Decision Making at End of Life

Transcription

1 Decision Making at End of Life MVMA, February 7, 2014 Alice E. Villalobos, D.V.M., FNAP Director, Pawspice at VCA Coast Animal Hospital, 1560 PCH, Hermosa Beach, CA Director, Animal Oncology Consultation Service & Pawspice, at Animal Critical Care & Emergency Specialty Service (ACCESS), Suite I, Ventura Blvd. Woodland Hills, CA & clinic cell: , office: Key Words: Decision Making, Compassion, Empathy, Quality of Life, Terminal, End of Life, Palliative Care, Hospice, Pawspice, Euthanasia, Introduction Emotions are stirred when a beloved pet is diagnosed with a life limiting disease, especially terminal cancer or recurrence of cancer. Decision making can be very difficult to facilitate. The sacrifice and cost of caring for a terminally sick animal, the dread of treating cancer and to battle against cancer s fatal agenda beats upon the emotional heartstrings of the patient s family members. Emotional issues with frustration, attachment, anticipatory grief, guilt, depression, and resignation, as well as hope and determination strum upon the core fibers of the family. The attending doctor needs to admit, face, and remove their own personal bias about treating cancer or geriatric animals with multiple co morbidities. Many pet owners have told me that they felt that their local doctor or a consulting specialist seemed insensitive to their grief, rushed, or fatalistic. Sometimes they felt that their doctor persuaded them to make decisions or did not offer them enough compassionate guidance with decision making. Some people felt that their local doctor seemed to give up on their sick old pet just when they needed help the most. Any of these factors can make pet owners feel let down in the decision making process. We need to remove the communication barriers between doctors and pet owners. This is sad but true. Clients may experience profound insensitivity on the telephone or from reception staff. Maybe they place clients on hold for too much time or they fumble trying to locate records and booking appointments. The brisk attitude of a receptionist or an officious office manager can extinguish a client s loyalty to their local doctor s pet hospital.

2 What are Common Decision Making Dilemmas? What if the patient is diagnosed with a second or third type of cancer? One of my patients, a 13 year-old black Cocker Spaniel named Ruben, developed 7 types of cancer over 4 years. Reuben started out with lymphoma when he was 9 years old. He responded well to chemotherapy. Then along the way, he developed sebaceous gland adenocarcinoma, ceruminous gland adenocarcinoma, sweat gland adenocarcinoma, bladder cancer, malignant melanoma, and finally squamous cell carcinoma (SCC) deep in the nasal septum. It was the challenge of the nasal cancer that caused Reuben s caregivers to surrender his battle against cancer. We helped them understand that a competent immune system, repair genes and tumor suppressor genes naturally suppress mutations that lead to cancer. We also explained that chemotherapy negatively affects the immune system. They understood that Reuben developed his many cancers due to aberrations of his normal immunosurveillance system. This type of explanation helped the family in their decision-making when Reuben developed nasal SCC. What if the recurrent cancer or relapse is in its early stages? Should you recommend aggressive treatment again as in the past? What advice do you give about recurrent small to medium sized mast cell tumors in the skin? What issues lay ahead if the aging pet is diagnosed in the late stages of recurrent cancer? What do you do for a long time lymphoma dog that develops PUPD? What if a lymphoma patient develops recurrent lymphadenopathy in a single lymph node? Do you underplay the possibilities and just give antibiotics and steroids and tell the owner to wait and see and schedule a recheck? Do you educate the client about the need for a cytology sample or a biopsy from at least two different lymph nodes? Do you suggest a current blood test to reevaluate organ function? Are you thinking that you need to rule out CRF, liver disease, diabetes, hypercalcemia, or relapsed lymphoma? Does the senior pet always need complete staging at the recurrence? Is an MRI necessary for every suspected metastasis to the brain? Do you send advanced recurrence cancer patients home with no hope and no supportive advice? Should you forgo further treatment when a remission is unlikely? Can we enhance a geriatric patient s quality of life with aggressive palliative care and metronomic chemotherapy such as (daily chlorambucil at 2mg/M2 or lomustine at 4mg/M2) that might achieve a partial remission or stable disease? (VCS 2014) When do you recommend a strictly palliative end of life care program that offers intense pain control? Do you consider feeding tubes and S.Q. fluids at home in an end of life care for cats with oral SCC in a Hospice/ Pawspice program?

3 What Treatments are Considered Too Aggressive? Many people in society, general practice veterinarians and specialists from other fields feel that oncologists in particular may go too far in the management of primary and recurrent cancer in geriatric pets. These same doctors may also eschew initial radical definitive surgical procedures that might actually cure cancer such as: amputation, nosectomy or mandibulectomy. They may call these procedures disfiguring and unfair to the pet especially if the cancer patient is old. Some veterinarians openly feel negatively towards recommending chemotherapy and or radiation therapy for their patients. In addition, some of these conservative doctors may be less likely to promote supportive home care such as SQ fluids or feeding tubes or mobility carts for failing geriatric patients. They unwittingly practice their bias on their clientele claiming that their approach to medicine is more down to earth and practical. The more progressive doctors have termed this approach as minimalist medicine. These minimalist doctors may be surprised when their client goes to the Internet or to some other animal hospital for a second opinion, palliative care or end of life Pawspice care services. There is a growing trend of pet owners keeping their terminal pet at home with sophisticated supportive care until they pass away on their own or require euthanasia. What Practice Model Works Best? Most veterinarians are currently taught to parallel the pediatrician model of practice where the pet is considered to be a member of the family. They leave the university with excellent textbook and disciplinary knowledge. However, there is a big gap in knowing what to do in situations of complexity and high client need. Many graduates leave veterinary school with few skills in communication and very little practical wisdom. They are told to hurry up in the exam rooms. How often do veterinarians experience emotion and confusion in the area of decision-making for aging family pets with cancer? There are so many issues to juggle regarding the wishes and financial ability of the pet owner and the needs and condition and the personality of the geriatric patient. Add the fact that many veterinarians feel busy, over booked and overworked. Another layer of professional disconnect that may paly a role in this scenario is the resentment that some associates feel against their employers (private or corporate) who seem to only care about the bottom line. It is understandable but not excusable that doctors and veterinarians may have difficulty in scheduling enough time to weigh all the issues and discuss them with their patient s caregivers.

4 If the doctor is indifferent, overwhelmed, or has a negative personal bias against treating cancer, the options offered for treating recurrence in the geriatric cancer patient get very slim. It is no wonder that many pet owners seek second and third opinions including alternative and complimentary, herbal or holistic or homeopathic medicine for advice and nurture. Has the bar for companion animal care been raised higher for veterinarians than most new graduates or seasoned practitioners are prepared or willing or to offer? Can pet owners all be trusted in every case to know what is best for their pet? How can the veterinarians depend on financially challenged pet owners to make the proper decision for their pet? Should the veterinarian bear the burden of animal advocate? Should the veterinarian become the shoulder and the counselor for distraught pet caregivers who would do anything to save their aging pet? What should be done do about those persistent pet owners who want to keep going despite their veterinarian s honest feeling that the patient has had enough effort? How often do you use a quality of life scale to help a pet owner friend assist their pets? What about the pet owners who are caught up in analysis paralysis and cannot seem to make a decision. What can you do to help a bewildered pet owner make their decision? What Frustrates Oncology and Ethics? Bernard E. Rollin, Ph.D., is a University Distinguished Professor and Professor of Philosophy, Animal and Biomedical Sciences at Colorado State University. He is a well-known bioethics speaker and author. He discusses many basic ethics issues and concerns in a paper titled, Oncology and Ethics. In this paper Rollin reminds us of essential issues and he ponders the following insightful questions: What are the animal s best interests? Given the nature of animal consciousness, it is above all else notsuffering, not prolonging life at all costs. The oncologist must be careful not to put the client s interest in prolonging life above terminating the animal s suffering. In addition, currently trendy talk in veterinary circles may seduce the veterinarian away from that ideal; to wit, the claim that veterinarians serve the human-animal bond. This, in my view, is wrong and dangerous, for it treats an abstraction as a reified (enforced) entity. Veterinarians serve the animal and must work through the client. They do not serve, in the end, the bond. Rollin asks every veterinarian to decide his or her answer to what he calls the Fundamental Question of Veterinary Ethics--- To whom does the veterinarian owe primary allegiance; owner or animal?

5 I had the pleasure of presenting case reports at an AVMA Ethics Sessions titled, Ethics, Empathy and Economics, alongside Dr. Rollin. He believes that veterinarians owe primary allegiance to the animal. We have debated this concept back and forth. Personally, I disagree with Dr. Rollin. I feel that veterinarians who are in private companion animal practices serve the human-animal bond. I feel that veterinarians owe their primary allegiance to the human-animal bond. The bond is often the real why that motivated us to enter veterinary medicine to begin with. I feel that the bond is what confers a tremendous societal and personal value on a particular companion animal patient. The bond gets stronger as the pet matures, becomes geriatric, and is nurtured during illness or cancer therapy. Honoring the human-animal bond inherently includes reverence and respect for quality of life as a personal ethic and as an appreciated and valued social aesthetic. Fear of Losing the Bond The human-animal bond, and the fear of losing that bond, motivates society to seek care for their companion animals. The bond drives pet caregivers into our hospitals. From my viewpoint, the bond emotes its own needs and rules our medicine while our personal and professional ethics serve the animal s needs. We must balance these needs in end of life care with situated knowledge, which is knowledge drawn from practical experience of dealing with clients and their time-bound companion animals. This knowledge is the missing piece or the gap in the knowledge acquired in the classroom. It exists as practical wisdom, intuition and common sense. Veterinarians need this wisdom to do a good job and be appreciated but there are no easy ways to study it. (Floersch 2004). This paper is an attempt to imbue readers with situated knowledge regarding compassionate management for decision making. Dr. Jessica Pierce wrote about her 14 year old dog, Ody, in the New York Times, September 22, Unfortunately, the love we feel for our animals can inure (habituate) us to their suffering. We may wait for our animal to tell us she is ready, but our love can make it hard to hear her cries. I couldn t bear the thought of losing Ody, so I sugarcoated his suffering. I focused on caregiving, feeling vindicated when he showed his typical interest in hot dogs and processed cheese. When, prodded by my husband, I finally called the euthanasia vet, I asked her to come the following day. I need one more day with Ody, to say goodbye, I thought. After realizing that this extra day was for me, not for Ody, I called back, and when I was able to control my voice, I asked her to come as soon as she could.

6 People need and seek more services for their geriatric pets as they age and develop medical problems such as arthritis, dental disease, organ failure, and neoplasia. People of all types and means bring personal pets to veterinarians. They openly define their pets to themselves and others as my boy or my girl who is definitely a member of their family. Society will entrust their companion animals into veterinary practices as patients all over the world. Because society brings their pets as family members to our doorstep, we have increasing ethical obligations to fill by assuming a more multidimensional role as a family practice veterinarian (Timmons, 2005) Recurrence Stimulates Intense forms of Grief Pet owners move into a defensive posture when they elect to deal with cancer and its related health issues. They entrust their veterinary team to go on the offensive and wage a surgical and medical battle against the cancer. If the pet is a service animal, the client is threatened with losing their independence, freedom and security. Naturally, all highly bonded clients want to defend their pet from dying of cancer. They often lapse into an intense type of grief. This intense fear of loss is called anticipatory grief. Some barely realize what is happening to them. Some clients may hide their grief or feel disenfranchised because their friends do not understand the importance of the bond they share with their geriatric pet (Meyers 2000, Corbin 2004). This author feels that anticipatory grief is the underlying, driving force that creates the demand for most veterinary services. It is the motivating reason the pet animal community has created the increasing demand for more specialized and sophisticated medical and supportive services for their pets. This increasing demand includes improved primary cancer care, earlier diagnosis of recurrence, and certainly includes an open mind to treating recurrent cancer in geriatric patients. Anticipatory grief also drives the increasing demand for improved palliative and end of life Pawspice and hospice care services. People Don t Want Their Pets to Die It is up to the veterinarian to figure out which client wants stepped-up services for their sick companion animals and which clients are content to let nature take its course. It is equally up to the client to alert their attending doctor of the intensity of their bond and how much of an emotional and financial commitment they will endure in order to care for their end of life pet. What can be done for pet owners who are caught in analysis paralysis or religious or cultural factors and cannot make a decision? A minimalist veterinarian may feel that a specific pet is too old and near the end of a natural life span, but that is not an excuse to turn clients away and evaporate palliative services. The veterinarian needs to find out who does and who does not want to pursue sophisticated and often costly services for and end of life patient in a nonjudgmental fashion.

7 The attending clinician needs to determine the level of service that will satisfy less bonded pet owners yet still provide comfort care for their pets. These issues need to be handled delicately. Veterinarians encounter dramatic ups and downs of human emotions on a daily basis. One exam room has a patient belonging to a highly bonded family and the next exam room has a neglected patient. The doctor who jumps in and out of exam rooms like a rabbit may not be addressing their client s emotions enough. Communications Training Most veterinarians did not get training in this area in veterinary school so they avoid or deflect their client s emotion. Physicians do not want to talk about bad news or death with their human patients. It is not different in veterinary medicine. Many graduates and specialists are highly focused on the disease and its statistics, and not the patient-client entity. They can be super technicians without interactive skills in collaboration, interrelationships and the needs of society. They may lack the perspective to learn about and understand the entire patient s attaché of family and environmental issues. When companion animals enter their end of life stage, there is a need to reach out and remove communication barriers between doctors and pet owners to improve decision making. Clients may experience insensitivity from reception staff on the telephone; get put on hold for too long; wait as records get located; or trouble booking appointments. The brisk attitude of a receptionist or an officious office manager can extinguish a client s return. If they are rushed or get only a 10-minute office visit, it is impossible to think of everything they need to say. Clients often leave with unsaid details that might impact patient care. Clients often fail to receive compassion and valuable practical wisdom and personalized advice that they so desperately need to make informed decisions for their EoL pets. They often feel alone with little guidance for their problem so they ask Dr. Google to help make important decisions Good communication skills are needed for these intimate consultations. The aging pet population parallels the aging of the human baby boomer population. People expect their pets to have a longer and healthier life. The public is asking for our help and expertise and they are willing to pay for it even when cancer recurs.

8 Honesty is the Best Policy On the other hand, as a profession, we must be wary of unscrupulous veterinarians. Our crooks are few and far between but every profession has a sociopath here and there. They prey on the human animal bond at the expense of the pet s quality of life and the pet caregiver s pocket book. There is a fine line between love and money. We must always remain true to the Veterinarian s Oath and remain ethical in our decision making with clients. Personal ethics tells one not to lie, not to steal, not to take advantage of people, to be charitable and to do-the-right-thing for pets and their people. Society has conferred upon veterinarians and other professionals, including priests, the Aesculapian authority. Aesculapius was the god of healing in Roman mythology. Aesculapian authority allows doctors to examine and make decisions for their patients. Society views violations of the Aesculapian authority as a very serious crime of betrayal (Rollin, 2000). The most professional approach aspires to Do it right the first time. A veterinarian s personal bias or negativity towards cancer may show up in the way he/she steers a consultation. But would a second opinion agree with yours? Would a second opinion agree with a conservative approach? Are we actually trying to protect the client from our fears? Do we fear that a referral would enter our clients and their pet into the mindless machinery of high tech medicine spending more money than we think they can afford? Are we being the advocates of our client s pocket book? Are we be being the pet s advocates? Or, are we really down underneath it all, just trying to keep the client s business at our own hospital? Ask yourself. Is that how you make decisions for your clients? Conflict of Interest Rollin and various esteemed colleagues, including specialists, formatted many of these haunting questions in a series of lively panel discussions at major professional meetings across the nation. Rollin proposes, no - he actually insists that we ask ourselves these revealing questions about conflict of interest. Questions such as; Has the high tech mega practice ascended into a new realm of economics and ethics? Do the doctors in super practices that have the mega facilities and the rotating schedules, make decisions that will favor the pet or the pet owner? Or, do they make decisions that favor their practice s financial interests and their own personal percentage of gross income as per their payroll arrangements? Are we redrawing the line of pet advocacy in the emergency room these days? When do veterinarians need to exert their professional authority and become the advocate for their patients to avoid unnecessary suffering, prolongation of life and expense? These may be difficult questions to confront; that is why Rollin asks them!

9 Prioritize Quality of Life It takes time to properly do the research and think about a case and the unique features that may positively or negatively influence your particular patient s survival. Most caregivers want their End of Life companion animals to have a good quality of life with no pain. When animals become sick, injured or geriatric, the V-team can provide the family with the HHHHHM Quality of Life Scale. The acronym s 5 H s and 2 M s indicate: no Hurt, Hunger, Hydration or Hygiene issues; Happiness, Mobility and More good days than bad days. This tool assists family members to evaluate QoL for their animals at all stages of life especially during end of life care and helps them make the final call for euthanasia. See Table 1. The QoL Scale may be downloaded at: and at: Although small animal veterinary medicine parallels the pediatrician model, it only takes a decade for the baby to become geriatric with multiple co morbidities that compete for treatment and survival against a newly diagnosed problem such as organ failure or cancer. There is a cry from society for veterinarians to provide more end of life care services, embracing the concept of palliative care and hospice for companion animals. Society resonates with the philosophic concept of Pawspice which simultaneously offers palliative care along with kinder gentler forms of standard care when indicated. Palliative care/pawspice transition into hospice when the patient nears the edge of death. So there should be no reluctance by the profession to offer needed and wanted end of life care services earlier; at the time of, or shortly after the diagnosis of any life limiting disease. (VCNA, Vol. 41, No. 3, May 2011) Communication Skills It takes more time to educate clients about the issues, options and treatment plans in early, middle and late stage cancer and especially recurrent cancer. Sadly, the preparation of veterinary students to face and properly handle these consultations and ethical issues for decision making is lacking in most veterinary colleges. Qualified personnel are seldom on staff to provide training classes for communication skills in veterinary colleges. Clinicians may provide some communication skills to their students by example or as an afterthought in the hallways or between exam room visits. Education and formal curriculum time to teach classes in medical ethics, grief and attachment theory are generally lacking in veterinary colleges. Three colleges in the USA have recently reduced time for ethics classes. Medical ethics and decision-making drills are not regarded with as much value as class time spent on how to diagnose and treat organ system disease.

10 Some pet owners confided that they felt completely misunderstood by their attending veterinarian or a certain specialist. They felt the doctors had an indifferent or a take it or leave it attitude. One scenario was a difficult radiation therapy protocol proposed by a radiologist who provided statistics and percentages for the clients (who were both CPA s). They felt that the radiologist proposed the protocol without listening to their worries or answering their questions or dealing with the specific concerns they had for their aging companion animal with nasal cancer. Attending veterinarians are expected to stay true to the patient s well being when it comes to selecting options and referrals for cancer management especially in the face of recurrence. We must guard against unrecognized and unnecessary suffering in our end of life cancer patients. We also have a social responsibility to ease the emotional pain of the pet owner while caring for their end of life pet. We must ensure that the pet gets adequate attention to the Five H s and Two M s in the Quality of Life Scale: no hurt, no hunger, no hydration problems, good hygiene and happiness, mobility and more good days than bad days (it may be downloaded at: Support that Emotional Clients Need and Deserve The caring public needs its veterinarians to have the ability to be aware of and deal effectively with the internal torment of decision making in end of life care. Pet owners may experience a heart-wrenching emotional shock at the diagnosis of cancer, its recurrence or any time during their pet s steady or bumpy decline toward death. Some clients may slide into a grief episode right in the doctor s office. They feel an acute emotional wound when they get the bad news on follow up met check x-rays that identify mets in the chest. The recurrence and projected ravages of cancer threatens their long-term human-animal bond and implodes their happiness. The veterinarian needs to be aware that he/she may not be talking to a rational person at the time of the appointment. The client may disconnect from reality and remain in denial or be in a daze. This compounds the problem of educating the client and the process of decision-making. This places additional stress on the relationship between the veterinarian and client. Unfortunately, the stress and confusion between veterinarian and clients may take its toll at the expense of the patient s quality of life. At times the pet gets sicker or the cancer enlarges during the work up or between visits. It is best to offer several options for care based upon the client s goals. It may be to repeat another cycle of chemotherapy or surgery or to enter the patient into an end of life care program such as Pawspice or hospice. Pawspice embraces both palliative care and kinder gentler standard care and transitions into hospice (more intense comfort care) when the patient s condition declines toward death.

11 Strategy for Recurrence A good strategy to deal with recurrence is to have an active surveillance program for all cancer patients at risk. I always warn clients of approximately when the literature tells us to expect recurrence or metastatic disease. I tell clients that we have done everything we can to offset recurrence. For example in hemangiosarcoma or osteosarcoma, if we go past four months without signs of recurrence, we congratulate the client for winning extra time for their pet in the battle against cancer. If we can win more rechecks with clean x-rays and ultrasounds, it is like scoring some runs and getting into overtime. We congratulate our client for their success and celebrate the meaning of each negative recheck. These are the joyful moments in oncology and they should be celebrated with sincere enthusiasm. We all deal with the likelihood of organ failure, progression of disease and cancer recurrence in our individual areas of practice. One of my colleagues, Dr. Chuck Cortese said, I see ACCEPTANCE or lack thereof as the primary determining factor when treating a terminal patient. If the owners do not accept that their pet's life will soon be over, then they chase anything anyone will offer. Dr. Cortese said, When confronted with a terminal situation, I talk with my clients about how much they have done for their pet over the years. How our animals need us to make decisions that do not put them through any unnecessary or prolonged pain. We also talk about how animals sometimes show their acceptance of death. It is a part of life that can easily be stripped of its dignity if we are not careful. Then we talk about Pawspice and prolonging their pet s life without pain and with dignity as long as possible. Options: Metronomic Chemotherapy, Immunonutrition, Chemoprevention Offer clients doable options, which they can administer at home, that may help their pet s quality of life and longevity. Consider referral for palliative metronomic chemotherapy for anti angiogenesis. This may include a prescription for an NSAID and a low continuous dose of an antineoplastic drug such as: chlorambucil, cyclophosphamide, lomustine or capecytabine along with TK inhibitors (masitinib or toceranib} or a combination. Offer options such as chemoprevention with NSAIDS that are Cox inhibitors. Consider immunonutrition as an overall helpful option using restorative nutritional supplements that have been shown to support the immune system, the musculoskeletal system and enhance mitochondrial function. Integrative, rehabilitative and complimentary therapy are also options. More detailed information on these helpful options is available upon request at: dralicev@aol.com.

12 Ethical Framework for Decision Making Michael McDonald s framework is to be used as a guide, rather than a recipe. Ethical decisionmaking is a process, best done in a caring and compassionate environment. It will take time, and may require more than one meeting with patient, family, and team members. It is important to know that there is no perfect answer. It is essential that all those involved with the patient must feel satisfied under the given circumstances and situation. Feel free to share this framework with others. For reprints or distributng it, please let the author know at: mcdonald@ethics.ubc.ca. See Ethics and Conflict of Interest by Michael McDonald, Univ. of British Columbia Deciding When a Pet Has Suffered Enough, New York Times, September by Dr. Jessica Pierce of Lyons, Colorado. She is a bioethicist on the BOD of the Society for Veterinary Medical Ethics and author of The Last Walk: Reflections on Our Pets at the End of Their Lives. ODY died peacefully last year, Nov. 29. He was 14 and a half. Truth be told, Ody didn t just die. I killed him. I paid a vet to come to my house and inject a chemical solution into a vein in Ody s back leg. People ask me how I knew it was time. There was no watershed, but a slow accumulation of miseries. Ody had been in serious decline for six months. Partial paralysis of his laryngeal muscles made it hard for him to breathe, and he would begin to pant at the slightest exertion. His once deep tenor bark had transformed into a raspy Darth Vader croak. The signals from his addled brain often failed to reach his body, so when I walked him he left a Hansel and Gretel trail of pee and poop behind him. His muscles atrophied, and his walk was crab-like and unsteady. He grew increasingly uninterested in food and people, his two great passions. Worst of all, he began falling more and more frequently and was unable to get up by himself. Toward the end, I would wake in the night to scuffling sounds. I d search the house and find Ody trapped behind the piano or tangled up in the exercise equipment. It was on the fourth such night that my husband said: It s time. We can t do this to Ody anymore.

13 Summary I hope this paper and the cases presented will help you feel more experienced in the process of decision making. By providing you with situated knowledge, the practical wisdom and knowledge to ponder the difficult medical and emotional issues encountered at end of life decline or at recurrence or relapse of cancer in a beloved companion animal. If you cultivate an optimistic attitude toward surveillance and educate your clients that recurrence is likely in oncology, you are preparing them. You will be better prepared to freshly assess the situation and offer your clients a clear set of options to follow. When facing recurrence, many of your clients are often willing to jump into the heart of battle once again to keep their pet live longer. They will enter round two, three, or four as long as a good quality of life can be maintained. They do not want discouragement unless you feel that further treatment would be practicing futile medicine. A second opinion may help decide. Veterinary medicine is one of the few professions that is readily handed the keys to a person s heart. We have a wonderful opportunity to provide a healing atmosphere for our cancer patients as well as for their family members. Brace yourself and reach out to help those heartbroken pet owners who have to stumble down the difficult road of relapse and recurrence that is attacking their pet s survival and their own personal happiness. Help them along the bumpy way at the end of the road. Be supportive. It should not matter if they choose to take the high road or the low road due to fear or economic limitations. Help them to pass through that difficult threshold of decision-making and re-evaluation when tumor recurrence strikes or decline ravages their companion animal. Help the carers go forward with their decisions. Offer the framework for decision making. Offer clients encouragement and validate their decision so they can maintain their pride. Use metronomic chemotherapy, chemoprevention and immunonutrition as viable options for pet owners to pursue if they decide to decline aggressive standard therapy. Treat the end of life patient for stress by presuming that illness and cancer causes physiologic stress. Treat the pet for cancer pain by presuming that cancer hurts by its mere presence, even if overt pain is not obvious. Teach clients to use the Quality of Life Scale. Give your clients the working knowledge and the tools to competently assist their pet in the battle against cancer s fatal agenda. Your guidance and kindness during decisionmaking, treatment and palliation will always be appreciated. For me, it is caring for the human-animal bond, as each heartstring is plucked out one by one. This goal bestows a greater and sublime purpose to the art of practice.

14 References: Cohen, L.A., Powers, B., Amin, S., Desai, D., Treatment of Canine Hemangiosarcoma with Suberoylanilide Hydroxamic Acid, a histone deacetylase Inhibitor, Veterinary and Comparative Oncology, Vol. 2, No. 4, December 2004, p Corbin, J., A Depth Psychological Analysis of the Human-Canine Bond and it s Implications to the Grief Response, Dissertation Proposal, Pacifica Graduate Institute, December, Floersch, J., Meds, Money, and Manners, the Case Management of Severe Mental Illness, Columbia University Press, Liptak, J.M., Monnet, E., Dernell, W.S., Withrow, S.J., Pulmonary Metastatectomy in the Management of Four Dogs with Hypertrophic Osteopathy, Veterinary and Comparative Oncology, Vol. 2, No. 1, March 2004). Myers, B. Anticipatory Mourning and the Human Animal Bond, Research Press, Timmons, R., Family Practice, American Association of Human Animal Bond Veterinarians Newsletter. Vol. 12, Winter Veterinary Cancer Society Proceedings, 2014 contained 5 articles and several posters on metronomic chemotx. Resources: Are Veterinarians Kinder than Physicians at End of Life? Is Pawspice Kinder than Hospice? A Veterinary Oncologist s Interprofessional Crossover Perspective on Euthanasia, Villalobos, A.E., International Journal of Ethics, Volume 9, Number 4, 2013, p Being Mortal: Medicine and What Matters in the End, Atul Gawande, MD, Henry Holt and Co., Oct. 7, Five Cancer Practices That Must Stop, Chustecka, Zosia, J Clin Oncol. Published online April 3, Canine and Feline Geriatric Oncology; Honoring the Human-Animal Bond, by Alice Villalobos, DVM, with Laurie Kaplan, MSC, 2007, Blackwell Publishing (Wiley) Hoboken, NY. Compassion, Our Last Great Hope, by Leo K. Bustad, DVM, Ph.D., 2000, Delta Society Press (Pet Partners), Renton, WS.

15 Table 1. HHHHHMM Quality of Life Scale Caregivers can use this Quality of Life Scale to assess animals and guide decision making for Pawspice care. Use numbers from 0 to 10 (10 is ideal or normal) to score the patient s condition. Score Criterion 0-10 HURT - Adequate pain control & breathing ability is top priority. Trouble breathing outweighs all concerns. Is pain being treated properly or not? Can the animal breathe properly? Is supplemental oxygen necessary? 0-10 HUNGER - Is the pet eating enough? Does hand feeding help? Does the patient need a feeding tube? 0-10 HYDRATION - Is the pet dehydrated? For patients not drinking enough water, use subcutaneous fluids daily or twice daily to supplement fluid intake HYGIENE - The pet should be brushed and cleaned, particularly after eliminations. Avoid pressure sores with soft bedding and keep all wounds clean HAPPINESS - Does the pet express joy and interest? Is the pet responsive to family, toys, etc.? Is the pet depressed, lonely, anxious, bored or afraid? Can the pet's bed be moved to be close to family activities? 0-10 MOBILITY - Can the pet get up without assistance? Does the pet need human or mechanical help? Is the dog willing/able to go out for short walks? Is the pet having seizures or stumbling? Some feel euthanasia is preferable to amputation. But a companion animal with 3 legs or limited mobility can be alert, happy and have a very good QoL only if the family is committed to helping their companion animal get around with: ramps, cart, harness, braces, rehab., acupunct., etc MORE GOOD DAYS THAN BAD - When bad days outnumber good days, QoL may be too compromised. When a healthy human-animal bond is no longer possible, the family must be made aware that the end is near. The decision for euthanasia needs to be made if the animal has pointless suffering. If death comes peacefully and painlessly at home, that is okay. *TOTAL *A total over 35 points represents acceptable life quality to continue with Pawspice/hospice. Original concept, Oncology Outlook, by Dr. Alice Villalobos, Quality of Life Scale Helps Make Final Call, VPN, 09/2004; scale format created for author s textbook, Canine and Feline Geriatric Oncology: Honoring the Human- Animal Bond, Blackwell Pub., Adapted for CB, VCNA, AAFP & IVAPM Palliative Care & Hospice Statement, Senior Dog Books, Merial s pre-vcs/esvonc/wvcc-rt,paris, , Western University College of Veterinary Medicine 2012,Mass.VMA, 2013, IAAHPC, 2014, Minn.VMA, 2015, with Dr. Villalobos permission.

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