Hi everyone, it's Jackie, head of membership and fellow VN here. Just wanted to jump on quickly, interrupting my walk to let you know that as a thank you for joining us on this free nurse membership webinar, we are offering you a 60% discount on our unlimited membership. That's our entire library of content, including all the companion animal.
Veterinary contents for a bargain price of 199 plus VAT instead of 499. Now this offer is only running for Vets Awareness Month, so you must take it up before the end of May using the discount code VA 60, and then you get that access for the entire year. It's time to empower yourself through education.
Come and join us. Good evening everybody, and thank you very much for joining me this evening while I discuss palliative care for the oncology patient. We are going to go through everything associated with palliative care about what to offer, what options we have, for, for our owners and for our patients.
So what is palliative care? It is described by the World Health organisation as improving the quality of life of patients and that of their families who are faced with challenges associated with life threatening illness, whether phys physical, physiological, social, or spiritual. Now we need to remember that palliative care may not actually slow down the disease progression or prolong life, but we are actually, we're just aiming to restore and maintain a really, really good quality of life and allow them to function as normally as possible.
So when can we offer palliative care at any point, any point following the diagnosis of cancer. And it can actually help owners come to terms with the patient's diagnosis before euthanasia has to be considered. So there are many reasons why we will opt for palliative care.
It might be that the the cancer or the the metastasis from the primary cancer are actually too advanced for any form of definitive treatment. There may be a presence of any other life life-limiting comorbidities, for that patient. A lot of these guys tend to be, older patients.
So there may be lots of, some arthritis, maybe some kidney disease, anything else that could be going on that might actually influence our decision as to how, how, how much we actually do, for treating their cancer. The patient's emotional health and behavioural welfare is really important. It might be that is this pet actually able to cope with coming back into the hospital multiple times, maybe weekly, every two weeks for checkups and medications and maybe some treatments to help them through, through this plan.
How was that patient's, what is that patient's behaviour like? It might be that we, he's actually just a poor candidate for behaviour, and, it might just be that way, he's not suitable for any forms of treatment, any form of, injectable chemotherapy or actually too much just because of his, his behaviour. There simply might not be any existing treatment options for these guys, depending on what cancers that they actually have.
We offer to patients who are no longer responding to treatment, so it could be that you've, these guys have been having a patient with lymphoma. They've been having lots and lots of treatment. They've been doing really well, and they are having, we've had to chop and, and then they've relapsed.
We've started them on a new protocol. They've then relapsed again and we've had to go, we've gone through multiple protocols and they're just simply not responding more to, the chemotherapy protocols. And it might be that the owner just simply doesn't want to go ahead with any treatment, any, any surgery or any treatment or any chemotherapy.
And maybe they've gone through with a previous pet or maybe they've had a family member who's who's gone through all of that and they don't want to go through that. But yeah. But it really, really shouldn't be offered to patients that they, there is, that are currently suffering, and that there is no chance of improving their quality of life, because this is, this is the main thing.
We need to make sure that we are, we're fighting a winning battle here. We're actually wanting to make them feel really, really, really well for whatever short period of time that they have left. So no treatment.
This is also an option. I said it might be that the owner simply doesn't want to go ahead, with any treatment, for whatever reason, and it, it might just be, they might just request to take the pet home just for a few days to spend some time with them and actually be able to plan euthanasia. And remember, the quality of life is the main thing for these patients, it's the most important thing, and we need to really advocate for, for them to make sure that they're not being.
They're not being taken home when they are really unwell or there's actually they're not going to do well at home even if it is for a day or two. We need to look after our owners as well, as much as, as, as well as our patients and it has been said that receiving a cancer diagnosis has been compared with watching the fireworks show and it's it's numbing, it's deafening, and it's completely overwhelming. We need to support the owner, .
For any parts of the grieving process, and this could be not all, not just after the patient has the pet has been put to sleep, but there's also the anticipatory grief when these owners are actually, they know the time is coming, they don't know when, they don't know how long they have. Is it going to be a couple of days? Is it going to be a couple of weeks?
Is it gonna be a couple of months? They will be anticipating this, and they, a lot of the, a lot of the times they do, they do want to have a little chatter with you. And, I've sat in a consult room many a time with our owners and just kind of talked it through with them and just let them, let them get some stuff off their chest and just have a nice little, have a, have a chat about it and just to be able to support them through, through the whole process.
So when we are coming up with a palliative care plan for our patients, we need to chat with our owners properly. We need to set some goals, and we need to to set the expectations as well. And we need to make sure that these owners absolutely understand that we are not, we're not, we're not fully treating these patients for the disease.
We're not gonna slow down the disease progression or prolong life. We are aiming for a really, really good quality of life. They must be educated on how that they can identify any disease progression, whether or not the lymph nodes in a lymphoma patients start to become even bigger, or that mass on the leg or the or the the the body starts getting any bigger.
Is it becoming more painful? Is it ulcerating? Is there any discharge?
It'd be good to actually discuss an end point of treatment with the owners, at this point as well as this, this can actually help, the owners if they start to lose sight of what's, what's going on as the disease actually starts to progress. And end points might include that maybe he's on some form of analgesia now, but if he starts to need a 2nd or 3rd. Analgesia, that's enough.
Maybe their pet doesn't want to actually go for a walk or doesn't want to play anymore, or if they're not wanting to eat, especially their favourite treats that normally they would normally lose fingers over. So it's good so that that the owners then have a, have a, have an end point in in mind. And the owners really must be supported and encouraged to keep in touch with the practise to make sure that we, that the patient's quality of life actually has been maintained and quite frequently, we will only issue maybe a week or 2 weeks' worth of medications, just so we can, we are actually seeing our patients back weekly to weekly, if we are concerned that they are going to progress quite quickly.
It can also be really good to have a, a euthanasia discussion and come up with a plan with the owners. Some absolutely might not want to discuss it. Absolutely fine.
And some might want to kind of talk things through, talk, talk through their options so that they've got, they can start making a plan for themselves. So on the day, or when they, they know the time is coming, that they know that they, they have a plan ready. Some owners may want a home visit, there's lots of telephone number, there's lots of at home euthanasia services.
What sort of cremation do they want? Do they want individual? Do they want communal cremation?
Do they want to bury their pet at home or at a pet cemetery? What type of casket do they want if they're going for cremation? Do they want to take some fur clippings and or nose and paw prints at the time as well or beforehand?
And these palliative care plans should be, treatment should be taken on a day to day basis, especially when nearing this patient's end of life, and remember, I'm gonna keep saying this, we should advocate for our patients and not euthanasia if we do see a decline in quality of life. And I remember, I, I sat in Linda Ryan's talk at BSAVA a couple of years ago, and I remember her saying, every day must be a great day. This is the focus that we really, really should be aiming for, for our patients, to make sure that it is whatever time that they do have left, must be really, really great for them.
They must be able to maintain their normal function, be pain free, be able to maintain their hydration and body condition. And be kept as free as possible from the adverse effects of their illness and the treatments that we're actually giving them because some of these treatments can actually cause other problems as well. So these plans are gonna be different for each patient comparing a are you, say, a, a youngish border collie who's used to running around like an absolute crazy beast, to a older, dog that he's used to just sitting on the couch all day, what the list of activities and their likes and dislikes and their activity levels will be different.
So we need to make it, we need to tailor it for them. And if, so that owners can actually monitor. Are they wanting to still go for walks?
Are they still wanting to run around the fields? And actually then be able to work this into their, their quality of life, monitoring. And exercise and play should be continued, as much as possible, as much as they're able to tolerate, as this can provide cognitive stimulation and assist with quality of life monitoring.
And so if that dog's had a surgery, he's had, either a limb amputation or he's had a splenic, he's had a tumour removed. We are on palliative plans, and they, they enjoyed going running with their owners. Let him go running, let him go and do whatever he wants.
If he's if he's enjoying it and he's tolerating it, we want them to be doing as much as they can what they would previously have been doing. So when we are coming up with these plans, again, we need to consider what type of cancer does this patient have, the tumour location and the patient's general health status and any comorbidities. We need to we need to consider, is there any kidney disease, or is there any arthritis that we might need to be careful with what medications we can start them on or we can't start them on.
And it's really, really important to us that our patients are actually able to cope with the stress of these frequent hospital visits. We are really good at using gabapentin and trazodone for our cats and dogs. There's lots of different protocols that are available.
And these can work really, really well, especially when they're own, the owners are on board with using this. And we use lots of treats and playtime when they're in the hospital as well. And we want these guys to get to that front door and go, yes, I'm not, I'm here again, I'm having, I'm here for a checkup, I'm coming in for a biscuit.
I know where that biscuit jar is in that oncology room, and yeah, we work really, really hard for these guys. And I heard, I just wanted to put this in, just because we have so many owners say, Oh, I didn't give the gabapentin and trazodone today, cause it made him really sleepy last time. I'm like, Oh, that's really the point.
We want these guys to be able to, cope, be able to cope with the stress and anxiety of coming to see us. And if having him gabapentin and trazodone for that visit helps him, it helps us. It helps him.
It makes everything a whole lot better for everyone. So we've had a couple of conversations, work with owners where we've had to say, look, you can see how worried and anxious that he actually is, by giving him the gabapentin and trazodone, we are helping him cope with this stress and this worry. And once they, once they understand that and they can see the changes and the benefits for the pet, most of them are usually pretty on board with giving it.
So what is the role of the RVN in palliative care? We, we should be, we can be involved in pretty much everything. We want to be able to provide, assess and provide key aspects of the palliative care plan.
We can chat through any own owner education that may, they may, they may need, with regards to medications or feeding or . How often we are needing to see their patients. And quite often we do tend to be the patient's advocate and then maybe they'll liaison between, the the veterinary surgeon and the owner, if, especially if the owners are really comfortable and get to know you really well, they will tend to call you and have a little chat and want to do regular updates.
And we can do the monitoring the day to day, even if the owners are calling us once a week for an update or a couple of times a week for an update, we can actually, we can guide them. And if we're seeing them back in for their palliative care checks, it might be that we do notice some subtle changes that the owner does not, that we then can discuss with them and then pass on to the veterinary surgeon. So at these checkups, we should be doing a, full, a full examination, a full TPR, body, body weight, body condition score, muscle condition scores, and then we can actually start seeing if the, how, what changes are actually starting to occur.
If there's any masses, or enlarged lymph nodes, we should be recording, measuring and recording, using callipers so we can monitor any changes. Are they getting bigger? Are they getting smaller?
Are they changing? Are they becoming harder, or are they becoming softer? Is there any discharge?
And we can go through these quality of life scale check sheets as well, which I'm just going to come into the next couple of slides and any food monitoring as well, so if if they're needing help with how much food their pet is or isn't eating, and we can advise that too. So we have, so we have to consider quality of life for these guys, that's the most important thing. And we need to make sure that they're able to, keep themselves nice and clean.
Are they able to maintain their hygiene? Is pain managed well enough, appetite? Are they wanting to eat enough?
Are they wanting to eat their normal foods? Or are they needing diets, chopping and changing? Are they maintaining their hydration?
Are they drinking enough? Are they having constant diarrhoea or vomiting? How happy are they?
Are they, are they living, are they living a, a really good life? Consider that they, this, if they're having to come to the hospital regularly for treatments, are they gonna be able to cope with their owner for, regular periods? How are they, go, how, how is their mobility?
Are they going to be able to cope if they're usually a regular, have quite a regular exercise if everything has to kind of be scaled back a little bit. And consider how are they having more good days than bad. Remember, we want an every day to be a great day, and make sure we want to make sure that there are more great days, than bad days.
So there are a number of quality of life scales around This one is the, the hate, hate, hate, hate, hate scale. And then there is the Ohio State Quality of Life scale. And both of these work on the basis of, we have a number of criteria and then a number of scores, and then we, the owners go through these, tot up the scores, and then we have we come to a number.
And then what's that, even if these are done, say, weekly or twice weekly, and if the owners can actually see changes, if the numbers are getting, indicating more that their quality of life is starting to to deteriorate, this can actually then be, a sign that they do start, they are needing to start to consider euthanasia sooner rather than later. So these are really good, a really good tool to use in practise, especially when for patients undergoing palliative care. So we can advise that some some at home care for these owners for these patients, it might be that we, they are needing some administration of some sub some subcutaneous fluids.
Have they got a concurrent condi Chronic kidney disease, where they're needing to maintain their hydration and, or if they are they not able to drink as much, are they having sort of a little bit of diarrhoea ongoing diarrhoea and they're just becoming dehydrated quite quickly. It might be that we're able to offer this, and owners can actually administers fluids themselves at home if they're taught correctly. Or it might be that there's a, there's a nurse in the area who's able to go round and do this regularly, regularly for them.
We can offer assistance, for their mobilities, either some harnesses or slings if they're needing them. And we can shave their paws if they've got some grinch feet going on, if they've got some fluffy feet, just to help them, actually be able to walk and actually grip on the floor. We might need to consider some environmental changes, raising food and water bowls or using some mats and rugs around the house, especially maybe if the patient has had a limb amputation just to give them a little bit of grip on the floor.
And owners I'm sure, will actually be really happy to kind of keep their their pet really clean and comfortable by keeping his face nice and clean and clipping nails so they don't get caught up in the carpet. And just making sure that they're the fur is kept nice and clean and maybe shorter around the bum and, just to make sure that they're not getting urine and faeces stuck to the fur. So this book has been recommended a number of times.
It's called No Walk, No Worries, and this is, been designed for, and there's lots of like activities in there to help maintain that dog's wellbeing, especially when they're on a restricted exercise. If they're not wanting to go out for some walks, maybe they will be quite happy to play, play some little games, for searching and seeking, and other little things that they might actually just give them a little bit of a boost, even if they can't go out for their proper walks. So pain management is important.
Pain in animals causes anxiety, fear, and helplessness, and this stress and negative emotional state actually lowers the body's immune resistance to cancer and enhances tumour cell growth and the metastasis. So that's another reason for a big reason to actually try and get this all under control. Pain may be caused directly or indirectly.
And the cancers that tend to be most associated with pain, the oral cavity within bones, the urogenital tract, eyes, nose, liver, GI tract and skin. So we need to consider, make sure that these patients are, if they have these tumours that we're looking after their pain management well. So direct pain is when the tumours are causing pain directly to the tissues because they're expanding maybe due to pressure.
These tumours are getting bigger. That pressure, on the skin and on the tissues, the tumour could be invading any surrounding structures, damaging local tissues, maybe even causing some obstruction of normal flow of maybe faeces, urine, and bile. Sometimes these masses will end up ulcerated and become can become infected and this too can cause some pain.
Tumours cause indirect pain by inducing stress and inflammation, so these tumours can actually start releasing inflammatory mediators that can stimulate pain, so such as like the cytokines and the interleukins. All of these can be released from the cancer cells and the immune cells and that and then that can infiltrate the tumour micro environment. So we have lots of pain scoring charts that can be used and we remember we need to consider any acute pain that patient may be having, chronic pain or any non-cancer causes such as like arthritis as well.
We need to be looking at all, all of their pain. Trust what the owner is telling you about their pet as well. If they come, you'll see, you, you, you'll all know that when a, a dog tends to come into the hospital, sometimes they will be bouncing around all excited and waggy tailed, and the owner will say, Oh my gosh, he's not been like that at home.
He's been really miserable. He's not been jumping up, he's not been jumping up on the sofa or coming down the stairs. Trust what them owners are telling you.
It might be that we say, OK, well, let's give you an analgesia trial for a couple of weeks and then you can report back, . Listen to what they're actually telling you because the pet, usually the pets will behave completely differently when they are at home and not full of adrenaline when they come to see us. So plans often tend to be multimodal and will may require the use of lots of different medications.
And opioids tend to just be used in the hospital in the acute setting where we get things under control, but we have had a, a few patients that we've sent home with a fentanyl patch, or some cats with, the mucosal buprenorphine. We may need to use some non-opioids such as ketamine, non-steroidals, or paracetamol in dogs. And maybe some adjuvant medications such as steroids, we use lots and lots of steroids, gabapentin, nutraceuticals and bisphosphonates which I'll discuss a little bit later on as well.
So there's some alternative treatments that we can use for pain as well, including acupuncture, physiotherapy, hydrotherapy, and possibly laser therapy as well, but making sure that we're using it just for arthritis and not on the tumours. We need to monitor, and manage some wound if there's any wounds. It could be that it's the primary tumour that has become, infected.
This one in the centre here was a, an injection site, sarcoma that grew very, very quickly and quickly became ulcerated and infected. So we needed to manage, we managed, had to manage this by removing the whole tumour. There could be some Jacubutous ulcers, this little one on the left hand side of your screen was a dog with multicentric lymphoma with rectal involvement.
And she, we could tell that she was, she, her lymphoma was relapsing because she would end up with a rectal prolapse. Once she was responding to treatment again, this went away, this resolved. And then as soon as she would, relapse, it would start up again.
So we had to make sure that she was kept clean and comfortable and that there was no damage or ulceration, happening to her, to the prolapse. So urination could be affected by primary tumour, especially if it's a a a transitional cell carcinoma, bladder tumour, or the or any metastasis. These can lead to sometimes a partial or complete obstruction, of the bladder, the urethra or the ureter.
Urination could be altered by medication side effects, such as if they become polyuric, especially if they're on prednisolone, or they could end up with sterile hemorrhagic cystitis if they, if they are on cyclophosphamide, which we'll discuss a little bit later on. Or they could have just ended up with a urinary tract infection if they do have one of these tumours, they are more susceptible to, infections. Owners need to be able to monitor the urine stream and make and the volume that that pet is producing.
And if the patient is starting to become completely obstructed, there is a possibility of placing the cystostomy tube for for management. This is something I've seen probably once in my time, where I am now. It's not something that is done very frequently.
We have to consider that pet's quality of life. They've got to have a GA for a pretty, pretty invasive surgery, and then there's the recovery, from all of this as well. And we need to think, is this owner actually going to be able to manage the, the recovery of this patient?
Are they going to be able to do wound management? Are they gonna be able to look after this tube? Are they gonna be able to empty the dog's bladder or the cat's bladder every every 46 hours?
How long are they out at work for, they're gonna be able to do this? It's lots of things to consider. So faeces could be affected by the primary tumour, if it's an in, maybe an intestinal mass, if it's an anal sac, adenocarcinoma or the metastases, there could be partial or complete obstruction.
And the dogs that I especially chat with, are the anal sac, tumour dogs that may end up with flattened or ribbon faeces, especially if they, If if there is progression. So I just wanted to show you this CT scan for this patient, and he was an eight year old cocker spaniel who had bilateral anal sac, adenocarcinoma. And he's had, metastasis to his sublumbar lymph nodes.
So you can see, his lymph, his, his anal sac mass was, he was pretty, pretty sizable, but his lymph node is absolutely ginormous, and this was what was causing, this is what caused most of the problems. This was not his. He was a non-surgical patient because this lymph node was wrapped around the aorta and the vena cava.
So we couldn't remove this. We could have removed his anal sac masses, but it wouldn't have really done all that much. It was because it was the lymph node that was causing the problems and the problems with, passing faeces.
So all the, the causes of any faecal problems and the and the treatments depends on what, what type of cancer it actually is, and it may be that we do need to go for some surgery, especially if there is any obstruction, especially if the patient is surgical medication, we might need to look for some form of chemotherapy or stool softeners. I've put in the manual evacuation if they are becoming really constipated, but this is something I think is, you've got to really consider this patient's quality of life, because if they're absolutely not able to pass any faeces, and we are not, we're trying to, we're having to manually evacuate this, we can't, we're gonna have to be doing this all the time and it's, I don't think that's, it's gonna be quite uncomfortable for them in between treatments and then they've got to go through this regularly, so I don't not really sure how feasible that really is. Need to be able to think whether or not these patients are actually able to stand enough.
Can they actually stand enough to pass urine and faeces? Are they urinary urinary or fecally incontinent? Are they on a really, really high dose of prednisolone, so they are peeing all over the place and they're just, they're just uncontrollably, is this what's going on?
So we need to consider, urine scalding. Fly strike if they're constantly got urine and faeces on them, and any distress for that patient as they'll be constantly having to clean themselves. So nutritional management is really, really important part of this palliative care plan.
We should be, when they're coming in for their checkups, we should be regularly assessing their weight, the body condition score, the muscle condition score, and it's really quick for some of these patients to become malnourished and dehydrated, especially towards the end of the palliative, towards the end of their, their care. And the World Small Animal Betterary Association have guidelines for the body condition score, the muscle conditions score, and you can download their their charts from their website. So them becoming hyperorexic or anorexic can can occur for lots of reasons, pain, and dysphagia or obstruction, if they're just generally not able to eat or swallow, difficulty opening the jaw, and if they've got extensive oral or nasal masses or any GI disturbance from either the .
Either the primary from either the tumours or treatments. As you can see, this little guy, he had a massive oral tumour, bless him. He, he was trying to eat, he just couldn't.
Sometimes he just couldn't quite get as much in as, as he was wanting to, but he felt pretty good. He just couldn't quite work out how to get some food actually in properly and he'd be able to eat properly without, without traumatising the, the tumour and quite often this, ended up bleeding. So GI disturbance can be put it can be stopping them wanting to eat and drink quite as much, especially that this could be caused by vomiting, nausea, diarrhoea.
And any of these could be secondary to the cancer, the primary cancer. It could be some of the chemotherapy or any of the treatments that we have given them, not just the chemotherapy, or if we're having to chop and change their diet, if they're becoming a little bit more, a little bit fussier with what They want to eat. If if they've been on some long-term chemotherapy treatments, this can actually, this can alter their, their taste and what they're wanting to eat.
So we might be having to chop and change their diet a little bit because they're not wanting to eat, but then in turn, this then leads to a little bit of diarrhoea as well. It could be that they're early satiated, if they've got a mass or lesion in the stomach, which is giving the the them, making them feel like they're full, which is artificial. Or there could be a mass elsewhere in the abdomen which is actually pushing on the stomach again, causing the feeling that their stomach is full, so they're not wanting to eat as much.
So again, the nutritional management aims, optimise quality of life. So this is always about the quality of life. We want them to maintain a reasonable body condition and prevent any metabolic complications from, from feeding as well.
We should be feeding via the GI tract. If we're having to start considering parental nutrition, something else needs to be changing for this patient, . It's if we're having to start using for further invasive forms of feeding, ideally we should be, if, if they we are moving that way, we should be getting some feeding tubes and everything else on board as well.
We're aiming to slow the onset and progression of cachexia as well. And we need to replace any nutrient losses associated with the disease process and or any anti-cancer treatments as well. So appetite stimulants are available and we use them quite readily as well, but we need to make sure that all all factors have been considered and dealt with for that patient.
Are they in the hospital and they're not wanting to eat? . So they're a little bit worried because there's half a dozen of the dogs barking in the in the in the ward.
So we need to be able to deal with that. Are they painful? So we need to deal with the pain for that patient as well to make sure that they're actually wanting to eat.
Are they nauseous or vomiting, which is why again why they may not want to eat anything. So there's lots of different, there's a couple of different appetite stimulants that are available. Mirtazapine tends to be the more common one and that we are able to use and it comes as a tablet or a transdermal gel now, which is wonderful for cats that especially you can't get the tablet into.
So yeah, Mota has is recently available and you just need to make sure that you guide the owners on how they are actually able to prepare and to administer their treatment correctly. Nice is a newer . Appetite stimulant that is available.
It's licenced over in America, but we're able to source over here, especially if you, if you're able to get a VMD special import certificate, and we do use this if we don't have much success with mirtazapine. Peractin is an older kind of an older anti oh appetite stimulant, that we, we still actually use, especially if we're not having much luck with any of the others and it is still worth considering for your patients. Feeding tubes are wonderful.
I do love a good feeding tube, and these can intake with, calories, fluids and medications. So if they're if they're not wanting to be eating, or drinking or struggling to take medications, the feeding tube is definitely the way to go. An O tube esophageal tube is the most suitable because these can actually stay in place for months if they're looked after properly and that owner maintains that.
And we can consider preemptive placement as well. The downside is that it does require an anaesthesia for placement. But if we're, if the patient is coming in for, Sedation for an ultrasound or anaesthesia for surgery, we could consider placing one at that time.
We've recently had a little cat in who's had come in because he'd been unwell, hadn't been eating for for a little while before he'd even, he'd been referred to us, and it, we determined that he did have, neoplasia and, we wanted to make sure that he was going to be well enough if he did want to start any form of treatment and. We placed the feeding tube while we were waiting on results and everything and it meant that we could get some calories into him. He could get some medications while we were making a plan and he's said he did really, really well, he did well with that feeding.
So cancer cachexia is the bane of my life. It's it's, it can just, it's just so, it can just be so sad to be having to deal with this, and a lot of these tumours can secrete a variety of cacexia promoting compounds, and these actually start to hasten a malnourish state. It causes extensive derangements in metabolism, it can alter the way that the glucose, proteins and lipids are all are all dealt with, and it can lead to a decrease rapid, quite dramatic decrease in body weight and body condition score.
And this can be despite consuming enough, calories as well, as you can see this, this, this dog was a lymphoma patient, and she was, we, we had her, we tried to, we were getting her under almost under control. And she was just becoming, cakey. We were just, yeah, we, we'd get her under control for a little bit, and then she'd relapse and then she just became so caexic and these, if you can see, it just absolutely zaps the patient of the, the body weight and then their energy and everything and It can dramatically affect that patient's quality of life, and it's often seen as the end stage of that pet's disease and is likely to contribute to euthanasia.
So these patients, when they're at home, it's handy for the owners to keep a food diary, to monitor how much the pet is actually consuming. They may need some guidance and once you start working out the calorie requirements, how much they. If you did that for them, you could work out how much food they should really be eating and to make sure that they're actually meeting their their RER as a minimum.
It might be that the owners need to spend a bit more time with the pet to encourage them to eat so like hand feeding, regular diet changes, warming of the foods as well. Might need, they might need to separate that pet from any other pets, if they are slower to eat. And the use of microchip feeders can be really handy, to avoid any other pets actually stealing their food, especially if you've been getting lots of different ones for them.
And obviously, Quver's not really a suitable food for cats. My cat thought they were. And make sure that these guys can actually get to their food and water when they're at home.
Have they got a buster collar on? Can you, can that be taken off, while they have something to eat and drink? Do they have neck pain?
Do they have arthritis? Are they, do you need to elevate the bowl? Do they need the bowl holding for them?
Would they just prefer it on a plate or just simply on the floor? So with hydration as well, some patients may struggle to actually maintain a suitable level of hydration, especially if they are feeling a little bit, if they end up with vomiting or diarrhoea. Owner I said, can be taught to give the sub fluids at home if needed.
We can add water to food and make a bit of a slop, and some of them do seem to really like it like that. Or we can add some food to water, just to kind of flavour and found a cup or maybe a spoonful or two, of some of the, the liquidy foods or. The softer foods just mixed in can actually make a, can actually encourage them to drink.
And even if you're boiling, you could even boil some fish or chicken. And the water that you've boiled them and you can use that to flavour water as well. And again a feeding tube is really good because it's really handy you can.
Add some water down that tube at the time of the feeds as well. So we really should be avoiding, force feeding, either in the hospital and and actually, of telling the owners not to force feed at home as well as leads to so, so many problems. It can lead to aspiration pneumonia, which can then lead to lots of complications and really poorly patients on top of what they're already dealing with.
And it can also lead to food aversion. This is catastrophic if this happens. It can take months to rectify if this does happen, and it might be simply that this pet doesn't have months to to get over being the food aversion.
And this will, if it, if this starts to happen, you will need to place a feeding tube to get them through this. So surgical intervention, may be part of the plan, for pain control. Sometimes just debulking a mass can release some of that pressure on the surrounding tissues.
It might be that we've not, we get, we don't get very good margins at all. We're just literally trying to do it for that patient's comfort. Limb amputation removes the, the source of pain for, any neoplastic bone lesions, such as osteosarcomas.
We've had, I can still, I can remember one patient from a few years ago who's, who came in, he had an osteosarcoma. He had the limb amputation. The owner was really a little bit worried about putting him through such a big surgery.
He was quite a big dog. He was a, I think, a 35 kg, flat coat retriever. She was a bit concerned about putting him through that, he went through it, he rocked it, he did so, so well, recovered really well from surgery, went home, and two weeks later she came back for his checkups, and she actually said she didn't, she hadn't realised, I think how, How uncomfortable he had been with the tumour, because he just kind of got on with it.
It had just been a steady decline in how he actually had been in himself. And now that pain was gone. He was back to being his normal little self, and he, she was really happy.
Doggo was really, really happy, and went on for, a little while, quite a while afterwards, been with a really, really good quality of life. He had just, just following that surgery. It might be that we need to do some wound management, especially if there's some ulceration of them of a mass.
Or if there's any haemorrhage, so we see these dogs coming in, they've got hemo abdomen and we've diagnosed that they've got there's a, there's a a mass either on the spleen or a liver, and we need to make a decision. We either need to euthanize immediately because the pet is probably not going to survive, . A continuous bleed like that, or we go to surgery and we remove the offending, organ, and then we make a plan once we've got histopathology results back, is it to moving forward?
So radiation can be used in the palliative setting, and this, and this can help improve the clinical signs with lots of different cancers, such as pain, swelling or discharge. Again, primary objective is to improve the patient's quality of life. Again, this is, this is always the main focus.
So palliative protocols do tend to use a lower total dose and we try, we're trying to avoid lots of the radiation side effects. So if we're using a palliative setting, hopefully we shouldn't, it's rare that we are, there are actually side effects. And we tend to commonly used in non-surgical osteosarcoma, large non-resectable, soft tissue sarcomas, mast cell tumours, or oral nasal tumours, and sometimes we might need to consider placement of an esophageal tube.
And I just thought I'd show you these, this was a little guy who had palliative radiation therapy. And he ended up with some, oral mucusitis, and he had some ulceration on his tongue and all on his mouth. This is really, really rare for this to actually happen, with the palliative, .
Radiation settings and the treat the doses that he actually received. And they were wondering whether or not because his mu mucosa was already compromised because of his disease, that this is why this happened. So he, he went on to have a feeding tube place and this little guy's rocking it now.
He's doing really, really well, thankfully. But it is just something that we just need to consider, especially depending on what considering the cause of why we're going for palliative radiation. And it's just that the owners need to be closely monitoring, the sites post treatment as well.
So radiation has been considered one of the most effective treatment modalities for the management of osteolytic bone pain in human cancer patients, and it's been used extensively for bone cancer pain in dogs with primary bone tumours. So the analgesic effects of the ionising radiation can be partially attributed to the induction of cell death in both the malignant osteoblasts and reabsorbing osteoclasts. Ower education is really important for these guys.
These are high risk of pathological factors, at the site of the bone lesion. So we've, we've dealt with the bone pain. These guys are feeling really, really good because they've now got no pain.
So they want to carry on as they have been previously, but we do need to we do need to restrict these guys just so that they don't end up with a pathological fracture. Electri chemotherapy is an option as well. We even if we do, we can just aim for hopefully a reduction or even just a stable disease.
This guy had a massive oral tumour that we did, we did the bulk, we did do surgery with him. And once it, we, once we ended up with a palliative setting, we ended up, we had some electro chemotherapy, and he responded in the areas that we were able to get the, the probes to, but kind of towards the back of his mouth and the, like the, the medial side, we just weren't actually able to get to it. So the parts that we could treat responded, but the other parts, we just couldn't quite get to.
And they did, they did start to progress. We need to consider the side effects for electro chemotherapy. Again, rare for these to happen sometimes might end up with just a little bit of irritation or inflammation.
I'm sorry. And this, occasionally there may be some, some wounds, but we've used the needles for the treatment. Infection is rare.
This was a little kitty cat who had tumours on her, her ears, and we've done, some electro chemotherapy, and she came back for her two weeks later for her follow-up treatment, and she had, they had all become infected, but this is something that is really quite rare. So we need to look at our non-surgical patients and consider these guys as well. And this was a mass cell tumour on a greyhound.
This has come up pretty quickly and as you can see, it was, there's no way that we were going to be able to just simply remove this tumour, without taking the limb at the same time. So for these guys, if they're not wanting to go down that any huge surgery route, we'd have to start considering, medical options and This could involve either chemotherapy, corticosteroids, non-steroidals, bisphosphonates, analgesia and GI support, alongside potentially an appetite stimulants if required. So chemotherapy could be used to stabilise the disease or to slow down progression.
With the palliative setting, the palliative treatment, we're, we're probably not going to get, we're not going to get a, a cure or a massive reduction in size of tumours, but if we can slow down that growth, or even stop it, just for a little time, just so we can, so they can go on and have some good quality time. That's our aim. It could be administered as intravenous injections, or, orally or metronomic at home.
And the metronomic chemotherapy is usually daily, given at home. It's usually a much, much lower dose than what we, would give as a on a, as part of an active chemotherapy treatment protocol. And we would use this ongoing until there's progression and then we may need to consider swapping this.
Pros and cons should be considered, so it's all the side effects that come associated with chemotherapy, so there's such as the bone marrow suppression, GI side effects, . A coat changes, all of that sort of stuff as well. We always pre-treat our chemo patients with antiemetics and make sure that they have plenty available at home, should they need them.
And if we're starting a patient with metronomic cyclophosphamide, we need to educate the owners in how to Do urine dipsticks at home. So, cyclophosphamide, the metabolite of cyclophosphamide is aquiline, and acroline can irritate the bladder mucosa and can cause a sterile hemorrhagic cystitis. I've seen it happen a couple of times, and it can, it can lead to quite, it can be quite nasty, but usually with the, the metronomic, it doesn't tend to be too awful.
So we need to educate the owners to be doing the dipsticks at least once a week at home. And then to make sure that they're reporting results, especially if they are seeing, any blood present in the, the urine. We need to advise owners on handling guidelines for cytotoxic medications, so it'll be the, the administration, the storage, any handling of the.
Chemotherapy and how to deal with any any excreta, so like the saliva, urine, and vomit. And just to make sure that they're not crushing tablets or opening capsules and stuff like that. And we need to we always prepare the owner for complications, so we provide the Mirropotin and anti-diarrhea treatments as well.
So corticosteroids, we do love prednisolone in our oncology unit, and it tends to be the one that we're we're we're gonna reach for quite commonly and it can be used in combination with other treatments, or it can be used on its own as well, and maybe as part of lymphoma protocols, if they're they're not wanting to go ahead with treatment or simply treatment is stopped working. So prednisone can alter the transcription of the DNA leading to the alterations in cellular metabolism, which result in any anti-inflammatory effects, which is great because it can, that's why it can be effective in helping treating cancers. So we need to consider the side effects of prednisolone and steroids, so a lot of these guys, especially with some of the higher doses that we tend to use, can be, PUPD.
There could potentially be some GI ulceration, panting and skin and coat changes. Some dogs seem to be particularly sensitive, and we've had a couple that have ended up with horrible hemorrhagic diarrhoea following a couple of days with the prednisolone. And a few dogs that have been excessively PUPD even on a really low dose as well and we just don't know how these patients are gonna respond until we've actually started them.
Non-steroidals can be used as well, meloxicam tends to be the one of choice. Or paroxicam can be used orally or as a suppository depending on the tumour. So no steroidals we'll use them for cancer pain, non-cancer pain, and some of these have actually got these anti-cancer and chemo prevention, .
Against many carcinomas, osteosarcomas and melanomas, so we tend to use a lot of paroxicam for our transitional cell carcinoma patients. To minimise any potential side effects that we tend to administer, on the chemo off days if we're using them alongside chemotherapy. So we tend to either alternate them or, make sure that they're given on the off days.
But we need to consider any other concurrent diseases as well. Do they have any other GI, renal or hepatic diseases before, while we're prior to starting these? So the bisphosphonates can be used for bone pain, especially associated with osteolytic conditions such as an osteosarcoma, or hypercalcemia, typically associated with anal sac adenocarcinoma.
Just a word on the hypercalcemia. You may see hypercalcemia for these anal sat patients and for some of the lymphoma patients. If the patient was then going for surgery or for chemotherapy or for an active protocol, we wouldn't use this as part of their treatment plan because we wouldn't want to then potentially cause hypocalcemia.
We would only use this in the non-surgical anal sac patients or any Other hypercalcemic patients that we're trying to treat. So we can either use permidronate or saladronate, and this is an IV infusion, given with saline. And so if you administer saline before and after it can sometimes hopefully help safeguard against nephrotoxicity, so we always check renal parameters as well, prior to administration.
An edronic acid can be given orally at home. Just know the word, if the hyper patient is coming in because they are hypercalcemic, because they have, a non-surgical anal sack or, something like that, these patients might potentially may feel a little bit, quite off colour. They may be vomiting, nauseous, as a side effect of the hypercalcemia.
So do consider that we do use some, antiemetics as well. We need to make sure that there's a suitable an analgesia plan in place as well, and we've already discussed that as well previously. So we like to, we need to make sure that we're supporting the GI tract as well.
So firstly we'll talk about antiemetics, and these are to prevent or control nausea and vomiting, and this can be caused either by the primary disease or the side effects of treatment. Most cases tend to be self-limiting and may resolve by restricting or controlling food or water intake for a little bit as well. So prima primarily we'll use Mirropotin and it's licenced, we can give it orally or IV for cats and dogs.
On Danatron we can we'll use on top of meropotin if we need to as well, and metoclopramide, we can use as well. And so we've had a few patients who've responded much better to metoclopramide than to meropotent, and it is just a case of trying to figure out what this what these patients actually need. So if these guys end up with any diarrhoea, treatment can be initiated using probiotics, maybe with some kalen.
We have moved forward into using the smectite or the BBS clay, especially for our chemotherapy induced diarrheas, and there was this lovely study that was done a couple of years ago. Which incited our change, change, a change in protocol, to use the BBS clay, as this could this clay has been shown to actually strengthen the mucosal barrier, has anti-inflammatory properties and can shown to decrease intestinal bacterial translocation. The dose in the study was actually much higher than what is on the label, so we use the study dose, and we use this for all of our chemo patients and, and then the other diarrheas as well.
The only, the only, the only pain is it's a powder and it's actually can be can be quite a large volume of powder, but I'm sure we could, most patients do seem to take it quite readily. So if they are not responding to the initial treatment of probiotics and kin or the snide, we then need to consider some form of antibiotic treatment as well, especially if it has become hemorrhagic due to the risk of bacterial translocation and the risk of sepsis. We will continue using the smectite alongside the antibiotics as well.
And if the diarrhoea is ongoing, we need to consider that there might be another cause for the diarrhoea and that we actually need to investigate that as well. We may need to consider some form of stool softeners or laxatives if there is a potential constipation or obstruction, just to try and make faeces be able to pass a little bit easier, but we need to make sure that the patients are suitably hydrated, . Before we start using all of these as well.
Appetite stimulants we've already discussed. So yeah, we just need to make sure that we are treating out all of the other reasons why they may not be wanting to eat beforehand. So euthanasia is the rubbish part of all of this.
We've had a it was a really good bond with your owners and with your patients, and then we know ourselves as well that this time is going to come, but for the owners, we need this can be really difficult, especially if they've been so. Invested, and I know, and, and all of them tend to be that they've been so invested in all of the treatments and the appointments and the backing and the towing and the feeding and the medications, and it gets to this point and it can be really difficult for them to, to make that decision. And we just need to try and help them remember what the end points were that we discussed at the beginning of the palliative plan.
If they'd made the decision that we were going to get them to a certain date or if they were needing a cer if they started needing additional medication or weren't wanting to do this, they need to need to chat with them about what their end points initially were. Hopefully they've already thought about the, preferences about what they want to do for euthanasia. Do they want it within the practise?
Do they want a home visit? Have they already been in talks with someone casket wise, cremation? We just need to, ideally, if they, it helps them if they've already had time to consider this.
If not, there's no need for them to rush. They don't need to be thinking about they, they can, they can get back to you a little bit later. Ideally we'd be wanting an IV placement and sedation, if the patient is especially anxious or infectious.
And lots and lots of tasty treats at the same time, especially if they, if they are foodies, I do love to be able to sit with them and the owners and just be feeding them lots and lots of treats, lots of tasty tasty snacks while they go off. And we like to follow up our care for the owners, after the euthanasia as well. Just to show that we've, we've been part of a team with them, for the whole, for the whole duration of their treatment.
And, if we could, we just like to be able to try and offer just a little bit more support, at the end. The, the Blue Cross have got lots of, lots of literature that you can send out in the sympathy cards or direct the owners to their website. And we always send a sympathy card, with some seeds following on from that euthanasia.
Oh. So, do you guys need any help, any oncology help? I'll say even oncology or even pain management help, give us a shout, or your local friendly oncologist or anaesthetist at your local referral centres.
We'd be happy to do any advice calls for, for management for palliative care, for an, analgesia or for palliative care treatment. Remember to look after yourself and your team. It's, it's hardcore when you're looking at, assisting with, oncology patients, and you get to, you get to know these owners and these patients really well.
Some of the guys that I've been seeing for, they've been coming for treatments, and then moved on for to palliative care. I've known some of these guys for years, and it can be, it can be really, it, it can be really, really difficult when it, when it gets to that point, . So yeah, you need to you need to look after each other.
So here's some further reading, lots of textbooks, and some websites and articles that you could have a little look at, and I've put them all in the notes as well, if you want, to have a little bit more of a look. And if you do have any questions, shoot me an email or send one to Northwest veterinary specialist, and it will get either to me or to our oncology team. So thank you very much for listening.
And if you do have any questions, as I said, just get in touch. Thank you. Hi everyone, it's Jackie, head of membership and fellow VN here.
Just wanted to jump on quickly, interrupting my walk to let you know that as a thank you for joining us on this free nurse membership webinar, we are offering you a 60% discount on our unlimited membership. That's our entire library of content, including all the companion animals. Veterinary content for a bargain price of 199 plus VAT instead of 499.
Now this offer is only running for Vets Awareness Month, so you must take it up before the end of May, using the discount code VA 60, and then you get that access for the entire year. It's time to empower yourself through education. Come and join us.