2023 AAFP/IAAHPC feline hospice and palliative care guidelines

**Background** The '2023 AAFP/IAAHPC Feline Hospice and Palliative Care Guidelines' were authored by a Task Force of experts convened by the American Association of Feline Practitioners and the International Association for Animal Hospice and Palliative Care. They address the growing field of veterinary hospice and palliative care, which focuses on the physical, emotional, and social needs of cats with long-term or life-limiting diseases, while also attending to the psychological and social needs of their caregivers. The guidelines emphasize specialized communication skills, ethical considerations, and a comprehensive, multi-step hospice consultation tailored to both the cat and the family. Key concepts introduced include 'budgets of care' (financial, emotional, physical, and time resources) and the 'care unit', which expands the focus from the feline patient alone to include the caregiver and other support members. The guidelines aim to honor and preserve the human-animal bond throughout the end-of-life journey.

**Methods** The guidelines are a narrative review and expert consensus document, not a systematic review or clinical trial. They were developed by a task force of experts in feline hospice and palliative care, referencing other feline practice guidelines for specific diseases, pain management, and cat-friendly interactions. The document synthesizes existing literature, validated tools, and expert opinion to provide a practical framework. It includes references to published studies on pain assessment tools (e.g., UNESP-Botucatu scale, Glasgow CMPS-Feline, Feline Grimace Scale), quality of life instruments (e.g., a 20-item generic HRQOL tool), and pharmacological studies (e.g., frunevetmab for DJD pain). The guidelines also draw on human hospice models, such as the 'four box' bioethical framework and illness trajectory patterns.

**Key Results** The guidelines present a structured five-step hospice and palliative care plan: (1) evaluation of the caregiver's needs, beliefs, and goals; (2) education about the disease process and care delivery; (3) development of a personalized plan for the cat and caregiver; (4) application of hospice or palliative care techniques; and (5) emotional support during care and after death. Ethical decision-making is guided by four bioethical principles: respect for autonomy, non-maleficence, beneficence, and justice. Four illness trajectories are described: Type 1 (short decline, e.g., cancer), Type 2 (chronic illness with sudden death, e.g., cardiac disease), Type 3 (progressive decline, e.g., chronic kidney disease), and Type 4 (sudden severe insult, e.g., saddle thrombus). Pain management recommendations include opioids (e.g., buprenorphine 0.02-0.04 mg/kg IV/IM/oral transmucosally q8h for standard formulation; long-acting transdermal buprenorphine 0.4 ml for small cats or 1.0 ml for larger cats q4 days), NSAIDs (e.g., meloxicam 0.05 mg/kg PO q24h after a 0.1 mg/kg loading dose; robenacoxib 1.0-2.4 mg/kg PO q24h), monoclonal antibody therapy (frunevetmab 7 mg SC q30 days for cats 2.5-7.0 kg), and adjunct agents (e.g., gabapentin 5-10 mg/kg PO q8-12h, with 50% dose reduction in CKD). Quality of life assessment tools include a validated 20-item generic HRQOL instrument and non-validated tools like the HHHHHMM Quality of Life Scale. The five pillars of feline essential needs (safe place, multiple separated resources, play/predatory behavior, positive human-cat interaction, environment respecting senses) are adapted for hospice patients. Feeding tube use (e.g., esophagostomy tubes) is recommended for medication and nutritional support when oral intake is insufficient. Antiemetics (maropitant 1 mg/kg IV/SC/PO q24h; ondansetron 0.5-1 mg/kg IV/SC/IM/PO q8h) and appetite stimulants (mirtazapine transdermal 2 mg q24h; capromorelin 2 mg/kg PO q24h) are detailed.

**Clinical Implications** These guidelines provide a comprehensive, evidence-guided approach for veterinary professionals to deliver feline hospice and palliative care. The emphasis on the 'care unit' and 'budgets of care' ensures that treatment plans are realistic and respectful of the caregiver's resources and the cat's preferences. The bioethical framework helps navigate complex end-of-life decisions, while the validated pain and QOL tools enable objective monitoring. Practical recommendations for environmental modification (e.g., low-sided litter boxes, heated beds, ramps) and medication administration (e.g., using gelatin capsules, feeding tubes) aim to minimize distress and preserve the human-animal bond. The guidelines also highlight the importance of emotional support for caregivers, including recognition of anticipatory and disenfranchised grief. By integrating these principles, veterinary teams can improve the quality of life for feline hospice patients and support their families through the end-of-life process.