We, the founding members of the GRACE consortium, have nearly 50 years of combined experience in hospice care for animal companions. Each of our affiliated organizations, BrightHaven, Spirits in Transition and The Nikki Hospice Foundation for Pets, offer assistance to caregivers of animals at the end of life who are reaching out for support in their challenging endeavor.
Animals and their
Care at the
End of Life
We have found that human hospice principles are applicable and essential in animal hospice. If even one or more of these principles is not met, the effectiveness of the care given becomes so severely limited that euthanasia is almost inevitably the outcome. We extend our profound gratitude and utmost respect to the human hospice movement for creating and continuously expanding the essential body of knowledge that facilitates successful hospice care and now also allows hospice to become a valid option for animal caregivers.
1. Hospice support is made available to patients whose prognosis includes shortened life expectancy, when comfort care rather than the pursuit of curative treatment is desired by the patient and/or the family caregivers. Animal patients can, at times, make their care preferences understood, as discussed under 6 (below). More commonly, the family caregivers will make decisions for their animal according to what they feel is in its best interest. It is noteworthy that, at times, the prognosis of a terminal diagnosis and a severe health crisis that can be overcome cannot always be accurately made. This means patients may “graduate” from hospice insofar as the care originally provided for their overall well-being and comfort allows, at the very least, a temporary recovery.
2. In hospice it is recognized that death is a natural part of the cycle of life, not a failed medical event, and that dying does not have to be feared or avoided. The focus is “intensive caring instead of intensive care” without prolonging or hastening death. The goal of animal hospice is to achieve, with proper support, a comfortable and peaceful passing for the animal, thus often eliminating the need for euthanasia.
3. Hospice care for both humans and animals is palliative. This means that the patient receives comfort care, with an emphasis on pain control and symptom management, including the anticipation and prevention of potential symptoms, not just treating symptoms once they occur.
The hospice care team is actively and continuously involved in ongoing care, ensuring that current needs are met and future needs are anticipated based on the evolving condition of the animal and the concerns of the family. Contingency plans are established in advance to manage potential crises and condition changes at home, avoiding stressful and disruptive emergency clinic visits whenever possible.
4. Hospice care is comprehensive care with an emphasis on quality of life throughout the changes brought about by the progression of a life-ending disease. Dame Cicely Saunders, the founder of modern human hospice, stated “… we will do all we can, not only to help you die peacefully, but to live until you die.” She had also discovered that it is essential to address “total pain,” which she defined as encompassing not only physical issues but also emotional, social, and spiritual aspects.
Given that the unit of care in hospice includes not only the patient but also the patient’s family (see 6), any of the aspects of total pain that may become evident in either the patient or the family, or in both, will be addressed in full animal hospice services.
5. In human hospice, this comprehensive care is a coordinated and individualized plan provided by an interdisciplinary team of professionals and volunteers that continues to be adapted according to the changing needs of patients and their families. The team works under the supervision of a medical director and includes physicians, nurses, social workers, spiritual care providers, home health aides and volunteers, and often—though not always—complementary and alternative medicine providers.
In animal hospice, the above-described comprehensive care is impossible to deliver with veterinary support alone. Animal hospice is largely successful in creating the conditions necessary to let patients live out their lives fully and comfortably and then pass peacefully when ALL aspects of their needs are tended to and their families are fully supported as well.
Our aim is to form full interdisciplinary teams. Although currently rare, interdisciplinary teams are a core component for providing comprehensive hospice care. Practitioners are encouraged to explore the many options for establishing hospice teams, including (but not limited to) teams that are created through a veterinary clinic’s existing staff; external services, care providers or local referral networks that collaborate with one or more veterinary clinics; and teams created through cooperation with existing human hospice services.
6. The unit of care is the patient and his or her significant others (family, close friends). The hospice plan of care must attend to the patient’s and family’s values, beliefs, culture, and priorities. The focus of hospice care is on the whole individual who is experiencing a life-ending disease process, not just the disease alone. The patient and family are instrumental in determining the plan of care, and it is individualized according to their particular desires and needs and updated throughout the end-of-life process.
In animal hospice, it can be as challenging to perceive the patient’s wishes as it can be to understand those of dying human patients incapable of using language (for example, infants and young children who cannot yet verbalize). Generally, in such cases, the caregiver closest to the animal patient becomes his or her main spokesperson and decision-maker. Sometimes the animal may be very clear about its preferences. For example, just as a dying person, at a certain point, may request to discontinue the administration of intravenous fluids, a cat or dog in chronic renal failure may suddenly refuse subcutaneous fluids, despite having been very cooperative previously, for months. If changes in technique do not alleviate the issue and other available routes for hydration are also rejected, the patient’s preference is honored in hospice. This is done without automatically assuming that the refusal of fluids equals the absence of the patient’s will to live out the remainder of its life, however short that may be.
7. Human hospice care emphasizes patient and family autonomy, and they are the primary decision-makers throughout this process. It is the responsibility of the hospice team to provide the information, education, and referrals needed so that patient and family can make informed decisions that meet their goals, values, and beliefs. In animal hospice, all of this information will be communicated by the hospice team to the animal patient’s family caregiver.
8. Hospice services are available 24/7. Although proper advance preparation by the hospice team and the consistent availability of a comfort kit for home use minimize such occurrences, animal caregivers need to have access to verbal guidance throughout the night and on weekends. In-home visits are also provided, including for those cases when urgent medical support or euthanasia is necessary.
9. Both human and animal hospice provide continuity of care, whether patients are at home, in a facility, in foster care or in a hospital. The same services continue to be provided, no matter the environment.
A representative of the hospice team is available to accompany the patient to the hospital or emergency clinic and to visit the animal if it is hospitalized. The hospice team helps to facilitate communication between the family and the hospital or clinic staff where hospice may or may not be a common experience. It ensures that the animal continues to receive comfort care while avoiding unnecessary procedures and stress. The team also assists in assuring the family that their wishes regarding care are fully identified, understood and honored.
10. Human hospice regularly utilizes trained volunteer support as part of the hospice team; originally, it was completely based on volunteer support. Today, Medicare mandates that at least 5% of all direct patient contact be supplied by volunteers.
Using the services of trained volunteers in animal hospice is highly desirable. It can considerably reduce the emotional, social and spiritual burden as well as the time limitations and financial constraints put upon the main family caregiver. Having volunteers available can often make the difference between family members being able or unable to provide hospice care to their animal loved one.
The basic training volunteers receive in human hospice can serve well as a foundation for the training of animal hospice volunteers. In the absence of trained volunteers, two main sources remain for locating volunteer support:
a. Animal family caregivers may find a like-minded person among their relatives, friends, neighbors or others within their immediate community;
b. The service provider may be able to arrange for local support through a previous animal hospice client who is willing to assist others in similar endeavors.
11. In human hospice, Medicare provides bereavement services, which are mandated for up to one year after the patient’s death.
Providing comprehensive bereavement services is also critical in animal hospice. These can include wide-ranging forms of assistance, such as supporting clients who wish to hold a vigil, creating paw-prints, sending sympathy cards and/or pet loss support packets expressly created for post-hospice care, making follow-up telephone calls to the animal’s family, inviting the family caregivers to join pet loss support groups either during or after providing end-of-life care to their animal, holding memorial ceremonies, and in rare urgent cases, facilitating contact between a family caregiver and a specialized mental health professional (as is applicable to any provider of euthanasia or end-of-life care).
Caregivers can be provided with suggestions on how to best memorialize their animals, such as planting a special tree, shrub or flower in their yards; laying a pet memorial stone or marker in a designated area; or creating unique pet scrapbooks. Animal hospice providers also help animal family caregivers understand all available aftercare options, including locating pet cemeteries or crematories and informing them of other alternatives for burial or preservation. It is very important for animal hospice providers to ensure that any pet loss support resources they refer their clients to be up-to-date, time-sensitive, functional and well-managed and that hotline or helpline services provide either 24-hour assistance or—at the very least—consistent, reliable and educated help when it is needed.
These are the broad concepts that describe and define both human and animal hospice programs. They were developed by recognizing and serving the needs that are particular to dying patients and their families.
Animal hospice care providers must be knowledgeable about, and experienced in the different manners of death and options for death, including hospice-assisted natural death and euthanasia, and must be willing and prepared to provide care and support throughout the dying process. Even if no full team is available (as of yet), the consistent availability of a comfort kit (including a strong, fast-acting pain medication with a route of administration that does not rely on the patient swallowing it); 24/7 access to both verbal advice and in-home visits for either care or euthanasia; an awareness of, and the ability to adequately tend to the emotional, social and spiritual needs of the family; and access to bereavement services are minimum requirements for providing animal hospice care.