How to develop a treatment plan for palliative and hospice care
1. Educate the client about the pet’s disease.
Educating clients about the patient’s disease is particularly important in EOL cases.5 The more the caregiver understands about the disease progression, the better he or she will be able to cope with the expanded, EOL caregiving role. The veterinarian should advise the client about the expected trajectory of the pet’s disease. This should include a discussion of diagnostic and treatment options, interventions to ensure the pet’s comfort, and a realistic prognosis. One of the goals of client education in EOL cases is for the client to have a clear understanding of all diagnostic and treatment options. Decisions on EOL care should be made only when the client has achieved such clear understanding.
2. Evaluate the pet owner’s needs, beliefs, and goals for the pet.
The best time to discuss the pet’s disease with the client is not necessarily when the individual is informed of a terminal or progressive disease diagnosis for the patient. Depending on the degree of attachment between the pet and its owner, the impact of such news will often evoke a strong emotional reaction in the owner. Practitioners should anticipate this reaction, respond to it by expressing empathy, and consider setting up a follow-up appointment to discuss EOL treatment options. This gives the caregiver time to come to terms with the new reality and to participate more fully in the development of a realistic, mutually acceptable treatment plan. The follow-up visit is an opportunity for a two-way information exchange between the veterinarian and client.
3. Develop a personalized EOL treatment plan.
A proposed palliative care plan should be detailed but presented in language that the client can understand without over-reliance on clinical terminology. The plan and the logistical implications for the owner should be discussed and agreed upon. Because of the sensitive nature of EOL care, it is critical for the client to make an informed decision regarding the pet’s treatment plan. The treatment plan should be entered into the patient’s medical record. Treatment plan components should include the following:
- Procedures assigned to the client based on the individual’s capability and willingness to assume specific responsibilities for care.
- An assessment of the patient’s willingness and capacity to receive care. This would also include the patient’s willingness to eat, as supplemental nutrition (i.e., feeding tubes, syringe feeding) or stimulation of appetite (e.g., mirtazipine) may be indicated.
- A written action plan, discussed point by point with the owner, to ensure that person’s active participation.
- An estimate of the time required for the client to execute those parts of the plan for which the individual is responsible.
- An estimate of costs itemized by fees for professional services and costs of medication, supplies, and nutritional products.
- A schedule for follow-up communication and reassessment.
4. Implement palliative or hospice care.
Whenever possible, palliative treatment and EOL care should be administered at home. This generally involves instructing the client on therapeutic techniques, how to assess the patient’s response, and sign recognition. The home environment should be evaluated to ensure the pet’s comfort and safety during EOL treatment. Environmental modification or enrichment might include modifying floor surfaces, improving accessibility to food and water, ensuring that bedding is comfortable, optimizing litter box location and design, selecting an ideal ambient temperature, and maintaining sanitation and hygiene. Clients should be instructed in the safe handling of their pets and their pets’ medications to prevent injury to themselves or their animals. Technologies such as video recording and video calling can be helpful in regularly communicating the patient’s home-care status with the healthcare team.
Within the first week after the initial EOL treatment plan is agreed upon, the client will begin to come to terms with his or her caregiving role. At this stage, the client may have questions for the healthcare team and may reconsider whether or not the agreed upon treatment plan was the right thing to do. Unanticipated roadblocks to the pet’s at-home care may also have emerged. Successfully responding to these challenges will help determine whether the client can maintain an appropriate level of care or if a different approach is needed. In fact, unexpected demands of at-home care can undermine or change the client’s relationship with the pet. Periodic follow-up appointments or phone consultations initiated by the healthcare team are vital to addressing and responding to these potential problems.
Compassionate communication opportunities
After a terminal diagnosis has been given, give the owner time to come to grips with the news. Then re-engage her with a plan to move forward.
Check in with the client during the first week after the initial EOL treatment plan has been agreed upon to see if unanticipated roadblocks have emerged.