a fatal agenda. Recommended Reading List for Helpful books:
Keep these helpful books in your hospital lending library or for sale.
Canine and Feline Geriatric Oncology: Honoring the Human-Animal Bond, by Alice Villalobos, DVM with Laurie Kaplan, MSC, Blackwell Publishing, 2007, HYPERLINK "http://www.blackwellvet.com" www.blackwellvet.com , OVMA attendees may use PRGC 67 for author’s code disc.
Pets Living with Cancer: A Pet Owner’s Guide by Robin Downing, D.V.M., AAHA Press, is a very helpful book to orient pet caregivers about the ins and outs of cancer treatment for pets. Dr. Downing tells about her own dog, Murphy, and her battle against osteosarcoma with limb sparing at CSU.
The insightful book, Help Your Dog Fight Cancer, by Laurie Kaplan, covers a wide range of home care tips and encouragement for pet caregivers. It includes illustrated instructions on preparing meals for dogs. This wonderful book is available at: HYPERLINK "http://www.helpyourdogfightcancer.com/" www.helpyourdogfightcancer.com.
By Appointment Only
Pawspice, Hermosa Beach 562-493-5025
Animal Oncology, Woodland Hills 818-712-0060