Page 146 - WSAVA2018
P. 146

 25-28 September, 2018 | Singapore
C. Cannon1, S. Ryan1
University of Melbourne, U-Vet Animal Hospital, Melbourne,
Claire Cannon BVSc (hons) DACVIM (Oncology) MANZCVS
Stewart Ryan BVSc (hons) MS DACVS MANZCVS University of Melbourne U-Vet Animal Hospital
Learning objective: To develop a framework for instituting a palliative care plan including pain relief and nutritional support in dogs and cats with cancer, and determining when surgery and radiation therapy can be applied with a palliative goal.
Definition and general approach to palliative care
Palliative care is aimed at improving quality of life and relief of suffering rather than specifically treating the underlying disease.
In the case of animals with cancer, offering palliative
care only as an option is appropriate in cases where the condition is likely to be terminal and owners elect not
to pursue treatment, or treatment is not successful. In human studies, early palliative care is associated with not only improved quality of life at the end of life but actually with improved survival time. Early discussion of palliative care also allows carers to prepare, resulting in reduced episodes of prolonged grieving and major depression following the death of the patient.
Many factors go into owners’ decisions when choosing treatment for pets with cancer. These include treatment related factors (cost, side effects, time commitment), disease related factors (prognosis with different treatments), and patient factors (comorbidities, amenability to different levels of treatment, age). Age is commonly cited as a factor in owner’s decisions though it may not directly affect the suitability of treatment options otherwise.
Suggested steps in developing a palliative care plan
· Client education - discussion of all of the options for diagnostic testing or treatment, and prognosis. Consideration of the bigger picture is necessary - for example, if the owners are not going to pursue specific treatment for a dog with osteosarcoma, will taking chest radiographs change the plan?
· Determination of the owners goals and beliefs. If owners goals are unrealistic, this should be
addressed clearly and honestly, with empathy. Determining owners beliefs about euthanasia may be appropriate at this time.
Developing a personalised treatment plan - patient assessment with regard to hydration, nutrition, pain, mobility, mood and engagement to determine which need to be addressed, client assessment with regard to their willingness and ability to provide care, plan should be agreed upon by vet and owner. Treatment protocols should be simplified as much as possible and instructions should be clear. Owners should feel able to express concerns about their ability to deliver the recommended care.
Implementation and reassessment: Once a plan has commenced, frequent reassessment is required
to ensure that goals of the owner and needs of
the patient are being met, and that quality of life is maintained as much as possible. Tumour progression alone does not mean that palliation is not successful, as long as quality of life is maintained. Use of the animal hospice care pyramid and/or the HHHHHMM quality of life scale may assist in assessing for changes in quality of life over time. At the beginning of the process, having owners make a list of the things that most impact quality of life for their pet (positive and negative) and then having them assess their pet regularly for these key behaviours may allow detection of changes in quality of life over time.
Pain management in cancer patients:
Pain is a major concern of human cancer patients and of owners of pets with cancer. Instituting analgesia early in animals with tumours likely to be painful is an important part of palliative care and of cancer treatment in general. Owners may not always recognise pain in their animals and careful questioning and client education is important. In some cases, an analgesic treatment trial may help
an owner to recognise that their pet was painful.
Drug therapy is the mainstay of pain management in veterinary oncology and the WHO cancer pain ladder
is a reasonable approach. For mild pain, an NSAID is recommended +/- adjuvant e.g. gabapentin. For more severe pain, addition of opioids is recommended. Multimodal management is recommended, with combinations of drugs and of modalities (i.e. massage or other physical therapy along with drugs). Using multiple drugs improves pain control and allows lower doses to be used of individual drugs. Adjuvant drugs are generally weak analgesics alone but when used in combination with other drugs can be beneficial. Simplifying timing
and frequency of dosing will improve compliance when prescribing multiple medications.
For tumours that are affecting quality of life due to
local effects, surgical removal or radiation therapy may improve quality of life even in cases with metastatic disease. For example, in appendicular osteosarcoma improvement in quality of life can be achieved with amputation or palliative radiation therapy due to relief of local pain even though these modalities may not improve overall survival. Intranasal tumours are likely painful due

   144   145   146   147   148