I first wrote about the subject of hospice care for animals in the first year of this blog, 2009. I feel strongly that there is a need to adapt the concepts of hospice and palliative care developed in human medicine to the needs of veterinary patients. While euthanasia is, thankfully, an option for most terminally ill veterinary patients, this does not obviate the need for appropriate relief of the suffering of our patients and for thoughtful conversations with pet owners about death and how to approach end of life issues.
One of my favorite authors, Atul Gawande, has written a brilliant book called Being Mortal, which looks at the successes and failures of the medical system in America when handling the end of life. One of the bright spots is the role of hospice care in providing a comfortable, meaningful, and dignified end to human life. Our veterinary patients deserve the same.
However, while I have great respect for the vets who are trying to bring the benefits of hospice care to animals under veterinary care, I have some concerns as well. One is the role of spiritual questions in animal hospice care. Because the end of life brings our spiritual beliefs to the fore, the beliefs of animal owners are certainly relevant to how a veterinarian manages the care of a patient at the end of life. In the most extreme cases, euthanasia may not be an option at all due to some people’s religious beliefs. While I may disagree with such a position, it is not the role of a vet to challenge a client’s personal beliefs in this situation. It is, of course, a vet’s role to act as an advocate for the welfare of the patient. Hospice care provides a way to protect the welfare of the patient even when there may be a conflict between the needs of the patient as the veterinarians sees them and the choices of the animal owner.
However, there are some in the animal hospice community who actively insert their own personal spiritual beliefs into the practice of veterinary hospice care, and this is troubling. The International Association of Animal Hospice and Palliative Care (IAAHPC) specifically supports, for example, the right of a hospice veterinarian to “have a principled moral objection to euthanasia, in general, and refuse to perform the procedure regardless of the circumstances.”
This seems an untenable position for a veterinarian providing end-of-life care when euthanasia is almost universally seen as an appropriate choice to minimize suffering in terminally ill animals. While the IAAHPC does recommend such veterinarians tell clients about their position before taking on a hospice care role and refer for euthanasia if a client wishes it, this seems an ethically dubious position.
The right of service providers of any kind, including healthcare workers, to refuse to provide services that are legal and ordinarily provided by people in their role as a result of their personal beliefs, including religious beliefs, has generally not been widely recognized as a legitimate right, nor has it been generally upheld by the courts. Personal beliefs don’t typically exempt one from performing the expected duties of one’s profession, so this seems a questionable exception to carve out for hospice veterinarians.
Much more worrisome, however, is the strong and consistent role of alternative medical therapies in educational and policy documents from the organized veterinary hospice community. The IAAHPC guidelines specifically endorse “integrative medicine” and the inclusion of alternative therapies in end-of-life care:
An integrative approach, using conventional and CAVM therapies, is recommended using the most appropriate interventions that control pain or other clinical signs. It is the recommendation of this Task Force that veterinary practitioners and animal hospice team members maintain current knowledge of the available treatment options for patients, whether these options are complementary or allopathic, and to choose therapies that are the most effective in treating the patient’s condition, most beneficial to the patient’s overall quality of life and have the fewest undesirable side effects.
Given the robust reasons to doubt the safety and effectiveness of most alternative therapies, this seems a perilous and irresponsible position to take. If a treatment doesn’t work, it provides no benefit to the patient, and integrating it into patient care cannot improve quality of life. Integrating it at the expense of scientific therapies, however, can certainly worsen patient care. As I discussed in my previous article, this appears to be the result of the fact that many of the leading figures in the animal hospice movement are also CAM providers. They have faith in CAM treatments regardless of the lack of evidence or even evidence against this belief, and as a result they assume the value of these therapies and promote them as a beneficial part of hospice care. Substituting personal belief and experience for scientific evidence is not the best way to protect patients, especially those as vulnerable as animals in hospice care.
There is, of course, limited and weak evidence for many veterinary therapies, conventional as well as alternative. And the area of pain control is especially difficult to generate strong, objective evidence in because the challenges in measuring pain and the effects of pain relieving treatments. Some CAM therapies fall into a grey zone where there is at least some plausible reason to think they may have benefits, or at least a level of evidence no worse than that available for conventional therapies. For example, though the evidence is not strong, there is some reason to think cold laser therapy (1,2), massage, and other kinds of physical medicine may have some benefits in terms of comfort, wound healing, and other issues relevant to hospice patients. Even acupuncture, if divorced from the nonsense of Traditional Chinese Medicine, might have some small beneficial effects, though the evidence is complex and uncertain.
Use of such methods, so long as it is not to the exclusion of science-based treatments, is not entirely unreasonable if measured claims are made and clients are given honest information about the limitations of the evidence. However, there are also CAM methods recommended by proponents of animal hospice that are clearly ineffective and can have no benefits at all. For example, a prominent and extreme proponent of veterinary homeopathy, Christine Chambreau (3,4,5), has lectured at the IAAHPC conference on the use of homeopathy in hospice patients. As always, suggesting that homeopathy has any legitimate role in veterinary care ignores the overwhelming evidence that it is ineffective, and this is completely unethical. Substituting homeopathy for any real medical therapy is dangerous and wrong, and this should never be even tacitly endorsed by anyone interested in legitimate compassionate end-of-life care.
Similarly, the IAAHPC has had proponents of Reiki speak at their conference, and the organization even has a link to a pro-Reiki web site on their own web page. Reiki, of course, is a variety of “energy medicine,” which amounts to nothing more than a non-denominational variety of faith healing. It is fundamentally a spiritual practice, not only not proven to have any beneficial effects but outside the domain of science altogether since it is entirely faith-based. Offering it as part of hospice care not only promotes an unproven and unscientific practice as if it were a legitimate medical intervention, it blurs the distinction between the veterinarian as a healthcare provider and a spiritual counselor. This intrusion of personal spiritual beliefs into animal hospice is not in the best interests of patients or the hospice movement.
The IAAHPC does appear to view CAM not only as likely to be effective, but potentially as a substitute for some conventional therapies. For example, in the organization’s hospice guidelines, they state, “CAVM therapies may aid in reducing the required dosages of certain drugs.” And the usual misguided notion of scientific evidence as an optional “extra” rather than essential to evaluating the safety and effectiveness of our treatments appears in IAAHPC conference talks about the use of CAM in hospice care:
These therapies are safe, noninvasive, relatively inexpensive, and accessible… Their use can promote natural healing mechanisms… and also will create a sense of wellbeing in the patient. Serious and life-altering medical conditions…have been found to be responsive, to some degree, to the use of diet, nutraceuticals and botanicals and acupuncture.
Patients who are in terminal care may not have the time to wait for the completion of more studies validating the benefit of the concurrent use of complementary therapies… Each clinician needs to decide where they stand in terms of the degree of rigor of the evidence versus the benefit-potential that complementary therapy could provide their patients’ QoL. In the hospice-palliative care realm, using evidence-based measures is of paramount importance, as long as the patient doesn’t suffer as a result of the time spent in academic bickering over the level of quality of the evidence.
This sort of position assumes the efficacy and safety of methods when these are often not, in fact, well-demonstrated, and it assumes that it is somehow better for patients to be exposed to therapies with little to no evidence of safety and effectiveness and significant controversy about their effects than to test these therapies before using them. The normal process of scientific investigation, which has brought such tremendous and unprecedented health benefits to the all of us, is dismissed as “academic bickering,” and it is assumed that any objection to trusting anecdote as the basis for using CAM treatments is a mere pedantry. Such views place the well-being of patients at the mercy of the beliefs and opinions of individual veterinarians, even when these conflict with scientific evidence.
I believe hospice care has the potential to make the end of life more comfortable and peaceful for many veterinary patients, and I think it is crucial that we do a better job as a profession of serving the needs of patients and their human caregivers at this challenging and emotional time in the cycle of life. However, I think our clients and patients are especially vulnerable when coping with terminal illness and death, and we have a responsibility at this time, perhaps more than any other, to be sure the care we offer is the best, safest, and most effective possible. Science and scientific evidence offers the best tool available for evaluating the treatments we offer, and it has earned the special roles it plays as the primary means of identifying the risks and benefits of the treatments we employ. While we must often make due with less than optimal evidence in making clinical decisions, we are ethically obligated to rely on science to the greatest extent possible in choosing therapies and counseling our clients.
Unfortunately, the organized animal hospice movement includes a relatively high proportion of veterinarians who are believers in unproven or even outright ineffective therapeutic practices, including acupuncture, herbal medicine, energy medicine, homeopathy, and others. Because of this representation, organizations and individuals promoting hospice care are often also promoting the misguided “integrative medicine” approach (c.f. 6, 7 for more on this concept). This includes treating both promising but unproven treatments (such as low-level laser therapy), disproven treatments (such as homeopathy), and even fundamentally spiritual or religious practices (such as Reiki) as if they were the equivalent of science-based conventional medical interventions. This misleads clients and places patient welfare at risk.
While the IAAHPC does acknowledge that hospice therapies should be effective and, to the extent possible, evidence based, in general it leaves the evaluation of these therapies to the discretion of individual veterinarians and takes a very weak stance on how efficacy and evidence are to be judged. While I truly do admire and share the goals of the animal hospice movement, and I appreciate the sincerity and commitment of hospice veterinarians, including those who offer CAVM treatments, to the well-being of hospice patients, I am troubled by the views of the IAAHPC and individual hospice providers towards CAVM and evidence-based medicine.
There is abundant evidence that our perceptions of the efficacy of our therapies are unreliable and misleading, and that caregiver placebo effects readily fool us into thinking we are alleviating suffering in our pets and patients even when we are using ineffective treatments. Sadly, the majority of veterinarians, whether primarily conventional of CAM-oriented, do not seem to appreciate this. In the case of hospice patients and their owners, this attitude has significant potential to lead to unnecessary suffering or ineffective care since there is often a perception of “nothing to lose” at the end of life. However, the experience of dying can be made more uncomfortable than it need be when ineffective treatments are used, and it is imperative the as a community veterinarians are vigilant in minimizing the risk of this in animal hospice patients.