There is a brief commentary (subscription required) in the current issue of the Journal of the American Veterinary Medical Association (JAVMA) on the subject of veterinary hospice care. I’ve written about this subject before, and I think it is one that deserves more attention and effort in the veterinary medical community.
Thanks in large part to the successful advances in preventative healthcare and treatment of disease, our pets are living longer. The natural consequence of this is that we are more frequently faced with the challenges of complex geriatric medicine and with individuals at the end of their lives who have multiple, often chronic diseases. These disease are generally not curable, but they can often be managed to provide a good quality of life for our patients. When we are able to accept the inevitability of death, which is difficult in our culture, then we can focus on trying to maintain a comfortable, satisfying life for our pets even as they are approaching the end of their lives. This is a worthy goal which presents a number of scientific, psychological, and logistical challenges.
The concern I expressed when I first wrote on this subject, about the role of CAM and associated ideologies in hospice care, is alluded to in the JAVMA commentary.
Hospice care may be more popular among those interested in alternative and complementary therapies. Thus, veterinarians engaged in hospice care should be comfortable working alongside individuals offering these therapies and be aware of the potential for conflicts and deleterious interactions between these therapies and conventional medical treatments.
Though I am not aware of any objective research data to support it, I tend to agree with the contention that pet owners interested in comprehensive hospice care, and often reluctant to consider euthanasia when their veterinarian suggests it is appropriate, are also owners more inclined towards CAM therapies. Much of CAM is vitalistic philosophically, emphasizing the “spirit” or “life force” of the individual as the primary focus of health and disease, with the physical body considered secondary. And from such a perspective, death is likely to be seen primarily as a transition of the spirit from one state to another, with the dysfunction and breakdown of the physical body as a secondary concern.
This blog, and certainly the veterinary consultation room, are not appropriate places to debate religion or metaphysical philosophy. I don’t see it as at all my role as a veterinarian to challenge my clients’ attitudes about the fundamental nature of life and death. However, I do see my role not only as a source of support and comfort for the client but as an advocate for the welfare of my patient.
Pet owners clearly want the best for their pets, but they also are influenced by their own feelings and needs, especially at intensely emotional times like the end of life. Under such conditions, it is not difficult to project one’s own needs and beliefs onto an animal companion, especially with the facilitation of “animal communicators” or others who claim to have mystical insight into the wishes or thoughts of animals. This can lead to decisions about care which are not truly in the best interests of the pet.
Insofar as CAM is sometimes more successful at meeting people’s psychological and spiritual needs than science-based medicine, and that it is most often employed in the treatment of chronic diseases for which there is no definitively effective conventional treatment, I am not surprised that CAM and CAM providers are playing a significant role in the nascent veterinary hospice movement. CAM providers are among the most active promoters of hospice care.
While I applaud these efforts, I am concerned that ineffective, pseudoscientific therapies may come to dominate end-of-life veterinary care, and that the consequence of this may be inadequate palliation of our pets’ physical suffering. I have had clients who were struggling to accept the inevitable loss of an animal companion and who sought any and all therapies that offered the promise of a benefit. Even when these therapies were clearly ineffective, or caused increased suffering, these clients have difficulty seeing and accepting this fact at the time (though they often come to me later and lament having persisted too long in the face of their pet’s suffering because letting go was too painful). There are plenty of examples in human medicine of ineffective alternative therapies that actually worsened the quality of life for terminally ill patients using them, and I believe this is a real risk for veterinary hospice care.
I have also seen clients whose pets were in great pain but who refused conventional pain therapy and persisted in the belief that homeopathy and other alternative therapies were effectively managing their pet’s discomfort despite clear and obvious evidence to the contrary. Again, this is not due to any lack of intelligence or compassion, but simply to the innate tendency of all human beings to see what they want and expect to see. Unfortunately, without legitimate scientific research it is not possible to know how effective a medical therapy really is, and I am concerned about patients in veterinary hospice care being denied effective palliative care in favor of bogus therapies because of a philosophical predisposition of some pet owners and hospice providers towards CAM approaches.
I would certainly not suggest that veterinarians who wish to provide comprehensive hospice care automatically refuse to work with CAM providers or accommodate their clients’ interest in such therapies. This would likely be counterproductive as it would drive these clients away from conventional care or lead them not to disclose the CAM therapies they are using, making it harder to monitor for possible adverse interactions.
However, I do think veterinarians have an ethical responsibility to advocate for the welfare of their patients, even if this means telling clients things they don’t want to hear. If an owner is unable to see or accept that their pet is suffering, or mistakenly believes they are providing effective care, their veterinarian must try, as kindly but clearly as possible, to help them see the true situation. And in extreme cases, where a CAM provider is actively discouraging an owner from taking advantage of appropriate conventional care, it may not be possible to serve that owner and one’s conscience at the same time.
And while there are some people who have a philosophical or religious objection to euthanasia, I think most veterinarians and pet owners see it properly as an act of kindness to relieve otherwise untreatable suffering. If a client is unwilling to consider euthanasia, then their veterinarian may have to accept this and do whatever they can to ensure that the pet is kept as comfortable as possible while dying. But there is nothing wrong with discussing the role of euthanasia in high quality, compassionate end-of-life care. And I vehemently reject the caricature promoted by some CAM advocates of veterinarians who practice science-based medicine as callous and forcing euthanasia on their clients prematurely.
Veterinary hospice care is a concept that needs to be developed and promoted more widely, and in order to best care for our pets as well as their owners, we need to ensure that the philosophy and techniques that make up hospice care include effective, evidence-based medicine. Offering comfort to clients in the form of therapies that don’t truly benefit our patients is not true compassion, and advocating aggressively for what we believe is the best, most effective scientific treatment available for our patients is not closed-mindedness but conscience. My hope is that conventional veterinary medicine will embrace the hospice concept, and that veterinarians committed to science-based medicine will continue to be involved in its development and implementation so that our pets get the best care possible at the end of their lives.