Terminal Care

In our study, only direct medical costs were considered, including cost of the drug utilization, PD-L1 test, main AEs, treatments for progression (including active treatments and supportive care), monitoring, and terminal care. Drug prices were estimated from the local bid-winning price (Drugdataexpy ). Only severe AEs with great clinical impact, including anemia, neutropenia, and thrombocytopenia, were calculated because they had a relatively considerable influence on the economic evaluation by decreasing quality of life and increasing utilization of health resource. In addition, AE costs were calculated only once in the first cycle.
Costs of monitoring, AEs, terminal care, and PD-L1 tests were obtained from previously published studies (Wu et al., 2012 (link); Zheng et al., 2018 (link); Jiang and Wang, 2020 (link); Wan et al., 2020 (link)). All patients were assumed to incur one-time PD-L1 test costs in the first cycle and one-time terminal care costs before death. Additionally, costs were discounted at an annual rate of 5% (Sanders et al., 2016 (link)). All costs were converted into United States dollars (USD) by exchange rate: 1 USD = 6.47 CYN. All these data are listed in Table 1. If the ICER is below $32,457 threshold (three times GDP per capita of China in 2020, ¥210,000.00), the treatment is generally considered to be cost-effective.

The interview guide consisted of four major chapters with additional sub-parts (see Appendix). The first two major chapters each presented a conversation starter, providing controversial examples from each discipline. The first example introduced a veterinarian and her two clients (mother and adult daughter) in a 5-min video clip from a German reality TV-show (18 ). The scene depicted the vet delivering a terminal diagnosis regarding an elderly dog to her owners in the waiting area of the veterinary practice. The interaction of the vet with the two overwhelmed owners was meant to provide the basis for an exchange about the appropriate setting for delivering diagnoses, the nature of communication in EOL situations, the involvement of clients in therapy decisions, decision-making criteria for elderly patients etc. The video clip was presented to create a shared experience among the participants and to prompt discussion. By starting with the reactions of human medical personnel to the scene, we captured reactions from people outside of the focused field first without already biasing these reactions through the responses of the professionals. This procedure was repeated in the second chapter, only with swapped roles. Here, we introduced participants to a newspaper article about a case of killing on request in the Netherlands (19 ). A 74-year-old woman had ruled in advance (written living will) that she wanted to be euthanized in case of progression of her dementia. Whenever asked, she said she did not want to die yet. Her doctor and family, however, determined one day that the state she had described in her living will had been reached. Therefore, the woman was euthanized, while still verbally complaining and fighting back whilst being administered with the injecting initiating death.
For the third part of the interview guide, three PowerPoint slides were prepared, each introducing a fictitious person uttering a statement regarding (1) terminal care for companion animals, (2) euthanasia of animals, and (3) high-tech veterinary medicine. A translated version of the slides is provided in the Appendix. The slides covered all topics the project team believed to be crucial for debating EOL situations. The fictitious persons on the slides served as outsiders giving their sometimes provocative, polarizing or minority opinion. In contrast to direct questions by the moderator, this method gave the opportunity to strongly (dis)agree with or criticize a position without having to take into account the other person's feelings and judgement. The slides were only used in case the topic had not been addressed earlier in the discussion and there was enough time left.
In the final chapter of the interview guide, participants were instructed to work with Padlet (20 ). Participants were asked as a group to think of the ideal human or companion animal death and assign some key words written on virtual notes to either “human death” or to “animal death” (or both) and discuss their decisions. Participants also had the option to create additional virtual notes with their own key words. A complete list of the provided key words can be found in the Appendix. Our aim was to clarify whether participants perceived the characteristics/conditions of good dying as more or less similar for humans and companion animals in light of their previous discussion.