Owner and cat watching cell phone

Hospice and End of Life Care

Hospice and End of Life Care

One of the hardest decisions you will likely have to make is deciding when it is time to let your beloved pet go. Sometimes the choice is an easy one; your pet’s disease has progressed and they are obviously distressed. Other times it can be difficult because your pet’s symptoms wax and wane or because in some areas they are worse but others the same or even better.

Our biggest concern here at the Cancer Center is quality of life (QOL) and maintaining it as long as possible. While there are some minimums to QOL, exactly where the line is drawn is a deeply personal choice. You, as the caregiver for your pet, are the best person to evaluate how they are doing in their daily life. Keeping a record of how your pet is doing daily, will help you evaluate how they are doing in the long run. We can give recommendations based on what we see in the clinic, but ultimately it is a decision that you and your family must make. Remember, too, that your pet has been diagnosed with a terminal disease, and there is no wrong decision to make in regards to your pet so long as they are happy and comfortable.

As difficult as the thought of euthanasia and end of life care is, it is important to talk with the members of the immediate family ahead of time. Knowing what actions will be taken, when they will be taken, and who is ‘in charge’ of making those decisions, will help make that time, when it comes, go much more smoothly. Consideration should also be given to aftercare and what ways, if any, you’d like to memorialize your pet.

This section contains some information about assessing quality of life, euthanasia (what it is and options for it), and options for aftercare of your pet. Also included are some pet grief and counseling resources for those who are interested or in need of them.

Owner and cat watching cell phone

Quality of Life

Quality of Life

Quality of Life (QOL) is how happy and ‘good’ your pet is doing on a day-to-day basis. For us at the Cancer Center, QOL is the main driving force behind what we do. From the first time we see your pet to the last, QOL is our top priority. QOL, though, is more than just the clinical side of how your pet is doing. There are several different factors that play into QOL and most of them involve how your pet is at home. The importance of each area and how it affects QOL is different for each family, and can even differ from one pet to another.

QOL should be assessed often after your pet is diagnosed with any disease. The exact frequency will vary based on your pet’s specific disease and how affected they are by it. At a minimum, QOL assessments should be made monthly or after any significant change in the status of your pet’s health. Weekly, or even daily, assessments may even be appropriate to best monitor your pet. You should do what feels most comfortable for you. If daily assessments help you feel in control of your pet’s QOL, then by all means do them, even when they are doing great. It is also important to review your pet’s previous assessments from time to time. This helps you see both their response and their progression. Some changes take time to notice and ‘normal’ for your pet can change without you realizing it.

The following is a list of questions you can ask yourself about your pet to help determine what QOL means for the both of you, what you are willing and/or able to do, what is acceptable for your pet to experience, and what is not. There will also be a list of explanations of some of the more common areas that help determine QOL. It is also important to discuss your goals and limitations with your doctor, as well as bring up any questions or concerns that you have with them. They can help guide you down this often difficult path and aid you in making educated decisions about, and for, your pet. We have created a QOL assessment table that you can use to monitor your pet. You can also take the information you get from the following pages and create your own that is tailored specifically to your pet and family.

Questions to consider

  • Is my pet experiencing pain? If so, how severe is it?
  • Can they eat, drink, urinate, and defecate normally/on their own? Am I willing or able to help them if they can’t?
  • Is my pet nauseous, vomiting, or having diarrhea/soft stools? If so, how often and how severely does it affect them?
  • Are they able to keep themselves clean and sanitary? Am I willing or able to do this for them if they can’t?
  • How is my pet doing mentally? Are they bright and alert? Are they mentally aware of their surroundings? Do they seem quieter than normal, or mentally altered? Are there any new behaviors that are concerning or hazardous to my pet or others in the household?
  • How much time can I realistically set aside to provide more intensive medical care for my pet? What am I able to provide financially for the care of my pet?
  • Do the good days outweigh the bad days? Are there more good days than bad days?
  • Is my pet able to experience or do the things they enjoy most?
  • Are there any side effects, symptoms, or medical conditions that I will not tolerate my pet experiencing?
  • Is euthanasia something I will consider for my pet? How much value is placed on the opinion of the veterinary team when it comes to recommendations about treatment versus euthanasia?

Areas to consider

  • Mobility is how well your pet can get around and how they feel when they get around.
    • Good: gets around without assistance; enjoys walks/playing; doesn’t hesitate to move around or jump up/down
    • Limited/poor: needs some help getting up, down, and/or around; can only walk or play for short periods of time; hesitates or isn’t able to jump or walk up/down stairs; has difficulties posturing to eliminate; pain can be controlled all or mostly with medications
    • None/minimum: requires assistance to get around or isn’t able to move at all; pain cannot be adequately controlled with medications
  • Nutrition includes what your pet is eating, how well they are eating, and how much of the nutrients your pet is absorbing.
    • Good: will readily eat their regular diet and eat an appropriate amount of food for their size; maintains their weight and appropriate muscle condition; missed meals, vomiting, and diarrhea are a rare occurrence (not more than a couple times a month or for more than a day or two in duration).
    • Limited/poor: will eat only some of their meal and/or needs some encouragement (verbal coaxing, hand feeding, etc.)  to eat; body and muscle condition decreases but is still acceptable; will only eat ‘special’ foods and treats; appetite waxes and wanes; missed meals, vomiting, and diarrhea occur often (only a couple times a month and lasts for only a few days at a time or sporadically for only a day or two but for at least 3 weeks out of a month).
    • None/minimum: will not eat at all; will not eat regular food but can be encouraged or coaxed to treats and ‘special’ food; body and muscle condition has decreased dramatically; missed meals, vomiting, and diarrhea occur several times a week to daily.
  • Hydration is how well your pet is able to maintain appropriate fluid levels in the body. This includes both increases and decreased in fluid intake. It is important to distinguish changes in hydration that are causes by the disease from those caused by medications.
    • Good/normal: stays adequately hydrated on their own without assistance or coaxing; urinates normally and of an appropriate volume
    • Poor/inappropriate: drinks more or less than normal; may need SQ fluids to maintain hydration or medications to remove excess fluid from the body; urination is altered based on the fluid intake
    • None/extreme: is not drinking at all or cannot stop drinking; need IV fluids or water rationing; urination is absent or very frequent
  • Attitude/Mentation is how your pet is acting and interacting with you and other members of the family. This can also include how many normal activities your pet voluntarily does.
    • Good/normal: is interactive, bright, and responsive to you and other members of the family; readily participates or wants to participate in normal family activities; seems happy and appears to be enjoying life.
    • Limited/poor: will interact some with family; might not interact as often or be as enthusiastic; may seem to ‘dragging’ or quieter than normal; will do some normal activities but not others; is responsive but might take more effort to get a reaction
    • None/minimum: will not interact at all or very little, even after a lot of effort; hides or runs away from interactions; will not participate or must be forced to do normal activities; is very quiet, minimally responsive, or not conscious at all.
  • Unique traits and favorite things can help you to monitor just how ‘happy’ your pet is. What falls into this category is different for each pet but include any activity, habit, or hobbies that your pet does.
    • Good/normal: participates in activities and acts normally
    • Limited/poor: desire to participate can vary or be limited; traits or habits may be decreased; may want to do it but can’t or won’t actually participate.
    • None/minimum: will not participate in most or any activities/hobbies; show no interest in activities/hobbies; traits are decreased or absent

Quality of Life Assessment Tool

This table can be used to track your pet’s quality of life.

Answer the questions as best you can by choosing the answer that fits best since the last assessment was taken. If this is the first assessment or an assessment after a significant change in health, choose the answers that best fit the symptoms your pet is currently having. 

photo of pills forming a question marke, sun, fork, knife, and plate to represent chemo drugs

In-patient Chemotherapy

The following information covers some of the more common drugs used at home to treat cancer. Which drugs are used will depend both on which disease your pet has and what other therapies are being pursued. If you have any questions about the medications here, please talk to your doctor or a staff member.

In-patient Chemotherapy

Most people have had experience with cancer and cancer therapy, whether it is personal experience, with a family member, or through a close friend. Often, these experiences are not pleasant, despite having positive rewards at the end. Cancer in veterinary medicine, though, is treated differently than in human medicine. Our goal in veterinary medicine is not to achieve a “cure” but to achieve the best quality of life for our patients. We may be able to achieve a remission (different than a cure) with some diseases, but for others we aim to stop or slow down growth.

When a pet experiences a side effect from chemotherapy, it typically starts the second or third day after treatment. This period, from three to five days after treatment, is when symptoms occur with the GI tract.  The bone marrow can have problems as early as day three but it is typically six to eight days after when cell counts are at the lowest. If white blood cells get too low, opportunistic microbes can get a hold and make pets feeling sick. Symptoms can include problems with the GI tract as well as decreased energy and generally “not feeling well”.

Most of our patients (greater than 90%) will have absolutely no side effects from chemotherapy. That is unless you want to include feeling better and happier with the side effects. For the majority of our patients that receive therapy and have a response, this will be the only “side effect” they experience.

Of the remaining 5-10% than develop side effects, most will be mild in nature and easily controlled from home. The most common side effects reported include loss of appetite, low energy, nausea, diarrhea, soft stool, and vomiting. To help treat these, we send home medications for you to have on hand in case side effects occur. Typically, cats will get upper GI side effects (nausea, vomiting, and loss of appetite), while dogs can experience the whole range of symptoms. The medications can be used prophylactically (starting the night of therapy) or held in reserve and used only if symptoms occur. It is important to use these medications at the first sign of symptoms. If started early, side effects can be stopped before they become more serious. The medications we send home are safe to use and will not cause your pet any issues if they are given them but did not actually need them.

A small number (1-2%) of pets will require more intensive care to control their symptoms. This includes outpatient injectable medications or inpatient hospitalization with IV fluids and injectable medications. This typically occurs when the symptoms come on suddenly and at home medications are not adequate to control them, or due to an overwhelming response of the cancer to therapy that “floods” the body with dead cancer cells. This can cause your pet to feel sick while the body plays catch –up in filtering out the dead cells. If symptoms are not addressed quickly, your pet’s condition can deteriorate rapidly. In extreme situations, a pet can have a fatal event after receiving therapy, usually from suppression of the bone marrow (low cell count), compromised body systems (like kidney or liver), or untreated symptoms (vomiting, diarrhea, etc). If your pet is not responding to medications at home or has severe symptoms that come one suddenly, please seek immediate care here, your regular vet, or your local emergency center.

Ultimately, the primary goal of veterinary chemotherapy protocols is to provide good quality of life for our patients while managing the cancer for as long as possible. Thus, if a pet has a side effect we switch drugs, adjust doses, or stop treatment entirely. We do not want our patients getting sick any more than you want your pet to be sick. If you have any questions or concerns about sick effects and your pet, please feel free to discuss these with your doctor.

photo of pills forming a question marke, sun, fork, knife, and plate to represent chemo drugs

Low-dose Chemotherapy

The following information covers some of the more common drugs used at home to treat cancer. Which drugs are used will depend both on which disease your pet has and what other therapies are being pursued. If you have any questions about the medications here, please talk to your doctor or a staff member.

Low-dose Chemotherapy

A handful of oral chemotherapies can be given at home, either as a low-dose long-term medication, or at a higher dose for a short, specific amount of time. These drugs are prescribed for at home use because the risk of side effects (to both pet and human) at the prescribed dose are low and they must be given over a long enough period of time that administration in the clinic would be unrealistic.

Side effects of the drugs to your pet are similar to other therapies: low white blood cell count, changes to the liver or kidneys, vomiting, nausea, diarrhea, and/or soft stool. The first two will be monitored by blood work performed at specific intervals. The latter are watched for at home. In either case, if side effects are noted, the medications are either stopped or the dose is adjusted to avoid side effects. If there are any concerns specific to a medication, your doctor will let you know before prescribing it.

Below are a few precautions and recommendations in regards to your pet and their medications. These guidelines help to avoid chronic health affects to you as their caregiver and anyone else in the family.

  • Most important: It is perfectly safe for people and other pets to be around the pet receiving medications, even while they are being treated.
  • Direct handling of medications should be avoided.
    • Certain individuals should avoid contact if possible. This includes children, other pets, and persons who are pregnant, may become pregnant, or are nursing.
    • A single exposure is unlikely to cause an issue, especially if cleaned up quickly by washing the affected areas with soap and water. The concern is with chronic exposure and the changes it can cause over time.
    • Wear non-powered latex or nitrile gloves (available as most pharmacies) when handling medication or anything that might be contaminated with the medication.
    • Wash your hands thoroughly after administering the medication, even if you wore gloves.
  • Do not open the capsule or crush the tablet.
    • Chemotherapy should be given whole, unless you are specifically instructed to break or open the capsule/tablet.
    • Unfortunately, due to the great chance of contamination, liquid formulations are discouraged. Medications come as either tablets or capsules.
    • If your pet chews the medication while taking it, that is fine. If they spit it out chewed up, make sure to thoroughly clean the area with soap and water or a detergent cleaning spray.
  • Less than 1% of the medication will be excreted by your pet as the active drugs, typically through the kidneys (urine).
    • Most drugs are broken down by the liver and these breakdown products are excreted in the feces.
    • Most drugs are also sensitive to light and temperature, breaking down very quickly when exposed to the natural environment.
    • Frequent cleaning of the yard or litterbox is all that is needed.
    • At our dosing levels, there is no drug found in the saliva of pets.

Targeted Therapy

The following information covers some of the more common drugs used at home to treat cancer. Which drugs are used will depend both on which disease your pet has and what other therapies are being pursued. If you have any questions about the medications here, please talk to your doctor or a staff member.

Targeted Therapy

There are many new drugs available to treat cancer (and various other diseases as well) that are not actual chemotherapy, but instead work by targeting the suspected genetic mutations involved in cancer cell growth. While there are new targeted therapies coming out all the time, the main three used here are masitinib, dasatinib, and toceranib. These medications can be used alone, but they work best when combined with other oral and/or injectable therapies.

Side effects to these medications are very rare and can often times be stopped with minor dose adjustments. We’ve also learned a lot about dosing over the years. We habitually dose below the ‘recommended’ amount without seeing a loss of efficacy, while also avoiding most/all of the side effects from the medication. Possible side effects to all targeted therapies include bone marrow suppression and GI upset, such as vomiting or diarrhea.

Some rare side effects that we monitor for that are specific to commonly used targeted therapies:

  • Masitinib can also cause a protein losing nephropathy (protein loss through the kidneys), so watch for a change in drinking and urination habits at home. We will monitor for any changes in blood work here at the clinic.
  • Toceranib can cause ulcers and bleeding of the GI tract that you would see at home as frank (red) blood in the vomit or stools, ‘coffee ground’ appearance to vomit, or stools/diarrhea that are tarry and/or dark. If you notice any of these side effects, please let you doctor know right away.
  • Dasatinib is especially prone to causing diarrhea, nausea, and vomiting so we typically prescribe an ‘antidote’ that is given one hour prior to the dasatinib to help prevent these side effects. However, if your pet still has trouble tolerating the medication, a dose adjustment often takes care of the issue.

Kirby the Golden Retriever at Four Paws Rehabilitation waiting in the underwater treadmill

Complementary and Integrative Therapies

Complementary and Integrative Therapies

At the Cancer Center, we believe in providing multiple options for the treatment of your pet. We use a combination of Eastern and Western medical approaches to treat your pet and enhance their overall wellbeing. This includes the use of medications, procedures, herbs, and acupuncture. At our other location, we also have a rehabilitation center.

In the following pages, you will find information about some of the complementary therapies we offer at Olympia Veterinary Specialists. Feel free to talk to your doctor or the staff if you have questions about any of these options or if you have questions about options that are not listed here.

Acupuncture in our Companion Animals

What is acupuncture?

Acupuncture is the insertion of very small, sterile needles into specific points on the body to achieve a desired effect. This technique was originally developed by the Chinese over 3,000 years ago, and has since been used to treat and prevent illnesses in humans and animals alike. In animals, it is performed by veterinarians who have gone through additional training to become certified in veterinary acupuncture.  Sessions may include dry needles, aquapuncture, and/or electrical stimulation of the needles based on the animal’s specific need.

What is acupuncture used for?

Acupuncture can help with a wide array of issues. It can help relieve pain and inflammation, improve nerve conduction, enhance the immune system, and help with reproduction issues. It will not help with surgical issues or infections, but can be used as supplemental therapy to these and many other conditions. It is NOT used immediately over a tumor, because it could increase blood flow and cause the mass to grow. It can be used, however, during therapy for cancer to help support the rest of the animal.

Some common uses for acupuncture in small animals include:

  • Musculoskeletal issues, such as:
    • Arthritis
    • muscle knots from over exertion
  • Skin problems, such as:
    • lick granulomas
    • allergies
  • Respiratory problems, such as:
    • chronic rhinitis
    • asthma
  • Gastrointestinal problems, such as the prevention or treating of:
    • Vomiting
    • Diarrhea
    • ileus (slowing of intestinal transit time)
  • Nervous system issues, such as:
    • seizure disorders
    • decreased nerve conduction (scuffing hind legs/degenerative nerve conditions)
  • Enhancement of the immune system

How does acupuncture work?

Acupuncture points are called channels or meridians and are often found in areas that contain blood vessels or nerves; therefore insertion of a needle at one point can cause a local as well as a distant effect along the channel. The local effect occurs when the needle disrupts surrounding mast cells causing them to release substances which send signals to the brain. The brain, in turn, sends a return signal that causes the release of additional hormones and endorphins. These new chemicals can induce relaxation, stimulate the blood vessels, and increase immune system mediators. When combined, these can cause local relaxation of the muscle fibers, stimulation of nerves, increased blood circulation, and localized pain relief. In ancient times, this was seen as releasing the “stuck” energy or Qi.

What happens during an acupuncture session?

During an acupuncture session, sterile needles are inserted into specific points along an animal’s body. These points are tailored based on the exam findings and individual issues/needs. The great thing about acupuncture is that it can be combined with other therapies and treat multiple issues during the same session. Once the needles are inserted, the animal sits with a staff member or the owner for 10-30 minutes. Most animals do not mind the needle insertion. It generally does not hurt the pet, but may cause a tingling sensation. Some animals even fall asleep during or right after the session!

How often are acupuncture treatments given?

The length and frequency of the sessions are based on the individual animal’s needs. Acute injuries/problems are often responsive to one or two sessions, while a chronic problem such as arthritis may need lifelong therapy. For acute issues or preventative sessions (such as to prevent nausea during chemotherapy administration), a single 5-10 minute session may be all that is required. For chronic issues, we generally recommend three to four 30 minute sessions done once a week or every other week. We then try to space out the therapy according to the animal’s needs. Oftentimes, once chronic issues are maintained, treatment every 4-8 weeks is recommended.

Fear Free

Trips to the vet can be stressful for your pet. Here at the Cancer Center, we want both you and your pet to have a great experience. Thus, we are integrating Fear Free into how we operate to make this as positive of an experience as we can.

So what is Fear Free? Developed by Dr. Marty Becker, “Fear Free” veterinary hospitals are those which promote a considerate approach and gentle control techniques used in calming environments. Once practice certification is available, we intend to pursue this accreditation. Until then, we are still planning on employing the recommendations of the Fear Free program.

Below are some of the recommendations and changes we have already made :

  • Don’t have your pet eat after 10pm the night before their visit. A calm stomach helps your pet have a calm mind. Bring food, we can feed them here!
  • Our exam rooms are meant to feel comfortable for both you and your pet. Comfortable beds for our patients can be found on the floor of each exam room.
  • “Fear Free” hospital  certification requires that at least 25% of our staff be individually certified, so you can trust that our technicians and assistants know how to create a stress-free environment.
  • For our extra nervous furry friends, we have a few options to help reduce their stress:
    • Calming pheromones (Adaptil for dogs and Feliway for cats): we use the diffusers so that the pheromones are always around to help calm our patients.
    • Thunder shirts: the gentle pressure placed on the thorax helps to calm some pets down.
    • Mild anti-anxiety medications (not sedatives) to help your pet relax and stay calm.
  • Cats and dogs have separate housing areas to rest in during their stay. Pets that are nervous around other animals or people are also welcome to stay in our exam rooms during drop-off times until they can be brought to the back of our hospital.
  • We encourage the “just because” visit for pets who are uncomfortable at the vet. They can just stop by for a short hello, get a few treats, and leave. This will help reduce the ‘negative’ associations with the office/staff and help to create a calmer pet when they do have to stay.

We hope that these changes help make your pet’s stay with us as low stress and fear free as possible. If you would like more information about the Fear Free program, you can check out their website at www.fearfreepets.com or talk to one of our staff members.

Four Paws Rehabilitation

Whether your pet is a high-octane athlete or a seasoned couch potato, Four Paws Rehab offers a variety of services to help with your pet’s wellbeing. They can assist with rehabilitation as well as improving the overall condition of your pet. They employ a variety of techniques and tailor each session to your pet’s specific needs and abilities. What services are available to your pet will be dependent on both the conditions being treated and what will work best for your pet. Below you will find a list of some of the services they can provide to your pet, and the benefits of rehab work and body conditioning.

Available services include:

  • Hydrotherapy with an underwater treadmill
  • Pain management
  • Cold laser, therapeutic ultrasound, and neuromuscular stimulation
  • Massage and body work
  • Nutritional and supplement recommendations
  • Education about neurological and/or orthopedic conditions
  • Custom home exercise programs

Benefits of rehab and conditioning work:

  • Reduced muscle atrophy and recovery time after surgery
  • Increased mobility, coordination, balance, and flexibility
  • Weight loss in overweight pets and muscle gain in under conditioned pets
  • Reduction of pain from chronic conditions like arthritis
  • Build confidence, abilities, and focus

If you think your pet may benefit from some rehab work or conditioning, feel free to talk to your doctor about it or simply schedule a consultation with the team over at Four Paws Rehabilitation.

Contact Information

902 Union Ave SE
Olympia, WA 98501

(360) 753-7297

(360) 810-2274 fax

fourpawsrehab.com