Home Care and End of Life Issues: Gentle Diligence, Grace and Compassion
World Small Animal Veterinary Association World Congress Proceedings, 2008
Margie Scherk, DVM, DABVP (Feline)
Vancouver, BC, Canada

Home care near life's end encompasses age-related and age-appropriate illnesses. In cats, these include renal insufficiency progressing to failure, hyperthyroidism, diabetes mellitus, degenerative joint disorders, neoplasia and chronic digestive disorders (inflammatory bowel disease, pancreatitis and cholangiohepatitis). By addressing organ and cell function, we can enhance well-being and match types of care to the final stages in life.

Stage 1. Support Function of Cells and Organism

Hydration

This is of utmost importance and should be included in any home care program. Most clients are able to give fluids subcutaneously. Subcutaneous fluid requirements are determined as for intravenous: deficit (percentage of ideal body weight in kg) + maintenance (60 ml/kg ideal weight/day) + ongoing losses (diarrhea, vomiting). If this volume is too large for administration, divide it into multiple treatments during the day. Warming the fluids may make the experience more comfortable. We administer fluids as rapidly as possible using gravity feed and an 18G needle.

Nutrition

Calories must be provided from fat and protein, anti-oxidants and other micronutrients. Carbohydrates are less essential for obligate carnivores, but can be a good source of energy. The goal is for the cat to eat 50 kcal/kg ideal weight/day on his/her own. Often illness interferes with this goal. Appetite stimulants such as cyproheptadine (1 mg/cat PO q12h) or mirtazapine (RemeronTM) (3 mg/cat PO q72h) can be used. Mirtazapine has the added benefit of being an anti-emetic.

Pain may decrease appetite. Optimize dental health wherever possible. Musculoskeletal pain makes crouching or bending the neck uncomfortable: bowl shape or placement may help. Treat nausea associated with renal disease with famotidine.

Declining senses result in lack of awareness of food. Warming food increases palatability. Small, more frequent meals may suit better than twice daily. Canned foods are preferable for greater water content. We often recommend feeding a prescription diet for a specific ailment, however, it is more important that patients eat sufficient amounts than a specific diet.

Feeding tubes make administration of nutrients and medications less stressful for the client and patient. Naso-esophageal tubes can be used short-term using a liquid diet, such as ReboundTM or Clinicare FelineTM(1.0 kcal/ml). Syringe feeding can be minimally stressful: face the cat away from you; use a small volume syringe (administration of more than 1 ml at a time exceeds the cat's oral capacity), place the tip of the syringe at the back of the mouth to make it harder for food to be spat out, feed at room or body temperature. A healthy cat's stomach can hold up to 100 ml; starting with 6 ml increasing in 6 ml increments to 48 ml total per feeding is realistic with most cats.

Large bore tubes are preferable because a wider variety of diets can be used. The easiest for home care is an esophagostomy tube. It requires only a brief anaesthetic. G-tubes must be aspirated before infusing food to determine residual gastric volume. Tubes must be flushed with water following feeding to prevent clogging.

Mobility

Numerous papers have been published regarding arthritis and degenerative joint disease in cats All agree that older cats have a greater incidence of clinically under-diagnosed joint problems. If specific questions are asked, one can often identify stiffness or discomfort: 'Have you noticed a change in how he jumps/climbs up/down/ walks?' In one paper, 90% of cats over 12 years of age had radiographic evidence of degenerative joint disease regardless of the reason for presentation. Many had lesions in the lumbosacral vertebral column; severe lesions occurred in 17% of the elbow joints.

Mobility problems can manifest as constipation, defecating outside of the litter box, falling when jumping onto or off furniture, inability to climb stairs, weight loss from inability to crouch to eat. Regular nail trimming helps by maintaining proper joint relationships. Ramps onto warm, padded sleeping spots are thoughtful. Ensure that the litter box is cleaned, the rim is not too high, the opening not too small, and place it to reduce walking distance.

Stage 2. Alleviate Discomfort, Optimize Comfort

Optimizing cell function may require medications. Compliance is best achieved through helping the client understand the illness and the medication.

A cat may groom less due to stiffness and require grooming to keep the coat clean and healthy. Massage may be appreciated as will warm soft padded perches.

A common complaint is night-time yowling. Differentials include: loss of special senses, hypertension, hyperthyroid agitation, pain, and cognitive dysfunction. The first may be alleviated by simply calling out, so that he/she is able to locate where you are. Hypertension and hyperthyroidism are readily diagnosed and controlled medically.

Pain may be difficult to assess. Often the best way to determine if pain is present is to administer pain relief and see if behaviour normalizes. Clients have the right to expect that our focus is going to be on alleviating (and preventing) pain. It is often preferable to minimize the potential adverse effects of a single agent by using lower doses of several agents. A narcotic (e.g., buprenorphine, hydromorphone, butorphanol or fentanyl) is combined with a NSAID like meloxicam, aspirin or ketoprofen, or Cartrophen (polysulphated glycosaminoglycan). Topical and local analgesia may also be provided either with EMLA crème, local block or acupuncture. Corticosteroids should not be combined with NSAIDs but can be used in conjunction with the other drugs. Because of possible effects on renal function NSAIDs are best avoided in patients with renal disease. As long as the client has been fully informed about the risk, quality of life without arthritic pain may well be preferable to a painful, risk-free existence. The author feels comfortable after describing the risks and adverse reactions dispensing meloxicam (0.05 mg/kg PO SID) for ongoing use. In addition to analgesics, nutraceuticals and chondroprotectants (e.g., glucosamine, chondroitin sulphate) play a role in the management of degenerative joint disease.

For further information, refer to the International Veterinary Academy of Pain Management at: http://www.cvmbs.colostate.edu/ivapm/ and The International Veterinary Acupuncture Society at: http://www.ivas.org/.

Many older patients require numerous medications. In order to minimize stress the importance of the particular agents should be prioritized to ensure that the most important ones are given diligently. If less critical ones cannot be omitted, perhaps they can be administered by a different, less psychologically invasive route. Feeding tubes permit most oral medications to be given without handling the patient. Many clients are comfortable giving subcutaneous injections.

Stage 3. Preparing for an Ending; Dying with Dignity

Clients worry about how they will know 'when it is the right time'. Our aim is to balance prematurely shortening an individual's life with exceeding the point when the kitty wishes to be alive.

I encourage caregivers to imagine what their cat is experiencing. Using a scale of 1-10, with 10 being the best day of their life and 1 being equivalent to agony and hopelessness, most of us live at around 6 or 7. Using this as a means to score a given day allows objectivity. When the scores are mostly 2s and 3s, it is time to consider helping kitty pass on. Advice from Dr. Bernie Rollin is to ask a client to write a long list of the things their cat enjoys doing while still well. As the cat becomes more debilitated, review this list and see what changes have occurred. This gives a gauge of progression and reassurance regarding the decision to euthanize. It will help the client to see gradual changes.

People like to feel that they have some control should their cat's condition deteriorate quickly. Make sure they have appropriate phone numbers for the emergency facility and a photocopy of the most recent medical record and lab work.

Let people know what euthanasia entails. Reassure the client that the dose is painless. We place kitty on a thick towel on the client's lap and tell them that cats generally keep their eyes open and that because muscles relax, the cat may empty his/her bladder or bowels. Also let them know that some cats may still make breathing movements as the body shuts down. While intravenous administration is the most common route for euthanasia, unless a cat is agonal, I prefer to administer euthanasia solution intraperitoneally, just caudal to a kidney. This avoids restraint distress for the patient. Additionally, the transition from life to death is less sudden: it may take 2 or 20 minutes. As soon as the cat is anaesthetized, should the client be wanting to 'finish it', a vein can be accessed. In my experience, clients who have witnessed intravenous euthanasia, prefer the more natural passing with the IP route.

The time of waiting gives them a good opportunity to remember and cry and laugh. This shows that they are working through their grieving normally and are going to be okay.

Stage 4. Caring for the Caregivers

Most people are able to cope with a loss if they know it is imminent and they have a support network. The veterinary team may be the only support the client has. Along with sending a personal card, it is usually greatly appreciated when we call the person after a few days. If there is any concern about the client's emotional security and you are concerned that they might be suicidal, be sure to get help from the human health care system.

For most, it helps to know that it is normal to experience a range of emotions, from grief to guilt to anger to uncertainty and emptiness, even days or weeks after the death of a beloved companion. What is NOT normal or healthy is getting stuck in one emotion. Sometimes the death of a cat companion is a reminder of unfinished grieving for another person or pet. Numerous grieving support networks exist e.g., www.petloss.com.

If clients haven't already adopted a new friend, they should give thought to that not only for themselves, but also for other critters who will be left alone. The new kitty isn't a replacement for the one who has died, but the newcomer receives a home and a heart to fill, easing grief and bringing joy.

Finally there is the cost of caring. Veterinarians experience dying and recovering from it approximately five times as often as our human health care equivalents. 'Compassion fatigue goes beyond just normal burnout. Compassion fatigue is a type of physical, emotional, and spiritual exhaustion that comes with frequent exposure to death and having to offer support to clients in highly emotional situations over long periods of time'(Durrance D, 2005 Western Veterinary Conference)

Some of the issues that have been associated with compassion fatigue in veterinary medicine include:

 Difficulty accepting that the patient's physical problems cannot always be controlled.

 Frustration at having invested large amounts of energy in caring for a patient who then dies, taking this investment with them.

 Disappointment if expectations for patients to die a 'good death' are not met.

 Difficulty ending a life you once saved.

 Difficulty establishing realistic boundaries and expectations on veterinary care.

 Caring for an animal more than the owner does.

 Guilt arising from a cat's death.

Without risking the tragedy of arms-length detachment, it is possible to take care of yourself. Suggestions for dealing with and protecting yourself from compassion fatigue include:

 Allow yourself to be human.

 Acknowledge and honor your own grief and emotions.

 Embrace your personal life away from work.

 Allow time to debrief and support other team members.

 Say your own private 'good-bye' to your patients.

 Believe in your ability to provide comfort and love to your patients.

 Re-define death: not as a failure but as an inevitable part of the life cycle.

 After euthanasia, know that the individual is no longer suffering.

 Think of euthanasia as a gift that owners want and appreciate.

 With euthanasia, realize that you are providing a loving and caring time for your patients and clients.

References

References are available upon request.

Speaker Information
(click the speaker's name to view other papers and abstracts submitted by this speaker)

Margie Scherk, DVM, DABVP (Feline)
Vancouver, British Columbia, Canada


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