Managing Chronic Pain: Our Ethical Responsibility

Shifting our perspective from healing to management

When we are working with chronic pain patients, we need to shift our thinking from curative to management. It is normal for us to work with our patients with the goal of eliminating pain – pain is the enemy, right? We want to do all we can to get rid of the pain. But in chronic pain patients, this is not realistic. We need to understand that, rather than completely removing pain from our patients’ lives, our goal is to manage and minimize the pain.  In such cases, we’re seeking ways to help our patient and their owner to live relatively comfortably, even with some level of pain.

This may mean adjusting and evaluating our own beliefs around pain and length of life. Both we and the animal’s owner may have deeply ingrained perceptions about pain, specifically chronic pain, and an awareness of these beliefs may help us to see the issues more clearly. We know, for instance, that we have an ethical responsibility towards our patient and our patient’s owner to alleviate pain, but we also have to know our limits, and know when to recognise that further interventions will not help.

How beliefs shape the perception of chronic pain in pets

Every party involved in the care of an animal in chronic pain will have different beliefs about pain and the extent of intervention that should be offered to a suffering animal. Understanding the thinking of each party can help us to manage expectations more effectively, ensuring that all members of the team surrounding the patient are on the same page or pathway. This will reduce the risk of conflict or disagreements because of unmet expectations or fundamental differences in treatment approaches between different team members.

Chronic pain management will involve a series of compromises as treatment options are discussed and pursued. Understanding our beliefs can help to simplify these decisions when the time comes to make them.

Assess client goals and expectations.

While assessing client goals and expectations is important for every patient we see, this aspect becomes increasingly important for chronic pain patients, enabling us to help the owner set realistic goals and navigate challenging decisions on the pain management journey. Because chronic pain management involves many decisions where compromise or side effects are inevitable, it helps to know what is most important to the individual patient and client.

For some families, activity may be very important, while for others, physical activity is a much smaller part of their lives with their dogs. This simple differentiation can guide treatment decisions about the use of certain medications, some of which might control pain but reduce the dog’s ability to engage in physical activity. Together with the client’s goals, we need to consider the things that bring our patient the most enjoyment in life. Then we can figure out the best ways to retain as many of these elements in their lives as possible.  

Navigating compromises

Every decision in chronic pain management will come with a compromise or a risk. Making home modifications can mean adding carpets or runners to the house that one or more family members do not enjoy, or that are inconvenient. Daily NSAIDs come at the risk of side effects to the GI system, and high-quality supplementation comes at a financial cost. Additional pain medications can affect mentation, balance and coordination, and can come at the cost of active participation in family life.

Helping our clients to fully evaluate their own beliefs around pain, and to understand what is most important to them when it comes to their dog’s quality of life, will help guide these decisions as they come into play.

The pain management pyramid

The pain management pyramid can be used as a tool to build a strong foundation of pain management, and to understand what the higher tiers of pain management might include. This can give the owner the opportunity to look ahead at future possibilities for their pets.

When it comes to our role and ethical responsibility, we really want to ensure that the lower two tiers of the pyramid are as effectively implemented as possible. This includes client education, weight management, diet and supplementation, environmental modification, therapeutic exercise, veterinary physiotherapy, and acupuncture.

These interventions all have a dramatic impact on pain management, quality of life and length of life when effectively implemented, and can delay or reduce the amount of pharmaceutical intervention that needs to be used to control pain.

Education is an incredibly valuable tool and can be implemented in a variety of ways to support owners. In an interview, Ansi Van Der Walt shared how she runs online education programs that bring owners together in a supportive community to help them manage their pets’ pain. Enjoy the interview here.

Measuring quality of life

Having a tool available that provides a measure of quality of life can be helpful for the owner. This can take the uncertainty out of decisions surrounding the end of life, as well as help them to recognize when pain is no longer under control and additional pain management measures may need to be pursued.

There are multiple quality-of-life tools available online. Some of the measures to look for include:

• Social interactions, such as the pet’s desire to be around the family and to engage in family activities. The tool might also evaluate interactions with other family pets.
• Mental health, including signs of anxiety or stress, changes in their normal behaviour, such as no longer barking when the doorbell rings, or an increase in apathy or confusion.
• Physical health, including changes in breathing or excessive signs of pain like pacing, panting or excessive licking.
• Bodily functions, including changes to their appetite and drinking habits, urination and bowel movements.

Another area we need to consider is the impact on the family. While this area is generally not included in quality-of-life assessments, it is an important consideration in evaluating end-of-life decisions. The impact on the family can be significant, varying from increased financial strain to a deterioration in the physical health and quality of life of the caretakers, as a direct result of having to care for a pet that has lost mobility. There may come a time when only deterioration and worsening of the pet’s condition lies ahead – when pushing through the hardships will not prove in the best interest of any party concerned.

Dive deeper into the ethical challenges we face, and how we can effectively manage chronic pain patients.

Join us at the Vet Rehab Summit on 31 August 2024 as we take a deep dive into the ethical challenges we face as Vetrehabbers.

Here is what you can look forward to at our annual online, live conference:

1. Placebo treatments in evidence-based practice: ethical or not ethical? Ansi van der Walt.
2. When pain-free is not an option. Ansi van der Walt.
3. A skeptic’s guide to Librela. Mike Farrell.
4. Incorporating the Ridden Horse Pain Ethogram into Competition and Training. Sue Dyson.
5. Ethical dilemmas in small animal vet rehab – what are the options? Tanya Grantham.
6. Saddle-fitting the lame horse. Jochen Schleese.
7. End-of-life care decisions. Ansi van der Walt.
8. The ethical considerations and impact of dissections. Kevin Haussler.
9. Hold or pass? (When to refer, and when not to). Amie Hesbach.
10. How to influence, educate and drive change. Celeste Leilani Lazaris.

These are all fascinating topics that promise to give us a deeper, broader understanding of our responsibilities as compassionate, realistic and ethical animal rehabilitation therapists.  Hope to see you there!