When evaluating these aspects with the caregiver, it is often helpful to frame conversations through "personal budgets," which refer to the amount of financial, emotional, physical, and time resources a caregiver has available to them. The following are examples of caregiver considerations as they relate to their individual personal budgets:
- Financial: Do I have the finances needed to care for my cat? Will paying for my cat's medications and treatments cause a financial strain on me or my family?
- Emotional: Am I emotionally capable of managing this situation? Will caring for my cat negatively affect me emotionally? Do I have the emotional capacity to provide the level of care my cat needs, given other responsibilities in my life?
- Physical: Will caring for my cat interfere with my physical well-being (such as lack of sleep in the presence of feline cognitive dysfunction)? Is my cat physically able to receive care, such as being able to take medications or receive subcutaneous fluids?
- Time: Do I have the time my cat's caregiving requires? Do my work and daily life responsibilities align with my cat's care needs? Will the burden of my cat's care be fully on me, or am I able to receive help from other family members or friends?
Understanding a caregiver's needs, beliefs, and goals requires the use of open-ended exploratory questions from the veterinary professional, and a mix of experience/goal sharing from the caregiver. Discussion should focus on personal budgets, how to achieve a balance between quality and duration of life for their cat, goals for their cat's treatment and care, and whether euthanasia or hospice assisted death is the preferred option. The caregiver should be invited to ask questions and should not feel rushed or pressured into making treatment decisions. Regardless of the decisions that are made, the caregiver should never feel judged.
Step 2: Education about the disease process and delivery of care
The main goal of caregiver education in hospice and palliative care is for the caregiver to have a clear understanding of all diagnostic and treatment options to ensure the cat's comfort, as well as the expected trajectory of the cat's disease and the prognosis. The more a caregiver understands, the better they will be able to execute their role with realistic expectations and make informed decisions based on goals.
The veterinary team should communicate information using language the caregiver can easily follow and understand, and decisions around care should be made only when the caregiver has a clear understanding of all options available. Caregiver education regarding the delivery of their cat's care should involve various forms of instruction, including verbal, written, and visual (i.e., illustrations, video), whenever possible. When giving instruction on particular care tasks, such as subcutaneous fluid administration, take a "see one, do one, teach one" approach to caregiver education.
Step 3: Development of a personalized plan for the cat and caregiver
Developing an effective, patient-specific hospice and palliative care treatment plan is a collaborative effort involving the veterinary team, caregiver, and entire unit of care, and includes the following components:
- An assessment of the caregiver's capability and willingness to assume specific responsibilities for care.
- An assessment of the patient's willingness and capacity to receive care.
- A detailed written plan presented in a way the caregiver can clearly understand.
- An estimate of the time required to provide the level of care needed for their cat.
- An estimate of costs, including costs of recheck appointments, additional diagnostics, medication, and supplies.
- A schedule for follow-up communication and reassessment.
It is helpful to approach creating the care plan in terms of three critical areas—the physical, emotional, and social needs of the individual patient.
Step 4: Application of hospice or palliative care techniques
A hospice and palliative care plan empowers the caregiver to care for their cat in a home setting. To a large extent, executing the care plan involves instructing the caregiver on various therapeutic techniques, as well as on how to assess their cat's response to therapies and treatments, and how to recognize signs of clinical decline.
The caregiver should be guided on how to provide safe interactions with and handling of their cat, including how to safely administer treatments such as subcutaneous fluids and medications. Administering medication should be a positive experience (e.g., providing oral medication in treats) or followed with a positive experience such as an engaging human–cat interaction. The home environment should be evaluated to ensure the cat's comfort and safety, with adaptations made where necessary. Environmental modifications might, for example, include improving accessibility of food and water, ensuring bedding is comfortable, optimizing litter box location and design, selecting an ideal ambient temperature, or providing an approved heat source. Technologies such as asynchronous communication through video recording or synchronous communication utilizing telehealth can be helpful for the caregiver in regularly communicating with the veterinary team regarding the patient's clinical status.
Step 5: Emotional support during the care process and after the death of the cat
Providing emotional support and empathy begins at the point of the family's first realization they are entering their cat's end-of-life stage and should be the responsibility of everyone within the veterinary practice. During the course of the hospice-care relationship, it is important to continually explore whether caregivers are experiencing anticipatory grief, which is a form of grief that occurs before an impending loss. Anticipatory grief includes all of the same stages (denial, anger, depression, acceptance) as post-mortem grief, and can make decision-making challenging. It may manifest as rehearsing the loss, and meticulous following of instructions or obsessive monitoring.
Disenfranchised grief is something many caregivers experience, as well. Often, they are grieving alone or do not get the emotional support they need because their family members, friends, co-workers, or acquaintances do not feel the grief they experience is legitimate. Encourage grieving caregivers to find the support they need and provide resources, such as information about support groups. Often, just naming and normalizing anticipatory, post-mortem, or disenfranchised grief goes a long way toward supporting caregivers and their families.
For caregivers who are struggling with one or other form of grief, it is strongly recommended the veterinary team considers a multidisciplinary approach to utilize the expertise of social workers and mental health professionals in providing support and expanding the unit of care. Most importantly, caregivers need to know it is okay to feel what they are feeling; their feelings need to be validated and supported.
Following the practices outlined in the AAFP/IAAHPC guidelines can help ease the end-of-life journey of feline patients. Sadly, that journey will come to an end at some point. When the cat's passing is planned with care and consideration, the outcome should be minimal pain and a peaceful transition.
Being present with the caregiver and the patient is one of the last opportunities for a veterinarian and the veterinary team to serve the cat and the caregiver directly. The caregivers who are present for the procedure should be fully informed and aware of the steps that will be followed. The desire for death to come quickly and gently should not override the importance of allowing the caregiver(s) the time they need, and the team the opportunity to have everything in place. When the focus moves from curative care to providing comfort care, veterinarians and their teams should commit to the cat's quality of life (QOL) leading up to death, which demands consideration of foundational bioethical principles. QOL assessments should center on whether the individual feline patient has a life worth living. The cat's acceptance of treatments and medical interactions must weigh into care decisions. Cats can and do express preferences, and respecting their autonomy means respecting their expressed preferences as much as possible. Honoring and preserving the human–animal bond involves attention to nonmaleficence (avoiding harm; i.e., not harming the caregiver's relationship with the cat) and beneficence (acting in the patient's best interests; i.e., allowing the human–animal bond to be a higher priority than intervening with aggressive procedures).
