Under the federal Americans with Disabilities Act (ADA), an individual is considered to have a disability if he or she has a current physical or mental impairment that substantially limits one or more life activities, has a history of such an impairment, or is perceived by others as having such an impairment. The ADA specifies that the determination of whether an impairment limits a major life activity should be made without regard to the beneficial effects of measures such as medication, medical supplies or equipment, prosthetics, hearing aids, or oxygen therapy supplies. Notably, there are state-specific variations in the definition of disability, but the federal (legal) definition must be applied with regard to ADA provisions. The ADA requires public (under Title II) and private (under Title III) hospitals and medical clinics to accommodate individuals with disabilities with service animals and to modify their policies, procedures, and practices accordingly (1).

A service animal is defined as a dog that has been specifically trained to perform specific tasks for an individual with a physical or mental impairment. Tasks are defined as specific and direct actions that the dog takes to assist the patient with a disability. For example, a person with diabetes may have a dog trained to alert him when his blood sugar reaches high or low levels. A person with depression may have a dog trained to remind her to take her medication. In terms of panic attacks, if a dog has been trained to sense that an attack is about to happen and take a specific action to help prevent the attack or lessen its effect, that dog would qualify as a service animal. However, if the dog's presence merely provides comfort, that would not be considered a service animal under the ADA.¹

The ADA permits two basic questions to determine whether an animal is a service animal: “Is this animal required because of a disability?” and “What work or task has this animal been trained to perform?”¹ Health care practitioners may not ask for more details about the disability, request documentation of training, or require that the animal demonstrate its task. They can only deny access if the service animal is deemed harmful and if the risk it poses is significant on the basis of evidence and not fear or opinion.¹ Notably, the ADA does not require formal training or certification for service animals. The ADA does stipulate that animals must be housebroken and owners must be in control of their animals. Specifically, animals must be harnessed, leashed, or tethered unless the owner is incapable of maintaining physical control of a tether and/or the tether interferes with performing the task. In addition, the handler is responsible for animal care and supervision, and service animals may be excluded for unacceptable behaviors (eg, uncontrolled barking, jumping on other people, running away from the handler).

An emotional support animal (ESA) provides comfort to the individual. ESAs comprise any type of species other than unusual animals that could pose safety or public health concerns, such as snakes, other reptiles, ferrets, rodents, and spiders. ESAs and other species of animals (whether wild or domestic, trained or untrained) do not fall under the purview of the ADA, although entities must make reasonable modifications in policies to accommodate miniature horses if they have been individually trained to perform tasks for individuals with disabilities.² Of note, ESAs that do not qualify as service animals under the ADA may still qualify as reasonable accommodations under the federal Fair Housing Act and Air Carrier Access Act. Thus, even if an ESA is barred from entering a clinic or hospital, clinicians may still consider providing documentation in support of patients’ requests to fly with an ESA or to waive a housing no-pet rule or pet deposit.

As noted, the ADA does not require formal training or certification for service animals, and clinicians must take a patient’s self-report at face value as to the existence of a disability and the animal’s status as a service animal. This may complicate the assessment of whether a service animal is legitimate. Several case reports in the inpatient hospital setting suggest the potential for putative service animals to pose an infection risk, distract health care staff from patient-related duties (particularly if staff is called upon to assist with animal care), and increase anxiety and stress in other patients.^3,4

Although not previously reported in the literature, to our knowledge, similar issues arise in ambulatory oncology settings. At our comprehensive cancer center, one patient undergoing chemotherapy for Kaposi sarcoma stated that, because his dog was a service animal trained to help him self-terminate panic attacks, the dog should be allowed to attend his appointments, including infusions. The dog, a pit bull mix, was perceived by some staff members to be friendly and harmless and by others to be behaving inappropriately; that is, more like a house pet than a service animal. Several staff members reported that the dog was malodorous and lunged at them. The dog was also noted to approach and make physical contact with other patients in the infusion waiting area (although there were no associated patient complaints). Furthermore, staff questioned the veracity of the patient’s report that his dog performed an ADA-supported task because they had never directly observed the dog interacting with the patient to calm him. Controversy arose as to whether the dog should be barred from the cancer center and who should deliver this news, particularly after the patient threatened to sue the institution should his service animal be banned.

In another case, a probable emotional support (not service) dog was permitted to accompany her owner, a patient with endometrial stromal sarcoma, to the cancer center. The patient carried her dog (a shih tzu) in a cloth wrap and, although acknowledging that her dog was not trained to perform a specific task, reported the dog was critical in helping her stay calm when receiving scan results. In deciding to allow the animal in clinic, the oncologist cited his desire to preserve patient rapport, the difficulty of ascertaining objectively whether the animal was a service animal versus ESA, and the fact that the dog was small, well-groomed, and well-behaved. The patient subsequently became psychotic and had to be escorted from the ambulatory oncology clinic to the emergency department (ED), where the dog had to be walked by ED staff and delayed her placement in a psychiatric hospital for almost a week; the town animal control agency eventually came to the ED and took possession of the animal.

These and similar cases illustrate the potential for unauthorized animals to enter health care facilities, where they can distract or even threaten staff and pose risk to vulnerable patients, including delaying appropriate care and transmitting infection. However, we have also encountered other situations in which service animals and ESAs were successfully managed in hospital settings. For example, a patient with desmoid tumors brought her service dog (whom she stated prevented her from experiencing dissociative episodes) to all her medical appointments; he was quiet, calm, and unobtrusive to the point where clinicians usually forgot that he was in the room. In another case, a young adult patient with sarcoma who was undergoing chemotherapy that required a 5-day inpatient hospital admission every 3 weeks requested that his ESA (a small terrier mix) be allowed to visit occasionally. Because he was in a private room, the nursing manager authorized this as long as the door was kept closed. The patient and his wife were extremely appreciative, reporting that the dog was a critical part of his cancer journey and support system.

We propose that clinical practices and hospitals develop and/or examine policies on service animals; ADA guides should be consulted while writing policy.^1,2 Service animals comprise dogs and miniature horses, and are subject to state and local regulations on licensing and vaccinations, with which the health care facility may confirm compliance. Policies should include the ADA-supported stipulations that the handler is responsible for animal care and supervision in the outpatient clinic (or for arranging such care or supervision during an inpatient hospitalization), and that service animals may be excluded at any time for unacceptable behaviors as defined earlier in this article. At larger institutions, a designated official—not the oncologist or another member of the clinical treatment team—should inquire as to whether the dog is an ESA or service animal and determine whether the animal is permitted to attend appointments regularly in the cancer center. Otherwise, such decisions may be made on the basis of a desire to maintain rapport in the clinician-patient relationship rather than on objective standards.

As noted, there are other ways in which clinicians may support patients with ESAs, such as providing documentation for housing or air travel, or potentially allowing brief visits in a stressful situation (such as prolonged hospitalization). Clinic staff and other patients should treat service animals as working dogs and not interact with them as though they are pets. We also suggest advanced planning with patients to ensure that family and/or friends are on standby to assist with care of their service animal in the setting of a crisis such as hospitalization.

Developing clear policies and procedures is also critical to mitigate the risk of legal action. Clinicians should be aware that ADA litigation has increased dramatically in the last several years, particularly in California and Florida, which lead the country in such suits because of their plaintiff-friendly state disability laws that provide for monetary damages. Legal experts have proposed prefiling restrictions for abusive litigation and a 30-day notice requirement so that businesses can make appropriate accommodations to ADA standards.⁵ Historically, most suits have pertained to general accessibility of facilities for individuals with disabilities as opposed to inappropriate barring of service animals. However, there is evidence supporting the proliferation of inappropriately registered service animals (even including cats in some jurisdictions),⁶ which may lead, in turn, to an increase in threatened lawsuits when hospitals question the appropriateness of such animals. In the long term, given that current standards are vague and the difficulty of distinguishing an ESA from a service animal, it would be optimal for the ADA to require formal certification/licensure for service animals, sparing hospitals and other health care facilities from individually developing regulations subject to conflict and potential litigation.

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jop/site/ifc/journal-policies.html.

Honoraria: Up To Date, American Physician Institute

Employment: Omega Rehab & Sports

No relationship to disclose

No relationship to disclose