# Palliative care for dogs and cats in France: A qualitative and descriptive study based on professionals of the field

A. Loscos, Geneviève Marignac

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## To cite this version:

A. Loscos, Geneviève Marignac. Palliative care for dogs and cats in France: A qualitative and descriptive study based on professionals of the field. Ethics, Medicine and Public Health, 2023, 31, 10.1016/j.jemep.2023.100953. hal-04342565

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# Palliative care for dogs and cats in France: A qualitative and descriptive study based on professionals of the field

A. Loscos, G. Marignac

## Abstract

*Background.* — Little academic research has been done on palliative care for dogs and cats in France. However, palliative care (PC) is often practiced in veterinary hospitals without naming it precisely, providing great opportunities for the management of pets' life-threatening diseases. *Method.* — In order to assess how pet end-of-life support is performed and PC could alleviate associated ethical dilemmas, we performed a qualitative study by interviewing two human PC professionals and nine veterinarians who often deal with pet end-of-life. After these interviews, we also made a comparison with existing literature, which mainly consists on experiencesharing.

*Results.* — Globally, the interviewed veterinarians define palliative care for dogs and cats as the support of a dog or a cat with a life-threatening disease intended to treat clinical symptoms, pain and suffering without curing the patient, giving its quality of life a high priority. It can be done at any stage of the disease. Support should also be provided to the pet's owners, alwayswith emphasis on the quality of life of the animal. All veterinary interviewees, as opposed to human medicine professionals, overlooked the support to the veterinary team included in a structured PC approach. Such a platform should include both in clinics and ambulatory care in order for the severely ill pet to stay as much as possible in a familiar environment. This also requires render to owner competent in pet nursing.

*Conclusion.* — This preliminary work tends to show the relevance of the ethics of care approach structured PC would provide to pets. Support from professionals such as veterinary nurses is mandatory.
## Background

Second only to economic and financial constraints, end-of-life related issues are the cause of concern and dilemmas for veterinarians, similarly in urban and rural practices [1]. Caregiver burden is present twice as much among owners whose pet experiences a serious illness compared to those whose animal is healthy, as shown from an on-line study by Spitznagel et al. Results were confirmed when repeated by interviewing 238 veterinary clients, using the Zarit Burden Interview Protocol adapted for veterinary medicine. In this study, 124 pet owners expressed caregiver burden at levels that were found twice as high as in the control group, formed by blindly matched owners having a healthy pet. Aspects of burden covered were multiple, such as: feeling like there is insufficient time or financial resources to provide care, experiencing emotional responses like guilt, anger or fear, or measurements of stress, anxiety, depression and quality of life of the pet owner. The caregiver burden of these owners was above the level considered clinically meaningful when care is given to a seriously ill human being [2].

Organizational, financial, emotional and ethical challenges associated with pet end-of-life are thus shared by the veterinary care team and the pet owners and their relatives, nowadays referred to as the ‘pet family’. Euthanasia, how it is required or refused as well as how it affects veterinarians, is a common entry to the subject [3–5]. Exploring palliative care and how it is practiced is part of a wider project concerning how animal care professionals deal with end-of-life and what solutions they pragmatically find.

In the present work, palliative care for dogs and cats is defined as the support of a dog or a cat with a lifethreatening disease, intended to treat clinical symptoms, pain and suffering without curing the patient, giving its quality of life a high priority. It can be done at any stage of the disease and it also provides emotional support for the pet’s owners.

Palliative care was developed as a specific branch of medicine in the 1960s, first in the UK, then in other English-speaking countries [6], and then in France in the 1980’s [7,8]. The rise of this field in veterinary medicine began in North America and in the UK in the early 2000s, together with the development of animal ethology that showed that animals suffer from pain similarly to humans and the growing interest for animals in general [9–11].

The 2011 volume of *Veterinary Clinics of North America: Small Animal Practice*, a scientific continuing education publication, which is widely read by veterinary practitioners around the world, shed light on its relevance in veterinary medicine [12]. It was followed by another volume, eight years later [13].

Nevertheless, in 2023, literature research on PubMed and other scientific platforms about palliative care in veterinary medicine yielded little results, except that the species receiving the care were companion animals, almost only dogs and cats. This is related to the social position of these species in the various authors’ countries and a consequence to the amount of expenditure and emotional investment they induce from their caregivers.

The terms ‘palliative care’ and ‘animals’ retrieve several publications dealing with the presence of animals in human palliative care grounds. More specific articles mainly describe the organization of veterinary clinics that have developed palliative care [14], some clinicians’ personal approaches on the subject [15,16], the emotional and/or ethical challenges associated [4,17] and guidelines to
communicate with the owners [18]. Indeed, a 2016 literature review concludes: “veterinary hospice and palliative care is currently hindered by an inadequate amount of scholarly research to guide clinicians. Given a lack of prospective studies in veterinary hospice and palliative care to date, a significant opportunity exists for veterinary teaching institutions to contribute to the literature in an important and growing field” [19]. This situation is easily explained as animal health-oriented research is mainly associated with pharmaceutical development and human public health issues. Funds dedicated to specific pet’s conditions are scarce, originating only from charities, scientific organizations such as the Veterinary Academies or the Colleges of Veterinary specialists, or from the veterinary universities. In France, veterinary thesis is a welcome source for academic staff to advance on subjects that are important for the profession but otherwise would not get funded.

Since the 2016 conclusion, some studies have been performed on the neurological issues animal encounter [20] as well as the above-mentioned caregiver burden studies [2]. Also, advances have been made in pain and its management: e.g. a French veterinary network, *CAPdouleur*, is dedicated in pain management in animals by providing continuing training for veterinarians, information for owners and gathering scientific literature into reports [21]. But, if end-of-life care is done daily in veterinary clinics to manage pets' life-threatening diseases and to respond to owners' demands, and several private and academic veterinary clinics provide geriatric consultations, to our knowledge, only one practitioner in France, DVM Yessenia Alves-Leiva, specifically refers to be a palliative care veterinarian [22]. To our knowledge, palliative care in the veterinary field is not covered in the literature in France, nor is there any scientific society or study group about it.

The aim of the present work is to pave the way for reflection on palliative care for dogs and cats in France that would constitute a global and structured approach. It is based on interviews of professionals working in the field. This project is part of a wider scheme to develop tools to help veterinarians solve ethical problems related to end-of-life issues. Our original aim for the present work was to create a practical guide, collecting working methods, means of organization at the clinic's level and tips for veterinary practitioners. Considering the scarcity of publications in our country on that field, we thought that the first important step was to provide a definition of palliative care for pets and describing how this discipline is practiced. Writing a guide about it later became a secondary objective and we postponed the project to enquire pet owners' points of view.

## Material and methods

The common method of an on-line questionnaire sent to veterinarians was dismissed even though it would have allowed us to obtain enough answers to produce quantitative results. Several reasons orientated us towards a more qualitative method.

## Theoretical framework

Firstly, we had little insight from the literature as highlighted above. French veterinarians often refer to North American or English publication or even to human medicine. However, end-of-life issues are far from being purely medical. Therefore, we thought that the existence of cultural differences and species differences in a field with few scientific research was a problem and that the precise questions we would ask about it could have been irrelevant. This was confirmed by the opposite comments we had when talking
about the subjects to colleagues that ranged from “what are you talking about” or “there is no such thing as palliative care for animals” to “that’s my every-day practice”. Hence, we were unsure how an on-line questionnaire would be received.

Finally, our aim was to report on the practitioners’ point of view and describe their practices. For the very reason that we had preconceived ideas on what they could be, we aimed to obtain our answers from the field [23] using a method that would as little as possible insinuate our point of view to the interviewees. From an epistemological point of view, an open qualitative approach was considered a more pertinent preliminary approach than a quantitative one, as plausibility was a more desirable touchstone than falsifiability because we wanted the field to be the central location for the production of data: “the hero is the one we’re talking about, not the one who’s talking. We are interested in the one who speaks, epistemologically speaking, insofar as what he can tell us about his personal is necessary to understand what he tells us about others” [23].

The aim being to gather the interviewee’s opinion, including information that was not expected by us, semi-structured interviewing was chosen. It consists on asking the interviewee a set of pre-prepared open questions that encompass the subject widely as much as possible [24]. An important issue while preparing the questions, beyond them being clear and univocal, was to define which sub-subjects should be considered as out of scope. Semistructured interviews are designed to remain on the topic, as opposed to free interviews [25]. Nevertheless, as opposed to questionnaires or structured interviews, the order of items is not rigid: the conversation decides as it goes, while all subjects must have been discussed at the end of the interview.

## Semi-structured interviews

The first author was the interviewer, the present work being her veterinary thesis. She was instructed and coached by the last author during the whole process, from writing the interview guide, contacting interviewees, and debriefing each interview. These were performed in person or by videoconferencing.

Interviews were conceived to begin with a presentation of the present work, its objectives and method. Consent of the interviewees for the publication and the conditions of the interview was obtained orally and by the fact that they answered positively to our emailed solicitation to participate to this research.

The core of the interview began by asking what the interviewee considered being palliative care (PC), applications in veterinary medicine and his/her opinion on the reasons for the relative absence of veterinary PC in France. In accordance with the above-mentioned result of our literature research, the present study is restricted to dogs and cats. As we had not been able to identify any in clinics PC service, but only an ambulatory one provided at owner’s home, our second group of questions concerned interviewees opinion on such a service. We also asked them if they had had request from owners who wanted to perform PC for their pet in their home, and if so, if they could provide such a service. Finally, the interviewee was asked for any further comment on the subject (Table 1).

The discussion was free as long as it remained in the topic of dog and cat palliative care. At the end of the interview or to reboot the conversion, the interviewer checked that each subject had been covered.
From written notes or recording, depending on the interviewee's preference, the interview was typed as precisely as possible within one week. Each answer was then attributed to the relevant question(s) to compare them between interviewees [24]. Unexpected propositions or comments were gathered and received particular attention, as such analysis was expected to identify themes or comment that were not expected when creating the interview guide [26,27]. Thus, a descriptive content analysis was performed based on each question as opposed to thematic analysis.

## Target population

The interviewees were chosen for their experience of end-of-life situations and/or life-threatening conditions. Two were practicing palliative care in human hospitals (one nurse and one doctor). All other were veterinarians: three professors in internal medicine at one of the French veterinary Schools, two surgeons, one cancerologist and one veterinarian whose main activity is palliative care. In order to get the impression of young practitioners, two were interviewed that had displayed interest for humanities related to veterinary medicine (Table 2). Also, both were interviewed first and asked to comment on the interview. That resulted in a few clarifications.

## Results and discussion

All human and animal medicine professionals contacted accepted the interview, even though among the eleven interviewed professionals, two veterinarians did not comprehend at first the pertinence of the subject in veterinary medicine. Interviews lasted from 13 to 83 minutes; the average duration was 33 minutes. They were performed from November, 11th 2021 to January, 10th 2022. Six were performed by videoconferencing and five in person (Table 2). Response analyses resulted in rich responses and comments to each of the topics that were included in the interview guide. One responder kept commenting on how to tackle cancer in the dog in general and had difficulty to consider palliative care and end-of-life treatment as distinct medical disciplines

## What is veterinary palliative care?

To define what is and what is not palliative care (PC), at the beginning of the process we interviewed two human medicine professionals with over 15-year experience. They both underlined the global and multidisciplinary aspect of PC, as well as the emphasis on comfort and quality of life. One cited Cicely Saunders, a British nurse and physician considered the founder of PC: "what remains to be done when nothing more can be done", underlying that PC aims at supporting the patient until the end. This vision was highly relevant when Cicely Saunders, started practicing PC, at a time when in most hospitals, severely ill patients who cannot be cured were often disregarded [7]. Such hospice care soon raised the prejudice that PC teams were involved only when death is near, while PC has evolved to encompass global support to patients through any kind of critical disease, as underlined by both human medicine interviewees and the WHO definition [28].

The question of how they would define PC was also asked to each veterinarian. The compilation results in a definition that is less 'what it is' and more 'when it is appropriate' and 'PC goals and priorities': 'an animal is eligible for PC when affected by a life-threatening disease, whatever in a short or long term. The aim is to provide a global care of the animal's suffering and clinical signs regardless of the disease stage.
Quality of the animal's life (QOAL) is prioritized over cure and should be monitored before and along the care. The animal caregivers should receive regular support, including emotional support.”

The fact that PC was not reduced to near death condition but their definition encompassed all life-threatening condition may be associated to the very fact that they were interviewed on the subject as most interviewed veterinarians seem to associate PC to the question of euthanasia when answering our solicitation.

All interviewees underlined the importance of the veterinary-owners link in PC. The difficulties, especially time constraints associated with PC were mentioned but veterinary team care burden *per se* was not mentioned by the vet interviewees, as opposed to the human medicine professionals. Owners' support included addressing their worries about financial aspects. Even though the compilation of veterinary PC practices was no more an objective of the present work, QOAL scales are proposed (in French) in the veterinary thesis [29].

## What palliative care may bring to the animal, the owner and the veterinary team?

Even though several of them expressing at first doubts about the pertinence of PC in animals, seven of the nine veterinary interviewees finally agreed on the positive impact that PC implementation would have in France. They also explained that end of life care is provided mainly in a medical form in French vet clinics, whether private or academic, and not as a structured care encompassing all aspects of animal welfare as well as owner and vet team support.

All veterinary interviewees, in agreement with the human medicine professionals, eventually concluded that lots of situations and medical conditions would benefit from PC. For the animals, the main benefits stated were that their life could carry on even though curative medical treatment is not available, and that QOAL would be prioritized. For the owner, PC gives them more time with their pet and probably helps them deal with the disease and the perspective of death. A professor in surgery also indicated that the interest in end-of-life condition for pets induces advances in veterinary medicine beyond reducing pain: "when I was a student, 5-6 year old dogs would too often be euthanized because of intractable arthrosis. It is no more the case thank to medical and surgical advances." They also have radically changed the treatment of several chronic diseases (diabetes mellitus, cardiac or renal failure, hyperadrenocorticism, atopic dermatitis, etc.) and many cancers.

This benefit is confirmed by experiences shared in publications such as those of Tamara Shearer [30]. This author also states that providing PC also benefits the veterinary team. In a study about care burden, Spitznagel et al. tried to identify the reasons leading owners to consider euthanasia. The most significant reasons were general strain, guilt regarding what could have been done or what cannot be, the uncertainty associated with end-of-life conditions and affective or relational discomfort [31]. The latter can partly be improved or aggravated by the veterinary team [2].

All interviewees underlined that PC may provide a lot of satisfaction into giving care to the severely ill animal. This is counter-intuitive, as studies shows that veterinarians, like human medicine professionals, resent as a loss of sense of their presence near the sick animal or persons when cure is no more a significant objective. Ethical dilemmas associated include the appropriateness of medical interventions, the
justification of their billing, and, concern about animals' welfare and suffering [1,2,32]. The
identification of these questionings in previous research has been a leading reason to undertake the
present study [1,3,5].

The explanation about why PC brings satisfaction for the veterinary team may be that a PC environment
allows the practitioner to be relieved from the mental obligation to cure. This obligation is converted
into the possibility of taking care of the animal as a subject and no more as an object of diagnosis and
treatment [32].

Another ethically difficult end-of-life situation veterinarians now encounter is the refusal of euthanasia in animals, which they consider they cannot alleviate the suffering. It is particularly difficult to accept in countries where suffering is now considered unacceptable [1,4,33], as opposed to other countries, such as India, where the conservation of life is a prioritized moral value [34]. PC could be an ethical solution for these practitioners as it involves a change of perspective, and possibly a change of staff. Ideally, PC has to be a structured solution, which deals with the animal's welfare, and offers a global support to the animal and to its owners. Indeed, as one of the younger interviewees expressed: when a euthanasia is refused "one is obliged to continue medications [...] in order for the animal not to be in a state of unwellness." A professor in veterinary internal medicine accurately underlined that a common vision of PC is "the maintenance of vital function despite a desperate clinical condition." This shows that continuing education in the veterinary field is necessary to make PC a serious alternative to this feeling of medical helplessness.

As in human medicine, the importance to begin PC early in the progression of the disease cannot be
underlined enough. This anticipation also helps the owner organizing when his pet is still able.

Misconception associated with palliative care?

As underlined above, palliative care is often confused with palliative treatment. Nevertheless, PC also
includes nursing care, adaptation of the patient's environment and owner nursing education [14,35].
Another misconception is that curative treatments have to be stopped, while, as mentioned by the
interviewed nurse: "no care is banned in palliative care." She added: "patients can even undergo
surgery if the procedure is expected to provide relief. A typical example is when a person breaks a leg: no
morphine can relieve it better than a surgery." A similar misconception is that medical examinations are
stopped. The last two points differentiate hospice care from PC and highlight the importance of integrating
the latter early in the course of the disease.

Differentiating PC and therapeutic eagerness is a commonly raised ethical issue. Therapeutic eagerness
can be defined as a useless or disproportionate care aiming to maintain life artificially [36]. It is indirectly
banned by article

R. 242-33 of the French veterinary code of conduct indirectly that requires veterinarian to “respect animals” and professional good practices. Also, Article R. 242-35 requires clear, unambiguous, and timely provided communication[37]. Nevertheless, daily practice shows that it is often difficult to differentiate appropriate from excessive care. It may differ from one person to another, especially from ownerto veterinary team, and from one moment to another. Inveterinary medicine, the care
relationship is particularly complex, adding to this ethical dilemma. This relationship is often compared to the triangular pediatric alliance considering the ever-growing tendency of owners to consider themselves as pet-parents [38]. As opposed to infants, a pet is not expected to be able to give a consent, in the medical sense of the term, nor to become autonomous. What may be quality of life (QOL) for an animal is often questioned: QOL is assessed by humans and the theories of animal welfare are the viewpoints. Moreover, external factors, such as financial constraint and, in some cases, public health [39–41], also have much influence making the triangle more of a square. Structured PC is not only nursing and environmental care for the pet, nor is it only owner support, but has strong organizational and care team support aspects, as well as institutional and educational, as underlined by indicators developed by the WHO [42]. These remain overlooked by the veterinary interviewees, as previously underlined. Compared to human medicine professionals, the responsibility of veterinary act still remains completely personal, as stated by the first article of the French veterinary code of conduct (article R. 242-33-I) [37]. If veterinarians often informally discuss medical cases with colleagues or refer to a specialist, there is no obligation nor widespread culture to organizestaff concertation around difficult cases. In France, practice analysis is becoming compulsory some professions such as ombudsmen or PC team members but it is absent in the veterinary field even though a strong network of veterinary driven associations provides support to the profession [43]. Economic constraints, responsibility culture, lack of continuing education tackling these issues can be blamed.

Nevertheless, a recent study showing that French veterinarians suicide rate and suicidal ideations are roughly double those of both the medical and agricultural professions is prompting the professional institutions to tackle this problem and promote such support [44].

## The slow development of palliative care in companion animal medicine?

Compared to the sudden rise of pain assessment and control in veterinary care, [33,45], it is surprising that palliative care has not encountered the same evolution. Indeed, a lot of ethological work has been done in various species to accurately assess their signs of pain. This is also a great advance in term of veterinary education as most animal have little to no facial signs of pain.

In the meantime, even in North America or in the UK, palliative care is still scarcely proposed to pet owners while veterinarians seem to have the willingness to spare suffering during end-of-life time. Furthermore, effective medication is growingly available in various countries, as well as the scientific and practical knowledge to perform PC, including ethological data to assess environmental needs of most domestic animal species. Several publications detail how to organize the clinic and the staff to do so, whether in hospital [14,16,46] or at home [35], including communication tips [18].

The interviews of practitioners highlighted the role of euthanasia in dealing with terminally ill patients. As opposed to the human species, for which it is still a taboo and it is permitted only in few countries, a very different situation prevails for animals. Until recently, refusing euthanasia for a vet was considered as a weakness, if not a way to hide a lack of competence for this act.

## In clinic or at home palliative care?

Continuity of veterinary care is a deontological obligation enforced by the national body representing
the profession, *Ordre National des Vétérinaires*. Intensive care or hospitalization are listed by French regulation among the services that veterinary clinics or hospital may advertise, so-called “activity modules” (AC), but not PC [47]. To our knowledge, no French veterinary hospital, either private or academic, provides such a platform. Only an ambulatory service, e.g. at owners’ home, is available [22].

In western countries, hospitalized pets are housed in a private area of the hospital: owner's visits are short and often limited to once a day. This contrast to various Asian countries where one or several human family members remain with the pet in the veterinary clinic. In Western countries, like France, hospitalized pets are kept in a cage with the veterinary team being almost always the only humans present. Animal care organization is such that severely sick animals are either treated in the clinic in the absence of the owner or at home away from veterinary care. Financial and legal constraints may explain the lack of vet nursing services such as what is involved during PC. Pet insurances tend to lower the reimbursement conditions when pets age and there is often a maximum yearly level. In France, there is no such profession as veterinary nurse. Care-assistant ('aide-soignant vétérinaire') activity is legally restricted to the presence of a veterinarian, thus prohibiting any liberal veterinary nurse service. Recently, animal osteopath has been legalized that may open the way to new professions in animal care alongside veterinarians.

Except during hospitalization, nursing is left to the animal caregiver. Beside financial and legal constraints, the actual process of animal care requires the animal cooperation that is best achieved in familiar environment: persons and setting. The interviewee whose activity is end-of-life pet care also mentioned that at home, both animal and owners are less stressed, more themselves, and that she can readily spot how the home is organized and can become more adapted for the care. Other veterinary interviewees mentioned that home PC can become a real burden for owners, entailing their own QOL, as mentioned above in the literature. They cannot be required to learn and perform certain technical procedures properly and in a manner most respectful for the animal welfare. Another aspect has been underlined: “I think that some procedures are difficult to perform by owners: their technical aspect are intermingled with the very relation that owners have with their animal. This can lead to emotionally difficult situations.” How the care can effectively be performed by the owner and how the animal accepts has much influence on its very possibility. As noted by several interviewees, the veterinary team should make sure owners know how to decrypt species specific patterns to express pain, frustration, tiredness, eagerness, and attract their attention that body language is dominant in most mammals vs. facial language in humans. The QOL should also be monitored at home.

The questions related to the death of their pet are another competence that most veterinary internists interviewed consider important for owner to develop. Its natural occurrence may be considered preferable, as long as the animal QOL allows it, but can be a shock for an unprepared owner. An internist underlined that more than euthanasia, it is the process that lead to the requirement of euthanasia, e.g. the disease, the poor animal QOL, the reaching of the limits what pet-parents can bare mentally, in their fallibility and home and, financially. For instance, a surgeon observes that, if animal suffering is most frequent cause of euthanasia, his experience had made him realize that incontinence may be the cause of too much decrease of owner QOL so that it leads them to ask for the cessation of home care.
Conclusion and perspectives

As pets are increasingly considered as family members, the general evolution of companion animal medicine is not more herd and production oriented but individualized similarly to human medicine. Even though the European Board of Veterinary Specialization lists 38 specialties, none is dedicated to palliative care [48]. The absence of taboo concerning animal death, closely associated with domestication, as well as organizational and economic reasons, may explain why palliative care undergoes a much slower development than most veterinary fields. This is surprising because animal welfare considerations are routine in veterinary care, ingraining an intolerance toward animal suffering [49—51] that morally grounds euthanasia as a common end-of-life procedure in severely ill animals, at least in western countries [4,34,52]. This may explain why palliative care remains almost completely out of veterinary consideration, as evidenced by the first reaction of some interviewees. Animal oriented PC is seldom the subject of scientific research, and is absent in the veterinary curriculum [53], including recent European recommendations [54].

Nevertheless, the present literature analysis and interviews show that structured palliative care could be important in solving end-of-life related dilemmas that both veterinarians and owners encounter. To do so, PC needs to be proposed as platforms. Part of the service should be ambulatory to educate and support of owners at their home in the framework of regular communication with the in-clinic PC platform. Considering the cost of veterinary care and the shortage of these professionals, at least in France, this service should be performed by nurses. This requires allowing such a profession at institutional and legal level: the "aide soignant-vétérinaire" are care-assistants that work strictly under the veterinarian's responsibility. PC may also be a welcome opening for the recently created animal osteopath profession in France (article L. 243-3) [37].

More globally, deontological ethical considerations from veterinary professionals make them struggle to accompany globally the severely ill animal and the ‘pet-family’. Economic and cultural constraints scale down this support to medico-surgical considerations. Considering the present structure of veterinary private sector, their organization and management, the lack of research funding outside what is provided by the Pharmacy industry and absence of PC in academic curriculum, palliative care is out of the scope. A major limit is the financial consequences for the clinics to spend hours supporting an animal and owner and being unable to adequately bill this time to meet the costs. Allowing more systemic scrutiny, ethics of care [55,56] points out unexpected benefits. The animal can experience an end-of-life care mostly in the familiar environment of his home. The owners can have the expertise they have of their animal empowered by being educated to become a competent caregiver. Veterinary team, outside the veterinarians, can also develop competence and a necessary role, while rendering PC affordable for pet owners. Veterinarians can leave the nursing part to professionals, and, themselves benefit from share decision processing and get emotional and ethical support.
<table><caption>**Table 1** Main themes of the semi-structured interviewguide.</caption><thead><tr><th></th><th></th><th></th><th></th><th></th><th></th></tr></thead><tbody><tr><td></td><td>Short presentation of the work, interview conditions and use (thesis, publication) and consent</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>Interviewee background</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>Type and length of veterinary practice</td><td>Clinic members and organization</td><td></td><td></td><td></td></tr><tr><td></td><td>Professional activity beside veterinary clientele?</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>Palliative care in general?</td><td>Interviewee definition</td><td></td><td></td><td></td></tr><tr><td></td><td>Desirability/feasibility in veterinary medicine</td><td>Reasons for the relative absence in France</td><td></td><td></td><td></td></tr><tr><td></td><td>Palliative care in practice</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>In the clinic/at home and personal feedback</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>Reasons why owners request/do not request palliative care</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>Palliative care at the animal's home?</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>Should veterinary team discuss palliative care with owners?</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>Role of veterinarians/other people in palliative care: owners themselves, relatives, veterinary assistants/nurses...</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>Concluding questions: Are there any subjects we haven't discussed that you find relevant? Any other comment?</td><td></td><td></td><td></td><td></td></tr></tbody></table>

<table><caption>**Table 2** Semi-structures interviews: profile of persons interviewed, date, condition and length of each interview</caption><thead><tr><th></th><th>Interviewee</th><th>Type of exercise</th><th>Interview date</th><th>Visio/in person interview</th><th>Interview (minutes)</th></tr></thead><tbody><tr><td>1</td><td>General practitioner</td><td>Private practice</td><td>2021-10-11</td><td>Visio</td><td>20</td></tr><tr><td>2</td><td>General practitioner</td><td>Private practice</td><td>2021-10-12</td><td>Visio</td><td>13</td></tr><tr><td>3</td><td>Senior lecturer in veterinary internal medicine</td><td>Veterinary school</td><td>2021-11-22</td><td>In person</td><td>17</td></tr><tr><td>4</td><td>Certified palliative care nurse</td><td>Ambulatory palliative care human hospital</td><td>2021-11-26</td><td>In person</td><td>83</td></tr><tr><td>5</td><td>Professor in veterinary Surgery</td><td>Veterinary school</td><td>2021-12-02</td><td>In person</td><td>39</td></tr><tr><td>6</td><td>Doctor</td><td>Head of ambulatory palliative care human hospital</td><td>2021-12-09</td><td>In person</td><td>46</td></tr><tr><td>7</td><td>Veterinary practitioner</td><td>Ambulatory palliative care services</td><td>2021-12-21</td><td>Visio</td><td>34</td></tr><tr><td>8</td><td>Professor in veterinary internal medicine</td><td>Veterinary school</td><td>2022-01-05</td><td>Visio</td><td>27</td></tr><tr><td>9</td><td>Veterinary practitioner</td><td>Head of a private practice specialized in oncology and imaging</td><td>2022-01-05</td><td>In person</td><td>60</td></tr></tbody></table>
<table><tr><td>10</td><td>Professor in veterinary internal medicine</td><td>Veterinary school</td><td>2022-01-10</td><td>Visio</td><td>25</td></tr><tr><td>11</td><td>Specialized veterinary surgeon</td><td>Head of a private practice specialized in surgery</td><td>2022-01-10</td><td>Visio</td><td>36</td></tr></table>
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