Page 339 - Withrow and MacEwen's Small Animal Clinical Oncology, 6th Edition

CHAPTER 16 Supportive Care for the Cancer Patient 317

prognostic information is affecting the client (“This is hard to talk for clients. Concrete information about what to watch for and
about.” or “I am wondering if this is the kind of information you what to do may make the decisions feel more manageable (“Things
to watch for in Mandy are a decrease in appetite or interest in drink-
need.”). Asking permission is a key skill in this conversation to
VetBooks.ir assess the client’s readiness to hear more information (“What ques- ing water; reduced activity level; difficulty breathing, such as panting
or increased effort; and change in personality, a lack of interest or
tions do you have at this point?” or “Would you like me to continue?”).
Read the client’s nonverbal cues to assess how clients are pro- responsiveness to you and her daily activities.”)
cessing the information (“I notice that you seem hesitant when I was To validate and support clients, veterinarians may need to
talking about survival time with chemotherapy. Could you tell me reassure their clients that they did everything they could for
more about this?”). To balance sustaining hope and maintaining their pet (“You have given Mandy every chance possible.”). 456
reality, it may be helpful to frame the prognosis using both posi- Words of empathy, reassurance, and partnership can be highly
tive and negative language (“Median survival time means that half supportive (“All along you have made your decisions with Mandy’s
the patients live longer than 2 years and half the patients live less than best interests in mind.” or “We will do this together, just as we have
2 years.”). 452 Given the overwhelming nature of this discussion, done everything that got us to this point.”). 456 Clients often are
take time to empathize with the client (“This is a lot of information overwhelmed and feel alone, and it is comforting to know that
to take in. How are you doing?” or “I can see how sad this is for you.”). their veterinarian will guide, advise, and inform them through
Offer partnership to walk beside the client during this conversa- this process.
tion (“This is really difficult to talk about, and we can take it one step
at a time.”). Transitioning to Palliative Care or Hospice Care

Assessing Quality of Life Fortunately much can be done for a veterinary cancer patient’s
comfort, despite the inability to effect a cure; this includes symp-
In human medicine a spectrum of hopes lies from the initial can- tom management, supportive care, enrichment, and pain man-
cer diagnosis to preparing for death. 453 In veterinary medicine a agement to ease suffering. Depending on the resources in your
cancer diagnosis means a client’s initial expectations may center region, it may be appropriate to provide palliative care or refer
around curing the cancer and the pet living longer, and then move the client and patient to a veterinary hospice service. 457,458 Pallia-
toward spending special time with their pet and then seeking a tive care begins at the cancer diagnosis and is incorporated into
peaceful death. This breakpoint discussion is a crucial conversa- the treatment plan. Hospice care begins after treatment of the
tion that signals the transition from striving for quantity of time cancer is stopped. Veterinary hospice is the care provided after a
to embracing QOL. 452 It can be challenging for clients who have terminal diagnosis of weeks to months has been given; it includes
been working so hard to treat the cancer to shift their energy to providing supportive care for the animal and emotional support
living the fullest life with their pet right now and preparing to for the family to prepare for the imminent death of the animal
let go (“It seems like it may be helpful to focus on what time Mandy and to help clients focus on spending quality time with their pet.
has left with you.” or “Just because we can do something does not At-home patient care entails administering medications, assess-
mean that we should.”). Warn clients of the difficulty in making ing and monitoring pain management, emotional well-being and
the transition from treating cancer to focusing on QOL (“It can be social enrichment, evaluating proper hydration and nutrition,
difficult to switch gears from fighting the cancer to preserving Mandy’s and educating families about euthanasia, the grief process, and
quality of life.”). death and dying. 458 Today, statements such as “There is noth-
Ask permission to ready the client to enter into a quality of life ing more we can do” can be replaced with words of encour-
discussion (“Would it be alright if we took some time to talk about agement and offers of partnership to comfort clients (“There is
Mandy’s quality of life?”) Pose open-ended questions to elicit the still much that we can do to make sure that Mandy is content and
client’s perspective of the pet’s quality of life (“What do you think comfortable.”). 454
Mandy’s quality of life is like now?”; “What makes life worth living Client and patient abandonment may be a concern that arises
for Mandy?” or “Under what circumstances would life not be worth during this stage of care. The value placed by the client on the
living for Mandy?”). Obtain the client and patient goals to move relationship with the veterinarian may increase as the patient’s
the conversation forward (“Can we create a plan together to ensure cancer progresses, as the desire for information lessens, and the
Mandy’s quality of life?” or “What is most important to you in caring need for support grows. 459 The relationship with the veterinar-
for Mandy at the end of life?”). A supportive way to acknowledge ian or nurse is foremost in reducing client uncertainty at the late
the client’s desire to do more is through expressions of “I hope” stages. 400 With the change in the care provided from cancer treat-
or “I wish” statements (“I wish there was something we could do to ment to palliative care, the client may perceive that the veterinar-
cure Mandy’s cancer.” or “I hope that Mandy has many good weeks ian’s relationship with the client and patient has ended. Offering
ahead.”). 454 At this stage it is equally important to reflect on the partnership helps create a sense of support for the client (“We will
veterinarian’s conversational emphasis and what influence the pre- work through these decisions together.” or “I will be here to help you
sentation of information may have on the client’s decision mak- and Mandy whatever your decisions may be.”) Clients may want to
ing, 455 such as how much time is spent talking about anticancer hear explicitly that their veterinarian will still be taking care of
therapy compared with QOL; supportive, palliative, or hospice their pet, even if they decide to discontinue treatment. Depending
care; or euthanasia. The veterinarian inadvertently can influence on the client’s relationship with the specialist and the referring vet-
the client’s decisions through the prioritization of the options for erinarian, it may be critical to determine the client’s expectations
care. 456 and offer to maintain the relationship to provide end-of-life care.
Educate the client on how to monitor the pet’s condition and Caring for clients and patients at the end of life can be a source
assess the pet’s QOL. Clients often wonder aloud “how they are of meaning and fulfillment for the specialist, in addition to an
going to know when it is time?” Anticipating that the end of life opportunity to recognize the special relationships formed during
care can be intimidating, overwhelming, and anxiety provoking this difficult time.