By Dr. Becker
Today I have a very special guest chatting with me via Skype -- Dr. Alice Villalobos. “Dr. Alice,” as she is known, is a University of California-Davis graduate, the director of Pawspice in Hermosa Beach, and she also runs the Animal Oncology Consultation Service in Woodland Hills.
Dr. Villalobos is a founding member of the Veterinary Cancer Society, the Association for Veterinary Family Practice, and the International Association for Animal Hospice and Palliative Care. She’s also the past president of the Society for Veterinary Medical Ethics and founder of the Peter Zippi Memorial Fund for Animals, which has found homes for 14,000 pets since 1977, primarily cats.
Dr. Villalobos is editor-in-chief for several veterinary-related journals, and she has authored textbooks including Canine and Feline Geriatric Oncology: Honoring the Human-Animal Bond. She also writes a column titled The Bond and Beyond for Veterinary Practice News.
Dr. Villalobos has received the Leo Bustad Companion Animal Veterinarian of the Year award, the UC Davis Alumni Achievement award for her pioneering role in bringing oncology services to companion animals, and a Distinguished Practitioner of the National Academies of Practice award. She lectures worldwide on veterinary oncology, companion animal quality of life issues, and “pawspice,” or veterinary hospice, which is the topic of our discussion today.
Dr. Villalobos made the decision when she entered private practice to see her cancer patients through to the end of their lives.
I asked Dr. Alice, since she has been a veterinarian for many years, how soon into her career she realized there was a huge gap in end-of-life care services for pets.
She explained that she was still in veterinary school when she decided to practice oncology, and her animal patients had their end-of-life experiences right there at UC Davis. So Dr. Villalobos was able to see the gap in services first-hand while still a vet student.
When she went into private practice, she made the decision to see her patients all the way through to the end of their lives, unlike what happened back in those days (1970s) in human medicine, when no one wanted to discuss death. This predated the human hospice movement and the concept of helping people die peacefully, without pain.
Dr. Alice decided to work with her animal patients and their families right through to the very end of the journey. Fortunately, we are able to help pets have a very peaceful passing because society condones euthanasia for animals. Dr. Villalobos made it a point to talk about the subject with each family from the first day she felt euthanasia was inevitable for their pet.
Next I asked Dr. Villalobos who she sought counsel from originally, since back in the 1970s there weren’t any mentors or role models for treating pets at the end of life. She answered that in the late 1960s and early 1970s at UC Davis, there was a very special pioneer in the field of animal oncology, Dr. Gordon Theilen.
Dr. Theilen wrote the first two textbooks on veterinary cancer medicine. Dr. Alice considers him a great role model who is filled with compassion. She mentions Leo Bustad as a role model as well. He was also a part of the UC Davis team and was responsible for the term “human-animal bond.”
Dr. Villalobos noticed that pet owners would come into her practice wanting to keep their dog or cat with them for as long as possible. They didn’t want a replacement. They wanted to get treatments for their pets and when the time came, they wanted to insure their animals were able to pass on in the right way – at home, with the best of care, surrounded by their human family.
Dr. Alice looked into what was being done with pediatric oncology. She interviewed human patients and asked questions like, “You have this cancer. How does it feel?” Part of the reason for her research was because at vet school, she was taught animals don’t experience pain on the level they actually, in fact, do. Back in those days, rather than being given pain medications, animals were restrained for procedures and prevented from moving after surgery. Fortunately, all that has changed.
As a member of the International Veterinary Association of Pain Management, Dr. Alice knows that veterinary hospice practitioners must have extensive knowledge and expertise in pain management, because it is one of the biggest problems for cancer patients (both human and animal) at the end of their lives.
Taking treatment of terminally ill pets and end-of-life care to the next level.
I asked Dr. Villalobos if, when she first got started, she was met with conflict. Were her colleagues confused? Did they question her? She replied, “Dr. Becker, I’m still pulling the arrows out of my back.” I asked her to expand on the conflicts and confrontations she has encountered.
Dr. Alice explained that back in the early 1970s, treating a cat with both leukemia and FIP was “almost blasphemy.” People thought, “What is she doing?” But at UC Davis, they treated cats with lymphoma, and the most likely cat to have lymphoma was also positive for the leukemia virus.
Dr. Theilen was the doctor who isolated the three subtypes of the leukemia virus that ultimately resulted in a vaccine. UC Davis was working extensively with leukemias and lymphomas in felines. In fact, Dr. Niels Pedersen of UC Davis is the person who characterized the FIP virus and discovered the feline immunodeficiency virus.
Dr. Alice explains she was surrounded by fantastic researchers and a wonderful atmosphere. When she finished vet school, she was actually in the midst of a “mock” residency with Dr. Theilen who wanted to put a veterinary student through a clinical oncology program. So Dr. Villalobos actually began her residency while still a sophomore in vet school, and she continued that work for Dr. Theilen through her next three years of school.
So in addition to the stigma attached to treating viropositive animals, Dr. Villalobos also had a passion for helping them die well. I asked her what kind of response she received. She answered that most of her colleagues felt they were already doing that – providing animals with a good end of life experience. But as she further explains, it requires a certain expertise. Palliative medicine is a specialty. She expects at some point it will become a specialty in veterinary medicine just as it is in human medicine.
Dr. Alice goes on to explain that hospice is another area of expertise. She views it as, “The types of psychology that we need to know to help comfort the bewildered, bereft, grieving, and the anticipatory grief that comes through, even suicide. People feel that they can’t go on another day.”
When a pet dies, veterinary professionals need to be well versed in all these forms of psychotherapy, comfort care and grief counseling. It’s a necessary service, but in a busy practice, when a DVM isn’t accustomed to working with end-of-life care patients and clients, it just doesn’t happen.
Dr. Alice’s “pawspice” concept and the HHHHHMM quality of life scale.
End-of-life care hasn’t been taught in vet schools. Students are taught how to euthanize animals, but that’s about it. I do think palliative medicine is coming, though, and certainly pain management is even farther along, thankfully. But putting all those pieces together to offer truly thoughtful, heartfelt support isn’t there yet.
I asked Dr. Villalobos if she thinks vet school courses are addressing some of these skills today. She replied she believes they are coming along. She says that after her textbook arrived in 2007, vet schools quickly took the book into their libraries, and some of the programs that were developed even taught pawspice.
Dr. Alice explains she wanted to call pet hospice “pawspice” because the word hospice is actually very confusing for those who want to adapt the concept for veterinary medicine. She says that in human hospice, the arrival of death isn’t slowed down. Patients receive pain management, but what everyone is doing is simply waiting for the patient to die.
In veterinary medicine, we can apply a quality of life scale to each patient. In fact, a scale that Dr. Villalobos proposed in 2004 went viral. It went everywhere. It’s the HHHHHMM scale. It’s designed to be easy to remember. The five H’s are for:
… no Hurt
… good Hydration
… no Hunger
… good Hygiene
Hurt, Hydration, Hunger, Hygiene, and Happiness. These are the five basic areas that pawspice professionals must be able to talk to their clients about.
The first M is for Mobility. This is extremely important for large pets, for example, Great Danes. If a Great Dane can’t move around on his own, it’s over unless there are some very strong family members who can physically move the dog as often as necessary. In smaller animals, mobility isn’t such a huge factor. On the quality of life scale, they can have a score of 0 all the way up to 10 and still be okay. It’s similar to people in wheelchairs – they can have great quality of life even though they don’t have full mobility.
The second M is for More good days than bad days. This is something the pet’s family has to focus on. Is this a good day for Buddy? Or is this a bad day? If there are more bad days, say two or three or four in a row and no really good days, it’s time for the family to consider the gift of euthanasia.
Our pets only think in present time. They exist in the now. Even if you’re five hours late coming home, they are still full of joy and not mad at you. They’re just happy to see you now, because they exist in the now. If they’re suffering now, that’s all they know, and if there are too many times of suffering, frustration builds up.
Sometimes people don’t understand this. It can be difficult to understand things from a pet’s viewpoint. When there are more bad days than good days, our pets welcome the gift of euthanasia. They don’t need to live for the graduation of a niece or nephew. They’re not looking back with regret and hoping to reconcile with someone before they die. The human hospice philosophy simply doesn’t apply at the end of an animal’s life. They’re here to enjoy the moment. It their quality of life is poor, it’s up to us as their protectors not to make them endure further suffering.
This is the way Dr. Alice talks to her clients, “You are his protector. Buddy needs you to make the decision to help him, you know, change worlds.” She says Barbara Myers, a pet loss consultant, uses that beautiful phrase, “Let’s help them change worlds.” It’s often comforting to families to use euphemisms like “transitioning,” or “crossing the Rainbow Bridge.” It’s not necessary to use tough words when talking about the death of a beloved companion animal. Families, and especially children, welcome thoughtful, loving words to describe what will be happening to their pet.
End-of-life care/pet hospice is the fastest-growing specialty in veterinary medicine today.
Next I asked Dr. Alice about her passion for teaching and consulting other professionals and vet schools about end-of-life care for pets. She explained that she has taught all over the world, and her textbook is translated into Spanish and Portuguese. When she goes to Portugal, Spain, or South America, she’s treated like a celebrity!
Dr. Villalobos is also well known in the U.S. for being one of the leaders of the pet hospice movement. She says her decision to treat pets with cancer in vet school was pivotal in creating a specialty service for animals in the final stages of life. She says it’s the fastest-growing specialty service in all of veterinary medicine. New veterinarians in particular are really embracing pet hospice.
Dr. Villalobos says one of the reasons for its popularity is that DVMs can set up an independent practice. They can do house calls. This is especially attractive to young DVMs who may not be able to find a practice they really like, or who work at a practice in which the owners want them to work more hours than they can handle while raising a family. Going the house call route has worked out very nicely for many of these young vets.
Dr. Stephen Withrow of Colorado State University’s Flint Animal Cancer Center has incorporated hospice and end-of-life care chapters written by Dr. Villalobos in his textbook, and she says his students call her all the time for help. She says CSU has set up a wonderful hospice service, as have a number of other veterinary colleges in the U.S. It’s also a growing movement in Canada, South America and France.
Helping pet owners give their animals a good quality death.
Dr. Villalobos is also passionate about using the term “pawspice” for pets to alleviate the confusion and negative impression many people have of hospice services for humans.
As she explains it, when a pet owner has arrived at those final moments, she or he is often paralyzed with doubt or fear about causing the pet’s passing by making that final decision to euthanize. Dr. Alice sees her job, and the job of all professionals in the specialty, to help comfort those pet owners by letting them know it’s actually a vet’s duty by the oath he or she takes to prevent suffering.
In my practice, I tell clients that the decision to help their pet transition is, of course, the most difficult decision they may ever make. But I also explain that as their veterinarian, the most important thing I can do is to help their pet die well rather than poorly. I ask them, “Do you want to rip the Band-Aid off really fast, or really slow?” I explain that they will be heartbroken either way, but for their pet’s sake, we can help by offering a good and peaceful transition. A good quality of death.
Dr. Villalobos believes quality of life/quality of death questions should also apply to humans. She says that if any of you listening or reading here today have a family member or a child with a terminal disease, you should advocate for a quality passing for that person.
In human medicine, it’s all about what can be done – we can do this, and we can do that, and we can do something else. Even at the end of the road with, say, a cancer that has been resistant to all forms of treatment, someone will come up with yet another treatment that is usually more risky. The patient has an adverse reaction, winds up in the ICU, and has a bad death.
One of the things I’m so grateful to Dr. Alice for is helping veterinarians understand it’s okay to tell a pet owner, “We’ve pushed this animal far enough.” It’s human nature, especially for optimists like me, to say, “We can try this and this and this” when our patients no longer want to keep going and their bodies are tired. I tell my clients that sometimes the body becomes a cage for the soul, and the body doesn’t work, so they need to think seriously about setting the soul free. Animals can become frustrated or depressed, and there comes a point where we should stop pushing, which actually takes all the pressure off the pet.
Sometimes we need to give clients permission to say, “You know what? We’re going to stop and we’re going to voluntarily withdraw all treatment.” Instead of trying to cure or change the disease situation, we’re going to switch our focus to helping the animal have a peaceful, good quality death.
The role of palliative medicine in end-of-life care.
Dr. Alice has really helped veterinarians understand and be able to talk about dying well versus just euthanasia. There’s a gap between the two. When we have a terminal patient and we know euthanasia is coming, there are things we can do to prepare the family, the pet, and our hearts. Dr. Villalobos has paved the way for veterinarians in this regard and I’m really thankful to her for that.
She explains that one of the reasons pawspice is different from hospice is that it incorporates palliative medicine, which is a very misunderstood area in human medicine, especially in the U.S. There’s this idea that palliative medicine is “giving up,” but it is not. It is simply taking care of symptoms that cause anxiety, distress and pain. Dr. Villalobos stresses that we use standard medicine inside palliative medicine.
She says that when a pet patient is diagnosed with a life-limiting cancer, with pawspice what she does is select standard therapy for that patient that will hopefully bring a period of welcome remission. But the therapy isn’t one that will be hard on the animal. It will be something that brings only good days – and few if any bad days. Dr. Alice avoids medications, therapies, treatments and regimens that will result in adverse events for the patient.
For example, she may use a strong drug, but split it to give in two doses instead of one. The techniques she uses are in her textbook, and many DVMs are adopting them. Dr. Villalobos says it has evolved into something called metronomic therapy, which is a continuous low-dose treatment that reduces the formation of new blood vessels, which all tumors need in order to grow. Sometimes she just tries to control the tumor, maybe slow down the growth a little, while preserving the patient’s level of happiness and quality of life.
Thank you, Dr. Alice!
Since not all veterinarians are providing hospice care, I asked Dr. Alice where my Healthy Pets listeners and readers can go to learn more about end-of-life care. She invites everyone to visit her Pawspice website, where you can find lots of information and links to other resources.
I so appreciate Dr. Villalobos taking the time to speak with me today. I’m grateful for all the work she has done and continues to do for sick and terminally ill animals.