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Private Practice Oncology: Viewpoint on End-of-Life Decision Making

By: SAGE Campbell Medical Director, Dr. Mike Kiselow

KEY POINTS
• Treatment of veterinary oncology patients involves not only aggressive, anti-tumor modalities, but also ongoing palliative care during the transitional period between cessation of therapy and end-of-life.
• Along with treating neoplastic disease, the veterinary team must also consider comorbidities, which may influence the safety and efficacy of anti-tumor therapies.
• Before and after euthanasia of oncology patients, resources for grief management should be provided to family members.
• Successful management necessitates frequent communication among the pet owner, primary veterinarian, and oncologist.

INTRODUCTION

As the cultural view of companion animals continues to evolve, many people perceive pets to be members of their families, equal in importance to their human counterparts. As such, when it comes to the pursuit of health care both preventive and for treatment of disease, there is a demand for high-quality veterinary services, including access to veterinarians specializing in individual areas of medical practice. In no other specialty has this change been as evident as in veterinary oncology, which has experienced rapid growth over the past 3 decades. From the early days of the first- established treatment protocols for canine patients with lymphoma in the 1980s,1 there has been a constantly accelerating expansion of this particular discipline. Large-scale, funded, clinical trials are now commonplace in both veterinary teaching institutions and private practices, and multi-modality treatment regimens including combinations of surgery, radiation therapy, chemotherapy, and immunotherapy represent standard strategies in specialty facilities. Indeed, it is common for families to travel hundreds (in some cases, thousands) of miles to seek out the latest diagnostic and therapeutic options. This behavior has been catalyzed by the concurrent development of Internet-based resources and social media communication tools, which provide instant access to information for owners seeking care for their pets.

In addition to the impact of technologic developments and resulting advanced care, veterinary medicine has also experienced a cultural revolution regarding end-of-life management for companion animals with terminal diseases. Whereas in past generations, pets that failed to respond to prescribed therapies would commonly have treatment discontinued altogether, with no further intervention until the family elected to have them euthanized, today’s pet owners often wish to maintain rigorous care during the transitional period between termination of aggressive treatment and death. Indeed, over the past 10 years, many veterinarians have shifted the focus of their practice toward providing end-of-life care; some are now exclusively dedicated to these services. This has been likened to hospice medicine in the human health care system and often involves time-intensive, in-home visits to provide treatment recommendations that incorporate both symptom management and augmentations to the pets individual environment. Although consistent, standardized definitions of the principles and guidelines under which hospice care should be provided in veterinary medicine are still being developed,2 one common philosophy among practitioners is the need for a patient-centered transition to death, balanced with attention to the individual needs of a pet’s family. This latter component can be multi-dimensional, including services such as pre-emptive and detailed discussions about a pet’s final days and death, non-traditional arrangements for the pet’s body after it is deceased, and provision of resources for grief management.

The impact of this trend on private referral oncology practice has been manifold. Primarily, it is evident in the expectations of clients as well as available options for palliative support beyond standard oncologic care. The role of the oncologist in providing emotional support to clients has also expanded, although no additional standardized training for veterinary oncologists exists to address how to perform this part of the job. This article will provide an overview of private practice oncology referral as it relates to end-of-life issues and decision-making. Its focus is patient care and dynamics between client, oncologist, and referring veterinarian, rather than treatment protocols or biologic behavior of disease. Its goal is to provide a framework for the medical aspects of care, which often dominate treatment planning and client communication.

THE ONCOLOGY REFERRAL

The professional relationship between veterinary specialists and general practitioners is one that continues to evolve as specialization becomes more common, and as the technologies for treating complex, diseases become more advanced and readily available. Developing and fostering this partnership is essential for the provision of the highest- quality care for veterinary patients, and is a responsibility that requires ongoing contributions from both parties.

Most cancers will be initially diagnosed by the primary veterinarian, who may subsequently arrange for referral to a specialty clinic for further diagnostic evaluation and treatment. Effective communication between veterinarians is of paramount importance for providing accurate client education, prompt referral once requested, and optimal management of complex diseases. It is, therefore, the duty of the specialty clinic to request all relevant case information for review before the consultation, and the referring clinic to ensure that complete, concise medical records are submitted in a timely manner.

INITIAL ONCOLOGY CONSULTATION

As most cancers are known to afflict veterinary patients have been well described in peer-reviewed literature, an essential part of the initial oncology consultation involves an assessment of the stage of disease within an individual pet. Not completely understanding this process, many pet owners—frightened by the diagnosis of cancer— will arrive at appointments with a list of questions pertaining to prognosis, clinical signs, and impact of the disease on quality of life. Although these questions are certainly relevant, and are ultimately influential for a client’s decision-making process regarding therapy, performing additional staging diagnostic tests is necessary to provide the most accurate prognostic information.

Equally important is an understanding of comorbidities, which may have significant implications for progression of a specific case—not only for guiding diagnostic and therapeutic recommendations, but also for determining prognosis. Many clients arrive at appointments having already researched their pet’s diagnosis, and therefore have preliminary notions of the outcome. However, it is common for this information to be incomplete and/or incorrect, such that a thorough and clear description of the disease should be provided to rectify any misunderstandings. Furthermore, even if an individual pet’s cancer is treatable, concurrent diseases may complicate—or in some instances completely preclude—anti-neoplastic therapy.

Based on findings from this initial assessment, clear, frank discussions may proceed with outlining objectives for managing a pet’s disease. Clarifying goals, which can be incongruent between pet owners and the veterinary team, is critical for cultivating trust and mutual understanding as diagnostic and treatment plans are formulated. In some cases, a client may have unrealistic expectations—such as avoiding all adverse effects from therapy or ensuring a specific survival time. It is therefore essential to engage in honest, compassionate dialogue so that both established facts and uncertainties of the case are reviewed openly, the client feels comfortable to ask additional questions, and that a mutually agreed upon action plan can be reached. As described previously, the Internet has afforded the current generation of pet owners a unique opportunity to easily research their pets’ diagnoses before consulting with an oncologist. Unfortunately, the quality and reliability of sources that pet owners may encounter online are highly variable, ranging from peer-viewed, scientific literature and veterinarian-sponsored layperson education programs, to pet owner forums and individual blogs. The latter, although potentially helpful for allowing owners to connect and empathize over shared experiences navigating their pets’ diseases, can also lead to the propagation of erroneous information in the form of misunderstanding of pathophysiology and adherence to anecdotal case outcomes that may not accurately reflect established, scientific knowledge.

It is also important to educate clients about the financial implications of working with a specialty hospital. Although monetary conversations can be awkward, especially in the emotionally charged context of a cancer diagnosis, the inevitable reality is that the provision of advanced, anti-neoplastic therapies for companion animals is expensive. Although utilization of veterinary health insurance has become more common in recent years, most owners still pay out-of-pocket for their pets’ medical care. Certainly, the costs of therapy should never be a primary motivating factor for the veterinary medical team. However, it is still essential to be transparent and direct with pet owners regarding anticipated fees. Furthermore, discussions about finances must be guided by the veterinary care team in consideration of an individual patient’s prognosis.

As is common in human oncology, some cancers in animals are diagnosed in advanced stages, and/or are known to be poorly responsive to treatment, such that efforts to control the disease can be futile. It is therefore of paramount importance that veterinarians provide honest and accurate prognostic information so that clients may be guided toward financially responsible decisions. Unfortunately, it is very common for owners to succumb to feelings of fear (“I cannot imagine losing him to this disease”) or guilt (“I could not live with myself if I did not give her every possible chance”), which can result in expensive diagnostics and treatments being performed despite a low likelihood of clinical benefit. It is fairly common for pet owners to insist on therapies that are expected to be of little-to-no value to patients. The concept of medical futility is broadly debated in human medicine, particularly among hospice specialists, and is considered a crucial factor for quality of life scoring. In contrast, this concept receives minimal attention in veterinary curricula and therefore represents an important educational opportunity for veterinarians, who—despite their medical training—are unprepared to navigate these emotionally complex conversations. In addition, the legal status of pets as personal property further complicates the matter, as owners feel entitled to demand specific treatments. Ultimately, if a pet owner’s mind cannot be changed following discussion of the futile nature of a pet’s disease, the veterinarian is not legally obligated to provide elective therapies and has the option of declining care that s/he feels is medically inappropriate.

In contrast, occasionally the diagnosis of an early-stage disease, which may be associated with a favorable prognosis, will prompt the veterinary team to encourage owners to pursue aggressive therapy, or—perhaps subconsciously—to frame prognostic information in a more positive light than would be presented for a patient with advanced disease. Such bias is a well-documented phenomenon.3 However, some clients may not be inclined to pursue such treatment, and instead may elect conservative management, with a shift to less-intensive, palliative care as the disease progresses. In these instances, it is important to respect and support the owners’ decisions, and to continue providing guidance as changes in the pet’s status emerge.

THE TREATMENT PROTOCOL

Once a therapeutic plan is agreed on and enacted, the oncologist should communicate regularly with the patient’s owners. This serves to continually advise them of achievements/progression of the process, as well as to maintain an open dialogue so that questions may be answered as needed. This frequent interaction can be empowering for family members—who may initially feel fearful and submissive to the direction of the doctor—and is therefore essential for building and maintaining trust. Furthermore, if the initial treatment protocol fails and disease progression is noted, the clients should again be educated in a continued effort to support informed decision-making. Depending on the specifics of the individual case, this may involve reviewing basic information provided in the original consultation following a pet’s initial diagnosis, outlining secondary (“rescue”) therapies, or recommending the transition to less-aggressive, palliative care.

The oncologist should also provide frequent updates to the primary veterinarian, particularly when significant changes in patient status are identified (eg, remission, complications from therapy, disease progression). This not only fosters collaboration and professional courtesy but also reduces the risk of medical errors if an unscheduled examination is required with the primary veterinarian, who may not have otherwise seen the patient in several weeks or months.

MANAGING COMORBIDITIES

As most veterinary oncology patients are adult-to-geriatric in age, many will present with one or more pre-existing medical conditions. Although usually unrelated to their oncologic diagnosis, these comorbidities may influence diagnostic and/or therapeutic options for their cancers. For example, a cat with an injection-associated fibrosarcoma and chronic renal failure may be at risk for exacerbation of azotemia when anesthetized for a staging computed tomography scan (which typically involves administration of potentially nephrotoxic contrast agents); an obese, arthritic dog with appendicular osteosarcoma may be a poor candidate for amputation because of expected difficulties with ambulation following surgery; a canine patient with lymphoma and pre-existing cardiomyopathy may not be able to safely receive doxorubicin chemotherapy because of its known cardiotoxic effects.

Fortunately, it is uncommon for concurrent diseases to completely impede treatment of cancer. Nevertheless, it is the responsibility of the managing oncologist to work collaboratively with the primary veterinarian, and with other specialists, to ensure all relevant diseases are considered appropriately. Indeed, management of oncology patients in a specialty facility typically allows for rapid, in-house consultation among doctors to augment treatment regimens regularly for continual refinement of care. These strategies must also be clearly conveyed to the pet owners, who should be aware of not only the potential complications of treating multiple diseases, but also of the additional logistical and financial implications.

END-OF-LIFE CARE IN ONCOLOGY PRACTICE

In the context of veterinary oncology, many patients’ diseases will ultimately result in their death, even with aggressive treatment efforts. As such, discussions regarding end-of-life care can be just as important as those outlining complex treatments focused on trying to control progression of cancer. Indeed, on learning of cancer diagnosis, many pet owners will decline anti-tumor therapy, and will instead focus efforts on conservative, palliative strategies. Furthermore, even when clients initially elect aggressive therapies, many still request information about prognosis and end-of-life management to prepare themselves logistically and emotionally for their eventual loss. Such conversations may certainly be guided by the primary veterinarian. However, some clients—and even some veterinarians—still prefer referral to an oncologist to ensure that all information regarding the biologic behavior of a particular disease and treatment options are understood, including options for palliative care.

Many oncology patients will eventually develop clinical signs that significantly affect quality of life. It is common for owners to not understand the severity of their pets’ decline and clinical signs. It is therefore incumbent on the veterinary care team to serve as the patient’s advocate and to guide clients toward palliative therapies, including euthanasia if deemed medically appropriate and in the patient’s best interests. If primary, anti-neoplastic therapy is discontinued (due to exhaustion of options, severity of clinical signs, and/or client decision), strategies for palliative care should be considered. These will vary depending on type/stage of cancer, as well as the specific signs experienced by an individual patient. Treatments may include, but are not limited to, anti-emetic/anti-diarrheal medications, analgesics, diuretics, antitussives, antibiotics, acupuncture, and physical therapy. Palliative measures are also provided by oncologists along with targeted, curative therapies throughout the treatment trajectory. Palliative therapies may include strategies that are more technologically and logistically involved, yet are still primarily focused on mitigating clinical signs of a disease. Examples include placement of urethral stents to alleviate obstruction from transitional cell carcinoma4; application of brief courses of radiation therapy for curbing epistaxis from intra-nasal tumors5; administration of bisphosphonates for reducing pain associated with primary and metastatic bone tumors.6 Although some of these modalities may certainly slow the progression of cancer, their principal goal is palliative, not life-prolonging in nature, and the intensity of treatment may be attenuated to minimize adverse effects.

Euthanasia in Oncology Practice

Traditionally, euthanasia for companion animals has been performed in the veterinary clinic. Families would occasionally inquire about the possibility of having it done at home, but this service was largely unavailable. However, this model has shifted over the past decade, and in-home, end-of-life care is now commonplace. In this au- thor’s experience, pet owners’ responses to this option are variable: some are relieved to know their pet does not need to endure the stress of a car ride before euthanasia. In contrast, others quickly express discomfort with the prospect of seeing their deceased pet in their home. Nevertheless, all appreciate learning of the option. It is therefore important for both primary and specialty veterinarians to be familiar with these services, and to develop professional relationships with in-home providers to facilitate referrals for euthanasia when requested.

Whether euthanasia is performed in the veterinary clinic or in a pet owner’s home, the experience should be conducted to help the family feel as comfortable as possible. In addition to honing the medical and technical aspects of euthanasia, attention to interpersonal relationships can help to transform what may be perceived as an abrupt, one-dimensional procedure into a shared, human experience between family and veterinarian. Indeed, this may help to diffuse emotional tension not only for the grieving family, but also for the veterinary team, which also often feels personally invested in the patient after having provided long-term care.

Continuous support of the primary veterinarian is of paramount importance when managing animals that are referred to an oncologist following a diagnosis of cancer. This includes the need for immediate notification following the euthanasia of a mutual patient. Not only does this allow for the primary veterinary clinic staff to extend its sympathy, but also helps to avoid the potentially awkward scenario in which the veterinarian unknowingly contacts the client for a status update and inadvertently upsets members of the family.

Human Support in Oncology Practice

Although euthanasia often represents the final step in relief of suffering associated with the progression of a patient’s cancer, further attention to the pet’s family members is also warranted, as clients’ grief typically continues long after the final encounter with the veterinary team. Along with the extension of simple, yet meaningful, gestures such as sympathy cards and flowers, veterinarians should also provide pet owners with information regarding options for grief support. Although compassionate euthanasia practices are likely to minimize complicated grief, many clients will still benefit from additional and ongoing emotional support. This requires both time commitment and professional training beyond veterinarians’ scope of practice. Fortunately, social workers are being integrated into more veterinary practices, and there are numerous resources that are readily accessible by phone and the Internet.7 Furthermore, as the concepts of professional burnout, moral distress, and compassion fatigue continue to be defined and evaluated within the veterinary profession, licensed mental health support services are being extended to the veterinary care team in addition to clients.8

Currently, the author’s organization (comprised of 4 clinics within a 70-mile radius) employs a Licensed Marriage and Family Therapist who is also a certified pet loss and bereavement counselor. She provides free services to people in various stages of emotional distress associated with their pets’ illnesses. These occur as anonymous telephone conversations, and as group meetings with multiple families (rotating among facilities). Both opportunities are used regularly, and have been very well received by our clientele. In addition, in an effort to support the veterinary staff, this counselor leads sessions intended to define common workplace stressors and to brainstorm solutions for lessening their impact on wellbeing.
Accompanying the positive feedback related to this service has been the realization that it needs to be expanded to provide broader access—for clients and for employees. Indeed, the psychological needs of people facing the impending loss of their pet often exceed the availability and professional training of the veterinary staff. As such, supporting dedicated, on-site, mental health professionals is an area of active development, not only in our organization, but also within many veterinary teaching institutions and private specialty hospitals.

UNIQUE END-OF-LIFE CARE EXPERIENCES IN ONCOLOGY PRACTICE

Veterinary oncologists engage in conversations about death—and provide euthanasia—on a frequent basis. Nevertheless, it is important to remain present and open-minded for each family, as needs can vary. In this author’s experience, following descriptions of routine end-of-life options, most owners elect for euthanasia to occur in the veterinary clinic. This often takes place in the specialty hospital, although some people decide to return to their primary veterinarian. Occasionally, unique requests are made based on an individual family’s beliefs and/or specific end-of-life plan for the pet. As long as these do not negatively affect the patient, every effort is made to accommodate these final wishes. Examples have included.

Having Other Family Pets Present

Some people express concern about the emotional impact of the loss of one pet on other animals in the home. They therefore bring these housemates to witness the act of euthanasia in effort to provide them with the opportunity to recognize the loss.

Witnessing Sedation Only

In the author’s clinic, barbiturate administration is preceded by heavy sedation (typically Propofol). Although most family members remain present until their pet is pronounced dead, some will ask to leave between medications (ie, following sedation, but before barbiturate).

Not Being Present

Rarely, pet owners decline being present for euthanasia, and instead elect to leave the clinic before the pet is deceased. Similar situations have occurred for patients that are hospitalized for several days, wherein the election of euthanasia is made over the phone, and the family decides to not return to the clinic. These instances have been particularly challenging for the veterinary staff, who are emotionally invested in the patients, and who—although usually in support of the decision to euthanize—will commonly express their dismay at the notion of the patient not having family present for its final moments. Once confirmed (verbal authorization for euthanasia involves pet owners sharing their decision with 2 doctors for documentation), euthanasia is performed immediately. Afterward, this author invites feedback from the nursing team to provide an opportunity for case debriefing and sharing of any concerns.

Request for “Natural” Death

Occasionally, people express an intention to never euthanize their pet, often citing religious or other personal beliefs. This decision has the potential to elicit criticism from the veterinary staff. Indeed, this is a product of the culture of modern veterinary medicine, wherein the unofficial dogma states that pets should ultimately die from chemical intervention. This is an intriguing contrast to human medicine, in which doctor- facilitated death has only recently started to gain societal acceptance. Nevertheless, it is important to foster a direct, respectful conversation, involving an explanation of the reasons for this choice, as well as an understanding of the family’s alternative end-of-life plan for their pet. In this author’s experience, many pet owners change their minds after understanding the anticipated clinical signs associated with progression of their pets’ diseases, and ultimately elect euthanasia. However, for those whose minds are unwavering, it is essential that the veterinary team remains actively involved to provide both guidance and continued, non-lethal medical treatments to minimize pain, anxiety, and any other clinical signs observed during a pet’s dying process.

Request for Cloning

Among the myriad commercial services that have accompanied the evolution of biotechnology over the past 20 years are options for pet owners to replicate their deceased pets. These products are marketed directly to pet owners, and only involve veterinarians for the step of sample retrieval. Owners purchase “kits,” which include vials of preservation media for patient tissues (typically multiple skin biopsies, collected immediately post-mortem), that are returned to the companies by the pet’s family. In this author’s experience, cloning requests are often met by the staff with skepticism, but have rarely been decried as ethically objectionable.

Overall, these experiences have served as profound educational moments, such that end-of-life plans do not—and should not—always proceed according to a single, rigid protocol. Quite the contrary; in this era when pets are considered family members, it is essential that every [medically sound] effort be made to grant clients’ final wishes to optimize healthy grieving following the loss of their animal.

Finally, it is common for oncology patients treated in private specialty hospitals to have been managed by a variety of doctors within different departments. As such, the emotional impact of patient death is often felt by several members of the doctor and nursing staff. Therefore, along with providing logistical and grief-related support for the pet’s family, it is important to acknowledge the shared sense of loss among the medical team. This occurs both formally and informally in this author’s clinic, from impromptu debriefings and collegial support, to official morbidity and mortality rounds, wherein cases are reviewed extensively to identify and learn from unique/un- expected challenges encountered before death.

SUMMARY

Despite the many advances achieved over the past 30 years within the specialty of veterinary oncology, many patients still ultimately succumb to their disease. Therefore, as clinical research continues and new therapies are developed, concurrent effort must also be lent to the ongoing education of veterinarians and pet owners regarding the many available treatment options for patients with terminal disease, as well as when and whether to use them. As outlined herein, this involves not only an understanding of pathophysiology and mechanisms of palliative therapies, but also an awareness of the emotional and psychological needs of pet owners as they proceed through their grieving process. Finally, a commitment to supporting clients through end-of-life management of their pets can also help the veterinary care team achieve personal closure following the loss of patients.

REFERENCES

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