Palliative Care in Pets with Cancer

[Daniel E.]

The cheapest way to talk online to a board-certified vet oncologist (who is also a cancer researcher / assistant professor at Ohio State):

This veterinarian on JustAnswer helped me. Try it yourself!

Dr. Megan Brown, a veterinarian on JustAnswer, gave me an expert answer to my veterinary question. Check it out — it’s easier than an in-person visit and better than searching the web.

www.justanswer.com

The oncologist, Dr. Brown, was very helpful in answering questions at JustAnswer about my elderly dog's kidney cancer. For one thing, she explained why my dog hasn't died yet. She confirmed my hunch that the cancer may not have spread to the liver. Unlike the primary care vets who were overly pessimistic about the prognosis (like he should have died two months ago), Dr. Brown says surgery is a possible option (though I am not going that route due to cost):



Also, there isn't any need to increase the steroid dose concerning the cancer itself. Palladia may help to some degree:



Here in Arizona, the cost for the surgery (a nephrectomy) is well over $4,000 USD, not including the cost of CT imaging, aftercare in the case of complications, etc. I have also read case reports where some of the dogs died soon after the surgery anyway, though that may have been due a lack of experience.

And a needle aspirate can be more expensive than I thought:



So, for now, instead of focusing on steroids or anything else as a potential solution, I am going to focus on just making the dog as happy as possible. I am still going with the relatively conservative route using NSAIDS or steroids (never both due to potentially deadly GI effects) along with gabapentin for any hidden pain, lots of toys and treats, low-dose marijuana tincture drops, nutritional and herbal supplements for overall health, and possibly frequent, basic bloodwork.

 

[Daniel E.]

Ultrasound-Guided Fine Needle Aspiration and Core Biopsy

Ultrasound-guided fine needle aspiration and needle core biopsy are relatively safe, low cost, minimally invasive techniques for obtaining diagnostic tissue samples.

todaysveterinarypractice.com

"Ultrasound guidance enables avoidance of low diagnostic yield regions, such as central tumor necrosis, and high-risk regions, such as blood vessels and the renal medulla."

 

[Daniel E.]

Novel veterinary oncologic treatments and diagnostics

Craig A. Clifford, DVM, MS, DACVIM (Oncology), offered an overview of the latest treatment and diagnostic tools accelerating veterinary oncology

www.dvm360.com

 

[Daniel E.]

"A couple arrives with a dog that has been diagnosed with cancer [lymphoma]. While there is no treatment for dogs, this resonates with Dr. Jeff, as he used to have the same type of cancer."

[The dog's lymphoma was treated with prednisone as well as chemotherapy. The chemo was provided as part of a clinical trial at Colorado State University. Since then, there are now more options for lymphoma, including the oral treatment Laverdia-CA1 used in primary care settings.]

 

[Daniel E.]

Why Your Old Dog Won’t Sleep at Night—and What You Can Do About It | BeChewy

If your old dog won’t sleep at night, it may be indicative of some underlying health problems. Here’s what pet parents need to know.

be.chewy.com

Another possible reason for why a senior dog is restless at night is pain, especially cancer, which Dr. Dodman says is the most common cause of death in older dogs.

“Tumors swell and grow and push things around,” Dr. Dodman explains.

And if a dog is in pain, that pain can be worse at night because there are no distractions, Dr. Dodman says.

Pain primarily presents as the senior dog having anxiety at night, so look for the same signs as fear, which include raised hackles—that is, the hair on a dog's back and neck standing on end—and enlarged pupils due to increased adrenaline. Dogs can also salivate from extreme fear or distress. Other symptoms pet parents should monitor are tucked tails and what Dr. Dodman calls “whale eye,” where the whites of the dog’s eyes are visible.

Learn more about safe pain management options for senior dogs.

 

[Daniel E.]

2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats

Multifactorial Clinical Measurement Instruments (CMIs) for Chronic Pain Assessment in Veterinary Medicine

Helsinki Chronic Pain Index (HCPI)
Canine Brief Pain Inventory (CBPI)
Cincinnati Orthopedic Disability Index (CODI)
Health-Related Quality of Life (HRQL)
Liverpool Osteoarthritis in Dogs (LOAD)
Feline Musculoskeletal Pain Index (FMPI)

 

[Daniel E.]

I see my dog's vet on Friday.

If an opioid is not prescribed (since he is not in any obvious pain), my plan for his pain regimen is to switch from a steroid to a NSAID since the steroids are making him too hungry.

So he would be on these prescriptions:

piroxicam (NSAID)
gabapentin
trazodone if needed (hard to be in pain if you are asleep)

 

[Daniel E.]

Companion Animal End-of-Life Doula Professional Certificate - UVM Professional and Continuing Education

When a beloved animal is nearing end-of-life, stress can be high. Enter UVM's End-of-Life Doula program specializing in companion animals.

learn.uvm.edu

Syllabus

Instructor's website:

Francesca Lynn Arnoldy

CONTEMPLATIVE DOULA

contemplativedoula.com

Books:

Saying Good-Bye to Your Beloved Pet

Amazon product

Some of the Youtube videos:

 

[Daniel E.]

2016 AAHA/IAAHPC End-of-Life Care Guidelines for Dogs and Cats

End-of-life (EOL) care and decision making are medically, emotionally, and ethically challenging for everyone involved...

Technologies such as video recording and video calling can be helpful in regularly communicating the patient’s home-care status with the healthcare team...





COMPONENTS OF AN INTEGRATED APPROACH TO END-OF-LIFE CARE

Component	Objective	Intervention
Physical care	Pain management	Anticipate, prevent, control, and regularly monitor acute and chronic pain; provide multimodal pain relief per 2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats: • Pharmacologic management • Environmental modifications • Dietary management • Gentle handling techniques
	Management of clinical signs	Examine patient to diagnose and treat dyspnea, GI signs, cognitive dysfunction, anxiety, pruritus, skin integrity (e.g., local infections, pressure sores), dental health
	Hygiene	Maintain urine and feces sanitation, access to elimination sites
	Nutrition	Perform dietary and body condition assessment; monitor dietary habits and changes; maintain balanced nutrition, adequate food intake, and hydration to the extent possible, keeping in mind that decreased food and water intake are normal in the dying process
	Mobility	Provide nonskid flooring in pet’s living area, accessible litter box location and design, physical assistance devices (harnesses, slings, carts, and wheelchairs), range-of-motion exercises
	Safety	Restrict access to environmental hazards (e.g., swimming pools), protect from aggressive pets, observe for self-trauma
	Environmental needs	Provide comfortable bedding, temperature and ventilation control, adequate space, peaceful environment
Social wellbeing	Engagement with family	Involve pet in family activities as illness allows, maintain regular owner-pet interaction
	Isolation avoidance	Avoid or minimize extended periods of isolation or non-socialization
	Interaction with other pets	Maintain appropriate interaction with other pets; monitor pet-to-pet hierarchal changes and adverse socialization behaviors
	Mental stimulation	Offer regular play opportunities and environmental enrichment
Emotional wellbeing	Preservation of dignity	Minimize house soiling, manage incontinence, maintain good hygiene and grooming
	Stress reduction	Minimize exposure to stress and changes in routine, assess pet’s willingness to receive needed treatments
	Preserve pet’s household role	Continue expectations for companionship, surveillance, or other household roles; adhere to daily routines
	Maintain the will to live	Monitor behavior; ensure regular interaction with family members; observe for signs of withdrawal, depression, or resignation

There are veterinarians with advanced skills and an interest in providing animal hospice and palliative care in a growing number of communities. The International Association for Animal Hospice and Palliative Care (IAAHPC) has a Providers Directory on their website. Additional providers can be found in the Resources section of these guidelines...

Euthanasia, a universally legal and widely accepted tool in veterinary care, is a two-edged sword. On one hand, it provides an end to animal suffering when it becomes medically, financially, or physically impossible to maintain the patient’s quality of life. On the other hand, it leaves significant numbers of caregivers struggling with doubts regarding the decisions they made, which prolongs and complicates their grief experience.

As the value of animal hospice care and its availability increase, so will the feasibility of ethically managed, high quality, hospice-sup- ported natural death, and the decision to euthanize will become more nuanced. A satisfactory decision to euthanize is heavily dependent on open, honest, and empathetic communication with the client.

 

[Daniel E.]

Unfortunately, it is not hard to find negative reviews for at-home euthanasia vets, especially at Yelp:

"There are not enough mean, nasty words in the English language to accurately describe my feelings about this whole experience."

"I have little use for these sort of people who hide behind a phony benevolence which in the daylight is simply greed. You play well off of peoples emotions, but when it comes down to it, it's all about the money and your own convenience."

"Berating me for not noticing sooner my dog needed to be put to sleep, as if she knew his situation better than me, and her demanding she would keep my money due to her cancellation policy."

In other words, filter for the most negative reviews before choosing a vet, including at Yelp.

 

[Daniel E.]

Regarding pediatricians and their clients, but applies to vets and pet parents as well:

Make Points, Not Enemies: How to Effectively Manage Angry Parents

According to research, consumers generally consider competence and expertise as most important in deciding whether to trust a professional. However, when consumers get angry, they care less about expertise and consider empathy and caring as most important. The old saw of “They don’t care how much you know until they know how much you care” is proven true, particularly with angry parents.

 

[Daniel E.]

My 12-year-old dog with kidney cancer deteriorated surprisingly quickly today, six months and three days after his kidney mass was discovered (the same day of adoption from the Humane Society).

He never "circled the drain" as we expected. One minute he was running up the stairs and begging for cheese. The next minute he had problems standing and breathing, and his gums had become white. We provided supplemental oxygen for comfort during the 40-minute drive to the animal hospital, which we called beforehand.

On the positive side, it was the most peaceful euthanasia I have witnessed, partly because he was already asleep (from the sedative routinely given beforehand).

His large kidney tumor was only getting bigger, so something had to give. My guess is that the dramatic change in his condition today was because of internal bleeding:

Thrive Pet Healthcare Specialists offers emergency vet care and specialty vet care to Albuquerque and the surrounding areas.

Thrive Pet Healthcare Specialists offers emergency vet care and specialty vet care to Albuquerque and the surrounding areas.

www.vescnm.com

Studies have shown that when a dog presents with internal bleeding in the abdomen, there is an 85% chance that this is because of cancer. The tumors can grow quite large in some cases, but they often don’t cause an issue until they bleed. Once they rupture and bleed, the patient becomes anemic and starts showing signs of weakness, collapse, or trouble breathing...

Despite the sad ending, I share Rice’s story for several reasons. The first is internal bleeding from cancer in older dogs is not uncommon, and signs develop very suddenly, and so I think it’s something the public should know about. I am hoping people that read this article have a little more knowledge on what signs should prompt them to bring in their pet for evaluation, even if in the middle of the night. Another reason I want to bring up this story is to bring up euthanasia. It is a terribly sad and hard part of the job that most veterinarians deal with on a daily basis, but I truly feel like in cases like Rice’s where he would have suffered if he was left to die naturally, that euthanasia is a gift that can help animals die with dignity. The last reason I wanted to write this story was Rice.

 

[David Baxter PhD]

I'm sorry to hear this, Daniel. The cruel part of bonding with animals is that in the majority of cases they predecease us and the pain of that loss is sharp and intense.

The other side of the coin is that he had you to care for him for as long as he was with you and you were able to ensure that the end was peaceful for him. I know that was a comfort to him.

 

[Daniel E.]

Thank you. Though it was very stressful to see him going down fast, it was also a relief since there wasn't much of a decision to be made.

And I remember when I was a tourist in Mexico, there were lots of street dogs with no one on their side (though there are some rescues): "Mexico is home to the largest population of stray dogs in Latin America, with estimates ranging between 15 and 18 million dogs living without — or abandoned by — human owners."

I found out this morning that my father has a minor case of COVID, so I was distracted by that today and shopping for a care package, including a pulse oximeter. Both my parents have kept up to date with the boosters, so they are still looking forward to their cruise to Alaska next month.

 

[Daniel E.]

What Veterinarians Should Tell Clients About Pain Control and NSAIDs

Veterinarians are in the best position to inform their clients about the side effects of NSAIDS, so the clients can take better care of their pets.

www.fda.gov

Content current as of: 09/26/2022



NSAID therapy can also unmask hidden disease that was previously undiagnosed due to the absence of apparent clinical signs. Dogs and cats with underlying kidney disease, for example, may experience worsening of their kidney function while on an NSAID. Dogs and cats at greatest risk for developing side effects from NSAID therapy are those that are dehydrated, on concomitant diuretic therapy, have recently been treated with a corticosteroid, or have pre-existing kidney, heart, or liver dysfunction.

No NSAIDs are approved for long-term use in cats.