Companion Animal End of Life Care for the Veterinary Technician

List of Contributors xvii

Acknowledgments xix

Introduction xxi

About the Companion Website xxv

Part I Overview of Hospice and Palliative Care 1

1 Introduction to Animal Hospice and Palliative Care 3
Alyssa Eslinger

1.1 Introduction 3

1.2 Terminology and Definitions 4

1.3 Psychosocial Considerations 5

1.4 The Interdisciplinary Team 5

1.4.1 Role of Veterinary Technicians 8

1.4.2 Role of Veterinary Social Workers 8

1.4.3 Effective Use of Interdisciplinary Teams 9

1.5 Hospice Care Approach 9

1.6 End-of-Life Care Delivery Models 10

1.6.1 Role of Telemedicine 11

1.6.2 Informed Consent and Liability Considerations 13

1.7 Takeaways 13

References 13

2 Pain Recognition and Assessment 15
Alyssa Eslinger and Amy Birchall

2.1 Introduction 15

2.2 The Physiology and Classification of Pain 15

2.2.1 Somatic and Visceral Pain 17

2.2.2 Acute vs Chronic Pain 17

2.2.3 Neuropathic Pain 17

2.3 Pain Recognition 18

2.3.1 Fear, Anxiety, Stress, and Pain Recognition 19

2.4 Pain Assessment Tools 20

2.4.1 Simple Pain Scales 20

2.4.2 Multidimensional Acute Pain Scales 21

2.4.3 Multidimensional Chronic Pain Scales 22

2.5 Practical Pain Assessment 28

2.6 Caregiver Communication and Education 29

2.6.1 Caregiver Myths and Misconceptions 29

2.7 Takeaways 30

References 31

3 Pain Management 33
Alyssa Eslinger

3.1 Introduction 33

3.2 Role of Veterinary Technicians and Approach to Pain Management 33

3.3 Pharmaceutical Pain Management 35

3.3.1 NSAIDs 35

3.3.2 Opioids 36

3.3.3 Corticosteroids 38

3.3.4 Gabapentinoids 38

3.3.5 NMDA Receptor Antagonists 39

3.3.6 Other Adjunctive Analgesics 40

3.3.6.1 Local Anesthesia 41

3.3.6.2 Monoclonal Antibody Therapy 41

3.3.6.3 Bisphosphonates 41

3.3.6.4 Cannabidiol 41

3.4 Physical Modalities 42

3.4.1 Manual Therapy Techniques 43

3.4.2 Thermotherapy 43

3.4.3 Therapeutic Laser 43

3.4.4 Electrotherapy 44

3.4.5 Therapeutic Ultrasound and Extracorporeal Shockwave Therapy 45

3.4.6 Acupuncture 47

3.5 Nutrition, Nutraceuticals, and Herbal Medicine 47

3.5.1 Nutrition 47

3.5.2 Chondroprotectants 48

3.5.3 Herbal Medicine 48

3.6 Pain Management Case Studies 48

3.6.1 “Leo” – Canine Osteosarcoma 48

3.6.2 “BB” – Feline Osteoarthritis and Intestinal Lymphoma 49

3.7 Exotic Pet Pain Management 50

3.8 Caregiver Education and Communication 51

3.9 Takeaways 51

References 52

4 Hospice and Palliative Nursing Care 55
Alyssa Eslinger

4.1 Introduction 55

4.2 General Comfort Care 56

4.2.1 Environmental Modifications 56

4.2.2 Mobility 57

4.2.3 Hygiene and Toileting 60

4.2.4 Nutrition 61

4.2.5 Mucous Membrane Comfort 63

4.2.6 Fluid Support 63

4.2.7 Medication and Treatment Administration 64

4.2.8 Mental and Emotional Wellbeing 65

4.3 Sign-Specific Nursing Care 65

4.3.1 Recumbency 66

4.3.2 Wounds 66

4.3.3 Gastrointestinal Signs 67

4.3.4 Respiratory Distress 67

4.3.5 Musculoskeletal Signs 68

4.3.6 Neurological Signs 68

4.3.6.1 Neuromuscular or Spinal Disease 68

4.3.6.2 Intracranial Disease 69

4.3.6.3 Cognitive Dysfunction (CD) 69

4.3.7 Neoplastic Signs 69

4.4 Comfort Kits 70

4.5 Takeaways 73

References 74

5 Understanding and Assessing Quality of Life 75
Alyssa Eslinger

5.1 Introduction 75

5.2 Quality-of-Life Assessments 76

5.2.1 Effective Use of Quality-of-Life Assessments 76

5.3 Components of Quality-of-Life Assessments 78

5.3.1 Physical Wellbeing 78

5.3.2 Social Wellbeing and Mental Stimulation 79

5.3.3 Emotional Wellbeing and Autonomy 80

5.3.4 Other Considerations 80

5.3.4.1 Global Score 80

5.3.4.2 Caregiver Burden 80

5.4 Sel‎ected Quality-of-Life Assessment Tools 80

5.4.1 Sel‎ected Quality-of-Life Assessments 81

5.4.2 Individualized Quality-of-Life Questionnaire 83

5.5 Role of Telemedicine 85

5.6 Large Animal and Exotics Considerations 87

5.7 Takeaways 87

References 88

Part II End-of-Life Communication and Decision-Making 91

6 Building Essential Communication Skills 93
Joye Sears and Becky Taylor

6.1 Introduction 93

6.2 Core Communication Skills 93

6.2.1 Nonverbal Communication 94

6.2.2 Asking Questions 95

6.2.3 Active Listening 97

6.2.4 Showing Empathy 100

6.3 Emotional Intelligence 101

6.3.1 Self-Awareness 102

6.3.2 Self-Management 103

6.3.3 Social Awareness 104

6.3.4 Relationship Management 104

6.4 Team-Based Communication 104

6.4.1 Getting the Team on Board 104

6.4.2 Building Skills Within the Team 105

6.5 Takeaways 105

References 105

7 Supporting Difficult Conversations 107
Joye Sears

7.1 Introduction 107

7.2 Difficult Clients vs Difficult Situations 107

7.3 Applying Communication Skills to Difficult Conversations 108

7.3.1 Partnership Statements 108

7.3.2 Warning Shots 108

7.4 A Model for End-of-Life Conversations 109

7.4.1 Setting 109

7.4.2 Perspective 109

7.4.3 Invitation 109

7.4.4 Knowledge 109

7.4.5 Empathize 110

7.4.6 Summarize and Strategize 110

7.5 Conflict Resolution 110

7.6 Types of Difficult Conversations 112

7.6.1 Grief 112

7.6.2 Delivering Bad News 112

7.6.3 Anger 113

7.6.4 Financial Conflict 114

7.6.5 Disagreement Within the Team 116

7.6.6 Disagreement Among Caregivers 119

7.7 Assess for Success 121

7.8 Takeaways 121

References 121

8 Ethical End-of-Life Decision-Making 123
Alyssa Eslinger

8.1 Introduction 123

8.2 Communication in EOL Decision-Making 124

8.3 Caregiver Perspectives on EOL Decision-Making 124

8.3.1 Conflicting Caregiver Perspectives 127

8.4 Factors for Veterinary Team Consideration in EOL Decision-Making 128

8.4.1 Quality-of-Life Assessments in EOL Decision-Making 128

8.4.2 Caregiver Burden and EOL Decision-Making 129

8.4.3 Caregiver Preferences and Euthanasia Timing 130

8.5 Considerations for Hospice-Supported Natural Death 131

8.6 Ethical Dilemmas and Moral Stress 132

8.6.1 Convenience Euthanasia 133

8.7 EOL Decision Documentation and Debriefing 134

8.8 Takeaways 134

References 134

9 Death and Dying 137
Alyssa Eslinger

9.1 Introduction 137

9.2 Animal Experience of Dying 138

9.2.1 Signs of Dying 138

9.2.2 Signs of Death 140

9.3 Natural Death vs Hospice-Supported Natural Death 140

9.4 Informed Consent for Hospice-Supported Natural Death 142

9.5 Ethical Challenges in Hospice-Supported Natural Death 143

9.6 Nursing Care in Hospice-Supported Natural Death 145

9.6.1 Environment and General Comfort 146

9.6.2 Anxiety 146

9.6.3 Pain 146

9.6.4 Nutrition and Fluids 147

9.7 Takeaways 147

References 148

Part III Euthanasia 149

10 Providing a Compassionate Euthanasia Experience 151
Kathleen Cooney

10.1 Introduction 151

10.2 Defining Euthanasia and Dysthanasia 152

10.3 Meaningful Components of the Euthanasia Appointment 154

10.3.1 Grief Support Materials Provided 155

10.3.2 Outline Caregiver and Pet Preferences 155

10.3.3 Offer Privacy Before and After Death 156

10.3.4 Deliver Proper Technique 156

10.3.5 Establish Rapport 156

10.3.6 Use Pre-euthanasia Sedation or Anesthesia 157

10.3.7 Thorough, Complete Consent 157

10.3.8 Helpful and Compassionate Personnel 157

10.3.9 Adequate Time 157

10.3.10 Narrate the Process 158

10.3.11 Avoid Pain and Anxiety 158

10.3.12 Safe Space to Gather 158

10.3.13 Inclusion of Loved Ones 158

10.3.14 Assistance with Body Care (Aftercare) 158

10.4 Technicians in the Role of Euthanasia Provider 159

10.5 Communicating Effectively Before, During, and After Euthanasia 160

10.5.1 Establish Rapport 161

10.5.2 Find Comfort with Silence 162

10.5.3 Use the Basics of Good Communication 162

10.5.4 Offer Praise 162

10.5.5 Piece It Out 163

10.5.6 Create Partnership 164

10.5.7 Attend to Emotional Intelligence 164

10.6 Medical Records 165

10.7 Takeaways 165

References 166

11 Anatomy of a Humane Euthanasia 167
Kathleen Cooney

11.1 Introduction 167

11.2 Technicians as Euthanasia Attendants 167

11.3 Euthanasia Methods and the Physiology of Death 168

11.3.1 Methods of Euthanasia 168

11.3.2 Body Changes 169

11.4 Pre-euthanasia Sedation and Anesthesia Protocols 171

11.4.1 Effects of Pre-euthanasia Sedation and Anesthesia Protocols 173

11.4.2 Administration of Pre-euthanasia Sedation or Anesthesia 174

11.5 Euthanasia Room Comforts 177

11.5.1 Euthanasia in the Hospital Setting 177

11.5.2 Euthanasia in the Home Setting 179

11.6 Balancing EOL Work and Well-Being 180

11.7 Takeaways 181

References 181

12 Euthanasia Techniques in Companion Animals 183
Kathleen Cooney

12.1 Introduction 183

12.2 Euthanasia Injection Techniques 185

12.2.1 Intravenous (IV) Injections 186

12.2.2 Intracardiac (IC) Injections 188

12.2.3 Intrarenal (IR) Injections 190

12.2.4 Intrahepatic (IH) Injections 191

12.2.5 Intraperitoneal (IP) Injections 193

12.3 Alternative Euthanasia Administration Techniques 194

12.3.1 Oral Administration of Euthanasia Drugs 194

12.3.2 Intrathecal Anesthetic Euthanasia 194

12.3.3 Physical Methods of Euthanasia 194

12.3.4 Euthanizing Fetuses 195

12.4 Physical Changes During Death and Pronouncing Death 195

12.5 Exotic Pet Considerations 197

12.5.1 General Considerations for Patient Comfort 198

12.6 Unique Circumstances 199

12.7 Takeaways 200

References 201

13 Respectful Deceased Body Care 203
Kathleen Cooney

13.1 Introduction 203

13.2 Aftercare Ordering Models 205

13.2.1 Veterinary Aftercare Ordering Model (VAOM) 205

13.2.2 Client Aftercare Ordering Model (CAOM) 205

13.3 Respectful Body Containment 205

13.4 Moving a Deceased Body 208

13.5 Modern Options in Aftercare 209

13.5.1 Cremation 211

13.5.2 Burial 212

13.5.3 Aquamation 214

13.5.4 Body Preservation 215

13.5.5 Educational Memorial Body Donation 216

13.6 Minimizing Aftercare Mistakes and Exceeding Expectations 217

13.7 Expected Postmortem Changes and Decomposition 218

13.7.1 Decomposition 219

13.8 Takeaways 221

References 221

Part IV Grief and Memorialization 223

14 Introduction to Grief 225
Sarah Bernardi

14.1 Introduction 225

14.2 The Fundamentals of Grief 225

14.3 The Human–Animal Bond: A Unique Loss 227

14.3.1 Guilt and Regret 229

14.3.2 Anger 231

14.4 Recognizing Grief Responses 231

14.4.1 Uncomplicated Grief 231

14.4.2 Disenfranchised Grief 232

14.4.3 Anticipatory Grief 232

14.4.4 Prolonged Grief Disorder and Suicidality 234

14.5 Factors Impacting Grief Responses from Pet Loss 234

14.5.1 Euthanasia 235

14.5.2 Sudden Loss 236

14.5.3 Loss of Service Animals 236

14.5.4 Culture and Spirituality 237

14.5.5 Perceived Social Support 238

14.5.6 Age 239

14.6 Considerations for a Grieving Pet 241

14.7 Takeaways 241

References 243

15 Pet Loss Support 245
Sarah Bernardi

15.1 Introduction 245

15.2 Language Sensitivity in Grief Support 246

15.3 Providing Grief Support and Memorialization 246

15.3.1 Aftercare Services 246

15.3.2 Memorial Activities and Keepsakes 249

15.3.3 Follow-Up Care and Support 252

15.3.3.1 Post-Death Phone Call 252

15.3.3.2 Sympathy Cards 253

15.3.3.3 Picking Up Remains 255

15.4 Developing a Pet Loss Resource Guide 255

15.4.1 Essential Components of a Pet Loss Resource Guide 255

15.5 Addressing Specific Grief Responses 256

15.5.1 Anticipatory Grief: Preparing Caregivers 256

15.5.2 Integrating Cultural Sensitivity in Grief Support 258

15.5.3 Integrating Spiritual Sensitivity in Grief Support 259

15.5.4 Supporting Grieving Pet Owners with Suicidal Ideation 259

15.6 Takeaways 260

15.a Pet Loss Resource Guide Template 262

15.b Suicide Response Guidelines for Veterinary Practices 263

References 264

16 Children and Pet Loss 267
Sarah Bernardi and Amy Sugar

16.1 Introduction 267

16.2 The Role of Technicians in Supporting Families with Children 268

16.3 Children’s Perceptions and Age-Specific Advice 269

16.4 Talking to Children About Death and Loss of a Pet 272

16.4.1 Use Simple and Direct Language 272

16.4.2 Validate Feelings 272

16.4.3 Be Patient and Nonjudgmental 274

16.4.4 Avoid Euphemisms 275

16.4.5 Avoid Lying 275

16.4.6 Avoid Blame 276

16.4.7 Spiritual and Religious Considerations 276

16.4.8 Parent/Caregiver Resources for Children of All Ages 277

16.5 Supporting Children Through Diagnosis and Treatment of a Pet’s Serious Illness 278

16.6 Involvement of Children Through Euthanasia 279

16.6.1 Preparing the Family for Euthanasia 279

16.6.2 Explaining Euthanasia to Children 280

16.6.2.1 Why Is This Happening? 280

16.6.2.2 What Does It Mean? 280

16.6.2.3 How Does It Happen? 281

16.6.3 The Presence of Children During Euthanasia 281

16.6.3.1 Children Under the Age of Five 282

16.6.3.2 Middle to Late Childhood (6–13 Years) 283

16.6.3.3 Teens and Young Adults (14–21 Years) 283

16.6.4 Preparing the Veterinary Team for Children-Present Euthanasia 283

16.6.4.1 EOL Comfort Kits for Children 284

16.7 Preparing for the Unexpected 286

16.8 Supporting Children’s Grief Through Memorialization 287

16.9 Considerations for Getting a New Pet 289

16.10 Takeaways 289

References 291

Part V Team Wellness and Growth 293

17 Empathic Strain and Veterinary Team Wellness 295
Sarah Bernardi and Kathleen Dunbar

17.1 Introduction 295

17.2 Empathic Strain in Veterinary Practice 295

17.2.1 Causes of Empathic Strain 297

17.2.2 The Role of Moral Distress in Empathic Strain 297

17.3 Personal Approaches to Mitigating Empathic Strain 298

17.3.1 Empathic Strain Personal Warning System 298

17.3.2 Mindfulness Practices 299

17.3.3 Professional Support and Mentorship 300

17.4 Organizational Strategies for Enhancing Well-Being 300

17.4.1 Leadership’s Role in Ensuring Psychological Safety 300

17.4.2 Developing Policies and Procedures 301

17.4.3 Peer Debriefing 302

17.4.4 Integrating Veterinary Social Work 303

17.5 Takeaways 303

References 304

18 The Future Is Bright 307
Alyssa Eslinger and Joye Sears

18.1 Technician Utilization and Lifelong Learning 307

18.2 Meaningful Purpose and Leadership 307

18.3 Business Considerations 308

18.4 Veterinary Social Work 309

18.5 Specialization and Collaboration 309

18.6 Quality of Life Perspectives 309

18.7 Research Priorities 310

18.8 Conclusion 310

References 310

Index 311