End Of Life Issues Research Articles

Medical students’ knowledge on palliative care – a survey of teaching in Finland

Background Most studies on palliative medicine (PM) undergraduate education have focused on contents and organizational issues but not the outcome. Students’ learning outcomes should be studied to improve teaching in medical schools. Methods A questionnaire about perceived PM education and attitudes on palliative care (PC) was sent to 543 last year students in all five Finnish medical schools in 2018–2019. In total, 175 (32 %) responses were received from four universities. The students evaluated both the quantity and quality of their PM teaching, implementation of European Association for Palliative Care (EAPC) guidelines and their satisfaction to the training. There were two palliative case scenarios, and the students were asked to find the best treatment option. In addition, students´ attitudes towards end-of-life (EOL) care issues were examined. Results In the Finnish universities, PM education was available mainly integrated with oncology, geriatrics, and general medicine. A total of two universities also offered a specific PM course. In average, 50–70% of the EAPC curriculum was covered by lectures, small-group teaching, seminars, and bedside teaching with significant differences between faculties. Only 30–60 % of students were satisfied with the education received. The highest rankings were given in the universities with a special PM course. Students from these universities expressed less anxiety in facing EOL issues. Conclusions In Finland, the coverage of EAPC curriculum is satisfactory, but the PM education is mainly given integrated with other specialties. The dedicated course on PM was associated with increased perceived knowledge and satisfaction of PM education. However, PM training was not associated with students’ attitudes on PC.

Medical students’ knowledge on palliative care – a survey of teaching in Finland

Background Most studies on palliative medicine (PM) undergraduate education have focused on contents and organizational issues but not the outcome. Students’ learning outcomes should be studied to improve teaching in medical schools. Methods A questionnaire about perceived PM education and attitudes on palliative care (PC) was sent to 543 last year students in all five Finnish medical schools in 2018–2019. In total, 175 (32 %) responses were received from four universities. The students evaluated both the quantity and quality of their PM teaching, implementation of European Association for Palliative Care (EAPC) guidelines and their satisfaction to the training. There were two palliative case scenarios, and the students were asked to find the best treatment option. In addition, students´ attitudes towards end-of-life (EOL) care issues were examined. Results In the Finnish universities, PM education was available mainly integrated with oncology, geriatrics, and general medicine. A total of two universities also offered a specific PM course. In average, 50–70% of the EAPC curriculum was covered by lectures, small-group teaching, seminars, and bedside teaching with significant differences between faculties. Only 30–60 % of students were satisfied with the education received. The highest rankings were given in the universities with a special PM course. Students from these universities expressed less anxiety in facing EOL issues. Conclusions In Finland, the coverage of EAPC curriculum is satisfactory, but the PM education is mainly given integrated with other specialties. The dedicated course on PM was associated with increased perceived knowledge and satisfaction of PM education. However, PM training was not associated with students’ attitudes on PC.

Patterns of Palliative Care Consultation in Neurosurgical Patients.

Numerous neurosurgical (NSG) conditions entail high morbidity, mortality, and prolonged ICU stays. Palliative care (PC) serves to alleviate suffering, align treatment with patient preferences, and is linked to enhanced patient and family outcomes as well as reduced care costs. Notably, no studies have addressed demographic and clinical factors associated with PC receipt in NSG patients. Our aim is to identify characteristics and outcomes, particularly end of life outcomes, of hospitalized NSG patients associated with a PC consult compared with usual NSG care. A retrospective chart review was performed of patients admitted to the NSG service from January 1, 2017 to December 31, 2018 at the University of Iowa Hospitals & Clinics. Data regarding demographics, clinical outcomes, and GOC and ACP documentation were collected. The most common reasons for a PC consult were goals of care, end of life issues, and comfort care. Of 121 total decedent patients, 97 (80.2%) had PC referrals. Patients with a PC referral had longer hospital stays (10.3days vs 4days) and had the majority of care in the ICU (90.7% vs 83.3%). However, fewer PC patients died in the ICU (42.3% vs 75%) and more had PCA/NCA use (51.5% vs 8.3%), code status changes to DNR (90.7% vs 62.5%), GOC documented (78.4% vs 0%) and ACP documentation (35.1% vs 16.7%). In conclusion, in NSG patients, the integration of PC may contribute to improved end-of-life care.

The difficult discussion on the deactivation of implantable cardioverter devices at the end of life: a systematic review.

Implantable cardioverter defibrillators (ICDs) reliably prevent death due to life-threatening arrhythmias; this may become less relevant in people with more severe heart failure who are reaching the end of life (EOL). This review aimed to explore the ICD deactivation process and identify ethical issues, especially around the initiation of relevant discussions among professionals and patients. Available literature was reviewed using four electronic databases to identify issues that may deter healthcare professionals from having important deactivation discussions and to address considerations for ICD management prior to the EOL. The search resulted in the retainment of 12 studies. Three themes emerged from the data: barriers and facilitators, ethical considerations in clinical practice, and nurse's role. Lack of knowledge, which has been associated with cultural differences, has been found among the barriers, and interdisciplinary education and open communication appeared as facilitators. As clinicians' ethical considerations and fears emerged from the literature, nurses' special role has not been sufficiently supported. Complex care requires facilitation by multidisciplinary teams and education around the device's function regarding EOL issues. Establishing expert consensus statements on advance care planning might help define the distinct roles of each healthcare practitioner involved. Further research is needed in addressing the identified gaps.

To Plan or Not to Plan? Experiences and Challenges of Older Swiss Adults Facing End-of-Life Decisions.

End-of-life (EoL) planning and the drafting of advance care directives (ACD) are challenging for older adults. As part of a mixed study, the content of 18 semi-structured interviews with Swiss community-dwelling older adults was analyzed to investigate contextual and interactional aspects that might influence their choice to complete ACD. Results show that EoL planning vary greatly. Three types of planners were highlighted: the solo planners, the collaborative planners, and the delegators. Each represents a specific way of conceiving autonomy, the usefulness of ACD and of involving third parties in the decision-making process. Whereas for solo planners, ACD is a personal, rational affair, for collaborative planners and delegators, reflection and decisions on EoL issues are interactional and iterative processes. The results suggest that health and social care professionals would benefit from taking into consideration the various types of planning, in order to provide the best support to older adults for ACD completion.

Caregivers’ Perspectives Towards Goals of Care and End of Life Issues in Egyptian Elderly Attending Geriatric Hospital

Caregivers’ Perspectives Towards Goals of Care and End of Life Issues in Egyptian Elderly Attending Geriatric Hospital

Factors associated with cancer patients' distinct death-preparedness states.

Facilitating death preparedness is important for improving cancer patients' quality of death and dying. We aimed to identify factors associated with the four death-preparedness states (no-preparedness, cognitive-only, emotional-only, and sufficient-preparedness) focusing on modifiable factors. In this cohort study, we identified factors associated with 314 Taiwanese cancer patients' death-preparedness states from time-invariant socio-demographics and lagged time-varying modifiable variables, including disease burden, physician prognostic disclosure, patient-family communication on end-of-life (EOL) issues, and perceived social support using hierarchical generalized linear modeling. Patients who were male, older, without financial hardship to make ends meet, and suffered lower symptom distress were more likely to be in the emotional-only and sufficient-preparedness states than the no-death-preparedness-state. Younger age (adjusted odds ratio [95% confidence interval]=0.95 [0.91, 0.99] per year increase in age) and greater functional dependency (1.05 [1.00, 1.11]) were associated with being in the cognitive-only state. Physician prognostic disclosure increased the likelihood of being in the cognitive-only (51.51 [14.01, 189.36]) and sufficient-preparedness (47.42 [10.93, 205.79]) states, whereas higher patient-family communication on EOL issues reduced likelihood for the emotional-only state (0.38 [0.21, 0.69]). Higher perceived social support reduced the likelihood of cognitive-only (0.94 [0.91, 0.98]) but increased the chance of emotional-only (1.09 [1.05, 1.14]) state membership. Death-preparedness states are associated with patients' socio-demographics, disease burden, physician prognostic disclosure, patient-family communication on EOL issues, and perceived social support. Providing accurate prognostic disclosure, adequately managing symptom distress, supporting those with higher functional dependence, promoting empathetic patient-family communication on EOL issues, and enhancing perceived social support may facilitate death preparedness.

The end of life issues - Part 2

The end of life issues - Part 2

End-of-life offerings in US medical schools: 1975-2020

ABSTRACT Forty-five years ago, the first author of this paper surveyed the US medical schools to determine their offerings on EOL (End-of-Life) issues. The results showed limited exposure for medical school students to learn about dying and death, thus their “learning” was apparently on-the-job training. The EOL offerings were so limited that the American Association of Medical Colleges (AAMC), following the 1975 publication from the survey, contacted the first author to inquire about death and dying in the curricula of their medical schools. Apparently, it was so insignificant that the AAMC did not have such information. Palliative medicine, geriatric medicine, and hospice were then in the “birthing” process, a mere blur on the horizon. Today, as in 1975, it is likely that most medical students have personally had minimal experience with death and that for many entering students, other than on television, the cadaver is their first sight of a dead person. The objective of this research is a longitudinal study at five-year intervals since 1975 reporting on EOL education in US medical schools. The total number of medical schools has increased from 113 in 1975 to 150 in 2020. The current study surveyed medical schools electronically and via postal services with a response rate of 37%. Findings from the survey over time revealed significant inclusion of death and dying and palliative medicine as well as geriatrics and hospice. Gross anatomy has evolved from strictly hands-on to integrating 3D/virtual models, a change not without controversy. A noticeable difference in emphasis is obvious as care now plays a more significant role in medical training than previously, thus making modern medicine not only about cure, but more about care than was previously emphasized. Communication with dying patients and families, analgesics for chronic pain, and advance directives all are covered in over 90% of schools today. The current emphasis on EOL care, not just disease management, is increasing and puts more of a human face on modern medicine.

Factors That Determine the Experience of Transition to an Inpatient Palliative Care Unit for Patients and Caregivers: A Qualitative Study.

Objective: Transitions in care settings near the end of life can present challenges to patients and families, especially when there are also adjustments in level of care and illness trajectory. In this study, we explored what factors influenced how patients and family caregivers experienced a transition to an inpatient Palliative Care Unit (PCU). Methods: This qualitative study was conducted at a PCU in Toronto, Canada. Semi-structured interviews were held with 29 participants (14 patients and 15 family caregivers) during their time on the PCU. Data was analyzed through an iterative process of constant comparison to generate themes. The recruitment process continued to the point of thematic saturation. Results: Five themes were identified that represented the participants’ experiences in transitioning to the PCU: Being prepared, Feeling supported, Coming to terms with end of life issues, Dealing with uncertainty, and Continuity of care. Conclusions: Our findings highlight the need for clear and iterative communication with patients and family caregivers during the transition to a PCU. Identification and consideration of the common themes involved in the experience of transfer to PCU can help guide future practice and improve the experience of patients and families during transitions at the end of life.

A mini-review of end-of-life management of wind turbines: Current practices and closing the circular economy gap.

Renewable energy generation and increased electrification are pivotal to reducing greenhouse gas emissions and mitigating climate change. Consequently, global deployment of wind turbines has soared, and the trend is expected to continue. Installed turbines have only recently started reaching the end of their design lives, and waste volumes are projected to escalate rapidly. Approximately 94% of a wind turbine (by mass) is recyclable, but the waste polymer composite blades are most commonly landfilled. This mini-review aims to review current end-of-life (EoL) management practices in the large-scale wind industry for countries with established EoL standards as well as those with less mature regulations. Data on current EoL management practices, initiatives and regulations in industry was sourced primarily from literature reviews and publicly available internet information. Additional insights and perspectives were gained from WindEurope's EoL Issues and Strategies 2020 seminar and through communication with select individuals from various sectors such as wind energy development and operations, government, industry associations, academia and research organizations. The results show that the decision on EoL options is dictated by the remaining useful life (RUL) of the wind turbines, prevailing policies and electricity prices. The contribution of this article is, firstly, identifying a number of key technical, economic and regulatory questions that must be asked before deciding on the most appropriate EoL option. Secondly, the article identifies factors that impede current EoL management efforts to close the circular economy gap and those that can support sustainable technology deployment. Finally, the article considers the way that countries with a young fleet of wind farms may learn from more experienced nations. There are few proven business cases, and barriers to the profitability and effectiveness of EoL strategies include uncertainty about the assets' RUL, collection logistics, the size of wind farm operation margins, low waste feedstock and limited markets for recycled products. Designing for circularity, stakeholder collaboration, circular business models and technology-specific regulations can improve EoL sustainability. The research found that wind turbine EoL management is dynamic and complex and needs to consider multiple, often conflicting factors. However, it is necessary and has immense environmental, technical and economic potential as the industry matures and business cases are proven.

Large-scale evaluation of a computer-based learning program to increase prison staff knowledge on geriatric and end-of-life care

PurposeThe purpose of this study is to continue research and development of the ECAD-P learning system with an emphasis on developing a scalable unit for testing in a larger number of more diverse correctional settings. There are almost 2.3 million US persons incarcerated. Geriatric and end-of-life (EOL) care in corrections is not as equitable as care in the free world. Technological delivery of geriatric training to staff through computer-based learning (CBL) offers a novel approach to improve care and reduce disparities among those who are most vulnerable during confinement.Design/methodology/approachThis mixed methods study built an interactive CBL for multidisciplinary staff to address EOL and geriatric issues in prisons. The CBL was iteratively built and tested prior to launching a full-scale evaluation using a pre/post-intervention design.FindingsEvaluation of the CBL occurred at 7 sites (i.e. 6 state prisons and 1 prison health-care vendor). A total of 241 staff were recruited with 173 completing post-tests. Outcomes were knowledge acquisition regarding care for aging and dying incarcerated persons (i.e. cognitive measure) and attitudes, motivations and values for providing care (i.e. affective measure). Cognitive and affective post-tests were significantly better than at pre-test (all ps < 0.01). ANCOVAs revealed no significant differences for sex or ethnicity.Originality/valueOutcomes reveal that the CBL is acceptable, feasible and usable in corrections. Staff improved their knowledge after receiving the training. Correctional settings face increasing pressures to better address the health care and management needs of aged, chronically ill and dying incarcerated persons. This e-learning holds promise to contribute to better preparation of corrections staff to effectively care for these populations.

Palliative Care and End-of-Life Issues in Elderly Cancer Patients With Head and Neck Cancer.

The number of elderly patients with incurable head and neck cancer will increase. They are in need of geriatric palliative care, that takes into account oncology, palliative care and geriatric medicine. In this review of the most recent and relevant literature and includes the expert opinion of the authors, several physical problems (e.g. pain, fatigue, malnutrition, and loco-regional problems) encountered by the elderly head and neck cancer patients are addressed. In addition end-of life issues in this patient population are discussed.

End-of-Life Care for End-stage Heart Failure Patients.

Efforts to improve end-of-life (EOL) care have generally been focused on cancer patients, but high-quality EOL care is also important for patients with other serious medical illnesses including heart failure (HF). Recent HF guidelines offer more clinical considerations for palliative care including EOL care than ever before. Because HF patients can experience rapid, unexpected clinical deterioration or sudden death throughout the disease trajectory, choosing an appropriate time to discuss issues such as advance directives or hospice can be challenging in real clinical situations. Therefore, EOL issues should be discussed early. Conversations are important for understanding patient and family expectations and developing mutually agreed goals of care. In particular, high-quality communication with patient and family through a multidisciplinary team is necessary to define patient-centered goals of care and establish treatment based on goals. Control of symptoms such as dyspnea, pain, anxiety/depression, fatigue, nausea, anorexia, and altered mental status throughout the dying process is an important issue that is often overlooked. When quality-of-life outweighs expanding quantity-of-life, the transition to EOL care should be considered. Advanced care planning including resuscitation (i.e., do-not resuscitate order), device deactivation, site for last days and bereavement support for the family should focus on ensuring a good death and be reviewed regularly. It is essential to ensure that treatment for all HF patients incorporates discussions about the overall goals of care and individual patient preferences at both the EOL and sudden changes in health status. In this review, we focus on EOL care for end-stage HF patients.

Conceptualizing impact in community-based participatory action research to engage communities in end-of-life issues.

Background:A health promotion approach to end-of-life (EoL) care is gaining traction internationally. However, there is a lack of evaluations of the impact of this approach, particularly regarding community-based initiatives. Conceptualizations of impact in participatory action research (PAR) may contribute to understanding ways in which impact can be investigated in community-based health promotion approaches to EoL issues. We aim to investigate impact and the process of impact development in our community-based PAR project, Studio DöBra, a Swedish health promotion initiative to engage communities in EoL issues.Methods:We do this through a qualitative framework analysis expanding on Banks et al.’s theory of co-impact in PAR, based on longitudinal empirical data of Studio DöBra. Studio DöBra was developed in partnership with a range of community organizations and engaged children (9 years old) and older adults (most 80+) with topics related to dying, death, and loss through arts activities. The analyzed empirical data reflect the perspectives of community-partners and academic partners from interviews and meetings spanning 4.5 years.Findings:We present a model of impact development consisting of impact on individual and group development, action-oriented impact, and strategy-oriented impact; ways they relate to and evolve from one another; and how they may be affected by contextual influences.Conclusion:Besides contributing to conceptualizations of impact in PAR, findings contribute a community perspective to the limited literature investigating the impact of health promotion initiatives related to EoL issues.

Chapter 10 - Prognostication in brain tumors

Despite the use of aggressive multimodality therapies, the prognosis of brain tumor patients remains poor. Tumors of glial origin typically have the worst prognosis, with a predicted median survival of 12-15months for glioblastoma multiforme (WHO grade IV) and 2-5years for anaplastic glioma (WHO grade III). Palliative care problems and needs in patients with primary and secondary brain tumors are significantly different, both due to different trajectory of disease and to variable prognosis which in metastatic brain tumors is related to the natural history of primary tumors. This chapter describes the complex interactions influencing communication and the treatment decision process in primary brain tumor patients. The whole trajectory of disease and particularly the end-of-life (EOL) phase of brain tumor (BT) patients are quite different in respect to the expected trajectory observed in the general cancer population. The need to improve the communication of prognosis in BT patients has been clearly reported in neuro-oncological literature, but several issues may hinder a good communication in these patients. Adequate prognostic awareness (PA) is important for several reasons: to respect patient autonomy, to obtain her/his preferences about treatments and goal of care, and to share EOL treatment decisions. The high incidence of cognitive deficits in BT patients is one of the most challenging issues influencing the quality of communication and the participation of patients in the process of treatment decisions. Impaired neurocognitive functions may impact capacities of understanding, appreciation, reasoning, and expression of choice, reducing Medical Decisions Capacity (MDC). The lack of capacity to express preferences about EOL treatment decisions represents an important ethical issue, with a great impact on both the patient's family and healthcare professionals involved in the decision processes. Also, patients' coping styles may have an important influence in critical aspects of care such as communication of diagnosis and prognosis, discussion with patients and their caregivers about goal of treatments, early introduction of PC, and advanced planning of patients' preferences concerning EOL treatment and issues. Several barriers hinder good communication in BT patients. This chapter analyzes emerging literature data and possible strategies to improve communication about prognosis and goals of care and to promote patients' involvement in the treatment decision process particularly in the palliative care setting.

End-of-Life Communication in the Emergency Department: The Emergency Physicians' Perspectives.

Introduction:End-of-life (EOL) conditions are commonly encountered by emergency physicians (EP). We aim to explore EPs’ experience and perspectives toward EOL discussions in acute settings.Methods:A qualitative survey was conducted among EPs in three tertiary institutions. Data on demographics, EOL knowledge, conflict management strategies, comfort level, and perceived barriers to EOL discussions were collected. Data analysis was performed using SPSS and SAS.Results:Of 63 respondents, 40 (63.5%) were male. Respondents comprised 22 senior residents/registrars, 9 associate consultants, 22 consultants, and 10 senior consultants. The median duration of emergency department practice was 8 (interquartile range: 6–10) years. A majority (79.3%) reported conducting EOL discussions daily to weekly, with most (90.5%) able to obtain general agreement with families and patients regarding goals of care. Top barriers were communications with family/clinicians, lack of understanding of palliative care, and lack of rapport with patients. 38 (60.3%) deferred discussions to other colleagues (e.g., intensivists), 10 (15.9%) involved more family members, and 13 (20.6%) employed a combination of approaches. Physician's comfort level in discussing EOL issues also differed with physician seniority and patient type. There was a positive correlation between the mean general comfort level when discussing EOL and the seniority of the EPs up till consultancy. However, the comfort level dropped among senior consultants as compared to consultants. EPs were most comfortable discussing EOL of patients with a known terminal illness and least comfortable in cases of sudden death.Conclusions:Formal training and standardized framework would be useful to enhance the competency of EPs in conducting EOL discussions.

Duration of life in the three common variants of primary progressive aphasia: A retrospective study in a tertiary memory clinic

AbstractBackgroundPrimary progressive aphasias (PPAs) are a group of neurodegenerative disorders characterized by an insidious and progressive language impairment. Clinical expression and underlying pathology remain highly heterogeneous. To date, there is a lack of knowledge on the natural history of each of the three main variants, particularly mortality. Moreover, advanced stages and end of life issues are rarely discussed with caregivers and families at diagnosis. In turn, this can cause additional psychological distress.We studied the natural history of the three main variants of PPA. More specifically, we focused on mortality and end of life issues in an attempt to better prepare patients and their families.MethodWe retrospectively studied all deceased patients with a diagnosis of PPA that had been followed at our tertiary memory clinic over the past twenty years (n=83). Clinical data included age of onset of symptoms, duration of illness, age at death and specific cause of death.ResultAge at death was similar across all three PPA variants but there was less variability in the non‐fluent variant (nfvPPA) group (M=76.6, SD=6.2) than in the semantic variant (svPPA; M=74.1, SD=8.5) or the logopenic variant (lvPPA; M=76.1, SD=9.1) groups. Age at onset of symptoms was earlier for svPPA participants (M=64.5, SD=8.3) then for the two other variants (lvPPA: M=69.3, SD= 10.7; nfvPPA: M=70.4, SD=6.3). Consequently, duration of the disease (number of years between symptoms’ onset and death) was longer for svPPA participants (M=9.6, SD=3.0) than for nfvPPA and lvPPA participants (respectively M=6.2, SD=2.1 and M=7.0, SD=2.9). Surprisingly, cause of death was unknown for most of the participants. When available (n=15), it included sepsis (n=6), respiratory failure (n=4), neoplasia (n=3) and stroke (n=2), and. There were no differences in causes of death among PPA variants.ConclusionDespite similar age of death across PPA variants, disease duration was longer in the svPPA. Causes of death per se were similar among PPAs. Future studies should include more participants with better emphasis on causes of death. Nonetheless, our study provides useful information about the natural history of the common variants of PPA.

Discussion of advance care planning on end-of-life decisions with lung cancer patients in Wuhan, China: attitude, timing and future directions.

BackgroundProgress in advance care planning (ACP) in China has been hindered for decades compared with other countries.AimsTo describe knowledge of ACP, end‐of‐life (EOL) care preferences and the predictors of patients' preference for ACP, as well as who should mention ACP among Chinese lung cancer patients.MethodsQuestionnaire‐based interviews were carried out. Two hundred and fifty‐eight lung cancer patients were recruited when first admitted to Tongji Hospital from October 2017 to November 2018. Social‐demographic factors, which might influence patients' preference on ACP decisions and who should mention ACP, were evaluated using multivariate logistic regression analysis.ResultsA total of 91.1% (n = 235) of patients favoured ACP on EOL issues. One hundred and sixty (60%) patients wanted to make EOL decisions on their own. Only 10% of patients were familiar with advance directions. Eighty‐two (31.8%) patients were familiar with do not resuscitate/do not intubate (DNR/DNI) directions. ACP was not mentioned in 92.2% of patients. Gender (male, OR = 4.87 (2.16–5.83)), tumour stage (Stage III, OR = 0.108 (0.06–0.51); Stage IV, OR = 1.780 (1.02–2.11)) and number of children (every increase in the number of children, OR = 0.267 (0.09–0.93)) were the significant predictors of preference for autonomous ACP. Female patients and patients currently receiving treatment are 2.743 and 1.8 times, respectively, more willing to need ACP initiated by doctors.ConclusionsChinese patients showed preferences towards ACP, but with inadequate knowledge. More assistance is needed with ACP for those patients, especially for females, patients with one child and those with early stage lung cancer. For female patients and patients receiving treatment, doctors may initiate ACP dialogue first.

Veterinary professionals’ experiences with human caregivers when providing animal hospice and palliative care

Abstract A significant role in veterinary medical practices is the provision of end-of-life (EOL) care to pets and their clients. Yet, U.S. veterinarians report being dissatisfied with the level of training they receive on EOL issues in their veterinary medical programs ( Dickinson et al., 2011 ). At the same time, the ubiquity of veterinary information on the Internet (e.g., “Dr. Google”) has the potential for instilling pet owners with a false sense of expertise that veterinarians must then negotiate when providing EOL care. In this context, we surveyed 86 veterinary members of the International Association for Animal Hospice and Palliative Care (IAAHPC) to explore whether and/or how veterinary medical information clients obtain from the Internet impacts the veterinarians’ delivery of EOL care to those clients’ pets; we similarly investigate the information that veterinarians prefer their clients knew before meeting with them to provide EOL care. In light of the inherent challenges of EOL veterinary care outlined above, we learn from veterinarians what they feel are the most challenging and rewarding aspects of providing palliative and hospice care. Using qualitative thematic coding, our results show, in sum, that veterinary information from the Internet is both helpful and harmful to veterinarian interactions with clients; veterinarians wished clients understood the value of hospice and palliative care as an EOL care option and that grief is normal; and veterinarians report a most positive aspect of dealing with these issues is the gratitude clients show for helping their pets die peacefully.