VETERINARY HOSPICE

 Global Veterinary Ethics Congress

GlobalVeterinaryEthicsCongress.blogspot.com

Donald H DeForge, VMD

Veterinary Hospice

End of Life Care for the Pet Your Love who has provided Unconditional Love to your and your family!

• This report will emphasize ways that palliative care teams [out-patient veterinary Hospice Teams] can support patients and families as they cope with their experiences of loss and grief.  
• The End of Life Stage is the stage of life when the Human-Animal Bond reaches its highest pinnacle.  It is the duty and responsibility of the veterinary team to supply unconditional love to the pet and pet advocate.  
• This is the Stage of Life that brings the Human Animal Bond to its pinnacle.  The doctors and veterinary nursing teams must be devoted to helping pet and pet family with compassion and empathy. 
• The palliative care team in a newly constructed out-patient Veterinary Hospice can support patients and families as they cope with their experiences of loss and grief. 
• It is very difficult in Hospice to support the patient who is a member of your practice family at end of life and at the same time provide emotion support to the pet advocate with a devoted level of empathy. 
• It can be accomplished through meetings that describe the importance of Hospice Care.
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  End of Life Palliative Care is not the same for dogs and cats. The Hospice concept is the same but the Palliative Care Team must work with the family to establish a pain control-quality of life environment for the pet that needs help, based on physical needs, more than at any other Stage of Life.
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  From the AVMA:

• Pet Hospice Care

  Pet hospice care, also known as palliative care, is an option if your pet is suffering from a terminal illness and a cure is not possible. The goal is to make a pet’s final days or weeks more pleasant with the proper use of pain medications, dietary strategies and human interaction. 

  A participating veterinarian will teach pet parents how to provide intensive home care to keep an ill pet as comfortable as possible. Hospice care requires an active commitment and constant supervision from pet parents, who work with their veterinary team to make sure their pet’s life ends comfortably. 

• If you decide hospice care is the right course for you and your pet, you will become your pet’s primary nurse and caregiver, as well as the link between your pet and the veterinary team. Consult with your primary veterinarian and see if she recommends Hospice care for your pet based on  specific needs.

• Pet hospice is not a place, but a personal choice and philosophy based on the principle that death is a part of life and can be dignified. 

• When considering hospice care, pet parents should be very careful not to prolong the suffering of pets who are in pain or experiencing poor quality of life.

• The health care Hospice Team has to allow the client to vent; feel their pain; and help them understand the difference between palliative care and futile care at the expense of the patient. The Hospice Team does not designate a date and time for euthanasia. 

• The Team does have a responsibility to explain to the pet owner when poor quality of life is becoming prominent and discomfort is leading to only "uncomfortable" days for the pet they love.

• As creators of Veterinary Hospice Teams, it is our responsibility to understand the history of Hospice for humans in the United States.

• There are many misconceptions about Hospice. It is often misunderstood and this results in Hospice services being underutilized.

  The word “Hospice” was derived from the Latin word hospes, which means both “guest” and “host.” Dating back to the 11th century, the concept of hospice referred to a place of hospitality for not only travelers and pilgrims but also for the sick and dying. 

  Dame Cicely Saunders was a nurse working with terminally ill patients. She became a physician and in 1963 started talking about what end-of-life care could really look like. 

  During this talk, Dr. Saunders presented pictures of terminally ill cancer before and after receiving Hospice care.  The difference in the patients’ appearance and overall wellbeing was astonishing. This one talk began the discussion of end-of-life care in the United States.  

  In 1972, Dr. Elisabeth Kubler-Ross testified before the US Senate Special Committee on Aging about the right to die with dignity. This included the right to make decisions about one’s end-of-life care and to die at home.

  Dr. Kubler-Ross became well known in the Hospice community, and many hospice workers enjoy reading her work. She helped pave the way to Hospice as we know it today.

  In 1974 the first hospice was founded in the United States. 

• Dr. Kubler-Ross gave a talk at Yale University and she talked about what specialized care for the dying could look like. She focused on comfort care (palliative care) rather than treatments and focusing only on a cure.

• Today, Hospice is not a place at all, it is a philosophy of care.  End-of-life care can take place wherever a patient calls home. While there are hospice houses and inpatient hospice units, it makes up only 4.8% of hospice care in the United States. 

Grief Model Background--DABDA

Throughout life, we experience many instances of grief. Children may grieve a divorce, a wife may grieve the death of her husband, a teenager might grieve the ending of a relationship, or you might have grieved the loss of a pet.

In 1969, Elisabeth Kübler-Ross described five common stages of grief, popularly referred to as DABDA. They include:

• Denial

• Anger

• Bargaining

• Depression

• Acceptance

A Swiss psychiatrist, Kübler-Ross first introduced her five stage grief model in her book, On Death and Dying. Kübler-Ross’ model was based on her work with terminally ill patients and has been the subject of debate and criticism in the years since. Mainly, because people studying her model mistakenly believed this is the specific order in which people grieve and that all people go through all stages.

Kübler-Ross now notes that these stages are not linear and some people may not experience any of them. Others might only undergo a few stages rather than all five. It is now more readily known that these five stages of grief are the most commonly observed in the grieving population.

As veterinary Hospice Team Members, we must realize that we are not social workers; psychologists; and/or psychiatrists. We do have the responsibility to understand grief so that we are prepared to face together the difficult times for the family and close friends of the patient reaching End of Life Care.

Some team members will feel uncomfortable in Hospice Palliative Care.  Those team members should not be forced into an uncomfortable situation.  With time and experience, they may ask to join the Palliative Care Hospice Team.  For certain individuals this can be a painful transition.  Allow your team member to tell you when they are prepared.

Hospice Care is a triad of pet advocate; pDVM; and appropriate specialists/Pet ER doctor based on medical history.  

The pDVM should contact any and all specialists to see if they can help with Hospice Care of the patient they have treated medically or surgically in the past. This specialist-pDVM contact can be accomplished by Telemedicine.  

The local ER Critical Care Center should be informed when end of life is close to alert them about a possible call from the pet advocate for euthanasia if the pDVM's hospital is closed.

Important Elements of Hospice Care: 

This care must be tailored to the patient and the reason[s] that the pet is in Hospice Out-patient Care.

Proper Nutrition-all patients

Adjusting the Environment-orthopedic beds; ramps; and easy access to food or water bowls.

Integrative Treatment--Photobiomodulation Therapy; Acupuncture; and Herbal Therapy-if indicated

Pain Control-all patients

Fluid Therapy if indicated to control
dehydration as needed

Antibiotics if indicated

Immunosuppressants if indicated

Weight monitoring-all patients

Blood pressure monitoring-all patients

Vital Oral Diagnostics as indicated

Cardiovascular Testing as indicated

Telemedicine videos showing the pDVM and the Hospice Team how the patient is able to locomote and get up and down, at home, after lying for long periods.  Most veterinary APPS have a way to upload photos and movies to the Health Care Team.

House Call visitations as indicated-this has been a problem with COVID-19 and has been replaced almost completely with Telemedicine re-evaluations.

Working with the client to assist in the cost of medicines at home with Pharmacy Discount Cards.

When a patient has a terminal disease or is living out the end of a chronic illness, your client may decide with your Veterinary Hospice care team that Hospice is the right decision for their pet.

When to say Good-bye:

Generally, with Hospice care, the patient may only have days, weeks, or a few months left. Dogs or cats that are placed in Hospice care can continue to maintain a good quality of life with home modifications and appropriate medications for quite some time.

If your patient has a poor quality of life and is suffering, continuing Hospice care may not be the right choice for that patient. 

When this time comes, it will accelerate communication with the client to decide on euthanasia well before they were prepared for it. 

Electing to say goodbye to their pet is never an easy decision. It is important for the Hospice team to work closely with the client and family members when it may be time to say goodbye.

Telemedicine videos to the Hospice Team can help the client visualize the pain that their pet is experiencing.  Telemedicine has been catapulted into a NEW vital role in medicine with the advent of ever improving Internet Technology Platforms.

Always remember that you are the guide and your presentation will be weighted by the pet advocate. Gentleness; being a good listener; and multiple communications are necessary to allow the patient not to suffer and for the correct end of life decision to be made by the pet advocate.

Internalize the importance of the Human-Animal Bond to the client.  Let the pet parent know that saying good-bye is extremely painful but it is also necessary, at a point in time, to stop severe discomfort in the pet they love.

Saying good-bye is returning unconditional love to the pet who has offered it freely to the family every day of their lives.    

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A Veterinary Equinox-Fighting Burnout in a New World

 

A Veterinary Equinox

Fighting Burnout in a New World

Is It Today?

What is an Equinox?

An Equinox is one of the two times of the year when the amount of daylight and nighttime hours are just about of equal length. The two Equinoxes occur around March 20–21 and September 22–23, marking the onset of both spring and autumn.

To avoid burnout, new graduates as well as senior veterinarians must strive, each day, to reach the stability of the Veterinary Equinox.  This is not easy!! The journey encapsulates finding daylight within your professional and social life while struggling with the darkness of society in today's world! 

We cannot remove the darkness of anxious clients; unjustifiable complaints; economic instability; and negative social media reviews.  

We can balance or lighten this darkness, we experience within our profession, with a journal encapsulating the wonders of being a doctor of veterinary medicine or a veterinary nurse.  A journal is important for a young veterinarian or veterinary nurse for multiple reasons.  It can help those struggling with the "Imposter" Syndrome" and it, also, reinforces the positive impact of their patient interventions.

When our light is not overshadowed by the dark, it is quite easy to realize how we have been blessed as caretakers of the Animal Kingdom. The doctor or nurse must ask each day...."Is it today!"  

If the balance of the Veterinary Equinox is not in your life, action must be taken immediately.

No one wants to speak about suicide.  It is the hidden word that makes us look upon ourselves as being different. The concept of suicide is not spoken about as it smothers us in deep darkness.

Similarly, addictions are denied.  We excuse our extra drinking and drug habits as normal in a world that rationalizes and allows abnormal behavior to be considered the norm!  Many times it is supported by our peers who abuse alcohol and drugs to hide the darkness in their lives.

There has been a plethora of articles, recently, in the Internet and in professional journals about burnout. Many are similar and contain the same information that has been written and rewritten.  Make sure you do not use these articles as a recipe book for solving all problems.  It just will not work.  The stages of burnout can initially be occult and in the beginning unrecognizable.

I have witnessed the loss of a friend and colleague from suicide.  We spoke often and there were no red flags of distress.  She lived on the west coast 1000's of miles away and we loved to chat and share experiences about our roles as caretakers of the Animal Kingdom.  I ask myself over and over again how did it go wrong?  How could this young vibrant beacon of veterinary education become so desperate to give up her life?  That I will never know!  Since her loss, she lives inside of me.  

As a disciple of hers, I have come to believe we all can make a difference in stopping others who seek suicide as an answer to their hidden suffering.  

This can be as simple as reading social media commentary from your special friend and noting if the commentary has become dark. If this darkness is evident, let your friend know about the vehicles of help that have been constructed by the AVMA and ancillary help groups recommended by the AVMA.

The connections between burnout; addiction; and suicide contemplation are complex.  Only a trained healthcare professional can separate and integrate these problems as they exist in their own life.  In many all three problems can co-exist.   

Finding a mentor or friend to help with professional work problems is not a substitute for finding a professional who is an expert in treating depression and other conditions that prevent the individual from being the advocate of the Animal Kingdom that once meant very much to them during their academic years.

The AVMA has important resources that are readily available.

Preventing Suicide: A new guide free to our profession

Published on October 14, 2022

A newly published resource guide developed by the AVMA and partner organizations provides strategies and practical actions that veterinary professionals can take to help prevent suicide.

The Suicide Prevention Resource Guide for Veterinary Settings outlines societal, community, relationship, and individual approaches, and can steer veterinary professionals and groups in developing a comprehensive suicide prevention plan. 

The guide provides information about suicide risk and protective factors, warning signs, and what organizations and individuals can do to help prevent suicide. It reflects learnings from suicide research and the implementation of evidence-based suicide prevention and response strategies in a variety of academic and workplace settings.

The resource guide was developed by the AVMA, the American Association of Veterinary Medical Colleges, and the American Foundation for Suicide Prevention, in collaboration with the National Association of Veterinary Technicians in America, Veterinary Hospital Managers Association, and Veterinary Medical Association Executives.

Suicide is preventable

Despite its complexity, suicide can be prevented. It’s not an inevitable outcome of someone experiencing pain or crisis in their life, and we can take actions to help protect ourselves and others who might be at risk.

The new resource guide joins AVMA’s growing library of wellbeing and suicide prevention resources that are available to everyone in the veterinary profession. Found at avma.org/Wellbeing, these include suicide response guides for veterinary workplaces and colleges, and free suicide prevention training for all veterinary professionals. 

The digital CE courses on AVMA Axon also include numerous wellbeing webinars, including several focused specifically on suicide prevention. Among these are a new, two-part series addressing the latest research and perspectives on preventing suicide, and ways our profession can chart a path forward by working together:

Suicide prevention 1: How we communicate matters

Suicide prevention 2: Lives built on hope

 The Veterinary Equinox can be reached and the excitement of the Animal Kingdom can again be a daily part of our lives.

The question to ask each and every sunrise is described in just three words:   Is it today?

GVEC: Making a Difference-The Global Veterinary Ethics Congress

 

Notes from the: 

Global Veterinary Ethics Congress

The GVEC: Making a Difference!

"Decisions regarding animal care, use, and welfare shall be made by balancing scientific knowledge and professional judgment with consideration of ethical and societal values.   AVMA

The AVMA, as a medical authority for the health and welfare of animals, offers the following eight integrated principles for developing and evaluating animal welfare policies, resolutions, and actions.

• The responsible use of animals for human purposes, such as companionship, food, fiber, recreation, work, education, exhibition, and research conducted for the benefit of both humans and animals, is consistent with the Veterinarian's Oath.
• Decisions regarding animal care, use, and welfare shall be made by balancing scientific knowledge and professional judgment with consideration of ethical and societal values.
• Animals must be provided water, food, proper handling, health care, and an environment appropriate to their care and use, with thoughtful consideration for their species-typical biology and behavior.
• Animals should be cared for in ways that minimize fear, pain, stress, and suffering.
• Procedures related to animal housing, management, care, and use should be continuously evaluated, and when indicated, refined or replaced.
• Conservation and management of animal populations should be humane, socially responsible, and scientifically prudent.
• Animals shall be treated with respect and dignity throughout their lives and, when necessary, provided a humane death.
• The veterinary profession shall continually strive to improve animal health and welfare through scientific research, education, collaboration, advocacy, and the development of legislation and regulations.

Working Together we Can Trace the Footprints to Help the Animal Kingdom! The journey is long and hard but the results can change the world.

Our Journey Continues:

Pandemic Notes from the GVEC............

Is the End of the Global Pandemic in Sight?

Here is What WHO has to say:

Dr. Maria Van Kerkhove, WHO’s technical lead on COVID-19, highlighted that the virus is still “ intensely circulating” around the world and that the agency believes that case numbers being reported are an underestimate.

“We expect that there are going to be future waves of infection, potentially at different time points throughout the world caused by different subvariants of Omicron or even different variants of concern”, she said, reiterating her previous warning that the more the virus circulates, the more opportunities it has to mutate.

However, she said, these future waves do not need to translate into “waves or death” because there are now effective tools such as vaccines and antivirals specifically for COVID-19.

How has the world changed?  We have become more impatient; more self-concerned; more anxious; more angry; and have withdrawn from the active concern for others.

We forget that our health service professionals are still in fox holes of hospital admissions and the care of COVID patients.

Everyone comments that the variants are not that bad.  It is just a bad cold.  That is not completely true as death rates are reported and hospital admissions climb in many states.

How do you explain the importance of Covid Vaccine and its variants?  It cannot be explained because those with closed minds will NEVER become immunized.

A New Health Issue-HRSV-Human Respiratory Syncytial Virus is affecting Children

This fall our country has had a high incidence of Respiratory Syncytial Virus [RSV] being reported. This virus has been around for years but it has made a major return in 2022.

From the Mayo Clinic Staff:

Causes of Human Respiratory Syncytial Virus:

Respiratory Syncytial Virus enters the body through the eyes, nose or mouth. It spreads easily through the air on infected respiratory droplets. You or your child can become infected if someone with RSV coughs or sneezes near you. The virus also passes to others through direct contact, such as shaking hands.

The virus can live for hours on hard objects such as countertops, crib rails and toys. Touch your mouth, nose or eyes after touching a contaminated object and you're likely to pick up the virus.

An infected person is most contagious during the first week or so after infection. But in infants and those with weakened immunity, the virus may continue to spread even after symptoms go away, for up to four weeks.

Risk factors

By age 2, most children will have been infected with respiratory syncytial virus, but they can get infected by RSV more than once. Children who attend child care centers or who have siblings who attend school are at a higher risk of exposure and reinfection. RSV season — when outbreaks tend to occur — is the fall to the end of spring.

People at increased risk of severe or sometimes life-threatening RSV infections include:

• Infants, especially premature infants or babies who are 6 months or younger
• Children who have heart disease that's present from birth (congenital heart disease) or chronic lung disease
• Children or adults with weakened immune systems from diseases such as cancer or treatment such as chemotherapy
• Children who have neuromuscular disorders, such as muscular dystrophy
• Adults with heart disease or lung disease
• Older adults, especially those age 65 and older

Complications

Complications of respiratory syncytial virus include:

• Hospitalization. A severe RSV infection may require a hospital stay so that doctors can monitor and treat breathing problems and give intravenous (IV) fluids.
• Pneumonia. RSV is the most common cause of inflammation of the lungs (pneumonia) or the lungs' airways (bronchiolitis) in infants. These complications can occur when the virus spreads to the lower respiratory tract. Lung inflammation can be quite serious in infants, young children, older adults, immunocompromised individuals, or people with chronic heart or lung disease.
• Middle ear infection. If germs enter the space behind the eardrum, you can get a middle ear infection (otitis media). This happens most frequently in babies and young children.
• Asthma. There may be a link between severe RSV in children and the chance of developing asthma later in life.
• Repeated infections. Once you've had RSV, you could get infected again. It's even possible for it to happen during the same RSV season. However, symptoms usually aren't as severe — typically it's in the form of a common cold. But they can be serious in older adults or in people with chronic heart or lung disease.

Prevention-What we can do!

No vaccine exists for respiratory syncytial virus. But these lifestyle habits can help prevent the spread of this infection:

• Wash your hands frequently. Teach your children the importance of hand-washing.
• Avoid exposure. Cover your mouth and nose when you cough or sneeze. Limit your baby's contact with people who have fevers or colds.
• Keep things clean. Make sure kitchen and bathroom countertops, doorknobs, and handles are clean. Discard used tissues right away.
• Don't share drinking glasses with others. Use your own glass or disposable cups when you or someone else is sick. Label each person's cup.
• Don't smoke. Babies who are exposed to tobacco smoke have a higher risk of getting RSV and potentially more-severe symptoms. If you do smoke, never do so inside the house or car.
• Wash toys regularly. Do this especially when your child or a playmate is sick.

Protective medication

The medication palivizumab (Synagis), given in the form of a shot (injection), can help protect certain infants and children 2 years old and younger who are at high risk of serious complications from RSV. High-risk children in this age group include those who:

• Were born prematurely
• Have chronic lung disease
• Have certain heart defects
• Have a weakened immune system

The first injection is given at the start of the RSV season, with monthly injections given during the season. This medication only helps prevent RSV infection. It does not help treat it once symptoms develop.

Talk with your child's doctor to find out if your child would benefit from this medication and to learn more about it. This medication is not recommended for healthy children or for adults.

Scientists continue working to develop a vaccine to protect against RSV.

The Flu season, COVID Variants, and Human RSV are with us!

We must be vigilant as we move indoors for winter activities and celebrations.

We must follow WHO and CDC recommendations.  We must continue to educate ourselves and read about simple recommendations that can make a difference in our lives.

What Else Can We Do?

But such is the irresistible nature of truth. that all it asks, and all it wants, is the liberty of appearing. Thomas Pain

GVEC PLATFORMS OF ACTION: 

Multi-Concerns----

Working Together----

Partnerships of Concern----

Change can happen!

The GVEC is researching ways to create partnerships to bring excellent animal health care to all Members of the Animal Kingdom.

The Pets of the indigent in need of medical and/or surgical assistance----- without access to emergency and specialty doctors because of financial stress-----is an enormous problem. 

Emotional support companions; those who help PTSD patients; and other therapy dogs........ ALL need assistance in times of need. There may not be income available to buffer the the cost of specialty medicine and surgery. The GVEC is searching for a national vehicle of assistance for these important members of the Animal Kingdom.

Shelter Medicine: 

Addressing and fulfilling the care of abandoned pets; overcrowded shelters; and lack of food for all members of the Animal Kingdom is an ongoing problem. The GVEC supports Shelter Medicine and the veterinarians; nurse technicians; and para-veterinary staff working hard to bring new homes to abandoned members of the Animal Kingdom.

The GVEC will work to partner with One Health to determine ways that veterinarians can contribute to zoonosis identification; control; and public awareness. The exciting coupling and integration of animals; people; and the environment is just beginning to be explored.  The GVEC seeks partnerships with One Health today and tomorrow.  

The GVEC supports the continued development of free range habitats that mimic natural habitats! New habitats and range environments for zoo species is part of our moral commitment to the Animal Kingdom. The GVEC in partnership with the private sector seeks otherpartners to work for species preservation.

The GVEC supports the creation of Veterinary Nurse Practitioner Education Programs to fill the deficiency in veterinarians throughout the United States.

The GVEC will help develop Mentorship Programs to assist new doctors in their journey from academia into clinical and surgical practices.  This mentorship is critical to allow new graduates a forum to verbalize their concerns in their new professional lives.

Telemedicine, APPS, and Hybrid Veterinary Hospitals will be addressed as we move into a new era of veterinary  client- doctor communication.

The GVEC will work with the private sector and the veterinary schools to address burnout; alcoholism; and drug addiction along with suicide prevention.  Proactive systems of help will be developed rather than retroactive capture once the doctor is in serious condition.

This is just the beginning of the construction of a GVEC national highway system of change to brighten the future of new and senior veterinarians; their nurse technicians; para-veterinary personnel; and all members of the Animal Kingdom!

Comments and Partner Communications can be sent to:

DonDeForge100@gmail.com

Acting Chair-Global Veterinary Ethics Congress [GVEC]