Let’s Regard End Of Life As A Distinct Stage
Lazarus with Carolyn Davis of Studio City, Calif. Lazarus entered pet hospice with acute lymphoblastic leukemia three years ago. He experienced cholangiohepatitis 18 months ago and liver failure seven months ago with ascites, low serum protein and anemia.
While I discussed end of life (EoL) care with Dr. Don DeForge on Connecticut radio, an exciting idea flashed through my mind.
We were finishing a 45-minute discussion when I said, “It is time for us to declare, once and for all, that end of life is a distinctly new stage of life. Veterinarians were taught to support four main stages of life. We were not educated to focus our professional attention and develop the skills and expertise for the very important and inevitable ‘End of Life Stage.’
“We need to provide more EoL services because society’s human-animal bond demands more care in this area despite the recession and fewer office visits.”
The main life stages we are educated to support are:
• Puppy and kitten stage
• Adult stage
• Senior stage
• Geriatric stage
I propose a fifth life stage, the End of Life Stage. It is the only life stage that can occur during the other stages. With luck, EoL may not impose itself on the kitten and puppy stage, but sometimes it does. Let’s start thinking about EoL as an inevitable life stage that deserves more focus and expertise in management.
Because we were taught to “End it all with Euthanol,” EoL was under-recognized and underappreciated by the majority of our profession until recently. Since the concept of pet hospice, which I call Pawspice, was introduced at the 2000 AVMA Convention, more attention is paid to palliative care, pain management and hospice for EoL care. The AVMA approved its first Veterinary Hospice Guidelines in 2001, responding to the animal hospice movement.
The discipline of palliative medicine and hospice care for all phases of the EoL stage needs to stand alone rather than being relegated to a sub-stage or something that happens before euthanasia.
Since our profession has bypassed the EoL stage for so long, do you think the concept of a fifth life stage will be accepted? It’s natural for some to resist new concepts or specialties. Older practitioners got along without paying much attention to EoL.
In fact, on an elevator at AVMA in St. Louis last summer, one experienced colleague told me that he is against palliative medicine and hospice, “because it drags out the inevitable.” Others are reluctant to discuss the EoL stage because it makes them uncomfortable. Discomfort should not prevent us from educating clients to understand that we care and are prepared to help their pets.
Look at Pain Control
For most of the 20th century, pain control was embarrassingly bypassed or ignored. Pain management was rarely utilized in veterinary medicine except for major procedures such as orthopedics. Just because we didn’t treat pain does not mean that pain and suffering were not endured by our patients.
We were blind. Most pre-1990 graduates like me are mortified when thinking of how many patients we recovered from surgery without using any pain medication. Pain management is now routine for most veterinarians.
EoL Stage Is Unique
What purpose do we serve in distinguishing EoL as its own stage? Contemporary veterinarians and staff require sensitivity training to provide psychosocial emotional support services on the front line in practice. Compassionate communication is needed to help clients get through difficult days on that bumpy EoL road toward pet death, pet loss and bereavement.
Skills are required to provide emotional support for anticipatory grief, maladaptive grief, depression and suicidal tendencies. Knowing when to refer clients for counseling or referring them to the Association for Pet Loss and Bereavement is important. These skills, palliation of symptoms and hospice services leading to the gift of euthanasia that assures a peaceful and painless passing mark the keystone services that differentiate EoL care from other stages of life care. (Read VCNA, Palliative Medicine and Hospice Care, Vol. 4, No. 3, May 2011).
When Does EoL Start?
“Geriatric” is defined as being in the last 25 percent of expected life span. Everyone knows active geriatric people who remain healthy into their 80s and 90s, and animals can do the same. Chronologic aging is not physiologic aging, which varies with each individual. For these reasons, we don’t want to tag our healthy geriatric companion animals as being in the EoL stage because they may be years away from their lives’ ending.
EoL needs to be separated from the geriatric stage because it can occur at any stage.
I propose that the EoL stage start at diagnosis of a life-limiting disease. This should clearly define when EoL starts as its own unique stage. Many of these patients may behave and look well at diagnosis, yet they have a general prognosis of less than one year.
The EoL stage may occur at any age because life-limiting disease or trauma may occur at any age. Cancer takes the life of 25 percent of companion dogs under 10 years of age, 50 percent of dogs over 10 and 33 percent of cats at various ages. Other main life-limiting diseases are organ failure, musculoskeletal failure and neurologic failure.
EoL’s Three Phases
Three phases are associated with the EoL stage: early, middle and late. Life-limiting diseases are diagnosed at various stages of advancement. Many animals present in acute or subacute crises and can be stabilized. Some patients have incurable diseases that are treatable and responsive for a period. Most diseases have routine medical protocols, such as treatment for kidney or heart failure, diabetes, lymphoma, bone cancer, etc.
Treatment for early phase EoL patients that are still healthy and functional is often more aggressive and might be labeled as “definitive,” although the overall poor prognosis is unchanged. Decision making is difficult, especially for older animals. Hospice embraces a gentler standard and palliative care simultaneously and transitions to hospice care for comfort when the patient nears death.
Many trauma and terminally ill patients (TIPs) present or are diagnosed in their last phases of life. Late-phase EoL care would immediately provide all aspects of the sociomedical programs of animal hospice.
The social program services are emotional support for family members; quality-of-life and preneed consultations for the animals’ well-being; well death; and after life services.
The medical program services are providing options (if possible) for the patient to go home with pain control and palliative medicine. The veterinary team follows up with phone calls, scheduling rechecks or home-care visits and making arrangements for euthanasia if or when the patient needs help to change worlds.
Read examples of the EoL stage here.
Veterinarians naturally help clients with their dying pets but inadvertently often underserve them. From now on, the difference is that we have an actual life stage designation for EoL and its special care requirements.
With a gentler standard of care, palliative medicine, personalized nutrition, immunonutrition, chemoprevention and love, we are likely to improve and extend quality of life for some early- and middle-phase EoL patients.
Most pet lovers find this therapeutic possibility very appealing. All veterinary teams can apply learned client support skills and their medical knowledge at each phase of the EoL stage.
Late-phase EoL patients deserve our best hospice skills. Highly bonded clients and their companion animals will benefit from the honor and expertise that you bring to their unique experience.
Dr. Villalobos is a past president of the American Association of Human-Animal Bond Veterinarians and is president of the Society for Veterinary Medical Ethics. Her column appears every other month.