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2016 AAHA/IAAHPC End-of-Life Care Guidelines

Gail Bishop, BS, Kathleen Cooney, DVM, Shea Cox, DVM, Robin Downing, DVM, DAAPM, DACVSMR, CVPP, CCRP, Kathy Mitchener, DVM, Amir Shanan, DVM, Nancy Soares, VMD, Brenda Stevens, DVM, DABVP (canine/feline)†§, Tammy Wynn, MHA, LISW, RVT

Click here to download the 2016 AAHA/IAAHPC End-of-Life Care Guidelines*

Abstract

End-of-life (EOL) care and decisionmaking embody the critical final stage in a pet’s life and are as important and meaningful as the sum of the clinical care provided for all prior life stages. EOL care should focus on maximizing patient comfort and minimizing suffering while providing a collaborative and supportive partnership with the caregiver client. Timely, empathetic, and nonjudgmental communication is the hallmark of effective client support. Veterinarians should not allow an EOL patient to succumb to a natural death without considering the option of euthanasia and ensuring that other measures to alleviate discomfort and distress are in place. Animal hospice care addresses the patient’s unique emotional and social needs as well as the physical needs traditionally treated in clinical practice. An EOL treatment plan should consist of client education; evaluating the caregiver’s needs and goals for the pet; and a collaborative, personalized, written treatment plan involving the clinical staff and client. Primary care practices should have a dedicated team to implement palliative and hospice care for EOL patients. How the healthcare team responds to a client’s grief after the loss of a pet can be a key factor in the client’s continued loyalty to the practice. Referral to professional grief-support counseling can be a helpful option in this regard. (J Am AnimHosp Assoc 2016; 52:341-356. DOI 10.5326/JAAHA-MS-6637)


From Colorado State University Flint Animal Cancer Center, Argus Institute, and Colorado State University Pet Hospice, Colorado State University, Fort Collins, Colorado (G.B.); Home to Heaven, Loveland, Colorado (K.C.); Bridge Veterinary Services, Berkeley, California (S.C.); The Downing Center for Animal Pain Management, Windsor, Colorado (R.D.); Angel Care Cancer Center for Animals, Memphis, Tennessee (K.M.); Compassionate Veterinary Hospice, Chicago, Illinois (A.S.); Macungie Animal Hospital, Macungie, Pennsylvania (N.S.); North Carolina State University College of Veterinary Medicine, Raleigh, North Carolina (B.S.); and Angel’s Paws, Cincinnati, Ohio (T.W.).

Correspondence: Ashanan1g@gmail.com (A.S.), bjsteven@ncsu.edu (B.S.)

EOL (end-of-life); QOL (quality of life); CF (compassion fatigue); AVMA (American Veterinary Medical Association)

* These guidelines were prepared by a task force of experts convened by the American Animal Hospital Association and the International Association for Animal Hospice and Palliative Care for the express purpose of producing this article. This document is intended as a guideline only. Evidence-based support for specific recommendations has been cited whenever possible and appropriate. Other recommendations are based on practical clinical experience and a consensus of expert opinion. Further research is needed to document some of these recommendations. Because each case is different, veterinarians must base their decisions and actions on the best available scientific evidence, in conjunction with their own expertise, knowledge, and experience. These guidelines were supported by a generous educational grant from the AAHA Foundation, Aratana Therapeutics, Ceva Animal Health, and MWI Animal Health/AAHA MARKETLink.

† A. Shanan and B. Stevens are co-chairs of the End-of-Life Care Task Force.

§ Primary Care Veterinary Educators Task Force member.


Introduction

For many pet owners, the events surrounding their pets’ final life stage are as important and meaningful as the sum of all the care provided by the practice team up to that point. Animal hospice care seeks to maximize patient comfort while minimizing suffering utilizing a collaborative and supportive approach with the caregiver client. The goals of animal hospice are perfectly aligned with our veterinary oath and the fundamental reasons why we do what we do.

End-of-life (EOL) care and decisionmaking are medically, emotionally, and ethically challenging for everyone involved. These guidelines will provide your practice team with the framework and tools to better recognize patient and pet owners’ needs at this difficult time. Additionally, they will enable you and your team to provide optimal patient care and client support that will preserve and enhance the human-animal bond.

Every companion animal veterinarian in primary care practice is confronted periodically with a client facing bereavement over the loss of a beloved pet. For these practitioners and their healthcare teams, few aspects of clinical practice are more important than effectively managing the terminal stage of a patient’s life. When the healthcare team and the caregiver recognize that death is a likely outcome for the patient, it is essential to develop a collaborative plan for the time between that recognition and the pet’s death.

Some practitioners have found it helpful to consider EOL events as a distinct life stage (juvenile, adult, senior, end of life). These guidelines support, and the authors recommend that, EOL should be designated as the “final life stage.” The benefits of expanding how we think about and deliver EOL care to the pet and pet owner are far reaching. These guidelines will describe the unique features and challenges for providing optimal compassionate care during this final life stage.

Objectives of the Guidelines

The objectives of the guidelines are to:

  1. Educate practitioners and their teams on the scope and importance of veterinary EOL care.
  2. Introduce principles of empathetic EOL communication to help practice team members have successful, courageous conversations with caregivers.
  3. Define and clarify hospice and palliative care.
  4. Provide a framework for developing a collaborative plan with pet owners for EOL events.
  5. Emphasize the importance of recognizing caregiver anticipatory grief and providing pet bereavement resources and support.
  6. Emphasize the importance of an overall team approach within the practice as well as the role of a dedicated patient and caregiver support team.
  7. Discuss the considerations for humane euthanasia versus hospice-supported natural death care.
  8. Encourage referral to veterinarians with advanced EOL training and expertise in cases where general practitioners cannot provide adequate hospice and palliative care themselves.
Definitions Used in the Guidelines

Animal hospice: A philosophy or program of care that addresses the physical, emotional, and social needs of animals in the advanced stages of a progressive, life-limiting illness or disability. Animal hospice care is provided to the patient from the time of a terminal diagnosis through the death of the animal, inclusive of death by euthanasia or by hospice-supported natural death. Animal hospice addresses the emotional, social, and spiritual needs of the human caregivers in preparation for the death of the animal and the grief experience. Animal hospice care is enhanced when provided by an interdisciplinary team approach.

Caregiver: As defined in this document, the caregiver is the animal’s owner and/or any others involved directly in the animal’s daily care and decisionmaking surrounding the animal and its healthcare. NOTE: The authors chose to use the terms “pet owner,” “caregiver,” and “client” interchangeably throughout this document, as all three are commonly in use and in the vast majority of cases refer to the same person.

Hospice-supported natural death: Use of palliative care measures during a patient’s terminal life stage, including the treatment of pain and other signs of discomfort under veterinary supervision until the natural death of the individual.

Humane euthanasia: The intentional termination of life by human intervention utilizing American Veterinary Medical Association (AVMA)-approved methods that cause minimal pain, discomfort, and anxiety for the purpose of relieving an animal’s suffering.

Palliative care: Treatment that supports or improves the quality of life (QOL) for patients and caregivers by relieving suffering; this applies to treating curable or chronic conditions as well as EOL care.

QOL: The total wellbeing of an individual animal that considers the physical, social, and emotional aspects of its life.1-3

Suffering: An unpleasant or painful experience, feeling, emotion, or sensation, which may be acute or chronic in nature; this is an umbrella term that covers the range of negative subjective experiences, including, but not limited to, physical and emotional pain and distress. In veterinary medicine, suffering can be experienced by the patient and the caregiver.

Animal Versus Human Hospice Care

Animal hospice care has its origins in human hospice philosophy and practice. Human hospice care focuses on the palliation of a chronically ill or seriously ill patient’s pain and symptoms and attending to their emotional and spiritual needs as they near the end of life and as they die. Human hospice care also assists patients’ families to help them cope with the patient’s circumstances and to provide care and support in the home care setting. Similarly, animal hospice care seeks to maximize comfort and minimize suffering for the patient, and address the needs of the caregiver in preparation for the death of the pet.

Several important aspects of animal hospice care, however, are distinct from its human counterpart. Legally, and in terms of our social norms, the acceptance of pet euthanasia is in sharp contrast to what is acceptable in human hospice care. A guiding principle of human hospice care is to “neither hasten nor postpone death.” Rather, as the death of a person becomes imminent, human hospice care seeks to relieve pain and anxiety.4 Life-prolonging interventions such as cardiopulmonary resuscitation are declined if they no longer contribute to the patient’s QOL. The same approach applies when the death of an animal is imminent. However, when caring for seriously ill animals, euthanasia is a legal and widely accepted option for relieving suffering. Animal hospice accepts that it is the pet owner’s ethical and legal right and responsibility to decide whether the terminally ill animal will die by euthanasia or by hospice-supported natural death. Animal hospice does not accept a pet owner’s decision to allow a pet to die without euthanasia unless effective measures are in place to alleviate discomfort under the care of a licensed veterinarian. Such practices are considered unethical and inhumane.

Unfortunately, there may be situations where a veterinarian must consider terminating the veterinarian-client-patient relationship because he or she is unable to provide a patient with the necessary standard of care required to fulfill the veterinary oath. As with any other such case, the practitioner should be guided by his or her ethical obligations to both patient and client and the legal considerations of his or her State Practice Acts.

Lastly, there are considerable differences between the resources, financial and otherwise, available for providing animal EOL care compared to human EOL care. In human hospice care, the patient’s main care providers are the family caregiver and a hospice nurse who makes periodic visits. Although the cost of providing care for a hospice patient at home is generally lower than the cost of hospitalization, significant expense is still involved.5 These costs are covered in the United States by Medicare and other health insurance providers. Qualifying for hospice benefits is dictated by law, limiting the coverage to patients who are medically certified to have a prognosis of less than 6 mo to live. This is in contrast to animal hospice, where a vast majority of the costs are covered by pet owners as an out-of-pocket expense. As a result, the financial resources available to some caregivers to cover the costs of animal hospice services are significantly more limited.


Take-Away Points
  • Like human hospice, animal hospice focuses on palliation of a patient’s clinical signs while addressing the emotional, social, and spiritual needs of the caregiver.
  • Animal hospice does not accept a pet owner’s decision to allow a pet to die without euthanasia unless measures are in place to alleviate discomfort and distress.

Patient Considerations

Identifying the Hospice and Palliative Care Patient

The overarching goal in providing palliative and hospice care is to maximize comfort and minimize suffering for our patients.

Canine and feline patients who are candidates for hospice or palliative care generally have at least one or a combination of the following conditions: a terminal diagnosis; a chronic progressive disease (e.g., end-stage renal disease, debilitating osteoarthritis, congestive heart failure); a progressive, undiagnosed disease; a chronic disability (e.g., neurologic or intervertebral disk disease); or terminal geriatric status, exemplified by wasting or failure to thrive.6,7 When developing a hospice or palliative care treatment plan to be executed by an interdisciplinary team, it can be helpful to assign the patient to one of the following categories:

  1. Diagnosis of life-limiting disease
  2. Decision not to pursue diagnosis or curative treatment
  3. Curative treatment has failed
  4. Clinical signs of chronic illness that interfere with normal routine or QOL
  5. Progressive illness with complications

These broad case descriptions are useful for managing the client’s expectations as well as developing a treatment plan.

Medical Conditions Appropriate for Hospice or Palliative Care
  • Terminal diagnosis
  • Chronic, progressive disease
  • Progressive, undiagnosed disease
  • Chronic disability
  • Terminal geriatric status
The Animal Hospice Care Pyramid

A patient’s passage from palliative to hospice care and, ultimately, to death is a progression that can range from hours to months to complete. As with human medicine, the physical, social, and emotional health of veterinary patients is strongly interrelated. It is difficult to achieve optimal QOL when any one of these components is missing. The Animal Hospice Care Pyramid (Figure 1) illustrates these complementary areas of patient care that should be considered during the EOL transition. Each level of the pyramid builds upon the others to achieve optimal EOL experiences. The base of the pyramid includes the animal’s physical wellbeing that represents the traditional clinical care services that veterinarians provide. However, successful management of the hospice patient must also consider the mid-level of the pyramid consisting of the social welfare of the pet, and the pyramid apex that focuses on the pet’s emotional wellbeing. When the healthcare team, working in collaboration with the pet owner, successfully addresses all three levels of the hospice care pyramid—physical, social, and emotional needs—the practice is best able to maximize comfort and minimize suffering. Those are, after all, the ultimate goals for every pet that has entered into its EOL stage. Table 1 lists important issues that need to be addressed at each level of the Animal Hospice Care Pyramid.

American Hospice Care Pyramid

FIGURE 1 Animal Hospice Care Pyramid. Veterinary hospice care can be segmented into a hierarchy of three components, each of which must be satisfactorily addressed to provide optimum end-of-life (EOL) care. The base of the pyramid consists of physical care, the traditional acute and chronic care services provided by veterinarians. The midlevel consists of the patient’s social wellbeing, centering on interaction with other pets and humans. The apex of the pyramid consists of the patient’s emotional wellbeing, including satisfaction of the individual animal’s unique set of needs and a meaningful engagement with her or his surroundings.8 Illustration Design: Shea Cox, DVM

TABLE 1

Components of an Integrated Approach to End-of-Life (EOL) Care

Physical care
Objective
Intervention

Pain management

Anticipate, prevent, control, and regularly monitor acute and chronic pain; provide multimodal pain relief per 2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats:28

  • Pharmacologic management
  • Environmental modifications
  • Dietary management
  • Gentle handling techniques

Management of clinical signs

Examine patient to diagnose and treat dyspnea, GI signs, cognitive dysfunction, anxiety, pruritus and skin integrity (e.g., local infections, pressure sores), dental health, respiratory signs

Hygiene

Maintain urine and feces sanitation, access to elimination sites

Nutrition

Perform dietary and body condition assessment; monitor dietary habits and changes; maintain balanced nutrition, adequate food intake, and hydration to the extent possible, keeping in mind that decreased food and water intake are normal in the dying process

Mobility

Provide nonskid flooring in pet’s living area, accessible litter box location and design, physical assistance devices (harnesses, slings, carts, and wheelchairs), range-of-motion exercises

Safety

Restrict access to environmental hazards (e.g., swimming pools), protect from aggressive pets, observe for self-trauma

Environmental needs

Provide comfortable bedding, temperature and ventilation control, adequate space, peaceful environment

Social wellbeing

Objective

Intervention

Engagement with family

Involve pet in family activities as illness allows, maintain regular owner-pet interaction

Isolation avoidance

Avoid or minimize extended periods of isolation or non-socialization

Interaction with other pets

Maintain appropriate interaction with other pets, monitor pet-to-pet hierarchal changes and adverse socialization behaviors

Mental stimulation

Offer regular play opportunities and environmental enrichment

Emotional wellbeing

Objective

Intervention

Preservation of dignity

Minimize house soiling, manage incontinence, maintain good hygiene and grooming

Stress reduction

Minimize exposure to stress and changes in routine, assess pet’s willingness to receive needed treatments

Preserve pet’s household role

Continue expectations for companionship, surveillance, or other household roles; adhere to daily routines

Maintain the will to live

Monitor behavior; ensure regular interaction with family members; observe for signs of withdrawal, depression, or resignation



TABLE 2

Practical Issues in Implementing a Palliative or EOL Care Plan

Issue

Topics to Discuss with Client

Treatment locations

  • Division between in-hospital and home care
  • Emphasis on maximizing home care
  • Frequency and time points for physical exams and treatment

Individual responsibilities

  • Specify who will provide palliative and end-of-life services

Client education

  • Specifics of client education on administering palliative home care
  • Hands-on instruction on specific home care tasks
  • Assessing client willingness and proficiency to provide home care

Environmental modifications

  • Photos or videos of home environment to assess suitability for home care
  • Home modifications to ensure patient comfort and safety

Owner safety and hygiene

  • Responding to patient incontinence
  • Managing secretions from non-healing lesions
  • Safe handling of patient medications
  • Safe and humane handling of patient with acute or chronic pain
  • Prevention of bite injury

Periodic plan assessments

  • Avoidance of patient suffering due to compliance shortfalls or lack of response to treatment
  • Client input and impressions of plan efficacy
  • Video documentation of patient’s behavior in the home environment
  • Veterinarian’s assessment of plan efficacy
  • Plan modifications and re-statement of prognosis and expectations

Medication, nutrition, and activity review and assessment

  • Evaluate extent of pet owner compliance and plan deviations
  • Revise palliative and EOL care interventions
  • Consider advisability of euthanasia
Developing a Treatment Plan for Palliative and Hospice Care

By using the following four-step process, the practice team will be able to implement a consistently effective palliative and hospice care treatment plan for EOL patients:

Step 1: Educate the Client about the Pet’s Disease
Educating clients about the patient’s disease is particularly important in EOL cases.9 The more the caregiver understands about the disease progression, the better he or she will be able to cope with their 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 a clear understanding of the options.

Clients should be advised that some diagnostic procedures, such as biopsies, might be painful for the pet. A thorough description of each diagnostic test, including how the results will influence patient care, will allow the client to make an informed choice about whether or not to authorize the procedure. The veterinarian should describe the diagnostic tests and therapies in a language that the client can understand and minimize the use of clinical terminology, abbreviations, or acronyms that can be overwhelming or intimidating to client. Effective client education about EOL care includes the cost of services and avoids giving false hope.

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 owner 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. An effective approach for conducting an EOL follow-up discussion is to schedule the appointment at the end of the day or as the last appointment before the lunch hour, giving the veterinarian and client time for an uninterrupted, open-ended discussion.


Take-Away Points
  • It is important to advise clients about the expected disease trajectory.
  • Ensure that there is a clear understanding of all diagnostic and treatment options available.
  • Consider scheduling a dedicated EOL appointment 1 wk after the need for hospice care has been identified.

Step 2: Evaluate the Pet Owner’s Needs, Beliefs, and Goals for the Pet
Whether conducted at a follow-up visit or at the time a terminal diagnosis is communicated to the client, it is important for the practitioner to explore the client’s needs, beliefs, and goals for the patient’s EOL care.10 Treatment goals described by the client should be as specific as possible and recorded in detail in the patient’s medical record. It is often helpful to have a checklist of questions to ask and issues to discuss with the client as the basis for developing a personalized EOL treatment plan for their pet. Table 2 provides a list of issues to discuss with the client when an EOL or palliative care treatment plan is developed. This inventory of practical concerns can be used as a resource during periodic exams or consultations with the client. The list will help the practitioner and client to assess the patient’s status, evaluate treatment plan efficacy, and revise the plan based on the patient’s response and the client’s willingness and capacity for implementing the plan. The discussion should focus on how to achieve a balance between QOL and duration of life, goals for pain management, and whether euthanasia or natural death is the preferred option.

Understanding the client’s viewpoints towards EOL care for the patient places a premium on effective listening skills. In addition, maintaining eye contact, displaying empathetic body language, and repeating in your own words what the client is saying are core communication techniques.11 The client should be invited to ask questions and should not feel rushed or pressured into making treatment decisions. Regardless of the decisions that are made, the client should never feel judged.

Step 3: Develop a Personalized EOL Treatment Plan
Developing an effective, patient-specific EOL care treatment plan is a collaborative effort involving the veterinary staff and the client. In general terms, there are two paths available for EOL care: (1) aggressive care, which seeks to extend the duration of life; and (2) palliative care, which seeks to maintain the patient’s best possible QOL. These approaches are not mutually exclusive. An aggressivecare treatment plan can, and should, place significant emphasis on QOL. The veterinarian has an obligation to consider the appropriateness of specific care recommendations. This includes answering the hard question: “Just because we can do something medically, does that mean we should?” This is a question that should be discussed during collaborative decisionmaking with the client.12 For terminal cases, not all aggressive interventions are in a patient’s or owner’s best interest. For example, performing radical surgery requiring a significant amount of rehabilitation may not be in the patient’s best interest if expected survival time is short. The goal of collaborative decisionmaking is to identify options that are reasonable from the standpoint of both the patient and the owner. In addition, it is important for the veterinarian to assess the current nutritional status of the patient (body condition score, muscle mass index) and develop a workable nutritional plan for the patient in consultation with their owner. It should be expected and explained that inappetance and anorexia are real concerns in hospice care and that specialized diets are available for use in critical or cachectic patients. Early intervention, whether through assisted feeding or appetite stimulants, may need to be offered, but with consideration to the fact that reduced food and water intake is normal in the dying process.

Consulting with a veterinary nutritionist could also be of benefit to assess the patient’s specific nutritional needs and to assist in the feeding plan.

All EOL treatment plans start with a thorough assessment of the patient and his or her medical, social, and emotional needs. These may include, but are not limited to:

  1. Organ system disease or failure and associated signs, including the special senses
  2. Pain (location, cause, severity, and ability to control)
  3. Difficulty eating and drinking
  4. Decreased oxygenation or difficulty breathing
  5. Elimination problems
  6. Mobility limitations
  7. Tumor disease or tumor activity
  8. Current mood (relaxed versus anxious, happy versus depressed)
  9. Need for and availability of companionship (humans and other animals)
  10. Engagement with her or his surroundings
  11. Emotional and cognitive status

When developing an EOL care treatment plan, the practitioner should discuss with the client his or her ability and willingness to provide the increased level of caregiving generally required for a terminal patient. The client’s capacity for caring for their pet is an important consideration in developing the treatment plan since it relies on the owner’s active involvement. Allowing time to hear the client’s questions and concerns and the extent to which the client can provide supportive care is essential in collaboratively selecting the best course of treatment.

A proposed palliative care plan should be detailed, but it should be presented in language that the client can understand without over-reliance on medical 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 their pet’s treatment plan. The treatment plan should be entered into the patient’s medical record. Treatment plan components should include:

  1. Patient care procedures assigned to the owner based on the individual’s capability and willingness to assume specific responsibilities for care.
  2. An assessment of the patient’s willingness and capacity to receive care. This would also include the patient’s willingness to eat, or the indication for the need for supplemental nutrition (i.e., feeding tubes or syringe feeding) or stimulation of appetite (e.g., mirtazapine).
  3. A written action plan, which has been discussed point-bypoint, with the owner, to ensure their active participation.
  4. An estimate of the time required for the owner to execute those parts of the plan for which they are responsible.
  5. An estimate of costs itemized by fees for professional services and costs of medication, supplies, and nutritional products.
  6. A schedule for follow-up communication and reassessment.

Take-Away Points
  • Collaboratively with the caregiver, hospice options that are reasonable for both the caregiver and the patient need to be determined.
  • It is important to provide a detailed EOL care plan using language that caregivers can understand.

Step 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 clinical sign recognition. The home environment should be evaluated to ensure the patient’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. The client should be instructed in the safe handling of their pet to prevent injury to self and the pet, as well as safe handling of owner-administered medications. Technologies such as video recording or video conferencing can be helpful in regularly communicating the patient’s home-care status with the veterinary healthcare team.

Bioethical Considerations

End-of-life case management and dialogue with the client about the patient’s treatment options should be guided by the four principles of medical bioethics: (1) respect for autonomy, (2) nonmaleficence, (3) beneficence, and (4) justice. These principles are described in a definitive and recently updated textbook by Beauchamp and Childress, Principles of Biomedical Ethics.13 As an EOL case progresses and the client’s attitudes toward their pet’s response to treatment evolve, the veterinarian may need to reconsider the balance between the four bioethical principles and adjust the treatment plan accordingly. One bioethical principle may take precedence over another. For example, when an animal is uncooperative for administration of analgesics (autonomy versus beneficence) or when analgesics administered cause adverse reactions (beneficence versus non-maleficence). It is important to acknowledge that this may occur and to be prepared to justify infringing on one bioethical principle in order to adhere to another. All four principles can apply to both the caregiver and the patient.

Respect for autonomy, as it applies to clients, is the obligation of the veterinary medical professional to disclose the information needed for a client to make the best decision on behalf of their pet. Although the client’s medical knowledge may be limited, they can still make informed decisions and exercise control over their pet’s treatment plan when the veterinary team explains outcomes clearly and completely. Actions by the team that support respect for the autonomy of the client include being truthful; respecting the client’s values, beliefs, culture, privacy, and confidentiality; obtaining consent before performing any treatments; and helping to direct decisionmaking when asked.

Respect for autonomy also implies consideration of the patient’s autonomy. Animals can become fearful and lonely, anticipate pain, and express preferences. These affective (emotional) states are important in palliative and EOL care. In order for EOL care to be successful, not only must the client be willing and able to implement the treatment plan, the patient must also be a willing participant. This is analogous to delivery of medical care to children. The parent is the decisionmaker when pediatric care is involved, just as the owner is the decisionmaker in companion animal medicine. Similar to children now routinely being included in their medical care at a level appropriate to their development, pets can and should be included in their EOL care by respecting the preferences they express about receiving care. Examples include cats jumping onto the counter versus disappearing under the bed when it is time for medication administration; non-ambulatory dogs expressing their pleasure when taken out for a wagon ride; and cats who will bite, scratch, or climb walls rather than go into their carrier.

Non-maleficence is the bioethical principle of “do no harm.” Non-maleficence in palliative and EOL care translates into avoiding iatrogenic escalation of discomfort and pain experienced by patients because of clinical intervention. Examples are skin reactions at the site of transdermal patch application, persistent postoperative pain, or depression induced by hospitalization. Non-maleficence also includes avoiding negligence in the form of deviating from the accepted standard of care. Non-maleficence towards the caregiver includes avoiding insensitive conduct and inadequate communication by veterinary staff that can aggravate the caregiver’s grieving experience. Non-maleficence is complemented by the bioethical principle of beneficence, or deliberate interventions that benefit the patient and/or their caregiver.

Beneficence toward the caregiver may consist of open and honest discussions about the patient’s prognosis and cost of care during the EOL stage. Beneficence toward the patient may involve discussing euthanasia in cases when continuing treatment will result in suffering.

The last of the four bioethical principles is justice, which implies fairness. It is just for the practitioner to provide all clients with their best effort on behalf of the pets, regardless of the client’s background. It is equally just to treat individual patients based on their preferences as well as the client’s financial resources, commitment to the treatment plan, and compliance with recommendations.


Take-Away Points
  • Treatment options should be guided by the four principles of medical bioethics.
  • The veterinary team may need to adjust the treatmentplan accordingly as an EOL case progresses.
  • Treatment options and clinical interventions should alwaysreflect the bioethical principle of “do no harm.”

Client Considerations

Loss and grief are universal human experiences. A pet owner’s emotional response to the loss of their pet is often as intense as the grief experienced following the loss of a family member or friend. Studies have shown that 30% of pet owners will experience significant grief following the loss of a pet and 50% will question their decision following euthanasia.14,15 Given the intense and sometimes conflicting emotions that attend client bereavement, responding to anticipated and actual pet loss with sensitivity and compassion is vital to the mission of animal hospice.

Although the grief response ranges from emotional to stoic depending on the individual, it is generally helpful for the bereaved pet owner to express their emotions to an empathetic listener. The attending veterinarian or other staff members can fill this role. Regular, empathetic communication is the hallmark of effective client support during EOL treatment and after a patient’s death. The veterinary healthcare team has a responsibility to see the EOL case experience through the client’s eyes and to provide nonjudgmental support.

How clients view the veterinary team’s response following the loss of a pet is a critical factor in their continued advocacy for and loyalty to the practice. Studies in human medicine have demonstrated a correlation between empathetic physician-patient communication and an improvement in patient emotional health, compliance with physician recommendations, and satisfaction with their healthcare.16

Client Support During EOL Care

Grief is the natural response to loss and is a dynamic process that changes over time. There are many ways to feel and express normal and healthy grief during the continuum of caring for a dying loved one. Grief can be manifested by emotional, spiritual, cognitive, or physical distress. It is useful for veterinarians to view the normal grief response that their clients experience in terms of the five stages described by Elizabeth Kubler-Ross in her seminal work on bereavement: (1) denial, (2) bargaining, (3) anger, (4) depression, and (5) acceptance.17 It is appropriate to inquire if the pet owner has experience with human EOL or hospice care when discussing their pet’s EOL care plan.

Genuine and empathetic interaction with a bereaved client is a skill that can be learned and improved. Asking open-ended questions is an excellent technique for assessing how a client is handling EOL caregiving responsibilities or bereavement over the loss of their pet. Examples include queries such as “How are you managing?” and “What concerns do you have?” The hospice team members can then validate the extent of the difficulty or grief the individual is experiencing. Reflective listening techniques, such as acknowledging that you heard what the client said and then summarizing the individual’s comments, are helpful for facilitating what is always a difficult topic of discussion.

Conversations about EOL, death, and grief with a bereaved client are never easy. Descriptions of various verbal and non-verbal communication techniques appropriate for veterinarians involved in EOL discussions with clients are available from a variety of sources.18-20 For example, client communication programs for healthcare professionals are available from the Institute for Healthcare Communication in New Haven, Connecticut (https:// veterinarycommunication.org/), and from the International Veterinary Communication Institute in Ontario, Canada. Among the many available resources are the Colorado State University College of Veterinary Medicine Frank clinical communication workshops (http://csu-cvmbs.colostate.edu/academics/clinsci/veterinarycommunication/ Pages/frank-workshops.aspx) designed to improve veterinarians’ communication skills. Other training opportunities are available at many veterinary conferences.

It is appropriate for veterinary team members to suggest to a bereaved client that professional grief-support counseling may be helpful. This recommendation should be accompanied by reassuring the client that most people whose pets have undergone EOL care experience grief and an often-profound sense of loss.14

Experts recommend that veterinary professionals focus on four specific roles in dealing with clients who have experienced the death of a pet: (1) educator, (2) supporter, (3) facilitator, and (4) a resource and referral guide. Specific actions related to each role are listed in Figure 2.18 Several universal principles that apply to each of the four client support roles are also shown in the figure. Healthcare team members often use one or more phrases intended to be consoling that can be perceived by the client as insincere or out of bounds (Figure 2).21 Team members should be careful to avoid these expressions, termed “the clichés of grief.”

Supporting Clients Experiencing Pet Bereavement

American Hospice Care Pyramid

FIGURE 2 The figure illustrates an integrated approach to supporting a client who is experiencing bereavement over the loss of their pet. The four client support roles (left box) can be assumed by the attending veterinarian or delegated among members of the veterinary healthcare team.18 All staff members should observe the client support principles (right box) when assuming any of the support roles.18 Certain phrases should be avoided (bottom box) because they may not be true, the client may not agree, or they represent a commitment the veterinarian may not be able to keep.21 Illustration Design: Mark Dana, Kanara Consulting Group, LLC

Within the first week after the initial EOL 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 veterinary healthcare team, and may reconsider whether or not the agreed upon treatment plan was the right thing to do. Unanticipated roadblocks to the patient’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 athome care can undermine or change the client’s relationship with their pet. Periodic follow-up appointments or phone consultations initiated by the veterinary team are vital to addressing and responding to these potential problems. Setting up a timeline of regular communication contacts with the client will avoid situations where the patient’s EOL needs are inadvertently overlooked.

Following the death of a pet, a significant number of owners will experience profound grief. In some cases, the client’s sense of bereavement may be accompanied by anger that is directed at the veterinary team. The power of appropriate follow-up by the team to offset the depth and duration of the client’s grief response cannot be overestimated. This type of outreach can take the form of a condolence card, phone call, sponsorship of a pet-loss support group facilitated by a professional counselor, or referral to counseling services or online resources.


Take-Away Points
  • Grief is a natural response to loss and it changes over time.
  • Timely, empathetic, and non-judgmental communicationis the hallmark of effective client support.
  • Bereaved caregivers may benefit from professional grief-support counseling.

Pet Body Care

Owners of pets that die while under a veterinarian’s care are usually concerned about the postmortem disposition of their pet’s body.14 The veterinarian should initiate a candid discussion of how the pet’s body will be handled and ask if the client has any questions or concerns. For example, the veterinarian should disclose whether the body would be refrigerated or frozen and discuss cremation and burial options. A necropsy should be offered and the findings entered into the patient’s medical record. Veterinary staff members are encouraged to visit local pet crematories and cemeteries to learn about options for body care.

Memorializing a Pet

Memorializing a pet is frequently helpful in the grieving process because it acknowledges and honors the human-animal bond. Ways of remembering a pet may include writing a letter to the pet or a poem about him or her, creating a photo album or journal about the pet, planting a memorial tree, or obtaining a professional portrait of the pet. Helping the caregiver memorialize their pet is one of the best ways of expressing support and empathy for bereaved clients. A donation on behalf of the practice, for example, to an animal welfare organization or a charity of the client’s choice, giving the client a memorial item, conducting an annual memorial service for all deceased patients, or sending a personalized condolence card are some of the actions taken by veterinarians to demonstrate empathy and to offer their clients support.

Veterinary Healthcare Team Considerations

Adopting an Interdisciplinary Team Approach

Because an interdisciplinary team approach can add a valuable dimension to EOL care, the task force recommends that all primary care practices have a dedicated team to implement palliative and hospice care. Moreover, it is advisable that all members of a primary care practice, clinical and administrative, be informed whenever a patient is undergoing EOL care.

In addition to EOL care provided by the primary care practice, there are veterinarians with advanced skills and an interest in providing animal hospice and palliative care in a growing number of communities. There is a need for professional training programs to ensure an advanced level of expertise and establish best practices in animal hospice care. Additionally, evidence-based research to support this rapidly evolving field is also necessary. Future recognition of hospice care and palliative medicine as a veterinary specialty is currently under consideration.

The skills required for optimal EOL care have become more advanced than many veterinary practices are equipped to provide. Partnering with human emotional and spiritual support professionals (social workers, pet loss support groups, religious leaders) for services that support pet caregivers involved in EOL care is an acceptable and even desirable adjunct to companion animal practice.22

Speaking with One Voice

It is important that the healthcare team speak with a unified voice and sense of purpose under any circumstances, particularly when EOL care is concerned. In EOL cases, each member of the veterinary healthcare team should have defined caregiving and client-support responsibilities, preferably ones that utilize individual skills, strengths, and experience. The objective is to provide seamless and consistent care for both the patient and his or her caregiver, leaving no gaps in medical or emotional support.

To this end, when new staff members are hired or when EOL care protocols are implemented, adequate training and establishment of roles and responsibilities should be provided to all staff members. No member of the veterinary staff should be left out of training. EOL training is not a static but an ongoing process due to inevitable staff turnover and evolving EOL strategies within a practice. It is also important to establish a system whereby all staff members are alerted when an EOL care case is initiated. This allows activation of appropriate interaction with the client and preparation for palliative and hospice services. Everyone, including reception, medical and technical staff, and kennel assistants, needs to understand their role in EOL care and be prepared to handle emotionally challenging situations.

Besides medical care, all veterinary healthcare team members should have the skills needed to effectively communicate with owners of pets receiving EOL care. Practice owners should consider communication skills training, including role-playing, specifically tailored for EOL care for their entire team.

Compassion Fatigue

Compassion fatigue (CF) is a phenomenon defined as the emotional, social, and spiritual cost of caregiving leading to a decline in the desire, ability, and energy needed to empathize with and care for others. Ultimately, CF results in the loss of satisfaction in both the professional and personal life of the caregiver. Veterinary team members who work with EOL patients and their owners and are immersed in an environment of intense emotional and physical suffering, often of extended duration, with little group awareness and support are at higher risk of CF. Veterinarians are especially at risk for CF and depression due to the significant occupational stressors they experience.23 It is important for the veterinary team to recognize the signs of CF in order to maintain a high level of professionalism.

CF can manifest itself in a variety of ways that are often overlooked or dismissed as “burn-out.” Anger, frustration, depression, crying, insensitivity, a negative attitude, anxiety, and irritability are all behavioral signs of CF. Physical symptoms include changes in sleeping behavior, somatic illness, lethargy, and impaired immune response. Psychological indicators include a loss of hope, increased skepticism, and excessive guilt. These changes can result in avoidance of certain clients, patients or procedures, loss of enjoyment in work, and fear or guilt about letting clients or patients down. Ultimately, CF can affect the morale of the team, either individually or collectively.

Awareness is the key to preventing or minimizing the impact of CF. The likelihood of CF becoming a chronic state or occurring in the first place is reduced when staff members have a high level of self-care, including adequate sleep, good nutrition, taking periodic breaks, and not over scheduling. Staff members who are particularly empathetic and motivated to provide patient or client support may be at higher risk of CF. Staff education on the realities of emotional exhaustion and overload that can accompany EOL cases is the best approach to avoiding, recognizing, and controlling CF. Simply being aware that CF is a normal risk of EOL care is often enough to prevent the serious consequences to team members.

Ways of effectively dealing with CF include:

  1. Accepting that emotions such as CF are normal and inevitable in EOL cases.
  2. Verbalizing the challenges of EOL care and avoiding “bottling it in.”
  3. Approaching a colleague who may be showing signs of CF.
  4. Having debriefing sessions at the end of each day.
  5. Seeking professional counseling when appropriate.
  6. In a staff training setting, role-playing techniques to offset theeffects of CF.

Take-Away Points
  • Members of the veterinary healthcare team should have defined patient and client-support roles.
  • Staff members who are particularly empathetic may be at higher risk for compassion fatigue.
  • Partnering with other healthcare professionals for services that support clients is desirable and provides for the highest level of patient and family care.
  • If a practice is unable to support optimum at-home hospice care, referrals should be made to veterinarians with advanced skills in providing animal hospice care.

The End-of-Life Event

Euthanasia Versus Natural Hospice-Supported Death

Both euthanasia and hospice-supported natural death are medically and ethically acceptable options in veterinary EOL care and animal hospice. Deciding between humane euthanasia and hospicesupported natural death should be the result of a collaborative discussion involving the caregiver and the animal hospice team. It is consistent with the principles of animal hospice that the caregiver has the ethical and legal right and responsibility to decide if, when, where, and by whom a terminally ill animal will be euthanized. Reaching consensus about these decisions between the veterinarian and family members, or within the family itself, may be challenging. It is important for the veterinarian and their team to be supportive once the decision for or against euthanasia has been made by the caregiver. If a consensus decision cannot be reached, referral to a veterinarian with advanced skills and an interest in providing animal hospice and palliative care should be considered. Animal hospice principles do not accept a pet owner’s decision to allow a pet to die without euthanasia and without effective palliative measures while under the care of a licensed veterinarian. Such a practice is considered unethical and inhumane.

The following guidelines will help the veterinary healthcare team to engage in ethical, collaborative EOL decisionmaking:

  1. Discuss all euthanasia and natural-death options with the pet owner (do not exclude or minimize any single option).
  2. Recognize that many pet owners rely on the veterinarian’s recommendation for the best approach to their pet’s end of life, while others prefer to take the primary decisionmaking role.
  3. Describe EOL options to pet owners in language they can understand.
  4. Describe EOL options in a factual and non-judgmental manner, articulating pros and cons of each option.
  5. Avoid a biased presentation of information designed to steer a client’s EOL choices in the direction of the veterinarian’s preferences.
  6. Support the pet owner’s EOL decision for their pet, accepting that their values and beliefs may be different from the veterinarian’s.

It is the veterinarian’s duty to recommend euthanasia to relieve the patient’s suffering when palliation no longer meets the animal’s physical, social, or emotional needs. However, for some pet owners, euthanasia may not be an acceptable procedure. In such cases, high-dose palliative sedation combined with adequate analgesia is an ethical alternative. An ongoing dialogue with the pet owner is essential during the course of palliative sedation.

Many pet owners express the wish that their terminally ill pet be allowed to die peacefully without the need for euthanasia. Public and scientific dialogue about what an animal experiences while dying without euthanasia, especially in the final phases of the process, is based on limited empirical or scientific data.

Considerable data are available from human studies on physiological changes that occur in the early and final phases of active dying. In the authors’ opinion, the human data can be relevant to caring for animals in the final stage of life. For example, in a recent European study of human cancer patients admitted to palliative home care programs, the patients’ principal caregivers were interviewed within a week after death and asked to report specific observations during the last 2 hr before death.24 These observations included various physiological signs indicative of death and peaceful death. Peaceful death was defined as a death free from distress and suffering for patients and their families.24 Of the cases where complete information was obtained from caregivers, 70% (126/181) reported the occurrence of peaceful death. Terminal sedation was used during the last 2 days of life in 33% (60/181) of cases.24 Peaceful death did not always coincide with palliative sedation, indicating that peaceful death is not sedation-dependent. Of non-peaceful death cases, more than half (29/55) suffered from death rattle, or sounds related to fluid accumulation in the airways during late stages of active dying.24 Death rattle is often distressing to caregivers, but is not an indication that the patient is suffering. Death rattle is not as common in animals as it is in humans. Only 15% of patients in this study experienced dyspnea (6.0%), agitation (6.0%), tremors (1.2%), convulsions (0.6%), or pain behavior (0.6%).24 These results are consistent with other human studies. 25,26

When an animal hospice patient is in the last hours of life, recognition and alleviation of pain are top priorities for the pet owner and the healthcare team. Pain should be addressed as soon as it is suspected, when physiologic or behavioral signs are noted. Contrary to a common fear, there is no evidence to suggest that pain suddenly intensifies during active dying.27 Treatment of pain in the imminently dying patient should follow general multimodal pain management principles.28 As suggested by the studies described above, aggressive pain management is a critical element in palliative care for dying human cancer patients, frequently assuming priority over maintaining the patient’s consciousness.24


Take-Away Points
  • Animal hospice care is inclusive of death by euthanasia as well as hospice-supported natural death.
  • When an animal hospice patient is in the last hours of life, alleviating pain is a top priority and multimodal pain management strategies should be utilized.
  • To minimize anxiety, the client should be informed of every step of the euthanasia procedure.

TABLE 3

Pros and Cons of Pre-Euthanasia Sedation or Anesthesia

Advantages

Disadvantages

Minimizes patient’s anxiety

Eliminates pain from underlying disease

Increases technique options

Eliminates need for restraint during euthanasia

May lessen peri-mortem side effects
(e.g., agonal breathing)

Increased expense

May alter body physiology, making certain techniques more difficult

Unpredictable transition into sedation

Potential for side effects
(e.g., vomiting, dyspnea)

Adapted from Cooney et al. with permission.30 Table created by Mark Dana.

In-Hospital Euthanasia

When euthanasia is to be performed at the veterinary hospital, it is possible and recommended to involve the entire healthcare team to make the experience as acceptable as possible to the client. When euthanasia is done with compassion in a safe and secure place, it increases the likelihood that the client will continue to use the practice’s services.14 The initial phone call to schedule the appointment should be met with empathy, followed by gathering all necessary information regarding the patient and the needs of the client. The hospital team should then be alerted that a euthanasia appointment has been scheduled in order to make preparations. It is preferable for the euthanasia room and waiting area for the pet owner to be located away from busy areas and surrounding distractions.

When the client and patient arrive, a staff member should greet them and lead them directly to the euthanasia room. If payment and arrangements have not been handled over the phone, it can be done in the euthanasia room to increase privacy. After consent forms have been signed, and the client is ready, the euthanasia procedure can be performed. The AVMA Euthanasia Guidelines for Animals recommends the administration of preeuthanasia sedation or anesthesia to companion animals, especially when clients are present.29 Because there are advantages and disadvantages to administering sedation or anesthesia (Table 3), the pros and cons of doing so should be considered when working with physically compromised patients in hospice.30

The AVMA also recommends the use of IV catheters for administration of euthanasia solutions to companion animals when clients are present.27 Other techniques can be utilized as long as anxiety and pain are minimized for the patient and are in compliance with the AVMA Guidelines. The client should be informed of every step in the procedure to manage expectations and minimize anxiety. Veterinarians and team members performing euthanasia are encouraged to keep the animal and family together during the entire procedure, including catheter placement. Clients should be given the opportunity to hold or comfort their pet during the euthanasia procedure. While veterinarians should always offer this option, they should recognize that some clients may prefer not to hold their pet or even be present during euthanasia. In either case, the client’s preference should be respected and the individual should not be made to feel guilty if they choose not to be present or to hold their pet during the procedure. Following euthanasia, clients should be offered time alone with their pet whenever possible.

At-Home Euthanasia

Euthanasia procedures can be performed in the client’s home, something many pet owners prefer. At-home euthanasia avoids subjecting the patient to travel and allows it to remain in familiar settings. Home euthanasia also provides increased privacy for the owner, allows a greater number of family members to be present, and tends to minimize time constraints.

The underlying rationale for home euthanasia is to provide a calm, anxiety-free EOL experience for the patient and their owner. Performing euthanasia in the client’s home can sometimes be inconvenient, even challenging, for the veterinary healthcare team. Examples include limited space, poor lighting or ventilation, not having access to all support personnel, and other environmental disadvantages. However, the ultimate goal is to keep the patient and client comfortable and secure at this difficult time. The veterinarian may want to bring a technician or other personnel along to the home if they feel additional staff support may be needed to successfully complete the euthanasia procedure or for safety reasons.

Veterinary staff will need to make certain preparations before traveling to a client’s home. Controlled substances should be kept in a secure place. Whatever medications are taken from the hospital need to be cataloged and recorded. A body stretcher and bag are also useful if a larger animal has to be transported back to the hospital for cremation.31

It is ideal to gather at a place in the home where the patient and client are most comfortable. This may include such places as a master bedroom or family or living room floor. An appropriate outdoor setting is also acceptable. Whenever possible, the veterinary staff should be willing to attend the animal anywhere the client deems best.

As with in-hospital euthanasia, preliminary sedation or anesthesia can be given before at-home euthanasia to minimize stress and anxiety. Euthanasia itself is usually performed by administration of an injectable euthanasia agent. Inhalant gases are rarely, if ever, used in the home procedure due to safety and logistical concerns associated with equipment transportation. Each of the AVMA-approved injectable euthanasia methods can be accomplished as safely in the home as in the hospital. Even in a home setting, veterinary personnel in attendance should offer to excuse themselves after euthanasia has been administered in order to allow the owner privacy. Arrangements should be made in advance for transportation and final disposition of the patient’s body by cremation or burial.


Take-Away Points
  • Never assume anything—it is important to adequately communicate to the client what to anticipate with the dying process as well as postmortem changes that may occur.
  • Never rush the process—clients want, and need, your undivided attention and you have an obligation to give it to them.
  • Consider the use of language and how subtle word differences can have an impact; instead of saying, “When you are ready,” say “When you are as ready as you can be.”

Unanswered but Important Questions for Continued Research

Do animals remember the past? Do they anticipate the future? Are they capable of assessment of self? Intentionality? Choice? These questions, once believed to be beyond the reach of any science, loom large in the minds of many pet owners/caregivers as they face the decisions they have to make for their pets throughout EOL care. These questions have been under extensive scientific examination in recent decades, and the weight of the evidence indicates that many species of animals do possess some of these capabilities, in widely varying combinations and in different degrees of complexity.

Summary: Challenges and Opportunities

The overarching goal of EOL care in veterinary medicine is to maximize patient comfort while minimizing suffering, utilizing a collaborative and supportive approach with the caregiver client. The primary means for addressing caregiver needs is competent, nonjudgmental, and empathetic EOL communication, including recognizing, acknowledging, normalizing, and validating the human emotional and spiritual distress associated with the caregiving role for a terminally ill pet when a strong humananimal bond exists. Other channels include suggesting resources such as books, articles, websites, support groups, and, in some cases, referral to a counseling professional.

A companion animal practice that gains a reputation for providing EOL care in a skillful, compassionate way will retain clients and gain referrals as a result. As the art and science of EOL care continues to evolve in veterinary medicine, practitioners will likely be influenced by the precedent set in human hospice care.

Although there is a great deal to be gained from lessons learned on the human side, it is important to remember that veterinary EOL care has unique characteristics and challenges that are distinct from human EOL care. Because pets are incapable of verbalizing their needs and wishes, veterinarians and their clients must resort to interpretation of animals’ behavior in their efforts to understand these needs. Recent advances in brain imaging techniques and longitudinal studies of animal behavior offer exciting insights into animals’ emotional and cognitive capabilities, though it is not possible to completely ascertain the motivation explaining an animal’s observable behaviors.

In spite of the growth of the pet insurance industry, financial considerations are a primary concern in many veterinary EOL decisions. Finances often dictate the extent and length of the client’s ability and willingness to provide their pet professionally guided EOL care. Various physical and infrastructure constraints also exist in veterinary EOL care. These include limitations on facilities for extended care, hospice services, hospitalization (e.g., in rural areas), and staffing to provide home assistance to owners. Physical constraints include lack of specialized equipment to handle non-ambulatory patients, especially large canine breeds. These limitations also influence many EOL decisions.

Although many owners consider their pets family members, there are profound differences between animals and human family members. This fundamental distinction often guides clients’ decisions regarding pet EOL care.

Euthanasia, a legal and widely accepted tool in veterinary care, is a double-edged sword. On one hand, it provides an end to animal suffering when it becomes medically, financially, or physically impossible to maintain the patient’s QOL. On the other hand, it leaves significant numbers of caregivers struggling with doubts regarding the decisions they made, which prolongs and complicates their grief experience. As the value of animal hospice care and its availability increase, so will the feasibility of ethically managed, high quality, hospice-supported natural death, and the decision to euthanize will become more nuanced. Navigating complex medical and ethical realities in the face of intense human emotions is one of the greatest challenges of veterinary EOL care and a central theme of these guidelines. A satisfactory decision to euthanize is heavily dependent on open, honest, and empathetic communication with the client.

It is likely that some of these challenges will be resolved by advances in veterinary EOL care. Veterinary medicine is a resourceful and innovative profession with a history of responding to societal change, including the growing population of canine and feline pets and the deeply embedded role that pets play in the lives of their owners.


The AAHA/IAAHPC Task Force gratefully acknowledges the contribution of Mark Dana of the Kanara Consulting Group, LLC, in the preparation of the Guidelines.

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