AAFP Position Statement

Veterinary hospice care for cats

The AAFP supports palliative or hospice care, which is a relationship-centered philosophy that all veterinarians can use in practice. The concept of hospice care is to provide an alternative to the premature euthanasia of a terminally ill cat — and not about heroic medical interventions.

Hospice care is an important resource that allows clients time to make decisions and prepare for the impending loss of a terminally ill cat companion. ¹ Hospice care provides a loving alternative to prolonged suffering either in the isolation of an intensive care setting or without treatment at home. ²

From time to time the AAFP will respond to emerging new knowledge or issues that are of concern to veterinary professionals caring for cats. Our position statements, which represent the views of the association, are available at: www.catvets.com/professionals/guidelines/position/

Qualifications/circumstances meriting hospice and palliative care

• A decision not to pursue curative treatments

• Diagnosis of a terminal illness

• Diagnosis of a chronic illness

• Symptoms of a chronic illness that are interfering with the routine of the pet

• Disease process in which curative treatment was possible but failed

• Problems that require long-term intensive care

• Illnesses that are progressive

• Diseases or traumas that have health complications associated with them

Hospice care

Hospice is a system for providing comfort care to animals nearing the end of their life and emotional support for the clients who love them.

Palliative care

Palliative care focuses on the relief of suffering while providing for the best quality of life regardless of the disease outcome.

Welfare considerations

• Every cat deserves the benefit of a life worth living; that is, a good life, as opposed to a life not worth living, taking into consideration the Five Freedoms. ³

• It is paramount for the veterinarian and the veterinary team to recognize and communicate respect for the special bond that links a cat to family members.

• The patient's comfort must always be considered when veterinary hospice care is provided.

• The veterinarian and the veterinary team should provide expertise in palliative care and pain control for the terminally ill feline patient.

• Providing hospice care is time consuming and requires a considerable commitment to the medical needs of the patient and to the emotional needs of the client. A veterinarian must make a thorough and realistic assessment of what services can be provided and what services will require a referral.

• Hospice care is not about heroic medical interventions that prevent quality of life in a pointless attempt to prolong it (see www.aahabv.org).

• Veterinarians should be aware of the ethical, moral and welfare considerations regarding end of life issues (see AAFP position statement on end of life issues in feline medicine). ⁴ Hospice and palliative care are options to the premature euthanasia of a terminally ill cat.

‘Nothing loved is ever lost’: it is paramount that the veterinary team recognizes and communicates respect for the special bond that links a cat to family members

Communicating and delivering hospice care in a five-step plan ⁵

1 Evaluation of the client's needs, beliefs and goals for the cat

• Veterinarians and the veterinary team must recognize that each cat family has its own belief system, personal life style and tolerance level. Many issues encompass value judgments such as religion, personal finances, logistics of travel to and from treatment facilities, scheduling of visits and home care requirements.

• All family/household members should be involved in, and aware of, the hospice care process. Children should be included with the other family members if so desired.

2 Education about the disease process

• Clients should be counseled regarding the severity of their cat's condition and the expected outcome. They should I also be informed of their responsibilities and the services the veterinarian can provide and what services will be referred. If possible, hospice care should begin as soon as a qualifying diagnosis is made.

• A dedicated hospice team is necessary to provide the emotional and palliative support the cat patient and family members need. Extra training in client communications, attachment theory and grief management is beneficial.

• The hospice team is essential in teaching clients how to provide comfort and palliative care in the home. Additionally, the hospice team educates clients on how to evaluate patient pain levels, quality of life and recognize advancing stages of organ failure.

• It is good medical practice to provide medical advice compassionately through home care instructions.

3 Development of a personalized plan for the cat and client should include:

• Discussion and understanding of where the cat spends its time at home, the willingness of the cat to take medications, the ability of the client to give medications, and how to recognize the stress of hospital visits for the patient.

• Scheduled recheck evaluations based on the veterinarian's recommendations while maintaining contact every 5–14 days to assess patient status and client satisfaction.

• Mutual understanding and use of the ‘5H2M’ Quality of Life scale (Table 1) by the veterinarian, veterinary team and family to determine the patient's status during each visit or evaluation. ⁵

• Access to 24-hour veterinary and emergency care for clients.

• Arrangements and discussion of the means and events associated with the dying process and euthanasia, and a prior decision regarding care of remains.

TABLE 1

5H2M Quality of Life scale

Score on a scale of 1 (poor) to 10 (best)	Criterion
H: 0–10	Hurt Adequate pain control, including breathing ability, is the first and foremost consideration Is the cat's pain managed successfully? Is breathing compromised and causing distress? Is oxygen necessary?
H: 0–10	Hunger Is the cat eating enough? Does hand-feeding help? Does the patient require a feeding tube?
H: 0–10	Hydration For cats not drinking or eating foods containing enough water, use SC fluids q12–24h to supplement fluid intake Is the patient dehydrated?
H: 0–10	Hygiene The patient should be brushed and cleaned. This is paramount for cats with oral cancer Check the body for soiling after elimination Avoid pressure sores and keep all wounds clean
H: 0–10	Happiness Does the cat express joy and interest? Is the cat responsive to things around him (eg, family, toys)? Does the cat purr when scratched or petted? Is the cat depressed, lonely, anxious, bored, afraid? Can the cat's bed be near the kitchen and moved near family activities so as not to be isolated?
M: 0–10	Mobility Is the cat having seizures or stumbling? Some care givers feel euthanasia is preferable to a definitive surgery, yet cats are resilient Cats with limited mobility may still be alert and responsive and can have a good quality of life if the family is committed to providing quality care
M: 0–10	More good days than bad When bad days outnumber good days, quality of life for the dying cat might be too compromised When a healthy human-animal bond is no longer possible, care givers must be made aware that their duty is to protect their cat from pain by making the final call for euthanasia. The decision needs to be made if the cat has unresponsive suffering If death comes peacefully and painlessly at home, that is acceptable
Total	A total score >35 is acceptable quality of life

Used with permission from Dr Alice Villalobos and Elsevier, St Louis ⁶

4 Application of hospice or palliative care techniques

• Pain assessment is an essential part of every patient evaluation. A change in behavior is the most common sign of pain, so understanding a patient's normal behavior is important in identifying changes and making an appropriate choice to intervene. Several resources to aid in this process are available to the veterinary hospice team. ⁶

• Integrating physical rehabilitation techniques can add great benefit to patient comfort and palliative care. The most common therapies used for cats are massage, acupuncture, therapeutic laser and warm water baths to strengthen the muscles. ^2,7

• Comfort requirements for patients are:

5 Emotional support during the care process and after the death of the cat

• The hospice team should consider developing an ‘Emotional SOAP’ format for each cat family to best support the human-animal bond along with the physical needs of the cat (Table 2). ⁹

• It is valuable to make available in the veterinary facility a special place to offer hospice care and consultations that is quiet, comfortable in temperature and seating arrangements, and offers few distractions.

• Many communities provide grief-counseling services for pet owners. This information should be provided along with additional resources for an emotional support system that includes friends, human hospice advisors, psychologists, social workers, volunteers, and clergy or other spiritual advisors who have advanced training in human palliative and hospice care.

• It is important for the veterinary hospice team to recognize that ‘compassion fatigue’ occurs in veterinary medicine and steps should be taken to identify, understand and address the issue (www.compassionfatigue.org).

TABLE 2

Emotional SOAP

Policy considerations

• Fees should be discussed and agreed upon before providing hospice care.

• All state medical and DEA licenses must be kept current and federal and state practice acts followed by the veterinarian and veterinary team. Records must be kept of all controlled drugs and supplies obtained and dispensed according to federal and state laws.

• Professional and non-professional liability insurance must be kept current. Liability and worker's compensation insurance must be provided for any veterinary team member who provides hospice care in clients' homes.

• Medical records must be completed, recording all interactions (eg, visits, patient observations, treatments, weights, telephone conversations and instructions) with cat patients and clients.

• If the client family desires therapy that is not expected to help, the request should be documented in the medical record. Discussion and clarification of the information, followed by the client's signature with the date and time, is appropriate.

Further resources

Veterinarians and veterinary team members wanting more information and involvement with veterinary associations connected to veterinary hospice care and the human-animal bond should explore the:

• International Association for Animal Hospice and Palliative Care www.iaahpc.org

• American Association of Human-Animal Bond Veterinarians www.aahabv.org

• Association for Veterinary Family Practice www.avfp.org

A partial listing of pet hospice services available nationwide in the USA is available at: www.catvets.com/professionals/guidelines/position