# A Holistic Decision-Making Tool for Canine Chronic Kidney Disease: Navigating Palliative Care and Euthanasia

## TL;DR

This paper introduces a decision-making tool for managing end-of-life care in dogs with chronic kidney disease, balancing clinical data and ethical considerations.

## Contribution

A novel algorithm is proposed to guide ethical decisions in canine CKD by integrating clinical staging with quality of life assessments.

## Key findings

- The tool categorizes patients into three clinical pathways based on quality of life and disease progression.
- Tier C identifies cases where euthanasia is ethically appropriate due to therapeutic futility and declining quality of life.

## Abstract

Ethical decision-making in veterinary medicine often suffers from subjective bias, particularly in the management of terminal conditions like chronic kidney disease (CKD). This paper presents a structured algorithm that translates clinical scores into actionable ethical tiers. We redefine palliative care as an active medical commitment—focusing on the mitigation of uremic gastrointestinal distress and the prevention of metabolic crises—rather than a passive withdrawal of care. This framework provides a transparent roadmap for clinicians, ensuring that every intervention, from proactive palliation to compassionate euthanasia, is grounded in the principle of non-maleficence and the preservation of the animal’s dignity.

Background: Managing end-of-life decisions in canine chronic kidney disease (CKD) remains one of the most significant challenges in veterinary nephrology, requiring a delicate balance between clinical data and ethical considerations. Objective: This study introduces a novel decision-making algorithm designed to guide clinicians and owners through the complexities of end-of-life care, focusing on the assessment of Quality of Life (QoL) and disease progression. Methods: The tool integrates IRIS staging with a multi-parameter QoL checklist, categorizing patients into three distinct clinical pathways: Tier A (Active Palliative Care), Tier B (Intensive Monitoring/Ambiguous Zone), and Tier C (Compassionate Euthanasia). Results and Discussion: The algorithm defines Tier A as a proactive palliative pathway grounded in systematic clinical evaluation and continuous QoL assessment, aimed at preserving patient comfort and dignity. Across all tiers, QoL functions as a dynamic and central parameter, guiding transitions between clinical pathways in conjunction with objective indicators of disease progression. Tier C delineates the threshold of therapeutic futility, where declining QoL and biological resilience converge, and euthanasia is framed as an ethically appropriate option to prevent refractory suffering. Conclusions: By providing methodological transparency and clear clinical thresholds, this tool facilitates communication between veterinarians and owners. It ensures that palliation is approached with high-standard medical rigor while safeguarding the animal’s dignity when biological resilience is exhausted.