Mission Statement for Hospice

Transcription

1 Mission Statement for Hospice To provide compassionate, comprehensive end of life care to our patients affected by an advanced illness, while supporting our client s needs, beliefs and wishes. We will help patients live comfortably in their final days and help caretakers cope with the care and ultimate loss of their loved ones.

2 CONSENT FOR HOSPICE AND PALLIATIVE CARE I,, am the legal owner/primary caregiver of as described above and do hereby agree to hospice and palliative care treatment at home and in the hospital by Cary Street Veterinary Hospital and its employees. I agree that Cary Street Veterinary Hospital and its employees or agents shall not be liable for any direct, indirect or consequential damages resulting from such care. I understand that hospice and palliative is aimed at improving quality of life and alleviating suffering, and is not focused on curative intent or routine preventative veterinary care, but I may elect to continue curative medicine and preventive care during hospice and palliative care if I wish. 1. At this time I do / do not wish to pursue curative medical practices such as chemotherapy, radiation, or surgery. 2. At this time I do / do not wish to continue with routine preventive care such as vaccines, heartworm prevention, and fecals. Rabies is required for all patients at all stages of life. 3. At this time I do / do not wish to continue with recommended diagnostics used to monitor therapy and disease process such as bloodwork and radiographs. I assume full responsibility for the actions of the animal described above and all charges incurred in its care. I also understand that all fees are due at the time services are rendered. I have carefully read and fully understand the above stated positions. Owner/Caregiver signature Date

3 Hospice and Palliative Care Plans Palliative Care Plan- Your pet has unspecified changes in health and unknown time until expected death. At a minimum, we d like to recheck your pet on a monthly basis. The doctor or technician will check in by phone once or twice a month. Early Hospice- Your pet has a life limiting illness and death is expected to come naturally within three to six months. Recheck visits should occur every two weeks. The doctor or technician will check in by phone weekly. Late Hospice- Your pet has a life limiting illness and death is expected to come naturally within a few hours to a couple of weeks. Recheck visits should occur one to two times a week. The doctor or technician will check in by phone every other day to every day.

4 Commonly Prescribed Drugs in Hospice and Palliative Care For Vomiting, Nausea and Inappetence: Famotidine Famotidine - (Pepcid) is an H2-receptor antagonist used to reduce GI acid production and is typically prescribed to dogs and cats to lower the amount of stomach acid produced. This remedy is used to treat and prevent stomach ulcers, gastritis, esophagitis, and gastric or esophageal reflux. Mixing the tablet with food may reduce its potency; skipped doses should not be combined. Side Effects of Famotidine: Rare include drowsiness, loss of appetite, and allergic reactions including swelling, hives, pale gums, cold limbs, seizures, and sudden diarrhea or vomiting. Omeprazole Omeprazole - (Prilosec) belongs to the class of drugs known as proton pump inhibitors. It prevents hydrogen ions from moving about in the stomach and stops the secretion of acids in the gastrointestinal tract. This in turn reduces acidity in the stomach and heals ulcers. Dogs and cats suffering from stomach ulcers caused by the ingestion of certain drugs also benefit from Omeprazole. Besides this, the drug keeps acid reflux in check. It not only reduces acidity in the stomach but also prevents stomach acid from rising up to the esophagus. Side Effects of Omeprazole: Can cause nervous system changes in some pets. Few pet owners also claim that their dogs have suffered from urinary tract infections after taking the medication. Some of the most common side effects of this drug are vomiting, watery stools, and flatulence. Some dogs develop sensitivity to the drug and suffer from hives, swelling of the lips and face, and skin reactions. Meclizine Meclizine - (Bonine) is a human antihistamine that helps control canine motion sickness symptoms. Although it is not officially registered for veterinary use, it can be prescribed legally by your veterinarian as an extra-label drug for your dog. For most dogs, meclizine is considered safe, but the medication can cause a few side effects. It can also interact with some drugs and potentially complicate some pre-existing conditions. Side Effects of Meclizine: As a member of the antihistamine drug class, meclizine can present a certain set of side effects for your dog, most of which are minor. These include appetite loss, diarrhea, dry mouth, increased heart rate, and lethargy. Cerenia Maropitant Citrate - (Cerenia) is a neurokinin-1 (NK-1) receptor antagonist that acts in the central nervous system by inhibiting Substance P, the key neurotransmitter involved in vomiting. Maropitant suppresses both peripheral & centrally mediated emesis.

5 Tablets as well as injections are used to help prevent and control acute vomiting and also to help prevent the onset of vomiting due to motion sickness in dogs and cats. Side Effects of Cerenia: Rare include drowsiness, drooling, lethargy, diarrhea, and anorexia. Ondansetron Ondansetron - (Zofran) is a serotonin 5-HT 3 receptor antagonist. [1] It is a medication used to prevent nausea and vomiting caused by cancer chemotherapy, radiation therapy, or surgery. [1] It is also useful in gastroenteritis. [2][3] Side Effects of Ondansetron: Diarrhea, constipation, headache, sleepiness, and itchiness. Metoclopramide Metoclopramide - (Reglan) is a Prokinetic drug. Metoclopramide has been used for both its GI stimulatory and antiemetic properties. It has been used clinically for gastric stasis disorders, gastroesophageal reflux, as a general antiemetic (for bilious vomiting syndrome, uremic gastritis, etc.), and as an antiemetic to prevent or treat chemotherapy-induced vomiting. Stimulates upper GI motility & has antiemetic properties; more potent as an antiemetic (in dogs) than a prokinetic agent. Might be a poor antiemetic in cats. Side Effects of Metoclopramide: Dogs Changes in mentation and behavior, constipation; Cats Signs of frenzied behavior or disorientation, constipation. Mirtazapine Mirtazapine - (Remeron) is Tetratracyclic Antidepressant; 5-HT3Antagonist. Used in veterinary medicine primarily as an appetite stimulant & antiemetic in dogs & cats with chronic kidney disease. Side Effects of Mirtazapine: Appears to be well tolerated in both dogs and cats, but use has been limited. Besides the desirable side effect of appetite stimulation, other currently reported side effects in animals include: drowsiness/sedation, vocalization, increased affection in cats, hypotension, and tachycardia (all dose-dependent). Increases in liver enzymes have been reported in some cats receiving mirtazapine. Cyproheptadine Cyproheptadine - (Periatin) is a Serotonin antagonist antihistamine. It is used as an appetite stimulant, primarily in cats. Can be useful in management of serotoninsyndrome in small animals. Has also been tried as an antipruritic/antihistamine in dogs & cats. Side Effects of Cyproheptadine: Sedation (cats might demonstrate paradoxical hyperexcitability) & anticholinergic effects-ts CNS depressant (sedation) and anticholinergic effects (dryness of mucous membranes, etc.). Cats can develop a paradoxical agitated state some reports of hemolytic anemia in cats. Diarrhea: Metronidazole

6 Metronidazole - (Flagyl) is an antibacterial, anti-parasitic. The drug has been used extensively in the treatment of Giardia in both dogs and cats. It is also used clinically in small animals for the treatment of other parasites (Trichomonas and Balantidium coli ) as well as treating both enteric and systemic anaerobic infections. It is commonly employed as a perioperative surgical prophylaxis antibiotic where anaerobes are likely (e.g., colon; periodontal). Side Effects of Metronidazole: Neurologic disorders, lethargy, weakness, low white blood cell counts, liver dysfunction, bloody urine, anorexia, nausea, vomiting, and diarrhea. Metronidazole is very bitter and might be more palatable when compounded. Tylosin Tylosin - (Tylan powder ) is a macrolide antibiotic related to erythromycin and used orally in cats/dogs for chronic colitis. Oral tylosin is commonly recommended for the adjunctive treatment of inflammatory bowel disease (IBD; idiopathic antibiotic responsive diarrhea) in dogs, cats, and some small mammals. It should be compounded or mixed with food for oral use in dogs and cats. Has a very unpleasant taste. Side Effects of Tylosin: Pain & local reactions after intramuscular injection, gastrointestinal upset (anorexia & diarrhea) after oral administration. Sucralfate Sucralfate - (Carafate) is a locally acting treatment for GI ulcers/esophagitis. Can also protect somewhat against GI ulceration. It is used to coat and soothe the GI tract and can be useful in diarrhea cases. Carafate could potentially be useful for lowering serum phosphorus in renal patients. Side Effects of Sucralfate: Unlikely; constipation is possible. Vomiting reported in cats. Loperamide Loperamide - (Imodium) is a synthetic opiate GI motility modifier used for symptomatic treatment of diarrhea, primarily in dogs. Contraindications: Dogs with ABCB 1-1Δ (MDR1) mutation (mutant/mutant). Side Effects of Loperamide: Dogs Constipation, bloat, and sedation. Potential for toxic, distended colon, pancreatitis, and central nervous system effects. Cats Use is controversial; can exhibit excitatory behavior. Constipation: Lactulose Lactulose - (Cepulac) is a Disaccharide laxative & reducer of blood ammonia levels. The primary use of lactulose in veterinary medicine is to reduce ammonia blood levels in the prevention and treatment of hepatic encephalopathy (portosystemic encephalopathy; PSE) in small animals. It is also used as a laxative in small animals. Side Effects of Lactulose: Flatulence, gastric distention, cramping, etc. Diarrhea and dehydration are signs of overdose. Cats dislike the taste of lactulose liquid, and administration can be difficult.

7 Docusate Docusate - (Colace) is a surfactant stool softener and is used in small animals when feces are hard or dry or with anorectal conditions when passing firm feces would be painful or detrimental. Side Effects of Docusate: Cramping, diarrhea, and GI mucosal damage. Pain Medications: Acetaminophen Acetaminophen - (Tylenol) is an oral analgesic and antipyretic- anti-fever and is contraindicated in cats at any dosage. Acetaminophen is occasionally used as an oral analgesic in dogs and small mammals. It can be particularly beneficial in dogs with renal dysfunction for the treatment of chronic pain conditions. In situations where moderate pain occurs, it may be used in combination products containing codeine, hydrocodone, or tramadol. Side effects of Acetaminophen: At suggested dosages in dogs, there is some potential for kidney, liver, GI, and blood cell effects occurring. NSAIDS - Non-Steroidal Anti-Inflammatory Medications Carprofen - (Rimadyl) licensed in dogs Meloxicam - (Metacam) licensed in cats and dogs Robenacoxib - (Onsior) licensed in cats and dogs Non-steroidal anti-inflammatory drugs are commonly used for treating pain, inflammation, and osteoarthritis in dogs and cats. ****DO NOT USE CONCURRENTLY WITH STEROIDS**** Side Effects of NSAIDS: GI effects (vomiting, anorexia, diarrhea, dark tarry stools, GI ulceration), elevated liver enzymes/hepatotoxicity, elevated creatinine, and renal failure. When NSAIDs are used chronically, blood work is often recommended to monitor kidney and liver values. Steroids Prednisone (Prednisone, Prednisolone) Dexamethasone (Dexasone, Azium) Methylprednisone (Medrol, Depo-medrol) Steroids are used as an anti-inflammatory, an immunosuppressive agent, and as an anti-neoplastic/anti-cancer agent. ****DO NOT USE CONCURRENTLY WITH NSAIDS**** Side Effects of Steroids: Stomach or intestinal ulcers, anorexia, fever, black tarry stools, or bloody vomit. Gabapentin Gabapentin - (Neurontin) is an anticonvulsant and analgesic. Gabapentin can be useful as adjunctive therapy for refractory or complex partial seizures. As an analgesic,

8 gabapentin has been demonstrated to be most useful in treating chronic pain, particularly neuropathic pain in small animals. Side Effects of Gabapentin: Sedation and ataxia are probably the most likely adverse effects seen in small animals. Starting the dose at the lower end of the range and increasing with time can alleviate these effects. Amantadine Amantadine - (Symmetrel) While amantadine can have efficacy and clinical usefulness against some veterinary viral diseases, presently, the greatest interest for its use in small animals is as an NMDA antagonist in the adjunctive treatment of chronic pain, often in those tolerant to opioids. It is generally used in combination with an NSAID, opioid, or gabapentin/pregabalin. It is also used as an adjunct drug for treating neuropathic pain. Side Effects of Amantadine: Agitation, loose stools, flatulence, and diarrhea have been seen, particularly early in therapy. Experience in cats is limited, and an adverse effect profile has yet to be fully elucidated, but some report that gastrointestinal effects are more likely than in dogs. Possible signs indicating toxicity include anxiety, restlessness, and dry mouth. Tramadol Tramadol - (Ultram) is an opiate-like (mu-receptor) agonist. Tramadol can be a useful alternative or adjunct for the treatment of post-operative or chronic pain or cough in cats. When used in combination with NSAIDs or other analgesic drugs (e.g., amantadine, gabapentin, alpha-2 agonists), it can be particularly useful for chronic pain conditions. Side Effects of Tramadol: Dose avoidance (unpalatability), vomiting, sedation, mydriasis, dysphoria or euphoria, and constipation have been reported. Buprenorphine Buprenorphine - (Buprenex) is an opioid partial agonist. Buprenorphine is most often used as an analgesic for mild to moderate pain or in combination in pre-anesthetic cocktails in small animals. Side Effects of Buprenorphine: Although rare, respiratory depression appears to be the major adverse effect to monitor for with buprenorphine; other adverse effects such as sedation have been noted. In dogs, salivation, low heart rate, hypothermia, agitation, dehydration, and constricted pupils have been reported. High heart rate, vomiting, and high blood pressure rarely occur. In cats, dilated pupils and behavioral effects (e.g., excessive purring, pacing, rubbing, etc.) can be seen. Vomiting and hyperthermia occur rarely. Butorphanol Butorphanol - (Torbutrol, Stadol, Torbugesic) is a partial opiate agonist/antagonist used as an analgesic, premed, antitussive, or antiemetic. Side Effects of Butorphanol: In dogs and cats, side effects include sedation, excitement, respiratory depression, ataxia, anorexia, or diarrhea (rarely).

9 Codeine Codeine Opiate used in small animal medicine as an oral analgesic (mild pain), antitussive, or an antidiarrheal. Side Effects of Codeine: Codeine is generally well tolerated, but adverse effects are possible, particularly at higher dosages or with repeated use. Sedation is the most likely effect seen. Potential gastrointestinal effects include anorexia, vomiting, constipation, GI stasis, and biliary and pancreatic duct spasms. Respiratory depression is generally not noted unless the patient receives high doses or is at risk. In cats, opiates can cause CNS stimulation with hyperexcitability, tremors, and seizures. Methadone Methadone - (Dolophine) is an opiate agonist and acts similarly to morphine with regard to its degree of analgesia and duration of action. Side Effects of Methadone: Panting, whining, sedation, defecation, constipation, bradycardia, and respiratory depression. Methadone tends to cause less sedation or vomiting than morphine. Fentanyl Transdermal Patches Fentanyl - (Duragesic) is an opioid. These transdermal patches are used primarily in dogs and cats and have been shown to be useful for the adjunctive control of postoperative pain, severe pain associated with chronic pain, dull pain, and nonspecific, widespread pain (e.g., associated with cancer, pancreatitis, aortic thromboembolisms, peritonitis, etc.). Side Effects of Fentanyl: Respiratory depression and slowed heart rate associated with fentanyl patches are the most concerning adverse effects, but incidence of these effects have not been widespread thus far when used alone (without other opiates or other respiratory and cardiodepressant medications). Rashes at the patch site have been reported, and should they occur, the patch should be removed. If an additional patch is warranted, a different site should be chosen. Urine retention and constipation can occur. Consider removing patch in patients developing a fever after application, as fentanyl absorption can increase. Some patients exhibit dysphoria or agitation after application. Hydrocodone Hydrocodone - (Tussigon or Hycodan) is an opiate and is used primarily as an antitussive in dogs, but is potentially useful as an oral analgesic for moderate pain in dogs. The human combination products containing hydrocodone and acetaminophen could be potentially useful oral analgesics in dogs (NOT in cats). Side Effects of Hydrocodone: Sedation, constipation (with chronic therapy), vomiting, or other GI disturbances. Ketamine Ketamine - (Ketaset) is a general anesthetic that possesses analgesic effects at subanesthetic doses. Ketamine can decrease wind-up effect in the central nervous system and is used to prevent exaggerated pain associated with surgery or chronic pain states in animals. Side Effects of Ketamine: At these lower dosages, adverse effects are generally minimal in most species.

10 Lidocaine Lidocaine - (EMLA-lidocaine/prilocaine) cream is used topically as a dermal anesthetic or antipruritic and is included in several products used for acute moist dermatitis, pruritic lesions, or painful skin conditions. When combined with prilocaine, commonly called EMLA cream. Side Effects of Lidocaine: Hypersensitivity reactions or skin irritation (burning, tenderness, etc.) are possible but do not occur commonly. Avoid contact with eyes, and do not use in ears unless specifically labeled for such. Hands should be washed after application, or wear gloves when applying. Anxiety Medications: Fluoxetine Fluoxetine - (Prozac) is a selective-serotonin re-uptake inhibitor antidepressant used in dogs (approved) and cats (extra-label) for a variety of behavior disorders and anxiety. Side Effects of Fluoxetine: In dogs, anorexia, lethargy, GI effects, anxiety, irritability, insomnia/hyperactivity, panting, and aggressive behavior in previously unaggressive dogs have been noted. Cats can exhibit behavior changes (anxiety, irritability, sleep disturbances), anorexia, and changes in elimination patterns. Amitriptyline Amitriptyline - (Elavil) is a tricyclic behavior modifier, antipruritic, and neuropathic pain modifier that can be useful for adjunctive treatment of pruritus or chronic pain of neuropathic origin in dogs and cats. In cats, it potentially could be useful for adjunctive treatment of lower urinary tract disease. Side Effects of Amitriptyline: The most predominant adverse effects seen with the tricyclics are related to their sedating and anticholinergic (constipation, urinary retention) properties. Occasionally, dogs exhibit hyperexcitability and, rarely, develop seizures. Cats may be more sensitive to amitriptyline than dogs; sedation, hypersalivation, urinary retention, anorexia, unkempt hair coat, vomiting/nausea, ataxia, disorientation, and cardiac conductivity disturbances are possible. Benzodiazepines Alprazolam - (Xanax) Lorazepam - (Ativan) Diazepam - (Valium) Clonazepam - (Klonopin) Oxazepam - (Serax) Benzodiazepines are used in dogs and cats for their anxiolytic, muscle relaxant, hypnotic, appetite stimulant, and anticonvulsant activities. Side Effects of Benzodiazepines: Sedation, increased appetite, and transient ataxia. Cats can exhibit changes in behavior (irritability, increased affection, depression, aberrant demeanor) after receiving benzodiazepines. Trazadone

11 Trazadone - (Dresyrel) is a serotonin 2a antagonist/reuptake inhibitor that may be useful for adjunctive treatment of behavioral disorders (esp. anxiety or phobia related) in dogs; not used in cats. Side Effects of Trazadone: The adverse effect profile for trazodone in dogs is not well documented. Potential adverse effects include sedation, lethargy, ataxia, priapism, cardiac conduction disturbances, increased anxiety, and aggression. Dexmedetomidine Dexmedetomidine - (Dexdomitor or Sileo) is an alpha-2 adrenergic agonist. The injectable is used as a preanesthetic and for sedation and analgesia in dogs and cats. The oromucosal gel, Sileo, is approved for noise aversion in dogs. Side Effects of Dexmedetomidine: Slowed heart rate, muscle tremors, transient hypertension, reduced tear production, occasional heart arrhythmias, decreased respiration, hypothermia, urination, and vomiting. Buspirone Buspirone - (BuSpar) is an anxiolytic agent used in dogs & cats. It is usually given 2-3 times a day. It might take a week or more to be effective; not appropriate for acute treatment of situational anxieties. Side Effects of Buspirone: Usually minimal; generally well tolerated. Slowed heart rate and GI disturbances are possible. Acepromazine Acepromazine - (PromAce) is a phenothiazine neuroleptic agent and is a useful tranquilizer/sedative in small animals. Side Effects of Acepromazine: Side effects on blood pressure (hypotension) have been well described and are an important consideration in therapy. OTC Anti-Anxiety Medications - (Nutritional Anxiolytic Agents) Composure/Anxitane Active ingredient L-Theanine Harmonese - Active ingredients Extracts of Magnolia officinalis and Phellodendron amurense (Relora ) 500 mg Honokiol (standardized) 9.5 mg Neutricks - Active ingredient Apoaequorin 5 mg Senilife - Active ingredients Phosphatidylserine 25 mg, Ginkgo Biloba extract 10 mg, Vitamin B mg,vitamin E 33.5 mg, Resveratrol (Grape Extract) 5 mg Zylkene - Active ingredient Casein, a protein in milk Adaptil and Feliway - Active ingredients synthetic copies of the pheromone released by mother dogs and cats from their mammary area after her puppies and kittens birth Melatonin - Active ingredient Melatonin, a hormone

12 NSAID (Non-steroidal anti-inflammatory drugs) RELEASE FORM This form releases Cary Street Veterinary Hospital and its employees from any liability that may arise from prescribing NSAIDs or other medications when the undersigned client declines annual or biannual blood work. NSAIDS help control inflammation and pain from arthritis, swelling, and fever. The work by blocking the production of prostaglandins, chemical produced by the body in the inflammatory process. Most patients tolerate NSAIDs approved for use in animals well when used correctly as prescribed. Side effects of NSAIDs may include loss of appetite, black tarry stools, vomiting, diarrhea, depression, and liver or kidney failure, or allergic reactions including hives, facial swelling, and itching. Examples of NSAIDs used in veterinary medicine: Rimadyl (carprofen), Metacam (meloxicam), Previcox (firocoxib), Deramaxx (deracoxib), Etogesic (etodolac), Zubrin (tepoxalin), Onsior (robenacoxib). Never give aspirin or corticosteroids (prednisone, dexamethasone) with an NSAID. A minimum of twice yearly bloodwork is recommended for all patients taking NSAIDs on a regular basis to assess liver and kidney function. o I agree to bloodwork every 6 months for monitoring of liver and kidney values while my pet is on chronic medications. I understand that I may change my decision at any time. o I decline bloodwork and have read the associated risks of administering NSAIDs and other medications. Owner/Caregiver signature Date

13 Comfort Kit We strive to prevent symptoms from occurring, but sometimes disease may progress more quickly or in unexpected ways. This emergency kit contains medications to manage unexpected symptoms in the case that you cannot reach us. All medications should be stored away from direct sunlight and out of the reach of children. 1. Pain crisis. If your pet s pain or discomfort escalates and they are not able to be comforted, please administer this injection subcutaneously. It contains hydromorphone and acepromazine, a strong opioid and a tranquilizer. It will last about 4-6 hours usually, and causes sedation. Some pets may experience brief nausea or vomiting with opioids, panting, or confusion. Please call us and let us know that you used this so we can make adjustments to our treatment plan. 2. Severe nausea or vomiting. If your pet s nausea is relentless and preventing them from becoming comfortable or if they are vomiting more than 2 or 3 times, please administer this injection subcutaneously. It is maropitant or cerenia. It will last for about 24 hours. Please call us and let us that you have used this medication so we can adjust your pet s treatment plan. 3. Seizures or anxiety/restlessness. If your pet experiences a seizure that lasts more than 3-4 minutes or is having more than one seizure in a 24 hour period, or is unable to relax or calm down and seems anxious or agitated, you can administer this medication rectally. It contains diazepam and will last about 2-4 hours. Some pets occasionally experience confusion or excitement from this medication, but most will be sleepy and relaxed. How to give a subcutaneous injection Giving your pet a injection/shot is much easier with help. The other person can restrain your animal and keep it calm while you perform the injection. Stay calm and speak in a soothing voice while giving a short petting session. During this, and other, petting sessions randomly pinch the loose skin around the neck area to get your pet used to what s coming next. With your non-dominant hand, pinch the loose skin between your thumb and forefinger. Hold the syringe with your dominant hand between your index and middle fingers with your thumb on the plunger. Angle the syringe at degrees with the bevel of the needle up. Quickly insert the needle and administer the contents. How to administer rectal medication Talk calmly and soothingly to your pet. It is helpful to have someone restrain your pet while you give the medication if possible. If your pet is conscious and interested in food, offering treats or peanut butter during the procedure is a helpful distraction. Spread the lubricant provided on the tip of the red rubber catheter. Insert the red rubber catheter into the rectum about 1-2 inches in cats and small dogs and 3-4 inches in larger dogs. Slowly depress the plunger to administer the drug. Gently withdraw the catheter from the rectum. PLEASE CALL US AT TO LET US KNOW YOU ARE USING ONE OF THESE MEDICATIONS.

14 DAILY HEALTH LOG Date: Concerns Time: Appetite Thirst Urination Defecation Mobility Happiness Medication Wound Care Pain Scale 0-Minimal 1-Mild 2-Mild to Moderate 3-Moderate 4-Moderate to Severe Date: Concerns Time: Appetite Thirst Urination Defecation Mobility Happiness Medication Wound Care Pain Scale 0-Minimal 1-Mild 2-Mild to Moderate 3-Moderate 4-Moderate to Severe Visit for more copies of the Daily Health Log, Quality of LIfe Scales and other resources.

15 Score 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: 0 to 10 (10 being ideal). Criterion 0-10 HURT - Adequate pain control & breathing ability is of top concern. Trouble breathing outweighs all concerns. Is the pet's pain well managed? Can the pet breathe properly? Is oxygen supplementation necessary? 0-10 HUNGER - Is the pet eating enough? Does hand feeding help? Does the pet 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 (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, but an animal with limited mobility yet still alert, happy and responsive can have a good quality of life as long as caregivers are committed to helping their pet.) 0-10 MORE GOOD DAYS THAN BAD - When bad days outnumber good days, quality of life might be too compromised. When a healthy human-animal bond is no longer possible, the caregiver must be made aware that 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 to continue with pet hospice (Pawspice). 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 book, Canine and Feline Geriatric Oncology: Honoring the Human-Animal Bond, Blackwell Publishing, Revised for the International Veterinary Association of Pain Management (IVAPM) 2011 Palliative Care and Hospice Guidelines. Reprinted with permission from Dr. Alice Villalobos & Wiley-Blackwell.

16 QoL Scale Introduction/Summary Alice Villalobos, DVM, DPNAP, a renowned veterinary oncologist, introduced Pawspice, a quality of life program for terminally ill pets. Pawspice starts at diagnosis and includes symptom management, gentle standard care and transitions into hospice as the pet nears death. Dr. Villalobos developed a scoring system to help family members and veterinary teams assess a pet s life quality, The HHHHHMM Quality of Life Scale. The five H s stand for: Hurt, Hunger, Hydration, Hygiene and Happiness. The two M s stand for Mobility and More good days than bad. The QoL scale is also a helpful decision making tool to assist pet lovers in the difficult process of making the final call for the gift of euthanasia to provide a peaceful and painless passing for their beloved pet. Available for download at QoL Scale Caption 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 book, Canine and Feline Geriatric Oncology: Honoring the Human- Animal Bond, Blackwell Publishing, Revised for International Veterinary Association of Pain Management (IVAPM) 2011 Hospice Statement. Reprinted with permission from Dr. Alice Villalobos & Wiley-Blackwell.

17 Additional Comments:

18 Canine Information and Products Argus Institute Counseling and Support Services- Helpful articlesargusinstitute.colostate.edu Pet Hospice Journal: free online Interactive Pet Hospice daily journal and Quality of Life Scale. pethospicejournal.com Visit our website for more information and links to all our handouts. How to Videos How to give your dog a pill How to give your pet a subcutaneous injection How to put eye drops or ointment in your pets eyes How to clean your dog's ears How to put medication in your dog's ears How to give subcutaneous fluids Brushing your dog's teeth How to trim your dog's nails How to collect a urine sample from a female dog ca/videos/collectingaurinespecimenfromyourdogfemale/ How to collect a urine sample from a male dog ca/videos/collectingaurinespecimenfromyourdogmale/

19 Online Stores Ramps and Stairs Non-slip Mats in/ Raised Bowls Harnesses Toe Grips Boots Braces Puppypads and Diapers Pet Strollers

20 Resources Emergency Veterinary Centers Dogwood Veterinary Emergency & Specialty Center-(804) W. Broad St Veterinary Emergency and Specialty Center (Carytown)- (804) W. Cary St Veterinary Emergency and Specialty Center (Midlothian)- (804) Colony Crossing Place, Midlothian, VA Animal Medical Center-(804) Fribble Way, Midlothian, VA Veterinary Referral and Critical Care- (804) Hockett Rd, Manakin-Sabot, VA Pet Cremation Services of Richmond, Ltd. Pet pick-up service-for direct cremation or burial- (804) Individual Counseling-Free for clients of Cary Street Veterinary Hospital VCU School of Medicine- The Center for Human-Animal Interaction- (804) 827-PAWS Social Workers Marion Brown, LCSW in Richmond- (804) Patterson Ave: Suite C Trish Mullen, LCSW in Chesterfield

21 Websites About Pet Loss Association for Pet Loss and Bereavement- Pet-Loss Supoort- Pet-Loss Grief Support Website- Pet Loss Hotlines Viginia Tech Pet Loss Support Hot-Line- (540) Iams Pet Loss Support Resource Center- (888) ASPCA National Pet Loss Hotline- (877) GRIEF10

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24 Pet Loss Resource List Pet Loss Books for Adults Anderson, M. (1994). Coping with Sorrow on the Loss of Your Pet, 2 nd Edition. Loveland, CO: Alpine Publications. Carmack, Betty J. (2003). Grieving the Death of a Pet. Minneapolis, MN: Augsburg Fortress. Kowalski, G. (1997). Goodbye, Friend: Healing Wisdom for Anyone Who Has Ever Lost a Pet. Walpole, NH: Stillpoint Publishing. Quintana, M. L., Veleba, S. L., King, H. G. (1998). It s Ok to Cry. Perrysburg, OH: Mariposa Press. Sife, W. (2005). The Loss of a Pet. Hoboken, NJ: Howell Book House. Wolfelt, A. D. (2004). When Your Pet Dies: A Guide to Mourning, Remembering and Healing. Fort Collins, CO: Companion Press. Pet Loss Books for Children Cochran, B. (2007). The Forever Dog. New York: HarperCollins. Mike and Corky do everything together until one day Corky is gone. Demas, C. & Hoyt, A. (2004). Saying Goodbye to Lulu. Little, Brown Books for Young Readers. After her dog dies, a little girl grieves but continues her life. Kramer, J. (2001). A Gift from Rex: Guiding Children through Life and Loss. Edina, MS: Beaver s Pond Press, Inc. Suggestions on how to facilitate a child s feelings while providing counsel to adults who are also grieving. Morehead, D. (1996). A Special Place for Charlee: A Child s Companion Through Pet Loss, Broomfield, CO: Partners in Publishing, LLC. Legitimizing the loss of a child s pet dog. Rogers, F. (1988). When a Pet Dies. New York: Family Communications, Inc. Talks to children about a pet dying. Viorst, J. (1971). The Tenth Good Thing About Barney. New York: Aladdin Paperbacks. When Barney, the cat, dies the family holds a funeral to remember him. Walsh, B. (2011). Sammy in the Sky. Somerville, MA: Candlewick Press. When Sammy, the hound dog s, life is cut short by illness, the girl s family keeps his spirit alive. Wilhelm, H. (1985). I ll Always Love You. New York: Dragonfly Books. Death of an old pet dog, Elfie. ***For additional pet loss books not listed, please search for pet loss books on amazon.com, visit the American Animal Hospital Association (AAHA) ( or see other websites listed below***

25 Other Books Concerning Loss for Children and Adults Grollman, E. A. (2011). Talking about Death: A Dialogue between Parent and Child. Boston: Beacon Press Hanson, W. (1997). The Next Place. Golden Valley, MN: Waldman House Press. James, J. W. & Friedman, R. (1998). The Grief Recovery Handbook, 20 th Anniversary Expanded Edition: The Action Program for Death, Divorce, and Other Losses including Health, Career, and Faith. New York: Harper Collins Publishers, Inc. Leeuwenburgh, E., and Goldring, E. (2008). Why Did You Die? Activities to Help Children Cope With Grief and Loss. Raincoast Books Mundy, M. (1998). Sad Isn t Bad: A Good-Grief Guidebook for Kids Dealing with Loss. St. Meinard, IN: Abbey Press. Audio Tapes Antinori, D. Journey Through Pet Loss. Basking Ridge, NJ: Yoko Spirit Publications. Butler, C., Hetts, S., & Lagoni, L. (1996). Friends for Life: Loving and Losing Your Animal Companion. Boulder, CO: Sounds True. Web Sites University of Tennessee Veterinary Social Work website with information about upcoming pet loss support group and other events as well as a link to our Pet Loss Support Facebook page. Lists of pet loss resources, Monday Candle Ceremony, list of pet loss books for children and adults, and links to other websites with pet loss resources. Pet Loss Support Page by Moira Anderson, M. Ed. Provides links to other sites with memorial ideas as well as pet loss support groups and counselors listed by state. A virtual memorial home for your departed baby. Also provides a place to submit your story or a poem, and links to other pet loss support resources. Memorial ideas for pets (and humans). Pet loss resources, Pet Hospice resources, and At Home Euthanasia resources for North Carolina, Tennessee, and Florida. Handcrafted tributes to the pets we loved. Memorial jewelry that has cremated remains infused into a beautiful glass bead pendant.

26 Adjusting to the Loss of a Pet Sandra B. Barker, Ph.D., LPC, NCC Professor of Psychiatry Director, Center for Human-Animal Interaction It is no surprise to pet owners to learn of research documenting the close emotional bond that rapidly develops between people and their pets. For most of us, our pets represent so much: a loyal companion, confidant, and loving family member. Our pets share our lives for years and support us in good times and bad. So when a pet dies, or is lost or stolen, many of us feel a deep sense of loss and our lives suddenly seem turned upside down. We find ourselves on an emotional roller coaster crying one minute, angry the next, and numb at other times. We grieve and grief is a normal reaction to a significant loss. And losing a beloved pet is certainly a significant loss. Unfortunately, many in our society don t understand the unique bond we share with our dogs. They make insensitive comments such as, "It was just a dog, get over it" or "You can always get another one". Such comments might be well intentioned, but clearly reflect a lack of understanding of the close and unique bond that exists between most owners and their pets. Grief is a normal, but individualized process. People grieve in their own way, based on their culture, beliefs, and past experiences with death and loss. For many, grief following the loss of a pet is very similar to grief following the loss of a family member or close friend. Owners often experience an initial period of shock to the news of the terminal illness or death of a pet, characterized by denial. In essence, our psychological defense systems kick in to protect us from the overwhelming news. Grief typically involves phases of feeling anger and guilt. This anger might be directed toward a veterinarian who was unable to save the pet, a careless driver who may have run over the pet, or the pet for dying and leaving the owner. Often the owners are angry at themselves for not being able to prevent the death and experience a great deal of guilt. Sadness is another phase typically experienced. The owner feels a deep void, an emptiness without the pet. Over time, if we allow ourselves to grieve, we reach a phase of recovery when we begin to reinvest our emotions and energy toward ourselves and other loved ones. A time when we remember more of the happy, special times shared with the deceased pet. In collaboration with participating veterinary hospitals and other animal-related facilities, telephone pet loss support is offered for clients of participating facilities. Support is provided by a licensed mental health professional with expertise in pet loss counseling. Cary Street Veterinary Hospital is participating in the Pet Loss Support Service through The Center for Human-Animal Interaction at VCU Health. All clients with pet loss issues, including terminally ill, deceased, or lost pets are welcome to call. Please call:

27 More Resources For those who don t have an understanding family member or friend to whom they can talk about their grief, and for others who need some additional support during this difficult time, there are a variety of pet loss resources available. A sample of these are listed below: Pet Loss Support Hot-lines (free service): IAMS offers a toll-free Pet Loss Support Resource Center at (888) , available Monday Saturday from 8:00 AM to 8:00 PM. They will connect callers with a veterinary college operating a pet loss hot-line at the time of the call. Virginia-Maryland Regional College of Veterinary Medicine in Blacksburg, Virginia also operates a Pet Loss Support Hot-Line. You can call and leave a voic message and your call will be returned on the following Tuesday or Thursday evening between 6:00 and 9:00 PM. You only pay for the initial call. Individual Pet Loss Counseling (pay for service): Most mental health professionals are sensitive to the pain and grief associated with the loss of a pet. The National Board for Certified Counselors maintains a national directory of certified counselors available to the public.

28 PET MEMORIAL WEBLINKS Pet Cremation Jewelry Pet Portraits Pet Urns Breed Specific Pet Urns Warm Wooly Pet Replicas Pet Cremains in Glass Pet Images in Marble Garden Memorials Memorial Lockets Engraved Stones