Animal Farm in healthcare: definitions,policies,laws and implications for health professionals

Recent years have seen a rise in the use of animals, especially, but not exclusively, dogs, as adjuncts in healthcare. We explore the Orwellian world that has ensued, with rules and regulations that differ from country to country, to the confusion of the people who use these animals, and the families and carers. For people with a wide range of disabilities, the confusion (even across states and communities within countries) must make them wonder if the world would not be a better place if the animals were those making the rules.

The traditional support animals are guide dogs for blind people, and a growing number of people with disabilities rely upon specially trained animals to enable them to achieve full participation in everyday activities, thus leading to a higher quality of life. Such activity can include hospitalisation and other forms or areas of healthcare. Likewise, therapy dogs are increasingly being used in healthcare facilities. Finally, support or comfort animals have been cited by a growing number of people as essential to their wellbeing and ability to function in everyday life. This article examines the essential differences between these categories, including legislative requirements and policy, and importantly, healthcare provision, to ensure that health professionals appreciate the distinctions when a patient is accompanied by an animal in healthcare settings. Most importantly, all healthcare professionals can benefit in their overall provision of better patient care if they are knowledgeable about the distinctions and can utilise these animals as adjuncts in healthcare provision.

‘Service’, ‘assistance’, ‘therapy’, ‘guide’ or ‘comfort’ animals

A range of terms are employed to define animals used to provide support to humans. There are a number of differences that vary from country to country with regard to the definition, training and documentation of these animals, and these can lead to confusion. Many benefits are provided by such animals, including increased independence, a decrease in paid assistance, and fuller engagement in community and social interactions. ¹ However, due to the rise of therapy, guide and comfort dogs, and other animals, distinctions are not always clear to those unfamiliar with regulations.

By far the most commonly used animals for service, assistance, therapy or comfort are dogs, but less common animals are sometimes used.

The terms ‘assistance dogs’ or ‘service animals’ cover a range of specific roles. They can be guide dogs, dogs for those with hearing problems, dogs who support people with mobility and daily living constraints, medical alert dogs trained to recognise symptoms that need an alert in people with conditions such as diabetes and epilepsy, and dogs who are trained to work with people with autism or who are mentally ill. ² The same term is used in the European Union and Australia. In the United States of America, the term ‘service animal’ is more common. In the United States of America under the Americans with Disabilities Act, a service animal is defined as a dog who has been individually trained to perform specific tasks, or functions for a specific individual with a disability ³ (United States of America Department of Justice, Civils Rights Division, Disability Rights Section, 2015). The definition of service animals is expanded to specify the meaning of the service, that is, the explicit work that the dog provides. Most commonly, and long established, are dogs in service to the blind. Historically, the first assistance dogs were trained in Germany during and after the World War I to help blinded war veterans; various other countries followed suit. ⁴ Today, guide dogs for the visually impaired are well recognised and accepted. Wenthold and Savage ⁵ noted the introduction of a service dog for a blind man in the late 18th century, with the first service dog school opening in the in 1929.

Service dogs are trained to provide a repertoire of skills. Currently, service dogs undergo training to provide, for example, assistance for the hearing impaired, assist people with compromised balance and mobility, and to detect diabetic crises during which the dog is trained to alert the person that blood sugar levels are too high or low. In some cases, service dogs are utilised to detect the onset of a seizure and assist in keeping the person safe during the seizure itself (United States of America Department of Justice, Civils Rights Division, Disability Rights Section, 2015). ³ Mental health is an area in which service dogs provide important functions, including assisting with post-traumatic stress problems. ¹ Service dogs are trained to remind a person to take medication on time. It is imperative to recognise that the service dog is not a pet, nor, in the case of mental disability or other less obvious physical impairment, a comfort animal, but rather a means to ensure a higher quality of life for a disabled person.

Therapy animals, most often dogs, are increasingly seen in healthcare facilities, especially long-term care. Unlike service dogs, who are trained for specific roles with individuals, therapy animals receive general behaviour training and are accompanied by certified handlers in their interactions. There is a clear distinction between service and therapy dogs, both in terms of training requirements, and the qualifications of the dogs’ handlers. Therapy dogs are found in children’s hospitals, ⁶ aged care facilities and many other healthcare settings. ²

The importance of the bond between the comfort animal and a patient was recognised many years ago. Florence Nightingale wrote, ‘A small pet animal is often an excellent companion for the sick, for long chronic cases especially’ (p. 103). ⁷

Comfort animals, while providing an important service for their owners, are not defined as clearly as either service or therapy animals, although owners may effectively consider the animal as family. Worry about the care of the animal while the owner is hospitalised may cause additional stress and impede recovery, particularly for people who live alone.

Why are such animals needed?

Service/assistance dogs provide many benefits, including increased independence, a decrease in paid assistance, and fuller engagement in community and social interactions. ¹ However, due to the rise of therapy and comfort dogs, and other animals, distinctions are not always clear to those unfamiliar with the plethora of regulations.

As one example of the benefits of such therapy, the use of therapeutic animals has been acknowledged as a means of providing assistance to children with psychiatric disorders, and a recent study found they helped children with Attention Deficit Hyperactivity Disorder. ⁸ In these instances, the animal is considered a part of the overall milieu. In some cases, one might consider the animal to serve a dual function of both friend and therapist. The use of animals in these situations may encourage involvement and human responses. ⁹ Thus, use of animal-assisted therapy potentially improves social interactions and self-esteem.

Therapy dogs are often covered by policies that allow dogs into public facilities, including hospitals that have standard policies preventing the entry of animals. The best way to appreciate the purpose of the therapy animal is to understand that the fundamental service of the animal is to provide emotional support and/or specific functions to people in general, rather than one specific person. ¹⁰

In all these encounters, the purpose is to provide a planned, goal-directed outcome. Thus, the aim is to improve patient care and outcomes in a general context. The contemporary use of pets as therapeutic adjuncts has involved a number of professional fields including psychology, sociology and veterinary medicine. ⁹

It is acknowledged that the interaction between animal and human affects the wellbeing and health of individuals. ¹¹ Such interactions, including touching, stroking and talking to an animal, may lower blood pressure and heart rate. Beetz et al. ¹² found direct evidence that such interaction affects endocrine responses such as changes in cortisol, epinephrine and norepinephrine levels, suggesting decreased stress levels. They also noted that such animal–human interaction improved social interactions in patients with mental illness. However, as yet, there are no defined standards, laws or overwhelming scientific evidence to determine the benefits of the animal–patient interaction.

Thus, a comfort or emotional support animal provides a benefit to its owner through companionship. This may apply to some patients or individuals who have mental impairments. However, such animals are not trained to perform a specific task for any person who may suffer from emotional disability, and their function is limited to one specific person, that is, the owner. Therefore, emotional support animals are not necessarily granted any access to public places that must accommodate a service animal. ¹³ Most significantly, no training is necessarily involved and anyone can claim an animal is an emotional support animal which, from the perspective of the owner, provides a vital service.

Concerns

There has been a rise in the number of pets, especially dogs, who have been claimed by owners as service/assistance dogs. ¹⁴ It is relatively simple to acquire a vest or a backpack to strap on the animal that states ‘service animal’. Owners attempt, and often do, to gain access to many public areas that would normally be denied to animals other than service animals who are performing specific and necessary tasks. As a result, owners of genuine service animals are increasingly worried about the safety of their trained animals, while business owners are concerned about health violations and damage to property and merchandise.

Under federal law in the United States of America, it is a violation to present what is essentially, ‘a fake dog’. ³ There is an obvious difference in most cases. A service dog will almost seem invisible by virtue of training, while the untrained animal is much more likely to urinate, bark and eat off floors in any facility in which food is delivered, and this can include healthcare facilities. While the law seems clear, enforcing it may be difficult.

A number of persons with accompanying comfort animals have demanded flight access for themselves and the animal leading to confusion, perceptions of safety issues, and distress for both flight staff and other passengers. Reports of animals soiling the passenger cabin and aggressive behaviour, including barking, biting and growling, have led airlines to institute new requirements. ¹⁵ In the view of the airlines, untrained animals can, and do, lead to safety problems. Equally important, these instances constitute a disservice to all passengers, but specifically, those who have documented needs and must travel with a service animal. Service animal owners worry about public misperceptions of their animals who are legitimately required for assistance, because of uncontrolled behaviour of comfort animals on flights, and they are concerned that their trained animals may be attacked by an untrained comfort animal. Consequently, a number of airlines and cruise ship companies in the United States of America now require passengers travelling with animals to show proof of the animal’s training and vaccinations at least 48 hours prior to travel. ¹⁶ Some companies have banned emotional support animals completely. ¹⁷ This precedent may spread to other public areas, not just travel.

Infection concerns have been raised due to the increasing numbers of therapy animals visiting healthcare facilities. In a study of 45 hospitals and 27 therapy animal organisations, it was found that both health and safety policies varied widely. ¹⁸ This lack of regulation potentially put both humans and animals at risk. As one example, 70% of therapy animal organisations allow their animals to eat raw meat diets, and this could compromise patient safety. It was noted that hospitals were generally more stringent in requirements than long-term care facilities for the elderly. Therefore, it was concluded that policy gaps continue to exist between the healthcare facility visitation guidelines and animal organisations involved in such visits.

Legislation and regulation: discrepancies between countries

Throughout many parts of the world, including the European Union, Canada, New Zealand and parts of Asia, dogs are the animals cited as recognised service animals. All of these countries require training of the dog, and likewise, require documentation to attest to the dog’s service qualifications, unlike the United States of America which does not allow staff to request documentation, nor a demonstration of the dog’s service task, or to ask anything about the person’s disability.

In the United States of America, staff in any situation, including a healthcare facility, are entitled to ask only two specific questions, namely, is the dog a service animal that addresses the needs of a person with a disability, and what specific work is the dog trained to perform. ³ Staff are not permitted to request documentation to attest to the dog’s training, nor for the dog to perform any task to verify the stated necessity for a service dog. The dog is not required to wear any identification tag, special vest or harness. As per these regulations, the dog does not require any special professional training programme; however, it must be trained before being permitted into public places. State and local laws apply with regard to animals that are still in training. Nevertheless, the handler must take responsibility for any care of the animal. A request to remove the service animal from any premises, including hospitals, can be instituted only if the animal is out of control, and the handler cannot or does not take action to control the behaviour. Likewise, staff are not required to care for the animal in any way including providing food. ³

Therapy animals in the USA are not defined by any federal law, although some individual states may have defined the distinction between therapy animals and service animals. Most obviously, the therapy animal, while well-trained in terms of behaviour, is not specifically trained to assist with a definitive disability. This distinction between therapy and service animals is clear in terms of legal protection as well as specified tasks as required for a service animal, compared with generalised support provided by a therapy animal. ³

The recent rise in the use of comfort animals has resulted in increased requests to permit emotional support animals into previously denied public spaces. Such public areas especially have included college/university dormitories to allow animals to live in student accommodation. In the United States of America, more and more campuses are relaxing rules that banned comfort animals. Federal judges ruled that the Fair Housing Act covers student housing as well as any other accommodation. ¹³ The United States Department of Housing and Urban Development ³ has confirmed that any housing provider may reasonably ask for documentation that the animal is providing a service, including emotional support, and helps to decrease the symptoms of an existing disability. Thus, documentation is required from a health professional and any housing provider can refuse to accommodate any animal that appears to pose a threat to the safety and health of any other person, or is destructive of property. However, in this context, no guidelines appear to determine what may be a threat to safety or health of another person.

These issues are further complicated by a lack of designation for comfort animals. Unlike service and therapy animals, who, for the most part, are dogs, an emotional support animal is most frequently a dog or cat, but many other species, including peacocks, kangaroos, snakes, pigs and ferrets, among others,^15,17 have been claimed to be emotional comfort animals.

Regulations vary across countries. For example, in the European Union, assistance (service) dogs must be trained by professional organisations such as Assistance Dogs International or the International Guide Dog Federation. ¹⁹

In the United Kingdom, ²⁰ and similarly in Sweden, ²¹ under the Equality Act 2010 and Sweden’s Disability Act, respectively, people with assistance dogs are not allowed to be discriminated against, and cannot be refused services available to everyone. Owners are required to have a trained and accredited animal. In the United Kingdom, other animals such as cats can be registered as ‘emotional support animals’, and these have to be prescribed by a therapist, psychiatrist other doctor or mental health professional. ²² However, this is somewhat controversial, with little regulation in place. ²³

In Australia, the Human Rights and Equal Opportunity Commission on Disability Rights ²⁴ directly addresses rights of people with disabilities who have trained assistance dogs. It is unlawful to deny access or service on the basis of the person requiring a dog to provide a specific service to alleviate the effect of the disability.

The Australian Human Rights Commission ²⁴ website explains the legal understanding of an assistance animal in the Disability Discrimination Act 1992, Section 9:

‘a dog or other animal that:

is accredited under a State or Territory law to assist a person with a disability to alleviate the effects of disability; or

is accredited by an animal training organisation prescribed in the regulations; or

is trained to assist a person with a disability to alleviate the effect of the disability and meets standards of hygiene and behaviour that are appropriate for an animal in a public place.’

Australian states have various laws regarding these animals – some require government issued passes for, for example, travel on public transport, while others have no specific laws. Assistance Dogs Australia ²⁵ state that refusal to allow these animals on public transport constitutes discrimination against a person with an assistance dog, and they cannot be refused entrance, nor can a charge be demanded for the dog. Dogs are required to wear a specified blue jacket. Across the Australian states, assistance animals must be trained and have validation certificates of such training. ²⁶ In Queensland, to gain a certificate, one must use an approved trainer to take the animal through the Public Access Test and the person who owns the dog must have a disability as defined by the Guide, Hearing and Assistance Dogs Act 2009. ²⁷ Other states have similar laws. However, the situation is confusing, as the Federal Disability Discrimination Act 1992, which overrides all state legislation, has no requirement for accreditation of such animals. ¹⁴

Information about animals other than dogs is difficult to find; however, the laws do include ‘other animal(s)’ but we could find no information about what these animals might be, nor how they are trained. An innovative programme in New South Wales trains prisoners in the state’s criminal justice system to train assistance dogs for war veterans who suffer post-traumatic stress disorder, and also from physical disabilities – ‘Dogs for Diggers’. ²⁸

In Hong Kong, according to the Disability Discrimination Ordinance and the Food Hygiene Code, visually impaired people can enter public places and food premises with their guide dogs. But such protection does not extend to trainers of the animals. Thus, dogs are not permitted entry, nor transit, unless a special permit has been issued in advance. ²⁹ In this case, a ‘guide dog’ is defined as one who has been trained to provide mobility assistance to the vision impaired. Although some progress has been made in recent years, the situation is less than ideal with estimates of 4300 visually impaired residents of Hong Kong and only 40 dogs available. This is due to stringency regarding the bloodlines and backgrounds of the dogs, all of whom are imported. This, in itself, creates difficulties. Training families must work with a dog for lengthy time periods, slowly allowing the dog to become accustomed to a variety of situations and noises, such as public transport. While the Disability Discrimination Ordinance legally acknowledges the right of the visually impaired to have a guide dog, the training families are not covered by the ordinance. For example, while The Housing Authority permits guide dogs to live in public housing areas, it does not permit dogs, including dogs in training, to live in public housing. Likewise, it appears that bus drivers will generally welcome guide dogs, but in doing so, they are in violation of the Public Bus Services Regulations. The Kowloon Motor Bus permits guide dogs in training to get on buses only if they are accompanied by a visually impaired person. Another bus company, City Bus, acknowledges the illegality of bringing a training dog onto a bus, but arranges trial rides for the dogs and trainers. Clearly, this situation is far from ideal, and potentially has significant impact on the visually impaired population.

Japan requires service dogs to be certified in Japan, although temporary identification may be requested upon application. ¹⁹ There, the definition includes service to vision, hearing or physically impaired people. A training school must be officially accredited by a recognised school that has been registered with the Ministry of Labor and Health. Additionally, the dog must wear a harness, a special cape with written service designation or a back pack. ¹⁹

New Zealand ¹⁹ requires additional information such as import permits that provide evidence that the dog is an assistance dog. Further training specific to air travel is required to allow the dog into passenger sections of aircraft.

What this means for health services and health professionals

Health services of all kinds, from community to high-end critical care, must acknowledge that some patients/clients/people require assistance and support from animals to have quality of life, and their needs met.

It is obvious that all healthcare staff in any facility should be aware of the distinction between all the types of animals and what they can and cannot ask. ³⁰ They also should be aware of their responsibilities, which may include identifying a situation in which the patient cannot care for the animal. Staff should support any patient/client who requires a service animal, and may even consider viewing the animal as an adjunct member of the healthcare team, since the animal enables the patient to maintain independence as far as possible with everyday tasks.

Staff should be aware of facility policy. Does it meet each country’s federal and state guidelines and recognise the various distinctions of the animal categories? Who determines the facility policy? Who should be notified when a patient is admitted with an animal? How should staff be assigned if a staff member has allergies to animal fur? Are there concerns if the patient requires isolation due to specific infections? Are service animals permitted into intensive care units? Who determines access for animals?

These are questions that will undoubtedly be causing headaches for many managers and policy makers, as well as clinicians, and patients/clients and their families. However, if one is mindful of history, the situation is not unlike that in which health service staff found themselves in the 1950s and 1960s when a revolution occurred in paediatric care and parents were allowed and encouraged to stay with their hospitalised child. Perhaps lessons can be learned from that.

Conclusion

Animals who provide assistance to people with a range of health conditions and disabilities are now common, but health services are slow at making room for them appropriately. This paper defines the range of terms used – service, assistance, guide, therapy, comfort animals– and discusses who and why they are needed. The evidence of benefits to people of having such animals is convincing, but there are some concerns that arise when animals are allowed into a health facility. The laws around such animals differ across, and within, countries, and this causes confusion.

Health professionals in all settings need to be aware of the needs of those in their care, in this case, in relation to the animals on whom they depend.

Supplemental Material

sj-pdf-1-jrs-10.1177_0141076821996003 - Supplemental material for Animal Farm in healthcare: definitions, policies, laws and implications for health professionals

Supplemental material, sj-pdf-1-jrs-10.1177_0141076821996003 for Animal Farm in healthcare: definitions, policies, laws and implications for health professionals by Ellen Ben-Sefer and Linda Shields in Journal of the Royal Society of Medicine