MIND MATTERS

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Special Challenges of End-of-Life Care
Franklin D. McMillan, DVM, DACVIM (SAIM) Best
Friends Animal Sanctuary Kanab, Utah
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END OF LIFE CARE

• In medical care, many of the considerations at
  the end of life differ considerably from those at
  other stages of a patients life
• The determination of when treatment is more harm
  than good
• The doctors duties to the patient
• The subject of the clinicians allegiance
• The emotional impact of the situation
• Questions regarding who best knows and decides
  the patients best interests
• The weighting of interests
• Whether euthanasia or natural death is the best
  death
• The absolute finality of decisions
• With the exception of the most obvious issue of
  euthanasia, the issues in human medicine and
  veterinary medicine are very similar
•  

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A COMMON GOALRIGHT?

• In veterinary medicine there is virtually no
  disagreement among all involved partiesthe pet
  owner/caregiver(s), the veterinarian, society,
  and, and (presumably) the animal patientas to
  what the overriding primary goal is in caring for
  an ill animal
• maximize quality of life
• And a generally strong consensus sees the single
  most important part of this goal
• relieve all relievable suffering
• In light of this remarkable uniformity of
  thought it seems surprising that there could be
  so much disagreement as to what is the right
  thing to do. If everyone is working toward the
  same goal, how can so much conflict develop in
  getting there?

4
The foremost responsibility in all animal care
To protect the animal against all of the hurts,
discomforts, and pains that life can inflict on
him
This protection extends from the animals birth
to his/her final moment of death
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OUR GOAL (figuratively)
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THE FOCUSComfort and Discomfort
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THE FOCUSComfort and Discomfort
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THE FOCUSComfort and Discomfort
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THE FOCUSComfort and Discomfort
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SOURCES OF DISCOMFORT

• PHYSICAL
• Hypoxia
• Pain
• Disease
• Nausea
• Toxicity
• Pruritus
• Cough
• Dizziness
• Thirst
• Hunger
• Full urinary bladder
• Constipation
• Temperature extremes

• EMOTIONAL
• Fear
• Anxiety
• Boredom
• Loneliness/Social isolation
• Separation anxiety/distress
• Grief
• Depression
• Frustration
• Anger
• Helplessness
• Hopelessness

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Comfort-Discomfort Continuum
comfort
DISCOMFORT
Goal of behavior
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Comfort-Discomfort Continuum
DISCOMFORT
comfort
SUFFERING
SUFFERING
Goal of behavior
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Comfort and discomfortin everyday animal life
What animals spend their lives doing Seek
comfort and avoid discomfort The Basic Rule of
Living
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Comfort in Health Care

• Why is health desirable?
• Disease creates discomfort
• Relief of discomfort leading reason people
  seek medical care
• dis-ease
• dis- (reversal) and aise (ease)
• The dis-eased body is without comfort
• Restoring health restores comfort

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Comfort-Discomfort Continuum
DISCOMFORT
comfort
SUFFERING
Goal of behavior
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Comfort-Discomfort Continuum
DISCOMFORT
comfort
SUFFERING
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Comfort in Health Care

• The animal brought to the veterinarian for
  illness or injury desires one thing comfort

• Animals dont care about health they only care
  about how they feel. They (and we) just want to
  feel good. And they dont care if the unpleasant
  feelings are health-related or from some other
  cause.

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The experience of discomfort(pain, distress,
suffering)A Schematic View
STIMULUS (CAUSE)
BRAIN/MIND
TRANSMISSION FROM SENSORY PERCEPTION TO BRAIN
SENSORY PERCEPTION
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Protecting the animal from discomfort
BLOCK THE EXPERIENCE OF DISCOMFORT

• 1st At the cause restore health, remove
  sources of fear, etc.
• 2nd At the origin NSAIDS, H2 blockers
• 3rd Between the source and the mind
• Block the transmission before it reaches the mind
  to become an experience -- epidural, nerve
  blocks, acupuncture
• 4th At the mind drugs (e.g., narcotics,
  anxiolytics, antidepressants, antiemetics)

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The experience of discomfort(pain, distress,
suffering)A Schematic View
STIMULUS (CAUSE)
BRAIN/MIND
TRANSMISSION FROM SENSORY PERCEPTION TO BRAIN
SENSORY PERCEPTION
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Protecting the animal from discomfort
BLOCK THE EXPERIENCE OF DISCOMFORT

• 1st At the cause restore health, remove
  sources of fear, etc.
• 2nd At perception NSAIDS, H2 blockers
• 3rd Between the source and the mind
• Block the transmission before it reaches the mind
  to become an experience -- epidural, nerve
  blocks, acupuncture
• 4th At the mind drugs (e.g., narcotics,
  anxiolytics, antidepressants, antiemetics)

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The experience of discomfort(pain, distress,
suffering)A Schematic View
STIMULUS (CAUSE)
BRAIN/MIND
TRANSMISSION FROM SENSORY PERCEPTION TO BRAIN
SENSORY PERCEPTION
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Protecting the animal from discomfort
BLOCK THE EXPERIENCE OF DISCOMFORT

• 1st At the cause restore health, remove
  sources of fear, etc.
• 2nd At perception NSAIDS, H2 blockers
• 3rd Between perception and the mind
• Block the transmission before it reaches the mind
  to become an experience -- epidural, nerve
  blocks, acupuncture
• 4th At the mind drugs (e.g., narcotics,
  anxiolytics, antidepressants, antiemetics)

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The experience of discomfort(pain, distress,
suffering)A Schematic View
STIMULUS (CAUSE)
BRAIN/MIND
TRANSMISSION FROM SENSORY PERCEPTION TO BRAIN
SENSORY PERCEPTION
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Protecting the animal from discomfort
BLOCK THE EXPERIENCE OF DISCOMFORT

• 1st At the cause restore health, remove
  sources of fear, etc.
• 2nd At perception NSAIDS, H2 blockers
• 3rd Between perception and the mind
• Block the transmission before it reaches the mind
  to become an experience -- epidural, nerve
  blocks, acupuncture
• 4th At the mind drugs (e.g., narcotics,
  anxiolytics, antidepressants, antiemetics)

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The experience of discomfort(pain, distress,
suffering)A Schematic View
STIMULUS (CAUSE)
BRAIN/MIND
TRANSMISSION FROM SENSORY PERCEPTION TO BRAIN
SENSORY PERCEPTION
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Things that prevent the successful relief of
discomfort
BUT we arent always successful in blocking the
discomfort

• Limitations of medical knowledge
• Medical science
• Individual
• Equipment, facilities
• Financial limitations

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Protection from discomfort
WHEN WE CANT STOP THE DISCOMFORT FROM REACHING
THE MIND

• PUT THE MIND IN A PROTECTED STATE
• Interrupt consciousness
• Temporary ? general anesthesia
• Permanent ? euthanasia

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Comfort-Discomfort Continuum
Alleviating discomfort
DISCOMFORT
SUFFERING
comfort
Goal of behavior
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EMOTIONAL SUFFERING
When MENTAL Health Cannot Be Restored

• Emotional vs physical pain
• Trauma victims with deep emotional scars some
  simply can never regain a life of emotional
  comfort
• Not a behavior problem

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EMOTIONAL SUFFERING
When MENTAL Health Cannot Be Restored

• Emotional vs physical pain
• Trauma victims with deep emotional scars some
  simply can never regain a life of emotional
  comfort
• Not a behavior problem

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When Comfort Cannot Be Restored

• When all available tools fail to adequately
  relieve discomforts
• Euthanasia
• The elimination of discomfort in the only
  effective way left

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OUTCOMES AND OBJECTIVESOF EUTHANASIA

• Euthanasia has 2 outcomes
• 1. Ending discomfort
• 2. Ending life

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OUTCOMES AND OBJECTIVESOF EUTHANASIA

• Euthanasia has 2 outcomes
• 1. Ending discomfort
• 2. Ending life

• We do not know how to separate these outcomes for
  many medical disorders
• Cant obtain the outcome we want without also
  getting the one we dont want
• Technological advancements uncouple the two we
  can choose only the one we want

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Normal canine hip
Severe bilateral hip dysplasia with secondary
osteoarthritis
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• Euthanasia has 2 outcomes
• 1. Ending discomfort
• 2. Ending life

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Euthanasia is not an act to end a life, its an
act to end discomfort
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Quality of life and euthanasia
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The Scales Model of Quality of Life

• Quality of life is represented by a balance of
  the pleasant and unpleasant feelings of life over
  time

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Quality of Life
PLEASANT FEELINGS
UNPLEASANT FEELINGS
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Quality of life as disease progresses

• The scales will tip increasingly toward
  unpleasant feelings

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QOL
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QOL
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QOL
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Euthanasia how do we determine when its time?

• Is there a right time?
• If so, how do we know weve reached it?
• What would determine that it is too soon?
• too late?
• If we use QOL as our determining factor, how do
  we characterize QOL at the point where it is time
  for euthanasia?
•  

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Youll just know.
?

• Look at Emma with your questions and she will
  tell you and communicate in some way when the
  time is right.
• Owner How will I know when the time comes? What
  do I do? I cant go through this. The answer to
  the first question should rest with the pet.
  Advise the family that their old pal will give
  them a clear sign. The signs may be physical,
  such as unresponsive vomiting, uncontrollable
  diarrhea, dyspnea, crying, and loss of mentation
  or slipping into a moribund state When
  counseling caregivers, you might say, Look into
  Stormys eyes and he will tell you when its the
  right time for him to go. The message will be
  clear and you will know
• Veterinarians are frequently asked, When is the
  right time to euthanize my beloved pet? How will
  I know? I tell them, One day, you will just
  know it is the right time because your pet will
  tell you with a look or a gesture, a sign or a
  series of bad days.

?
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Youll just know.
I will?

• Will you see a SIGN?
• How will you recognize a sign?
• What will you do when you see a sign?
• Anorexia Patients with inappetance often need
  to be hand or force fed to maintain a proper
  nutritional status.

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Using quality of life to determine when it is
time

• Quality of life scales
• When scales tip toward unpleasant feelings and
  there is nothing more the animal or we can do to
  tip scales back toward pleasant
• Quality of life questionnaires

?
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HURT
HUNGER
HYDRATION
HYGIENE
HAPPINESS
MOBILITY
MORE GOOD DAYS
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PET QUALITY OF LIFE EVALUATION 1. List all the
things during you pets life that have given him
pleasure, such as going on walks, interacting
with people or animals, playing, being petted,
eating, rolling in the grass, and exploring
objects and places. How many of these things is
your pet currently getting meaningful pleasure
from? ______ (1a) How many of these things was
your pet getting meaningful pleasure from when he
was feeling his best, physically and emotionally?
______ (1b) 2. List all the activities and
experiences during you pets life that feel he
would regard as fun. Examples include playing
games, chasing butterflies, playful pouncing on
things or animals, digging holes, and running
through the water at the beach. (Note that all of
the things on this list give pleasure and thus
would also have been on your list in Question 1.
However, this list will be considerably shorter
since there are many things that bring pleasure
but are not generally considered fun, such as
curling up on your lap, getting a massage, and
lying on cold surfaces.) How many of these things
is your pet currently experiencing as fun? ______
(2a) How many of these things was your pet
experiencing as fun when he was feeling his best,
physically and emotionally? ______ (2b) 3. On a
scale of 1 to 10, 1 being unbearably severe
discomfort (extreme distress, suffering) and 10
being complete comfort (no discomforts), what do
you judge your pets comfort level to be? (For
reference, a discomfort is any unpleasant feeling
such as nausea, sickly feelings, difficulty
breathing, pain, itchiness, hunger, fear,
separation anxiety, general anxiety, loneliness,
boredom, anger, and depression). ______
4. On a scale of 1 to 10, 1 being no enjoyment
and 10 being the highest possible level of
enjoyment, what do you consider your pets
current enjoyment of life? ______ 5. Imagine
that you are a pet animal of the same species as
your pet and that you have the best quality of
life you can imagine a member of this species
having. On a scale of 1 to 10, 1 being extremely
unwilling and 10 being extremely willing, how
willing would you be to exchange your life for
the life your pet is currently living?
______ CALCULATIONS Add 1a 2a _______
(This is A) Add 1b 2b _______ (This is B) Now
subtract B - A _______ (This is Y) Add up the
answers for questions 3, 4, and 5 _______ (This
is X) SCORING INTERPRETATION Note This is a
nonscientific interpretation of the quality of
life score. This test has not been validated by
scientific methods. The highest score is 30, and
the lowest is 0. 26-30 Very good to excellent
quality of life 21-25 Good quality of
life 16-20 Fair quality of life 11-15 Low
quality of life 0-10 Poor quality of life
2. List all the activities and experiences during
you pets life that feel he would regard as fun.
Examples include playing games, chasing
butterflies, playful pouncing on things or
animals, digging holes, and running through the
water at the beach. (Note that all of the things
on this list give pleasure and thus would also
have been on your list in Question 1. However,
this list will be considerably shorter since
there are many things that bring pleasure but are
not generally considered fun, such as curling up
on your lap, getting a massage, and lying on cold
surfaces.) How many of these things is your pet
currently experiencing as fun? ______ (2a) How
many of these things was your pet experiencing as
fun when he was feeling his best, physically and
emotionally? ______ (2b)
From McMillan FD, Lance K. Unlocking the Animal
Mind, Rodale, 2004.
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PET QUALITY OF LIFE EVALUATION 1. List all the
things during you pets life that have given him
pleasure, such as going on walks, interacting
with people or animals, playing, being petted,
eating, rolling in the grass, and exploring
objects and places. How many of these things is
your pet currently getting meaningful pleasure
from? ______ (1a) How many of these things was
your pet getting meaningful pleasure from when he
was feeling his best, physically and emotionally?
______ (1b) 2. List all the activities and
experiences during you pets life that feel he
would regard as fun. Examples include playing
games, chasing butterflies, playful pouncing on
things or animals, digging holes, and running
through the water at the beach. (Note that all of
the things on this list give pleasure and thus
would also have been on your list in Question 1.
However, this list will be considerably shorter
since there are many things that bring pleasure
but are not generally considered fun, such as
curling up on your lap, getting a massage, and
lying on cold surfaces.) How many of these things
is your pet currently experiencing as fun? ______
(2a) How many of these things was your pet
experiencing as fun when he was feeling his best,
physically and emotionally? ______ (2b) 3. On a
scale of 1 to 10, 1 being unbearably severe
discomfort (extreme distress, suffering) and 10
being complete comfort (no discomforts), what do
you judge your pets comfort level to be? (For
reference, a discomfort is any unpleasant feeling
such as nausea, sickly feelings, difficulty
breathing, pain, itchiness, hunger, fear,
separation anxiety, general anxiety, loneliness,
boredom, anger, and depression). ______
4. On a scale of 1 to 10, 1 being no enjoyment
and 10 being the highest possible level of
enjoyment, what do you consider your pets
current enjoyment of life? ______ 5. Imagine
that you are a pet animal of the same species as
your pet and that you have the best quality of
life you can imagine a member of this species
having. On a scale of 1 to 10, 1 being extremely
unwilling and 10 being extremely willing, how
willing would you be to exchange your life for
the life your pet is currently living?
______ CALCULATIONS Add 1a 2a _______
(This is A) Add 1b 2b _______ (This is B) Now
subtract B - A _______ (This is Y) Add up the
answers for questions 3, 4, and 5 _______ (This
is X) SCORING INTERPRETATION Note This is a
nonscientific interpretation of the quality of
life score. This test has not been validated by
scientific methods. The highest score is 30, and
the lowest is 0. 26-30 Very good to excellent
quality of life 21-25 Good quality of
life 16-20 Fair quality of life 11-15 Low
quality of life 0-10 Poor quality of life
5. Imagine that you are a pet animal of the same
species as your pet and that you have the best
quality of life you can imagine a member of this
species having. On a scale of 1 to 10, 1 being
extremely unwilling and 10 being extremely
willing, how willing would you be to exchange
your life for the life your pet is currently
living? ______
From McMillan FD, Lance K. Unlocking the Animal
Mind, Rodale, 2004.
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Timing for euthanasia

• There are only 3 times when euthanasia can be
  done
• Too early
• Too late
• The exact right time

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Timing for euthanasia
There is no exact right time. And even if
there were, we could never know when it was
Natural death
Time line
TOO EARLY
TOO LATE
Exact right time
That leaves only too early or too late
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Timing for euthanasia
Your duty do everything humanly possible to
protect the animal from discomforts, hurts, and
unpleasantries of life This means doing
everything possible to prevent it from being too
late
Natural death
TOO EARLY
TOO LATE
YOUR DUTY PROTECT AGAINST
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DIFFICULTIES INVOLVED IN END-OF-LIFE CARE
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Difficulty 1Medical futility and Overtreatment

• The issue of overtreatment in human medicine is
  the concept of medical futility
• Overtreatment is referred to as futile treatment
• While virtually no one disputes that there is a
  time in the progression of many illnesses that
  treatment is no longer effectivethat is, becomes
  futilethere continues to be vigorous debate on
• Who has the qualifications and the right to
  determine the criteria on which the utility or
  futility of a treatment should be judged
• How to know whether certain treatments are futile
  unless they are tried

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DEFINING MEDICAL FUTILITYQUESTIONS
?

• As disease progresses and efficacy of treatment
  diminishes, what best represents the cut-off to
  label treatment futile?
• How low do the odds of responding to treatment
  have to be to label the intervention futile? 1 in
  10?, in 100?, in 1000?, in a million?

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DEFINING MEDICAL FUTILITYTHE HUMAN LITERATURE

• WHEN IS MEDICAL FUTILITY REACHED?
• THE POINT AT WHICH
• there is an unacceptably low chance of achieving
  a therapeutic benefit for the patient
• the patient is no longer able to achieveat a
  minimuma life other than complete preoccupation
  with his distress, illness, or disability
• a life beneficial to the patient is no longer
  reasonably possible
• FUTILE TREATMENT
• LIFE-SUSTAINING CARE THAT IS HIGHLY UNLIKELY TO
  RESULT IN MEANINGFUL SURVIVAL

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DEFINING MEDICAL FUTILITY DIFFERENCE VETERINARY
AND HUMAN

• Human Overtreatment is defined as and equated
  to futile treatment (treatment beyond point of
  medical futility)
• Veterinary Overtreatment not necessarily tied
  to futility If a treatment could help medically
  (thus is not futile) but harm emotionally, then a
  treatment could be OVERTREATMENT WITHOUT BEING
  FUTILE
• Example Milani (1995) describes a common
  problem
• if the Whitmans tell Dr. Fiedler they dont
  want to try another treatment because Seymour now
  runs from them fearing more medication

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Why do caregivers overtreat?
?

• Why does a pet owner choose a course of action
  that is not, in the veterinarians judgment, in
  the animals best interests?

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WHY DO PEOPLE OVERTREAT? IN HUMAN MEDICINE

• Theological beliefs
• Family members are not ready to lose the people
  they love
• Family members have confused medical persistence
  with genuine devotion and caring. Some parents
  think that halting treatment means they no longer
  care for their child. The result is that they
  often insist on continued aggressive treatment,
  feeling anything less would make them bad
  parents.

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WHY DO PEOPLE OVERTREAT? IN VETERINARY MEDICINE

• Inability or unwillingness to let go
• Theological/religious God gives life, only
  God can take it away
• Unrealistic optimism and expectations or hope in
  face of extremely negative odds
• Inability or unwillingness to see suffering
• Confusing treating with caring seeing
  cessation of treatment as lack of caring or
  abandonment
• Desire for absolute certainty that they did
  all they could wanting to leave no stone
  unturned

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How hopeful is too hopeful? How pediatric
physicians respond to unreasonably optimistic
parents

• Some parents are unreasonably hopeful (we
  havent given up hope), insisting on aggressive
  therapy for their children even when such
  treatment would cause additional suffering with
  little or no chance of success
• Parents who see stopping treatment to as a form
  of abandonment and makes them bad parents should
  be clearly told that good, loving people can
  still recognize the futility of treatment and
  agree to its withdrawal

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Difficulty 1Medical futility and Overtreatment
UNRESOLVED
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Difficulty 2What should be done when quantity
and quality of life are in conflict?

• It is believed by many that medical care
  decisions should focus solely on improving the
  animals quality of life
• Pet owners frequently express this sentiment when
  their pet has a terminal condition I just care
  about his quality of life.
• BUT this approach is challenged in the many
  situations in which a decision may permit a
  greater QUANTITY of life but at a lower QUALITY
  of life
• People, for themselves, will elect to undergo
  renal dialysis or aggressive multi-modal
  treatment of malignant canceroften involve
  accepting a lower QOL in order to live longer 

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TRADING QUALITY FOR QUANTITYAccepting a lower
QUALITYin exchange forgreater QUANTITY
WHEN QUANTITY AND QUALITY OF LIFE ARE IN CONFLICT
IN VETERINARY MEDICINE
TRADING QUANTITY FOR QUALITYAccepting a
shortened lifein exchange forhigher QUALITY
WHAT DO THESE TRADE-OFFS LOOK LIKE?

• Feeding less palatable diet to delay disease
  progression
• Unpleasant effects of chemotherapy
• Repeated transfusions for FeLV-related non
  regenerative anemia

• Feeding a renal failure cat a standard diet that
  he likes
• Chronic corticosteroid treatment for severely
  pruritic condition or asthma

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TRADING QUANTITY FOR QUALITY
QOL
TIME
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TRADING QUALITY FOR QUANTITY
QOL
TIME
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WHAT HAPPENS WHEN THE CHOICE FOR YOUR PATIENT IS
BETWEEN QUALITY AND QUANTITY OF LIFE?
DO YOU WANT YOUR PET OWNER TO CHOOSE QUALITY?
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Consider this conversation
PET OWNER
VETERINARIAN
The tests tell us that Little String Bean has
diabetes. Hes going to need to be treated with
insulin.
Thats going to mean that I have to poke him with
a needle every day?
Well, yes. Actually, twice a day. But its very
little trouble for either one of you.
But injections hurt. I dont like getting
injections.
Its a very minimal discomfort and it will
allow him to live many more years.
I dont know, doctor. To me, quality of life is
everything. Getting shots every day will lower
his quality of life, wont it?
Well, only a teeny bit. The benefits of a much
longer life far outweigh this minor drawback.
To you, maybe. I just cant let String Beans
quality of life be overshadowed by anything else.
If the only treatment is insulin injections, Im
going to have to put him to sleep.
Have you lost your mind? Quality of life isnt
THAT important, for Gods sake!
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QUESTIONSWhen quantity and quality of life are
in conflict in veterinary medicine
DECISIONS ARE MADE IN BOTH DIRECTIONS EVERY DAY

• SO QUALITY OF LIFE IS NOT ALL-IMPORTANT AFTER
  ALL WHICH DIRECTION SHOULD YOU DECIDE IN?
• How do we know which direction the animal would
  favor?
• Longer life at lower quality?
• Or happier life of shorter duration?
• At what point does the trade-off change from a
  net benefit to a net detriment for the animal?
• TRADING QUANTITY AND QUALITY
• WHAT DOES THIS MATH LOOK LIKE?

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EXCHANGING QUALITY AND QUANTITY
?
HOW IS THIS CALCULATION MADE?
QOL
TIME
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When quantity and quality of life are in conflict
in veterinary medicine

• Rollin (2007)
• we have no reason to believe that an animal can
  grasp the notion of extended life, let alone
  choose to trade current suffering for it 

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Difficulty 2What should be done when quantity
and quality of life are in conflict?
UNRESOLVED
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Difficulty 3 Acting in the patients best
interests How accurate are doctors in judging
patients interests, preferences,desires, and
QOL?

• A multitude of studies in human medicine have
  studied the accuracy of health care professionals
  in judging patients self-stated preferences for
  life-extending care, pain, and QOL.
• In light of their findings, what weight should
  veterinarians assessments of their patients
  interests carry? 

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HOW ACCURATE ARE SURROGATE RATERS IN KNOWING WHAT
THE PATIENT WANTS?

• 2006 study Patient treatment preferences
  compared to spouses substituted judgments in
  continuing dialysis Patients preferences and
  spouse judgments were only moderately
  correlated.
• Research consistently indicates that surrogate
  decision makers are NOT ABLE TO PREDICT A
  PATIENTS TREATMENT PREFERENCES AT LEVELS OF
  ACCURACY BEYOND THOSE EXPECTED BY CHANCE ALONE
  even interventions aimed at communicating
  patients values to surrogates do not promote
  surrogate accuracy

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HOW ACCURATE ARE SURROGATE RATERS IN KNOWING WHAT
THE PATIENT WANTS?
SOME STUDIES SHOW PATIENTS WANT LESS CARE THAN
THEIR FAMILIES WANTED FOR THEM
OTHER STUDIES SHOW PATIENTS WANT MORE CARE THAN
DOCTORS BELIEVED THEY DID
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Difficulty 3 Acting in the patients best
interests How accurate are doctors in judging
patients interests, preferences,desires, and
QOL?
UNRESOLVED
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Difficulty 4How effective are veterinarians in
relieving discomfort, distress, and suffering in
patients with terminal diseases?

• There is a broad consensus that the priority for
  end-of-life care in veterinary medicine is the
  relief of distress and suffering
• Our ability to achieve this goal is the most
  important element in end-of-life decisions
• HOW GOOD ARE WE AT IT?

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As long as hes not in pain and other
outdated concepts

•  Relief of one type of sufferingphysical
  painreceives the most attention in veterinary
  medicine
• Two major studies of the practice of euthanasia
  in people in the Netherlands looked at the
  reasons why patients request euthanasia
• Both studies found that pain was the sole reason
  in only 5 of patients and for over 50 pain
  played no role in their decision
• THUS
• (1) pain meds would have very limited ability to
  help MOST who desire euthanasia, and
• (2) even 100 effective pain control would leave
  MOST patients with their reasons to still desire
  euthanasia.
• Many other forms of distress and suffering occur
  in terminal illnesses, including dyspnea, the
  sense of suffocation, struggling for breath,
  sickness feelings, fever, toxic feelings (e.g.,
  uremic renal failure), nausea and vomiting,
  loneliness, anxiety, and fear  

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HOW EFFECTIVE ARE WE IN RELIEVING SUFFERING IN
TERMINAL ILLNESSES?OPINIONS FROM THE HUMAN FIELD

• Timothy Quill family physician and professor at
  University of Rochester medical school article
  in New England Journal of Medicine Death and
  dignityA case of individualized decision making
  (1991)
• Society has been shielded from the real truth
  about the degree of suffering that people often
  undergo in the process of dying. Suffering can be
  lessened to some extent, but in no way eliminated
  or made benign
• Although I know we have measures to help control
  pain and lessen suffering, to think that people
  do not suffer in the process of dying is an
  illusion. Prolonged dying can occasionally be
  peaceful, but more often the role of the
  physician is limited to lessening but not
  eliminating severe suffering.
• I wonder how many families and physicians
  secretly help patients over the edge into death
  in the face of such severe suffering.

85
HOW EFFECTIVE ARE WE IN RELIEVING SUFFERING IN
TERMINAL ILLNESSES?
ABOUT HUMANS OR ANIMALS?
euthanasia concerns patients whose lives, while
they are dying, are filled with severe and
unrelievable pain, and for whom euthanasia is the
only release from their otherwise prolonged
suffering and agony. This argument from mercy has
always been the strongest argument for euthanasia
in those cases to which it applies. But how often
are patients forced to undergo untreatable agony
which only euthanasia could relieve? It is
crucial to distinguish those patients whose pain
could be adequately relieved with modern methods
of pain control, though in fact it is not, from
those whose pain is relievable only by death.
(Brock 1995)
86
Difficulty 4How effective are veterinarians in
relieving discomfort, distress, and suffering in
patients with terminal diseases?
UNRESOLVED
87
Difficulty 5Is a natural death beautiful?

• We just saw that we are not fully capable of
  relieving all suffering during the dying process
• Is there such a thing as a beautiful natural
  death?
• Natural deaths Should veterinarians encourage,
  discourage, or stay neutral on the matter?

88
Euthanasia versus natural deathSome questions

• As terminal illness causes progressive increase
  in discomforts, is there any difference in our
  role of protector in terminal illness versus
  nonterminal illness?
• Is our duty to relieve discomfort any less
  strong near death than any other time?
• Does the animal have any less desire to be rid
  of the discomforts in terminal illness than those
  during any other time in life?

89
Euthanasia versus natural deathSome questions

• Does death have special meaning, significance, or
  symbolism for animals? Does the animal have a
  concept of death that outweighs his desire to be
  rid of his discomfort and suffering? Is it the
  animals or the humans view of life and death
  that prevents the animal from being relieved of
  his discomfort, and does it matter?
• If a natural death resulted in any greater degree
  of suffering than a euthanasia death, what would
  justify this greater suffering?

90
Its not all bad
Last Rights Rescuing the End of Life from the
Medical System Stephen P. Kiernan It may sound
bizarre, but it is true There is such a thing as
a beautiful death. it is the promise and the
potential made possible by gradual dying. There
is such a thing as a beautiful death. (2006)
91
Difficulty 5Is a natural death beautiful?
PARTIALLY RESOLVED
92
Difficulty 6 Is palliative and hospice care
beneficial to animals with terminal illness?

• HOSPICE is a philosophy and program of care that
  addresses the physical, emotional, and spiritual
  needs of the terminally ill person and his
  family. Hospice care emphasizes palliative care
  and supportive services rather than cure-oriented
  therapies and interventions.
• Hospice is not about surrender or passivity or
  hurrying death along it is a vigorous, active
  effort to make the quality of a persons life as
  optimal as possible for as long as possible

• WHAT IS HOSPICE CARE?

93
ANIMAL HOSPICE
THE GOOD

• The hospice philosophy places the patient at the
  center of care
• Hospice strives to deliver the dying experience
  the patient wants with as little of what they
  dont want as is possible
• The guiding premise of hospice is that an
  individuals needs at the ends of his or her life
  are much more than medicalthey are emotional,
  psychological, and more
• Hospice also attends to the sick persons
  family, their fears, challenges, and grief. Not
  only is the family benefited, but by them feeling
  stronger and more supported the patients
  experience with his human family can be of higher
  quality

94
ANIMAL HOSPICE
THE BAD

• Physician Elisabeth Kubler-Ross proposed a now
  well-known 5-stage grief process for those facing
  impending or recent death of a loved one or
  companion Denial, Anger, Bargaining, Depression,
  and Acceptance. Veterinarian Myrna M. Milani
  (1995) has written that pet owners may get stuck
  at one stage in the process such as denial
  and these clients often try to buy time and
  will deny a patients illness right up until the
  day the animal dies
• Descriptions of human hospice care when people
  in hospice care enter their lives final stages,
  they are not abandoned. They continue to receive
  care up to and beyond their last breath This
  view of hospice carean almost beautiful picture
  of pleasant passing awayis what presents the
  risk for pet owners to choose it to avoid
  euthanasia Why choose euthanasia when this
  wonderful alternative exists?
• Can the hospice option be a refuge for deniers
  and hanger-onners?

95
Difficulty 6 Is palliative and hospice care
beneficial to animals with terminal illness?
PARTIALLY RESOLVED
96
?
Questions?
97
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