Recommended Nomenclature of Services for Animal End-of-Life Care
The purpose of this document is to clarify the terminology used in end-of-life veterinary care in order for consumers of veterinary services to be properly informed about the services they can expect to receive from veterinarians advertising these options.
I. MOTIVATION FOR CORRECT USE OF TERMINOLOGY ENCOMPASSING END-OF-LIFE SERVICES
All veterinarians engaging in end-of-life care should be informed as to why it is so crucial to apply terminology correctly when naming a business or service.
Professional veterinary end-of-life care is an emerging field and terminology has repeatedly been applied in an indiscriminate manner by veterinarians offering and advertising these services. The inaccurate use of terms has created several undesirable consequences, including confusion among consumers of such services and a misunderstanding within the general public since improper use of terminology often contradicts the current understanding of existing services such as human hospice. To address this situation, the GRACE Consortium proposes that the veterinary profession adopt standardized wording of end-of-life services as defined in this document.
In human medicine, specific minimum requirements are expected to be met before a service qualifies as a hospice service, and the public has a reasonable expectation of an equivalent systematized approach in veterinary medicine. For example, it would be inappropriate for a veterinarian who offers in- home euthanasia, but not twenty-four-hour emergency access to in-home palliative care such as pain control, to advertise a hospice service.
Use of proper terminology supports individual veterinarians’ choices as to how and to what extent they wish to offer end-of-life care and enables veterinarians to refer to another clearly identified end-of-life service provider, if necessary, to meet the needs of specific clients.
Arguably, one of the most misused terms in the veterinary profession is the term “hospice” in reference to what is becoming an increasingly important and emerging field in the profession. The template for animal hospice has already been forged by human hospice providers and certain basic precepts should be consistent within both groups.
The term “end-of-life care,” which is an umbrella term, is not equivalent to the term “hospice,” which is a specific form of end-of-life care. Hospice is already familiar to many people with its basic premise of providing comfort care to the terminally ill until they die in their own time, while aiming to neither postpone nor hasten death.
In veterinary medicine, the vast majority of caregivers seeking animal hospice services remain open to employing euthanasia if that is the only effective means to relieve suffering. However, caregivers can feel pressured or rejected when veterinary providers suggest euthanasia because they themselves are unprepared to meet the more intensive medical needs of terminally ill animals in a different way. This can result in a complete loss of medical care for the animal at a time likely requiring extensive care—which is contrary to the veterinary profession’s commitment to reduce suffering in animals. This inevitably also increases the stress experienced by the caregivers.
As with human hospice, an inherent feature of animal hospice care is to view the patient’s will to live as paramount, including the recognition that even in the presence of considerable discomfort, that will to live often remains present. Great discomfort can temporarily override that inherent will, only to resurface as soon as the appropriate palliative care measures have taken effect.
Additionally, the animal hospice provider must understand the natural changes in cognition and behavior that are unique to the dying process. These symptoms are easily misconstrued and are often inappropriately interpreted as the loss of a will to live.
Furthermore, the hospice provider must be grounded in the intrinsic ability to prepare interested caregivers for their encounter with the dying process and to help them properly support their animals through the end of life. This last part of life with its unique symptoms may be of value for the dying individual as well as for its family. Many caregivers who have chosen to give this type of care report dealing with their anticipated grief far more easily after a hospice-supported natural death.
The wish to provide the same level of high-quality care at the end of life to an animal family member as one would to a human relative is consistent with our ever-increasing understanding of the depth and strength of the human–animal bond. Yet, caregivers seeking an at-home, hospice-supported death for their animal can also still be viewed as inhumane by their social circle and often by veterinarians. This paradoxical reaction to a nonhuman animal’s dying process has further been perpetuated by the veterinary profession, which has traditionally used the changes normally encountered in the dying process, such as lack of appetite, as the deciding factor for euthanasia, promoting it as the main, if not the only compassionate and correct choice to make.
In the face of the rising demand for fully integrated hospice care as an option for animals, this view is outdated. The veterinary profession must become responsible for educating itself, its clients and the public in general, including the media, if our patients in this growing segment of the population are to be properly and professionally cared for.
Witnessing and participating in the care of a terminally ill companion animal is often a child’s first experience with death. This experience is prone to shape perspectives they may hold for a lifetime. Young children do not readily make a distinction between how human and animal family members are treated. Seeing euthanasia used as the answer to treat the medical needs of an animal patient can lead them to believe this is all that can be done when in reality, hospice services have become so skilled that the vast majority of symptoms present during the dying experience of both humans and animals can successfully allow them to have a comfortable and natural passing.
Experiencing an end-of-life journey often elicits a spiritual query, even in people who do not normally concern themselves with such matters. Spiritual beliefs of animal caregivers inform their decisions, which short of grave neglect are to be respected by all end-of-life service providers of all categories. This applies whether such perspectives are religious in nature or not. In hospice care, it is essential that spiritual perspectives be validated not only by a spiritual counselor, if involved, but also by all veterinary staff members in contact with the caregivers.
The mistaken use of terminology in end-of-life care by veterinarians has already led to human hospice service providers receiving inquiries regarding whether they euthanize human patients. Hospice nurses are sometimes asked by patients during intake when they will be euthanized—not because this is their wish but because society has led them to believe this is what happens. While such profound misperceptions have also been fueled by misinformation through sources other than the veterinary profession, the GRACE Consortium believes it is crucial to take a correctional course through a clearer definition of terms.
Veterinary professionals must not allow personal opinions regarding end-of-life care options for humans to detract from the highly-valued position human hospice has, with great effort, rightfully gained in society. Rather, they should make correct distinctions in their end-of-life care for animal patients, especially when providing hospice as an end-of-life option.
The GRACE Consortium advises veterinary professionals offering any type of end-of-life care for pets to clearly and properly declare which of the categories their services fall under.
II. CATEGORIES OF PROFESSIONAL END-OF-LIFE SERVICES IN ANIMAL CARE
The following table offers a quick comparison for easy categorization of services offered. The GRACE Consortium acknowledges that each of the services has its own inherent value.
A brief outline of select characteristics for each category of end-of-life services currently involving veterinarians can be found here:
The following is not intended to be a comprehensive description of end-of-life care services, but rather, focuses on core elements that in practical application are crucial to client and patient outcomes. Overlap between categories is possible, and further clarification may be necessary if clients are to be fully informed in their selection of services.
Client education, timely patient re-assessment, effective symptom management and proper record-keeping are required in all types of veterinary end-of-life care although they may vary considerably in detail of execution depending on the service category. The Principles of Veterinary Medical Ethics of the AVMA apply equally to all veterinary professional providers. By the same token, mental health care providers are an important resource for all types of end-of-life services.
The following is a brief outline of select characteristics of each category of end-of-life services as currently involving veterinarians. The included table offers a quick comparison for easy categorization of services offered.
- Palliative end-of-life care and euthanasia: in-hospital services
This category entails the services traditionally delivered by veterinarians, mostly inside the hospital setting. This includes euthanasia being offered as a solution for conditions that, from a physiological perspective, are not considered terminal diseases. Common examples are mobility issues and urinary incontinence not controllable by treatment. Such conditions may be viewed as warranting euthanasia when the owner does not wish for, or is unable to provide the often extensive daily effort involved if continued care were to be the preferred option.
Generally, services are offered within the hospital setting during regular hours of operation. Occasionally, veterinarians or veterinary technicians may be available for consultations outside office hours, at times including home visits.
- In-home euthanasia services
Mobile services to provide euthanasia in the home setting have developed to cater to animal caregivers wishing to have their animal die at home in its familiar environment. A commonly expressed concern is that transporting the animal in its fragile state adds discomfort and/ or anxiety at a time when creating a peaceful experience is the priority.
In addition, the home setting is generally the most soothing environment for the caregivers and other persons in attendance of the event.
- Palliative end-of-life care and euthanasia: mobile services
This category of service has developed as a more recent trend in veterinary medicine, delivering support to animal caregivers who are ready to take on the daily care of their special-needs or terminally ill animal companion further than is typical for the majority of users of the services outlined above.
Although clients initially may express the wish to have their animal die on its own, in the vast majority of cases euthanasia is the end result. Euthanasia is usually pre-scheduled to be performed in the home; in a crisis the patient may have to be taken to an emergency clinic.
- Collaborative (partial) and full hospice services
Some animal caregivers wish to elect a level of care for their animal that is similar to the care provided in human hospice. They may be familiar with these services from previous experience with relatives or friends. Hospice aims to keep the patients comfortable in the home setting, allowing them to fully live out their lives. The explicit hope of caregivers is to achieve a peaceful un-hastened passing in the animal’s own time, though they are ready to euthanize if comfort cannot be maintained.
Just as in human hospice, it is possible to achieve this objective in animal hospice in the majority of cases, when the professional care providers are fully aligned, well trained and have practical experience giving palliative care to naturally dying patients. The guiding principle of hospice services is the same for humans as it is for animals: neither to postpone nor hasten death. The dying process is embraced as a normal part of life that does not have to be feared or avoided.
4.1. Collaborative (partial) hospice services:
The veterinary provider of partial hospice services is ready to design treatment plans that are in alignment with the goal expressed by the animal caregiver, yet the professional may be unable to provide all aspects that comprise full hospice services. For example, in-home treatment or in-home euthanasia during the night or on weekends may be granted by collaboration with a veterinarian offering services as specified under sections III. 2. or 3.
Advertising collaborative hospice services requires that the provider ensure that all aspects of care, as outlined in the table below under “Collaborative (partial) and full hospice services”, as well as under 4.2. are covered via collaboration with local resources complementary to their own services.
4.2. Full hospice services:
Full hospice services, or any local professional veterinary services offered as hospice or under a business name that includes the word “hospice”, are assumed to follow the foundational principles of hospice care. An adaptation of human hospice principles to animal care can be found here (link).
The services include, but are not limited to availability of 24/7 access to both support via phone as well as home visits.
In addition, a comfort kit is provided to the animal caregiver at the beginning of the service relationship. This serves to bridge possible delays until professional support is available if rapidly changing conditions occur that unacceptably impair an animal’s wellbeing.
Euthanasia may still be chosen to end hospice care if sufficient comfort of the animal cannot be maintained, or the caregiver can no longer provide the needed care. However, hospice service is defined by successfully delivering comfort until the patient dies on its own.
[Download EOL categories]EOL categories short 2-28-18
III. STEPS TO TAKE
If a current business name or advertising of services does NOT comply with the terminology as outlined above, here are recommendations:
The information this section provides is most easily implemented at the commencement of a business or practice intending to offer end-of-life care for animals. It is advisable that veterinary professionals offering any type of end-of-life care for pets to clearly declare which of the following categories their services fall under as outlined herein with an explanation of any exceptions to that service category:
Palliative end-of-life care and euthanasia (in-hospital services)
In home euthanasia services
Palliative end-of-life care and euthanasia (mobile services)
Collaborative (partial) hospice services
Full hospice services
If the lives of most animals considered “hospice” patients end via euthanasia, regardless of whether this was a planned outcome from the very beginning or because a peaceful hospice-supported natural death is only achieved in exceptional cases, this strongly calls for:
- Renaming the service. This can be accomplished, for example, by including a highly visible statement on the website properly identifying the type of end-of-life service, adding stickers to already existing printed material (i.e. brochures), removing or complementing adhesive lettering on vehicles and booths with professional signage, updating the wording printed on business cards, and (in some cases) adopting a new domain name for the business website.
- Rigorously identifying and addressing missing aspects in client education and/or patient and family support. For this step it can be helpful to refer to the document “Animal Hospice Definition and Foundational Principles – adapted from human hospice”. (link) Additional clarification can be gained by consulting with an experienced professional animal hospice provider.
The GRACE Consortium asks veterinarians to adhere to these recommendations regarding nomenclature of services for animal end-of-life care to prevent misleading the public or being viewed as fraudulent.
Observance of proper terminology helps clients understand the service options available to them, ensures informed consent, fosters the overall welfare of patients, preserves the integrity of the term “hospice” and its associated body of knowledge, and thus assists in normalizing the dying process in society.