Special Challenges of End-of-Life Care

1. Special Challenges of End-of-Life Care Franklin D. McMillan, DVM, DACVIM (SAIM) Best Friends Animal Sanctuary Kanab, Utah

2. END OF LIFE CARE In medical care, many of the considerations at the end of life differ considerably from those at other stages of a patient’s life • The determination of when treatment is more harm than good • The doctor’s duties to the patient • The subject of the clinician’s allegiance • The emotional impact of the situation • Questions regarding who best knows and decides the patient’s best interests • The weighting of interests • Whether euthanasia or natural death is the best death • The absolute finality of decisions With the exception of the most obvious issue of euthanasia, the issues in human medicine and veterinary medicine are very similar

3. A COMMON GOAL…RIGHT? • In veterinary medicine there is virtually no disagreement among all involved parties—the pet owner/caregiver(s), the veterinarian, society, and, and (presumably) the animal patient—as to what the overriding primary goal is in caring for an ill animal: maximize quality of life • And a generally strong consensus sees the single most important part of this goal: relieve all relievable suffering • In light of this remarkable uniformity of thought it seems surprising that there could be so much disagreement as to what is the ‘right’ thing to do. If everyone is working toward the same goal, how can so much conflict develop in getting there?

4. The foremost responsibility in all animal care To protect the animal against all of the hurts, discomforts, and pains that life can inflict on him This protection extends from the animal’s birth to his/her final moment of death

5. OUR GOAL (figuratively)

6. THE FOCUSComfort and Discomfort

7. THE FOCUSComfort and Discomfort

8. THE FOCUSComfort and Discomfort

9. THE FOCUSComfort and Discomfort

10. SOURCES OF DISCOMFORT • PHYSICAL • Hypoxia • Pain • Disease • Nausea • Toxicity • Pruritus • Cough • Dizziness • Thirst • Hunger • Full urinary bladder • Constipation • Temperature extremes • EMOTIONAL • Fear • Anxiety • Boredom • Loneliness/Social isolation • Separation anxiety/distress • Grief • Depression • Frustration • Anger • Helplessness • Hopelessness

11. Comfort-Discomfort Continuum comfort DISCOMFORT Goal of behavior

12. Comfort-Discomfort Continuum DISCOMFORT comfort SUFFERING SUFFERING Goal of behavior

13. Comfort and discomfortin everyday animal life What animals spend their lives doing: Seek comfort and avoid discomfort The Basic Rule of Living

14. Comfort in Health Care • Why is health desirable? • Disease creates discomfort • Relief of discomfort – leading reason people seek medical care • “dis-ease” • dis- (reversal) and aise (ease) • The dis-eased body is without comfort • Restoring health restores comfort

15. Comfort-Discomfort Continuum DISCOMFORT comfort SUFFERING Goal of behavior

16. Comfort-Discomfort Continuum DISCOMFORT comfort SUFFERING

17. Comfort in Health Care • The animal brought to the veterinarian for illness or injury desires one thing: comfort • Animals don’t care about health – theyonly care about how they feel. They (and we) just want to feel good. And they don’t care if the unpleasant feelings are health-related or from some other cause.

18. The experience of discomfort(pain, distress, suffering)A Schematic View STIMULUS (CAUSE) BRAIN/MIND TRANSMISSION FROM SENSORY PERCEPTION TO BRAIN SENSORY PERCEPTION

19. Protecting the animal from discomfort BLOCK THE EXPERIENCE OF DISCOMFORT 1st – At the cause – restore health, remove sources of fear, etc. 2nd – At the origin – NSAIDS, H2 blockers 3rd – Between the source and the mind Block the transmission before it reaches the mind to become an experience -- epidural, nerve blocks, acupuncture 4th – At the mind – drugs (e.g., narcotics, anxiolytics, antidepressants, antiemetics)

20. The experience of discomfort(pain, distress, suffering)A Schematic View STIMULUS (CAUSE) BRAIN/MIND TRANSMISSION FROM SENSORY PERCEPTION TO BRAIN SENSORY PERCEPTION

21. Protecting the animal from discomfort BLOCK THE EXPERIENCE OF DISCOMFORT 1st – At the cause – restore health, remove sources of fear, etc. 2nd – At perception – NSAIDS, H2 blockers 3rd – Between the source and the mind Block the transmission before it reaches the mind to become an experience -- epidural, nerve blocks, acupuncture 4th – At the mind – drugs (e.g., narcotics, anxiolytics, antidepressants, antiemetics)

22. The experience of discomfort(pain, distress, suffering)A Schematic View STIMULUS (CAUSE) BRAIN/MIND TRANSMISSION FROM SENSORY PERCEPTION TO BRAIN SENSORY PERCEPTION

23. Protecting the animal from discomfort BLOCK THE EXPERIENCE OF DISCOMFORT 1st – At the cause – restore health, remove sources of fear, etc. 2nd – At perception – NSAIDS, H2 blockers 3rd – Between perception and the mind Block the transmission before it reaches the mind to become an experience -- epidural, nerve blocks, acupuncture 4th – At the mind – drugs (e.g., narcotics, anxiolytics, antidepressants, antiemetics)

24. The experience of discomfort(pain, distress, suffering)A Schematic View STIMULUS (CAUSE) BRAIN/MIND TRANSMISSION FROM SENSORY PERCEPTION TO BRAIN SENSORY PERCEPTION

25. Protecting the animal from discomfort BLOCK THE EXPERIENCE OF DISCOMFORT 1st – At the cause – restore health, remove sources of fear, etc. 2nd – At perception – NSAIDS, H2 blockers 3rd – Between perception and the mind Block the transmission before it reaches the mind to become an experience -- epidural, nerve blocks, acupuncture 4th – At the mind – drugs (e.g., narcotics, anxiolytics, antidepressants, antiemetics)

26. The experience of discomfort(pain, distress, suffering)A Schematic View STIMULUS (CAUSE) BRAIN/MIND TRANSMISSION FROM SENSORY PERCEPTION TO BRAIN SENSORY PERCEPTION

27. Things that prevent the successful relief of discomfort • Limitations of medical knowledge • Medical science • Individual • Equipment, facilities • Financial limitations BUT… we aren’t always successful in blocking the discomfort

28. Protection from discomfort WHEN WE CAN’T STOP THE DISCOMFORT FROM REACHING THE MIND PUT THE MIND IN A PROTECTED STATE Interrupt consciousness • Temporary  general anesthesia • Permanent  euthanasia

29. Comfort-Discomfort Continuum Alleviating discomfort DISCOMFORT SUFFERING comfort Goal of behavior

30. When MENTAL Health Cannot Be Restored EMOTIONAL SUFFERING • Emotional vs physical pain • Trauma victims with deep emotional scars – some simply can never regain a life of emotional comfort • Not a “behavior problem”

31. When MENTAL Health Cannot Be Restored EMOTIONAL SUFFERING • Emotional vs physical pain • Trauma victims with deep emotional scars – some simply can never regain a life of emotional comfort • Not a “behavior problem”

33. When Comfort Cannot Be Restored When all available tools fail to adequately relieve discomforts Euthanasia The elimination of discomfort in the only effective way left

34. OUTCOMES AND OBJECTIVESOF EUTHANASIA Euthanasia has 2 outcomes 1. Ending discomfort 2. Ending life

35. Euthanasia has 2 outcomes 1. Ending discomfort 2. Ending life OUTCOMES AND OBJECTIVESOF EUTHANASIA • We do not know how to separate these outcomes for many medical disorders • Can’t obtain the outcome we want without also getting the one we don’t want • Technological advancements uncouple the two – we can choose only the one we want

36. Normal canine hip Severe bilateral hip dysplasia with secondary osteoarthritis

39. Euthanasia has 2 outcomes 1. Ending discomfort 2. Ending life

40. Euthanasia is not an act to end a life, it’s an act to end discomfort

41. Quality of life and euthanasia

42. The Scales Model of Quality of Life Quality of life is represented by a balance of the pleasant and unpleasant feelings of life over time

43. Quality of Life PLEASANT FEELINGS UNPLEASANT FEELINGS

44. Quality of life as disease progresses The scales will tip increasingly toward unpleasant feelings

45. QOL

46. QOL

47. QOL

48. Euthanasia – how do we determine when “it’s time”? • Is there a right time? • If so, how do we know we’ve reached it? • What would determine that it is “too soon”? • “too late”? • If we use QOL as our determining factor, how do we characterize QOL at the point where it is time for euthanasia?

49. “You’ll just know.”   “Look at Emma with your questions and she will tell you and communicate in some way when the time is right.” Owner: “How will I know when the time comes? What do I do? I can’t go through this.” The answer to the first question should rest with the pet. Advise the family that their old pal will give them a clear sign. The signs may be physical, such as unresponsive vomiting, uncontrollable diarrhea, dyspnea, crying, and loss of mentation or slipping into a moribund state… When counseling caregivers, you might say, “Look into Stormy’s eyes and he will tell you when it’s the right time for him to go. The message will be clear and you will know…” Veterinarians are frequently asked, “When is the right time to euthanize my beloved pet? How will I know?” I tell them, “One day, you will just know it is the right time because your pet will tell you with a look or a gesture, a sign or a series of bad days.”

50. “You’ll just know.” “I will?” • Will you see a SIGN? • How will you recognize a sign? • What will you do when you see a sign? Anorexia: “Patients with inappetance often need to be hand or force fed to maintain a proper nutritional status.”