Owner: Address: City: ZIP: Telephone: Cell: Pet's Name: Sex: M F Spayed/Neutered. Breed: DOB or age: Wt: Description (color, markings) :
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1 Home Pet Euthanasia of Southern California Hospice Care Form Owner: Address: City: ZIP: Telephone: Cell: Pet's Name: Sex: M F Spayed/Neutered Breed: DOB or age: Wt: Description (color, markings) : Reason for Hospice visit: Primary veterinarian: Primary veterinarian phone number: Any other veterinarians your pet has seen in the last 2 years As a courtesy, Home Pet Euthanasia will update your veterinarian on the visit and course of treatment of your pet so that they may update their records and advise us of any diagnosis or tests that may be relevant to your pet s hospice care or choice of medication. If you do not wish HPESC to call your veterinarian, please check this box Who referred you to us? Signature: Date: Home Pet Euthanasia of Southern California copyright 2014 HPESC
2 Hospice visit Case history The information you will provide about your pet will help us greatly on deciding on the course of action that will be most beneficial for your pet and your family. Please answer the following questions as accurately as possible. Primary reason for hospice visit: When did you first observe symptoms? Please check symptoms your pet currently has (include the frequency and severity of each): Vomiting? Diarrhea? Constipation? Coughing? Sneezing? Skin conditions? (itching, hair loss, redness, etc...) Seizures? (frequency, duration) Excessive drinking? Excessive urinating? Urine Incontinence? Fecal incontinence? Accidents? Limping? Dementia? Lack of appetite? Excessive appetite? Weight loss? Weight gain? Halitosis? (foul breath) Was your pet diagnosed with any particular condition? If so, by whom? What tests were done? What treatment is your pet receiving or has received? Please attach any laboratory results or diagnostics results if you are able to obtain them with any doctor comments. If possible, please have the full medical record faxed over ahead of time so that the doctor can review your pet s condition in details. What has the response to the treatment been?
3 What medication is your pet currently on? (Please list all medication and neutraceuticals your pet is currently receiving as well as the dose and frequency): Has your pet had any adverse reactions to any medication? If so, what medication and what reaction? What is your pet s current diet? What are your pet s favorite foods? Please fill out the Quality of Life test: Quality of Life Scale: The HHHHHMM Scale Pet caregivers can use this Quality of Life Scale to determine the success of pawspice care. Score patients using a scale of 1 to 10. Score Criterion 1-10 HURT** - Adequate pain control, including breathing ability, is of top concern. Trouble breathing outweighs all concerns. Is the pet's pain successfully managed? Can the pet breathe properly? Is oxygen supplementation necessary? 1-10 HUNGER - Is the pet eating enough? Does hand feeding help? Does the patient require a feeding tube? 1-10 HYDRATION - Is the patient dehydrated? For patients not drinking enough, use subcutaneous fluids once or twice daily to supplement fluid intake HYGIENE - The patient should be brushed and cleaned, particularly after elimination. Avoid pressure sores and keep all wounds clean HAPPINESS - Does the pet express joy and interest? Is the pet responsive to things around him or her (family, toys, etc.)? Is the pet depressed, lonely, anxious, bored or afraid? Can the pet's bed be close to the family activities and not be isolated?
4 1-10 MOBILITY - Can the patient get up without assistance? Does the pet need human or mechanical help (e.g., a cart)? Does the pet feel like going for a walk? Is the pet having seizures or stumbling? (Some caregivers feel euthanasia is preferable to amputation, yet an animal who has limited mobility but is still alert and responsive can have a good quality of life as long as caregivers are committed to helping the pet.) 1-10 MORE GOOD DAYS THAN BAD - When bad days outnumber good days, quality of life might be compromised. When a healthy human-animal bond is no longer possible, the caregiver must be made aware the end is near. The decision for euthanasia needs to be made if the pet is suffering. If death comes peacefully and painlessly at home, that is okay. TOTAL *A total over 35 points represents acceptable life quality Adapted by Villalobos, A.E., Quality of Life Scale Helps Make Final Call, VPN, 09/2004, for Canine and Feline Geriatric Oncology Honoring the Human-Animal Bond, by Blackwell Publishing, Table 10.1, released Used by her gracious permission. What are your considerations regarding your pet s Quality of Life? Which family members are most involved in your pet s care? What other family pets interact with your pet? Who are your pet s best friends? Whose company does your pet enjoy the most? How does your pet s condition affect your quality of life?
5 Pain Please fill out the pain indicator list below. It is recommended that, when assessing your pet's pain, you rate each indicator below with a score from (0 being that the symptom is absent and 10 being maximum manifestation of the symptom). Please see the "Home tests" page where you will find the list in a table format ready to print and check off each symptom. Keeping track of these symptoms and how their intensity varies throughout the course of the disease your pet has will help you monitor the progress and the success of any pain management being conducted. Pain Indicators table 1. Droopy head 17. Avoidance of direct eye contact 33. Hunched back 49. Doesn't rest easily when lying down 2. Droopy ears 18. Lips may be retracted, exposing the teeth in a submissive grin (dogs) 3. Tucked tail 19. Almond shaped eyes (caused by facial tension) 4. Does not want to play 20. Whiskers pulled back against cheeks (caused by facial tension) 34. Compulsive licking or rubbing of a certain body part 35. Looking at sides or other body part suddenly and/or worriedly 36. Suddenly running away from nothing in particular 50. Aggressive behavior to protect a particular area 51. Aggressive behavior on a usually docile pet 52. Crying when a particular area is touched 5. Lack of social interaction 21. Uncomfortable when resting 37. Can't jump on couch or bed 53. Wakes up at night 6. Does not enjoy games 22. Shifts frequently when resting 38. Reluctance to lie down 54. Does not sleep well 7. Subtle lack of alertness gradually increasing to a deep apathy (early sign will be subtle) 23. Head held abnormally low 39. Sleeps in a position that avoids a certain body part from touching the ground or bed 55. Refusal to go on walks 8. Diminished appetite 24. Difficulty getting up 40. Any change in normal sleep patterns 56. Moaning 9. Body tension 25. Excessive panting (particularly when it is not hot) 41. Purplish tongue color (NOT gums: tongue) 57. Whimpering 10. Facial tension 26. Shivering/trembling/shaking 42. Guards a particular body part 58. Refusing to eat 11. Accepting treats or food gingerly (particularly if pet used to accept them enthusiastically) 27. Unsettled 43. Reluctance to be touched in a certain area 59. Pressing head against wall (if head pain is present) 12. Lack of interest in walks 28. Pacing 44. Reluctance to be picked up 60. Unable to get up 13. Doesn't respond when called 29. Difficulty moving after a long rest 45. Lying down at a distance from everybody and somewhat isolated 61. Crying in pain 14. Worried or sad facial expression 30. Difficulty lying down 46. Disinterested in surroundings 62. Teeth clenched, biting down on an object (particularly cats) 15. Ears pulled back or flattened 16. Eyes wide open to expose white of the eye 31. Slow or unusual gait 47. Unusual attention seeking 63. Howling/screaming uncontrollably 32. Limping 48. Flinching when touched in a certain area
6 What are your expectations regarding your pet s hospice? Do you have religious/spiritual beliefs that you wish us to know about and which should be taken into consideration during your pet s hospice care and/or euthanasia? Anything else you would like to communicate? (feel free to say as much as you like, use additional paper as needed) Your pet s hospice care is a matter we take to heart. We will do our very best to ensure that your pet has the most comfortable End of Life experience possible. Caring for a terminal pet can be time consuming and requires a commitment both on your part and on our part. Therefore communication between doctor and pet parent it is of prime importance. For routine updates, please the doctor. For urgent matters, you can contact us 24/7 via phone at Do not use text messages under any circumstance. In the case of urgent matters, it is possible that you may speak to a different doctor than the one who did the original hospice consultation, depending on who is on call at the time. For prescription refills, please contact the doctor via at least 3 days in advance. For refill authorizations of prescriptions, you may be required to repeat the Quality of Life scale, the pain indicators table as well as give us an
7 update on how your pet is doing so that we may adjust the dosage and prescriptions in your pet s best interest. The first consultation fee includes a one hour consultation in your home and one month of follow-ups. Over-the-phone followups are subject to a fee of $50/15 minutes. Follow-up hospice (not euthanasia) visits within one month of the original visit are offered a 50% discount of the full price (excluding any applicable travel and off hours fee). An update on Quality of Life scale and pain table are required to benefit from discounted fee on monthly visits. A fee of $100 per month will be assessed for follow ups after the first month. This fee will be waived if a follow-up home visit is made within one month of original visit. We have 5 amazing doctors in our team. Each doctor was chosen for her exceptional compassion and caring. Due to our doctors' schedules (both personal and professional), it may not be possible for the same doctor who attended your pet's hospice visit(s) to be the one helping you with your pet's euthanasia. Rest assured that your pet, you and your family will be treated with the utmost compassion regardless of which doctor helps you during the course of your pet's hospice and euthanasia. I understand and agree to the above terms and conditions. Signature date copyright 2014 HPESC
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