POSITION STATEMENTS, VETERINARY SOCIETY FOR HOSPICE AND PALLIATIVE CARE. SPRING 2014.
K. GOLDBERG, DVM
C. MCDONALD, DVM, DACVIM (ONCOLOGY), DACVR (RADIATION ONCOLOGY)
M. KISELOW, DVM, DACVIM (ONCOLOGY)
MODE OF DYING
All animals should be afforded a humane death. The VSHPC believes that a good death is best defined by those who know the patient best: the patient’s family and caregivers. While hospice and palliative care for animals commonly utilizes euthanasia as a means of dying, hospice-assisted dying without euthanasia is also an acceptable option that should be facilitated by skilled veterinary professionals when elected. Un-palliated dying in the name of “natural death” is unacceptable and is not supported by the VSHPC.
SANCTUARY BASED HOSPICE
While the VSHPC accepts that some animal organizations are, and will be, housing animals in a sanctuary setting under the designation of “hospice”, it believes that these organizations bear significant responsibility to the physical and psychological welfare of such animals. Additionally, under the AVMA Hospice Guidelines, organizations purporting to provide hospice care to animals residing in sanctuary settings must do so under the guidance and direction of a licensed veterinarian. Housing large groups of animals brings with it particular concerns relative to animal husbandry & hygiene, infectious disease control, behavioral health of co-housed animals, and carrying capacity of each organization’s resources. The same standards of animal welfare that apply to individually owned companion animals must apply to animals living within a sanctuary setting. All additional standards of care under the AVMA Hospice Guidelines apply, including access to 24 hour care and provision of euthanasia when indicated.
The VSHPC fully supports the use of integrative medical modalities within comprehensive hospice and palliative care plans. As with any other treatments, these services must be provided by practitioners trained and credentialed in their various modalities. The VSHPC understands that modalities that do not fall under the jurisdiction of established Western medical organizations, and/or lack sufficient data from peer-reviewed literature, can be challenging to assess, yet may confer significant benefit to patients. Therefore, it is the position of the VSHPC that all practitioners of integrative modalities should pursue credentialing to the highest level possible within their respective fields. In this way, integrative care will have the best opportunity to move forward in a credentialed way, not only for hospice and palliative care, but for integrative and complementary medicine as a whole. It is essential that all treatment modalities within a hospice care plan be directly supervised by a veterinarian, and pain assessed on a regular basis to re-evaluate treatment efficacy. Pain management via complementary modalities provided solely by non-DVM personnel is not appropriate. It is the position of the VSHPC that complementary modalities on their own may not provide sufficient control of pain or air hunger in dying patients and are likely to be most useful in combination with traditional medical interventions.
VALID VETERINARY CLIENT PATIENT RELATIONSHIP
The AVMA’s Principles of Veterinary Medical Ethics defines the Veterinary Client Patient Relationship (VCPR) and the VSHPC requires that this standard be upheld throughout the provision of hospice & palliative care. A valid VCPR may not be established online, via email or over the phone. An in-person examination of the patient is essential, either within a hospital setting or the patient’s home. Without a valid VCPR, medication may not be prescribed, nor dosages of medications altered. Other members of the interdisciplinary hospice care team (i.e., technicians, assistants, social workers) cannot maintain a valid VCPR for the veterinarian. Treatment recommendations via “consulting” professionals who have not examined the patient in person must be judiciously and carefully considered for validity in this regard.
The VSHPC fully supports the AVMA Hospice Guidelines and requires that hospice and palliative care clinicians follow them at all times. Any additional guidelines are an addition to the standards set forth by the governing body of the veterinary profession and may not act as a substitute for them.
INTEGRATION OF HOSPICE AND PALLIATIVE CARE INTO VETERINARY TEACHING INSTITUTIONS
As stated by the American Academy of Hospice and Palliative Medicine, “Academic medical centers can no longer afford to look at palliative care as an optional “nice to have” program.” The VSHPC maintains that this is true for veterinary academic teaching institutions as well. As the role of companion animals in our contemporary culture continues to evolve, pet owners have created a demand for highly skilled veterinary care to address a myriad of medical disorders. These may include, but are not limited to, finite/curable diseases such as trauma and infectious disease, and chronic pathologies such as cancer, osteoarthritis and multiple organ dysfunction. Inherent in the latter is the need for provision of ongoing palliative care, and ultimately, hospice for animals with terminal disease(s). Additionally, as the unique nature of veterinary medicine involves both treatment of animal patients, and education of their human caregivers, a comprehensive hospice and palliative care training program must address the psychosocial, emotional and spiritual needs of the human family. As demand grows for veterinary hospice and palliative medical services, we must prioritize the training and education of veterinarians and veterinary students to meet the demand with integrity.