Hello, everyone, and welcome to this webinar on palliative care and quality of life. So I thought I'd just do a little brief introduction to myself. My name's Kelly.
I've currently moved into a new job role as senior lecturer for veterinary nursing at Wrexham University, but I'm also really lucky to continue the work that I did at the Feline Healthy ageing Clinic for 7 years as an honorary research associate. So, the Feline Healthy ageing Clinic is a research project based at the University of Liverpool and funded by Royal Cannon. And we basically assess lots of different aspects of cat ageing.
We see cats every 6 months. And we have lots of conversations, especially as we are, you know, 7 years into the study around quality of life and palliative care because our cats are now reaching kind of 1314, 15. So, it's something that really fascinates me, this topic, and I think there's so much more that we can delve into in the veterinary world, so I'm really excited to be able to talk to you about this today.
So, first of all, why is palliative care important? Why are we here? Why am I talking to you about this topic, and why are you listening in to this webinar?
So palliative care is really important in human healthcare, and it's, it's really widely discussed in human healthcare. We have hospice care, we have, you know, we have children hospice, we have so many discussions around palliative care in the human healthcare field. And it's starting to become more kind of widely recognised in veterinary as well.
There's still a lot of research that needs to be done in this area. But the strengthening of the human bond. Between people and animals, it's, it's really strengthening, it's becoming more apparent, and this evolution of the human bond is driving palliative care and quality of life conversations in veterinary practise.
So it's definitely something as veterinary professionals that we need to be confident talking about and happy to have these conversations surrounding it with our owners. And contextualised approaches are definitely becoming more widely used. Excuse me, they're definitely becoming more widely used in practise.
We have a lot to think about. We have a big kind of holistic approach that is very evident at the moment, and quality of life, it really is a big part of the contextualised approach, making sure that we're doing things right, not just for kind of the owner, but also for the patient as well. So by using quality of life and having palliative care conversations, it's really gonna help us be able to monitor the welfare of the the patient better and support that owner too.
And chronic pain management is some is an area where we can really take use of these quality of life tools and have conversations with owners. And chronic pain management is again something that we're becoming much more aware of. We have lots of multi-modal treatment options out there for cats, particularly surrounding like osteoarthritis.
And we're really discussing chronic pain with our owners and, and really monitoring their welfare throughout these diseases. And we have to be aware as well that the caregiver, our owner, does suffer with an emotional burden at this time when our pets are in this stage of kind of palliative care. So we need to be thinking about that too, making sure we can support our owners and our caregivers.
And this can have many implications, you know, you can. Have an increased client bond in practise, ensuring that the owners are happy to come into practise, ask questions, they feel comfortable. And ultimately that's also gonna benefit revenue as well for the practise, because people are gonna be coming back and, and returning to the practise as they trust them.
And palliative care and quality of life conversations and quality of life tools really help make the end of life decisions just a little bit easier for the owner and also a little bit easier for us as professionals too. It gives us guidance, it provides owner with visual visuals and really educates them around this topic to help them come to those decisions. Hopefully for them a little bit easier.
So what is palliative care, when we talk about palliative care, what exactly are we talking about? So this is where we diagnose a life limiting illness. So something that can't be cured necessarily, and we kind of move from this kind of curing, I say attitude, but kind of this curing kind of encompassing feeling to it to more of a comfort and quality of life and monitoring stage.
So we really need to make sure that we are relieving clinical signs that the patient might be suffering, and we're starting comfort care. So we're thinking about things like pain management, environment, all these different things that really, really encompass the physical, emotional and social needs of the cat. So we really need to be thinking about their physical ability, the stress that that this condition might be having on, on the patient and their ability to socialise with their owners.
With other members in the household. So it's, it's a really kind of a compassing approach that when we get this life limiting illness diagnosed, that we really need to start changing things. We're not aiming to treat the patient, we're aiming to keep them comfortable.
And we also want to be thinking about the human-animal relationship here as well, and I'll mention this human-animal bond quite a lot throughout this, this webinar. But protecting that human-animal relationship is really important, and I had some firsthand experience with this not long ago. We had one of our clients came in with a cat, and the cat had been seen recently.
They weren't quite sure what was going on with it. The cat was really quite poorly, but the cat needed about 4 to 5 different medications throughout the day. And the owner came in and she was really upset and she said that, you know, I'm, I'm having to give my cat these medications all the time, and my cat now hates me.
And I'm worried that in his last few months of his life, he no longer loves me and I don't have that relationship with my cat anymore. So sometimes we forget about that aspect and we're very kind of honed in on treating the patient, improving their welfare, but we need to think about other little aspects as well, especially that human-animal relationship. And this is something from the feline hospice and palliative care guidelines from the AAFP.
And I wanted to put it in here because it really helps to have these conversations with our owners and make sure that we are thinking about everything really, and it's based on something called clinical bioethics. Now bioethics is the study of ethical, social, and legal issues that arise in medicine and biomedical research. And clinical bioethics, bioethics really grounds ethical decision making in medical practise, and we can use these four principles to help guide conversations with our owners as well.
So the four principles are respect for autonomy, so supporting decision making. Without coercing the client, non-malleficent, so we're avoiding harm to the patients, beneficient, so we're acting in that patient's best interests, and justice, which is also expressed as fairness, so implying equity and treatment recommendations. And, so I just wanted to make this box a bit bigger so we can look at the four box method, into care decision making and just have a look at each of the methods, so.
Let's have a look at, look at respect for autonomy here, so this is where we're considering if the client's been fully and truthfully informed about the condition. And then we need to think about what's the cat's temperament and receptiveness to interactions, is able to take medication? And what really constitutes a good quality of life for this patient, and I'll talk about quality of life, a little bit further on in this webinar.
And then we've got beneficient, so what is the patient's condition? It's gonna be likely to be chronic at this stage, it's likely to be something that's a bit irreversible. And what are the prospects of return to a normal life?
Is that something that's possible here? So what are our goals gonna be? So we really need to be thinking about what the goals and probabilities of success are.
Is it really worth putting the cat through any kind of treatment or anything that might reduce its quality of life? So it's really thinking about that. And then we've got non-Malleficent, so can harm be avoided?
Are the treatment options going to cause any adverse effects that's gonna negatively impact the patient? And what physical, emotion and social deficits might the patient experience if we do carry out this treatment? And then justice as well, so have we considered financial resources available to the client?
Do they understand everything and do we have any religious aspects that might be affecting the clinical decision? So it's a really nice tool, it's a really nice kind of method to consider, to help us guide conversations and make sure we're encompassing everything when we're thinking about palliative care in our patients. And again, I just wanted to touch on the things that might impact our ability to carry out a palliative care plan and other kind of a bit more detail of things that we might need to think about.
So, first of all, kind of evaluating the caregiver's needs. And obviously, the welfare of the patient is really important, but we also need to make sure that the caregiver, the owner, is aware of everything and their ability to carry out the treatment plan or carry out giving medication and things like that is doable for them too. And first of all, finances.
We are in a difficult time at the moment in the economy, and we're aware that finances are difficult for everybody. And we don't want to give an owner a treatment plan where they need to spend, you know, 200 pounds, 300 pounds a month on medication, and they can't do this. And so we need to make sure that we're allowing the owners to feel comfortable talking about finances.
And making sure that they are aware that there are maybe different options, you know, maybe we give this medication once a day instead of 3 times a day to reduce the cost. Is that change in the treatment plan still going to benefit the patient? So it's balancing things like that.
Does the owner have time? We all have a busy schedule. Are they the type of person that's in and out of the house all day?
Do they have meetings? If there is something that they need to do for their cat to improve their quality of life in regards to treatment and comfort, that's gonna take them half an hour in an evening, you know, are they able to do that? And it's just difficult because our owners will, won't want to turn around and say, you know, oh, I don't have time to do that, cause they might feel guilty.
So it's important that we have the conversations with them at the time to allow them to feel that they can open up and be completely honest about their situation. We might have reg religious beliefs that might impact the ability to carry out some treatment, or maybe even euthanasia might be impacted by religious beliefs. And we need to be able to understand the cultural differences and diversity as well and make sure that we respect that.
Again, schedule relates to time. Do, are they able to include a treatment plan in the schedule? One of the examples of this that this that tends to spring to mind is diabetes management.
Are the owners available to give injections every day, monitor, the amount of food that cat's eating, provide them with the right amount of diet. That's a really real change in the schedule for an owner. And do they have any negative experiences?
Have they had a cat in the past that's, that they've already had to deal with palliative care, and maybe they didn't get the support they need. So do they have this real negative association when it comes to having this conversation? So it's always important and worth asking our owners, do you have any experience with this before, or what have your past experiences been like?
Just to make sure that if there is any anxiety there from anything that they've experienced before, we're able to talk this through with them and reassure them. And are they physically capable? We might have an old lady that needs to give, you know, tablets and oral liquid solutions or give injections and, oh, is she able to do that?
Do they have arthritis in their hands that might make it difficult for them to carry out providing the medication? Are they able to hold the cat in the position that it needs to be? And again, they're not gonna want to turn around and be like, I can't actually do that.
They'll probably go home, attempt to do it. Be unable to do it, be embarrassed about getting back in touch and saying they can't do it, and then the cat doesn't get the medication. So if we're thinking about of all these things at the beginning, we're less likely to lose the compliance of the owner.
And can they ask family members? Is there anybody else that can help support them in this, in this process that can come and help, maybe do, do medication or check on the check on the cat maybe when their schedule is a bit busy. So just having the conversations with, with our owners is really important to try and gauge as much information as possible that might impact the ability for them to, to continue with the palliative care for their pets.
And then obviously we need to evaluate the patient's needs. And this is just as important. Past experiences again.
If a cat has had to have real intense medication in the past, maybe they've had, a problem, I don't know, some problem where they've needed multiple medication, they've recovered from it, but they really have a negative association to perhaps being tableted. So if we're going to want to try and tablet this cat again, it's gonna be really, really difficult. And that's gonna cause stress on the patient, and that's gonna impact their emotional health.
And the cat's lifestyle too. This may be a cat, for example, that spends 12 hours outside, rarely comes in, comes in for a little bit of attention, comes in to be fed, and then spends its its life outside. And we might now be saying to the owner, the cat needs to stay indoors.
It's not safe for that cat to go outside anymore. Is that fair for that cat? Is there options that maybe we can think about where the owner can spend time outside with the cat?
So the cat is still able to achieve the things it really enjoys doing, if it's physically able to. Medication preferences again relates to past experiences. We might know that oral liquid works better with this cat, or crushing the tablets and putting it in putting it in the food works better.
And I think this is where we can do better at making notes as well when we're having conversations with our owners, even just in general. If it might just be, you know, a cat bye abscess or something that needs some medication and the owners reported that they can't tablet the cat, make a note on the record that we know then for future, and then when it comes to these situations, we're already a little bit aware of the cat's preferences. And all of this encompasses emotional health, the change of lifestyle, the impact of constantly being medicated.
How are they also dealing emotionally with the chronic disease that they might be suffering with, with pain and things like that. So we really need to evaluate and look at the big picture when we're advising what we're going to do when it comes to palliative care. And we want to be able to educate owners about the disease as well.
And it's really important that the owners are fully aware of the disease as much as possible. We want to, we don't want to overwhelm them, we don't want to, you know, be giving them an hour webinar themselves about what the disease means, but we want them to have a basic understanding because with understanding then becomes more kind of understanding of the whole process in general, the owner will understand why we're maybe making these decisions. And it's also important that we let the owner know of the tra trajectory of that disease.
Which way is this disease going? Is this going to be something that's a very short period of decline before death? Or is it going to be a progressive steady decline?
Or maybe a sudden onset of disease with extreme impairment, you know, so something like, aortic thrombolysse, you know, palliative care for those patients is very rare. It's not very often we take it to that extreme, but, you know, this is the trajectory that I'm talking about, progressive, steady decline, we might have chronic kidney disease and we need to make them aware that it moves in stages and and things like that. And making sure they're aware of the treatment options that are available to them as well.
We want them to know and understand as much as possible cos it's really gonna help them to make decisions and help them to care for their, for their cat at this time. And communicating as well is something that can be tricky, and something that we probably don't really get as much support out with when we're in our training and, you know, we're moving into this profession. Communication is a tricky one.
And there are particular ways of communicating that we can make this, this whole scenario a little bit easier for the owners to understand and help them to trust in us as well. And we really want to minimise that distress that they're going to be feeling at this time. You know, they're being told that there's something that, that maybe they're worried about and we need to start thinking about palliative care.
It's, it's not gonna be a nice time for that owner. So we want to make sure that when we're having those conversations to build that trust with them, we're doing it in the right setting. You know, the last thing we want to be doing is talking to be doing is talking to them in a busy waiting room.
You know, they're not gonna want, want to be hearing bad news in the waiting room. We want to be having these conversations in the consultation room. Either on the phone, we don't want to be you know, having email conversations around this kind of thing.
Some people have concert rooms in their practise that are particularly used for like euthanasia and and difficult conversations. They have a bit more of a relaxed feel to them. And they might have a sofa and some pictures on the wall.
So sometimes, you know, taking the owner to a setting where they might feel a little bit more relaxed can help with communication. And we want to be using simple terminology. We don't want to be using big words, you know, we don't want to be saying polydipsia and all this kind of thing to the owner, because they're not gonna listen to it.
Those words, as soon as they hear a word they don't understand, that we've lost them. So we wanna make sure that everything's as simple as possible for them to understand, and we want to make sure that they are feeling listened to as well and. Using some techniques, some particular techniques can help guide the conversations.
We've got signposting language, which is letting the owner, the caregiver know where we're going next for the conversation. So, for example, I've discussed the condition today. Do you understand the condition?
Are you happy for me to discuss treatment options next, as that's the next thing that we're going to start discussing. You know, allow the owner to have control over the conversation too, they might be like, oh, actually no, I'm not ready for treatment options yet, can we go back to just understanding the disease a little bit more, rather than than just skipping through all the, the disease, the treatment, not giving the owner time to feed us back anything. And a chunk and check technique is another really useful technique that we can use, so we give them a piece of information and we check that they're understanding what we're saying.
So we, we do it in chunks and then we check that they're understanding. And we know that they're understanding, then we move on to the next kind of chunk of information. And then reflective listening as well is a really great technique when we're having conversations with our owners about their pets and, and quality of life.
It's where we have the owner provide us with the information, and we repeat that information back to the owner, just to make sure that we have understood what they have told us as well. And all of these techniques, this effective communication really helps to build trust and can really have a great impact on the relationship between the owner and really have a difference on the welfare of the cat in this in this period of palliative care. And the other challenge we have with cats in general, is they are difficult to discuss when it comes to behaviour changes in relation to chronic pain, for example.
They are very good at hiding signs of pain. Their behaviours are very subtle when they're struggling. So it can be really difficult to say to our owner, you know, your cat is actually really poorly.
And the owner may respond with her, but he's still eating. You're still going to the toilet, you know, he's fine. When in fact, cats have, especially with the eating one, I find that the eating one is really a challenge, and I did my master's in anthrozoology, where I looked at dental disease in cats, and I asked owners to fill in a little questionnaire to provide me with what signs they may be seeing in their cat.
And then we did a dental exam on the cat to see if there was any behaviours and if there are more subtle behaviours or obvious behaviours that owners are recognising for, for dental pain in their cats. And these are the behaviours that came out, so irritability, sleeping more, chewing on one side, matted coat, and grooming less. And quite a lot of the cats in my study had severe dental disease.
But as you can see, one of the behaviours isn't not eating. They're still eating. Cats have this real drive to eat.
In their previous, you know, in their wild ancestry time, they would be hunting and they would see some food, and they would attempt to, to catch that food and attempt to have a meal from that food because they don't know where their next meal might be coming from. They don't want to leave it and wait for the 5th mouse that wanders past them because by that time they might be hungry. They are unable to then get that prey, and they're more likely to lose that prey.
So they're called opportunistic feeders because they take the opportunity to eat when they see it. And this is still a very strong drive that's in cats today. So having conversation with owners about educating on cat behaviour and subtle changes in cat behaviour and explaining this kind of behavioural process that cats go through can really help them to have a little bit more recognition of actually, oh, OK, no.
And he's he's maybe being a little bit more irritable than normal, but he still wants my attention. That's a change, it's subtle. This is, this is having an impact.
So it can be quite difficult to communicate things like that with cat owners. And I also did a little bit of research into some cat owner behaviour, and how cat owners in particular like to be communicated to. And I found this study from 2016, which was evaluating communication skills taught at a veterinary school, and it revealed that cat caregivers in particular value chunk and check and signposting, more so than dog k caregivers.
So these are those two techniques that I mentioned previously. Cat care caregivers appear to appreciate a focus on their cat when conversing with their vet. Cat get one made me laugh a little bit.
Cat caregivers appear to be along for the ride as passengers, whereas dog caregivers appear to be the drivers that direct the course of the visit. And then cat caregivers appear to accept the vet taking the lead, provided that the vet signposts the direction of the visit. So as I mentioned before, this signposting, cat care for caregivers accept the vet taking the lead and taking control of that conversation as long as they know where the conversation is going.
And cat caregivers appear to prioritise communication skills as a mean of lessening distress, distrust and fear, so to limit the transfer of that negative emotion to their cat. So cat owners are aware of how their feelings can impact their cat and they're aware of the cat's feelings when they come to the vet. But I thought this was just a nice little bit of research there, just to support our communication skills in these scenarios.
Mhm. And I mentioned earlier about how there's lots of research in human health. And we can take a lot of, a lot of advice and support from conversations that they have in human health.
This is called the Serious illness Conversation Guide, from May 2023. And it just goes through, have a look at that. I'll, make sure I provide the link so you guys can see that.
As it provides examples of sentences that we can use when we're having conversations about serious illness and. You know, we're still talking to a person, we still want that, we still need that person to understand what's going on so they can then have the improved, they'll be in the improved position to help their pets. So these conversations that are used in human healthcare can really be adapted quite easily and really effective in veterinary medicine as well.
So I'm only briefly gonna touch on this cos palliative care plans you can go into real detail, and I do encourage you to look at that palliative care and hospice guidelines from the AFP that I mentioned earlier on. So I just thought I'd touch on this briefly, of things that kind of what we want to consider, in cats in particular, when we're thinking about palliative care plans. So pain management.
So it's very likely that the condition that they're suffering with is likely to be causing them some pain and we need to make sure that we're thinking about multi-modal pain management. We don't just have one option of pain relief now. We have lots of options.
We can reduce treatment doses, we can adapt the treatment plan. I'm a veterinary nurse, so obviously providing treatment is out of my remit. But I think it's really important that as nurses that we're fully aware of the way the medication works, the dosages, the differences so that we can, Kind of take, take control of these monitoring with these patients, we can have the vet provide this treatment plan, and the nurses can really be part of that journey with the caregivers and the owners throughout.
And as long as we've got that deeper knowledge and understanding of the condition and the different options, then nurses are absolutely more than capable of taking taking charge of these treatment processes and monitoring processes. So I digress there, but we'll come back, so multi-modal pain management, lots of different options there that we can use. Again, just touching on considering that human-animal bond, I know I'm mentioning it again, but it is something that we need to be aware of, and obviously finances and those other, other things I touched on earlier on when we're thinking about the caregiver's needs.
Nausea and appetite is something that is quite common with cats if they're feeling nauseous, they're quite commonly will become a food aversion. And that's one of the reasons why there's lots of different flavours for the renal diets, because cats quite often feel nauseous, and if they approach their food or they're eating their food and they do feel nauseous, it's likely that they're not gonna want to eat that again. So we want to make sure that we're keeping, keeping the nausea and, and the vomiting to a minimum as much as possible.
We can provide stimulants, you know, there's medication that can help encourage appetite. We can heat up food. Cats like food when it's a little bit warmer.
It just mimics prey when they're eating their prey that they've caught, they're gonna be warm. So we can just gently heat up the food, we can use palability enhancers on the food. But as I said, we really want to consider food aversions.
We don't want owners to be giving them loads of different types of food either. We need to make sure that we're only providing these cats with one or two types of food at a time. We don't want to overwhelm their senses too much either.
So 1 to 2 different types of food at a time, heating up, adding extra, you know, liquid to it to encourage fluid, to encourage them to be drinking, things like that. So nausea and appetite is one of the big things that we need to be thinking about with our cats. And then do we need to be grooming them more?
Are they struggling to groom themselves, their own self-care. We know how clean cats are. You know, you don't get, you know, stinky dog, kind of smells from our cats cause they look after themselves really well.
But as they get to this stage of their life where they're struggling to care for themselves, this is where our owners may need to step up and. Increase grooming and things like that, maybe, you know, cleaning around their face and things if if they allow it, if it's gonna stress the cat too much to be groomed and have this additional care, then we don't want to be doing that to them, but it's worth just thinking about. Providing and supporting the self-care for our cats.
And environment is a massive one, and I could talk for a full webinar on environmental changes for cats as they're getting older. So I'll just touch on a couple of things, making sure that the cats can still reach their favourite place. If there's an area in the house where they really like to be and maybe they can't get there anymore because of their physical ability, then can we provide them with something like this, you know, some steps up to their favourite place?
Litter trays, making sure we've got the right substrate, you know, we don't want litter if there's a cat really struggling with chronic pain, you know, advanced osteoarthritis. We don't want them going into a litter tray where they have to crouch, or the substrate is all slippy under their feet, or there's litter liners, there's not enough room. So thinking about litter tray, and causes litter tray and emotional stress, you know, things like FIC and things like that, we really want to minimise the, the risk of that happening.
So litter tray care is really important, making sure the owners are on top of it, cleaning it more regularly, that kind of thing. And then hydration too, raising food bowls and water bowls to prevent the need to bend over, using fountains that make the water more, kind of approachable. You know, they want to, they'll move in water, I'll have a drink of that.
Some cats prefer to drink out of a, a glass next to the bed. So sometimes just leaving a glass, somewhere for them to drink out of, just making sure that there are lots of options. And also one of the big thing is making sure that there's plenty of resources.
We don't want a cat that's struggling, maybe moving around, finds it a bit of an extra effort to go to the toilet, to have to go all the way upstairs to the toilet. So making sure that we're we're advising our owners to keep the environment as comfortable as possible for them, that they don't have to go and move too far. But we also want them to be moving, depending on their condition and mainly focusing on osteoarthritis here, but we also want our cats to continue moving to maintain that muscle strength, to ensure that the digestibility is is still moving around, you know, everything is, is, is still moving and.
Especially when it comes to osteoarthritis, moving the making sure the cat gets up and moves every 4 to 6 hours is really good to ensure that those joints stay nice and and supple. But all of this plan is really what we're trying to do is improve the quality of life, or ensure that the quality of life of these cats is as good as it possibly can be. And quality of life is a really important part of palliative care and quality of life tools and assessments.
And which brings me on nicely to the next part of my webinar where we discuss quality of life. And what is quality of life? How do we define quality of life?
So the World Health organisation for people is bases quality of life on an individual's perception of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns. And then we have health related quality of life which relates to a specific effect of a medical condition on an individual's health. And we can, we can put that in position for, for our patients as well, slightly, but we really do need a, a quality of life definition in the veterinary profession, and we don't really have one.
There's lots of different quotes out there and, you know, I'm looking at papers and things, there's lots of different definitions of quality of life, but I think the best one that I've probably found is from Belshore Hotel in 2015. Zoe Belshaw does lots of work with ageing pets and quality of life, and she defines quality of life as an individual's satisfaction with its physical and psychological health, it's physical and social environment, and it's ability to interact with that environment. And I think that's a nice definition here, and I think that's a nice one to kind of work from.
And I just thought I'd put in a little bit here about how often we talk about quality of life. Is it something that we're mentioning in practise? Do we need to do better?
And there was a clinical audit at the University of Liverpool that explored the euthanasia and quality of life discussions at the university small animal practise from a period of around 6 months. And they had a look at how it's mentioned. So in this period of time, there were 77 euthanasias completed, and 47% had quality of life discussed around 33 days prior to the procedure.
And I really like that quality of life is being discussed a month before euthanasia because it's obviously given the owners time to really consider their pets' welfare and help them come up with this decision. But we need to do better than this 47%. We need to be discussing quality of life more regularly.
Even when we see cats coming in for maybe a senior cat clinic where they're only, you know, 8 or 9 and we're starting to talk about things that change in our older cats, let's start talking about quality of life there, let's start using tools in that moment. So why should we use quality of life assessments? Why am I banging on about it so much and saying that we should be talking about it more?
There's lots of benefits to using Quality of life assessments and I think one of the big ones is it really helps an owner and a professional come to an end of life decision. We have this nice visual in front of us that we can use and we can really say, look, the quality of life in your pet is really declining, we can see it here. Let's have a conversation about what to do next.
And it can also help us see how the treatment process is working, and monitor different stages of treatment. If we start a new treatment plan or a palliative care plan and we continue to do quality of life checks and we start to see that the quality of life is actually declining rather than improving, then we know that our treatment plan isn't quite right and we maybe need to make some adaptions. It raises awareness as well with our owners and educates our owners really to understand a little bit more about quality of life and how it is impacting their pet, which then in turn is gonna improve the welfare of a patient, and this is our main goal, isn't it?
You know, we want to make sure that the welfare of the patient is not suffering. And quality of life assessments are really good for showing us that and allowing us to monitor and really get a good understanding of their quality of life, as well as helping us to support the owner and help the owner to understand as well. But there are some challenges with using quality of life assessment tools.
It's so subjective, as is pretty much, you know, a lot of stuff when it comes to veterinary medicine. We, we can't understand cats. Cats can't tell us how they're feeling, if only they could, but they can't.
So quality of life assessment tools will always be subjective. And I think sometimes they rely on the owner's knowledge of behaviour too. If they're answering questions on their pet's behaviour, maybe they're not really in tune with specific questions that are on that quality of life to, so they're not able to answer the question as effectively as maybe somebody that had more knowledge of the the cat behaviour.
You might have cat owners that are, they've owned cats all their life, or you might have an owner that this is their first cat. So it's gonna change and it's gonna differ depending on the knowledge of the owner. And owner compliance, we need them to be completing these tools.
If they don't complete them, then they're pointless. So we really need to make sure that the owner understands the tool and why we need them to do, to use them, and I'll touch on compliance a little bit more further on. And I just wanted to pop this on here as well, so when we're discussing feline quality of life, assessment tools.
There is a lot out there, and this is a lovely review paper from Hannah Doy. I really encourage you to have a read of this, because it looks at all the different quality of life, assessment tools that are out there for cats in the published literature. And having a little look at the paper.
So it's 32 tools in total, with only 26% of them validated. When it comes to validation, obviously, when working in research, like myself, we ensure that we use validated tools where we can, as it's going to strengthen our research. But I do question whether we need to use validated tools in practise.
Is it validated tools that we should be using with our clients? Or is it better than nothing, just to be using something, you know. But I'll touch back on that again further on.
But coming back to this paper, so we had the, I had a little look and there's a lot of tools that are very specific for very specific diseases. So chronic kidney disease, cardiac disease, skin disease, mobility questionnaires with quality of life, that kind of thing. But there isn't many that really encompass comorbidities.
And when our cats are reaching this end of life stage where they're in palliative care, it's very likely that they're gonna have more than one condition, there's gonna be comorbidities going on, so. I think hopefully we'll, we will eventually get a really, really successful validated quality of life measurement for cats that encompasses all these different comorbidities. We're nearly there, not quite there yet, but we're almost there with something called vet metrica.
And this is something that we use at the Feed and Healthy ageing clinic, and we encourage owners to complete this questionnaire from their very first appointment. So the first time they come to see us, so that we have a real nice baseline for that cat's quality of life. And on healthy pets, you know, even if there's a cat that we detect, nothing at all wrong with them when they're at the age of 7, when they first enrol, we still ask them to do it because I think it's really helpful.
And the nice thing is about Vet Metrica is it doesn't consider multiple chronic diseases. So it does take that into consideration. It is a paid subscription at the moment, which I think, it still is a paid subscription, but it's really useful to use in practise.
But it has a vet and an owner assessment, so the owner completes a list of questions. I think it's about 45 questions, but they're very quick questions, and they ask it on a scale of like 0 to 6, how happy is your cat today? 0 being not very happy, 6 being very happy.
Is your cat able to rest, get comfortable when resting, or no, 6, yes, you know, that kind of process. And it throws out this really nice graph at the end, so once the owner's done the assessment, the vet's done the assessment, throws out this really nice graph. So this is what the vet sees here.
And you can see here that the cat's quality of life is OK, but as it started nearing the end of life, it started to decrease. But we've also got this owner assessment here as well, which shows that the cat's vitality, the coloured ones are where the cat is this time, the grey ones are where the cat was previously. And that line there is where 70% of healthy cats will score.
So it's a really nice visual to kind of show owners, I think. And helps them to really see where the cat's vitality, comfort, and emotional wellbeing sits. And it's a really nice guide for us to follow.
As you can see here at the end of life for this patient, the quality of life was really, really low. And then we've also got some examples here that I've just put on of tools that aren't necessarily validated, but are still really useful, and I think it doesn't matter if they're not validated. We can still have conversations with owners and use anything that the the owner might just quickly Google quality of life scale, and this is what we see here, this calculator.
We're having conversations with owners about it, and that is what is key here. But I do like the, this one on the left, particularly the HH H H HMM scale. Because it takes into consideration, you know, pain, hunger, hydration, hygiene, are they able to look after themselves?
Are they happy? Are they doing things that they normally like to do? Can they move around?
And they're more good days than bad. So when bad days outnumber good days, the pet's suffering is appreciable and quality of life might be compromised. So it just as I say, it's just making the owner think about things and educating the owner on what we need to be thinking about when it comes to these patients' quality of life.
And as I mentioned very briefly before, compliance is a tricky one, and I think that occurs, you know, through whole of our veterinary profession when we're coming into treatment and trying to get owners to, to do things that we want them to do. And there's a few things we can do to really help our owners to comply with using quality of life tools, and it's education is one of the big things. Educating owners why we're using quality of life tools, you know, discuss with them, we're using it to help you if you need to come to a decision, we're using it to help monitor the patient of our cats.
They're really nice tools that help us really encompass everything. So just educate the owners and let them know why we're doing it, rather than saying, so we want you to do a quality of life tool, fill it in every week, bring it back to us. And they're gonna be like, well why?
If they don't understand why they're probably less likely to do it. Use visuals as well. Quite often you'll you give an owner some information.
5 minutes they'll be taking it in. Once that point is passed, it's hard for them to obtain any information. So we really want to make sure we're giving them literature to go home with leaflets and maybe links to websites, and we can do little videos ourselves, little webinars for our owners, that can go on practise website.
Even on, you know, social media, start talking about quality of life a little bit more in general, just to make owners a little bit more aware. And make sure the whole team know which tool you like to use. Maybe you stick to using one particular tool for the whole practise.
This can help with consistency as well, to make sure that you're all using the same tool, so it's nice and easy when maybe another staff member is dealing with a patient that somebody else has been dealing with. It just makes that that a little bit easier. But by the whole team, using the same tool and communicating in the same way, it's gonna make sure that the owners are gonna feel a bit more confident in using this tool.
And as I said, discuss which tool with your team to make sure that you're all using the right tool, and provide ongoing support to the owners. We don't just want to give them the quality of life tool, off they pop. Two weeks later we see them again.
Think about checking in with them, maybe just a little email, or a lot of systems can send text messages, maybe just a little text to say, just a reminder to complete Fluffy's quality of life scale today, so we can monitor and see how she's doing. So just provide that ongoing support to our owners as well, because they may have. Listen to everything in the consult room, you've sent them home with a leaflet, and actually they're like, I don't know how to use this quality of life at all.
I don't have a computer, or maybe I can't see it very well. I can't use the, you know, the, the screen on my phone. But just by checking in with them and giving them some support, gives them the opportunity to let you know the barriers that they might be struggling with.
And emotional support is really important, and I'm not saying that we, you know, we need to all be counsellors and all be well trained in emotional support for owners, but there's a little, there's some little things that I think we do need to think about and be aware of that our owners often struggle with. And one of these is called anticipatory grief. And this isn't, this is almost an unconscious form of coping to pre to prepare, so when an owner is informed of some negative news that their, their cat is maybe into palliative care stages and.
Maybe their length of life is a lot shorter than they expected them to be. They start to get this anticipatory grief, which is predominantly anxiety, about what's to come. And it quite often brings this really high pet caregiver burden, and it's often stronger where they've had a real connection to a memory or a person.
So for example, if their cat maybe loved their father, but they lost their father, so their cat is the connection to their father too, and it can amplify this anticipatory grief. So we really want to work together with the owner, and we can talk to them about this type of grief and let them know when we're giving them this bad news that you might feel anxious, you might feel some guilt, or maybe some dread about what's coming, and that's normal. So allowing the owner to be aware of their own emotions can help improve that client bond, which in turn improves compliance, which in turn is going to improve the welfare of the patient.
But just make sure that we are having this conversation with our owners and just letting them know that it's kind of OK to not be OK. And then we have something else which is called disenfranchised grief, and this often occurs after euthanasia, after they've lost their pets. Where an owner feels like their grief isn't acknowledged by society, and we can impact this when we're having conversations with our owners.
We want to avoid kind of saying things that make them think that their grief isn't acknowledged. Oh, they lived a long life, or, you know, oh, he was 15, he had a good life, or, oh, you know, they're only a cat. Obviously we're not going to say those kinds of things, but these are the things that society say.
And there's been lots of talk about having, kind of bereavement, breaks from work when people lose their pets. And there's a lot more awareness in, in employment, I think at the moment of. Allowing for time off when our pet passes away.
And again, this is coming from the kind of evolution of the human-animal bond in the last kind of, you know, couple of couple of decades. But, it's just important that when we're talking to our owners, we allow them to know that it's OK to feel sad. It's OK to feel like they're losing a member of their family.
We want to really acknowledge those grief, the grief, and not, not let them have the opportunity to inhibit that grief at any stage. And just being aware of these just helps us to have those conversations and it just provides a little bit more support to our owners and allows the owners to feel a little bit more understood with what's happening at that time. And there are some really great resources out there for owners as well.
You've got the Blue Cross which offer pet bereavement and pet loss. They have a online, I think they have an online chat, they have an email service, they have a phone line, that's open to owners, so do let owners know that these. Resources are available.
And you can do a pet loss course as well for pet professionals, so you can do a bereavement course to help support your owners. I don't think it's very expensive. I think it's a couple of days, and they're quite commonly put on.
So do check out the Blue Cross website if that's something that you're interested in. And by making owners aware of the that the practise has took these extra steps to kind of care for them, can really help to bond them. There's other things we can do as well just to minimise the kind of emotions and try and support them the best we can.
And like I said before, we can offer a follow-up phone call. We don't want them to leave the practise and they're not hearing from us for, say, two months when their next checkup is. We want to check in with them and make sure that everything's going OK.
Are they having any problems? Do they need some extra support in any other areas, that kind of thing. And I think it's worth sometimes as well, pre-booking appointments.
So rather than letting them leave the practise and saying come back in 2 weeks, we say, look, let's book your next appointment for 2 weeks. We've got it in the diary. You don't need to get in touch.
It's all booked in. If you need to come in sooner, do let us know. But that's fine, we will see you on this date at this time.
And they haven't got to think about picking up that phone, making that, that appointment, having that conversation, explaining everything to the receptionist again. So it's quite good. No useful tip just to try and get them to pre-book their appointments before they come back in.
And having end of life conversations and preparing them for euthanasia sooner rather than later can allow them more time to process and allow them more time to really understand and think about what is right for them and their pet. We want to be discussing the options for them as well, as soon as possible, you know, if we're at the stage where we know that euthanasia is coming. But maybe it's still not for another 6 months.
I still think it's OK to have those conversations. We're not scaring them. We're providing them with education and we're trying to improve their knowledge to help support them emotionally.
So it's OK to talk about euthanasia. I think we kind of scuffle away from conversations around death and things in this country, but I think we do need to be a lot more open, and have these conversations and not be afraid to suggest euthanasia. As well in certain situations, but again, that's that's another long webinar.
So I'm just briefly touching here as well on euthanasia, and the processes and how it happens and things that we need to think about when we're, going through euthanasia with our patients in practise and supporting our owners. I mean, we have some research out there, there is some research there that shows that the owner experience during euthanasia does impact the grief. And it can, the attachment, anger, and guilt can be emphasised depending on the euthanasia experience.
And it depends on things like the care and empathy offered during the time of euthanasia, and particularly the way the animal is handled. But I'm pretty confident that we all know that during euthanasia, handling the patients, we have our cat friendly practises that we should be taking into consideration still at these appointments, which I'm sure we all do. We, we are, we are not a profession that isn't empathetic in these scenarios, so.
I think how the way the animal is handled isn't something that we need to be too worried about, but, I think just. Being open with the clients and providing them with as much as possible, so we can want to make sure we provide them with an estimate pretty soon. The last thing we want them to do is come in, have their pet put to sleep, and then they're handed a really high bill that they can't pay.
We want them to be able to process what's happened, process their grief without worrying about things like financial burdens. Again, discuss options for cremation sooner rather than later, so this isn't something that they need to be thinking about in that moment. Tell them about the process.
Let them know what is going to be happening. And they don't have to come into the practise for these conversations either. This is a conversation that you could have over the phone with an owner if you wanted to, allowing them to have some time put aside to speak to you on the phone to really discuss what's going to happen.
You would explain your steps, you know, are we going, we're going to sedate, then we will use this medication which will act on the body in this way. Your pet may show. Signs of, you know, twitching or gasping, those kind of things, it's important to let them know all this information so they're as well prepared as possible, so as I said, the drugs use, reactions to the drugs, that kind of thing.
Again, schedule that appointment. So if you are having a conversation around euthanasia and the owner is saying that they're nearly ready, for example, or they are ready, while they haven't got that decision in mind, let's get that appointment booked in. So they haven't got to again phone up, have the conversation, get the appointment booked, feel that emotion while going through that process.
And we want to make sure that we're choosing a quiet time in the practise for these appointments. We don't want them to be coming in at 8:30 in the morning when everyone's being admitted and there's dogs barking in the waiting room and people queuing up at reception. We really want to make sure that we're trying to have a look at the time, have a look at what kind of day it is for the practise and really choose a quiet time as possible, which I know is sometimes impossible, and that cue word is not the word you want to be using in practise, but, try and find a nice suitable time during the day that you can make these appointments.
Again, quiet time time for staff as well. The last thing you want is to be booking a euthanasia and you need a veterinary nurse to help you, and there's nobody available. And the whole situation becomes a little bit messy.
You're trying to find staff, you're trying to find resources, all that kind of thing. So yeah, make sure that it's a suitable time for the euthanasia and in how the practise generally kind of works. Again, provide resources to the owner as well.
We want to make sure that we're, we're at least giving them something to take away with them, so they've got something. In their hand that we know they're going to potentially read when they get home, we can just hand them a leaflet and say that this isn't for now, but here's a leaflet for you to have a read over when you're feeling ready. And there's lots of the bereavement support out there as well.
And at the actual time of euthanasia. There's just a few little things to think about, as I say, this could be, I could really delve into this, but it's just gonna hit a few pointers. I wanna make sure that the whole team know what's happening.
Make sure that they know that there is a euthanasia going on. These candles are quite nice, but I think it also depends on the owner as well. The owner might not want to walk into a practise and then see that the candles like ready for them.
So I think these are nice and some practises they really work really well, but it's just something I think to have a good discussion with the team and see if they think it's gonna work for your practise. But just having a way of the team knowing that a euthanasia is going on. Choose a quiet room, make sure that it's not a room that's next to maybe the guest staff kitchen or something like that.
You want to make sure that it's a nice, quiet, suitable room, have some signal, as I said, for the staff to a candle or something like that. Make sure everything's ready. Get that room ready before that owner walks in there.
You want a bed laid out on the table, all the medication that you might want to be using, your your sedation, your drugs. Get your syringe and needles put together, drugs drawn up, everything is ready as soon as possible, so there's no faffing. And everything is kind of focused on the euthanasia process.
Things like tissue as well is something that we forget about, make sure that there's some tissues in the room. Maybe an option for the owner to have some water if they feel like they might need it. Do they want to take the cat's collar home?
Do they want to take the cat's carrier home? Make sure we've got provisions for these things, so it looks like we really have thought of everything. Greet them positively, and I know this might sound weird, but this is going to be something that's they're gonna probably remember for a long, long time.
And we don't want to greet them by being all sad and upset. We want to be like, oh hi, fluffy, oh, you know, try and keep it as positive as possible, in relation to the scenario. And I always do think that sedating is the best option, especially for cats.
If we can sedate them in a way that they don't feel distressed. It just allows for a more peaceful scenario for the owner, it's peaceful for the the cat as well, and it's also just a bit more peaceful for the staff involved as well. Again, repeat the process to the owner, make sure that they know what's about to happen, but keep it personal.
If there's moments in the past where you, you know, you have a memory of this patient, maybe it is a patient that you've seen for years and you've been in the palliative care process and through the quality of life conversations, you're gonna have a good connection with them, so remember those connections and there's nothing wrong with bringing that personal aspect to this scenario. Make sure you've got plenty of time, which I know is easier said than done, but I think we should always be given at least half an hour for euthanasia. And just making sure that we use in a room which doesn't need to be used directly afterwards, just in case that owner wants time with that patient and wants time to be saying goodbye.
And, one nice tip that I've heard of a colleague is giving them a little kind of bell or a ringer that goes to a phone. And we can say, you know, just push this button when you're ready to leave, and we will come, we'll come back in. And it just gives them time with the patient and they're not gonna feel the pressure, they know that they've got as much time as they want.
We can also offer home visits as well, obviously this is something that can also be offered, home visits are a lovely way of being able to say goodbye. And sympathy cards, and this is something that we, it's very commonly used in practise, but I do think it's a nice way to just kind of close off that whole relationship that you've had with that patient and that owner by just sending them that sympathy card, letting them know that you are still thinking of them, reinforcing maybe that extra support that's out there. I think Blue Cross do sympathy cards and they actually have their resource on the back of them, so I think they're really, they're a really nice tool to use and.
I think really thinking about quality of life and palliative care and euthanasia, again, it's something that we don't really talk about that much in in practise. So I just really want to thank you for coming along and listening to this webinar today. And I really hope that it helps to encourage conversations with our owners, improves the welfare of cats in practise, and that we really start to use palliative care and quality of life assessments and tools as commonly as we do everything else.
Thank you very much.