Monday, July 18, 2016

Why Palliative Care for Pets is so Important

By Keith Loria
Veterinary Practice News

"As veterinarians, we must do everything we can to relieve our patients from pain, stress and discomfort, whether it is a curable or terminal disease.


Medical advances and the ever-changing dynamics of the human-animal bond are combining to make palliative pet care even more important today.

Kathy Cooney, DVM, immediate past president of the International Association for Animal Hospice and Palliative Care, noted that a multimodal approach is helping dying pets live pain-free.

"The time is right to improve care at the end of a pet's life," said Dr. Cooney, the owner of Cooney Animal Hospice Consulting in Loveland, Colo. "Pets are like family, and many caregivers are searching for more options, especially when euthanasia has been the only option presented to them."

Perhaps that's why efforts to improve palliative care now include the association's new certification program for veterinarians and technicians. An upcoming book from the organization explores the trend, plus a passionate and growing veterinary population that is opening shop.

Mary Gardner, DVM, co-founder of Lutz, Fla.-based Lap of Love Veterinary Hospice, with 47 locations in 22 states, noted that palliative care is the foundation to hospice.

"With the increase of veterinary hospice services being offered around the country, more pet families are looking for ways to decrease pain and increase quality of life," she said. "Our well-loved and cared-for pets are now reaching the geriatric life phase in ever-increasing numbers, and like their human counterparts, experience pain as part of the aging process."

Many of today's owners are highly attuned to changes in their pet's activity levels and disposition, and are open to palliative care options.

"It's imperative to remember that palliative care is not just for the old or dying; it is to provide relief of symptoms of any serious illness or injury," Dr. Gardner said. "As veterinarians, we must do everything we can to relive our patients from pain, stress and discomfort, whether it is a curable or terminal disease."

Honest Conversation
Veterinarians should listen to a pet owner's wants and needs before offering up end-of-life advice - and they need to be truthful about each method.

"We have to learn their goals and even previous experiences before we can offer options," Cooney said. "So much of what will be put forth to them will be based on this."

"The next step is to formulate a plan of care that meets their needs, as well as the pets'," Cooney added. "We discuss expected disease trajectories, and we educate about all possible outcomes... and risks, and make decisions in everyone's best interest."

In end-of-life palliative care, the patient may be seen as not just the pet but the family unit, too. Palliative care can be complex. Staying in regular communication with caregivers and monitoring the situation closely, is crucial.

"Education and expectations are important to disseminate early on in the conversation," Gardner said. "A palliation guide and plan should be developed to inform the owner of changes to look for, how not to get discouraged, and knowing when to reach back to the veterinarian for modifications."

The biggest challenge is to make sure pets and owners do not slip through the cracks.

"It's also important to set real expectations," Gardner said. "Some owners may expect a full recovery from a chronic disease like osteoarthritis and may want to run five miles a week with their dog. But educating them on their dog's limitations is important, so the owner doesn't get frustrated and feel the plan is a failure."

Making Inroads
While home care is growing in popularity, Cooney said, the problem is that some in the veterinary community don't embrace palliative care.

"It's well-documented in human hospice that palliative care plays a vital role in dying patients' overall well-being," she said. "Some actually leave hospice altogether because finally, their symptoms are being lessened to the point that some normal life is returning. Our field can and should follow suit."

Palliative care is a multimodal approach and has to be addressed from different angles using different tools and often multiple medications. Gardner has seen an increase in physical therapy and laser treatments.

"Acupuncture has always been an important ingredient to palliative care, but what's great about physical therapy is that we can teach owners techniques to help their pets, so the treatment continues after they leave our practice." she said.

Endigo Sports Medicine in Palm Beach, Fla., for example, built a mobile water treadmill so that when pets are in pain and have difficulty getting places, the doctors come to them.

Advancements in Drugs
Gardner is intrigued and excited about two emerging drugs from Aratana Therapeutics, Inc. of Leawood, Kan.

"They are targeting the two biggest symptoms we see in our patients: pain and inappetence," she said. "For pain, they have grapiprant, which blocks the EP4 prostaglandin receptor, and in studies has had no effects on liver, kidney or GI ulceration.

"For inappetence, capromorelin looks promising from trials. This will not only help patients with chronic inappetence due to pain or illness, but those in treatments such as chemotherapy or recovering from surgery."

Veterinarians must keep up-to-date on the latest medications, as well as the older drugs, she said. For example, she noted that tramadol is widely used for canine pain, but recent studies showed it was not a good option for chronic pain.

"Oftentimes I see way too many pets not on proper pain control who may have enjoyed a better quality of life before my end-of-life visit," she said. "As a whole, we need to be addressing out geriatric and chronically ill pet parents inside the clinic with better education and marketing plans, because palliative care can really extend the amount of good days that our pets deserve."

Cooney pointed to a few new drugs hitting the market. "With all the wonderful medicine at our fingertips, we can palliate those symptoms that cause discomfort," she said. "Remove discomfort and miracles can happen."

Putting Software to Use
Set to launch in mid-2016 is a new software designed for veterinarians who are providing hospice and home-care services.

Dennis Hopkins, founder of Edmonds, Was.-based Rex Mobile Vet Hospice Software, said his wife, a mobile hospice veterinarian, needed special software for her line of work. What makes Rex different is that it's not meant for the brick and mortar general practitioner. It's designed for the hospice veterinarian.

"There is a tremendous amount of redundant paperwork that needs to be done, and Rex is trying to streamline it and take out the redundancy," Hopkins said. "The software will help create custom documents like notice of euthanasia, consent to euthanize, hospice proposals, notice to crematorium that will auto-populate all the important details for each appointment, and allow for an e-signature, where required, thus keeping all documents electronic, efficient, and organized."

Final Thoughts
Gardner is part of a committee that plans to ask the American Veterinary Medical Association to recognize a new specialty group: the American College of Veterinary Hospice and Palliative Medicine. She expects to have further details available next year.

In the meantime, Cooney is focused on providing palliative care at various points throughout a pet's life. It may be applied to any condition where a cure is not possible.

"The objective is to relieve discomfort, relieve distress, and maintain the highest quality of life for as long as we are able," Cooney said. "If there is pain, we relieve it. If there is nausea, we erase it. If there is anxiety, we calm it."

"Palliative care is paramount at the end-of-life, too, when we know that death is coming. If we don't palliate, suffering is sure to present, and that is just not an option in our world today. We are beyond that."'

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