The 2012 DVM Newsmagazine State of the Profession survey found some surprising results regarding end-of-life issues in practice: First, the stop treatment point (the dollar amount at which clients refuse treatment or choose to stop treatment for their pets) jumped to $1,704—up 21 percent from 2009 (see Table 1, below).
If people are choosing to pay more for their pets’ treatment, why are more pets being euthanized? Two of the industry’s experts on end-of-life care try to make sense of these seemingly contradictory results—and also discuss how veterinarians can provide better palliative care while guiding clients through pet ownership’s most difficult decision.
The ‘problem’ population
“I see many of my patients living much longer than people expect them to,” says Lisa Moses, VMD, DACVIM, certified veterinary acupuncturist and director of pain medicine at Angell Animal Medical Center in Boston. “I certainly never expected to be seeing the number of cats over the age of 15 every day that I do.”
Moses says there has been an explosion in geriatric medicine in the last few years. In her experience, clients are choosing to keep their animals alive longer because, medically and financially, they can. In fact, she says, at her clinic a stop-treatment point of $1,704 is modest. “My clients don’t euthanize because they can’t afford medical care,” she says. Rather, it’s because there’s nothing else that can be done for the pet. However, she acknowledges that this is probably not true for many general practitioners, as Table 3, below, supports.
The large uptick in the senior pet population, Moses continues, may be driving the uptick in euthanasias. The sheer number of aging pets ultimately reaching the point when their doctors and owners make the difficult decision to provide end-of-life euthanasia is increasing as well. “I wonder if veterinarians’ perceptions are that they’re spending more time doing euthanasia and end-of-life care because they’re spending more time with geriatric pets,” Moses says.
Robin Downing, DVM, a certified veterinary pain practitioner who is also certified in a variety of pain management modalities, including acupuncture, is owner of the Downing Center for Animal Pain Management in Windsor, Colo. She points out that DVM’s survey results do not distinguish between euthanasia of healthy pets and that of sick pets. “The most telling euthanasia statistic in this survey is the fact that the No. 1 reason cited for euthanasia is ‘behavior problems,’” Downing says (see Table 4, below). “We have known for a very long time that euthanasia due to ‘problem’ behaviors is the No. 1 reason cited for euthanasia under all circumstances. It casts a very dark shadow on the veterinary profession that the number of behavior-related euthanasias exceeds euthanasia for all sickness-related reasons.”
While neither Downing nor Moses is often asked to euthanize a healthy pet, other doctors outside the speciality of pain management may deal with it more frequently. “I don’t see a lot of people making the choice to euthanize who don’t give it agonizing thought and explore other options,” Moses says. However, she says it’s hard not to be judgmental toward those who euthanize healthy pets even though she knows the decision may be difficult for a client.
Downing goes to great lengths to avoid unwarranted euthanasia. She feels it is the veterinarian’s obligation to advocate on behalf of the animal that cannot advocate for itself. “If the family is willing to discuss or negotiate an alternative outcome, we start there,” she says. “We generally reach next for breed-specific rescues if those are available. Next, public and private humane societies and rescues. Occasionally we feel the best first step is for the pet to be relinquished to our practice so we cab then take those next steps. We have never had an owner decline to relinquish a healthy pet.”
With that protocol in place, Downing’s clinic hasn’t had a request for euthanasia of a healthy pet in five years.
The burden of end-of-life care
Moses feels compassion fatigue may be a big factor for veterinarians when faced with a client making the decision to euthanize rather than treat. “We spend a lot of time with end-of-life decision-making and that is really hard,” she says. “It’s draining and it begins to wear on you very quickly.”
While in the past euthanasia was often seen as the only choice for a pet with a serious disease or injury, Downing says, it’s simply no longer an acceptable approach. “The vast majority of veterinarians have no idea how to engage in a rational discussion with pet owners when the end of life is in sight,” Downing says. “The knee-jerk reaction to a diagnosis of a life-limiting disease like cancer in most practices is still, ‘Mrs. Jones, your dog has cancer and there is nothing we can do.’”
Moses says she would love to see people embrace the option of comprehensive quality-of-life therapies. “We can provide palliative care in ways that most don’t realize,” she says. “We can make the end of life better for patients without so much intervention.” That means helping people do better nursing at home and managing feeding and cognitive function changes. “It makes the client’s and the animal’s life easier at the end,” she says. “As a profession, we’re not used to making those issues worthy of an appointment.”
Downing recommends that veterinarians refer clients to advanced pain management specialists for palliative care patients that may exceed a clinic’s capacity. “Find the house call or in-home euthanasia practices in your area and have conversations with those doctors to create an appropriate backup plan for patients approaching their deaths,” she advises.
Moses says the decision to euthanize—or even to face the death of a pet—is often so difficult for clients that she feels she should have a degree in social work to help them navigate the process. “I try to have a lot of empathy about the enormous burden of that decision-making,” she says.
Both doctors believe that veterinarians have a responsibility to work closely with pet owners to assist them in end-of-life decision-making. Downing’s staff utilizes Dr. Alice Villalobos’s Quality of Life Scale to guide clients through the process. “Because this is a part of our practice culture, my team as well as our client population are very comfortable tackling the difficult decisions that come up at the end of life,” she says.
Although the topic is difficult, Moses says, most companion animal veterinarians have already spent years developing what is essential to effectively discussing euthanasia with clients. “What most general practitioners have going for them is that they often have a really nice long-term relationship with these clients,” Moses says. “You need to have that relationship to help people with this decision-making.”
She encourages veterinarians to look at the big picture within the context of each client and patient individually. An already established relationship can allow a doctor to factor in a client’s personal and ethical beliefs and what their lifestyle will permit in terms of palliative care. “I ask them early on to start thinking about what lines they are not comfortable crossing with their particular animal,” Moses says. Some clients don’t want to see their pet defecate on itself or get to the point where it refuses a meal. “That’s something you can remind people of when you get to that place—it’s very helpful,” she says.
Moses also suggests seeing those clients and patients regularly who are struggling with the question of when. “Have them come in. See the animal, talk about daily maintenance things. Doing it on a regular basis helps people be realistic about the changes,” she says. “Write down a list of things the animal used to get pleasure from. Sometimes that’s very helpful to people if they’re having trouble seeing it.”
Moses says there are often things that are worse than pain for dogs. “Suffering encompasses a lot more than pain—look at the larger issue of having better quality of life,” she says.
In the end, clients genuinely do trust their veterinarian to tell them when it’s time and to understand the pain and suffering an animal is enduring when they can’t be objective. “I tell clients I have a dual responsibility: to them and to the patient,” Moses says. But she emphasizes that ultimately her responsibility is to the animal in her care. “If we have crossed a line and the animal is suffering I will take that on as my primary role,” she says.
If end-of-life care has been a process—a partnership—the decision may not be any less emotional, but the client may have comfort knowing he or she did everything possible for the pet. “The thing we have going for us is that people really do believe we are compassionate and empathetic people and that’s why we do what we do,” Moses says. “They trust us to do the best thing we can do. It’s wonderful that the public has such trust in us.”
Robin Downing’s 6 STEPS to better end-of-life care
1. Become educated about the palliative care model for end-of-life human patients because it is a great template for managing terminal animal patients.
2. Get a copy of Palliative Medicine and Hospice Care (Elsevier, 2011), then read it and apply the principles and practices outlined.
3. Get a better grip on how to manage pain from a multimodal perspective; pain relief is the most important aspect of managing end-of-life patients.
4. Get comfortable with Dr. Alice Villalobos’s Quality of Life Scale and use it with clients and patients. (Visit pawspice.com and click on “Quality of Life Scale.”)
5. Find out who in your area is practicing advanced pain management and refer to these people for patients who exceed your capacity.
6. Find the house call or in-home euthanasia practices in your area and have conversations with those doctors to create an appropriate backup plan for patients approaching their deaths.