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Introduction

Jessica Pierce, BA, MTS, PhD

A paradigm shift is under way in how we understand and relate to companion animals. Although neglect and poor treatment are still endemic to pet keeping, a growing number of guardians seek to provide their animals with everything they need to be healthy and happy, including good, quality food; proper socialization; ample physical and mental stimulation; and thoughtful veterinary care during all life stages. As people integrate animals into their families, they are paying more attention to the physical needs of their companions. They are also increasingly attentive to their companion's emotional and behavioral well-being.

At least some of the changes in how people view and relate to companion animals are a result of evolving ideas not just about the human-animal bond, but about animals themselves. Over the past several decades, a tremendous surge in research into animal cognition and emotions has altered our understanding of who animals are, which has led to a much greater appreciation of their intelligence, emotional sensitivity, and sociality. We now understand, for instance, that a whole range of animals, including fish and birds, feel pain in much the same way as humans. We also understand that all mammals - and perhaps other taxa as well - have the same repertoire of basic emotions as humans and many of the same patterns of social attachment. This scientific knowledge is gradually translating into a greater sense of responsibility for animals and an appreciation of all the good care that this involves for an animal. An example of this translation is the fact that nearly all discussions of well-being now pay attention not only to physical comfort, but also to the emotional and social needs of companion animals.

An outgrowth of this changing paradigm of animals and human-animal relations is that pet guardians and veterinarians are giving greater attention to the final stages of life. When animals are highly valued members of a family, it is only natural that people would strive to provide loving care even as an animal becomes elderly, sick, or otherwise near the end of life. Caregivers and veterinarians are challenging what they see as unnecessarily stark choices: allow an animal to suffer or euthanize; provide aggressive curative treatment; or do nothing. Hospice veterinarians are broadening the possibilities for providing care and helping pet caregivers take a pro-active role in making sure animals are eased more gently through their final months, weeks, days, and hours. Furthermore, veterinary teams increasingly recognize that the death of a companion animal can be a source of both meaning and profound suffering for people, and as a result, they are looking for ways to make the dying process less painful not only for the animals, but also for their human families. The provision of home-based care allows animals and families a greater measure of privacy and comfort. Finally, hospice veterinary teams are paying attention to the details of death itself, whether it occurs over time and is supported by palliation, or whether euthanasia is the ultimate end point, and are helping caregivers honor their animals through ceremonies, memorials, and aftercare.

In human medicine, end-of-life care has undergone a metamorphosis. After decades of misunderstanding and fear, hospice has been firmly embraced by the public and by health professionals as a sensible and compassionate alternative to intensive, cure-oriented, hospital-based care. Palliative care, which focuses on pain and management of symptoms both in the context of curative treatments and hospice care, finally became a board certified subspecialty of internal medicine in 2006. A similar transition is now occurring within the veterinary realm: more and more veterinarians are interested in offering clients a broad range of end-of-life options, and many are specializing in hospice care and in the treatment of pain.

Hospice care and palliative care represent two separate though overlapping modes of care within human medicine; within veterinary medicine, they are comfortably paired - at least for now - and will likely develop as a single intertwined entity. Although there is currently no certification or advanced training in animal hospice and palliative care, it is our hope that this possibility will eventually be realized in the veterinary field. This book represents a step in this process, by officially introducing the field of Animal Hospice and Palliative Care (AHPC) and providing what we hope will be an indispensable text for hospice and palliative care practitioners.

Four core philosophical concepts lie at the heart of human hospice philosophy, as developed by Cicely Saunders, one of the leading voices of the early hospice movement. These concepts stand at the core of animal hospice, too. And building from these core concepts, the field can work to develop consensus over how these values can best be served.

1. Dying is a meaningful experience. The experiential process of dying involves all aspects of personhood (emotional, physical, spiritual, and social) and can be deeply meaningful, for the dying and for their loved ones.
2. Dying takes place within a system of interrelationships and a network of shared meanings. Care should support relational structures, not disrupt them.
3. Hospice takes an expansive and holistic view of the nature and relief of suffering. Saunders used the phrase "total pain" to reflect that suffering is not just physical, but also psychological and relational. When it is not possible to eliminate the physical causes of pain, the goal becomes to keep suffering below the level of phenomena experienced by the patient.
4. Care should seek to protect the integrity of the patient and allow the patient to live in ways that honor what they find most valuable and meaningful in their lives (Kirk 2014,?p. 43).

Animal hospice and palliative care is an inherently moral practice, embodying in its philosophy and practice this basic set of values. It is also an area of heightened ethical complexity: the potential for prolonged life must often be delicately balanced against the potential for suffering, and decisions often have life or death consequences for an animal. As Kirk and Jennings note, ethics is more than just discussing or settling disagreements about right and wrong; it is also about "creating moments of stillness and introspection, allowing teams to identify and explore resonances and dissonances.." and finding "ways of bringing the values, hopes, and fears of team members from the background to the foreground so they can be discussed, explored, addressed" (Kirk and Jennings 2014,?p. 4).

As ethicist Courtney Campbell points out (in the context of human hospice), the language we use embodies - either consciously or not - a set of values. Which phrase is chosen makes a big difference (e.g. physician-assisted suicide, physician-assisted death, aid-in-dying, or death with dignity). "One important task for hospice ethics," says Campbell, "is conceptual clarification and movement toward consensus on terminology" (Campbell 2014,?p. 231). The development of an increasingly nuanced vocabulary for animal hospice and palliative care is also vitally important. The term "euthanasia" is a very blunt instrument. It carries negative connotations in human medicine; likewise, in the context of animals, the term has a huge variety of applications, not all of them salutary. Furthermore, "euthanasia" doesn't allow moral distinctions between, for example, killing a healthy animal and offering a very sick animal relief from intractable and prolonged suffering. AHPC practitioners sometimes use, instead, "veterinarian-assisted death" or "veterinary aid-in-dying" (VAD) to describe the process of humanely taking the life of a suffering animal. The phrase "natural death" similarly lacks precision and carries unwanted associations. "Hospice-assisted natural death" is a great improvement. The thoughtful choices made by the authors of the chapters in this volume contribute to the evolution of a useful and morally precise vocabulary for the field of AHPC.

The philosophical core of AHPC needs to coalesce, but the ways in which AHPC is practiced need to spread and grow, like seeds of change being carried by the winds. Many different models of care need to be developed and refined, and as practitioners innovate they need to share what they learn. There are practical and financial challenges to building a multidisciplinary care team, just as there are unique difficulties in providing mobile, home-based services. Even medically, there is a great deal of work to be done in understanding how to help animals die comfortably. Because it is so rare for companion animals to die a natural death, we don't know as much as we could about the dying process or care of the terminally ill. AHPC promises, over the next decade, to become one of the most vibrant, exciting, and important areas of veterinary medicine.

References

1. Campbell, C. (2014) Moral meanings of physician-assisted death for hospice ethics. In: Hospice Ethics: Policy and Practice in Palliative Care (eds T.W. Kirk and B. Jennings). Oxford University Press: New York, pp. 223-249.
2. Kirk, T.W. (2014) Hospice care as a moral practice:...