Estimated reading time: 8 minutes
Palliative care is specialised medical care that focuses on providing relief from pain and other symptoms of a serious illness. It also can help patients cope with the side effects from medical treatments1. Palliative care can be provided to any animal, of any age, at any stage of any disease. Hospice is palliative care provided at the end of life.
Palliative care aims to provide comfort and to improve quality of life for patients as well as their caregivers. It is often an adjunct to treatments already being provided to the patient, and it is more caregiver focused.
Palliative care teams can include any and all of the following: specialists, veterinarians, veterinary nurses, and allied health service providers such as physiotherapists, social workers and spiritual guides.
A 17-year-old female spayed Staffordshire terrier with a lifelong history of coughing presented to emergency for respiratory distress. The patient was sedated for a thorough examination due to her respiratory distress combined with her severe anxiety in the clinical setting.
On thoracic auscultation, the patient’s respiratory sounds seemed to be slightly harsher on the right side and the SpO2 was low ranging between 92% and 94%. Thoracic radiographs revealed a marked interstitial-alveolar pattern in the right cranial, middle and caudal pulmonary fields. The caregiver was offered the option of treating in hospital with the possibility of running advanced diagnostics such as thoracic CT scan, or euthanasia. The caregiver elected to have the patient hospitalised and monitor her response over the next 12-24 hours.
The patient was admitted into hospital and treated for pneumonia with supplemental oxygen via nasal prongs, intravenous fluids, and intravenous antibiotics. Due to the patient’s severe anxiety, she was given trazodone which proved inadequate. This was then escalated to intravenous sedation via midazolam bolus. This, too, was found to be inadequate. The patient was then placed on a midazolam and medetomidine constant rate infusion (CRI) which seemed to help.
Overnight, while on sedation and supplemental oxygen, the patient stabilised. The following morning, she was weaned off the oxygen and her SpO2 was stable on room air while she was sedated.
The patient’s caregiver then transferred the dog to a specialist veterinary hospital for a consultation with a medicine specialist. During the transfer process the patient was disconnected from her sedation. On arrival at the specialist hospital, she was given butorphanol which was inadequate. She was then given acepromazine which only lasted two hours. Eventually, the patient was placed on a butorphanol CRI.
It is important to note that every time the patient’s sedation was reduced or wore off, she became so distressed that her respiratory rate and effort would increase substantially and her SpO2 would decrease. As such, while in hospital, in order to maintain appropriate oxygenation, the patient had to remain sedated at all times.
During the admission consultation at the specialist veterinary hospital, the caregiver was offered the option to have a CT scan performed, or to continue treatment for pneumonia and monitor, or euthanise. The caregiver elected to proceed with referral to a veterinary specialist with a view to having further diagnostics performed.
Overnight the primary clinical veterinarian tried to wean the patient off the sedative CRI but was unable to do so as the patient would become immensely distressed, leading to an elevation in her respiratory rate and effort again. It was difficult for the attending clinicians to wean the patient off the oxygen and sedation, and monitor her respiratory rate and effort as well as her SpO2, and ensure she was safe to go home.
This was quite distressing for both the caregiver and the patient. As a result, the caregiver declined further diagnostics and reached out to me with a request to ‘set up a mini hospital at home’ so that the dog could be in familiar surroundings.
Initially there was some resistance in releasing the patient to be treated at home given the level of care she needed, and her underlying condition being so advanced. There was also some hesitation as palliative care is still considered a fairly new field and many veterinary clinicians are not familiar with how to set up oxygen therapy at home, while trusting the caregiver to nurse the patient.
Once we received the call from the caregiver, we reached out to medical gas supplier Supagas and acquired an oxygen converter. The patient was then transported home via a pet ambulance maintaining her on oxygen and sedation. We received the patient at home with bilateral nasal cannulas and an IV line in place. We had all her medications dispensed to be given orally, and we had access to oxygen at home.
Once home, the patient was quite sedate from her stay in hospital, but she was ambulatory and eating small amounts. While at home, at no point did she require any supplemental oxygen. Her respiratory rate and effort remained normal at home. During our two-hour consultation she remained completely focused on her caregiver.
We continued with her medications, comprising antibiotics and prednisolone. In addition, she was prescribed ondansetron in case of nausea leading to hyporexia, paracetamol for her arthritis and cannabidiol (CBD) oil to assist with arthritis and for antioxidant effect to counter neoplastic inflammatory mediators.
It took the patient almost two days to recover completely from all the sedation at the veterinary hospital. Gradually, with help from her caregivers, she recovered. Within three weeks she was back to her normal self. She even joined the family on a rural getaway for 10 days where she ran energetically through the fields.
Eighteen months later, the patient remains unstoppable. Her current medical regime includes prednisolone, CBD oil, and stilboestrol. She does have a dry non-productive cough and occasional unilateral nasal discharge which does not seem to bother her too much. Her caregiver monitors her respiratory rate and keeps her on a structured daily routine. The dog continues to have a wonderful time with her family at home.
This case provides us with an interesting insight into the value of palliative care. As veterinarians, we often talk about nurturing the human-animal bond, only to then remove the human from the equation and make clinical decisions based on the pathology at hand.
Once all known treatment options are exhausted, we tend to resort to euthanasia because it is available, and it seems the kindest thing to do. However, in some cases, it is prudent for us to investigate other avenues, for instance to engage people who are qualified in providing services at home for the comfort of both the patient and their family.
We also tend to underestimate a patient’s emotional stress. In this particular case, the sedatives helped as long as the patient was asleep but then she could not be roused in hospital. As soon as she was home with her family, she stabilised. I feel this case highlights the fact that just as humans do, animals will often recover better in the least stressful environment. Palliative care teams allow for exactly this—providing support at home to ensure the best possible outcome for all involved.
There is a big gap between treatment (whether supportive or curative) and euthanasia. To provide what’s needed during this phase of care requires considerable effort, emotional bandwidth, and much more time than a standard consultation allows, or indeed one typically can offer in a clinical setting.
I am by no means against euthanasia. However, if the client is willing and able to nurse their pet at home, then I feel one should consider engagement of a palliative care team as a valuable and powerful option to assist the family. But early intervention is paramount!
Reference:
1. Mayo Clinic (2023). Palliative care https://www.mayoclinic.org/tests-procedures/palliative-care/about/pac-20384637
Dr Anupam Sharma
BVSc MANZCVS DipMgt CHPV CMFT
Animal Comfort Care Centre
Dr Sharma graduated from the University of Sydney in December 2006 with a Bachelors degree in Veterinary Science. Afterwards, she worked as a vet in general practice and in vet emergency hospitals in Sydney, Melbourne and London.
Having worked as a relief veterinarian worldwide, Dr Sharma then undertook further studies in Small Animal Medicine, soon becoming a member of Australia and New Zealand College of Veterinary Scientists.
In 2016, Dr Sharma acquired a Diploma of Management, and in 2023, she acquired her certification from the International Association of Animal Hospice and Palliative Care (IAAHPC). The IAAHPC certification is the first of its kind and presently it is the highest academic achievement in veterinary palliative care.
Dr Sharma is a certified Mental Health First Aid provider which enables her to assist colleagues as well as clients with much needed emotional and psychological support in times of distress.
Dr Sharma, a certified Canine Myo-Manipulative Functional Therapist, is a strong believer in physical therapy as a means of providing pain relief, calming the nervous system, and also strengthening the human-animal bond between patients and their caregivers.
