ArticleLiterature Review

Scoping review of end‐of‐life decision‐making models used in dogs, cats and equids

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Abstract

Background: End-of-life decisions for companion animals can be stressful for veterinarians and owners, and when delayed result in poor animal welfare. Delayed euthanasia has been identified as a particularly prominent issue for horses. This scoping review aimed to identify the available literature on veterinary decision-making models, which can support end-of-life planning. Methods: A protocol was preregistered, and a structured literature search was performed on six electronic databases. Publications were reviewed against specifically developed eligibility criteria. Data from original studies and narrative-type reviews were extracted separately, and the components of each model were charted. Results: A total of 2211 publications were identified, 23 met the inclusion criteria and were included in the final review. Eight were original research studies and 15 were narrative reviews or similar. Publications were not indexed uniformly, increasing the difficulty of discovering relevant sources. The end-of-life decision-making process comprised three stages: (1) making the decision, (2) enacting the decision and (3) aftercare. Twenty key components of decision-making models were identified, although no publication reflected all of these. Conclusions: A lack of original research studies and equine-specific publications was identified. Shared decision-making models for euthanasia in veterinary practice should include all three stages and consider species-specific issues.

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A qualitative study using group and individual interviews involving 10 veterinary hospitals in Wellington County, Ontario, explored how the practices involved in euthanasia-related care impacts the wellbeing of veterinary professionals. Thematic analysis indicated two major outcomes: the goal and desire of veterinary professionals was to facilitate a ‘good death’ for the companion animal and navigating the euthanasia decision process was more challenging than the actual event of performing euthanasia. When successful in achieving a ‘good death’ and navigating euthanasia decisions, participants reported feeling that their own sense of wellbeing and the veterinary client’s sense of wellbeing were improved. When unsuccessful, participants reported experiencing a reduced sense of wellbeing, reduced job satisfaction, increased emotional strain and feeling that the client was also detrimentally impacted. For many participants, navigating euthanasia decision-making consultations was seen as a greater challenge and a greater contributor to a reduced sense of wellbeing than the act of euthanasia itself. These findings suggest that there is a need for greater attention and support for veterinary professionals, particularly when navigating euthanasia decision-making consultations. Additional training and resources on navigating euthanasia consultations may assist in improving the wellbeing for veterinary professionals and the companion animals and owners under their care.
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Medical progress has greatly advanced our ability to manage animals with critical and terminal diseases. We now have the ability to sustain life even in the most dire of circumstances. However, the preservation of life may not be synonymous with providing ‘quality of life’, and worse, could cause unnecessary suffering. Using the results of an electronic survey, we aim to outline and give examples of ethical dilemmas faced by veterinary anaesthetists dealing with critically ill animals, how the impact of these dilemmas could be mitigated, and what thought processes underlie decision-making in such situations.
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End-of-life care is one of the most ethically complex and challenging areas of veterinary practice and animal caregiving. Caregivers and animals are both particularly vulnerable during the final stages of an animal's life, when illness, suffering, and mortality push their way onto center stage. This chapter focuses on how clinicians and clients can navigate through treatment decisions with moral and emotional integrity. It explores how professional standards and practices can influence clinical decision making in both subtle and overt ways, often out of the direct control of either clinicians or clients. The chapter looks at how cultural and social attitudes can influence moral decision making in the hospice and palliative care setting. Clinical plans that involve hospice and palliative care must be included in the range of options presented and are best described as “comfort care”.
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This chapter is a compilation of the views of the authors regarding the judgment of changes in management, including medical therapies, approaches to foot care, the decision for euthanasia of the laminitis case and, importantly, the communication of these changes in management with the owner of the horse. Medications for the predisposing disease processes are primarily a concern for sepsis-related laminitis and endocrinopathic laminitis, although they play an important role in supporting limb laminitis if due to a septic condition in the originally affected limb. Foot care in the laminitis case requires a great deal of teamwork between the veterinarian and farrier, with constant communication with the owner and/or trainer. Since laminitis cannot be effectively cured, but will not lead directly to the death of the horse, euthanasia becomes an important consideration for horses that have progressive or persistent lameness or dysfunction.
Article
Background When companion animals become seriously ill clients may have doubts about treatment choices, if any, and turn to veterinarians for help. But how should veterinarians reply? Influence on clients’ decision-making may or may not be acceptable—depending on one’s attitude to principles such as ‘paternalism’, ‘respect for autonomy’ and ‘shared decision-making’. This study takes as a starting point a situation where the animal is chronically ill, or aged, with potentially reduced animal welfare and client quality of life, and thus where clients need to consider treatment options or euthanasia. It is assumed throughout that both veterinarians and clients have the animals’ best interest at heart. The purpose of the study was to explore the challenges these situations hold and to investigate how clients experience veterinary influence. A second aim was to reflect on the ethical implications of the role of veterinarians in these situations. Qualitative interviews were conducted with 12 dog owners considering treatment or euthanasia of their chronically ill or aged dogs. Results Challenges relating to the dog and to the client were identified. Some situations left the interviewees hesitant, e.g. if lacking a clear cut-off point, the dog appeared normal, the interviewee felt uncertain about treatments or animal welfare, or experienced conflicting concerns. Some interviewees found that veterinarians could influence their decisions. Such influence was received in different ways by the interviewees. Some interviewees wanted active involvement of the veterinarian in the decision-making process, and this may challenge a veterinarian’s wish to respect client autonomy. Conclusions Different preferences are likely to exist amongst both veterinarians and clients about veterinary involvement in clients’ decision-making, and such preferences may vary according to the situation. It is suggested, that one way to handle this challenge is to include respect for client preference on veterinary involvement under a wider understanding of respect for autonomy, and to apply models of shared decision-making to veterinary practice. In any case there is a need to further explore the challenges these situations raise, and for the veterinary profession to engage in more formal and structured deliberation over the role of veterinarians in relation to clients’ decision-making. Electronic supplementary material The online version of this article (doi:10.1186/s13028-016-0211-x) contains supplementary material, which is available to authorized users.
Article
Cancer is a common diagnosis in companion animals and, increasingly, clients choose to pursue treatment for their pets. Veterinary oncology is a rapidly growing field and diagnostic and treatment options for animals with cancer are constantly improving and becoming more widely available. Treatment outcomes can be good, but in many cases definitive treatment is not an option and palliative treatment is necessary. This article explores the palliative care of dogs and cats that have been diagnosed with cancer and summarises the various treatment options, with a particular focus on quality of life and the role of communication in the decision-making process.
Article
Making palliative care decisions for a patient who lacks decision-making capacity presents several challenges. Other people, such as family and caregivers, must choose for the patient. The goals and values of these decision makers may conflict with those of each other and with those of the patient, who now lacks the capacity to participate in the decision. This paper presents a case study of a patient with severe Alzheimer disease who has two common clinical problems: neurogenic dysphagia and aspiration pneumonia. The case study describes a consensus-based decision-making strategy that keeps what is known about the patient's wishes and values in the foreground but also expects guidance from the physician and elicits input from family members and other people who care for and have knowledge about the patient. The steps of this process, including key clinical prompts and potential transition statements, are outlined and described. The overall goal of the case commentary is to demonstrate that physicians can guide a highly emotional and personal process in a structured manner that has meaning for the patient, family, physician, and other caregivers.
Article
Dealing with clients’ distress, especially at euthanasia, is one of the main stressors for veterinary nurses. However, few have had formal training in how the death of an animal companion affects clients, and how to communicate with them. This article introduces some practical approaches and wording that you might use to support clients at the end of their animals’ lives.
Article
We describe a protocol for disclosing unfavorable information—“breaking bad news”—to cancer patients about their illness. Straightforward and practical, the protocol meets the requirements defined by published research on this topic. The protocol (SPIKES) consists of six steps. The goal is to enable the clinician to fulfill the four most important objectives of the interview disclosing bad news: gathering information from the patient, transmitting the medical information, providing support to the patient, and eliciting the patient’s collaboration in developing a strategy or treatment plan for the future. Oncologists, oncology trainees, and medical students who have been taught the protocol have reported increased confidence in their ability to disclose unfavorable medical information to patients. Directions for continuing assessment of the protocol are suggested. The Oncologist 2000;5:302-311
Article
As a unique species of equine, the donkey has certain specific variations from the horse. This review highlights the origins of the donkey and how this impacts on its behavior, physiology, and propensity to disease. The donkey is less of a flight animal and has been used by humans for pack and draught work, in areas where their ability to survive poorer diets, and transboundary disease while masking overt signs of pain and distress has made them indispensable to human livelihoods. When living as a companion animal, however, the donkey easily accumulates adipose tissue, and this may create a metabolically compromised individual prone to diseases of excess such as laminitis and hyperlipemia. They show anatomic variations from the horse especially in the hoof, upper airway, and their conformation. Variations in physiology lead to differences in the metabolism and distribution of many drugs. With over 44 million donkeys worldwide, it is important that veterinarians have the ability to understand and treat this equid effectively.
Article
The human–horse bond is powerful and unique and strengthened with years of ownership. Yet, in aged horses, the decision for euthanasia will be faced at some time by most horse owners. We hypothesized that euthanasia is a difficult and distressing decision for most horse owners, and that the decision will be influenced by the owners' personality, difficulty of euthanasia decision, and experiences of euthanasia, as well as external factors. Horse owners were recruited by the use of a postal questionnaire distributed to an equestrian group. A subgroup of surveyed owners was selected based on postcodes for selected regions. One hundred and eleven owners of 350 aged horses in South East Queensland, Australia, completed a personality assessment and were asked to indicate the perceived difficulty in making the decision to euthanize an aged companion horse. Their experience of euthanasia and the perceived distress over the loss of their aged horse, as well as the acceptability of the procedure, were determined. Personality scores were compared with published reference ranges against perceived difficulty to euthanize and experience of euthanasia. The importance of factors that influenced the decision to euthanize an aged horse was also determined. Most owners considered euthanasia of a horse to be a difficult decision, which they based on considerations of the horse's current health, anticipated future quality of life, and veterinary advice. Owners reported the loss of their horse to be a distressing experience rather than providing a sense of relief, although the procedure itself was more acceptable than distressing. Female owners who found it more difficult to make the decision were more likely to have neurotic personalities and they based their decision more on their relationship with the horse and the horse's quality of life. Veterinarians play a central role in the diagnosis of health factors that influence the decision to euthanize but also need to appreciate the distress perceived by owners, in particular as a result of the loss of their horse rather than the act of euthanasia itself. The personality of the owner may influence the extent to which they find this distressing, especially in female horse owners who find the decision to euthanize more difficult.
Article
Breaking bad news to patients is one of the most difficult and demanding tasks that oncologists face—and one for which they are often poorly trained and emotionally ill equipped. The S-P-I-K-E-S protocol described in this article provides a simple, easily learned strategy for communicating bad news and suggests ways to assess the situation as it evolves and respond constructively to patients. Showing empathy, exploring the patient's understanding and acceptance of what he or she has just learned, and validating that patient's feelings can provide much-needed support to the patient, an essential psychological intervention for managing distress and helping the patient face the treatment decisions ahead. Although breaking bad news will never be easy, having a plan of action and knowing that you can support your patient through a difficult period should help considerably.
Article
This paper focuses on scoping studies, an approach to reviewing the literature which to date has received little attention in the research methods literature. We distinguish between different types of scoping studies and indicate where these stand in relation to full systematic reviews. We outline a framework for conducting a scoping study based on our recent experiences of reviewing the literature on services for carers for people with mental health problems. Where appropriate, our approach to scoping the field is contrasted with the procedures followed in systematic reviews. We emphasize how including a consultation exercise in this sort of study may enhance the results, making them more useful to policy makers, practitioners and service users. Finally, we consider the advantages and limitations of the approach and suggest that a wider debate is called for about the role of the scoping study in relation to other types of literature reviews.
Article
This study builds upon existing protocols for breaking bad news (BBN), and offers an interaction-based approach to communicating comfort to patients and their families. The goal was to analyze medical students’ (N�21) videotaped standardized patient BBN interactions after completing an instructional unit on a commonly used BBN protocol, commonly known as SPIKES. Through post hoc interviews with the medical student, standardized patients, and faculty member for the unit, we revealed discrepancies between clinicians’ idealized BBN interactions and their actual bad news delivery enactment. COMFORT, is an acronym for the seven empirically derived, resulting core communication competencies that seek to overcome some of the communicative constraints to effective BBN experienced by clinicians and patients. COMFORT is built around the fundamental principles of interaction adaptation theory (Burgoon, Stern, & Dillman, 1995), which in this case is applied to communication in medical encounters.
Article
The scale of the ethical challenges faced by veterinary surgeons and their perceived stressful consequences were investigated via a short questionnaire, completed by 58 practising veterinary surgeons. Respondents were asked to report how frequently they faced ethical dilemmas, and to rate on a simple numerical scale (zero to 10) how stressful they found three common scenarios. Fifty seven per cent of respondents reported that they faced one to two dilemmas per week, while 34 per cent stated they typically faced three to five dilemmas per week. The three scenarios provided were all rated as highly stressful with 'client wishing to continue treatment despite poor animal welfare' rated as the most stressful (median 9). The female veterinary surgeons gave two of the scenarios significantly higher stress ratings than the male veterinary surgeons. Stress ratings were not influenced by number of years in practice (which ranged from one to more than 25 years). The results show that veterinary surgeons regularly face ethical dilemmas and that they find these stressful. This has implications for the wellbeing of veterinary surgeons and supports the case for increased provision of training and support, especially for those who entered the profession before undergraduate ethics teaching was widely available.
Article
Assessing patients' quality of life (QOL) is a core part of clinical decision making. Various methodologies for assessing patients' QOL have been developed in human medicine and small animal veterinary disciplines. In contrast, the lack of aids for QOL assessment in equine veterinary practice leaves practitioners reliant on subjective assessments of QOL, which may be prone to avoidable errors. This paper suggests pragmatic ways in which QOL may be enhanced, while remaining appropriate for the time, financial and owner-based constraints within equine practice. Through interdisciplinary research, this paper identifies, adapts and applies insights from several areas of research and practical experience in order to develop an overarching approach to making QOL-based decisions in clinical cases. The paper identifies 6 steps involved in QOL-based decision making and provides examples of how these steps may be practically applied. These include deciding what each clinician feels is important; deciding how to evaluate it, including taking owners' views into consideration; making decisions about each case and achieving the desired clinical outcomes. Practitioners can draw their own conclusions on how they may improve QOL assessment in practice and may usefully share these with colleagues. Reporting cases and sharing practical examples of QOL tools used on the ground are vital to the development of this field and appropriate methodologies. Improvements in QOL assessment are relevant to all areas of equine veterinary practice, and several areas of research. Further research may develop QOL assessment in practice, but more important are the personal improvements that each practitioner may achieve.
Article
The E4 model for physician-patient communication is presented with specific techniques for implementing the model. Derived from an extensive review of the literature on physician-patient communication, the model has proved to be a useful tool in workshops for and coaching of physicians regardless of specialty, experience or practice setting. Information on how to obtain descriptive materials about the workshop and an annotated bibliography is included.
Article
Geriatric horses (aged≥15 years) represent a substantial proportion of the equine population, yet very few studies have investigated the prevalence of diseases within the UK equine geriatric population. To describe the provision of routine preventive health care measures, prevalence of clinical signs of disease and the prevalence of owner reported diseases. Additionally, the effect of increasing age on the provision of preventive health care and the presence or absence of clinical signs and disease was assessed. A cross-sectional study was conducted, surveying a randomly selected sample of veterinary registered owners with horses aged≥15 years, using a self-administered postal questionnaire. As geriatric horses increased in age, there was a reduction in the provision of preventive health care measures, such as vaccination, farrier care and routine veterinary checks. Only 68.7% of horses had received a routine veterinary visit within the previous 12 months. Owners frequently observed clinical signs in their animals, with 77% reporting at least one clinical sign of disease. Increasing age was associated with increased reporting of many clinical signs of disease. Over half (58%) of horses had at least one episode of disease within the previous 12 months, yet only 31% of owners reported that their animal currently suffered from a known disease or disorder. Although owners frequently observed clinical signs in their aged horse, there may be incorrect or under recognition of many diseases and health problems. Reduced frequency of routine preventive health care measures, along with suboptimal owner recognition of health and welfare problems may lead to compromised welfare in the geriatric population.