HOSPICE and palliative care has become the gold standard for high quality end of life care in human medicine.
On a personal level I am grateful for this because, and I suspect this sentiment applies to a lot of people, although I have no fear of being dead, I don’t relish the actual process of dying. I don’t tolerate pain or anguish well, and the prospect of either during the act of dying is something that troubles me.
I therefore hope that if I am not one of those lucky enough to expire suddenly in my sleep at a ripe old age, I will receive all the help available to make my passing as smooth and reassuring as it can be.
This might seem like a morbid start to this month’s Periscope but it has been prompted by the May blog on the RCVS Vet Futures page which concerns the provision of hospice and palliative care for animals – something that appears to be gaining ground in the USA and to some extent in the UK as well. I have reservations about its use in animals and I urge caution before we embrace it with enthusiasm.
To consider the issue rationally I think it is necessary to understand why hospice and palliative care for terminally ill people has become “mainstream” in recent years. Euthanasia of people is illegal in the UK and from time to time high-profile stories appear in the press concerning a patient who has travelled to the Dignitas clinic in Switzerland in order to die at the time of their choosing. Since this option is not available to the majority, the “gap” is filled by hospice and palliative care which has developed into a speciality of its own.
I have some very close personal experience of the importance and benefits of good palliative care both to the person receiving it and those closest to them who need to be reassured that their loved one’s suffering is minimal.
I therefore applaud its continuing development and refinement as a speciality in human medicine and hope that further down the line it will be possible to remove all pain and anxiety without reducing lucidity of thought and the spoken word. In that way the sharing of thoughts and memories with loved ones at this most poignant and emotional of times can be facilitated.
When it comes to animals the benefits of hospice or palliative care are less obvious in my view. One of the clear aims in human medicine is to arrive at a course of action that involves the patient in the decisionmaking process; action which the patient is ultimately satisfied with as the best way forward for them.
Clearly they will take into account the views of those closest to them, but it needs to be they that decide, so long as they have the capacity to do so.
Animals clearly have no capacity to be involved in the decisionmaking process. In the end it is their owners who make all decisions on their treatment or otherwise, guided hopefully by caring vets and veterinary nurses who can advocate on the animal’s behalf.
Problem is two-fold
As I see it, the problem here is two-fold. The first problem, and we will all have come across this in our professional lives, is the owner who can’t let go. Regardless of the hopelessness of the situation there are those owners who consider the potential death of a pet to be an insurmountable hurdle. They cannot imagine life without it. Regardless of the animal’s suffering they consider their own personal feelings to be paramount.
These owners may demand palliative care in order to protect their own emotions for as long as they possibly can, and the animal’s wishes (if animals even have “wishes” – a debate for another time) are not considered.
What is the purpose of palliative care in such cases? Surely it is aimed more at preventing the suffering of the owner than it is in preventing the suffering of the animal?
What benefit is the animal receiving? This is a question we should all ask ourselves in such cases when we remember the oath we took on entry to membership of the RCVS.
If we are not doing what is best to end the animal’s suffering (and palliative care is not guaranteed to be suffering-free, particularly as the animal has no understanding of what is happening to it) then one could argue we are complicit in that animal’s suffering since euthanasia would of course remove it.
The other problem is one of professional judgement and conduct. Being somewhat pessimistic I can foresee there is an opportunity here to set off a particularly tricky and lucrative “gravy train” that once on the move will be hard to slow down. It will develop a momentum all of its own and there are bound to be those who, for philosophical, religious or financial reasons (among others) will want to milk it as a cash cow.
The only option
Someone who develops an interest in palliative care for any of the above reasons can espouse the view (to owners who may be in an emotionally vulnerable state) that this is not only the best option for their beloved pet, but the only option if the owner really wants to do best by them.
I have always been against aged animals ending their days in a veterinary hospital cage, on a drip, surrounded by strange sights, sounds, smells and people. It’s not something I would want for any pet of mine.
Providing hospice and palliative care (even if undertaken at home) will in my view take this to a new level. Prolonging the lives of terminally ill pets because that is what the owner wants is not in the best interests of the animal and certainly not why most of us became vets.
I should like those vets who believe this is the next road we need to go down to make their case based on evidence that this will genuinely reduce animal suffering.
If they cannot do so then I will conclude that its function is more to do with appeasing owners and improving their own “bottom line”. I look forward to reading and considering their argument.
