Chronic Disease Management for Small Animals E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 769

Veröffentlichungsjahr: 2017

Beschreibung

Practical guidance on managing chronic illnesses in small animals

Chronic Disease Management for Small Animals provides a complete resource for the long-term care and therapy of canine and feline patients with incurable conditions. Offering practical strategies for successful management of chronic disorders, the book presents expert guidance on handling these ailments and the animals that they afflict.

Written by leading experts in their respective fields, Chronic Disease Management for Small Animals takes a multidisciplinary approach to the subject, covering chronic diseases across many categories, including mobility, dermatology, ophthalmology, internal medicine, and more.  The book is not meant to replace existing textbooks, but is designed to be used as a practical guide that educates the reader about the many therapeutic options for chronic disease management. Coverage encompasses:

• The impact that chronic disease has on the quality of life for both the patient and its owner
• Specific chronic diseases, outlining diagnostics, therapeutics, and quality of life concerns
• Hospice care and end of life, including client and pet needs, quality of life, cultural sensitivities, dying naturally, euthanasia, and death

Chronic Disease Management for Small Animals is an essential reference for recently qualified and seasoned practitioners alike, supporting clinicians in making decisions and communicating with clients regarding long-term care. It is an ideal book for all small animal practitioners and veterinary students.

Leseprobe

Table of Contents

Cover

Title Page

List of Contributors

Preface

Acknowledgments

Part One: Communication and Caregiving

1 Communication, Caregiving, and Chronic Disease

Introduction

Overview

Impact of Chronic Disease on Quality of Life for Both the Patient and Caregiver

Part 1: Know Yourself—Set the Stage for Collaborative Decision Making, Active Listening, and Caregiving

Part 2: Verbal Communication

Part 3: Nonverbal Communication

References

Part Two: Syndromes and Clinical Signs of Chronic Disease

2 Pruritus, Atopic Dermatitis, and Pyoderma

Introduction

Diagnosis

Management

Quality of Life for Patient and Caregiver

References

3 Managing Mobility:

Introduction

Diagnosis

Therapeutics

Quality of Life

End‐of‐Life Decisions

References

4 Chronic Diseases of the Eye and Adnexa

Introduction

Adnexa

Ocular Surface Disorders

Corneal Disease

Intraocular Disease

Conditions of the Uvea

Lenticular Changes

Posterior Segment Disease

Blindness

References

5 Heart Disease

Introduction

Treatment of Acute Heart Failure

Management of Chronic Congestive Heart Failure

Specific Heart Diseases

Further Reading

6 Canine Cognitive Dysfunction

Introduction

Diagnosis

Therapeutics

End of Life

Further Reading

7 Vestibular Syndromes

Introduction

Diagnosis

Therapy

End‐of‐Life Decisions

Further Reading

8 Seizure Disorders

Introduction

Diagnosis

Therapy

Quality of Life

Further Reading

9 Feline Hyperthyroidism

Introduction

Diagnosis

Management

Renal Function and Hyperthyroidism

Iatrogenic Hypothyroidism

References

10 Hypoadrenocorticism in Dogs

Introduction

Clinical Presentation and Diagnosis

Treatment

Quality of Life

References

Further Reading

11 Canine Hypothyroidism

Introduction

Diagnosis

Main Influences on Thyroid Function Tests

Treatment

Quality of Life

References

12 Hyperadrenocorticism in Dogs and Cats

Introduction

Therapy

Quality of Life

References

13 Diabetes Mellitus

Introduction

Diagnosis

Therapy

Monitoring

Remission

Quality of Life

References

14 Chronic Pancreatitis

Introduction

Diagnosis

Treatment

Quality‐of‐Life and End‐of‐Life Assessments

References

15 Mega‐Esophagus and Esophageal Dysmotility

Introduction

Diagnosis

Therapeutics

Quality of Life

References

16 Chronic Gastritis

Introduction

Diagnosis

Therapeutics

Quality of Life

References

17 Ulcerative Colitis

Introduction

Diagnosis

Therapy

Quality of Life

References

18 Mega‐Colon

Introduction

Diagnosis

Therapeutics

Quality of Life

References

19 Inflammatory Bowel Disease

Introduction

Diagnosis

Therapeutics

Quality of Life for Patient and Caregiver

References

20 Protein‐Losing Enteropathy

Introduction

Diagnosis (see also Chapter 19 on IBD)

Therapeutics (see also Chapter 19 on IBD)

Quality of Life

References

21 Cholecystitis

Introduction

Clinical and Diagnostic Findings

Therapeutic Management

References

Further Reading

22 Biliary Mucocele

Introduction

Pathogenesis

Diagnostics

Therapeutic Management

References

Further Reading

23 Chronic Hepatitis

Introduction

Diagnosis

Therapeutics

Quality of Life for Patient and Caregiver

References

Further Reading

24 Portosystemic Liver Shunts

Introduction

Diagnosis

Therapeutics

Quality of Life

References

Further Reading

25 Hepatic Lipidosis

Introduction

Diagnosis

Treatment

Quality of Life

References

Further Reading

26 Feline Cholangitis

Introduction

Diagnosis

Treatment

Quality of Life

References

27 Chronic Kidney Disease

Introduction

Diagnosis

Management

Quality of Life

References

28 Chronic Urinary Tract Infection

Introduction

Management

Monitoring

Treatment Failure and Chronic Management

Prophylactic/Preventative Treatment

Quality of Life

References

29 Feline Interstitial Cystitis

Introduction

Diagnosis

Treatment

Quality of Life

References

30 Canine Chronic Bronchitis

Introduction

Etiology

Diagnosis

Therapy and Monitoring

Quality of Life

References

31 Bronchiectasis

Introduction

Etiology and Classification

Diagnosis

Treatment

Quality of Life

References

32 Interstitial Lung Diseases

Introduction

Etiology and Classification

Diagnosis

Treatment

Quality of Life

References

33 Feline Asthma

Introduction

Diagnosis

Comorbid Conditions, Diagnostic Conundrums, and Differential Diagnoses

Therapeutics

Quality of Life

References

34 Collapsing Trachea

Introduction

Diagnosis

Comorbid Conditions, Diagnostic Conundrums, and Differential Diagnoses

Therapeutics

Quality of Life

References

35 Allergic Rhinitis

Introduction

Diagnosis

Therapy

Quality of Life

References

Further Reading

Part Three: End of Life

36 Hospice Care and End of Life

Hospice Care

Client Needs

Pet Needs

Quality of Life

Cultural Sensitivities

Dying Naturally

Dying with Assistance – Euthanasia

Dying Well

Death and Aftercare of the Body

Summary

References

Index

End User License Agreement

List of Tables

Chapter 01

Table 1.1 Examples of Average and Ideal expressions.

Chapter 02

Table 2.1 Primary, secondary, and coexisting diseases that may be pruritic. (Many patients have more than one concurrently.)

Table 2.2 Favrot’s 2010 criteria for canine atopic dermatitis.

Table 2.3 Pruritus therapies.

Chapter 03

Table 3.1 Suggested macronutrient profile (grams per 1000 kcal) for dogs of normal body condition with mobility impairment.

Table 3.2 Diets labeled for degenerative joint disease.

Table 3.3 Therapeutic supplements.

Table 3.4 Nutritional Supplements.

Table 3.5 Recommended macronutrient composition (grams per 1000 calories) for weight‐loss diets in animals with mobility challenges.

Table 3.6 Therapeutic exercises.

Table 3.7 Weight loading as a result of water height.

Table 3.8 Ultrasound settings.

Table 3.9 Acupuncture points used in the management of mobility.

Table 3.10 Common TENS and NMES settings.

Table 3.11 Regenerative therapies.

Table 3.12 Clinical scoring system for assessing dogs with osteoarthritis.

Chapter 04

Table 4.1 Breed predisposition to chronic ocular disease.

Table 4.2 Interpretation of STT I values and treatment recommendations.

Table 4.3 Types of Glaucoma.

Table 4.4 Treatment of Glaucoma.

Chapter 05

Table 5.1 Severity of aortic regurgitation.

Chapter 06

Table 6.1

Canine

De

mentia Scale (CADES) Frequency: 0 points ‐ abnormal behavior of the dog was never observed, 2 points – abnormal behavior of the dog was detected at least once in the last 6 months, 3 points – abnormal behavior appeared at least once per month, 4 points – abnormal behavior was seen 2–4 times per month, 5 points ‐ abnormal behavior was observed several times a week.

Table 6.2 Canine cognitive dysfunction rating scale with example data for a dog over the threshold (P50) for query diagnosis.

Chapter 09

Table 9.1 Advantages and disadvantages of different treatment options for feline hyperthyroidism.

Chapter 11

Table 11.1 Summary of the most common clinical signs observed in dogs with hypothyroidism.

Table 11.2 Advantages and limitations of the most commonly used thyroid tests.

Table 11.3 Effects of drugs on canine thyroid results.

Chapter 18

Table 18.1 List of drugs used in megacolon in the canine and feline patient.

Chapter 19

Table 19.1 The most important therapeutic options for IBD in dogs and cats.

Table 19.2 Canine inflammatory bowel disease activity index (CIBDAI).

Chapter 36

Table 36.1 Variations between religious rituals and beliefs.

List of Illustrations

Chapter 01

Figure 1.1 Quality of life scales.

Chapter 03

Figure 3.1 Canine brief pain inventory.

Figure 3.2 Questionnaire for patients with altered mobility but without significant pain.

Chapter 04

Figure 4.1 Chronic immune‐mediated blepharitis in a mixed‐breed dog. This case was steroid responsive.

Figure 4.2 Immune‐mediated blepharitis in a German Shepherd Dog. This case presented with ulcerated lesions rather than the nodular swellings seen in Figure 4.1 and had lesions at sites distant to the eyes.

Figure 4.3 Meibomianitis in a Shih Tzu. Note the accumulations of glandular secretions in the subconjunctival space.

Figure 4.4 Keratoconjunctivitis sicca in a West Highland White Terrier. Note the discoloration of the facial fur. This is common in many types of tear and ocular surface disorders. Also note the mucoid discharge present.

Figure 4.5 A deep stromal corneal ulcer that has resulted from dry eye. The axial location is typical for ulcers that develop from exposure and KCS.

Figure 4.6 Mild to moderate KCS with early corneal changes and mucoid discharge.

Figure 4.7 Keratitis in a Shih Tzu secondary to moderate dry eye. Note the corneal vascularization and superficial pigmentation.

Figure 4.8 Severe KCS with extensive corneal pigmentation and fibrosis in a Chinese Crested Dog.

Figure 4.9 Allergic conjunctivitis in a mixed breed dog. Note the conjunctival hyperemia and chemosis.

Figure 4.10 Herpetic keratitis is a cat with profound conjunctival chemosis and hyperemia.

Figure 4.11 Chronic conjunctivitis in this Labrador Retriever has resulted in follicle formation.

Figure 4.12 Severe herpetic blepharokeratoconjunctivitis in an eldery feline.

Figure 4.13 Eosinophilic keratoconjunctivitis conjunctivitis in a cat.

Figure 4.14 Lipogranulomatous conjunctivitis in a cat.

Figure 4.15 Refractory, or indolent ulcer, in a dog. Not the loose lip of epithelium and the fluorescein that has seeped underneath this non‐adherent tissue.

Figure 4.16 Diamond burr debridement of a refractory superficial corneal ulcer in a dog.

Figure 4.17 Chronic superficial keratitis, or pannus, in a Greyhound.

Figure 4.18 Goggles may limit exposure to UV radiation. They may also be helpful for protecting the eyes of visually impaired animals that may be injured or at risk.

Figure 4.19 Corneal degeneration in an aged dog. Some of the corneal stroma and deposits have slough leaving a deep stromal corneal ulcer. Note the white, crystalline opacities surrounding the defect and the corneal vascularization.

Figure 4.20 Corneal endothelial degeneration in a Chihuahua. In this breed, the condition is inherited. Note the mid‐range pupil. Pupil size and responsiveness may help differentiate endothelial disease from glaucoma, which is one of the differentials for corneal edema.

Figure 4.21 Corneal endothelial degeneration in a Bassett Hound. Note the corneal vascularization present that was the response to a long‐standing superficial corneal ulcer. Microbullae form within the stroma and epithelium when significant corneal edema is present which may rupture resulting in ulceration that may be slow or refractory to healing.

Figure 4.22 Bilateral corneal edema in a Bichon Frise from endothelial degeneration.

Figure 4.23 This Boston Terrier has had bilateral keratectomies and Gunderson conjunctival flaps placed laterally in an attempt to minimize the progression and complications from endothelial decompensation.

Figure 4.24 Acute glaucoma in a dog. Note the episcleral injection, corneal edema and mydriasis.

Figure 4.25 a and b Chronic glaucoma in a Cocker Spaniel. Note the buphthalmos, corneal edema, fibrosis and pigmentation. The tapetal reflection is bright, indicating likely retinal degeneration secondary to chronic elevations of IOP or segmental vascular infarcts.

Figure 4.26 Secondary glaucoma in a dog. Note the episcleral injection, peripheral corneal vascularization, and edema. The pupil is mid‐range, which is commonly noted when uveitis is present concurrently.

Figure 4.27 Chronic lens‐induced uveitis has resulted in considerable intraocular damage, including 360 degree posterior synechia.

Figure 4.28 Acute uveitis in a dog. Note the episcleral injection and miosis.

Figure 4.29 Chronic uveitis in a cat. Note the iris color change, iridal neovascularization and cataract.

Figure 4.30 Uveodermatologic syndrome in a Jack Russell terrier. This dog has severe uveitis and secondary glaucoma as well as lesions on the nasal planum.

Figure 4.31 Pigmentary uveitis in the Golden Retriever. Not the pigment deposition on the anterior lens capsule and the hyperpigmented iris.

Figure 4.32 Uveal cysts in a Golden Retriever. This dog has no other active signs of pigmentary uveitis, but should be monitored closely.

Figure 4.33 Diffuse iris melanoma in a cat.

Figure 4.34 Diffuse iris melanoma in a cat.

Figure 4.35 Nuclear sclerosis in a middle aged dog. Note the homogenous spherical structure in the central lens and the unobstructed tapetal reflex.

Figure 4.36 Anterior lens luxation of a clear, non‐cataractous lens in a Chinese Crested dog.

Figure 4.37 Lens subluxation in a mixed‐breed dog. Note the dorsolateral aphackic crescent.

Figure 4.38 Posterior lens luxation in a dog.

Figure 4.39 Anterior lens luxation of a mature cataract in a cat. Note the iridal neovascularization that had adhered to the nasal aspect of the lens. This luxation was secondary to chronic uveitis.

Figure 4.40 Hypertensive retinopathy in a dog secondary to renal disease. Note the multifocal retinal detachments and retinal hemorrhages.

Chapter 05

Figure 5.1 X‐ray of acute pulmonary edema pre treatment. Lateral and DV radiographs of a 7 year old Doberman pinscher with dilated cardiomyopathy dog with pulmonary edema and after treatment. In Figure 5.1a, the extensive interstitial/alveolar pattern can be seen especially in the perihilar region on the lateral and in the right caudal lung field on the DV.

Figure 5.2 X‐ray of acute pulmonary edema post treatment. After treatment with diuretics, the lung pattern has normalized and the outline of the left atrium is clearer as it is now surrounded by air. Notice the heart size is smaller.

Figure 5.3 A dog with acute heart failure being administered oxygen. It is important that this does not stress the dog or cat.

Figure 5.4 Echocardiogram of a dog with advanced degenerative mitral valve disease. This right parasternal long axis 2D view (Figure 5.4a) shows the thickened mitral valve especially the anterior leaflet. The left atrium and left ventricle show eccentric hypertrophy due to the volume load. On color flow (Figure 5.4b), the green turbulent jet of mitral regurgitation can be seen filling the left atrium during systole.

Figure 5.5 ECG from an 8‐year‐old Labrador with atrial fibrillation. This ECG shows the hallmarks of this rhythm abnormality: tachycardia, irregularly irregular, no P waves and a narrow supraventricular QRS. Note the irregular baseline which represents the atrial fibrillation. This movement, called F waves, can be fine or coarse. 50 mm/s and 1 cm/mV.

Figure 5.6 Echocardiogram of dog with dilated cardiomyopathy. The left atrium and left ventricle are dilated and the ventricle appears thin walled (Figure 5.6a). On M mode (Figure 5.6b), the reduced fractional shortening can be appreciated and this is consistent with reduced contractility.

Figure 5.7 Lateral (Figure 5.7a) and DV (Figure 5.37b) chest radiograph from a 13‐year‐old DSH cat with congestive heart failure. A moderate pleural effusion is present and patches of pulmonary edema. In cats, these can occur anywhere in the lungs unlike the perihilar distribution seen in dogs.

Figure 5.8 Echocardiogram from a cat with hypertrophic cardiomyopathy. The right parasternal long axis view (Figure 5.8a) shows the thickened left ventricular walls and dilated left atrium. During systole (Figure 5.8b) color flow shows the green turbulence shows high velocity flow in the left ventricular outflow tract caused by dynamic obstruction with end systolic cavity obliteration. There is also a jet of mitral regurgitation secondary to systolic anterior motion (SAM) of the anterior mitral valve leaflet.

Figure 5.9 Echocardiogram from a 1 year old Chow Chow with subaortic stenosis. In this right parasternal 5 chamber view optimized for the left ventricular outflow tract, the discrete sub valvular ridge can be seen. The left ventricle shows concentric hypertrophy due to the pressure load.

Figure 5.10 Echocardiogram from a 2 year old cavalier King Charles spaniel with severe pulmonic stenosis. In the right parasternal short axis view (Figure 5.10a), the right ventricular free wall is hypertrophied due to the increased pressure with flattening of the interventricular septum as the pressures in the the right ventricle near or exceed those in the left ventricle. On color flow (Figure 5.10b), the green jet of turbulent flow can be seen starting at the valve and the pulmonary artery is dilated post stenotically.

Figure 5.11 Lateral chest fluoroscopic image from a small breed dog with pulmonic stenosis showing contrast being injected into the right ventricle. The right ventricle is hypertrophied with prominent papillary muscles and the outflow tract can be visualized. The discrete valvular stenosis and the post stenotic dilation can be seen.

Figure 5.12 Echocardiogram from a dog with a patent ductus arteriosus. This left parasternal cranial view (Figure 5.12a) shows the pulmonary artery with blood flowing away from the transducer coded blue. The ductus enters the pulmonary artery distally and the red flow of blood in the ductus flowing toward the transducer changes to a green turbulent jet when it enters the pulmonary artery. The pulmonary artery is dilated. The transesophageal view (Figure 5.12b) shows the blood from the ductus on top entering the main pulmonary artery. In this color compare view the shape of the ductus can be appreciated as it narrows at the pulmonary artery entrance.

Figure 5.13 This lateral chest fluoroscopic image shows a catheter in the aorta injecting contrast. The PDA can be visualized as a finger like projection extending ventrally towards the pulmonary artery. It narrows at the pulmonary artery entrance and the pulmonary artery is dilated. This is the most common type of PDA and is amenable to closure with an Amplatz canine duct occluder (ACDO).

Figure 5.14 Lateral chest fluoroscopic image showing an ACDO deployed in the ductus. The first disc is in the pulmonary artery and the second in the ductus itself. Contrast is injected to check placement and lack of flow through the ductus.

Figure 5.15 ECG from a dog with 3 degree AV block. The P waves continue through the ECG with no relation to the QRS – every P‐R interval is different. The QRS are wide and bizarre as they are ventricular escape complexes. The atrial rate is 180 bpm and the ventricular rate is 30 bpm. The atrial rate is fast as the intrinsic mechanisms are trying to increase the heart (ventricular) rate. 25 mm/s and 1 cm/mV.

Figure 5.16 ECG from a dog with sick sinus syndrome. There are long pauses and ventricular escape complexes. 50 mm/s and 1 cm/mV.

Figure 5.17 ECG from a dog with persistent atrial standstill due to atrial myocardial disease. There are no P waves on any leads. The QRS is narrow suggesting a supraventricular origin and this is because the SA node is still active with the impulse transmitted to the AV node via intermodal tracts. 50 mm/s and 5 mm/mV” as the rate is not slow.

Figure 5.18 ECG from a young Labrador with supraventricular tachycardia. The complexes are narrow suggesting their supraventricular origin and the rhythm is regular. Vagal maneuvers help confirm the mechanism when the rhythm breaks to sinus. 50 mm/s and 1 cm/mV.

Figure 5.19 ECG from a miniature schnauzer with atrial flutter and one ventricular complex. The QRS complexes are narrow suggesting a supraventricular origin and the rhythm is irregular. A regular saw tooth like pattern can be seen on the baseline which represents the flutter wave going round the, usually tricuspid, annulus. 50 mm/s and 1 cm/mV.

Figure 5.20 ECG from a boxer with arrhythmogenic right ventricular cardiomyopathy showing sinus rhythm and an isolated VPC. The VPC is upright in lead 2 suggesting a right ventricular origin. 50 cm/s and 1 cm/mV.

Figure 5.21 ECG from a dog with dilated cardiomyopathy showing ventricular tachycardia. The rhythm is fast and regular and the complexes are wide and bizarre suggesting a ventricular origin. This responded to lidocaine. 50 mm/s and 1 cm/mV.

Figure 5.22 Left parasternal long axis cranial systolic frame showing the right ventricle, right atrium, and tricuspid valve. There is a green turbulent jet of tricuspid regurgitation and the velocity can be measured. Using the modified Bernoulli principle, the pressure in the right ventricle and hence pulmonary artery can be estimated. This can be used to asses for pulmonary hypertension non‐invasively.

Figure 5.23 Right parasternal long axis echocardiogram from a dog with a pericardial effusion. The dark ring around the heart is the effusion. The collapse of the right atrial free wall can be visualized suggesting cardiac tamponade is present. Detection of a tumor is easier if fluid is still present but once this has been performed, drainage of the fluid is indicated.

Figure 5.24 Image of a dog undergoing drainage of a pericardial effusion. The dog has been sedated with an opiate and a local anesthetic was used in the chest wall. Having obtained an echocardiographic image maximizing the depth of pericardial effusion, a fenestrated catheter is advanced under suction along the probe line until fluid returns. The catheter is then fed off the needle and a three‐way tap attached. Echocardiography can be repeated to assess the amount of fluid remaining.

Chapter 07

Figure 7.1 Magnetic resonance image of a brain with lines. Inside the lines is central vestibular (brainstem and cerebellum) while outside are peripheral vestibular structures (ear canals, tympanum, tympanic bulla and CN VIII).

Chapter 09

Figure 9.1 Technique for palpation of thyroid glands.

Figure 9.2 Facial excoriations in a cat treated with methimazole.

Chapter 12

Figure 12.1 Cat (11 years old, spayed female, domestic shorthair) with pituitary‐dependent hyperadrenocorticism. Skin tears are observed on the dorsal aspect of the thorax due to increased cutaneous fragility (Figure 12.1a). Trilostane treatment allowed healing of lesions (Figure 12.1b). At diagnosis the cat was not diabetic. Diabetes mellitus developed after approximately 1 year of trilostane administration, despite improvement of hyperadrenocorticism.

Figure 12.2 Dog (6 years old, intact female, Dachshund) with pituitary dependent hyperadrenocorticism. The dog received trilostane treatment (2 mg/kg, twice daily) without food and showed polyuria, polydipsia, and alopecia; cortisol post‐ACTH stimulation was 23.6 µg/dL. To ameliorate trilostane absorption the dog received it with food and, after one month, had improved polyuria and polydipsia and cortisol post‐ACTH stimulation dropped to 10.5 µg/dL.

Chapter 13

Figure 13.1 Diabetic cat treated with insulin glargine switched to a diet with very low content of carbohydrates from day 119 to 194 (grey box). The dose of insulin was decreased in order to maintain stable glycemia, clinical signs and fructosamine concentrations. The cat was a 10 years old, neutered male, domestic short‐hair with body weight of 6 kg. The graph shows the insulin dose administered with each injection (bottom) and the morning glucose concentration (top).

Chapter 14

Figure 14.1 Analgesic ladder for dogs and cats with chronic pancreatitis, based on the human analgesic ladder in Sebastiano et al. (2005), which is based on the World Health Organization analgesic ladder for cancer pain. Note each step in the ladder can be added to the previous step for multimodal analgesia. *Preferred non‐opioid drug in dogs, provided liver function is normal. Not to be used in cats.

$

Non‐steroidal anti‐inflammatories – higher risk of GI side effects in pancreatitis and only to be used when renal function is normal. ^Animals can be sent home with Fentanyl patches but great care must be taken about human contact particularly with children.

@

Substance P has been implicated in the neuropathic pain of chronic pancreatitis so maropitant has a role in multimodal analgesia.

Chapter 15

Figure 15.1 Right lateral thoracic radiograph (Figure 15.1a) and transverse computed tomography at the level of the third intercostal space (Figure 15.1b), using a soft tissue window width with the dog in dorsal recumbency, of an 11‐year‐old, spayed female, Springer Spaniel diagnosed with myasthenia gravis. There is a demarcated, soft tissue opacity visible in the cranial mediastinum (asterisk). A tentative diagnosis of thymoma was made.

Chapter 16

Figure 16.1 Gastric mucosa from a full thickness biopsy collected from the fundus of the stomach of a dog showing severe lymphoplasmacytic gastritis. Lymphocytes and plasma cells are present in severely increased numbers, diffusely and in aggregates, beneath epithelium and between glands, occasionally disrupting glandular architecture. Note mucous neck cell hyperplasia, increase in mucosal fibrous connective tissue, and nested, atrophic or loss of glands.

Chapter 18

Figure 18.1 Right lateral abdominal radiograph in a skeletally mature domestic shorthair cat diagnosed with idiopathic mega‐colon. The colon is severely dilated and filled with fecal material.

Chapter 21

Figure 21.1 Ultrasound image of a dog with cholecystitis. There is a markedly echogenic and thickened gall bladder wall. The gall bladder is filled with echogenic fluid and sediment, and dilation of the proximal cystic duct also appears to be present (arrow).

Chapter 22

Figure 22.1 Longitudinal ultrasound image of a gallbladder mucocele demonstrating the characteristic “kiwi‐fruit” or stellate appearance. The mucin layer is hypoechoic while the hyperechoic bile is centrally located.

Chapter 24

Figure 24.1 Contrast portogram showing extra‐hepatic porto‐caval shunt entering the caudal vena cava but with partial arborization of the liver.

Chapter 31

Figure 31.1 Bronchoscopy from a dog with bronchiectasis.

Chapter 32

Figure 32.1 Ventro‐dorsal thoracic radiograph of 6‐year‐old dog with pulmonary fibrosis showing advanced interstitial pattern involving all the lung lobes.

Figure 32.2 Lateral thoracic radiograph of 6‐year‐old dog with pulmonary fibrosis showing advanced interstitial pattern tending to be bronchial to nodule and involving all the lung fields.

Chapter 34

Figure 34.1 Tracheoscopy from a dog with tracheal collapse.

Chapter 35

Figure 35.1(a, b) Rhinoscopy image from a dog with lymphoplasmacytic rhinitis showing hyperemic and swollen nasal mucous membranes.

Chapter 36

Figure 36.1 Dr. Dani McVety teaching owners how to give sub‐cutaneous fluids to a terminally ill patient.

Figure 36.2 Romeo during his first hospice appointment.

Figure 36.3 Dr. Dani McVety during a hospice visit with patient Fiona.

Figure 36.4 Hospice patient Lance who’s food bowl needed to be elevated.

Figure 36.5 Dr. Mary Gardner and hospice patient Cali. Cali needed to be boarded for IV fluids and her owner was allowed to come in the morning and evening for visits and the clinic would send texts with pictures to the mom during the day.

Figure 36.6 Hospice patient Andy loved to sit on his bed by the window but it was too high for him to jump into anymore. Owners build him a modified bed so he could easily enjoy his favorite pastime.

Figure 36.7 Hospice patient Daisy in a cart used for walks. Daisy’s owner was willing to do whatever it took to allow Daisy to enjoy her final days.

Figure 36.8 Bogey on his favorite couch. It was important to the family that Bogey was still able to get on his couch – even with assistance. And they wanted this final moments to be on the couch.

Figure 36.9 Dr. Mary Gardner and Jindu. The patient had a difficult night and the owners called at 6am asking for Dr. Gardner to get there as soon as she could. (After giving the sedation, the owners wanted to take a picture of him so peaceful as they had not seen him resting that well in weeks.)

Figure 36.10 Dr. Mary Gardner explaining the euthanasia process to a client.

Figure 36.11 12‐year‐old Dixie was diagnosed with Osteosarcoma and the family wanted to say goodbye to Dixie on a good day – before she ever struggled with the disease. This picture was taken the morning of her euthanasia when she was given treats and love by the entire family.

Figure 36.12 Jupiter’s Memorial Table. This was created the day of the euthanasia and left out for the family to look at for a week.

Guide

Cover

Table of Contents

Begin Reading

Pages

iii

iv

xiii

xiv

xv

xvii

1

3

4

5

8

6

9

7

10

11

12

13

14

15

16

17

18

19

20

21

23

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65

66

67

68

69

70

71

72

73

74

75

76

77

78

79

80

81

82

83

84

85

86

87

88

89

90

91

92

93

94

95

96

97

98

99

100

101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

116

117

118

119

120

121

122

123

124

125

126

127

128

129

130

131

132

133

134

135

136

137

138

139

140

141

142

143

144

145

146

147

148

149

150

151

153

154

155

156

157

158

159

160

161

162

163

164

165

166

167

169

170

171

172

173

174

175

176

177

178

179

181

182

183

184

185

186

187

188

189

190

191

192

193

194

195

196

197

198

199

201

202

203

204

205

206

207

208

209

210

211

212

213

214

215

217

218

219

220

221

223

224

225

226

227

228

229

230

231

232

233

234

235

236

237

239

240

241

243

244

245

246

247

249

250

251

252

253

255

256

257

258

259

261

262

263

264

265

267

268

269

270

271

273

274

275

276

277

278

279

281

282

283

284

285

286

287

288

289

290

291

292

293

294

295

296

297

298

299

301

303

304

305

306

307

308

309

310

311

312

313

314

315

316

317

318

320

321

322

323

324

325

326

327

328

329

330

331

333

335

336

337

338

339

340

341

342

344

345

346

348

349

350

351

352

353

354

355

356

357

358

359

Chronic Disease Management for Small Animals

Edited by

W. Dunbar Gram

University of Florida College of Veterinary MedicineFlorida, US

Rowan J. Milner

University of Florida College of Veterinary MedicineFlorida, US

Remo Lobetti

Bryanston Veterinary HospitalBryanston, JohannesburgSouth Africa

This edition first published 2018© 2018 John Wiley & Sons, Inc.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.

The right of W. Dunbar Gram, Rowan J. Milner, and Remo Lobetti to be identified as the authors of the editorial material in this work has been asserted in accordance with law.

Registered Office(s)John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA

Editorial Office111 River Street, Hoboken, NJ 07030, USA

For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com.

Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in standard print versions of this book may not be available in other formats.

Limit of Liability/Disclaimer of WarrantyThe contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.

Library of Congress Cataloging‐in‐Publication Data

Names: Gram,W. Dunbar, editor. | Milner, Rowan J. editor. | Lobetti, Remo, editor.Title: Chronic disease management for small animals / edited by W. Dunbar Gram, Rowan J. Milner, Remo Lobetti.Description: Hoboken, NJ : Wiley, [2017] | Includes bibliographical references and index. |Identifiers: LCCN 2017020145 (print) | LCCN 2017027035 (ebook) | ISBN 9781119201588 (pdf) | ISBN 9781119201052 (epub) | ISBN 9781119200895 (pbk.)Subjects: | MESH: Dog Diseases–diagnosis | Cat Diseases–diagnosis | Dog Diseases–therapy | Cat Diseases–therapy | Chronic Disease–therapyClassification: LCC SF991 (ebook) | LCC SF991 .C55 2017 (print) | NLM SF 991 | DDC 636.70896–dc23LC record available at https://lccn.loc.gov/2017020145

Cover Design: WileyCover Images: (center left, center right) courtesy of Mary Gardner; (bottom & center middle) courtesy of Remo Lobetti

List of Contributors

Michele Berlanda PhDDepartment of Animal Medicine,Production and HealthUniversity of PadovaLegnaro, Italy

Richard K. Burchell BSc (Hons), BVSc, MMedVet (Med), DECVIM-CAMassey University Veterinary Teaching HospitalMassey UniversityNew Zealand

Iwan A. Burgener Dr.med.vet., Dr. habil, PhD, DACVIM, DECVIM-CASmall Animal Internal MedicineVetMedUni Vienna, Vienna, Austria

Sheila Carrera-Justiz, DVM, DACVIM (Neurology)Department of Small Animal Clinical Sciences, University of Florida,Florida, US

Sylvie Daminet DACVIM, DECVIM-CA, PhDDepartment of Small Animal Medicine and Clinical BiologyFaculty of Veterinary MedicineGhent University, Belgium

Mary Gardner, DVMLap of Love Veterinary Hospice, 6061 Grandview Ave, Yorba LindaCA 92886

W. Dunbar Gram, DVM, DACVD, MRCVSDepartment of Small Animal Clinical Sciences, University of Florida College of Veterinary Medicine, Florida, US

Kate Hill BVSc MANZCVS DACVIM PhDSchool of Veterinary ScienceThe University of Queensland, Australia

Ninette Keller BVSc, BVSc (Hons), MMedVet (Med), Grad Cert Tert EdVeterinary Specialist ServicesCarrara, Gold Coast, Australia

Frank Kettner MMedVet, DECVIM-CA Tygerberg Animal HospitalCape Town, South Africa

Liza S. Köster BVSc MMedVet (Med) DECVIM-CA (Internal Medicine)Small Animal Hospital, Glasgow University Veterinary School, 464 Bearsden Road, United Kingdom

Remo Lobetti BVSc (Hons) MMedVet (Med) PhD DECVIM-CA (Internal Medicine)Bryanston Veterinary HospitalBryanston, Johannesburg, South Africa

Joanne L. McLean BSc (Vet Biol) BVSc (Hons) MMedVet (Med), DECVIM-CABakenkop Animal Clinic Centurion, South Africa

Dani McVety, DVMLap of Love Veterinary HospiceFlorida, USRowan J. Milner BVSc (Hons), MMedVet (Med), PhD, DECVIM-CA, DACVIMUniversity of Florida College of Veterinary Medicine,Florida, US

Caryn E. Plummer, DVM, DACVODepartment of Small Animal Clinical Sciences, University of Florida, Florida, US

Tanya Schoeman BVSc (Hons) MMedVet (Med) DECVIM-CA Cape Animal Medical CentreKenilworth, Cape Town

Gilad Segev DVM, DECVIM-CAKoret School of Veterinary MedicineHebrew University of JerusalemRehovot, Israel

Justin Shmalberg, DVM DACVN DACVSMR CVA CVCH CVFTBoard-certified in Small Animal Clinical Nutrition and in Sports Medicine & Rehabilitation, Integrative Medicine (Nutrition, Acupuncture, Rehabilitation, and Hyperbaric Oxygen Therapy) University of Florida College of Veterinary Medicine, Florida, US

Simon Swift, MA, VetMB, CertSAC, DECVIM-CA (Cardiology) MRCVSDepartment of Small Animal Clinical Sciences, University of Florida, Florida, US

Penny Watson MA VetMD CertVR DSAM DECVIM-CA Senior Lecturer in Small Animal MedicineDepartment of Veterinary MedicineMadingley RoadCambridge, United Kingdom

Eric Zini PD, PhD, DECVIM-CA (Internal Medicine)Clinic for Small Animal Internal MedicineVetsuisse FacultyUniversity of ZurichZurich, SwitzerlandDepartment of Animal Medicine, Production and HealthUniversity of PadovaLegnaro, ItalyIstituto Veterinario di NovaraGranozzo con Monticello, Italy

Preface

The goal of this first edition of Chronic Disease Management for Small Animals is to provide a textbook aimed at the management of chronic diseases in dogs and cats. The format of the book is concise so veterinarians quickly can find answers to questions relating to chronic diseases. This book is not intended to be another internal medicine textbook, but rather serve to catch a reader’s attention and to educate regarding compassionate therapies for chronic diseases.

Virtually all a veterinarian’s professional education is focused on acquiring and assimilating knowledge to properly diagnose and cure diseases. With experience, we realize that a significant part of our day is devoted to managing chronic conditions, for which there is no cure. This reality can be a challenge not only for the veterinarian but also for the owner/caregiver. The steps required to make a correct diagnosis often require less financial and emotional commitment than long‐term therapy and management. Client education and “shared decision making” are critical components of successful therapy with the goal of improving both the patient’s and the client’s quality of life.

This book is aimed at both the recent graduate and seasoned practitioner. The recent graduate, with some level of comfort in the diagnosis and treatment of diseases, soon discovers that chronic and incurable conditions often require a different approach than what was taught in veterinary school. For the seasoned practitioner who has achieved success in the management of chronic diseases, the benefit of the book is an up‐to‐date reference guide.

The book is divided into three parts. Part One on Communication and Caregiving, is aimed at the impact chronic disease has on the quality of life for both the patient and the owner/caregiver. Part Two, which forms the bulk of the book, deals with chronic diseases outlining diagnostics, therapeutics, quality‐of‐life and end‐of‐life decisions. Part Three focuses on hospice care and end of life. It covers client and patient needs, quality of life, cultural sensitivities, dying naturally, euthanasia, and death.

Acknowledgments

Together, we would like to recognize and thank the individuals (both animal and human) as well as their caregivers who have taught us much about the management of chronic disease. They and their primary care veterinarians were our inspiration. The editors and project managers at Wiley, including Erica Judisch, were instrumental in bringing this book to fruition and we thank them for their expertise. Lastly, we are grateful for our families who continually encourage and support us and our careers.

Part OneCommunication and Caregiving

1Communication, Caregiving, and Chronic Disease

Dani McVety

Introduction

Disease is often conceptualized as a temporary state and recovery as close as a single dose of medication, a round of antibiotics, or a few days of rest. Sometimes the “quick fix” doesn’t resolve the issue. Instead, we are left with the realization that sickness and death do not happen because medicine fails. Sickness and death happen because breakdown is the natural aging of biology.

Veterinary medical schools are designed to prepare their graduates for the practice of medicine. How prepared they are is directly related to how those institutions define that practice. Is it merely the ability to apply diagnostics and treatment protocols, surgical preparedness, and so forth? Or does the practice of veterinary medicine include something more: the ability to define and seek an optimal outcome when there is no quick fix or any fix at all?

Veterinarians need to graduate with the knowledge, experience, and resources clients need and expect to properly handle these situations. Veterinarians must learn and apply other nonmedical skills if they expect their medical knowledge to be put to good use, particularly in situations of chronic disease management. These nonmedical skills include displaying empathy and active listening. So what is the importance of learning these skills and methods that go beyond veterinary medical science? Simply put, these tools are needed when treating patients with chronic diseases.

Empathy, active listening, and other nonmedical skills form the solid rock upon which the veterinarian stands when implementing medical knowledge to the highest potential allowed by the client. Only by establishing rapport and trust with clients will veterinarians help them expend their financial, emotional, time, and physical resources to make the investment necessary to improve the health, well‐being, and quality of life of their pet.

Managing chronic disease brings a great deal of change for both the patient and the family. This change can happen both quickly, in the form of a terminal diagnosis, and/or subtly, in the form of symptomatic changes evolving over a period of time. Establishing this solid trust‐based relationship is particularly important. Therefore, how a veterinarian establishes a relationship with a client, then delivers the news of change, and finally manages the emotions surrounding the change may determine whether medical treatment is facilitated for the well‐being of the pet. Because veterinarians have the obligation to deliver the best medical care to patients, which hinges almost entirely on the veterinarian–client relationship, they must develop and utilize the skill sets necessary to communicate with, find common ground with, and persuade their clients.

This first chapter will explore how veterinarians can properly implement techniques to communicate the ideas learned in medical school to the client to improve the treatment and/or supportive care for the betterment of the chronically/terminally ill or aging pet. We will then discuss various specific skills that will aid the veterinarian in setting up the conversation appropriately, ensuring all parties are on the same page, learning how to adjust one’s communication under certain difficult situations, and, finally, having the conversation about potentially ending a pet’s life to mitigate pain and suffering.

Box 1.1

It would be interesting to investigate how veterinarians may be impacted in situations where the client could not serve as legal proxy.

In veterinary medicine, our clients served as proxy for their pet’s wishes in almost every interaction they have with a veterinarian. As veterinarians, we have two parties to serve; the owner/client and the patient. (Shelter medicine is the only exception to this rule, as treatment of animals in a shelter setting rarely include an owner.) In human medicine, the client and the patient are generally one person. Even in pediatric medicine, the parent is the guardian of the child, not the owner of the child. The parent generally has the levity to make decisions, but if that decision is not in the best interests of the child (as reasonably determined in a court of law), then the parent will lose the ability to make decisions for that child. In fact, it took a groundbreaking case in 1984 (In re Guardianship of Barry, 445 So.2d 365 (Fla. 2d DCA 1984)) to determine that a parent can serve as proxy for their dying infant child’s wishes, allowing the removal of life support in this case.

And particularly in cases involving chronic disease, we remove “life support” frequently in many different ways. Legally, clients are owners of the patient and our communication and established rapport with that owner is imperative if we are to gain the trust such that our medical knowledge will be put to use for the betterment of the pet and/or the treatment of a disease.

Overview

You are more likely get back on a horse if your dismount is smooth rather than if you are bucked off. The trauma of a difficult dismount may hinder your desire to return to the saddle; pet ownership is similar. When clients have a peaceful end‐of‐life experience with their pet, they will heal more quickly, return to pet ownership more quickly, and more readily be back in your clinic. The clients that feel that the loss of their pet is “so traumatic, there’s just no way I’ll ever get another dog” are usually the ones that we want to have adopt another animal! Those are the clients that truly care for their pets, providing good medical care and giving animals safe and loving homes.

This end‐of‐life experience applies to more than the actual euthanasia process. The experience begins much sooner, when a chronic or terminal condition arises, even if that condition is simply “old age.” The presence of an undesirable situation leaves the client feeling cornered. Emotions are heightened. There is more sensitivity to a veterinarian’s communication. Each may contribute to the client’s difficulty in making a decision on a treatment plan. Therefore, how veterinarians respond and adjust their communication in this tense situation will impact whether treatment plans are accepted, productive, and helpful to the pet and client.

In this chapter, we will first explore the mentality of clients by understanding the emotional impact of chronic disease. We will explore how to establish relationships with clients, how they respond to stress, how to best approach clients, and finally how to adjust your verbal and nonverbal communication to reach maximal effect and avoid conflict.

Impact of Chronic Disease on Quality of Life for Both the Patient and Caregiver

Veterinary medicine aims to recognize and effectively manage pain in a way that decreases suffering and increases the patient’s quality of life for those pets with chronic conditions. In assessing and determining quality of life, the term “quality” has many meanings. Essentially, “quality” signifies a “general characteristic or overall impression one has of something” (Welmelsfelder 2007). Veterinary professionals recognize quality as a separate entity from quantity, as the concept “more is better” is not necessarily true. Therefore, to optimize an ill patient’s quality of life, the veterinarian might encourage treatments that favor the patient’s perception of welfare rather than longevity.

Illustration of the above concept is seen through the treatment options for a pet diagnosed with cancer. The characteristic methods of cancer treatment are typically surgery, chemotherapy, and/or radiation. Upon evaluating the type of cancer, how quickly it grows or spreads, and its location, a veterinarian must weigh the effects of treatment to the patient’s quality of life. This information is then shared with the caregiver, and together, they make an informed decision based on the client’s ability to pay for, provide, and emotionally handle the care associated with extended treatment.

For instance, when deciding whether to perform surgery, the veterinarian should determine whether the costs to the animal outweigh the benefits. If the removal of a large tumor also requires removing a vital organ, thus resulting in the loss of an essential bodily function, the costs largely overtake the benefits. If the patient must live in anguish to increase lifespan, it is best to choose an alternative route that allows instead for comfort and contentment. However, if the treatment offers longer life expectancy in addition to a positive prognosis with only acute adverse effects, it is worth further exploring. Often, those associated acute conditions can be remedied with medication or simple lifestyle changes, generating a wise investment in exchange for long‐term well‐being.

To understand how chronic diseases impact a companion animal, there must first be a clear understanding of what quality of life is and how it is assessed. We can expand on the previous definition of the term “quality” by defining “quality of life” as “the total well‐being of an individual animal” (August et al. 2009). Although definitions of the term vary, most can agree that quality of life encompasses the physical, social, and emotional components of the animal’s life (August et al. 2009) in the current daily environment.

Although veterinary medicine has made vast improvements in assessing quality of life, it wasn’t until the past decade that it has been extensively studied and measured in companion animal medicine (Lavan 2013). Due to its complex nature and modernism, no accepted standards or protocols currently exist (August et al. 2009); however, various quality‐of‐life surveys have been developed and are tailored toward many of the individual chronic diseases. Overall, these questionnaires evaluate a combination of physical versus nonphysical factors, including needs satisfaction, sense of control, social relationships, physical functioning, hygiene, mental status, and management of stress (see Figure 1.1). The principal aim of the surveys is to broadly assess and evaluate over time the states and changes of comfort or discomfort (Lavan 2013).

Figure 1.1 Quality of life scales.

Due to the common element of self‐reporting in determining quality of life, which is obviously not possible for animals, research has been done to support and establish signs, symptoms, mannerisms, and other qualitative measures people can use to gauge this. Although many hope for a more scientific approach to quality for an animal, its primary reliance remains on human perception and interpretation (Welmelsfelder 2007). Hence, studies show that the skill to communicate with a companion animal is age‐old and does not need scientific validation to prove its worth (Welmelsfelder 2007).

The best approach to assessing animal quality of life is through a combination of interpretation of behavior and physical traits by both the caregiver and the veterinarian over time. The animal’s owner has the day‐to‐day first‐hand experience of understanding changes in mannerisms and personality. Owners also typically administer treatment at home and are the first to notice their pet’s reaction, such as side effects to medications or response to a procedure or therapy. Correspondingly, veterinarians play the vital role of determining and communicating the options and effects of various treatments. Healthcare providers offer the knowledge of species‐ and breed‐specific behavioral repertoires as well as extensive experience in observing and acting with different species in various contexts (Welmelsfelder 2007). This proficiency allows them to accurately judge and share with the caregiver the meaning of their pet’s body language (Welmelsfelder 2007).

Ideally, quality‐of‐life surveys could be conducted and discussed with a veterinarian throughout the lifespan of the animal, regardless of health status. By regularly using a quality of life survey for both healthy and chronically ailing patients, the caregiver and the veterinarian can document changes over time, have a familiarity with quality‐of‐life assessments, and, most importantly, enable the ability to discern minor quality‐of‐life changes caused by aging, chronic conditions, and/or disability.

For animals suffering from chronic diseases, even the subtlest changes over time can offer a significant impact to their quality of life and may indicate the need for additional or more formal approaches to treatment. Depending on the specific ailments, many patients suffering from chronic diseases experience changes in their levels of “anxiety,” “fear,” “restlessness,” “sociability,” and “playfulness,” which are witnessed and reported by the owner (Welmelsfelder 2007). In these quality‐of‐life assessments, it is important to distinguish between the physical and mental parameters. For instance, if an owner of an arthritic animal expresses that his/her pet is “slower during walks,” a determination should be made on whether this is because of pain, a mental state, or weakness associated with aging, a physical parameter (Yeates and Main 2009). If the determination is “pain,” adjustments should be made for alleviation.

Similarly, this “body language” established by the physical movement of the animal associated with corresponding psychological qualities displays the verifiable impression of chronic diseases on quality of life. Among countless examples, here are just a few:

Consider a sudden onset of blindness, affecting access to food and water (physical parameters), in addition to discerning whether the blindness leads to fear, distress, decreasing the animal’s companionship with others, or inability to “explore” during walks (physiological parameters).

Diabetes mellitus is another common chronic condition among cats and dogs. If well managed and treated, a diabetic pet can enjoy the same quality of life as any other pet. However, if uncontrolled or mistreated, diabetes can cause increased water consumption and urination, weight loss, dehydration, weakness, seizures, and possibly death. These quality‐of‐life ailments are evident through the pet’s body language, such as lethargy, smelling like urine, or acting depressed.

As common as osteoarthritis is, it might be hard to spot at first considering that the pet’s behavioral changes could be subtle. Arthritis doesn’t necessarily mean a poor quality of life for a pet; it is simply joint inflammation caused by an increase in stiffness and immobility. If this inflammation can be controlled, the pet may enjoy a relatively good quality of life. Changes like medications, therapies, and household adjustments can be made to control these painful symptoms. Pets display these symptoms of pain by avoiding once enjoyable activities, acting depressed, moving less, decreasing their hygiene (unable to keep clean due to immobility), and/or changing their eating habits. Anti‐inflammatory drugs, holistic therapies, acupuncture, herbal supplements, and household alterations, such as keeping food and water at a comfortable height, adding nonskid runners to avoid slips, and extra warmth at night, can help to regulate the symptoms and provide for a happier life.

As indicated in the examples above, chronic diseases can have a significant bearing on a companion animal’s quality of life. However, with careful selection and administration, therapies and treatments can help to assure good quality of life. Side effects must be considered so the measures executed will denote visible changes in quality of life or will otherwise provide a positive prognosis for long‐term quality despite acute ailments.

While organ systems and treatment issues vary by illness, they all share the commonality of requiring daily attention from a caregiver to perform routine tasks for monitoring and management. Research has highlighted the enormous devotion owners have to their pets and the efforts and expenses they are willing to incur to provide optimal healthcare for them (Kelly 2014). There is an undeniable overlap in comparing the management of a pet’s discomfort to that of a human; for both, the caregiver often administers a scheduled regimen of medication, monitors for signs of adverse reactions, and is prepared to transport the patient for emergency treatment if needed. The stakes are high if the conditions are not treated properly, as common results are brain damage or death. Among many examples, this is the case with diabetes management and allergic reactions to medications. This ambiance creates an immense amount of pressure and highly stressful conditions for the caregiver. As a result of the pressures associated with providing care, a caregiver is likely to experience substantial adjustment problems, higher levels of psychological distress, deprived health, and reduced well‐being; thus referred to as “caregiver burden” (Kelly 2014; Christiansen et al. 2013).

The pressure is better understood when compiling research that supports the notion of viewing a pet in much the same way as a child. A survey conducted by the American Veterinary Medical Association (AVMA) found that of 47,842 US households, nearly half (49.7%) of the respondents owning at least one pet “considered their pets to be family members” (Kelly 2014). Furthermore, similar to the human caregiving model, women are typically the primary caregivers of pets; AVMA’s national study showed that 74.5% of pet owners with primary responsibility for their pets were female (Kelly 2014). Based on this, a conclusion can be made that caregivers of pets, especially mothers, endure the same form of quality of life reduction as do human caregivers.

The most common challenges reported by caregivers are the time it takes to provide extra care, changes in the use of the home to tailor the pet’s needs, and restrictions relating to work, a social life, and finances (Christiansen et al. 2013). Many individuals described these changes as “time‐consuming,” “tough,” “concerning,” and “annoying” while also being “sad” and “frustrated” with the decline in the human–animal relationship. It is common to hear owners speak of “loss,” “guilt,” and “emotional distress” when caring for a chronically ill patient, as they are trying to weigh treatment options to euthanasia. Overall, caregivers tend to agree with veterinary professionals that the quality of life of their pet is more important than longevity. In fact, in a recent study, 86% of owners of dogs being treated for cancer were willing to exchange their dog’s survival time for an improved or stable quality of life.

As advances in veterinary medicine continue, managing the quality of life for both the chronically ill patient and the caregiver is becoming increasingly possible. Palliative care providers offer guidance to families faced with caring for a pet; they aid in creating plans for living well based on the animal’s needs and assist in treatment options to provide optimal quality of life for their patients (August et al. 2009). They also help to develop and administer the caregivers’ goals while providing emotional and spiritual support. By establishing and following the treatment options provided by a veterinary professional and confiding in this professional, both the pet and the caregiver can enhance their shared quality of life, maximize their time spent together, and make important decisions when the pet’s life can no longer be prolonged due to an unacceptable quality of life.

Part 1: Know Yourself—Set the Stage for Collaborative Decision Making, Active Listening, and Caregiving

It’s not what you look at that matters, it’s what you see.

—Henry David Thoreau

Trust is the foundation for collaborative decision making toward a common goal. The veterinary–client–patient relationship is based on that one shared goal: the well‐being of the pet. The client may bring a dog into the emergency room at 2:00 a.m. after seeing a tapeworm in the feces while being completely oblivious to the swollen lymph nodes and coughing that has “just recently started, but I’m not too worried about it.” Treatment of the tapeworm, or at least some dedicated time discussing the plan for treatment, is essential to establish trust with this client before an in‐depth discussion on oncology ensues. Otherwise, the client will feel like you did not treat the most immediate and pressing issue (what the client sees with his/her own eyes) and instead chose a more expensive and deadly route.