The editors Amir Shanan, DVM, is the Founding President of the International Association for Animal Hospice and Palliative Care and a Founding Partner of the Animal Hospice Group. He owns Compassionate Veterinary Hospice, a veterinary practice dedicated to end-of-life care, in Chicago, Illinois, USA. Jessica Pierce, BA, MDiv, PhD, is a bioethicist and Faculty Affiliate at the Center for Bioethics and Humanities, University of Colorado, Anschutz Medical Campus, in Aurora, Colorado, USA. Tamara Shearer, DVM, CCRP, CVPP, CVA, MSTCVM, owns Shearer Pet Health Services and Smoky Mountain Integrative Veterinary Clinic in Sylva, North Carolina, USA, and serves on the faculty of Chi University.

• List of Contributors xxiAcknowledgments xxiiiAbout the Companion Website xxivPart I Core Concepts 11 Introduction 3Pierce, BA, MTS, PhDReferences 5Further Reading 52 What Is Animal Hospice and Palliative Care? 6Amir Shanan, DVM and Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVMIntroduction 6History of Animal Hospice 8Scientific and Philosophical Roots 8Early Beginnings 9Organization and Recognition 10Animal Hospice and Human Hospice 12Ethical and Legal Differences 12Economic Differences 13Summary 14References 143 The Interdisciplinary Team 16Tammy Wynn, MHA, LISW, RVT, CHPT and Amir Shanan, DVMInterdisciplinary Teams in Human Hospice and Palliative Care 16Interdisciplinary Teams (IDT) in Animal Hospice and Palliative Care 17Operating a Successful Interdisciplinary Team 18Common Mission and Vision 18Team members, Their Roles, and Responsibilities 19Effective Communication and Collaboration 22Summary 25References 254 Quality of Life Assessments 26Jessica Pierce, BA, MTS, PhD and Amir Shanan, DVMWhat are Quality of Life Assessments and Why are they Important in End- of- Life Care? 26Definitions of Quality of Life 26Quality of Life and Well- being 27Quality of Life Assessments and Euthanasia Decisions 28The Importance of Context in Quality of Life Assessment 28Quality of Life and Patient- Centered Care 29Physical Discomfort, Emotional Distress, Pain, and Suffering 30Coping and Adaptation 32Measuring Quality of Life in Animal Patients 33A Variety of Approaches to QOL 34McMillan’s Affect Balance Model 35Weighing Positive and Negative Affect at the End of Life 36Quality of Life Assessment Tools 36Quality of Life Assessment Over Time 38Summary 40References 40Further Reading 425 Recognizing Distress 44Emma K. Grigg, PhD, CAAB, Suzanne Hetts, PhD, CAAB, and Amir Shanan, DVMStress, Distress, Emotions, and Suffering 44The Stress Response 44What Is Distress? 45Behavioral Needs of Dogs and Cats 46Assessing Quality of Life in Nonhuman Animals 47Relevance to Animal Hospice and Palliative Care (AHPC) 48Are Humans Adept at Recognizing Emotional States in Animals? 49Body Language of Fear, Anxiety, and Pain 49Fear- and Discomfort- Related Body Postures Commonly Observed in Dogs and Cats 49Pain- Related Facial Expressions Commonly Observed in Dogs and Cats 51Relevance to Animal Hospice and Palliative Care (AHPC) 52Changes in Behavioral Patterns as Indicators of Pain and Distress 53Do Animals “Hide” their Pain? 53Decreased Response to and Engagement with their Surroundings 54Unusual Patterns of Movement or Positioning 55Focused Attention to One Specific Body Part 56Displacement Behaviors 56Can Sick Animals Suffer from Boredom? 56Relevance to Animal Hospice and Palliative Care (AHPC) 57End- of- Life Decisions 57Conclusion 58References 586 Balancing Efficacy of Treatments Against Burdens of Care 62Kristina August, DVM, GDVWHM, CHPVEstablishing the Goals of Care 63Assessing Efficacy and Burdens of Medical Treatment 66Assessment of Treatment Efficacy 66Appetite and Hydration Needs at the End of Life 66Emotional Well- Being 67Animal Individual Preferences 67Do- Not- Resuscitate and “Advance Directives” 67Assessment of Treatment Burden 68Assessing Diagnostic Procedures 69Adverse Events: Treatment- Related Consequences 70Steroids and End- of- Life Care 71Adverse Events: Indirect Consequences of Medical Care 71Assessing the Burdens of Caregiving 72Conclusion 73References 737 Ethical Decision- Making in Animal Hospice and Palliative Care 76Jessica Pierce, BA, MTS, PhD and Amir Shanan, DVMA Method for Moral Decision- Making 77Part 1: Clinical Considerations and Their Moral Dimensions 77Part 2: Patient Considerations: How the Animal Feels and What the Animal Wants 78Understanding What Animals Want 79Will to Live 79Respecting What Animals Want 80Suffering 80Part 3: Human Factors Influencing Moral Decision- Making 83Providing Adequate Information 85Guiding Client Decision- Making: How Much Is Too Much? 86Guiding the Choice between Euthanasia and Continued Palliative Care 88Societal Ethics and the Role of Cultural Values 90Ethical Business Practices 91Moral Stress, Decisional Regret, and Mental Health 91Conclusion: Finding the Path of Least Regrets 92References 938 Supportive Relationships: Veterinarians and Animal Hospice Providers’ Nonmedical Roles 95Amir Shanan, DVM and Laurel Lagoni, MSDefining the Nonmedical Roles of Veterinary Professionals and Other Animal Hospice Providers (except licensed mental health professionals) 98The Role of Source of Support 98The Role of Educator 100The Role of Facilitator 100The Role of Resource and Referral Guide 101Resources 101Extended Services 102Limiting the Role of Animal Hospice Veterinary Professionals and Other Providers (except licensed mental health professionals) 102Know Thyself, Healer 105Conclusion 105Grief Support Resources 106Memorials and Grief Support Resources 106Counselors and Grief Support 106Grief Support Training 106Books for Caregivers 106Books for Veterinarians 107References 1079 Management and Administration: Business Models 108Kathleen Cooney, DVM, MS, CHPV, CCFPGuidelines for Animal Hospice and Palliative Care Practice 108Service Delivery Models 109Model 9.1 Hospice in the Veterinary Hospital Setting 110Model 9.2 Hospice with Specialized Mobile Veterinarians 112Model 9.3 Animal Hospice Case Managers 113Model 9.4 Animal Hospice Sanctuaries/Rescues 114Practicalities of Starting an Animal Hospice Service 114Telehealth as a Bridging Component for all Models 117Conclusion 118References 119Part II Patient Care 12110 Cancers in Dogs and Cats 123Alice Villalobos, DVM, FNAP and Betsy Hershey, DVM, DACVIM (Oncology), CVAApproach to End- of- Life Cancer Patients 124Tumors of the Skin and Soft Tissues 124Canine Lymphoma 125Head and Neck Cancer 126Oropharyngeal and Neck Tumors in Dogs and Cats 126Nasal Passage Cancer 127Brain Tumors 127Cancer of the Skeletal System 128Abdominal Tumors 129Hemangiosarcoma in Dogs 129Transitional Cell Carcinoma 129Hepatic, Pancreatic, Intestinal, Adrenal, and Renal Cancer 130Chest Cavity Tumors 130Palliative Cancer Medicine 131Advances in Noninvasive Technology for the Diagnosis of Cancer 134Summary 135Conflicts of Interest 135References 13511 Integrative Therapies for Palliative Care of the Veterinary Cancer Patient 138Betsy Hershey, DVM, DACVIM (Oncology), CVANutrition and Food Therapy 138Herbs and Supplements 141Herbal Supplements 141Antioxidants 143Medicinal Mushrooms 143B Vitamins 143Digestive Enzymes 144Probiotics 144Vitamin d 144Omega- 3 Polyunsaturated Fatty Acids (PUFAS) 145Curcumin 145High Dose IV Vitamin C Therapy 145Acupuncture 146Manual Massage Therapies 147Energy Therapy (Biofield Therapy) 148Sound Therapy 148Reiki, Therapeutic Touch, and Healing Touch Therapies 148Ozone Therapy 148Hyperbaric Oxygen Therapy 150Cannabis and Cannabidiol (CBD) Oil 151Essential Oils 154Homeopathy and Homotoxicology 155Chiropractic 156Photobiomodulation Therapy (PBM) 157Summary 158References 15812 Chronic Kidney Disease 163Shea Cox, DVM, CHPV, CVPP and Christie Cornelius, DVM, CHPVDescription of Disease 163Disease Trajectory 163Clinical Manifestations of Disease 163Management 164Management of Factors that Accelerate Chronic Kidney Disease Progression 164Dehydration 164Nonregenerative Anemia 164Systemic Hypertension 165Proteinuria and Activation of the Renin–Angiotensin–Aldosterone System 165Renal Secondary Hyperparathyroidism 165Symptomatic, Supportive, and Palliative Therapies 166Oral Ulcerations and Uremic Gastritis 166Nausea/Vomiting 166Constipation/Obstipation 167Loss of Appetite 167Urinary Tract Infection 167Hyperphosphatemia 168Hypokalemia 168Seizures 168Dietary Considerations 168Other Comfort Measures 168Conclusion 168References 16913 Congestive Heart Failure 171Shea Cox, DVM, CHPV, CVPP and Christie Cornelius, DVM, CHPVDescription of Disease 171Disease Trajectory 171Clinical Manifestations of Disease 171Palliative Management 172Pulmonary Edema/Cardiac Function 172Diuretics 173Ace Inhibitors 173Positive Lonotrope, Vasodilator 174Calcium Channel Blocker 174Pleural and Abdominal Effusion 174Hypokalemia 174Prerenal Azotemia 174Balancing Renal and Cardiac Disease 174Coughing 175Respiratory Distress 175Aortic Thromboembolism 175Dietary Considerations 176Heart- Gut Interactions in Heart Failure 176Other Considerations 176Conclusion 176References 17614 Respiratory Distress 178Cheryl Braswell, DVM, DACVECC, CHPV, CHT-V, CVPPAirway Collapse 178Description 178Trajectory/Prognosis 179Manifestations 179Management 179Pharmacologic 179Physical 179Nutritional 180Surgery 180Brachycephalic Airway Obstruction Syndrome 180Description 180Trajectory/Prognosis 180Manifestations 181Management 181Pharmacologic 181Physical 181Nutrition 181Surgery 181Airway Inflammation 181Description 181Trajectory/Prognosis 182Manifestations 182Management 182Pharmacologic 182Physical 183Nutritional 183Pneumonia 183Description 183Trajectory/Prognosis 183Manifestations 183Management 183Pharmacologic 183Physical 184Nutritional 184The Suffering of Dyspnea: Palliative Care 184References 18515 Gastrointestinal Conditions 186Shea Cox, DVM, CHPV, CVPP and Christie Cornelius, DVM, CHPVInflammatory Bowel Disease 186Description of Disease 186Disease Trajectory 186Clinical Manifestations of Disease 186Palliative Management 186Medical Support 186Immunosuppressive Therapy 186Antibiotic Therapy 187Additional Support Therapy 187Nutritional Support 188Fecal Microbial Transplantation (FMT): The Ultimate Probiotic 188Pancreatitis 188Description of Disease 188Disease Trajectory 188Clinical Manifestations of Disease 189Palliative Management 189Medical Support 189Analgesia 189Antiemetics 189Antibacterials 189Immunosuppressants 189Subcutaneous Fluid Therapy 189Nutritional Support 189Cholangitis/Cholangiohepatitis Syndrome 190Description of Disease 190Disease Trajectory 190Clinical Manifestations of Disease 190Palliative Management 190Medical Support 190Antimicrobial Therapy 190Immunosuppressive Therapy 190Analgesia 191Antiemetics 191Support Therapy 191Subcutaneous Fluid Therapy 191Nutritional Support 191Conclusion 191References 19116 Musculoskeletal Disorders 193Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVMOsteoarthritis 193Description 193Trajectory/Prognosis 194Manifestations 194Management 195Cranial Cruciate Ligament Pathology 197Description 197Trajectory/Prognosis 197Manifestations 197Management 197Medical Management 198Surgical Management 198Strains, Sprains, and Myofascial Pain 199Description 199Trajectory/Prognosis 199Manifestations 199Management 199Coxofemoral Luxation 200Description 200Trajectory/Prognosis 200Manifestations 200Management 200Fractures 201Description 201Trajectory/Prognosis 201Manifestations 201Management 201Conclusion 201References 20217 Nervous System Disease 204Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVMIntervertebral Disc Disease 204Description 204Trajectory/Prognosis 205Manifestations 205Management 206Cervical Spondylomyelopathy 207Description 207Trajectory/Prognosis 208Manifestations 208Management 208Fibrocartilagenous Embolic Myelopathy 208Description 208Trajectory/Prognosis 209Manifestations 209Management 209Vestibular Disorders 209Description 209Trajectory/Prognosis 210Manifestations 210Management 210Laryngeal Paralysis/Geriatric Onset Laryngeal Paralysis Polyneuropathy 211Description 211Trajectory/Prognosis 211Manifestations 211Management 211Degenerative Myelopathy 212Description 212Trajectory/Prognosis 213Manifestations 213Management 213Disorders of Micturition/Urination 214Description 214Trajectory/Prognosis 214Manifestations 214Management 214Bladder Is Difficult or Cannot Be Expressed 215Bladder Can Be Expressed with Effort 215Straining to Urinate with Spurts of Urine Produced 215Bladder Easily Expressed with Continuous Leakage 216Urine Leakage when Urine Accumulates 216Ancillary Therapies for Micturition Disorders 216Conclusion 216References 21618 Cognitive Dysfunction 219Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVMDescription 219Trajectory/Prognosis 220Manifestations 220Management 221Client Education and Prevention 221Behavior Modification and Environmental Enhancement 221Diet Modification 222Supplements 222Alternative Care 223Pharmaceutical Interventions 223Conclusion 224References 22519 Pharmacology Interventions for Symptom Management 227Shea Cox, DVM, CHPV, CVPPIntroduction 227Pain 227Clinical Signs of Pain 227Behavioral Indicators of Pain 227Pharmacology for Pain Management 228Nonsteroidal Anti- Inflammatory Drugs 228Glucocorticoids 229Acetaminophen 229Opioids 229Tricyclic Antidepressants 231Serotonin- Norepinephrine Reuptake Inhibitors 232Anticonvulsants 232N- methyl- d- aspartate Receptor Antagonists 232Monoclonal antibodies 233Pharmacologic Protocols 233Assessing Response to Treatment 234Anxiety 234Dysphoria 236Weakness or Fatigue 237Respiratory Symptoms 237Dyspnea 237Cough 239Nausea and Vomiting 239Anorexia and Cachexia 240Dehydration 241Constipation 241Oral Health 242Ulcers 242Dry Mouth (Xerostomia) 242Conclusion 242References 24220 Physical Medicine and Rehabilitation for Hospice and Palliative Care Patients 245Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVMPhysical Medicine vs. Physical Rehabilitation 245Considerations for Physical Medicine with Hospice and Palliative Care Patients 245Assistive Devices: Priority in Hospice Care 247Slings and Harnesses 247Straps and Bands 248Protective Footwear 248Support of Joints: Orthotic Devices 249Support for Paralysis/Pararesis: Carts and Drag Bags 250Four Simple but Important Manual Therapies and Therapeutic Exercises 250Range of Motion 250Assisted Standing and Walking 251Proprioceptive and Balance Techniques 251Massage and/or Tui-na 252The Role of Acupuncture for Hospice and Palliative Care Patients 252Innovative and Noninvasive Techniques 254Kinesiology Taping 254Extracorporeal Magnetotransduction Therapy: EMTT 257Extracorporeal Shockwave Therapy 257Targeted Pulsed Electromagnetic Field Therapy 258Other Therapeutic Modalities for Hospice and Palliative Care Patients 259Thermal Modalities 259Photobiomodulation Therapy (also known as Laser Therapy) 260Pulsed Signal Therapy 261Electrotherapy 261Therapeutic Ultrasound 262Manual Therapy/Medical Manipulation/Chiropractic Care 262Conclusion 263References 26321 Integrative Medicine in Animal Hospice and Palliative Care 265Kristina August, DVM, GDVWHM, CHPVTerms 265Going Mainstream 266Safety and Adverse Reactions 267Healing Philosophies 268Nutritional Supplements 269Herbal Medicine 269Essential Oils 271Other Therapies 272Ensuring Quality of Life 273Reliable Choices and Client Education 273Conclusion 274Educational Opportunities 274References 27422 Nursing Care for Seriously III Animals: Art and Techniques 278Shea Cox, DVM, CHPV, CVPP and Mary Ellen Goldberg, CVT, LVT, SRA-retired, CCRVN, CVPP, VTS-lab animal-retired, VTS-Physical Rehabilitation-retired, VTS-anesthesia/analgesia-HonoraryIntroduction 278Nurses’ Medical Roles 279Intake 279Planning of Care 279Ongoing Monitoring and Assessments 279Frequency of Assessments 279Parameters of Assessments 279Assessment of Pain 280Pain Scales 280Assessment of Other Signs of Discomfort 282Assessment for Dehydration 282Assessment of Medication Administration 282Assessment of Mobility 282Assessment of Mental and Emotional Status 283Delivery of Care: Nursing Care Considerations 284Comfort for the Patient 284Oral and Ocular Comfort 284Nutrition 286Hydration 287Treating Fluid Deficit (Dehydration) 287Maintenance Fluids Administration 288Calculating Fluid Deficit 288Hygiene 288Bedding 288Environment 289Mobility 289Range of Motion (ROM) 289Transitions 290Standby Assisted Standing 290Weight Shifting Exercises 290Assisted Standing Exercises 290Aids for Assisted Standing 290Mobility Carts 290Nursing Care for Recumbent Patients 290Urination 291Defecation 291Respiration 291Skin Care 292Mobilizing the Recumbent Patient 292Nurses as Advocates and Educators 292Nurses’ Role as Advocates for Patient and for the Caregiver 293Nurses’ Role as Educators 293Awareness of Signs of Pain 294Hygiene and Safety 294Death and Dying 295Conclusion 295References 296Further Reading 29823 Comfort Care During Active Dying 299Gail Pope and Amir Shanan, DVMNatural Death and Euthanasia 299Goals of Caring for the Dying Patient 301Advance Preparation and Education of Caregivers and Hospice Team 301Desirable Environment of Care 302Prognostication 303Changes During Early and Late Stages of Active Dying 303Available Information 303Changes During Early Stages of Active Dying 303Physical Changes 303Behavioral Changes 304Indications of Pain 304Changes During Late Stages of Active Dying 305Behavior, Sleeping Pattern, Responsiveness 305Respiration 305Eyes, Mucus Membranes, Jaw, and Extremities 306Muscle Twitching, Stretching, and the Agonal Position 306Odor 306Summary 306At the Time of Death 306The Different Types of Active Death 308Managing Clinical Signs During Active Dying 309Management of Pain 309Management of Anxiety and Agitation 310Fatigue and Weakness 310Loss of Ability to Swallow 311Respiration 311Cardiac Dysfunction and Renal Failure 311Diminished Skin Vitality 311Mucosal and Conjunctival Care 312Incontinence 312Administration of Medications, Fluids, and Food 312Administration of Fluids 313Administration of Food 314Administration of Medications 314Summary 315References 31524 Euthanasia in Animal End- of- Life Care 318Kathleen Cooney, DVM, CHPV, DACAWDecision- Making for the Animal Hospice Patient 318Advance Preparation and Education of the Professional Team 319Advance Preparation and Education of Caregivers and Family 321Euthanasia Setting: Desirable Environment of Care 323Euthanasia Techniques and Criteria 324Intravenous Injection 325Intracardiac Injection 325Intraperitoneal Injection 327Intrahepatic Injection 328Intrarenal Injections 329Variability and Unpredictability 330References 331Part III Caregiver Needs: Providing Support 33325 Caregivers’ Emotional Burden: Understanding, Acknowledging, and Addressing Caregivers’ Emotional Burden 335Amir Shanan, DVMCaregiving Experience 336The Mental Health Impact of Caregiving 339Supporting caregivers’ Emotional Needs 340The Role of a Licensed Mental Health Professional 343Qualified Mental Health Professionals 345Summary 346References 34726 Caregiver Burden in the Companion Animal Owner 349Mary Beth Spitznagel, PhD and Mark D. Carlson, DVMWhat Is Caregiver Burden? 349A Word About Research Data, the Terminology Used, and this Article’s Audience 349Caregiver Burden Is Present in Owners of Seriously Ill Companion Animals 350How Caregiver Burden Differs from Other Client Experiences in this Context 350How Does Caregiver Burden Affect the Veterinary Client? 351Impact of Caregiver Burden on the Client 351Impact of Caregiver Burden on the Patient 352Research- Based Suggestions for Interacting with the Burdened Owner 352Understand the Owner’s Perspective 352Collaborate on the Care Approach 353Lighten the Load 353One Size Does Not Fit All: Toward Individualized Client Interactions 354Interacting with the Distressed Client 354Interacting with the Resilient Client 355Interacting with the Non- Distressed Client 355Interacting with the “Other Influences” Client 355More than Compassion Fatigue: When Client Burden Transfers to the Clinician 355The Burden Transfer DANCE 356Conclusions 357References 35727 Addressing Spiritual Needs of Caregivers 360Carol Rowehl, LVT, MAR, STMSpiritual Needs of Caregivers 361Spiritual Distress 362Taking a Spiritual History 363When to Call in the Experts (and Who Are the Experts?) 364Spiritual Questions Unique to Veterinary Practice and Hospice and Palliative Care 366Including a Chaplain on the Interdisciplinary Veterinary/Hospice Team 367Resources 370References 37128 Factors Contributing to the Decision to Euthanize Pet Dogs and Cats 374Nathaniel Cook, DVM, CVA, CVFT, CTPEP and Beth Marchitelli, DVM, MSIntroduction 374Pet Factors: Symptoms and Clinical Signs that Affect Quality of Life 374Appetite and Weight Loss 375Appetite 375Weight Loss 377Elimination Disorders 377Impaired Mobility 379Sensory and Cognitive Decline 380Dyspnea and Respiratory Compromise 381Perception of Pain 382Pet Factors: Severe Illness Diagnosis 382Cancer 382Organ Failure: Congestive Heart Failure 383Endocrine Disorders: Diabetes Mellitus 384Pet Owner Factors: Psychosocial Factors of Caregiving 384Conclusion 385References 38529 Supporting Other Needs 389Shea Cox, DVM, CHPV, CVPP and Mary Ellen Goldberg, CVT, LVT, SRA-retired, CCRVN, CVPP VTS-lab animal-retired, VTS-Physical Rehabilitation-retired, VTS-anesthesia/analgesia-HonoraryCaring for the Caregiver: Addressing Emotional and Physical Needs 389Maintaining Self- Care 390Maintain Personal Nutrition and Sleep 390Engage in Exercise 390Make Time for Relaxation 390Time Considerations of Hospice Care 391Managing Time Commitments of Care 391Tips for Balancing Caregiving with Ongoing Responsibilities 391Understanding the Physical Labor of Care 391Utilizing Proper Body Mechanics During Delivery of Care 392Environmental Considerations of Hospice Care 393Assessment of the Physical Space 393Household and Environmental Modifications 393Financial Considerations of Hospice Care 393Cost of Medications 394Cost of Diagnostics 394Cost of Other Healthcare Providers 394Cost of Environmental Modifications 394Cost of End- of- Life Care 394Helping to Defer Costs of Hospice Care 395Pet Health Insurance 395Equipment Rental, Recycling, and Reduced Cost Programs 395Creating a Memorial Fund 395Creating a Donation Bank 395References 396Further Reading 39630 Aftercare 398Coleen A. Ellis, CT, CPLPHospice Options and Accompanying Rituals 398Emotional Support: Honoring the Journey 401Assisting Children, Other Pets, and Family Members in Their Journey 402After- Death Care Options 402Summary 406References 406Index 407

The editors Amir Shanan, DVM, is the Founding President of the International Association for Animal Hospice and Palliative Care and a Founding Partner of the Animal Hospice Group. He owns Compassionate Veterinary Hospice, a veterinary practice dedicated to end-of-life care, in Chicago, Illinois, USA. Jessica Pierce, BA, MDiv, PhD, is a bioethicist and Faculty Affiliate at the Center for Bioethics and Humanities, University of Colorado, Anschutz Medical Campus, in Aurora, Colorado, USA. Tamara Shearer, DVM, CCRP, CVPP, CVA, MSTCVM, owns Shearer Pet Health Services and Smoky Mountain Integrative Veterinary Clinic in Sylva, North Carolina, USA, and serves on the faculty of Chi University.

• List of Contributors xxiAcknowledgments xxiiiAbout the Companion Website xxivPart I Core Concepts 11 Introduction 3Pierce, BA, MTS, PhDReferences 5Further Reading 52 What Is Animal Hospice and Palliative Care? 6Amir Shanan, DVM and Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVMIntroduction 6History of Animal Hospice 8Scientific and Philosophical Roots 8Early Beginnings 9Organization and Recognition 10Animal Hospice and Human Hospice 12Ethical and Legal Differences 12Economic Differences 13Summary 14References 143 The Interdisciplinary Team 16Tammy Wynn, MHA, LISW, RVT, CHPT and Amir Shanan, DVMInterdisciplinary Teams in Human Hospice and Palliative Care 16Interdisciplinary Teams (IDT) in Animal Hospice and Palliative Care 17Operating a Successful Interdisciplinary Team 18Common Mission and Vision 18Team members, Their Roles, and Responsibilities 19Effective Communication and Collaboration 22Summary 25References 254 Quality of Life Assessments 26Jessica Pierce, BA, MTS, PhD and Amir Shanan, DVMWhat are Quality of Life Assessments and Why are they Important in End- of- Life Care? 26Definitions of Quality of Life 26Quality of Life and Well- being 27Quality of Life Assessments and Euthanasia Decisions 28The Importance of Context in Quality of Life Assessment 28Quality of Life and Patient- Centered Care 29Physical Discomfort, Emotional Distress, Pain, and Suffering 30Coping and Adaptation 32Measuring Quality of Life in Animal Patients 33A Variety of Approaches to QOL 34McMillan’s Affect Balance Model 35Weighing Positive and Negative Affect at the End of Life 36Quality of Life Assessment Tools 36Quality of Life Assessment Over Time 38Summary 40References 40Further Reading 425 Recognizing Distress 44Emma K. Grigg, PhD, CAAB, Suzanne Hetts, PhD, CAAB, and Amir Shanan, DVMStress, Distress, Emotions, and Suffering 44The Stress Response 44What Is Distress? 45Behavioral Needs of Dogs and Cats 46Assessing Quality of Life in Nonhuman Animals 47Relevance to Animal Hospice and Palliative Care (AHPC) 48Are Humans Adept at Recognizing Emotional States in Animals? 49Body Language of Fear, Anxiety, and Pain 49Fear- and Discomfort- Related Body Postures Commonly Observed in Dogs and Cats 49Pain- Related Facial Expressions Commonly Observed in Dogs and Cats 51Relevance to Animal Hospice and Palliative Care (AHPC) 52Changes in Behavioral Patterns as Indicators of Pain and Distress 53Do Animals “Hide” their Pain? 53Decreased Response to and Engagement with their Surroundings 54Unusual Patterns of Movement or Positioning 55Focused Attention to One Specific Body Part 56Displacement Behaviors 56Can Sick Animals Suffer from Boredom? 56Relevance to Animal Hospice and Palliative Care (AHPC) 57End- of- Life Decisions 57Conclusion 58References 586 Balancing Efficacy of Treatments Against Burdens of Care 62Kristina August, DVM, GDVWHM, CHPVEstablishing the Goals of Care 63Assessing Efficacy and Burdens of Medical Treatment 66Assessment of Treatment Efficacy 66Appetite and Hydration Needs at the End of Life 66Emotional Well- Being 67Animal Individual Preferences 67Do- Not- Resuscitate and “Advance Directives” 67Assessment of Treatment Burden 68Assessing Diagnostic Procedures 69Adverse Events: Treatment- Related Consequences 70Steroids and End- of- Life Care 71Adverse Events: Indirect Consequences of Medical Care 71Assessing the Burdens of Caregiving 72Conclusion 73References 737 Ethical Decision- Making in Animal Hospice and Palliative Care 76Jessica Pierce, BA, MTS, PhD and Amir Shanan, DVMA Method for Moral Decision- Making 77Part 1: Clinical Considerations and Their Moral Dimensions 77Part 2: Patient Considerations: How the Animal Feels and What the Animal Wants 78Understanding What Animals Want 79Will to Live 79Respecting What Animals Want 80Suffering 80Part 3: Human Factors Influencing Moral Decision- Making 83Providing Adequate Information 85Guiding Client Decision- Making: How Much Is Too Much? 86Guiding the Choice between Euthanasia and Continued Palliative Care 88Societal Ethics and the Role of Cultural Values 90Ethical Business Practices 91Moral Stress, Decisional Regret, and Mental Health 91Conclusion: Finding the Path of Least Regrets 92References 938 Supportive Relationships: Veterinarians and Animal Hospice Providers’ Nonmedical Roles 95Amir Shanan, DVM and Laurel Lagoni, MSDefining the Nonmedical Roles of Veterinary Professionals and Other Animal Hospice Providers (except licensed mental health professionals) 98The Role of Source of Support 98The Role of Educator 100The Role of Facilitator 100The Role of Resource and Referral Guide 101Resources 101Extended Services 102Limiting the Role of Animal Hospice Veterinary Professionals and Other Providers (except licensed mental health professionals) 102Know Thyself, Healer 105Conclusion 105Grief Support Resources 106Memorials and Grief Support Resources 106Counselors and Grief Support 106Grief Support Training 106Books for Caregivers 106Books for Veterinarians 107References 1079 Management and Administration: Business Models 108Kathleen Cooney, DVM, MS, CHPV, CCFPGuidelines for Animal Hospice and Palliative Care Practice 108Service Delivery Models 109Model 9.1 Hospice in the Veterinary Hospital Setting 110Model 9.2 Hospice with Specialized Mobile Veterinarians 112Model 9.3 Animal Hospice Case Managers 113Model 9.4 Animal Hospice Sanctuaries/Rescues 114Practicalities of Starting an Animal Hospice Service 114Telehealth as a Bridging Component for all Models 117Conclusion 118References 119Part II Patient Care 12110 Cancers in Dogs and Cats 123Alice Villalobos, DVM, FNAP and Betsy Hershey, DVM, DACVIM (Oncology), CVAApproach to End- of- Life Cancer Patients 124Tumors of the Skin and Soft Tissues 124Canine Lymphoma 125Head and Neck Cancer 126Oropharyngeal and Neck Tumors in Dogs and Cats 126Nasal Passage Cancer 127Brain Tumors 127Cancer of the Skeletal System 128Abdominal Tumors 129Hemangiosarcoma in Dogs 129Transitional Cell Carcinoma 129Hepatic, Pancreatic, Intestinal, Adrenal, and Renal Cancer 130Chest Cavity Tumors 130Palliative Cancer Medicine 131Advances in Noninvasive Technology for the Diagnosis of Cancer 134Summary 135Conflicts of Interest 135References 13511 Integrative Therapies for Palliative Care of the Veterinary Cancer Patient 138Betsy Hershey, DVM, DACVIM (Oncology), CVANutrition and Food Therapy 138Herbs and Supplements 141Herbal Supplements 141Antioxidants 143Medicinal Mushrooms 143B Vitamins 143Digestive Enzymes 144Probiotics 144Vitamin d 144Omega- 3 Polyunsaturated Fatty Acids (PUFAS) 145Curcumin 145High Dose IV Vitamin C Therapy 145Acupuncture 146Manual Massage Therapies 147Energy Therapy (Biofield Therapy) 148Sound Therapy 148Reiki, Therapeutic Touch, and Healing Touch Therapies 148Ozone Therapy 148Hyperbaric Oxygen Therapy 150Cannabis and Cannabidiol (CBD) Oil 151Essential Oils 154Homeopathy and Homotoxicology 155Chiropractic 156Photobiomodulation Therapy (PBM) 157Summary 158References 15812 Chronic Kidney Disease 163Shea Cox, DVM, CHPV, CVPP and Christie Cornelius, DVM, CHPVDescription of Disease 163Disease Trajectory 163Clinical Manifestations of Disease 163Management 164Management of Factors that Accelerate Chronic Kidney Disease Progression 164Dehydration 164Nonregenerative Anemia 164Systemic Hypertension 165Proteinuria and Activation of the Renin–Angiotensin–Aldosterone System 165Renal Secondary Hyperparathyroidism 165Symptomatic, Supportive, and Palliative Therapies 166Oral Ulcerations and Uremic Gastritis 166Nausea/Vomiting 166Constipation/Obstipation 167Loss of Appetite 167Urinary Tract Infection 167Hyperphosphatemia 168Hypokalemia 168Seizures 168Dietary Considerations 168Other Comfort Measures 168Conclusion 168References 16913 Congestive Heart Failure 171Shea Cox, DVM, CHPV, CVPP and Christie Cornelius, DVM, CHPVDescription of Disease 171Disease Trajectory 171Clinical Manifestations of Disease 171Palliative Management 172Pulmonary Edema/Cardiac Function 172Diuretics 173Ace Inhibitors 173Positive Lonotrope, Vasodilator 174Calcium Channel Blocker 174Pleural and Abdominal Effusion 174Hypokalemia 174Prerenal Azotemia 174Balancing Renal and Cardiac Disease 174Coughing 175Respiratory Distress 175Aortic Thromboembolism 175Dietary Considerations 176Heart- Gut Interactions in Heart Failure 176Other Considerations 176Conclusion 176References 17614 Respiratory Distress 178Cheryl Braswell, DVM, DACVECC, CHPV, CHT-V, CVPPAirway Collapse 178Description 178Trajectory/Prognosis 179Manifestations 179Management 179Pharmacologic 179Physical 179Nutritional 180Surgery 180Brachycephalic Airway Obstruction Syndrome 180Description 180Trajectory/Prognosis 180Manifestations 181Management 181Pharmacologic 181Physical 181Nutrition 181Surgery 181Airway Inflammation 181Description 181Trajectory/Prognosis 182Manifestations 182Management 182Pharmacologic 182Physical 183Nutritional 183Pneumonia 183Description 183Trajectory/Prognosis 183Manifestations 183Management 183Pharmacologic 183Physical 184Nutritional 184The Suffering of Dyspnea: Palliative Care 184References 18515 Gastrointestinal Conditions 186Shea Cox, DVM, CHPV, CVPP and Christie Cornelius, DVM, CHPVInflammatory Bowel Disease 186Description of Disease 186Disease Trajectory 186Clinical Manifestations of Disease 186Palliative Management 186Medical Support 186Immunosuppressive Therapy 186Antibiotic Therapy 187Additional Support Therapy 187Nutritional Support 188Fecal Microbial Transplantation (FMT): The Ultimate Probiotic 188Pancreatitis 188Description of Disease 188Disease Trajectory 188Clinical Manifestations of Disease 189Palliative Management 189Medical Support 189Analgesia 189Antiemetics 189Antibacterials 189Immunosuppressants 189Subcutaneous Fluid Therapy 189Nutritional Support 189Cholangitis/Cholangiohepatitis Syndrome 190Description of Disease 190Disease Trajectory 190Clinical Manifestations of Disease 190Palliative Management 190Medical Support 190Antimicrobial Therapy 190Immunosuppressive Therapy 190Analgesia 191Antiemetics 191Support Therapy 191Subcutaneous Fluid Therapy 191Nutritional Support 191Conclusion 191References 19116 Musculoskeletal Disorders 193Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVMOsteoarthritis 193Description 193Trajectory/Prognosis 194Manifestations 194Management 195Cranial Cruciate Ligament Pathology 197Description 197Trajectory/Prognosis 197Manifestations 197Management 197Medical Management 198Surgical Management 198Strains, Sprains, and Myofascial Pain 199Description 199Trajectory/Prognosis 199Manifestations 199Management 199Coxofemoral Luxation 200Description 200Trajectory/Prognosis 200Manifestations 200Management 200Fractures 201Description 201Trajectory/Prognosis 201Manifestations 201Management 201Conclusion 201References 20217 Nervous System Disease 204Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVMIntervertebral Disc Disease 204Description 204Trajectory/Prognosis 205Manifestations 205Management 206Cervical Spondylomyelopathy 207Description 207Trajectory/Prognosis 208Manifestations 208Management 208Fibrocartilagenous Embolic Myelopathy 208Description 208Trajectory/Prognosis 209Manifestations 209Management 209Vestibular Disorders 209Description 209Trajectory/Prognosis 210Manifestations 210Management 210Laryngeal Paralysis/Geriatric Onset Laryngeal Paralysis Polyneuropathy 211Description 211Trajectory/Prognosis 211Manifestations 211Management 211Degenerative Myelopathy 212Description 212Trajectory/Prognosis 213Manifestations 213Management 213Disorders of Micturition/Urination 214Description 214Trajectory/Prognosis 214Manifestations 214Management 214Bladder Is Difficult or Cannot Be Expressed 215Bladder Can Be Expressed with Effort 215Straining to Urinate with Spurts of Urine Produced 215Bladder Easily Expressed with Continuous Leakage 216Urine Leakage when Urine Accumulates 216Ancillary Therapies for Micturition Disorders 216Conclusion 216References 21618 Cognitive Dysfunction 219Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVMDescription 219Trajectory/Prognosis 220Manifestations 220Management 221Client Education and Prevention 221Behavior Modification and Environmental Enhancement 221Diet Modification 222Supplements 222Alternative Care 223Pharmaceutical Interventions 223Conclusion 224References 22519 Pharmacology Interventions for Symptom Management 227Shea Cox, DVM, CHPV, CVPPIntroduction 227Pain 227Clinical Signs of Pain 227Behavioral Indicators of Pain 227Pharmacology for Pain Management 228Nonsteroidal Anti- Inflammatory Drugs 228Glucocorticoids 229Acetaminophen 229Opioids 229Tricyclic Antidepressants 231Serotonin- Norepinephrine Reuptake Inhibitors 232Anticonvulsants 232N- methyl- d- aspartate Receptor Antagonists 232Monoclonal antibodies 233Pharmacologic Protocols 233Assessing Response to Treatment 234Anxiety 234Dysphoria 236Weakness or Fatigue 237Respiratory Symptoms 237Dyspnea 237Cough 239Nausea and Vomiting 239Anorexia and Cachexia 240Dehydration 241Constipation 241Oral Health 242Ulcers 242Dry Mouth (Xerostomia) 242Conclusion 242References 24220 Physical Medicine and Rehabilitation for Hospice and Palliative Care Patients 245Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVMPhysical Medicine vs. Physical Rehabilitation 245Considerations for Physical Medicine with Hospice and Palliative Care Patients 245Assistive Devices: Priority in Hospice Care 247Slings and Harnesses 247Straps and Bands 248Protective Footwear 248Support of Joints: Orthotic Devices 249Support for Paralysis/Pararesis: Carts and Drag Bags 250Four Simple but Important Manual Therapies and Therapeutic Exercises 250Range of Motion 250Assisted Standing and Walking 251Proprioceptive and Balance Techniques 251Massage and/or Tui-na 252The Role of Acupuncture for Hospice and Palliative Care Patients 252Innovative and Noninvasive Techniques 254Kinesiology Taping 254Extracorporeal Magnetotransduction Therapy: EMTT 257Extracorporeal Shockwave Therapy 257Targeted Pulsed Electromagnetic Field Therapy 258Other Therapeutic Modalities for Hospice and Palliative Care Patients 259Thermal Modalities 259Photobiomodulation Therapy (also known as Laser Therapy) 260Pulsed Signal Therapy 261Electrotherapy 261Therapeutic Ultrasound 262Manual Therapy/Medical Manipulation/Chiropractic Care 262Conclusion 263References 26321 Integrative Medicine in Animal Hospice and Palliative Care 265Kristina August, DVM, GDVWHM, CHPVTerms 265Going Mainstream 266Safety and Adverse Reactions 267Healing Philosophies 268Nutritional Supplements 269Herbal Medicine 269Essential Oils 271Other Therapies 272Ensuring Quality of Life 273Reliable Choices and Client Education 273Conclusion 274Educational Opportunities 274References 27422 Nursing Care for Seriously III Animals: Art and Techniques 278Shea Cox, DVM, CHPV, CVPP and Mary Ellen Goldberg, CVT, LVT, SRA-retired, CCRVN, CVPP, VTS-lab animal-retired, VTS-Physical Rehabilitation-retired, VTS-anesthesia/analgesia-HonoraryIntroduction 278Nurses’ Medical Roles 279Intake 279Planning of Care 279Ongoing Monitoring and Assessments 279Frequency of Assessments 279Parameters of Assessments 279Assessment of Pain 280Pain Scales 280Assessment of Other Signs of Discomfort 282Assessment for Dehydration 282Assessment of Medication Administration 282Assessment of Mobility 282Assessment of Mental and Emotional Status 283Delivery of Care: Nursing Care Considerations 284Comfort for the Patient 284Oral and Ocular Comfort 284Nutrition 286Hydration 287Treating Fluid Deficit (Dehydration) 287Maintenance Fluids Administration 288Calculating Fluid Deficit 288Hygiene 288Bedding 288Environment 289Mobility 289Range of Motion (ROM) 289Transitions 290Standby Assisted Standing 290Weight Shifting Exercises 290Assisted Standing Exercises 290Aids for Assisted Standing 290Mobility Carts 290Nursing Care for Recumbent Patients 290Urination 291Defecation 291Respiration 291Skin Care 292Mobilizing the Recumbent Patient 292Nurses as Advocates and Educators 292Nurses’ Role as Advocates for Patient and for the Caregiver 293Nurses’ Role as Educators 293Awareness of Signs of Pain 294Hygiene and Safety 294Death and Dying 295Conclusion 295References 296Further Reading 29823 Comfort Care During Active Dying 299Gail Pope and Amir Shanan, DVMNatural Death and Euthanasia 299Goals of Caring for the Dying Patient 301Advance Preparation and Education of Caregivers and Hospice Team 301Desirable Environment of Care 302Prognostication 303Changes During Early and Late Stages of Active Dying 303Available Information 303Changes During Early Stages of Active Dying 303Physical Changes 303Behavioral Changes 304Indications of Pain 304Changes During Late Stages of Active Dying 305Behavior, Sleeping Pattern, Responsiveness 305Respiration 305Eyes, Mucus Membranes, Jaw, and Extremities 306Muscle Twitching, Stretching, and the Agonal Position 306Odor 306Summary 306At the Time of Death 306The Different Types of Active Death 308Managing Clinical Signs During Active Dying 309Management of Pain 309Management of Anxiety and Agitation 310Fatigue and Weakness 310Loss of Ability to Swallow 311Respiration 311Cardiac Dysfunction and Renal Failure 311Diminished Skin Vitality 311Mucosal and Conjunctival Care 312Incontinence 312Administration of Medications, Fluids, and Food 312Administration of Fluids 313Administration of Food 314Administration of Medications 314Summary 315References 31524 Euthanasia in Animal End- of- Life Care 318Kathleen Cooney, DVM, CHPV, DACAWDecision- Making for the Animal Hospice Patient 318Advance Preparation and Education of the Professional Team 319Advance Preparation and Education of Caregivers and Family 321Euthanasia Setting: Desirable Environment of Care 323Euthanasia Techniques and Criteria 324Intravenous Injection 325Intracardiac Injection 325Intraperitoneal Injection 327Intrahepatic Injection 328Intrarenal Injections 329Variability and Unpredictability 330References 331Part III Caregiver Needs: Providing Support 33325 Caregivers’ Emotional Burden: Understanding, Acknowledging, and Addressing Caregivers’ Emotional Burden 335Amir Shanan, DVMCaregiving Experience 336The Mental Health Impact of Caregiving 339Supporting caregivers’ Emotional Needs 340The Role of a Licensed Mental Health Professional 343Qualified Mental Health Professionals 345Summary 346References 34726 Caregiver Burden in the Companion Animal Owner 349Mary Beth Spitznagel, PhD and Mark D. Carlson, DVMWhat Is Caregiver Burden? 349A Word About Research Data, the Terminology Used, and this Article’s Audience 349Caregiver Burden Is Present in Owners of Seriously Ill Companion Animals 350How Caregiver Burden Differs from Other Client Experiences in this Context 350How Does Caregiver Burden Affect the Veterinary Client? 351Impact of Caregiver Burden on the Client 351Impact of Caregiver Burden on the Patient 352Research- Based Suggestions for Interacting with the Burdened Owner 352Understand the Owner’s Perspective 352Collaborate on the Care Approach 353Lighten the Load 353One Size Does Not Fit All: Toward Individualized Client Interactions 354Interacting with the Distressed Client 354Interacting with the Resilient Client 355Interacting with the Non- Distressed Client 355Interacting with the “Other Influences” Client 355More than Compassion Fatigue: When Client Burden Transfers to the Clinician 355The Burden Transfer DANCE 356Conclusions 357References 35727 Addressing Spiritual Needs of Caregivers 360Carol Rowehl, LVT, MAR, STMSpiritual Needs of Caregivers 361Spiritual Distress 362Taking a Spiritual History 363When to Call in the Experts (and Who Are the Experts?) 364Spiritual Questions Unique to Veterinary Practice and Hospice and Palliative Care 366Including a Chaplain on the Interdisciplinary Veterinary/Hospice Team 367Resources 370References 37128 Factors Contributing to the Decision to Euthanize Pet Dogs and Cats 374Nathaniel Cook, DVM, CVA, CVFT, CTPEP and Beth Marchitelli, DVM, MSIntroduction 374Pet Factors: Symptoms and Clinical Signs that Affect Quality of Life 374Appetite and Weight Loss 375Appetite 375Weight Loss 377Elimination Disorders 377Impaired Mobility 379Sensory and Cognitive Decline 380Dyspnea and Respiratory Compromise 381Perception of Pain 382Pet Factors: Severe Illness Diagnosis 382Cancer 382Organ Failure: Congestive Heart Failure 383Endocrine Disorders: Diabetes Mellitus 384Pet Owner Factors: Psychosocial Factors of Caregiving 384Conclusion 385References 38529 Supporting Other Needs 389Shea Cox, DVM, CHPV, CVPP and Mary Ellen Goldberg, CVT, LVT, SRA-retired, CCRVN, CVPP VTS-lab animal-retired, VTS-Physical Rehabilitation-retired, VTS-anesthesia/analgesia-HonoraryCaring for the Caregiver: Addressing Emotional and Physical Needs 389Maintaining Self- Care 390Maintain Personal Nutrition and Sleep 390Engage in Exercise 390Make Time for Relaxation 390Time Considerations of Hospice Care 391Managing Time Commitments of Care 391Tips for Balancing Caregiving with Ongoing Responsibilities 391Understanding the Physical Labor of Care 391Utilizing Proper Body Mechanics During Delivery of Care 392Environmental Considerations of Hospice Care 393Assessment of the Physical Space 393Household and Environmental Modifications 393Financial Considerations of Hospice Care 393Cost of Medications 394Cost of Diagnostics 394Cost of Other Healthcare Providers 394Cost of Environmental Modifications 394Cost of End- of- Life Care 394Helping to Defer Costs of Hospice Care 395Pet Health Insurance 395Equipment Rental, Recycling, and Reduced Cost Programs 395Creating a Memorial Fund 395Creating a Donation Bank 395References 396Further Reading 39630 Aftercare 398Coleen A. Ellis, CT, CPLPHospice Options and Accompanying Rituals 398Emotional Support: Honoring the Journey 401Assisting Children, Other Pets, and Family Members in Their Journey 402After- Death Care Options 402Summary 406References 406Index 407

The editors Amir Shanan, DVM, is the Founding President of the International Association for Animal Hospice and Palliative Care and a Founding Partner of the Animal Hospice Group. He owns Compassionate Veterinary Hospice, a veterinary practice dedicated to end-of-life care, in Chicago, Illinois, USA. Jessica Pierce, BA, MDiv, PhD, is a bioethicist and Faculty Affiliate at the Center for Bioethics and Humanities, University of Colorado, Anschutz Medical Campus, in Aurora, Colorado, USA. Tamara Shearer, DVM, CCRP, CVPP, CVA, MSTCVM, owns Shearer Pet Health Services and Smoky Mountain Integrative Veterinary Clinic in Sylva, North Carolina, USA, and serves on the faculty of Chi University.

• List of Contributors xxiAcknowledgments xxiiiAbout the Companion Website xxivPart I Core Concepts 11 Introduction 3Pierce, BA, MTS, PhDReferences 5Further Reading 52 What Is Animal Hospice and Palliative Care? 6Amir Shanan, DVM and Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVMIntroduction 6History of Animal Hospice 8Scientific and Philosophical Roots 8Early Beginnings 9Organization and Recognition 10Animal Hospice and Human Hospice 12Ethical and Legal Differences 12Economic Differences 13Summary 14References 143 The Interdisciplinary Team 16Tammy Wynn, MHA, LISW, RVT, CHPT and Amir Shanan, DVMInterdisciplinary Teams in Human Hospice and Palliative Care 16Interdisciplinary Teams (IDT) in Animal Hospice and Palliative Care 17Operating a Successful Interdisciplinary Team 18Common Mission and Vision 18Team members, Their Roles, and Responsibilities 19Effective Communication and Collaboration 22Summary 25References 254 Quality of Life Assessments 26Jessica Pierce, BA, MTS, PhD and Amir Shanan, DVMWhat are Quality of Life Assessments and Why are they Important in End- of- Life Care? 26Definitions of Quality of Life 26Quality of Life and Well- being 27Quality of Life Assessments and Euthanasia Decisions 28The Importance of Context in Quality of Life Assessment 28Quality of Life and Patient- Centered Care 29Physical Discomfort, Emotional Distress, Pain, and Suffering 30Coping and Adaptation 32Measuring Quality of Life in Animal Patients 33A Variety of Approaches to QOL 34McMillan’s Affect Balance Model 35Weighing Positive and Negative Affect at the End of Life 36Quality of Life Assessment Tools 36Quality of Life Assessment Over Time 38Summary 40References 40Further Reading 425 Recognizing Distress 44Emma K. Grigg, PhD, CAAB, Suzanne Hetts, PhD, CAAB, and Amir Shanan, DVMStress, Distress, Emotions, and Suffering 44The Stress Response 44What Is Distress? 45Behavioral Needs of Dogs and Cats 46Assessing Quality of Life in Nonhuman Animals 47Relevance to Animal Hospice and Palliative Care (AHPC) 48Are Humans Adept at Recognizing Emotional States in Animals? 49Body Language of Fear, Anxiety, and Pain 49Fear- and Discomfort- Related Body Postures Commonly Observed in Dogs and Cats 49Pain- Related Facial Expressions Commonly Observed in Dogs and Cats 51Relevance to Animal Hospice and Palliative Care (AHPC) 52Changes in Behavioral Patterns as Indicators of Pain and Distress 53Do Animals “Hide” their Pain? 53Decreased Response to and Engagement with their Surroundings 54Unusual Patterns of Movement or Positioning 55Focused Attention to One Specific Body Part 56Displacement Behaviors 56Can Sick Animals Suffer from Boredom? 56Relevance to Animal Hospice and Palliative Care (AHPC) 57End- of- Life Decisions 57Conclusion 58References 586 Balancing Efficacy of Treatments Against Burdens of Care 62Kristina August, DVM, GDVWHM, CHPVEstablishing the Goals of Care 63Assessing Efficacy and Burdens of Medical Treatment 66Assessment of Treatment Efficacy 66Appetite and Hydration Needs at the End of Life 66Emotional Well- Being 67Animal Individual Preferences 67Do- Not- Resuscitate and “Advance Directives” 67Assessment of Treatment Burden 68Assessing Diagnostic Procedures 69Adverse Events: Treatment- Related Consequences 70Steroids and End- of- Life Care 71Adverse Events: Indirect Consequences of Medical Care 71Assessing the Burdens of Caregiving 72Conclusion 73References 737 Ethical Decision- Making in Animal Hospice and Palliative Care 76Jessica Pierce, BA, MTS, PhD and Amir Shanan, DVMA Method for Moral Decision- Making 77Part 1: Clinical Considerations and Their Moral Dimensions 77Part 2: Patient Considerations: How the Animal Feels and What the Animal Wants 78Understanding What Animals Want 79Will to Live 79Respecting What Animals Want 80Suffering 80Part 3: Human Factors Influencing Moral Decision- Making 83Providing Adequate Information 85Guiding Client Decision- Making: How Much Is Too Much? 86Guiding the Choice between Euthanasia and Continued Palliative Care 88Societal Ethics and the Role of Cultural Values 90Ethical Business Practices 91Moral Stress, Decisional Regret, and Mental Health 91Conclusion: Finding the Path of Least Regrets 92References 938 Supportive Relationships: Veterinarians and Animal Hospice Providers’ Nonmedical Roles 95Amir Shanan, DVM and Laurel Lagoni, MSDefining the Nonmedical Roles of Veterinary Professionals and Other Animal Hospice Providers (except licensed mental health professionals) 98The Role of Source of Support 98The Role of Educator 100The Role of Facilitator 100The Role of Resource and Referral Guide 101Resources 101Extended Services 102Limiting the Role of Animal Hospice Veterinary Professionals and Other Providers (except licensed mental health professionals) 102Know Thyself, Healer 105Conclusion 105Grief Support Resources 106Memorials and Grief Support Resources 106Counselors and Grief Support 106Grief Support Training 106Books for Caregivers 106Books for Veterinarians 107References 1079 Management and Administration: Business Models 108Kathleen Cooney, DVM, MS, CHPV, CCFPGuidelines for Animal Hospice and Palliative Care Practice 108Service Delivery Models 109Model 9.1 Hospice in the Veterinary Hospital Setting 110Model 9.2 Hospice with Specialized Mobile Veterinarians 112Model 9.3 Animal Hospice Case Managers 113Model 9.4 Animal Hospice Sanctuaries/Rescues 114Practicalities of Starting an Animal Hospice Service 114Telehealth as a Bridging Component for all Models 117Conclusion 118References 119Part II Patient Care 12110 Cancers in Dogs and Cats 123Alice Villalobos, DVM, FNAP and Betsy Hershey, DVM, DACVIM (Oncology), CVAApproach to End- of- Life Cancer Patients 124Tumors of the Skin and Soft Tissues 124Canine Lymphoma 125Head and Neck Cancer 126Oropharyngeal and Neck Tumors in Dogs and Cats 126Nasal Passage Cancer 127Brain Tumors 127Cancer of the Skeletal System 128Abdominal Tumors 129Hemangiosarcoma in Dogs 129Transitional Cell Carcinoma 129Hepatic, Pancreatic, Intestinal, Adrenal, and Renal Cancer 130Chest Cavity Tumors 130Palliative Cancer Medicine 131Advances in Noninvasive Technology for the Diagnosis of Cancer 134Summary 135Conflicts of Interest 135References 13511 Integrative Therapies for Palliative Care of the Veterinary Cancer Patient 138Betsy Hershey, DVM, DACVIM (Oncology), CVANutrition and Food Therapy 138Herbs and Supplements 141Herbal Supplements 141Antioxidants 143Medicinal Mushrooms 143B Vitamins 143Digestive Enzymes 144Probiotics 144Vitamin d 144Omega- 3 Polyunsaturated Fatty Acids (PUFAS) 145Curcumin 145High Dose IV Vitamin C Therapy 145Acupuncture 146Manual Massage Therapies 147Energy Therapy (Biofield Therapy) 148Sound Therapy 148Reiki, Therapeutic Touch, and Healing Touch Therapies 148Ozone Therapy 148Hyperbaric Oxygen Therapy 150Cannabis and Cannabidiol (CBD) Oil 151Essential Oils 154Homeopathy and Homotoxicology 155Chiropractic 156Photobiomodulation Therapy (PBM) 157Summary 158References 15812 Chronic Kidney Disease 163Shea Cox, DVM, CHPV, CVPP and Christie Cornelius, DVM, CHPVDescription of Disease 163Disease Trajectory 163Clinical Manifestations of Disease 163Management 164Management of Factors that Accelerate Chronic Kidney Disease Progression 164Dehydration 164Nonregenerative Anemia 164Systemic Hypertension 165Proteinuria and Activation of the Renin–Angiotensin–Aldosterone System 165Renal Secondary Hyperparathyroidism 165Symptomatic, Supportive, and Palliative Therapies 166Oral Ulcerations and Uremic Gastritis 166Nausea/Vomiting 166Constipation/Obstipation 167Loss of Appetite 167Urinary Tract Infection 167Hyperphosphatemia 168Hypokalemia 168Seizures 168Dietary Considerations 168Other Comfort Measures 168Conclusion 168References 16913 Congestive Heart Failure 171Shea Cox, DVM, CHPV, CVPP and Christie Cornelius, DVM, CHPVDescription of Disease 171Disease Trajectory 171Clinical Manifestations of Disease 171Palliative Management 172Pulmonary Edema/Cardiac Function 172Diuretics 173Ace Inhibitors 173Positive Lonotrope, Vasodilator 174Calcium Channel Blocker 174Pleural and Abdominal Effusion 174Hypokalemia 174Prerenal Azotemia 174Balancing Renal and Cardiac Disease 174Coughing 175Respiratory Distress 175Aortic Thromboembolism 175Dietary Considerations 176Heart- Gut Interactions in Heart Failure 176Other Considerations 176Conclusion 176References 17614 Respiratory Distress 178Cheryl Braswell, DVM, DACVECC, CHPV, CHT-V, CVPPAirway Collapse 178Description 178Trajectory/Prognosis 179Manifestations 179Management 179Pharmacologic 179Physical 179Nutritional 180Surgery 180Brachycephalic Airway Obstruction Syndrome 180Description 180Trajectory/Prognosis 180Manifestations 181Management 181Pharmacologic 181Physical 181Nutrition 181Surgery 181Airway Inflammation 181Description 181Trajectory/Prognosis 182Manifestations 182Management 182Pharmacologic 182Physical 183Nutritional 183Pneumonia 183Description 183Trajectory/Prognosis 183Manifestations 183Management 183Pharmacologic 183Physical 184Nutritional 184The Suffering of Dyspnea: Palliative Care 184References 18515 Gastrointestinal Conditions 186Shea Cox, DVM, CHPV, CVPP and Christie Cornelius, DVM, CHPVInflammatory Bowel Disease 186Description of Disease 186Disease Trajectory 186Clinical Manifestations of Disease 186Palliative Management 186Medical Support 186Immunosuppressive Therapy 186Antibiotic Therapy 187Additional Support Therapy 187Nutritional Support 188Fecal Microbial Transplantation (FMT): The Ultimate Probiotic 188Pancreatitis 188Description of Disease 188Disease Trajectory 188Clinical Manifestations of Disease 189Palliative Management 189Medical Support 189Analgesia 189Antiemetics 189Antibacterials 189Immunosuppressants 189Subcutaneous Fluid Therapy 189Nutritional Support 189Cholangitis/Cholangiohepatitis Syndrome 190Description of Disease 190Disease Trajectory 190Clinical Manifestations of Disease 190Palliative Management 190Medical Support 190Antimicrobial Therapy 190Immunosuppressive Therapy 190Analgesia 191Antiemetics 191Support Therapy 191Subcutaneous Fluid Therapy 191Nutritional Support 191Conclusion 191References 19116 Musculoskeletal Disorders 193Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVMOsteoarthritis 193Description 193Trajectory/Prognosis 194Manifestations 194Management 195Cranial Cruciate Ligament Pathology 197Description 197Trajectory/Prognosis 197Manifestations 197Management 197Medical Management 198Surgical Management 198Strains, Sprains, and Myofascial Pain 199Description 199Trajectory/Prognosis 199Manifestations 199Management 199Coxofemoral Luxation 200Description 200Trajectory/Prognosis 200Manifestations 200Management 200Fractures 201Description 201Trajectory/Prognosis 201Manifestations 201Management 201Conclusion 201References 20217 Nervous System Disease 204Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVMIntervertebral Disc Disease 204Description 204Trajectory/Prognosis 205Manifestations 205Management 206Cervical Spondylomyelopathy 207Description 207Trajectory/Prognosis 208Manifestations 208Management 208Fibrocartilagenous Embolic Myelopathy 208Description 208Trajectory/Prognosis 209Manifestations 209Management 209Vestibular Disorders 209Description 209Trajectory/Prognosis 210Manifestations 210Management 210Laryngeal Paralysis/Geriatric Onset Laryngeal Paralysis Polyneuropathy 211Description 211Trajectory/Prognosis 211Manifestations 211Management 211Degenerative Myelopathy 212Description 212Trajectory/Prognosis 213Manifestations 213Management 213Disorders of Micturition/Urination 214Description 214Trajectory/Prognosis 214Manifestations 214Management 214Bladder Is Difficult or Cannot Be Expressed 215Bladder Can Be Expressed with Effort 215Straining to Urinate with Spurts of Urine Produced 215Bladder Easily Expressed with Continuous Leakage 216Urine Leakage when Urine Accumulates 216Ancillary Therapies for Micturition Disorders 216Conclusion 216References 21618 Cognitive Dysfunction 219Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVMDescription 219Trajectory/Prognosis 220Manifestations 220Management 221Client Education and Prevention 221Behavior Modification and Environmental Enhancement 221Diet Modification 222Supplements 222Alternative Care 223Pharmaceutical Interventions 223Conclusion 224References 22519 Pharmacology Interventions for Symptom Management 227Shea Cox, DVM, CHPV, CVPPIntroduction 227Pain 227Clinical Signs of Pain 227Behavioral Indicators of Pain 227Pharmacology for Pain Management 228Nonsteroidal Anti- Inflammatory Drugs 228Glucocorticoids 229Acetaminophen 229Opioids 229Tricyclic Antidepressants 231Serotonin- Norepinephrine Reuptake Inhibitors 232Anticonvulsants 232N- methyl- d- aspartate Receptor Antagonists 232Monoclonal antibodies 233Pharmacologic Protocols 233Assessing Response to Treatment 234Anxiety 234Dysphoria 236Weakness or Fatigue 237Respiratory Symptoms 237Dyspnea 237Cough 239Nausea and Vomiting 239Anorexia and Cachexia 240Dehydration 241Constipation 241Oral Health 242Ulcers 242Dry Mouth (Xerostomia) 242Conclusion 242References 24220 Physical Medicine and Rehabilitation for Hospice and Palliative Care Patients 245Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVMPhysical Medicine vs. Physical Rehabilitation 245Considerations for Physical Medicine with Hospice and Palliative Care Patients 245Assistive Devices: Priority in Hospice Care 247Slings and Harnesses 247Straps and Bands 248Protective Footwear 248Support of Joints: Orthotic Devices 249Support for Paralysis/Pararesis: Carts and Drag Bags 250Four Simple but Important Manual Therapies and Therapeutic Exercises 250Range of Motion 250Assisted Standing and Walking 251Proprioceptive and Balance Techniques 251Massage and/or Tui-na 252The Role of Acupuncture for Hospice and Palliative Care Patients 252Innovative and Noninvasive Techniques 254Kinesiology Taping 254Extracorporeal Magnetotransduction Therapy: EMTT 257Extracorporeal Shockwave Therapy 257Targeted Pulsed Electromagnetic Field Therapy 258Other Therapeutic Modalities for Hospice and Palliative Care Patients 259Thermal Modalities 259Photobiomodulation Therapy (also known as Laser Therapy) 260Pulsed Signal Therapy 261Electrotherapy 261Therapeutic Ultrasound 262Manual Therapy/Medical Manipulation/Chiropractic Care 262Conclusion 263References 26321 Integrative Medicine in Animal Hospice and Palliative Care 265Kristina August, DVM, GDVWHM, CHPVTerms 265Going Mainstream 266Safety and Adverse Reactions 267Healing Philosophies 268Nutritional Supplements 269Herbal Medicine 269Essential Oils 271Other Therapies 272Ensuring Quality of Life 273Reliable Choices and Client Education 273Conclusion 274Educational Opportunities 274References 27422 Nursing Care for Seriously III Animals: Art and Techniques 278Shea Cox, DVM, CHPV, CVPP and Mary Ellen Goldberg, CVT, LVT, SRA-retired, CCRVN, CVPP, VTS-lab animal-retired, VTS-Physical Rehabilitation-retired, VTS-anesthesia/analgesia-HonoraryIntroduction 278Nurses’ Medical Roles 279Intake 279Planning of Care 279Ongoing Monitoring and Assessments 279Frequency of Assessments 279Parameters of Assessments 279Assessment of Pain 280Pain Scales 280Assessment of Other Signs of Discomfort 282Assessment for Dehydration 282Assessment of Medication Administration 282Assessment of Mobility 282Assessment of Mental and Emotional Status 283Delivery of Care: Nursing Care Considerations 284Comfort for the Patient 284Oral and Ocular Comfort 284Nutrition 286Hydration 287Treating Fluid Deficit (Dehydration) 287Maintenance Fluids Administration 288Calculating Fluid Deficit 288Hygiene 288Bedding 288Environment 289Mobility 289Range of Motion (ROM) 289Transitions 290Standby Assisted Standing 290Weight Shifting Exercises 290Assisted Standing Exercises 290Aids for Assisted Standing 290Mobility Carts 290Nursing Care for Recumbent Patients 290Urination 291Defecation 291Respiration 291Skin Care 292Mobilizing the Recumbent Patient 292Nurses as Advocates and Educators 292Nurses’ Role as Advocates for Patient and for the Caregiver 293Nurses’ Role as Educators 293Awareness of Signs of Pain 294Hygiene and Safety 294Death and Dying 295Conclusion 295References 296Further Reading 29823 Comfort Care During Active Dying 299Gail Pope and Amir Shanan, DVMNatural Death and Euthanasia 299Goals of Caring for the Dying Patient 301Advance Preparation and Education of Caregivers and Hospice Team 301Desirable Environment of Care 302Prognostication 303Changes During Early and Late Stages of Active Dying 303Available Information 303Changes During Early Stages of Active Dying 303Physical Changes 303Behavioral Changes 304Indications of Pain 304Changes During Late Stages of Active Dying 305Behavior, Sleeping Pattern, Responsiveness 305Respiration 305Eyes, Mucus Membranes, Jaw, and Extremities 306Muscle Twitching, Stretching, and the Agonal Position 306Odor 306Summary 306At the Time of Death 306The Different Types of Active Death 308Managing Clinical Signs During Active Dying 309Management of Pain 309Management of Anxiety and Agitation 310Fatigue and Weakness 310Loss of Ability to Swallow 311Respiration 311Cardiac Dysfunction and Renal Failure 311Diminished Skin Vitality 311Mucosal and Conjunctival Care 312Incontinence 312Administration of Medications, Fluids, and Food 312Administration of Fluids 313Administration of Food 314Administration of Medications 314Summary 315References 31524 Euthanasia in Animal End- of- Life Care 318Kathleen Cooney, DVM, CHPV, DACAWDecision- Making for the Animal Hospice Patient 318Advance Preparation and Education of the Professional Team 319Advance Preparation and Education of Caregivers and Family 321Euthanasia Setting: Desirable Environment of Care 323Euthanasia Techniques and Criteria 324Intravenous Injection 325Intracardiac Injection 325Intraperitoneal Injection 327Intrahepatic Injection 328Intrarenal Injections 329Variability and Unpredictability 330References 331Part III Caregiver Needs: Providing Support 33325 Caregivers’ Emotional Burden: Understanding, Acknowledging, and Addressing Caregivers’ Emotional Burden 335Amir Shanan, DVMCaregiving Experience 336The Mental Health Impact of Caregiving 339Supporting caregivers’ Emotional Needs 340The Role of a Licensed Mental Health Professional 343Qualified Mental Health Professionals 345Summary 346References 34726 Caregiver Burden in the Companion Animal Owner 349Mary Beth Spitznagel, PhD and Mark D. Carlson, DVMWhat Is Caregiver Burden? 349A Word About Research Data, the Terminology Used, and this Article’s Audience 349Caregiver Burden Is Present in Owners of Seriously Ill Companion Animals 350How Caregiver Burden Differs from Other Client Experiences in this Context 350How Does Caregiver Burden Affect the Veterinary Client? 351Impact of Caregiver Burden on the Client 351Impact of Caregiver Burden on the Patient 352Research- Based Suggestions for Interacting with the Burdened Owner 352Understand the Owner’s Perspective 352Collaborate on the Care Approach 353Lighten the Load 353One Size Does Not Fit All: Toward Individualized Client Interactions 354Interacting with the Distressed Client 354Interacting with the Resilient Client 355Interacting with the Non- Distressed Client 355Interacting with the “Other Influences” Client 355More than Compassion Fatigue: When Client Burden Transfers to the Clinician 355The Burden Transfer DANCE 356Conclusions 357References 35727 Addressing Spiritual Needs of Caregivers 360Carol Rowehl, LVT, MAR, STMSpiritual Needs of Caregivers 361Spiritual Distress 362Taking a Spiritual History 363When to Call in the Experts (and Who Are the Experts?) 364Spiritual Questions Unique to Veterinary Practice and Hospice and Palliative Care 366Including a Chaplain on the Interdisciplinary Veterinary/Hospice Team 367Resources 370References 37128 Factors Contributing to the Decision to Euthanize Pet Dogs and Cats 374Nathaniel Cook, DVM, CVA, CVFT, CTPEP and Beth Marchitelli, DVM, MSIntroduction 374Pet Factors: Symptoms and Clinical Signs that Affect Quality of Life 374Appetite and Weight Loss 375Appetite 375Weight Loss 377Elimination Disorders 377Impaired Mobility 379Sensory and Cognitive Decline 380Dyspnea and Respiratory Compromise 381Perception of Pain 382Pet Factors: Severe Illness Diagnosis 382Cancer 382Organ Failure: Congestive Heart Failure 383Endocrine Disorders: Diabetes Mellitus 384Pet Owner Factors: Psychosocial Factors of Caregiving 384Conclusion 385References 38529 Supporting Other Needs 389Shea Cox, DVM, CHPV, CVPP and Mary Ellen Goldberg, CVT, LVT, SRA-retired, CCRVN, CVPP VTS-lab animal-retired, VTS-Physical Rehabilitation-retired, VTS-anesthesia/analgesia-HonoraryCaring for the Caregiver: Addressing Emotional and Physical Needs 389Maintaining Self- Care 390Maintain Personal Nutrition and Sleep 390Engage in Exercise 390Make Time for Relaxation 390Time Considerations of Hospice Care 391Managing Time Commitments of Care 391Tips for Balancing Caregiving with Ongoing Responsibilities 391Understanding the Physical Labor of Care 391Utilizing Proper Body Mechanics During Delivery of Care 392Environmental Considerations of Hospice Care 393Assessment of the Physical Space 393Household and Environmental Modifications 393Financial Considerations of Hospice Care 393Cost of Medications 394Cost of Diagnostics 394Cost of Other Healthcare Providers 394Cost of Environmental Modifications 394Cost of End- of- Life Care 394Helping to Defer Costs of Hospice Care 395Pet Health Insurance 395Equipment Rental, Recycling, and Reduced Cost Programs 395Creating a Memorial Fund 395Creating a Donation Bank 395References 396Further Reading 39630 Aftercare 398Coleen A. Ellis, CT, CPLPHospice Options and Accompanying Rituals 398Emotional Support: Honoring the Journey 401Assisting Children, Other Pets, and Family Members in Their Journey 402After- Death Care Options 402Summary 406References 406Index 407