In addition to ensuring relief from pain in our patients it is equally important to consider factors that may cause stress to a dog or cat in a hospital setting; stress like pain results in an unpleasant emotional state. It is helpful to think about the 5 freedoms that should be afforded to all animals and assess if these are being met in your hospital:

1.  Freedom from hunger and thirst

2.  Freedom from discomfort

3.  Freedom from pain, injury and disease

4.  Freedom to express normal behavior

5.  Freedom from fear and distress

Cats are especially susceptible to becoming fearful in a hospital setting. Inappropriate physical restraint and the stress of an unfamiliar environment will have detrimental effects; for example, distressed cats will have elevated catecholamine levels, increased heart rates and blood pressure, elevated cortisol and blood glucose levels and may be anorexic. These physiologic changes may result in an incorrect diagnosis being made.¹ A cat that is stressed will often resent handling that is required for treatment purposes resulting in suboptimal care.² The body postures adopted by cats that are fearful may be difficult to differentiate from those associated with pain adding to difficulty in our overall assessment of these patients. In addition, under these circumstances cats are more likely to become aversive to nursing care and retaliate resulting in personnel being bitten or scratched. It is important to understand that the number one cause of aggression in cats in these situations is fear. For a cat, what is familiar is safe; therefore, stressors to consider include the journey to the clinic,³ new smells, an unfamiliar environment and exposure to "strangers."

Cats that live primarily outdoors and are used to freedom may become very stressed when confined to a small cage. Veterinary clinics, and especially intensive care units, tend to be chaotic and the stimuli and smells present may be overwhelming to a cat. If a cat has never encountered a dog before, the noise and smell can be extremely distressing. Whenever possible cats and dogs should be separated (physically, visually and audibly). The impact of strange environments is often underestimated; Rochlitz and co-workers⁴ reported that it took up to five weeks for cats to show adaptation in quarantine facilities and several weeks for their cortisol:creatinine ratios to return towards normal. Zeiler and colleagues have also shown that young healthy cats admitted for neutering surgeries and housed in a cat-only ward with enrichment have altered behaviors and decreased food intake and elimination (urine and feces) for at least 24 hours.⁵

The use of a synthetic fraction of feline facial pheromones (Feliway®, CEVA Santé Animale) in a spray formulation was assessed for its calming effect on cats in a veterinary clinic before intravenous catheterization.⁶ The cage was sprayed with Feliway® or placebo prior to placing the cat in it and 30 minutes later cats were videotaped and behavior assessed by a blinded observer. The facial pheromone had additional calming effects in cats that had been sedated with acepromazine and, to a lesser degree, helped to calm cats that were not given acepromazine and the authors concluded that Feliway® helps to calm cats in unfamiliar surroundings. In another study which included clinically ill cats, a significant increase in facial rubbing, grooming, activity and interest in food were found in cats exposed to facial pheromones compared with placebo.⁷ Over a 24-hour period, food intake was significantly greater in cats exposed to pheromones and allowed access to a small cat carrier to hide in suggesting that exposure to Feliway® and the provision of a "private" place to rest is beneficial in hospitalized cats. Having access to a place to hide is an important coping mechanism for cats. This can be achieved at minimal expense, by using paper bags, cardboard boxes and placing a cover over the front of their cage. Pheromone spray can be used in cages, on tables and blankets and a diffuser can be used in the area where cats are housed. For dogs, Adaptil® (CEVA Santé Animale), which mimics the pheromone emitted by bitches after birth, can be helpful; this is available as a spray and in a diffuser.

It is essential that the veterinary care team is well trained in compassionate and respectful handling of canine and feline patients. Excellent guidelines have been published by the International Society of Feline Medicine and the American Association of Feline Practitioners. Information on creating a cat friendly clinic and detailed videos on examination and physical restraint techniques can be found at the CATalyst Council website (http://catalystcouncil.org) and at the Feline Advisor Bureau website (www.fabcats.org). The positive benefits of good nursing care with attention to cleaning, grooming, comfort and interaction cannot be underestimated in hospitalized cats and dogs. Excellent information on low stress, or "fear free" handling of dogs can be found at: https://drsophiayin.com/low-stress-handling.

Thermal comfort is important in hospitalized animals. Sick, sedated, young and old animals may not thermoregulate well and have little control over their environment. Nursing areas should be kept warm, and a warm "microclimate" can be provided by using insulated cages and kennels, keeping drafts to a minimum and providing blankets and areas to hide. The recommended thermoneutral zone for cats is 29–38°C (85–100°F).

Senior and geriatric patients frequently have degenerative joint disease and require special consideration. They require easy access to their cage or kennel (no high steps in or out) and soft comfortable bedding. They must be restrained gently, and positioned carefully, avoiding undue stress on their painful joints. Our older patients may also have cognitive dysfunction and be confused by a change in their routine. Whenever possible these patients should be treated on an outpatient basis; this may mean scheduling them for early in the day so they can be discharged later the same day.

The value of human interaction and "tender loving care" (TLC) should never be underestimated. If the only interaction a patient has with a human is related to a medical procedure, including having their temperature taken, they become anticipatory and associate human interaction with a negative experience. The treatment plan should include interactions that are positive, for example, playing, petting or grooming. Gourkow and Phillips reported that human interactions (4x10 minutes/day) helped maintain contentment, increased secretory IgA (a marker of mucosal immunity) and decreased upper respiratory tract disease in shelter cats.⁸

References

1.  Rodan I, Sundahl E, Carney H, Gagnon AC, Heath S, Landsberg G, et al. AAFP and ISFM feline-friendly handling guidelines. J Feline Med Surg. 2011;13(5):364–375.

2.  Carney HC, Little S, Brownlee-Tomasso D, Harvey AM, Mattox E, Robertson S, et al. AAFP and ISFM feline-friendly nursing care guidelines. J Feline Med Surg. 2012;14(5):337–349.

3.  Quimby JM, Smith ML, Lunn KF. Evaluation of the effects of hospital visit stress on physiologic parameters in the cat. J Feline Med Surg. 2011;13(10):733–737.

4.  Rochlitz I. Welfare of animals in quarantine. Vet Rec. 1999;144(20):568.

5.  Zeiler GE, Fosgate GT, van Vollenhoven E, Rioja E. Assessment of behavioural changes in domestic cats during short-term hospitalisation. J Feline Med Surg. 2014;16(6):499–503.

6.  Kronen PW, Ludders JW, Erb HN, Moon PF, Gleed RD, Koski S. A synthetic fraction of feline facial pheromones calms but does not reduce struggling in cats before venous catheterization. Vet Anaesth Analg. 2006;33(4):258–265.

7.  Griffith CA, Steigerwald ES, Buffington CA. Effects of a synthetic facial pheromone on behavior of cats. J Am Vet Med Assoc. 2000;217(8):1154–1156.

8.  Gourkow N, Phillips CJ. Effect of interactions with humans on behaviour, mucosal immunity and upper respiratory disease of shelter cats rated as contented on arrival. Prev Vet Med. 2015;121(3–4):288–296.