Palliative care: The missing piece of chronic disease management
“There’s nothing more that can be done,” the primary veterinarian says to the family of the 16-year-old spayed domestic shorthair with chronic renal failure whose renal values continue to climb despite standard medical management.
“Without surgery, we recommend euthanasia,” says the emergency veterinarian to the family of the 5-year-old golden retriever who has just been diagnosed with hemoabdomen from a splenic tumor.
These are what some families hear from veterinary practices before they call Lynn Hendrix, DVM, CHPV, owner and consultant at The Palliative Vet. Hendrix has been practicing palliative care exclusively for the last 12 years and has seen how much better life can be for pets with chronic, progressive diseases.
The role of palliative care
Many veterinarians view palliative care as a “hail Mary” at the end of life: Sometimes, it works. But for Hendrix and other veterinarians who specialize in palliative care, it is an intentional way to improve life, for both the patient and their family, when managing chronic disease.
Definitions of animal hospice and palliative care have been adapted from human medicine. The two closely related terms define care that is provided to patients with a chronic, progressive disease that cannot be cured.
Hospice care is often thought of as care immediately preceding death, whereas palliative care can last for months or even years. Palliative care focuses on improving the quality of life for an animal and their family as a disease progresses.
Hendrix notes that it often requires an interdisciplinary team including veterinarians, veterinary technicians, groomers, pharmacists, and professionals providing spiritual and/or mental health support for the family.
Palliative care doesn’t mean that curative or definitive treatment of a disease stops. Hendrix referenced a 2010 study in human medicine by Jennifer Temel that found patients who received palliative care earlier in the course of their disease had better quality of life. More surprisingly, they also lived longer.
“Imagine if you’re a practitioner and find out that if you did palliative care well, your patients would live longer and better,” said Hendrix. “What’s not to like about that?”
While palliative care is a part of the spectrum of options we can provide to clients, it exists as its own spectrum. Hendrix again notes that in human medicine, palliative efforts start early, and “as curative medicine tapers off, palliative medicine ramps up.” Hendrix wants the same for veterinary medicine.
Hemangiosarcoma: Better outcomes are possible
Early in her mobile veterinary career, Hendrix was called to an in-home euthanasia of a golden retriever with known hemangiosarcoma. “They’d done everything,” she said, “They’d gone to the university, gotten the spleen out, done the chemotherapy, done whatever they’d been told. Six months later, it was back in the liver.”
When she arrived, she was greeted by a dog who was so anemic he fell over after standing to greet her. One of the owners asked if euthanasia was the only decision. They discussed all the options and what could or couldn’t be done. “I ended up doing some subcutaneous fluids and pain meds as a ‘hail Mary,’ fully expecting the dog to die,” she said. “Two days later they called me back out and said, ‘let’s talk about what to do next.’” Hendrix thought for sure he would have died by then, but instead, when she returned to the house, he ran to her car to greet her.
“It’s been a learning experience,” she said. As an ER veterinarian, Hendrix would see the patients with hemangiosarcoma go home against medical advice and not know what happened. Now, she sees many live well for anywhere from six to eight weeks to up to six months.
She noted that her “outliers for hemangiosarcoma, or presumed hemangiosarcoma, are 10 months, 12 months and 20 months.” They had a few bleeds but “the majority of it was really good time.”
“It’s a longer time period on average than if they have no medical intervention,” Hendrix said: “They go through potentially multiple cycles [of bleeding] before we get to the point of euthanasia. It depends on what the client has decided is their crisis point.”
Part of the palliative care process is supporting the patient with subcutaneous fluids and medications like tranexamic acid as well as pain control. Clients are educated in how to recognize clinical signs of a bleed and what treatments to give in those situations to support them.
Incorporating palliative care into chronic disease management
Hemangiosarcoma is just one example of a condition that can be palliated. Generally, these conditions are chronic, progressive diseases, like organ failure, degenerative myelopathy, dementia, and neoplasia.
Not all conditions can be palliated, Hendrix notes, such as acute emergencies like a GDV or renal failure from ingesting ethylene glycol. But for those chronic conditions, she encourages veterinarians to think about what more they can do to improve quality of life.
Hendrix recommends that veterinarians not familiar with advanced palliative care refer to a veterinarian with hospice and palliative care training when possible, though she knows there is a shortage of veterinarians doing this work.
Setting up a plan for palliative care requires long conversations with pet owners about goals of care and what is and isn’t feasible for both the pet and their human family members. “It’s hard for GPs who are seeing 15- to 30-minute appointments, or an ER doctor who is constantly on triage mode, to have these conversations,” she said: “It’s not a fast conversation; you can’t focus on the people and their needs for as long as they need you to focus on them. That’s why my appointments are three hours long.”
For veterinarians who are exploring palliative care, Hendrix stresses the importance of pain management. She feels that “animals don’t hide pain: People aren’t recognizing it.”
Hendrix shared the case of an uncontrolled diabetic cat who was barely walking: “I hardly ever see diabetic animals on pain management, and yet we know from humans that diabetic neuropathy is really painful.” A week after starting gabapentin, the owner sent Hendrix a video of the cat running down the stairs.
“It’s all about training more on chronic pain,” said Hendrix when it comes to pain management. Sometimes, even veterinarians may miss subtle signs of pain. We must be vigilant and proactive. We also must communicate clearly with owners about how to recognize chronic pain signs. Many clients who are labeled as “in denial” about their pet’s condition are actually just looking at different things, like the emotional side of life such as eating or activity, than the physical side that the veterinarian focuses on.
The future of palliative care
Two of the biggest barriers to offering advanced palliative care are lack of education for veterinarians and evidence-based studies, Hendrix said. Much of the current evidence of palliative care is in the human literature and extrapolated to veterinary medicine.
As the field grows, Hendrix hopes to have more evidence-based literature to support the treatments that are being used. We need to “take away the language of ‘there’s nothing more we can do,’” she said. “There is more we can do: We’re just not educated in it.”
For veterinarians who are interested in learning more about palliative and hospice care, education is available. The International Association of Animal Hospice and Palliative Care (IAAHPC) offers a certification program and continuing education opportunities at conferences are growing.
Hendrix has also authored Animal Hospice and Palliative Medicine for the House Call Veterinarian. Despite the title, Hendrix shared the book is not just for house call veterinarians, “I wrote it so that people could have additional education in what they could do to improve the lives of both the families and their beloved pet toward the end of the pet’s life.”
Hear more from Lynn Hendrix on Central Line: The AAHA Podcast in Episode 33: “Bridging the Gap: Palliative Veterinary Care Takes a Team.”
Kate Boatright, VMD, is a small animal veterinarian, speaker, and author in western Pennsylvania. She graduated from the University of Pennsylvania in 2013 and has worked in rural small animal general practice and emergency clinics ever since. She is passionate about inciting positive change in the profession through mentorship and servant leadership in organized veterinary medicine. She writes a monthly column for NEWStat on the role of the spectrum of care in improving outcomes in clinical practice.
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Disclaimer: The views expressed, and topics discussed, in any NEWStat column or article are intended to inform, educate, or entertain, and do not represent an official position by the American Animal Hospital Association (AAHA) or its Board of Directors.