End-of-Life Guidelines

As death is inevitable, preparation is wise

The death of a loved one, whether human or furry, is never easy. We all hold on to the hope that our cat will live a long, healthy life and that, when her time comes, she peacefully moves on to wait for us at the foot of the Rainbow Bridge. Often, though, we are not that lucky. Instead, many of us are forced to make tough end-of life decisions for our beloved cats. While it’s an emotional time, objective end-of-life guidelines can help us make the right decision, no matter how difficult.

The Animal Hospice Care Pyramid from the American Animal Hospital Association (AAHA) gives guidance in evaluating your cat’s physical, social, and emotional well-being.

Physical well-being is usually the easiest to assess. You need to consider your cat’s ability to:

  • Eat and drink
  • Eliminate waste
  • Keep herself clean
  • Live reasonably pain-free.

These conditions depend somewhat on her underlying health status, including any chronic illnesses. This is also where your ability to care for her, her tolerance for human help, and financial considerations are factored in.

Social well-being is a bit more subjective. Look at her interactions with you and any other pets you have. Can she still play, or does she even want to? Do her favorite toys still get a reaction? Does she still enjoy her favorite perches?

Emotional well-being is difficult to measure and may take a little anthropomorphizing, which means momentarily ascribing your cat human emotions. Does your cat still enjoy life? Considering your cat’s dignity may help you answer this question. Consider the same types of things that are considered in human health care, such as autonomy and respect from the other members of the household. Stress is another important factor. Some cats become stressed due to physical limitations, such as being unable to outrun the relentless, annoying dog.

There are no one-size-fits-all guidelines. Each cat has a unique set of circumstances surrounding their existence and their care. It’s up to you, as your cat’s caretaker, to determine what is most important. For those struggling, it can help to make an appointment with your cat’s veterinarian to outline her prognosis (whether you’re dealing with a disease or the infirmities of old age), a realistic path for a hospice or palliative care program, and how to handle the end of her life. “Realistic” means considering her health, your ability and time to care for her, and your finances.

Hospice vs. Palliative Care

The veterinary definitions for hospice and palliative care come from human medicine, in which the lines between the two types of care are becoming blurred. Both strive to keep the patient comfortable and as pain-free as possible. Palliative care generally starts with a diagnosis and overlaps the treatment protocol. So, palliative care, for example, would work to reduce your cat’s pain and help her eat and drink while she is undergoing radiation therapy for cancer.

Hospice starts when treatment options have been exhausted and life expectancy is six months or less. For most of us, that means keeping kitty at home and comfortable until a natural death or euthanasia occurs.

Dr. Alicia Brown (Cornell DVM, 2013) emphasizes that you should seek quality, pain-free time with your kitty rather than just more time without respect to her well-being.

End-of-Life Decisions

Most of us begin to make end-of-life decisions when our cat has a terminal illness or she has aged to the point at which her life becomes difficult due to things like arthritis pain making it too hard to reach the litterbox in time or to move around easily. Either way, it comes down to available treatments and how aggressive you should be in fairness to your cat.

For example, if she has chronic kidney failure, will she tolerate receiving subcutaneous fluids from you at home? Do you have the time, skill, and comfort level to give her subcutaneous fluids? If both you and your cat are OK with this procedure, it can add months to her life. If it amounts to a wrestling match, panic, and bloody scratches, this is not quality time. You don’t want your cat to run and hide whenever she sees you coming!

This is the time to go back to the Animal Hospice Care Pyramid and evaluate your cat’s life.

Safety and Environment: Restrict her to keep her away from potentially dangerous places, such as a staircase or aggressive housemate pets.

Mobility: Use ramps to help her go to her favorite places to rest. Move litterboxes and food and water bowls to one level. Get a litterbox with lower sides so she can step into it more easily.

Nutrition: For some conditions and some families, an in-place feeding tube might be the best solution for a cat’s final weeks if she cannot be prompted to eat via other means. If your cat won’t eat her prescribed diet, it won’t do her any good.

Hygiene: Can your cat eliminate on her own? If not, can you express her bladder and administer enemas as needed? There should be no guilt if you cannot. If she can’t eliminate on her own and has incontinence, will she handle you cleaning her? If not, she can develop bad ulcers and infections.  If your cat is at that stage, her time is likely limited, and she may not want the intense handling necessary for those procedures. Can your cat groom herself or will she allow you to groom her?

Pain Management: Most often, senior cats will experience some pain from osteoarthritis. Perhaps joint supplements and pain medications can help. Be aware that you and your veterinarian may need to attempt trials of different medications or a combination of medications to find the ideal fit for your cat. Virtually all medications come with some side effects, and you need to weigh these against your cat’s overall comfort. Once again, you also need to look at your part in this. Can you easily pill your cat? How about once a day versus three times a day? Can you get a flavored compounded medication into her or mix it with her food?

When it comes down to social and emotional well-being, you may need to dig deep into your own soul to determine your cat’s happiness. Take note of what she does. Is she happiest if you place her on her window seat in a sunbeam where she can watch your bird feeder? Does she want to lie on your lap in the evenings to watch TV? If she no longer enjoys playing with your other pets, do they realize and respect that?

While the thought of evaluating your cat’s emotional wellbeing may seem difficult, most of us intuitively sense how are pets are doing. A cat who has urinary incontinence and doesn’t want to be bathed regularly may give off more than a bad scent. You may also pick up on her unhappiness. You can sense frustration in the cat who has lost most mobility and clearly wants to go somewhere. Overall, your goal should be for your cat to have more “good” days than “bad” days.

When It’s Time

When it becomes clear that you can no longer keep your cat happy or comfortable, you must decide between a “natural” death and euthanasia. A “natural” death is often not pleasant. If your veterinarian feels that this is not an option for your cat, he/she will advise you of this. The oath taken when becoming a veterinarian compels your veterinarian to advocate for a humane end of life for your cat.

Many veterinary clinics have special arrangements for euthanasia, with a quiet time and place for the procedure. In some cases, your veterinarian may be able to go to your home or connect you to a veterinarian who provides that service. Sedatives are given to your cat first, so a catheter can be placed without discomfort. If you can stay with your cat, she may be calmer as she passes. If you are too distraught, however, it’s OK. Sedation can provide a sense of calm to cats during the euthanasia process.

The passing itself is usually quick and peaceful. While there may be a final breath, and bladder and bowels may be released as they pass, the combination of drugs used for feline euthanasia is believed to provide a pain-free, stress-free transition in the majority of cases.

Preferably, your family has decided ahead of time how to handle your cat’s remains. You might choose burial in a pet cemetery (some states allow home pet burials, some do not), or you may prefer a private cremation so you can take the ashes home. Again, whatever is most comfortable for you is right.

“Euthanasia is one of the most unselfish and courageous decisions you will ever make,” says Debra M. Eldredge, DVM (Cornell, 1980). You are accepting your heartache in return for a safe and humane ending for your pet. This is a decision made from love.

Feline Quality of Life Scale

The HHHHHMM Quality of Life Scale

Feline caregivers can use this scale to evaluate the success of their Pawspice program. Grading each criterion using a scale of 0 to 10 will help caregivers determine Quality of Life for sick cats. Score criterion:

H: 0 – 10 HURT – Adequate pain control, including breathing ability, is the first and foremost consideration. Is the cat’s pain successfully managed? Is Oxygen necessary?

H: 0 – 10 HUNGER – Is the cat eating enough? Does hand feeding help? Does the patient require a feeding tube?

H: 0 – 10 HYDRATION – Is the patient dehydrated? For cats not drinking or eating foods containing enough water, use subcutaneous fluids once or twice daily to supplement fluid intake.

H: 0 – 10 HYGIENE – The patient should be kept brushed and cleaned. This is paramount for cats with oral cancer. Check the body for soiling after elimination. Avoid pressure sores and keep all wounds clean.

H: 0 – 10 HAPPINESS – Does the cat express joy and interest? Is the cat responsive to things around him (family, toys, etc)? Does the cat purr when scratched or petted? Is the cat depressed, lonely, anxious, bored, afraid? Can the cat’s bed be near the kitchen and moved near family activities so as not to be isolated?

M: 0 – 10 MOBILITY – Can the cat get up without help? Is the cat having seizures or stumbling? Some caregivers feel euthanasia is preferable to a definitive surgery, yet cats are resilient. Cats with limited mobility may still be alert and responsive and can have a good quality of life if the family is committed to providing quality care.

M: 0 – 10 MORE GOOD DAYS THAN BAD – When bad days outnumber good days, quality of life for the dying cat might be too compromised. When a healthy human-animal bond is no longer possible, caregivers must be made aware that their duty is to protect their cat from pain by making the final call for euthanasia. The decision needs to be made if the cat has unresponsive suffering. If death comes peacefully and painlessly at home, that is okay.

*Total= * A total score >35 is acceptable Quality of Life for maintaining a good Feline Pawspice. (Created by Dr. Alice Villalobos. Visit her website at www.pawspice.com.)

Reprinted with permission from author Alice Villalobos, DVM, a founder of the Veterinary Cancer Society and a pioneer of hospice care for pets. Now retired, this 1972 graduate of the University of California at Davis School of Veterinary Medicine and former president of the Society for Veterinary Medical Ethics (svme.org) believes, “Veterinarians have to communicate compassionately yet frankly with clients regarding options for pets with cancer and other terminal diseases.”