Part VI: Determining and Managing the Care of the Avian Cancer Patient

6.1 Tumor Analysis

In order to manage the bird’s cancer treatments, the owner must have a basic of knowledge of the consequences of the various treatment protocols available to him so that he can make the decisions about how the bird’s neoplasia is to be treated. To do that, he needs to know the type of cancer the bird has, what has been used on that specific type of cancer in the past, and what the potential outcomes of those treatments are.

Not all that long ago, most neoplasias were diagnosed at necropsy because there was little-to-no treatment and most birds died. Today, though, many of these birds are surviving since avian health care has improved sufficiently for these birds to be treated successfully. This provides veterinarians with a greater database for appropriate therapy and care.²⁰

In Dr. Reavill’s paper, “Tumors of Pet Birds,” she outlines some basic information about tumor types frequently found in birds, their treatment, and success rates.²⁴ The following tumors were analyzed by Dr. Reavill. The information gleaned from them is in the table below.²⁴

To view another listing of tumors in birds, see  Appendix F: Reported Metastatic Tumors in Birds

6.2 Supporting the Avian Cancer Patient

6.2.1 Recognizing the signs of cancer in birds

• Wounds that don’t heal, particularly if their appearance is changing
• Lumps and bumps that don’t go away
• Limping or other signs of pain while walking or flying
• Unexplained weight loss
• Less energy, less willingness to play, walk or fly
• Difficulty breathing
• Bleeding, including from the nares or skin, in the droppings or vomitus. Pale oral or eye tissue can show blood loss.
• Bad odors from the mouth or vent
• Abnormal discharge such as blood or pus; vomiting or diarrhea, particularly if accompanied by other signs
• Behavior changes such as lethargy, depression, lack of appetite, biting, and guarding behavior
• Changes in excretory habits, such as straining or having too-frequent droppings.⁵

These symptoms can be caused by other illnesses, and some are a result of age. The owner is advised not to wait to take the bird to the avian veterinarian; the earlier the bird is seen, the better the chances are that the illness can be treated.

6.2.2 Caring for a bird with cancer 

It takes a team of individuals to care for a pet with cancer; central to the team is the owner.  He will be performing the daily care involving medicating the bird, managing the disease,  and providing support and comfort. The veterinarian and his staff provide information, offer recommendations, perform tests, and offer treatments. The owner will make the decisions that will guide the treatment plan. Successful treatment will come about only with the owner’s cooperation. He must educate himself about the disease and learn the skills needed to care for the bird.  Supportive care is key to the treatment plan. He will need to learn how to give the medications, recognize signs of pain, and provide the best nutrition possible.²¹

6.2.3 Giving medication

Birds who have cancer will be given medications. Sometimes, in the past, chemotherapy and radiation therapy were used. These drugs were meant to destroy the cancer cells, and then the bird would be given other drugs to reduce the side effects, and of course, these drugs also had side effects. If surgical procedures are performed, the bird will be administered pain medications to control postoperative pain. If cancer itself causes pain, medications to control that pain will also be provided.²¹ The medications may be given in the office, and some may need to be given by the owner at home. It is critical that the correct dosage be given at the right time each day. The owner needs to monitor the bird’s food and water intake, behavior, and activity levels to determine if the medication is working. “If your pet does not respond as expected to the medication, or if he responds in an unusual or unexpected way, you will need to contact the veterinarian promptly so that dosages or medications can be adjusted.”²¹

The owner should keep a log of all the medications and the days and times they are given. He should check each off daily to make sure none were missed. Also, he should add other data, such as changes in eating habits, fluctuations in appetite or lack of it, weights, behavioral and sleep changes, and anything else that is noteworthy. He should share this with his avian veterinarian at his follow-up visits. A spreadsheet or table can come in handy for this.²³

6.3 Recognizing Cancer Pain

Pain in humans is a subjective experience and is difficult to measure accurately. Even if the owner has had his pet for a long time, recognizing and assessing pain during cancer treatment is challenging. Careful and close observation of the pet is needed.²¹

Analgesics can be given if the owner believes the animal to be in pain. There are several types of pain medication: 

• Nonsteroidal anti-inflammatory drugs (NSAIDs). These block the production of inflammatory molecules that contribute to pain and swelling. The best of these is celecoxib (Celebrex). It works the best for pain and inflammation in birds.
• Corticosteroids (cortisone). Like NSAIDs, these are anti-inflammatory drugs that reduce pain and allow the pet to be more comfortable. However, caution is needed in giving steroids because they may have unwanted side effects when used for an extended period of time. 
• Opioids. Opioids include morphine and codeine. These are prescribed when advanced cancers cause prolonged, severe pain.
• Local anesthetics and alpha-2 agonists are possibilities, although the use of these medications is not as common as the use of other pain relievers.²¹

Pain is best controlled by giving medication before it gets too severe. If the owner waits, he will need to give higher doses to control the pain. Pain medication is more effective by giving it on a preset schedule rather than providing pain medication “as needed.” If the pet is in pain, it is likely to be stressed, nervous, and upset. This makes the administration of the medication more difficult for both the owner and the pet; and again, he may need to administer higher doses when the bird is highly stressed. The higher dosages increase the risk of adverse effects. It is best to set up a pain medication schedule with the veterinarian before treatment begins, and then follow that medication schedule as closely as possible.²¹

For those who are not familiar with the normal behaviors of a particular species or an individual animal, assessing pain can be very difficult. The challenge is greater in some cases because many animals (such as birds) instinctively attempt to hide any behavior or sign that might show they are weak or in pain. These difficulties are complicated by the fact that the amount of pain caused by various cancer treatments can vary greatly. Furthermore, pain is not simply physical; it can be emotional and psychological as well.²¹

In the face of these challenges to pain assessment, owners are much more likely than veterinary caregivers to notice the small variations in behavior that indicate pain. This is because owners are familiar with their pets' normal responses and movements and their pet’s reactions to a variety of situations. The owner is in the best position to take primary responsibility for judging the pet’s tolerance for pain, for recognizing when the pet is in pain, and for taking the steps needed to reduce or eliminate it.²¹

6.3.1 Categories of pain

There are different types of pain, as classified by physicians and neuroscientists. These are the general categories under which many sub-categories fall:

• Acute Pain: caused by an injury to the body. It warns of the potential damage that requires action by the brain, and it can develop slowly or quickly. It can last for a few minutes to six months and goes away when the injury heals. Examples: accidents, falls, surgery, cuts.²³
• Chronic pain: persists long after the trauma has healed, and in some cases, it occurs in the absence of any trauma or tissue damage. Chronic pain does not warn the body to respond, and it usually lasts longer than six months. In humans, examples include arthritis, fibromyalgia, headaches, and back pain. Arthritis affects animals, too, sometimes to a greater extent.²³
• Cancer pain: associated with malignant tumors. Tumors invade healthy tissues and exert pressure on nerves or blood vessels, producing pain. Cancer pain can also be associated with invasive procedures or treatments. Some physicians classify cancer pain as chronic pain.²³ Cancer pain is usually defined as “the uncomfortable and disagreeable response of the body to the development and presence of cancer itself or the treatment for the disease.” ²¹  Some cancer-related pain may be acute. Acute cancer pain occurs when a tumor invades nearby tissues and expands. It may also occur in response to surgery, radiation therapy, or chemotherapy. Other cancer-related pain may be chronic. To assess your pet’s pain level, you may have to look for behavioral changes that are associated with both acute and chronic pain.²¹

6.3.2 How can you tell if your bird is in pain?   

Many pet bird owners have difficulty recognizing when their pets are in pain or are uncomfortable, fearful, upset, or depressed. Birds are very good at hiding their illnesses, many times until it is too late to help them. How does the owner determine if his pet is are in discomfort or pain? Birds give us signals that something is not right with them, but we have to be very observant. Birds are prey animals and they know it; they realize that if they show any signs of weakness (and pain and illness are weaknesses) they will not live long. The following guidelines will assist the owner in better understanding his bird's level of comfort and/or pain and help him determine if his bird is indeed suffering and should be seen by the  avian veterinarian.²³ 

6.3.3 Assessing pain levels in a bird

In the wild, showing pain is a sign of weakness, and even other birds will attack the weak one so that predators don't find it and attack the flock. But birds give off clues to their pain levels. The questionnaire in Appendix A will assist you in recognizing those clues in the bird.

Observe the bird’s behavior and answer the questions about the bird’s pain level presented in Appendix A

6.4 Pain Management

Pain management is a vital part of exotic animal medicine in general and may be especially helpful concerning oncology cases. Cancer pain is usually acute, chronic, or intermittent and is related to the disease itself or to the treatment. Although mild-to-moderate pain may be alleviated with a non-opioid such as an NSAID, opioids may be needed for more severe pain. NSAIDs such as aspirin, carprofen, ketoprofen, celecoxib, and meloxicam have been used with exotic animal patients successfully. (Although they are both COX-2 inhibitors, celecoxib is preferable to meloxicam because it produces fewer and less extreme side effects effects and it alleviates pain more effectively.) Potential side effects of using NSAIDs include the risk of gastrointestinal ulceration, nephrotoxicity, hepatotoxicity, and hemorrhage. Mild to moderate pain from intrathoracic and intraabdominal masses and bone metastases can be relieved with NSAIDs. If opioids must be added, they can be combined with NSAIDs so lower doses of opioids need to be used. Opioids such as buprenorphine and butorphanol are often used with exotic animals. Studies in pigeons show that they have more kappa opioid receptors than μ-opioid receptors (μ-opioid receptors (MOR). Because of this, birds do not respond to μ-agonists like morphine, buprenorphine, and fentanyl as do mammals. Research suggests that butorphanol is a more efficacious analgesic than buprenorphine in African grey parrots and possibly other species.¹²

6.4.1 Nutritional support

Every animal needs appropriate nutrition to live a healthy life. When cancer strikes, good nutrition takes on an even more important role in the life of the pet. While we do not yet fully understand the nutritional needs of animals with cancer, researchers have learned that animals undergoing cancer treatment may need different foods and different amounts of food than healthy animals.²¹

Metabolism is the term that describes the physical and chemical processes used to build and maintain body tissues. Both the cancer and cancer treatments can change the bird’s metabolism. His usual diet may not provide sufficient nourishment while the cancer is growing or while cancer treatments are being provided. Animals often lose their appetite during cancer treatment. If the bird does not eat enough to fuel its body, then tissues may be broken down to create the energy needed to survive. In these circumstances, the pet may “waste away” due to malnutrition. This occurs most frequently if the treatment continues for a long time. Another common risk is dehydration; pets with cancer may not drink enough water. Just as people can die more quickly from dehydration than starvation, so can animals. Drinking enough water is as important as eating enough solid food.²¹

Researchers are still studying the nutritional needs of animals with cancer. Some studies show that the high-carbohydrate and low-fat nutrition traditionally found in pet foods may not be the best for animals with cancer. Instead, these studies support the idea that animals with cancer need diets that are low in carbohydrates and high in fat; these may help reverse some of the negative changes found in the metabolism of pets with cancer.²¹

If the pet is diagnosed with cancer, the owner should ask his veterinarian about any changes he may need to make in his pet’s diet. He should also ask about any appetite stimulants and other medications to reduce side effects, such as pain, that can discourage healthy eating. Once the nutritional program has been developed, he may then need to adjust it to his pet’s individual likes and dislikes. The goal is to supply the pet with the nutrition needed to fuel the normal functions of the animal’s healthy organs and tissues.²¹

Alternative ways of providing the pet with the needed nutrition may be required if cancer or cancer treatment has caused metabolic changes that prevent it from consuming enough food and water. In some cases, special nutritional supplements may be needed or unusual feeding methods adopted. If, for example, part of the jaw has had to be removed due to mouth cancer, the pet will have to adapt to the new mouth shape. While recovering and adapting to the new shape, it may be necessary to feed him with a feeding tube. There are 3 common ways to provide a feeding tube: A tube may be run through the nasal passages to the stomach (nasogastric tube), through the neck into the esophagus (esophagostomy), or directly into the stomach (gastrostomy). These tubes are removed once the animal recovers sufficiently to eat on its own.²¹

The metabolic changes caused by cancer or cancer treatment sometimes continue long after cancer has been cured. In these cases, the owner needs to provide the most appropriate diet after cancer has been removed or destroyed. Follow the veterinarian’s advice regarding the diet the pet needs following cancer.²¹

One of the most common paraneoplastic syndromes (signs or symptoms caused by substances produced by a tumor) seen in veterinary patients is cachexia (wasting syndrome). Cachexia in cancer patients results from altered metabolism of proteins, carbohydrates, and lipids that leads to anorexia, impaired immune function, fatigue, and weight loss despite adequate nutritional intake. It is significant to note that the metabolic alterations seen in animals with cancer occur before clinical signs are evident. Thus, nutritional intervention should begin early in the treatment of patients and be maintained diligently throughout their care. As in other species, nutrition is a vital component of treatment for exotic animal patients with cancer.¹¹

When considering appropriate nutrition for exotic animal patients with cancer, there is a wide variation in dietary requirements among species. The correct dietary plan must be in place to make sure the diet does not cause further complications. The owner should consult exotic animal veterinary texts (and discuss the diet with the avian veterinarian). The owner should pay attention to the following suggestions: ¹¹

• Avoid diets high in simple carbohydrates and sugar since certain types of cancers may use simple carbohydrates as a preferred energy source. 
• Diets for carnivores and omnivores may contain moderate amounts of highly bioavailable protein. 
• Certain amino acids such as glutamine, cysteine, and arginine are beneficial. (Vetomaga is a good source of these amino acids. It is available from the avian veterinarian through Scott Echols.)
• Soluble and insoluble fibers are important to prevent cancer and enhance gastrointestinal function. In addition to treating disorders of the gastrointestinal tract, adequate fiber can also prevent concurrent diseases such as clostridial colitis. 
• Data demonstrate that antioxidants, minerals, proteases (an enzyme that breaks down proteins and peptides), enzymes, and tea have the potential for reducing the risk of cancer or the growth and metastases of established malignant diseases.¹¹

6.4.2  ©Emeraid intensive care nutritional supplements for birds

Lafeber’s ©EmerAid System for Exotic Critical Care, Omnivore, and Carnivore are nutritional supplements for birds. It can only be purchased through an avian veterinarian. It can be found on the Lafeber website at the following link: https://emeraid.com/vet/emeraid-omnivore/ Outside of the United States, it can be purchased by the veterinarian through the Lafeber website.

The national and international ©Lafeber locations from which it may be purchased are listed in Appendix C.

Nutritional needs of exotic animal oncology patients require further study. Much of the available data concerning diets is based on work with humans, canine, and feline patients, and experimentally induced tumors in laboratory animals. Research on this is ongoing.¹²

6.5 Treatment Protocols for Tumors

6.5.1 Surgical removal of tumors

Surgical excision of tumors has been and still is the preferred method of treatment for most tumors. If possible, complete excision of the tumor will provide an immediate cure of cancer since it is not using carcinogenic or immunosuppressive therapies. It is most often used for solitary tumors which have not spread to surrounding tissues or have become systemic. “Oncologic surgical techniques must be followed to avoid tumor seeding to normal tissues. Resection should be aggressive to avoid compromising margins when possible. Histologic examination of removed tissue is recommended to evaluate the completeness of excision. If the tumor is well-differentiated and excision is complete, no further treatment may be needed. If the tumor cannot be completely excised or is poorly differentiated, further therapy is indicated.”⁸

6.5.2 The ©Elekta Gamma Knife

The © Elekta gamma knife is a new,  non-invasive tool being used in human and animal medicine. “It gives high doses to very narrow areas of tissue, it can reach tight margins of the brain tissue and can reach every lesion independently. It is accurate and can treat tumors effectively and safely. It has proven to be a safe, effective tool.” The patient is moved through the tunnel, as they would for an MRI. The machine moves the patient to the exact place for beams to strike the tumor. Information and a video on the Gamma Knife can be found at  https://gammaknife.com/

6.5.3 Use of lasers to surgically remove growths

A budgerigar in the Long Beach Animal Hospital clinic had a growth removed that weighed nearly as much as the bird did. It was continuing to grow and interfere with his ability to evacuate. Birds this size have little blood, so bleeding control (hemostasis) is critical. The veterinarians at Long Beach Animal Hospital removed it using the laser, taking advantage of its tremendous bleeding control, pain control, and lack of postoperative inflammation.¹⁴

Anesthesia monitoring for laser surgery

“Birds tend to be more sensitive to anesthesia than most mammals, so special precautions are taken to minimize the risk. We always perform pre-anesthetic diagnostic tests prior to surgery to make sure there are no internal problems. We use special monitoring equipment during all our surgeries.”¹⁹ The following images involve monitoring for anesthesia administration.¹⁹

The following images are courtesy of Long Beach Animal Hospital.

6.5.4 Radiation therapy and chemotherapy with case study

Radiation and chemotherapy had been used during the 1990’s and 2000’s and even later in an attempt to reduce and/or eliminate tumors in birds. This work has been based on some successes that were had with other animals, most often cats and dogs. These successes prompted veterinarians to attempt the therapies with birds. The difficulties of this, however, were that those were mammals, and practitioners had no idea what kind of chemotherapy and radiation should be used, what the effects would be, or what the dosages should be for birds. Consequently, there was a great deal of experimentation in this area.¹⁵

The complications encountered in the use of chemotherapy in birds have to do with the differences in the anatomy and function of the digestive tracts between mammals and birds, and these differences alter oral drug absorption. Another issue involved the elimination of the drugs by hepatic or renal excretion. These differences made modification of drug dosages for birds difficult.¹¹

In many cases, the treatment was worse than the disease. For all practical purposes, chemo and radiation are no longer being used because of biohazard to people and poor results. The birds are put through a tremendous amount of suffering and die anyway. There is not a great deal practitioners can do for most tumors. Due to the cost of research, more definitive research is not being carried out.¹¹

Radiation and chemotherapy case study

In one case, a squamous cell carcinoma (SCC) was discovered in a 20-year-old mitered conure’s lower beak. This bird had been exposed to tobacco products and UV light for years which probably contributed to the disease. The bird had a “large, keratinaceous mass projecting from the right lateral aspect of the lower beak.”¹⁵

The owners had noticed the growth five months previous to the presentation; it had grown to this size fairly quickly.  The owners were having to crack the seeds for the bird. “At the time of presentation, the mass had defaced approximately 30% of the lower beak and appeared to ‘dive-down’ between keratin sheaths towards the center of the beak.” ¹⁵

Because there was no bone damage yet, they decided to debride the wound, apply cryotherapy for initial treatment, then have the owners return for more cryotherapy a week later. The bird was sent home with sulfamethoxazole and trimethoprim. The tumor was reduced in size.¹⁵ 

Two weeks later, the bird returned and was in good condition, After more testing, the bird received 5-fluorouracil (5-FU) intralesionally at the base of the lesion. Owners were told to continue the piroxicam and TMS and return two weeks later. At that appointment, the tumor was confirmed to be growing, so the practitioner and an oncologist decided to use Cobalt-60 teletherapy and an added drug, bleomycin, for intralesional therapy following radiation therapy since 5-FU did not appear to have had any effect on the tumor. He received these treatments for the next 4 weeks. Over this time, the bird’s health remained good.¹⁵

After that, the patient continued to receive intralesional injections of bleomycin, and the tumor appeared to be responding to this therapy, so the piroxicam was continued through chemo-radiation therapy. Three months later, the tumor returned and was surgically removed. The owners were instructed on how to apply topical 5-FU to the surgical site, and piroxicam therapy was continued. Three months after the bleomycin therapy, a second growth appeared in the same region. The owners were given several options. They chose to administer intralesional carboplatin rather than subject the bird to more radiation therapy.  Several months later, a CT scan revealed the tumor had returned and spread along the tongue to the glottis. More chemotherapy and radiation therapy were given, and the bird looked to be free from tumor regrowth. The owners were instructed to continue the piroxicam indefinitely and to return for recheck which included whole-body radiographs, CBC, biochemical panel, and repeat CT scan of the head and neck. At the time of this writing, there appeared to be no tumor regrowth; however, the tumor was likely to recur.¹⁵

Overall, the prognosis for long-term recovery in this particular case, as in other cases of SCC in birds, is poor. A survey by Reavill (2001) revealed that all birds with SCC of the beak, oral cavity, or esophagus either died or were euthanized due to uncontrolled tumor growth and secondary infections.¹⁵

(This case study was included to demonstrate the extremes that some owners and their avian veterinarians will go to in order to save a bird’s life and the pain and discomfort the bird endures as a result. Birds may appear not to be experiencing pain because that is a defense mechanism they use to prevent being attacked by predators. This is why most of today’s avian veterinarians do not subject their patients to these drastic measures. Unfortunately, some clients pressure their veterinarians to do this therapy and, if necessary, search for an avian veterinarian that will.)  
 

The following describes the radiation therapy of a budgerigar.
 

Today, close-up Strontium-90 probes are hard to come by - they are no longer produced. This procedure was done at a diagnostic imaging facility several years ago.¹⁵

6.6 Quality-of-Life Assessment in Birds

Veterinarians have not always concerned themselves with animal pain. In the 20^th century, increased scientific advances made animal and human pain subordinate to scientific progress. Pain and suffering were considered unscientific; therefore, they were less important than the scientific progress attained. Physicians and veterinarians focused on prolonging life more than improving the quality of the patient's life. Cure became more important than care. Quality of life is difficult to measure and impossible to quantify. Even today, in some countries and for some doctors and veterinarians, pain control is irrelevant and secondary to scientific progress.²³

We now realize that animals have thoughts, mental states, and feelings. Even though such mental states are probably not exactly like ours (since animals cannot communicate verbally), we still must concern ourselves about their pain, fear, and distress. Their pain may actually be worse than human pain; lacking language, sophisticated reasoning skills, and the ability to understand time, animals cannot comprehend the reasons for or causes of pain. Therefore, they lack the ability to hope for and anticipate pain relief and cessation.²³

Today’s practitioners now recognize the effect that pain and discomfort have on the patient’s quality of life. Without a better-than-average quality of life, animals’ lives are not worth living.²³

To assist the owner in evaluating the bird’s - or any pet’s- quality of life, Appendix B contains an assessment questionnaire.

6.7  Moral and Ethical Obligations

If we keep these animals as family members, love them, and accept love from them, we are morally obligated, without question, to prevent and control their suffering. Not only is uncontrolled pain emotionally and mentally harmful, but it is also biologically deleterious; it is a major biological stressor that affects all aspects of the patient’s physical health and well-being.²³

This new interest in providing pain relief for animals has encouraged the development of many therapies, both effective and ineffective—some even harmful. Owners have decided that if their veterinarians are not concerned about their pets’ suffering, they will find people who are. This has led to an increase of many “alternative” therapies, most of which have not been tested or proven to alleviate pain. The animal may be cheated out of a proven modality for pain control during the time of alternative therapy use, making his situation even worse than it had been. If veterinarians will not manage pain, they risk the loss of credibility among the public and loss of clients who will go elsewhere to find either another practitioner who will address the pain or alternative therapy.²³

6.8 Providing Comfort Care

Not all cancers can be cured, and not all cancer treatments are fully successful. Cancer may decrease, or go into remission, and then return later. The treatment needed to control cancer may cause considerable pain or cause significant adverse effects without any hope of curing the cancer. In such a case, the owner may need to decide at some point whether or not the continuation of treatment so degrades his pet’s quality of life that it should be discontinued. The issues become a longer life in pain and misery versus a shorter life in less pain and discomfort. When this point is reached, the treatment focus shifts to one of providing as much comfort and nurturing care for the pet as possible in its final days or months. For situations where a cure is unlikely or not possible, where treatments have proven ineffective, or where the costs (especially any physical or emotional harm to the animal) outweigh the benefits, comfort care is the most appropriate answer.²¹

The goal of comfort care, just as it is in hospice care for people, is to prevent pain and discomfort while providing emotional and physical support. This type of care allows you to focus on the quality of life for the pet rather than the length of life. A safe, stress-free environment in familiar surroundings helps the pet live out its life while its family emotionally adjusts  to his terminal illness and prepares to say goodbye.²¹ 

In most cases, the best environment for comfort care is at home. This permits the family to spend more time with the ailing pet. It also permits the family to be aware of its day-to-day needs and desires. This will allow the owner to react more quickly when the animal’s needs and desires change. In addition, providing comfort care at home helps prevent the pet’s unnecessary pain, fear, and suffering as he approaches the end of his life.²¹

Providing comfort care at home may not be for everyone. Caring for a terminally ill animal is an emotionally difficult and time-consuming responsibility. In most cases, the animal will lose some body functions which will require you to provide an increased level of care. Owners who decide to provide comfort care at home should consult with a veterinarian who is knowledgeable about home comfort care and can provide information and support. In particular, a comfort care program should be developed, followed, and adjusted as the condition of the pet changes.²¹

One primary goal of comfort care is the control of pain. Once that issue has been resolved, other issues may also need to be addressed. For example, it may be necessary to relocate the pet’s bed and change water and food containers to make sleeping, eating, and drinking easier and less painful. (For birds, it may mean moving the bird from its cage to the comfort of a storage bin where the bird may sit on soft towels and have his food, water, and toys closer to him.) Family members may also re-arrange their schedules to spend more time with the pet and provide more attention, well-loved treats, and affection. Because visits to the veterinarian are often stressful for a pet, the owner might elect to reduce the number of such visits. If so, you may need to learn how to perform medical tasks, such as giving injections. These are all issues the owner will need to discuss with his veterinarian when he makes the decision to provide home comfort care.²¹

6.9 Euthanasia: The Most Difficult Decision of All

Animals do not fear death since they lack the ability to understand the concept, but they do fear pain. The veterinary community today urges euthanasia as a merciful tool for relieving the animal of his suffering. Allowing an animal to live in unalleviated pain is the worst thing we can do for them. If indeed the health and well-being of the animals in his care is his top priority, he will seek to eliminate or at least manage the animal’s pain. There is now scientific proof that uncontrolled pain is a major stressor for the animal; it retards healing and increases the possibility of infection. It can even cause death.²³

A great number of treatment options have been developed in the last two decades in human medicine, and clinicians have turned to many of them for use in their practices. These areas include oncology, transplantation, dialysis, and pain relief. Animal medicine is following in the path of human medicine by developing the concept of “pawspice” - a hospice for animals. These state-of-the-art care facilities and palliative care options promise to alleviate suffering, but they have created another set of ethical and moral dilemmas. Clients have shown a willingness to spend, in some cases, unlimited amounts of money on their animals. This may be beneficial for the veterinarian and in some cases, the animals, but it raises ethical challenges that both practitioner and client have not had to deal with in the past.²³ 

For example:

• Should the veterinarian pursue the management of the animal’s pain and suffering to the point that the more affluent clients will favor extending treatment well past the time when the animal would have died of the illness?
• Will he allow the animal to suffer through such extraordinary treatments because the clients cannot accept the death of their pets?
• Should the veterinarian encourage euthanasia because the client cannot afford treatment for a pet that might pull through with heroic efforts?²³

These new developments in veterinary medicine have created a quandary for the practitioner: He must learn to balance the owners’ wishes with the needs of their animals. In the past, the practitioner would encourage euthanasia when there seemed little hope of recovery for both the wealthy and the poor clients since he had no other options. Now, the practitioner must convince the client that euthanasia is in the best interest of the animal, even when the client can afford more treatment and is not willing to discontinue treatment in the hopes the animal will pull through. In addition, he must weigh a potentially life-saving treatment against the client’s inability to afford it and ask himself if he is willing to provide this care pro bono. These expensive treatments could make for financial difficulties if done even infrequently. This has indeed made the practitioner’s job much more challenging.^23,31