Acknowledgements: The authors would like to acknowledge the extensive efforts of the outpatient and inpatient
providers involved in the coordination of care for this patient.

Case Summary

Mr. S, a 39-year-old homeless man, presented to the ED with two months of progressive abdominal pain. His medical history included poorly controlled HIV, severe post-traumatic stress disorder (PTSD), and testicular cancer. Eight months prior to this presentation, the patient underwent a right-sided orchiectomy with expectation of further treatment for curative intent; however, the patient left the hospital against medical advice before his team could enact this plan.

Before entering the patient’s room, the physician was notified by ED staff that the patient was accompanied by a dog. The patient explained that the dog, which had accompanied him continuously for six years, helped him manage his PTSD. Per the patient, the hospital’s inability to accommodate his service animal prompted him to leave against medical advice eight months prior. He avoided clinical settings ever since until the pain became too severe to manage.

In the ED, the patient underwent a CT of the abdomen and pelvis that demonstrated densely matted retroperitoneal lymph nodes concerning for metastatic testicular cancer. Serum biomarkers returned positive for beta HCG and AFP, both indicators of advanced disease. The patient was admitted to medicine for expedited workup and management of progressive testicular cancer. However, Mr. S’s main concern was whether his dog could stay with him. Though he could not provide vaccination records or documentation status for the service animal, the medical team obtained these documents by contacting Animal Care & Control (ACC). Furthermore, hospital policy required the patient to arrange for the dog to be boarded by a local shelter or to identify a person who could stay in the hospital to independently feed, exercise, and toilet the animal. Hospital staff were not permitted to aid in these activities.

Mr. S declined to board his animal due to the inability to afford the costs and distrust that his animal would be returned. The medical team reached out to all known contacts via phone calls and coordination with the Homeless Outreach Team (HOT). However, after 24 hours, no one had volunteered to care for the animal while Mr. S was in the hospital, reflecting the patient’s social isolation. Utterly frustrated by the experience, the patient left the hospital against medical advice again, without a treatment plan in place.

Social Determinants of Health: Service Animals as Partners in Care

Social determinants of health are often the most important factor in dictating health outcomes in vulnerable patient populations. This case demonstrates how Mr. S’s reliance on a service animal for emotional support and treatment of PTSD, combined with social isolation, led to the progression of localized testicular cancer to metastatic disease. Just as hospitals invest in care plans for patients with specialized needs, such as medical interpreters for language discordant provider relationships or mobility services, hospitals should invest in solutions to care for patients with service animals.

Numerous qualitative and quantitative studies over the past decades tout the mental and physical benefits of service animals and pets to their handlers. Emotional benefits include reduced social isolation and anxiety, and improved self-esteem and mood.¹ Pets have been associated with reduced cholesterol levels, mean arterial blood pressure, and cardiovascular disease.² The effect of service animals in veterans with PTSD includes increased quality of life and decreased psychiatric symptom scores.^3,4 Though there are few studies of the benefits of service animals on civilians with PTSD, these results can reasonably be extrapolated. People experiencing homelessness often suffer from social isolation and loneliness, and many have histories of physical and emotional abuse resulting in severe PTSD.

For those who cannot depend on other human beings for support, service animals provide invaluable companionship. The threat of separation from a trusted companion may supersede other health concerns. Ensuring accommodations of service animals for hospitalized patients may improve health outcomes, providing a sense of safety in a foreign environment, and maintaining bonds of trust between patients and providers. Mr. S reported fear of sleeping alone in the hospital, fearing flashbacks to his trauma, exacerbated by the added stress of a cancer diagnosis.

Barriers to accommodating service animals in hospitals are significant. Hospitals must prioritize the health and safety of their employees, and ensure the presence of a service animal does not prevent the provision of necessary care. Requiring documentation of service animal and vaccination status is vital, but these requirements should not interfere with a patient’s right to remain close to his or her service animal.

One possible solution is assigning one staff member, such as a patient care assistant (PCA), to care for a patient’s service animal. We assign PCAs to perform one-on-one observation for patients with dementia and a similar system could be employed for patients with service animals who require additional support. Alternatively, hospitals could utilize volunteers from local shelters to walk and feed patients’ animals during the day. Lastly, if patients are willing to board service animals at local shelters, volunteers could bring patients’ service animals for daily visits to lessen the toll of separation. Further discussion among hospital leadership, patients, and advocacy groups is needed to develop a sustainable solution to care for patients and their service animals.

Clinical Implications

1. Educate physicians and healthcare practitioners about the emotional benefits of service animals on their handlers. Hospital staff who do not have personal experience with service animals may be unaware of the evidence base supporting their use, specifically for patients with social isolation and PTSD, which includes many patients experiencing homelessness. Hospital staff should understand that perceived threats to the service animal may damage the therapeutic relationship and negatively impact patients’ willingness to engage with the healthcare system.
2. Recognize patients with service animals as a population with special care needs and considerations. Just as patients with dementia may require increased nursing ratios, patients with service animals can be viewed as having a legitimate specialized need that requires accommodation. The presence of the animal should not be viewed as inconvenient, just as arranging a wheelchair van for a patient with mobility limitations is not viewed this way.
3. Establish clear hospital guidelines for inpatient and outpatient management of service animals. Much of Mr. S’s frustration stemmed from receiving inconsistent information from hospital staff regarding requirements for his service animal during hospitalization. The United States Department of Health and Human Services provides a guide to accommodating service animals in healthcare facilities.⁵ Having clear protocols regarding service animals and communicating them consistently to patients may improve trust of the healthcare system and reduce administrative burden on staff members, allowing them to focus on clinical care.

Case Follow-up

After the patient left against medical advice, his primary care doctor coordinated with the urologic oncology service to develop a care plan for the patient. Prior to hospitalization, his case manager arranged for members of the patient’s outpatient care team, whom the patient trusted, to care for his service animal while the patient was hospitalized. Thanks to the dedication of his care team, he agreed to re-hospitalization and was subsequently initiated on chemotherapy with cisplatin and etoposide. His outpatient care team developed a care plan for the patient’s service animal during his multiple cycles of chemotherapy. At the time of publication of this article, the patient had completed his fourth and last cycle of chemotherapy and his prognosis for remission was >90% per his oncologist.