Episode 31: Patient Suffering in the ICU

October 12, 2026

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In this episode of Wheeler the Healer: Small Animal Emergency and Critical Care, Lance Wheeler, DVM, DACVECC explores patient suffering in the veterinary ICU and reframes it as both an ethical and physiologic problem rather than simply an emotional one. Inspired primarily by Chapter 12 of Small Animal Critical Care Medicine, 3rd edition, the episode examines primal alert signals like dyspnea, pain, nausea, thirst, hunger, anxiety, and sleep deprivation, emphasizing that critically ill animals often experience many of these simultaneously. The discussion reviews why air hunger may be more distressing than pain, how untreated nausea and sleep disruption can worsen recovery, and how ICU noise, repeated handling, and hospitalization stress may contribute to physiologic instability. Integrating recent literature on dyspnea-targeted therapy, anxiolytics, feline environmental modification, wireless monitoring, and individualized nursing care, the episode focuses on practical strategies to reduce suffering in real time. Ultimately, the episode argues that comfort-focused interventions are not separate from critical care—they are a fundamental part of stabilizing the critically ill patient.

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Episode Transcript

Hey everyone, welcome back to Wheeler the Healer: Small Animal Emergency and Critical Care—practical ECC education to keep you sharp when it matters most.

My name is Lance Wheeler, and I’m a small animal emergency and critical care specialist.

In this episode, we’re shifting gears a bit from the last discussion. Previously, we focused on interstitial edema, fluid movement, and the physiology happening at the tissue and vascular level during critical illness. Now we’re zooming back out and focusing on the patient’s actual experience in the ICU— what critical illness and hospitalization may actually feel like to dogs and cats, and how suffering itself can influence physiology, recovery, and patient care.

The material for today is inspired by Small Animal Critical Care Medicine, 3rd edition, specifically Chapter 12, “Patient Suffering in the Intensive Care Unit,” by Matthew Mellema. I’m also going to weave in relevant literature on dyspnea, sleep disruption, ICU noise, hospitalization stress, and practical comfort-focused interventions where they help us apply these ideas in real time.

Why should an ECC clinician care about patient suffering? Because suffering is not just an ethical issue. It’s a physiology issue. Dyspnea, pain, nausea, thirst, hunger, anxiety, sleep deprivation, and generalized discomfort can all affect cardiovascular stability, oxygen demand, immune function, appetite, patient tolerance of care, and recovery.

And the reality is this—critically ill animals are rarely suffering from just one thing. A dyspneic patient may also be painful, nauseated, thirsty, exhausted, hungry, anxious, and unable to sleep. If we only treat the disease and ignore those unpleasant sensations, we may miss a major part of the patient’s critical illness.

So today, we’re going to take a practical approach to patient suffering in the ICU—defining suffering, connecting it to primal alert signals and basic physiologic needs, exploring why dyspnea may be even more distressing than pain, reviewing symptom burden in critically ill patients, and translating all of that into real-time clinical interventions we can apply in the ER and ICU.

As I call out key numbers or define important terms, take a second to repeat them to yourself. That repetition helps reinforce what you already know and lock in the details that are most testable. At the end, we’ll review them again during the rapid-fire board review so you can check your recall and reinforce them one more time.

A useful working definition of suffering is an experience of unpleasantness and aversion associated with the perception of harm or threat of harm. That definition matters because it moves us beyond pain alone. Suffering can come from actual tissue injury, but it can also come from the perception that something essential is threatened. The patient may not understand their disease, but their nervous system is constantly monitoring whether core needs are being met.

That brings us to the idea of primal alert signals. These are deeply conserved warning systems that tell the animal something important is wrong or becoming dangerous. Pain is probably the easiest example to understand. Pain is the alert signal for threats to tissue integrity. When tissue is injured or at risk of injury, nociceptive pathways generate an unpleasant sensation that drives protective behavior: pull the paw away, stop using the injured limb, avoid repeating the harmful action.

But pain is only one type of alert signal. Dyspnea is the alert signal for inadequate ventilation or air hunger. Thirst is the alert signal for disrupted water balance. Hunger is the alert signal for inadequate nutrient intake. Nausea is the alert signal associated with toxin exposure or harmful substances within the GI tract. Drowsiness and exhaustion are the closest signals we have for sleep debt, even though sleep deprivation doesn’t create one single, well-defined sensation the way pain or thirst does.

This is important because ICU patients often have multiple alert signals firing at the same time. A dog with aspiration pneumonia may be dyspneic, painful from coughing, nauseated from medications or ileus, thirsty from restricted oral intake, hungry from anorexia, and exhausted from noise and handling. That’s not just ‘stress.’ It’s multiple physiologic distress signals happening at the same time.

One helpful mental model comes from Abraham Maslow, who proposed the hierarchy of needs in 1934. The basic idea is that living beings prioritize survival needs first, and only once those are reasonably met can they focus on higher-level needs. Maslow organized those needs into a hierarchy, starting with basic physiologic needs like breathing, water, food, and sleep. Above those come safety, social connection, self-esteem, and ultimately self-actualization, meaning fulfillment of one’s potential. The important point for us in critical care is that when the most basic physiologic needs are threatened—especially breathing—everything else becomes secondary.

For veterinary ICU patients, the most clinically relevant part of this hierarchy is the physiologic foundation. The body prioritizes the most immediate survival needs first. Air and effective breathing come before everything else. Next comes protection of tissue integrity, followed by toxin avoidance and waste clearance, then water balance, nutrient intake, and finally sleep. Each of these needs is linked to its own primal alert signal: dyspnea signals inadequate ventilation or air hunger, pain signals tissue injury, nausea signals toxin exposure or GI threat, thirst signals disrupted water balance, hunger signals inadequate nutrient intake, and drowsiness or exhaustion signal accumulating sleep debt.

That order matters. Air hunger appears to take priority over many other unpleasant sensations. Human hospice patients experiencing both pain and dyspnea often report dyspnea as the more unpleasant sensation. In experimental models, dyspnea can make pain less noticeable, but pain does not make dyspnea less unpleasant. In animal studies, many animals will remain hungry rather than enter an environment that produces dyspnea.

That should change how we think about respiratory patients. Oxygen saturation is important, but oxygen saturation is not the same thing as comfort. A patient can have an acceptable peripheral oxygen saturation, or SpO2, and still feel air hunger.

So when we assess a dyspneic dog or cat, we’re not just asking, “Is the oxygen number okay?” We’re asking, “Is this patient experiencing air hunger?” That question changes the treatment goal from oxygenation alone to relief of respiratory distress.

A 2022 study titled “Effects of Inhaled Furosemide on Dyspnea and Pulmonary Function in People With COPD: A Literature Review,” by Zeina Atwi, reviewed inhaled furosemide as a potential therapy for dyspnea in people with chronic obstructive pulmonary disease. The review included 4 publications, including 3 randomized controlled trials, and found that 3 studies reported statistically significant improvement in patient-reported dyspnea, while pulmonary function values improved across the included studies. The clinical point is not that we should automatically nebulize furosemide in every veterinary respiratory patient. The point is that dyspnea relief can be treated as its own therapeutic target, separate from simply chasing oxygen numbers.

A 2025 study titled “Comparison of the Effects of Inhalant Furosemide, Oxygen Therapy, and Placebo in Patients With Acute Dyspnea Referred to Emergency Departments by EMS in Various Hospitals in Tehran,” by Mahdi Rezai et al., evaluated acute dyspnea treatment in people aged 18 to 75 years. Patients received nebulized furosemide, oxygen, or placebo in the prehospital setting. The furosemide group received 40 mg of furosemide in 10 mL of distilled water, and all patients received oxygen at 8 to 15 L/min by nebulizer mask. Dyspnea intensity, heart rate, blood pressure, and oxygen saturation improved over time, but between-group differences were not statistically significant for most of those parameters. Hospitalization duration was shorter in the furosemide group, while intensive care unit admission duration was shorter in the oxygen group. The clinical meaning is that inhaled furosemide remains interesting, but it’s not a magic bullet. For us, it reinforces a broader principle: dyspnea is a symptom worth targeting directly, but we still need careful case selection and veterinary-specific evidence.

Now let’s move from dyspnea to pain. Pain is the primal alert signal we already monitor most aggressively, and that’s appropriate. Pain scoring, multimodal analgesia, local anesthetic techniques, opioids, nonsteroidal anti-inflammatory drugs when appropriate, ketamine, lidocaine, gabapentinoids, and nursing care all matter. But pain control should not make us complacent. A comfortable pain score does not mean the patient is comfortable overall. A dog can have good incisional analgesia and still be thirsty, nauseated, sleep-deprived, and anxious.

Nausea is another major source of suffering that is easy to underestimate. Nausea is linked to toxin avoidance and waste clearance. It drives aversive behaviors like food refusal and vomiting, but it can also show up as lip licking, drooling, swallowing, hiding, hypersalivation, food aversion, or just “not right.” In critical care, nausea may come from gastrointestinal disease, pancreatitis, uremia, medications, ileus, vestibular disease, opioids, chemotherapy, or systemic inflammation.

A 2022 study titled “Effectiveness of Orally Administered Maropitant and Ondansetron in Preventing Preoperative Emesis and Nausea in Healthy Dogs Premedicated With a Combination of Hydromorphone, Acepromazine, and Glycopyrrolate,” by Jasper Burke et al., highlights how common opioid-associated nausea may actually be in dogs. Healthy dogs premedicated with hydromorphone, acepromazine, and glycopyrrolate developed vomiting in 61% of untreated controls and signs of nausea in 87% of untreated controls.

That 87% number is honestly remarkable.

The investigators specifically evaluated behaviors associated with nausea, including hypersalivation, lip licking, hard swallowing, restlessness, hunched posture, and retching. Those are behaviors ECC clinicians see constantly in hospitalized patients, especially after opioid administration, but they are easy to dismiss as “stress,” dysphoria, or just odd behavior in the hospital environment.

The study found oral maropitant administered 2 hours before premedication reduced vomiting from 61% to 10% and reduced nausea from 87% to 10%. Ondansetron reduced nausea severity and incidence compared with controls but did not significantly reduce vomiting.

One especially useful point from the discussion was the authors’ observation that hypersalivation, lip licking, and hard swallowing may actually be the most reliable clinical indicators of nausea in dogs. Clinically, that matters because vomiting is easy to recognize, but nausea is often much more subtle. A hospitalized patient repeatedly lip licking, swallowing, drooling, refusing food, or appearing generally uncomfortable may be nauseated even if they never vomit.

And that becomes important in the ICU because untreated nausea doesn’t just contribute to suffering. It may worsen appetite, delay nutritional recovery, increase aspiration risk, increase handling stress, and make patients appear behaviorally anxious or painful when nausea is the major driver of their discomfort.

This is important because anorexia in the ICU’s not always just lack of appetite. Sometimes it’s untreated nausea. And if nausea prevents eating, then hunger and nutrient deficit begin stacking on top of nausea. That creates a miserable loop: the patient feels sick, doesn’t eat, becomes weaker, develops more GI dysfunction, and may become harder to discharge.

Thirst deserves more attention than it usually gets. We often assess mucous membrane moisture as a hydration marker, but we don’t always treat dry mouth as an unpleasant symptom. That distinction matters. A patient may be appropriately restricted from large-volume oral intake and still benefit from small amounts of oral liquid, oral swabbing, ice chips when safe, or other strategies to keep the mouth moist. This is an important nuance: maintaining oral comfort is not the same thing as allowing uncontrolled water intake.

Human ICU data make this point hard to ignore. In critically ill people, thirst and dry mouth are consistently reported as distressing symptoms. In veterinary patients, we can’t ask about dry mouth, but we can recognize when patients have tacky mucous membranes, prolonged panting, oxygen therapy, anticholinergic exposure, fever, dehydration, or restricted oral intake. Those patients may be uncomfortable even if the fluid plan is medically appropriate.

Hunger is similar. In critical care, we often think about nutrition in terms of calories, protein delivery, nitrogen balance, and recovery, but hunger itself is also an unpleasant physiologic experience. Critically ill patients may be anorexic because of disease, but they may also simply be unable to eat normally. An Elizabethan collar may make food difficult to access. Weakness may prevent the patient from reaching the bowl comfortably. Repeated procedures or interruptions may prevent them from settling down long enough to eat. And unlike pain or vomiting, hunger rarely presents as an obvious clinical sign in ICU patients. Instead, it may show up more subtly as restlessness, agitation, attention-seeking behavior, chewing at lines or bedding, or even a noticeably improved demeanor after assisted feeding.

Now let’s talk about sleep. Sleep is a fundamental physiologic need, and ICU sleep disruption is probably one of the most underrecognized forms of suffering. Patients may be awakened by alarms, treatments, vital checks, cage cleaning, blood sampling, medication administration, barking, bright lights, and staff movement. Severe sleep debt may eventually lead to microsleeps, which are involuntary sleep episodes lasting 1 to 60 seconds.

A 2025 study titled “Factors Affecting Sleep Among Dogs and Cats in a Veterinary ICU,” by Emma Devereux et al., evaluated 96 dogs and 16 cats in a veterinary ICU over 4 weeks. Dogs were observed asleep for a median of 40% of observed time, while cats were observed asleep for only 11% of observed time. During natural nighttime hours, defined as 9:00 PM to 6:00 AM, the odds of a patient being asleep were 1.7 times higher when lights were dimmed. Patients were less likely to be asleep as noise increased, with an odds ratio of 0.66 for each increase in noise level. The clinical meaning is simple: light and noise are not background details. They are modifiable ICU variables that affect whether patients sleep.

A 2020 study titled “Noise Levels in an Academic Veterinary ICU,” by Josephine Dornbusch et al., measured veterinary ICU noise levels for 41 days. The average noise level was 77 A-weighted decibels, the median was 76 decibels, and the maximum was 87 decibels. For perspective, normal conversation is usually around 60 decibels, a vacuum cleaner is roughly 70 decibels, and heavy city traffic is often around 80 to 85 decibels. The louder ICU periods occurred from 6:00 AM to 9:00 AM and 6:00 PM to 9:00 PM. The clinical point is painfully practical: our ICUs are loud, and our patients are trying to recover inside that soundscape.

Sleep fragmentation is not benign. Repeated sleep disruption in dogs caused by alarm sounds has been associated with systemic hypertension. In a busy ICU full of fluid pump alarms, syringe pump alarms, monitor alarms, ventilator alarms, barking patients, and shift-change noise, it’s very plausible that sleep disruption contributes to physiologic instability in some patients.

A practical ICU goal should be protected rest whenever medically safe. That means clustering treatments. Dimming lights overnight. Reducing alarm volume when safe. Responding to alarms quickly. Avoiding unnecessary cage-side conversations. Planning blood draws and medication timing thoughtfully. And recognizing that waking a patient is not neutral. Sometimes it is necessary. Sometimes it is not.

A 2025 study titled “Validation of Wireless Harness for Measuring Respiratory Rate, Heart Rate, and Body Temperature in Hospitalized Dogs,” by Jessie Warhoe et al., evaluated a wearable wireless harness designed to continuously monitor respiratory rate, heart rate, and body temperature in hospitalized dogs. The investigators collected 87 paired measurements in 19 hospitalized dogs and compared harness measurements to standard manual monitoring.

What makes this study especially relevant here is the underlying goal behind the technology. Repeated vital checks mean repeated handling, restraint, awakenings, and interruptions of rest. The authors specifically discussed the possibility that continuous wireless monitoring could reduce patient stress by decreasing the need for repeated physical interaction.

The harness tracked heart rate and respiratory rate trends reasonably well, although agreement was not strong enough to replace manual confirmation for clinical decision-making. But honestly, the bigger takeaway is conceptual: in critical care, there’s always a balance between monitoring the patient and disturbing the patient. We need serial reassessment, but every interaction also has the potential to interrupt sleep, increase stress, worsen anxiety, or contribute to handling fatigue in already exhausted animals.

This brings us to symptom clustering. In human ICU patients, unpleasant symptoms rarely occur in isolation. Dyspnea, thirst, tiredness, anxiety, generalized discomfort, hunger, pain, depressed feelings, and nausea often overlap. One human ICU study found unaddressed symptoms in 100% of patients. All patients reported some degree of dyspnea. Other symptoms were also common, including thirst, tiredness, anxiety, hunger, generalized discomfort, pain, depressed feelings, and nausea.

A related human ICU cancer-patient study found that 6 symptoms occurred at moderate-to-severe levels in more than 50% of patients. Those 6 symptoms were discomfort, unsatisfied thirst, difficulty sleeping, anxiety, pain, and unsatisfied hunger. Depression and dyspnea occurred at moderate-to-severe levels in 34-39% of patients.

In chronically critically ill people, more than 50% prevalence was reported for all 16 assessed symptoms. Those symptoms included weight loss, lack of energy, inappetence, pain, dry mouth, hunger, drowsiness, dyspnea in 2 settings, insomnia, nausea, difficulty communicating, thirst, worry, sadness, and nervousness. Some of those translate imperfectly to dogs and cats, but the overall message translates extremely well: critically ill patients can carry a large symptom burden that’s easy to miss if we only focus on survival.

The practical veterinary translation is that anxiety and discomfort should trigger a broader checklist. Is the patient painful? Dyspneic? Nauseated? Thirsty? Hungry? Sleep-deprived? Unable to urinate or defecate normally? Too hot? Too cold? Unable to hide? Unable to rest? Unable to see the owner? Unable to perform any normal behavior?

A 2021 paper titled “The Introduction of a Patient Admission Tool, or PAT, as an Aid to Tailored Nursing Care in a Small Animal Referral Hospital,” by Juliet Morrison, explored the use of a structured owner-completed questionnaire to help veterinary nurses provide more individualized inpatient care.

We discussed this paper briefly back in Episode 2 during the ICU physical exam discussion, but it fits even better here because it highlights how individualized care may reduce patient suffering.

The core idea was simple: owners often know small details about their pet that dramatically affect comfort and stress in the hospital, but those details may never be captured unless someone intentionally asks. The admission tool collected practical information like food preferences, toileting habits, handling tolerance, medication behavior, sleeping habits, temperament, grooming routines, preferred treats, and even whether the patient responded to commands in another language.

A patient refusing food may not truly be anorexic—they may hate the bowl placement, dislike the food texture, refuse to eat near dogs, or only eat when hand-fed. A patient labeled “aggressive” may simply panic during certain types of restraint. A dog repeatedly urinating in the kennel may not be incontinent at all—it may simply need more frequent walks or a familiar toileting routine.

The broader takeaway is that reducing suffering is not always about adding another medication. Sometimes it’s about understanding the individual patient well enough to modify the environment, handling style, feeding strategy, or daily routine in a way that makes hospitalization less distressing.

A 2025 study titled “Determination of Serum Cortisol Levels as a Stress Marker in Hospitalized Dogs,” by Emre Tüfekçi et al., evaluated 30 dogs divided into 3 groups: 10 hospitalized dogs, 10 outpatient-treated dogs, and 10 healthy controls. Dogs were monitored over a 3-day period. Cortisol differed significantly between groups on day 1, with hospitalized dogs having higher cortisol than outpatient and healthy dogs. On day 2, hospitalized and outpatient dogs still differed, but by day 3 cortisol did not significantly differ between hospitalized and outpatient dogs. The clinical meaning is that hospitalization can measurably activate stress physiology, but some dogs may adapt over time as they become familiar with the environment, procedures, or caregivers.

A 2016 study titled “Effects of Trazodone on Behavioral Signs of Stress in Hospitalized Dogs,” by Shana Gilbert-Gregory et al., evaluated 120 hospitalized dogs, including 60 dogs treated with trazodone and 60 environmentally matched control dogs. The mean trazodone dose was approximately 4.7 mg/kg orally, with most dogs receiving about 4 mg/kg every 12 hours. Dogs were evaluated shortly after treatment and again about 90 minutes later. Compared with controls, trazodone-treated dogs showed reductions in stress-associated behaviors such as lip licking, panting, and whining. They were also more than twice as likely to show reductions in panting and frantic stress-related behaviors, such as pacing, inability to settle, or repeated attempts to escape restraint. The clinical takeaway is that anxiolysis can be an important part of humane critical care, especially when anxiety is worsening patient distress or interfering with patient care.

A 2024 study titled “Orally Administered Gabapentin and Alprazolam Induce Comparable Levels of Anxiolysis and Sedation in Cats,” by Virginia Papageorgiou et al., evaluated 60 healthy female cats admitted for elective ovariohysterectomy. Cats received gabapentin at 100 mg per cat, alprazolam at 0.125 mg per cat, or placebo 90 minutes before evaluation. Gabapentin and alprazolam produced similar sedation levels, and gabapentin-treated cats had lower stress scores than placebo-treated cats. Clinically, this supports what many of us see every day: preemptive anxiolysis can make feline hospitalization and handling less aversive.

But medications are only part of the answer. Environmental modification matters too, especially in cats.

A 2017 study titled “The Use of Hides to Reduce Acute Stress in the Newly Hospitalised Domestic Cat,” by Louise Buckley and Laura Arrandale, evaluated 30 newly hospitalized cats admitted for elective neutering. Cats provided with a cardboard hide had lower stress scores after only 20 minutes of hospitalization compared with cats without hides, along with small reductions in heart rate and respiratory rate. And importantly, the cats actually used the hides, overwhelmingly choosing to sit inside the box rather than on top of it. The practical takeaway is simple: hiding is often a normal coping behavior, not something we should reflexively interrupt.

A related 2021 study titled “Evaluation of a Stimulus Attenuation Strategy to Reduce Stress in Hospitalized Cats,” by Regan Stoneburner et al., evaluated cats exposed to simulated veterinary ward noise and visual stimuli while allowing them to choose between unshielded cage fronts and cage fronts partially covered with clear or opaque plexiglass barriers. Cats with higher stress scores preferentially chose the cage fronts that provided the greatest reduction in visual and auditory stimulation. The authors specifically discussed common feline ICU stressors including unfamiliar dogs, foot traffic, bright lights, and ambient noise in mixed-species hospital environments.

And honestly, these studies reinforce something feline clinicians have been saying for years: many hospitalized cats are not being difficult. They’re trying to feel safe. Sometimes reducing suffering is as simple as giving the cat a place to hide, reducing stimulation, and allowing some degree of environmental control.

A 2022 study titled “Evaluation of Music Therapy to Reduce Stress in Hospitalized Cats,” by Juliane Paz et al., evaluated 35 hospitalized cats exposed to cat-specific music, classical music, or no music over 31 hours. Cat-specific music increased positive social interactions during the first evaluation, and classical music was associated with lower respiratory rate than control at the fourth evaluation. The Cat Stress Score did not differ among groups, and salivary cortisol was not useful in that study. The clinical takeaway is not that music fixes feline stress. It’s that sensory environment may influence specific behaviors and physiologic variables, and stress reduction often requires multiple small interventions rather than one dramatic fix.

A 2024 study titled “The Influence of Noise Level on the Stress Response of Hospitalized Cats,” by Marisa Girão et al., evaluated 33 female cats undergoing elective ovariohysterectomy and grouped them by ward noise exposure: quiet under 60 decibels, medium 60 to 85 decibels, and noisy over 85 decibels. Stress scores, respiratory rate, and plasma cortisol tended to increase with higher noise levels and longer exposure. Respiratory rate correlated strongly with final stress value, with a Spearman rho of 0.91. The clinical takeaway is that respiratory rate in a hospitalized cat may reflect more than cardiopulmonary disease. It may also reflect stress.

So where does this leave us clinically?

It means palliative care is not separate from critical care. It is part of good critical care. Treating dyspnea, pain, nausea, thirst, hunger, anxiety, and sleep deprivation is not “extra.” It’s patient stabilization. It’s also likely to improve handling tolerance, reduce negative patient-caregiver interactions, improve workplace safety, and potentially reduce sedative and analgesic escalation.

In real time, this means we should be more proactive. Offer small amounts of oral liquids when safe, even if large-volume oral intake is restricted. Keep the mouth moist. Treat nausea early. Use validated pain scoring serially. Cluster treatments to minimize awakenings. Create quiet periods with reduced lighting overnight. Encourage owner visitation when appropriate. Get patients outside for a portion of the day when it’s safe. Provide opportunities for normal behaviors. Give cats hiding spaces. Reduce visual exposure to dogs. Use anxiolytics when fear, anxiety, or stress are worsening the patient’s experience or interfering with care.

And when a patient seems restless, don’t reflexively assume the answer is more sedation. Ask what unmet need might be driving the behavior. Is this dyspnea? Pain? Nausea? Thirst? Hunger? Exhaustion? Fear? A full bladder? A wet cage? A line pulling? A beeping pump? A dog barking across the room?

A 2025 study titled “Is It More Stressful for Dogs to Be Examined on a Table Versus the Floor? A Randomized Crossover Study,” by Pierrette Mercier et al., evaluated 37 dogs undergoing standardized physical examinations on both an exam table and the floor. Interestingly, the investigators found no major overall difference in stress scores, heart rate, or respiratory rate between the two examination surfaces. Some dogs appeared more comfortable on the floor, while others tolerated the table well, suggesting that handling style and patient preference may matter more than the surface itself.

And honestly, I think that’s an important ICU concept. Sometimes we get locked into routines that prioritize convenience over patient comfort. But critically ill animals may feel safer with less restrictive handling, more owner involvement, lower-stress examination techniques, or simply being allowed to stay where they appear most comfortable. The goal is not to eliminate handling—it’s to reduce unnecessary distress whenever possible while still delivering appropriate medical care.

And I think that’s really the central idea here.

Addressing suffering is part of stabilizing the critically ill patient.

Now let’s finish with the rapid-fire board review.

- Suffering can be defined as unpleasantness and aversion associated with perceived harm or threat of harm.

- Pain is not the only unpleasant sensation critically ill animals may experience.

- Primal alert signals are warning systems tied to fundamental physiologic needs.

- Dyspnea is linked to air and alveolar ventilation.

- Pain is linked to tissue integrity.

- Nausea is linked to toxin avoidance or clearance.

- Thirst is linked to water balance.

- Hunger is linked to nutrient intake.

- Drowsiness and sleep debt are linked to the need for sleep.

- Abraham Maslow proposed his hierarchy of needs in 1934.

- Maslow’s classic model has 5 tiers: physiologic needs, safety and security, love and belonging, self-esteem, and self-actualization.

- The physiologic subhierarchy discussed here has 6 major needs: air, tissue integrity, toxin avoidance or clearance, water balance, nutrient intake, and sleep.

- Dyspnea may be more unpleasant than pain in patients experiencing both.

- Microsleeps are involuntary sleep episodes lasting 1 to 60 seconds.

- One human ICU study found unaddressed symptoms in 100% of patients.

- One human ICU cancer-patient study found 6 moderate-to-severe symptoms in more than 50% of patients: discomfort, unsatisfied thirst, difficulty sleeping, anxiety, pain, and unsatisfied hunger.

- In that same population, depression and dyspnea occurred at moderate-to-severe levels in 34% to 39% of patients.

- In one veterinary ICU sleep study, dogs were observed asleep for a median of 40% of observed time, and cats were observed asleep for a median of 11% of observed time.

- During nighttime hours from 9:00 PM to 6:00 AM, dimmed lights increased the odds of sleep by 1.7 times.

- Increasing noise reduced the odds of sleep, with an odds ratio of 0.66 for each increase in noise level.

- Veterinary ICUs routinely reach noise levels comparable to heavy city traffic.

- In hospitalized cats exposed to noise, respiratory rate correlated strongly with final stress value.

- Trazodone reduced several behavioral signs of stress in hospitalized dogs.

- Gabapentin and alprazolam produced comparable sedation in cats when evaluated 90 minutes after administration, and gabapentin-treated cats had lower stress scores than placebo-treated cats.

- In one opioid-associated nausea study, untreated dogs premedicated with hydromorphone, acepromazine, and glycopyrrolate developed vomiting in 61% of cases and signs of nausea in 87% of cases.

- In that same study, oral maropitant administered 2 hours before premedication reduced vomiting from 61% to 10% and reduced nausea from 87% to 10%.

- Hypersalivation, lip licking, and hard swallowing may be some of the most reliable clinical indicators of nausea in dogs.

- In hospitalized cats, providing a hide reduced stress scores within 20 minutes of hospitalization.

- Hospitalized cats preferentially chose environments with reduced visual and auditory stimulation when stress levels were higher.

- Repeated handling, restraint, awakenings, and interruptions of rest may themselves contribute to ICU stress and patient suffering.

- Continuous wireless monitoring systems may help reduce handling-related stress, although current systems still require manual confirmation for clinical decision-making.

- Individualized care planning may identify small environmental or behavioral factors that significantly affect patient comfort and stress during hospitalization.

- In one randomized crossover study, dogs showed no major overall difference in stress scores between floor examinations and table examinations, suggesting handling style and patient preference may matter more than examination surface alone.

Palliative interventions in the ICU include treating pain, dyspnea, nausea, thirst, hunger, anxiety, and sleep disruption.

Comfort-focused care is not separate from critical care. It is part of critical care.

Thank you for listening—I really appreciate you spending this time with me.

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You can also check out similar educational content, including podcasts and YouTube videos, from my colleague Igor Yankin on VetEmCrit.

Thanks again for being here, and I’ll see you in the next episode.

Long Days and Pleasant Nights.

Episode 31: Patient Suffering in the ICU

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