When faced with a diagnosis of cancer, invariably the most consistent concern owners have is being assured of maintaining their pets' quality of life. Though they may have trouble with articulation and stumble over word choice, I know they wish to select a treatment plan that refrains from inflicting pain or adverse side effects while simultaneously providing a lifespan longer than would be expected without any additional intervention.
I fiercely agree that quality of life for animals undergoing anti-cancer treatment is important, but I’ve also come to appreciate the attention that must also be focused on the opposing side of the spectrum: We must give credit and recognize the importance of the quality of their death.
What defines dying with quality? What exactly are we are hoping to provide or maintain during this time? How can veterinarians and owners ensure pets are able to die with dignity and respect, worthy of the unwavering companionship they provide during their lives?
To me, a quality death means an animal dies without pain, distress, or discomfort. They die while they are still self-sufficient and ambulatory. And they die without fear and without suffering. If death is a likely consequence of their disease, every effort must be taken to maintain an animal’s dignity and preserve their pride.
To fully understand quality of death, I think we need to clarify the definition of what we mean by palliative and hospice care as these terms relate to animals. Many people use the terms interchangeably when, in truth, the meanings of these terms are quite different.
Palliative care refers to care designed to maintain an animal in a state of self-sufficiency, where we infer (based on both quantitative and qualitative factors) animals are enjoying the things we would define as indicators of a good quality of life. Palliative treatment, by definition, is not designed to prolong life. However, as cures are rare in veterinary oncology, when we successfully palliate adverse signs associated with cancer, we afford pets the ability to live out their remaining time with their disease as more of a “chronic condition,” which often translates into potentially longer survival. Palliative care is active, ongoing, and a huge focus of my career as a veterinary oncologist.
Hospice care occurs when death is pending. There are no further heroic gestures, treatment is ceased, and the focus is on relieving the pain and suffering related to disease. Hospice care allows for the patients and their families to be supported through the process of dying. Hospice care is also active and ongoing, but instead of maintaining quality of life, we are now compelled to provide a quality of death.
In veterinary medicine, and specifically within the specialty of veterinary oncology, there is a remarkably narrow and blurry gap between what constitutes palliative care and hospice care, further confounding our ability to understand the concept of quality of death.
As an example, consider a dog diagnosed with an inoperable oral melanoma tumor. Without treatment, its expected lifespan would be anywhere from a few weeks to maybe a month or so before it would become so debilitated from the disease that we would recommend humane euthanasia. Without euthanasia, the dog would quite literally waste away and, eventually, likely die from dehydration and malnutrition.
Most dogs presenting in such a condition will already be experiencing difficulty ingesting food or water so they may not satisfy my criteria of being self-sufficient. They are likely to be in pain from either the physical presence of the mass, or invasion of the tumor into surrounding bone or muscle. Again, failing one of my main standards for having a quality of life.
In some cases, the lifespan of a dog with inoperable oral melanoma can be extended with additional treatments such as radiation therapy and/or immunotherapy. These actions would not be expected to result in a cure, but would rather be expected to provide temporary palliation of signs, with death being a near inevitable consequence at some point in the future.
Let’s say the chance of success of the treatment is 30 percent, and the chance of some impacting side effect is 25 percent, and the chance of eventual death is near 100 percent. Considering an owner’s (and their oncologist’s) priority is to make sure their pets do not undergo adverse consequences from the options we have for attacking the cancer, how do we decide whether to focus on palliation or hospice care? Do such figures allow us to be comfortable with providing further options, or should we focus truly on the quality of death that is imparted by excellent hospice care?
For some owners, simply hearing me say “There is nothing more I can do” will be enough for them to draw the line and end their pet’s life. Others will need to know they’ve exhausted every option before “giving up” on their beloved companion, trying second, third, and even fourth line protocols, with the hope that something could be successful.
People never hesitate to tell me they think my job has to be hard, or that it must be sad, but likely they underestimate that the absolute hardest and hands-down saddest part of my profession is discussing with owners when I feel that we are at the crossroads between palliation and hospice care for a particular patient. The second most stressful part is feeling confident that I am the one best equipped to make that decision for the pet.
Our concern for the quality of life for animals with cancer prevails, sometimes surprisingly, even to the detriment of achieving our goal of helping them live a longer life. I argue that an equally important effort needs to be made to maintain pets' quality of death. And attention should be paid to both ends to make sure we’re maintaining our responsibility to the legacy they leave us during this most difficult of times.
Fpr more information on the American Veterinary Medical Association’s (AVMA) stance on hospice care, please read Guidelines for Veterinary Hospice Care.
Dr. Joanne Intile