June 12, 2023

#94: Beyond the disease: The Emerging Field of Veterinary Palliative and Hospice Care. With Dr Shea Cox.

#94: Beyond the disease: The Emerging Field of Veterinary Palliative and Hospice Care. With Dr Shea Cox.
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Season 1

Dr Shea Cox is a global leader and subject matter expert in veterinary hospice and palliative care. She’s certified as a Pain Practitioner, a Hospice & Palliative Care Veterinarian and a Pet Loss Professional. With a focus on technology, innovation and education, her efforts are changing the end-of-life landscape in veterinary medicine. In addition to launching the first hospice and palliative care service integrated within a specialty hospital setting in 2012, she was also the first to launch a nationwide Telehealth platform dedicated to quality of life and end of life support in 2017.  In 2020, PetHospice was acquired by BluePearl Specialty + Emergency Pet Hospitals, and Shea and her team are leading the expansion of specialty-level, in-home pain management, hospice and palliative care and end-of-life services across the US.  Shea believes palliative care for pets should become more common and less scary for us GP vets, and after listing to this I’m sure that you’ll  agree!

In this episode, Dr Shea introduces us to the concept of hospice and palliative care to improve the quality of life for pets with both curative and non-curative conditions. We untangle some common misconceptions regarding these care options and emphasise the importance of advocating for both the pet and the client during the end stages of a pet's life. Dr Shea talks us through her career journey from starving art student to palliative care vet, highlighting the significance and satisfaction of providing quality care during a pet's final stages of life. Tune in and learn about resources and tools for end-of-life care management, such as quality of life scales, the importance of personalised goals, as well as the growing industry of in-home euthanasia and hospice practices and how you can integrate it into your work or clinic.

 

Topic list:

07:48 From art school to vet school: Dr Shea's journey.

10:29 Palliative care vs hospice care - what's the difference?

14:22 Dr Shea's view on palliative care and how it can be both curative and non-curative.

22:20 Why Dr Shea moved from emergency to palliative care and the difference palliation can make to a patient's quality of life.

29:59 Are most vets too quick to euthanise?

35:26 The different attitudes towards euthanasia and convincing owners that they don't always need to euthanise immediately.

39:50 The importance of goal setting with owners - what do they want for their pet? How can they recognise pain at home?

46:55 Why should more vets look into palliative care and what is it like working predominately in the end-of-life space?

52:01 How do we make palliative care more practical to roll out in clinics? Hint - utilise your amazing nurses!

54:21 The benefits of telehealth palliative care, for clinics, owners and patients.

 

Join our community of Vet Vault Nerds to lift your clinical game and get your groove back with our up to date easy-to-consume clinical episodes at ⁠vvn.supercast.com, ⁠visit ⁠thevetvault.com⁠ for the show notes and resources for this episode, and connect with us through our online ⁠Vet Vault Network.⁠ for episode highlights, discussions, questions and support.

Join us with Dr Shea Cox at ⁠Vets on Tour in Wanaka, New Zealand⁠ on 13 - 18 August 2023 for great CE, live podcasting and snow... lots of snow!

 

One of the things that I love most about doing these podcasts is when I go into recording about a topic that I'm not wildly enthusiastic about, maybe it's something that I know will be of interest to someone out there and Wetland but it's not overly relevant to me and my working life like as an emergency weight.
If you don't have a problem, that's really bothering you right now and that I can make much better in the next site. 24 hours.Then I'm not that interested so palliative.Care.I'm sure it's good for some, but not my circus on my monkeys, right?
Or so I thought until we were about 10, or 15 minutes into this conversation.When I realized that, this could be one of the most important conversations we've had on here for me, personally, in my clinical working life and probably also for you, your patience and your clients.
First off, I realized, I didn't really understand what palliative care means, if you like me.That it's kind of just delaying the inevitable as humanely as possible.Not true.There's much more to it.Dr. She explains how including differentiating palliative care from hospice care.
Also, I would have said that emergency and critical care and palliative care are like the opposite ends of the case Spectrum.Also, not true.And if you work in a sec, you'll understand why I say that.Once you've listened to this so virtually palliative care, you have yourself one More enthusiastic than me.
And I suspect, there'll be a few more of you who will have some serious light bulb moments once this goes live.So who is Jay?And who is Dave, if you're a regular listener, you'll know that dr.Dave Collins is a prolific contributor to our clinical podcasts and I'm thrilled to have him as a co-host for this episode.
Dave is a registered specialist in small animal, internal medicine at Northside Veterinary Specialist in Sydney and also the founder and director at vets on tour.Possibly the most fun, read conference In the world, which will tell you about later.And it's because of Dave's snow conferences, that we get to speak to dr.
Shay Shay, is going to be one of the key speakers at one of the upcoming fit, onto our events.And because Dave's been chatting to her about her topics and what she's doing in the field of palliative care.He called me one day and said, you need to get shy on the podcast.She's awesome.
And a lot of people will be interested in our work and he was right besides being awesome.Dr. Shay Cox is also a global leader.And subject matter expert in Veterinary.Hospice and palliative care.She certified as a pain practitioner as well as in hospice and palliative care.
And in pet loss with a focus on Technology Innovation in education.Efforts are changing the end of life landscape in veterinary medicine.In addition to launching the first hospice and palliative care service integrated with a specialty hospital setting in 2012.She was also the first to launch a nationwide Telehealth platform, dedicated to quality of life and end of life support, In 2017 and 2020 pet.
Hospice was acquired by blue pill specialty and emergency pet hospitals and these days share in the team are leading the expansion of specialty level.In home, pain management, hospice and palliative care and end-of-life services across the United States, she believes that palliative care forbid should become more common and less scary for us Jeep events.
And after listening to this, I'm sure that you will agree in this episode dr.Shane introduces us to, and helps us differentiate the Steps of hospice and palliative care to improve the quality of life.For pets with both Curative and non curat of conditions, we untangle some common misconceptions regarding these care options as shade talks us through her career Journey.
From starving art student to palliative care of it.She shares some resources and tools for end-of-life Care Management such as quality of life scales and we talked about the growing industry of in-home euthanasia and hospice practices and about how you can integrate it into your Work and your Clinic, of course, I asked Shay what it's like, as a career.
Like, doesn't it get depressing.Shay.Also challenges, a few verbal leaves, and our systems around what to find suffering as well, as end-of-life decision making.And she shows us some new ways to think about some of the most important clinical decisions that we make almost every day in practice.
As always, we also go down all sorts of rabbit holes.Like figuring out your personalized goals.Why those bleeding spleens have a third treatment option.How to leverage telemedicine to increase connection with your clients and how cauliflower as your main source of nutrition can serve as a real motivator.
Okay, dr.Shay Cox and dr.Dave Collins Thank you so much for joining us on the vet, Vault.Thank you.And here we have Dave, Dave Collins dr.
Dave Collins, our Specialists, do we normally listen to on the clinical stream is joining us as the co-host today.Why are you here talking to us about palliative care?I was really Keen to meet cha a and as you know, we're planning an amazing conference in Wanaka where shows going to talk to us all about palliative, care.
And so, I didn't want to miss the opportunity to hear about it first hand.Mmm, I'm dying to learn about palliative care.It's something that's It's becoming a thing individual for good reason, but it wasn't a thing when I started 20 years ago.But before we dig into that, let's start with our standard question of say, once I was driving, and I saw graffiti on the side of a building that said, bad decisions lead to good stories.
And I thought that's a maybe.Think about whether that's true or not.So, that's my opening line for the podcast.Do you agree with that?And if you do, do you have any examples to back that up?I wholeheartedly agree with that.And with that question, the first thing that came to mind was bad decision.
Dropping out of school, three months, prior to graduation buying, a one-way ticket, on a Greyhound bus to LA and not having a plan.Wow, the story didn't follow it.Some other time.So schooled, meaning high school because I always get confused with the with American worker initiative.
What is school?That school school or University or?University university so vet or what were you studying at the time.So I always wanted to be a vet and I ended up failing chemistry three times.
So I ended up going to art school instead.Something I could do and about almost yeah.But three months prior to graduation I was like what am I going to do with this degree and had a little bit of a mini freakout bought a ticket to La one way?
A on a bus that took about four days to get there and just I'll figure it out when I get there.And I still remember to this day I Rakesh I was 25 years ago or so longer, 30 years ago, picking up my mom and opening up the phone.I was like, Mom, guess where I'm at?
She's like, we're like La, she's like what when are you coming home?And like I don't think I am well, here we go.Home for vet school I actually yeah for veterinary school, I finally made it.Through.That's a whole, another story, that's part of the good outcomes from the bad decision.
I end up going back to Michigan where I was living at the time meant, but that lasted just throughout school and then I was back to California.And so what happened from there, show you manage to get into vet school, obviously and talk us through your journey.
Yeah.So I will, when I landed an Ela, it was all right, now, what am I going to do?So there wasn't a real high demand for Ceramics was actually like my profession.That makes the ceramic drop out exactly.
So funky ceramic funky.And I was like, what, what am I going to do?And when I was in art school back in Michigan, I worked as a home health aide and so I was taking care of different families.That had expense a special needs families.
That had special needs with their children and such, so I With patients with Alzheimer's.And I worked with a girl who had cerebral palsy and just various nurse's aide type of roles like that.And I thought well maybe I could do that here in California.
So I started working as a nurse's aide and then I was like, oh maybe I could be a nurse and to go to nursing school.You had to have chemistry, but I failed three times and I was literally broke as a joke.It's just, I still remember at the end of the week.
Having a dollar 18 in my bank account for groceries.So I would buy two heads of cauliflower and what I would try to try to eat on and I have scraped a five bucks to buy a baby chemistry book, from a school parking lot sale where they were selling used books.
And there was a baby chemistry book there and I was like, all right, I'm going to do this and I just started self-studying something clicked and I went to chemistry again after trying to sell teach it.And I Sounds like, hey, maybe I could do this vet school thing and so went to nursing school and a strict cauliflower diet.
It's right.Under the strict cauliflower diet bucket Gene that's been.So, I got accepted nursing school and then started taking prerequisites for vet school, and really went into the world of Home Health, hospice, realm, and human medicine as a nurse went to that school went into ER, as one of my tenth year of emergency medicine and just felt the same things that were happening on The Human Side of medicine, where you just didn't have the time that you needed to really understand what was going on and to make a plan and to really get at the root of of care.
And I approached the owners of the specialty hospital where I worked and said, hey I'd like to start up a hospice and palliative care program here in the Specialty Hospital.Are you game for this?And they were really supportive and that was 2012 and that's when Shifted back to my roots and started, providing palliative, care and cycle.
The rest is history.Well, can you talk us through?You seem to use the term hospice.A lot in the US where as we Roper melee with palliative care over here.What is this sort of a different?So I mean technically, there is a difference and this is one of the things I'm really excited to just speak with people about outside of the US and New Zealand during the conference But there's palliative care is a no, is it a is an umbrella of parent?
It's, it's Comfort Care.No matter if it's cured of, or non curat event can happen at any time during the course of the disease process.Hospice Care is a specialized form of palliative care.That's usually when there's a terminal diagnosis and the last six months of life.
So there's a bit of a Venn diagram between the two here in the United States.Most people say Hospice Care to mean end of life.Palliative care and hospice care.Whereas what I'm understanding especially from from Jackie is, is palliative care?
It's almost flip flop.That is referring to the hospice component and, and comfort components.So it's just so there is a different language.Curious, what does it mean to you guys?When you hear hospice care or palliative care?
What do you think?I kind of thought there's the same thing.I thought it was just an American thing.I know from listening to American podcasts in that, I've heard the term Hospice Care there, but definitely the word palliative to me, always sounded like palliative.Well we're not going to fix this.
So let's make you as comfortable.Let's palliate, your discomfort while we're in the end, run.So I thought it was the same thing.Dave.Yeah, I think palliative care to me is kind of tations of your non Curative and we're not going to make this better, but let's make it as comfortable and as, as pleasant as possible for owners and patients all around.
And Rotations of get, chronic pain management, chronic cancer therapy, like a lot of my, like, my medicine specialty.I deal with a lot of oncology patients and a lot of clients or either untreatable cancers or owners choose not to do conventional chemo, that would do sort of low-grade metronomic chemotherapy.
It's pretty well, tolerated and just keeps them comfortable and keeps the cancer at Bay for a little while, but took with not necessarily A Curative intent, And I mean that's true, your Hospice Care palliative, care, and we palliate disease all the time.
You probably ate the flu, you don't care, the flu you, pally with it till you feel better, or you could have a patient or a human that has cancer that you can cure or go into remission.But you still can have a palliative, care, team come in and help better manage those symptoms.
Where the oncologist is really focused on.Let's treat the disease.Let's treat this cancer.Let's provide this.X y&z therapy for this cancer, where a palliative care team can come in and be.All right.You're experiencing nausea or you have pain from this type of cancer or such.
So it can be cured of or non Curative which is palliative care us.This is, is generally geared towards non Curative disease and the end stage of it.But one of the things that is just a what I hear all the time when at least here in the states is oh my patient needs Hospice Care, palliative care.
R, it translates, both from veterinarians and clients of, oh, I was referred to you for hospice care because my pet has three days to live and there's nothing else we can do.So it's almost synonymous with impending death, which I would just love to change that perception and misconception because there's so much we can do with palliative care and hospice care.
And patients, often times just like in human medicine, live Way Beyond expectations, because we're managing the whole body, the whole pet.And doing a better job at it.So is it fair to say that in your definition of palliative care?It's anything that looks at patient Comfort.
It looks at the whole patient, that's not necessarily associated with the curing or the treatment of the disease.So it can be for any disease that we are trying to pick me.And Dave talked about, I am Ajay immediate hemolytic anemia, right at the start of the clinic podcast and the treatment there is the immunosuppressed as right.
So that's the real thing but then there's All the stuff surrounding it.The side effects of the medication, or the discomfort, or is it.So palliative care per definition, is all the stuff that's not the, it's not the fix, but it's get you through this in as comfortable away as possible.Whether this being a treatment for a curable disease or this being the thing that is going to be the end of you that make sense 100%.
Yeah.That's that's a great reframe of it and it's and it's it extends to a just a Safiye of palliative care.Hospice Care, is it extends to the family and it becomes that collaborative care.So, not just the doctor saying, we should do X Y and Z and here's the treatment plan.
But, but collaborating with the, the pet owner and what makes sense for, what you can do, what makes sense for what, your pet will receive bringing in the other patient in the room, so to speak to, to make sure goals are aligned.
And to make sure that what, Is recommended is actually makes sense from a quality-of-life perspective.I think that's two are just trained to do the perfect medicine like you had this disease.
And here's the perfect way to treat that disease but palliative care, I think is less like that.And it's that Gray Zone of medicine is that art of medicine.And so instead of this might be the standard of care but what makes sense for this patient and Situation and asking yourself.
Why, why couldn't we do this and really making those medical recommendations not just to treat disease?But equally focusing on making those medical recommendations to treat quality of life.And I think that's a big differentiator between just practicing medicine and actually practicing palliative care that phrase like it's a framework of medicine that provides comfort.
And Us' on comfort.And how can you tell us how the difference in this field between humans and the veterinary field?Like, obviously humans don't have the euthanasia options.So how does that affect in stage management of all life stage management?
That is a, the, the main differentiator, there's some states in the United States where where you can have physician-assisted euthanasia, but for the most part, That's not accepted and for pets when we get to that point where there's no longer quality of life, despite what palliative measures, you can provide to improve that quality of life.
And that's usually when when we begin to shift towards those end of life decisions, but there's so much we can do to keep pets comfortable for such a long time.If we have the time and space to actually do it, and I think taking the The concept of it can oncologist, you have all these patients that come in through the door.
You have an hour of time with them at the most.It's usually, here's the disease.Here's the treatment plan.Here's what its cost.Here's your options, any questions?And there's so much information overload clients walk away.Not really knowing what to do and a lot of balls, get dropped.
Not because the veterinary team is doing a poor job, it's because the system doesn't work.And the way we approach care doesn't work, the perfect example is you know a patient with osteosarcoma which we see all the time for palliative care and hospice care is most patients that come to us.
They're they're coming to hospice translation.They're coming to get euthanized any day now because they have osteosarcoma.And when you look at the treatment plan, or what's actually happening, the pain management part of it is subpar not because The veterinary doesn't know how to treat pain.
There's just this Gap and care where you can't manage all of these patients as an oncologist and really have that one-on-one time.And it's like boy, you implement these multimodal pain management plans with a really strategic pain plan and pets, feel great and they continue to do great for several more months, six months, seven months.
And then that family has that time to really wrap their head around the Ascend and really making sure that end of life journey is what they want for themselves and for their pet and you can really manage Comfort incredibly well, but you just, you don't have the time to do that in that rapid clinical setting and the follow-up clients don't call back saying, oh I stopped this Gabapentin because it made my pet wobbly, you know, and then they don't hear the fact that your pets going to be wobbly for a few days at these doses because that's what Gabapentin does.
So, There's just this disconnect and the same thing guys, worked as a nurse for almost a decade and human medicine, and you see the same things.So that was part of the journey was like, boy, what's, what's broken is the time component?
And our names are doing a great job.They just don't have the time to do it.Well and clients need support and they're not getting it.And when I started the hostas practice, I'd said, I'm going to start offering three.Our appointments that was literally what I led with.
And people that the practice owners, they were like, there's no way you can make that a financially sustainable model.You know, it's, I'm going into my 11th year of doing this spreading this Nationwide and Specialty hospitals, and it's a sustainable model.
So provide value and do it well.And you're eating more than cauliflowers, like you having balanced meals and That's right protein.Oh man, that's amazing.Show.
Quick Interruption for a bit of housekeeping.If you're listening to this and you're thinking man, I'd love to learn more from Shea.Then the conference that we keep referring to is in one occur in New Zealand from the 14th to the 18th of August.So that's 2023.In case you listening to this way.
In the future one again, is a magical place in a magical country and in August, the conference venue.Should be surrounded by snowy mountains and long ski runs.So outside of learning about palliative, care and oncology, and a whole bunch of other stuff will So be doing a lot of snow stuff and a favorite of socializing.
So if you can at all, come and join us, there are still tickets available.The details are at Waits on tor.com .a you or click the link.In the show, description will be doing some live recording sessions at the conference, that will share over on the clinical podcasts.So if you can't join us in the snow, but you are Keen to get practical on this stuff.
Then join our weight field notes for a drip feed of.Can I say this about my own product really, really good, clinical content.I'm still posting some amazing stuff that I recorded at the last conference, I attended with Superstar speakers from the land of ECC like dr.
Karen Boyd.And the one and only Professor Kate Harper.Yes, the one from your textbook, those are all live at Vivian dot super cars.com.The first two weeks are free.Okay, back to shape.It's a bit of eye-opening.
I'm fascinated by the shift that you made from emergency because I do, I've been working in emergency critical care for them.Last decade or so.And the fact that you had the desire to shift from emergency into this, which on at first glance, it feels like Two Worlds, Apart, right?
Because emergencies that, alright, we've got many things to deal with and it's life and death and we don't have time for the warm fuzzies just get shit done and then let somebody else can worry about the repercussions of it.But yet having said that you do bump into this all the time in, emergency the staff that comes in suddenly the old dog that suddenly crashes or Well that's this and you have to deal with it all the time and it's often that decision of well there's a sudden crisis I want to put out the fire and then that letting them go and saying well I don't have time to go through an hour consult of all the things that we can do but I'm going to send you back to your regular vet and cross my fingers that they'll do a good job at this.
But a little bit of your head but of your minds going for have this animal is going to get the key that it needs.Was that your the impetus was that the drive for you to start this think that.Yes, it is.It starts to get me very excited, internally and ramped up.And there's there's three big points where my brain went with with just that the comment one was they go back to their veterinarian and at least in the states, the average Face Time a client has with their veterinarian a year.
The 16 minutes?Yeah a year.So a veterinarian to do a good job with this complex disease.That was hunted from the ER back to the regular vet is really tough on that regular.I bet that's one one big thing, but other big thing and this is what I would really love to also changes.
When I started this, practice this hospice practice, I continued to do, ER, on the weekends and then palliative care Monday through Friday.And so I spent two years straddling both sides and it really was such an eye-opener for me, because as, as an emergency vet him, angiosarcoma comes in hemo abdomen.
Surgery, euthanasia not your typical to two ways to go.And it is today.My shift yesterday morning.I had exactly that case and There's a third option and that third option is, is palliative, care and sending that pet home with Comfort kid or I call it a comfort kit, but just injectable pain medication and sedation.
Let him recover at home from that, that bleed and see what happens.Euthanasia is permanent they're gonna die.Anyways, if you go that route but if you can guide them through a palliative care option that they if they can't or don't want to do surgery, our average.
Each command, Joe, sarcoma patients, and we look back at our ten-year patients.He know, abdomens that come to us and hospice.The average lifespan is four months which is the same as if we would have done surgery and way longer than if we would have euthanized in the emergency room when clients don't even have an option to to think about it because it's such a it's such a gutshot diagnosis and it feels very urgent in the moment to actually make this decision.
And there's so many disease, processes and situations that when I was straddling, those two things in the ER I would like okay well we can move to hospice /.Palliative care tomorrow.Let me come see you and the most amazing outcomes happen.
Not every case sometimes I go and euthanasia happens, several days later.But I mean I can tell you literally hundreds of stories of just, huh?Wow.Wasn't didn't expect that wasn't seeing that coming.I had a patient with an invasive adrenal tumor that went into the vena cava that came in with bleeding shocky.
Non-surgical, we went through an ultrasound we stabilized him.Send him home.It was going to their home.For euthanasia that next morning.Showed up dogs, wagging his tail, super happy and the owners like I know he's got really bad disease and of you're here too.
It's a nice and but how can I use the guys?And when he looks like this, I know he's going to get bad again.Like we don't have to a year and a half later is when Youth and Life to him, I just like crazy stuff and if we take that third option away, you know, the alternative is death.
So why not go into that Gray Zone of medicine and be that collaborative partner with that pet parent and offer them options and get a little bit outside, the comfort zone of that perfect medicine.Have the internist would always give me shit.Like you can't send that patient home on oxygen and then to go blah blah blah blah.
I'm like why not?You can't give the clients injectable Lasix to give it home if they get into a crisis, why not?We're gonna we're gonna euthanize.So it's just thinking about things differently.So that's Point number two, point number three.See our vets are where they go out to pasture as hospice and palliative care.
I see it all the time and that's like the running joke is when we had 20 vets in our practice, before we ended up expanding.And most of them were ER, vets and they were doing this either full time or on the side.But the joke is where hospice is where TR vets.
Go out to pasture.There is this Synergy between hospice Karen ER medicine.And I've been trying to understand this for for over a decade and I think it's that a space, it's emotional, its short-lived relationships, it's doing something doing a really good job and you know, the next thing that's that's part of my theory but still working through that one.
But anyways I'll take a pause I'd like.So I start to get very excited about this.I love it.I love your passion chai and yeah, it's really eye-opening the Shift from from AR to hospice.I was just wondering what kind of that's really interesting about her.
Mangia sarcoma in particular, a number of my cases of surprise me just going home on anti fibrinolytics and just to try and prevent blades becoming severe bleeds.But is there any published information on sort of survival times and things?
That would really surprise people that is on the list of a thousand things to do?You know, having all this data And trying to to compose and directional prospective studies and connecting with other trying to create this network of other hospice providers across.
Not just the us but internationally and begin collecting this information, begin doing things.That that perfect medicine doesn't really allow like stage 3, Iris kidney disease cats.
Give a medicham if they have arthritis, you know, all these things that we're not supposed to.To do in perfect medicine.If we could begin these studies with showing the outcome and the Improvement in quality of life, that's, that's amazing.I don't hesitate to do to do anything, to that effect balancing that quality versus quantity.
And again, you just are always surprised at the outcome, but just need more more time.More resources, more mise to pull this together, but so short answer.No long answer is like man.That and I I'd love to do something like that.Following up from your previous discussion Shay.
This might be controversial question, but do you think that as in the profession and obviously not always, but are too quick to euthanasia.It took about the Amanda stock guy.So, but there's many others where we just go now.It's not going to do well.
Let's just let's just kill it.I do and it's because I see that and I think it's multiple fold in as veterinarians.We are were empaths.
Our number one role is to make sure there's no suffering and perception is reality.Like we see something.Well, what really defines suffering.A classic example is as a veterinarian, you get such a small snapshot into the Life of this pet and this family.
And so, I had a patient, Jacob that saw one of our oncologist.And he had this big old nasty gnarly stinky tumor on his mouth.That was a squamous cell tumor.And everyone was like this pet.She needs to be euthanized.
And this pet needs to be.This is how could this owner let this happen.And it's like, so she came.She was referred to me, was an oncologist from a different Specialty Group showed up at that home.Black cat with this nasty, stinky gross tumor was in and out of my bag looking for treats.
Rubbing up against my pant, legs, super happy, eating and the family the mom, the pet mom was so conflicted.She's like I'm being told I need to do this but this is what I'm seeing.And the veterinary teams, they would that snapshot in time.
They don't see the home, they don't see the interaction.They don't, they They don't see the bigger picture and so decisions are being made on disease and how it looks not on that unit, the patient and the family and it's not a wrong thing, but we're just not trained to think about things.
That way again.It goes back to that perfect medicine.You have this.We have to do that.And I don't know other than just raising awareness and sharing stories and such Any other way to change it, but I always say, treat the patient, not the disease, and I think, as veterinarians weird.
So protective of trying not to get anywhere near suffering.That we, we often euthanize early, which isn't bad either, but it's suffering.But it's also, there's a weird thing in our profession that I've it's been a bugbear of mine for the last 10 years.
Is that we have this thing that if something does Sighs without us, euthanizing it.If it dies without me, then I've failed, then it's something.You know.I've got to kill you before you die.That it's this weird Obsession that it's a failure is where I do, I say to my teammates and I've saved two clients before.
Look, we're all Guido.I'm going to die unassisted because I'm just going to happen.I'm gonna suffer, and hopefully, not too much.Hopefully, I'll have somebody taking care of me, like you do, but eventually I'm going to go.So, why do or be in such a rush to say well, so, Again, that I had this exact conversation with my image of stock patient yesterday because I for years, I've been saying or take them home option, three owners come in for to euthanize their dog that I've been stabilizing for the past six hours and it looks fine.
Like I have can I kill you?You look absolutely fine.So then I started sending them home and saying that two owners saying are we can send them home but with the Proviso that you understand, there is a risk that is going to be a catastrophic fatal bleed at home.One day you can I come home from work and he might be dead on the lawn if you're okay with that and then I'll say to them but whether that That happens or whether I kill him.
He's going to be equally as Dead And getting people to have, that mindset is really hard for a profession.Do you find that we struggle with that it?Yeah. 100 percent.And we're just, we're not taught to think about it that way, it's so cured of driven.
And so perfect medicine, driven, and so avoid suffering at all costs.But to your point, we all pretty much died unassisted meaning without And the important part is, is when you get to that point, we have the ability just like in human medicine to palliate that we can do palliative sedation, we can do increasing, pain medications and Pain Management until that time of euthanasia.
But sometimes people just need an extra day and when you coerce someone into making them feel pressured into a euthanasia that they're not ready for the pet, may be ready.But But boy, if that clients not ready, that is going to leave lasting brain damage and regret and all sorts of negative consequences for the rest of their life.
And it's like, boy, if you can support both of those patients, palliate one.Get that family to where they're comfortable with that dishes and that's, that's the magic.That's the wind.That's the serving both patients.
We always have two patients in hospice.Elliott of care more than any other time.It's a really good point about the euthanasia and US feeling like we have to intervene, I guess my biggest fear is that the animals going to be in pain and there's going to be suffering if it's not supervised or if we don't take care of it but maybe that's misguided.
I was just going to comment that a lot of.I feel like maybe there's Regional attitudes difference in attitudes towards euthanasia or not sure what things are like in Southern California.California versus Australia.But I often find I'm trying to convince owners that they don't need to euthanize their pets.
That there's good management options for CKD or various Cancers.And yet some, some owners of sort of got a farmer's mentality, they are.It's just a dogs, just a cat and just got terminal disease.What are we doing?
So, and even when convincing them that we've got Good long quality of life ahead.It's sometimes I find it hard to talk them out of euthanasia which is you know it's got to be their decision but I find that's a battle sometimes.Yeah.
Yeah.The 180 battle the, the reverse of that and that's something that's a really interesting perspective and something.I don't often see obviously from what I do.But yeah, I'm just in thinking gosh, what would I do?
I would almost Rather have that then then the opposite.But yeah well I mean I guess my role a role is the patient advocate and all I can do is present the case of the disease and the quality of life and it's their decision.
Ultimately there's definitely an attitude like that in Australia and South Africa is the same.I do find that.Sometimes those people are more open to conversation, then I did you first.Give them credit.He's I've got friends like that.Who have animals are go.Yeah.When they we talked about, A staff I do and they go.
Oh, that's ridiculous.I'd never spend that much when it comes to it.I'll just smack him on the head with the shovel but that's big talk and then I always tease him.I said, yeah, we'll see.I'll see you in my console dream.One day, when we having this conversation and you'll be in tears crying about your little dog and then we'll talk about players acquaintance of the hard kicks in when it actually happens, and then you won't be so tough.
That, that is a tough one, Dave, and that's great, quite common in emergency and critical care as well, where you get a patient present for euthanasia and you've never seen them.And you don't know the background and you've ended that's old.And it's got really bad arthritis, and it can't get up out of bed.
And they go, it's time and then you discuss it with him.He said, well what painkillers is Ian?No nothing.It's a tough conversation because almost emotionally.Once people make that decision, they there they've spent the week thinking about it and they're emotionally at the place where they ready to let go.
And then to intervene, it's always very sensitive to me to go.Well, I don't want to change your mind and then we, Something and it doesn't work and then you have to be back here next week and you've gone through this extra week of anguished thinking about should I shouldn't I?But but I can't not say that.
Kind, let's say, look before we do this.Exactly.As you said, Shea this this final went once we've euthanasia, we're done.There's no going back from that but there are a bunch of new things that we can try.I've seen some of these dogs or cats with kidney failure or something dirty too well.So there are things but no pressure, If you are and I will always finish by saying if you are ready and you had to place where you feel Feel it's time to let go no judgment at all but there are options to discuss if you opened it.
And then often people will say oh come on let's let's talk about it.It does how the opposite end of the scale.Say there's a third option.So now we talked about two things.There's a third one will have people listening to this growing.Yeah but we've all seen that patient where the owners gone too far where we've dragged it out too long and they've actually where you start getting their concern.
Well, is this this patient actually suffering?Is it worthwhile doing to it?What we're doing.Good.Or I've had clients come in saying.Yeah I regret I regret the last month should have let it go a month ago because this last month was just unpleasant for both of us.
How do you find that balance?How do you, how do you guide veterinarians or clients to make the decisions?Okay, well we've done what we can.This is too much.What are you measures for drawing?A line and a pets life?Yeah, I think.
One tool that I Find very helpful is and that's the importance of really carving out this time to to explore goal and lines in the sand so to speak.And one of the things that during our initial consult is, what do you want for your pet?
What don't you want for your pet, and really creating those lines in the sand and sharing that what we say today, what tends to happen is, I don't want this provide pet.Here's the Line in the Sand and then a month goes by.And all of a sudden were at That line and they're like, your, erase erase erase.
And the line gets moved.And the, the new, the new abnormal becomes the new normal, and you just keep moving forward like that.So, addressing these things early.And creating these anchor points, here's what we talked about what you didn't want.
And just clear is kind when you get to that point.It's like hey here's what you didn't want, I'm seeing this, you you are probably not seeing this because it has Um, your new normal like we talked about two months ago, as your Advocate and the person you entrusted to ensure that we didn't cross these lines in the sand, I'm bringing this up because I'm seeing this and having these predetermined points of or lines in the sand, I think is really helpful for families, so that when they do get there you can go back to that and it's something that you mutually agreed upon.
Or discussed at the time.So it's not like you're saying, hey, your pets now suffering, it's reframing it.Here's where you didn't want your pet to get as we talked about two months ago.And now we're here, I'm here to be your eyes, when you can't always see and I find, I find that really helpful and it's like such a tangled mess, really when you get into the ethics and the moral of morals of too far, what suffering Defines it all we can do is the best we can do and work to be that advocate for the pet, and for the climbers, you always have to be an advocate for both and having conversations early so that you can help as you move forward.
That that helps and to find it helpful to do use pain, scores or quality of life scores, or things like that to help in the process, given everything so subjective.Otherwise and I developed a Pain Scale just because there wasn't one out there that really fit the home setting.
It's all the pain scales that we use didn't quite equate to the language of pain as I would call it.So yes, we use pain scales and it's the one we use is framed on the clinical signs that client see in the home that would indicate discomfort.
So it's really Home based signs, that clients would see like trouble going up and down the stairs.You know that doing the Elvis leg shake.As they're trying to go to the bathroom, all these signs for just comfort and quality of life skills.
Boy there's a lot of them out there and I like to just share with clients.Here's a bunch of.Here's all the tools that we have currently at our disposal.Each one has their own shortcomings and each one has their own really good strength.
What one resonates with you and what I find is is that resonates the best for people is creating their own custom quality of life, scale, so to speak.So, we're in a hospice appointment.
It's like think back to six months before your pet, had this illness, or this disease, or was acting this way, what were the five things that made his day?Great?What would give him a rating of 10 for these days?And then we list those individual markers for that pet, because it's different for every pet.
For some pets, is bringing a ball to the door every single time.The owner comes home for other pets.It's, you know, wanting to walk 40 feet ahead of them when they go out on their daily hike.So Lee fine, tuning it to that and then on the other end of the spectrum it's like all right.
Think back to the worst day, what?Think?Back to a zero day a one or two out of ten day.What did that look like to you?Oh gosh, he was doing this Behavior or he didn't want to eat at all his favorite tree, it becomes individualized.
So the client makes a list of all of the awesome things.The client makes a list of all of the, the negative things on their best and worst day.Day and then we sort of back fill in.All right, well, this is a Tenon, this is a 0.What would make a five?
And so we create this gradation and then, that helps them, customize it to their own pets likes and joys and normal behaviors as opposed to a scale that is more not as not a specific to that pet, or that doesn't have waited things.
There's there's great quality of life scale.Out there.But if you can't breathe and if you hurt, I don't care how good your hygiene is, and how well you can get around.Like quality is not there.So it's really understanding the teaching clients, the weight of individual things, as well when it comes to quality of life, that's really interesting.
Child, love the customers, you get to the home environment and your support on in the the 55 minutes or more that we spend with the client talking about the Pets life at home, doesn't begin to describe their normal behavior.
And I've got a 14-year old dog next to me now that isn't in hospice just yet, but he's got some issues, one of which is just been diagnosed with Cushing's and his whole personality has been consumed by voracious.
One track mind about food and it's just been an absolute pain in the neck and staring Us in the face.Every time we're eating licks his bowl clean.In like five times even after he's just consumed his meal and we've just started trading him and he's just started doing some of the behaviors that we've forgotten about.
Like, we get home and he starts his full.Whoa, which we literally haven't heard phrases because you just stare at this morning his meal as soon as we get home.So, so yeah, Translating that to sort of quality of life measures and in the home environment is, is fascinating, and it's not validate is not scientific.
But it's pretty hard to standardize and tell me you've sort of enlightened us with a few things from your career at the moment.It's one of the few things that you would sort of tell veterinarians interested in this field to sort of find out more or what do you think would sort of wow them and Inspire them to find out more or even start the journey into becoming a hospice.
It.Yeah, it's there are a lot of resources and here I can share those resources that I ate a HPC is a hospice organization that I was a really integral part of, for a long time.
It's where you go to learn if you want to become involved in that community.So that's a great resource.And the other thing too, is it's when we hire someone, we expand and a veterinarian come Is to us.There seems to be this mysticism around the hospice and palliative care.
Like, oh my God.I don't know how to treat this pet because blah blah blah.And it's like it's doing the same thing that you're doing but without actually the pressure.Because what's the alternative, right?You're providing palliation.You're providing symptom management.So to me, it's less about how to do something as it is changing your mindset.
In what you do letting go of again of that perfect medicine or you know, everyone's doing palliative care, every veterinarians doing hospice care.It's but it's taking it to that next step where it's it's ask.
Why not?What would I do?If it were my pet white, why couldn't I dispense an NSAID without blood work once a year when the alternative is euthanasia or discomfort and it really is An emerging career.
It's I don't know about where you guys are, but it's almost becoming also like a gig economy here where people are getting out of clinical practice in there.I'm going to start an in-home euthanasia practice or I'm going to start a hospice practice.Yeah, so I think I might really sideways with the question.
You were asking about resources.I be c.org is one of them and I can provide more Kata, is another great, the companion animal euthanasia.Asia, training academy by Kathy Cooney, it's another great resource for all things, end of life and hospice.
I liked me, you were going with it rather than just the resources rather than the how I'd love to find out more about this as a career option, A couple of things of what it's like to work in this.The, my first question is is it is it super satisfying?Or is it does it get a bit depressing because you're often working with the end of life?
Does it weigh you down or to Build You Up?It it fills the cup and it is such a unique Mission medicine.And you know, when you think about the emergency room, you get great clients and then you get clients that are like, oh my God, you did all these tests and you couldn't tell me what was wrong with my pen.
I spent $5000, I still don't know what's going on.You went over the estimate by two bucks and, you know, you you get this population of clients at end of life and hospice and palliative care.It's like selected for all the best claims they're just so grateful that you're there.
They're so grateful that you spent the time they're so grateful that you created this experience for them that they wanted.And so even though it's sad and you know, you're dealing with end of life issues, You guys have been an ER, who do you get the most?
Thank you cards from the pets that you've euthanized or had a good death with.So imagine a career where you get all the, thank you cards, and love mail and none of the you went to Bucks over my estimate and still couldn't figure out what was wrong with my pet.
So but it's also, you know, are you wired that way?Like it's very fulfilling.I think ER, vets are wired that way.Way.But just like, people are born to be surgeons.There's people who are boring to provide this care.
So it's not for everyone, but boy, if it's for you and it's something you resonate with the satisfaction you get, despite what you're doing is is incredible.I I think I've done three space in my life and I wanted to vomit every time I did it because I was sure I sewed, something up wrong or didn't do something like that.
Was that was anxiety all day long for me.Ending a life.Well doing palliative care.It's like huh?Wow, look what I did.So I think it's personality dependent also.Yeah, yeah, absolutely.
Right.I'm in imagined clients must be so grateful to everything you do.And certainly the oncologist that I've worked with getting more chocolates and flowers and anyone have ever seen because people are so, so grateful for what they do and I represent Can I ask a practical question Dave before we move on?
So for somebody who's listening to this going, yeah, that a two types of people listening to this.The one is the general practitioner or the practice owner goes.Alright, this resonates, I think we should be better at this.How do I make it practical though?Because you talk about time and energy, it does take time.
The reason we don't do it is because we have 20-minute consoles or 10-minute consults and it doesn't.So how do you, how do we make this practical for practices and the The follow-up will part of that question.I think is the exact resistance that you had at the start where they said, well, how the hell do you make of three-hour consult financially viable.
How do you make it financially viable?Yes.So, two big broad stroke.Answers is engage your nurses and nurse driven model, that's what makes it work.And Telehealth really implementing Telehealth.And if you go, okay, here comes a Shameless plug to the vets on tour there.
There will be two out.Or is on just the how, how to do this, how to integrate this into your practice, how do you make it?And it really is that 75% of hospice, palliative care is non-medical, so slice that 75% off teacher nurses, how to do that, engage your nurses, Elevate their license and then you the doctor can drive the medicine.
You know, here's what we need to do to palliate these symptoms but we have a virtual nursing department and our nurses are all across the United States and they manage all of our palliative care patients.So you can there's so many creative ways to provide really high-touch care through nurses and through tapping into resources that don't necessarily have to be right there in your brick and mortar building.
It's it's yeah, it's another area that gives me really excited.Yeah, I'm super excited to hear about it in one occur.And yeah, I mean nurse driven models, I think with a lot of our practices nurses could be and want to be doing so much more and they're amazing people to work with and can make it really successful.
I feel like this might be a rabbit hole, no guile of rabbit.Holes might be to deeper, I would hold, but the Telehealth as of your answer fascinates me because I feel like from what we've discussed so far, a lot of the palliative care stuff is very Compassion based, right?
Heart-based relationship-based.So by default goes, but it's going to be face-to-face.I have to have to feel each other, not just sit on the end of a computer screen.Go to clean all these the drugs, these are drugs for the week.It had is the Telehealth tick that box.Well enough it does.
And there are ways to be very engaged in virtually.I really heavily went into into telemedicine in 2015 and it is definitely an area of passion of mine and trying to engage that more.
But the beautiful thing is we're managing symptoms.So we don't have to touch the field of pet.We generally know a diagnosis or the clients don't want to get to a diagnosis so we can manage 95 percent of what's going on by just history and understanding.
So, here in the United States, we actually have to touch in California.We have to touch a pet, to establish the vcpr.But once we have that initial so our nurses, do an hour and a half and take it's a virtual intake.They go through all of the questions and history and goals and all the things that are non-medical.
Our doctor goes to the home for an hour, 40 minutes, part of the medical part, does the physical exam, discusses the medical plan.And then from that point forward, everything is done via telemedicine clients don't have to schlep their pet.
Back into the hospital.We don't have to drive back to the home.Everyone's happy, they have this team available to them, seven days a week.It's, it's phenomenal.It's and as what makes things cost effective for everybody, it's a really Yeah.
Okay.Wow.I think come to Wanaka up until now.I was just excited for the snowboarding, Dave, but that's changed.Now, I'm actually really excited for the sessions as well.Yes, I know we've got a few people sort of doing a bit of what you do in Australia shape, but to put, it sounds like developing it the way that you have fascinated to hear more about it.
And he'll, if you're going to be there, obviously conversations can continue and happy to share everything.But also really happy to evolve just inorganic way with what the people who are there want to hear.So if they'd rather hear more about, how do I make this work?
In a practice over, how to manage squamous cell carcinoma?It's like, let's go that route.Yeah.What about some live podcasting?Dave, we do a live podcast.Absolutely.Right.All voted Dave.If you got more stuff, or should we start wrapping?
Oh no, I'm happy to wrap it up and you can't wait to listen and make chain person.Yes, a this was been really cool.It's a love conversations like this, where suddenly a new part of my brain opens up when I go wow like 20 years in the profession and suddenly light bulb goes over there there's a whole new thing to explore and I hope it's the same.
I said I think there will be a lot of people listening to this who feel the same.Let's wrap up with a getting a little bit more personal back from Back away from the palliative, care attractive shade podcasts.Are you a podcast listener?I am, I am an audiobook addict and podcast listener.
So what should be on my playlist for the weekend ahead?So I like podcasts that are focused on marketing, oddly enough.So two of my favorite podcasts are business made simple and it's a podcast by Donald Miller and also online marketing Made Easy, which is a pod I'd cast by Amy Porterfield and what I love about them is it's about anything we do in life is about crafting a story, right?
It's veterinary medicine, you are a veterinarian but you have to craft your story, you have to sell what you're doing, whether you're a practice owner, or you're in the exam room, trying to get an estimate approved for X treatment but it really helps to frame.
How do you create clarity?Around what it is.You want to say and how do you create story and interest that people want to engage in your conversations?So I think these are although their marketing and business podcasts, they really extend skills into a lot of different areas whether you own a business or do marketing or you don't right?
I love marketing stuff so that's good.That's definitely going on the list.Now, the pass along question, I'm sloppy with because I forget what the last people asked, but I get the guests to ask the question that we want to ask of the next guest on the podcast.
So the one that I've got for you from one of our previous guest is, do you feel like a profession like the veteran profession is becoming a part-time profession?That's a very interesting question, and I have to look at it from kind of a macro lens and I Micro lens.
I think as a profession is a whole no, because there's so many facets to our profession, whether it's research or education or Pharma or you name it.If we bring the lens into just clinical practice, I would say yes the complete opposite I think we are becoming a part-time profession and I wouldn't go so far as a gig economy but at least what I'm seeing is as a relief that you get more autonomy and you get paid more than as a full-time veterinarian.
We also have this demographic of women who want to raise families and they To be sexist, but they're usually the primary caregiver.And so a part-time role makes the most sense for them.Then there's work-life balance where five days a week four days.
A week is often too much for people given.It's not an easy job.So given the intensity of the days that you work.Less days are often a good a better balance between It's why so many people come to hospice.
We have ER vets like what me do 6er shifts a month and six hospice shifts a month because it gives a better balance.And also, the I think the the burnout level that's happening is causing people to pull back a little bit where they I can do three days but I can't do four days or I can do two days.
So I do think.And clinical practice, that is a trend, profession is a whole less.So Your question for my next guest not knowing who the next guest will be.I am glad that I saw that is.
And for me it's this is just a Nutty.There's something that you want to try and crack and try and figure out but I just Trends.I'm seeing our veterinarians and Veterinary teams are meeting to work less and get paid more like salaries at least in.
My lenses from the United States but the profession is demanding a higher wage rightly.So pet parents are demanding, lower cost of care, and higher value with that lower cost of care.
And so, there's this Chasm that's happening between the two.And it's not something that can keep going the way it's going.So, how do we solve for that problem, Telehealth pet insurance?You know, these are all things that At that are possible pieces of the solution but they're not gaining traction.
And my fear is things are going to crack before before we get to these Solutions.So what can we do as a profession to bridge that Gap?What happens if we have this implosion?What do we do about it?Just yeah.
There's a big disconnect that's happening, and especially with this Millennial, they want more.They want more education.They want more time and that cost more money.There's just a big gap.If I have a guest on that can answer that question.
Quite an extraordinary.Yeah I'm gonna ask it and see they sighs.It'll be like but it's a very good question.So these are the things that keep me up at night.Probably be able to solve a lot of the world's problems if I'm sold.
They exactly this question where we've solved their word climate change.Next, what's the solution?So that it's a very real problem.We're living in right now.What are we going to do about it?How do we address it?Like it's, you can't have both at the same time but we do.
Yeah.Right.The last wrap-up question Che is you are at a conference somewhere and you have the opportunity to speak to all of the veteran in new grants of where we now 2023.And you have a couple of minutes to give them one little bit of advice.What's your bit of advice for them?
My bit of advice is life is too short to live in mediocracy.It's it is it's just too short.If you are not happy doing what you're doing, change it.If you're not happy in your situation, change it don't compromise.
You can compromise life is always a compromise in one way or the other, but if you find yourself feeling stuck, getting stuck, don't settle.And I think so many people get into these ruts and just like, we talked about lines in the sand and, you know, the new abnormal becomes the new normal and then pretty soon.
They wake up and they're like, what happened to these last five years.So maybe we need quality of life scales for ourselves right where we where we like this is What makes a 10 day for me?And this is what makes a zero day for me and when we start getting towards that recognize it but just really.
Yeah, Life's too short for me, the accuracy.So don't fall into that.That rut Love that.Cool.All right we will see you on the slopes Dave, Shea say thank you so, so much for expanding our minds and opening up a whole new rabbit hole.
We will have to have you back on some of the clinical stuff to dig into some of the nitty-gritty of how do we do this because now I want to do it but I want to get better at it and I want to be me dijo que.Thank you so much for your time and Dave, thank you for the intro and for bringing us an awesome guest and have a lovely day.Thanks so much.
Thanks show.Lovely, to talk to you.You.I want to share an email from one of our clinical podcast described as it's edited likely to take out some personal details but I love it because it demonstrates something that I've learned over the last couple of years.
That continued professional growth is an integral part of personal growth.So here goes, I wanted to thank you from the bottom of my heart for what you've been doing with the podcast.I can honestly say that you have genuinely saved my career.No exaggeration.I came back for my third maternity.
Leave a tired.And Confused vet, senior and age, but not confidence.Straight into an emergency job to say.That it was a steep learning.Curve is an understatement dealing with the guilt of leaving my eight month old and my two other young children in childcare and working long shifts with varying levels of support, honestly, nearly pushed me into giving it all up.
But the podcast allowed me to revise knowledge that was buried in my brain very deeply at times and become current.Again, it honestly gave me so much more confidence.Fast forward a year.And I'm proud to say that I mostly thriving as an emergency vet and still learning loads.
That resonates with you.Then we would love you as a part of our Community of Faith V nerds.Join us at VV n dot super cast.com.

Dr Shea Cox