Veterinary Hospice: Ways to nurture our pets at the end of life
(From Best Friends Magazine, 2009)
Kramer, a black poodle-terrier mix with warm brown eyes and silky black ears, sports a slightly tousled tuft above his triangular face that makes him resemble his “Seinfeld” namesake. He has lived with Frank and Carol Miller for eight of his nine years, ever since the couple adopted him from a local shelter. To an outsider, Kramer appears healthy and vibrant, as a dog his age should. But the Millers see what a stranger cannot—slight stubble on his chin and thinning back hair caused by chemotherapy, a slight thickening around the waist from prednisone.
Last September during a routine dental cleaning, Kramer’s vet discovered a mass on the dog’s tongue. The news was dire. Though pathologists were unable to discover the exact type of tumor, they did discern it was an aggressive immune cell cancer. Because of the tumor’s location, radiation was not an option, but with surgery and chemotherapy, vets estimated Kramer could live for one more year. The Millers were instructed not to expect a cure. Seven months and many treatments later, it’s unclear whether the dog will make it to another September or perhaps live longer than predicted. Whatever the case, the Millers are determined to do everything they can to keep Kramer healthy, happy, and by their sides for as much time as possible.
In a small room bordering the sitting area of their Maryland home, alongside a refrigerator that holds Kramer’s medications, Carol maintains a calendar to keep track of the dog’s treatments. She has filled in each day of the month to use as a cheat sheet when giving Kramer his meds—“C” for chemo; “P” for prednisone; and “1,” “2,” or “3” for the particular homeopathic remedy he is to receive that day. The drugs keep Kramer’s tumor in check, minimizing his discomfort and allowing him to eat. The Millers haven’t given it a name, but essentially what they’re providing Kramer is hospice care.
What is veterinary hospice?
Veterinary hospice has existed for over a decade, but it is far from mainstream. That appears to be changing, however, as more and more practitioners begin to focus on end-of-life care and discover a huge demand for their services. Which shouldn’t be surprising: An increasing number of pet owners are willing to give subcutaneous fluids or learn how to inject pain medication, especially if that means a few more months, weeks, or days with their pet.
Dr. Liz Palmer of Charlottesville, Virginia, opened a mobile end-of-life care practice a year and a half ago. Despite having never marketed her services, Palmer has a client list large enough to keep her busy. After a local newspaper published an article about her business, she received more phone calls than she could handle. Other hospice providers report similar experiences—when people read or hear about their services, they get an influx of calls.
“There’s a Catch-22 right now, and that is, we don’t have very many people who see themselves as providers in this area, and there are a lot of potential users of animal hospice who have no idea that it exists,” says Dr. Amir Shanan, who has offered veterinary hospice in his one-doctor general practice for over ten years. “Pet owners don’t ask about hospice services and veterinarians don’t offer information because, they say, well pet owners aren’t asking about it. It’s a vicious cycle.”
Part of the problem is that neither general-practice veterinarians nor the general public knows exactly how to define pet hospice. The confusion stems, in part, from the term itself, because “hospice” also refers to a standard of care provided to dying humans. Pet hospice takes many forms, however—a couple like the Millers tending to their dying pet; veterinarians who travel to people’s homes; or even a physical location where animals live out their final days. In the broadest sense, hospice is a philosophy of caring for a dying animal in a gentle, loving, appropriate manner, while also supporting the pet’s family.
Most everyone agrees that the best place for a pet to die is at home, surrounded by familiar sights and smells and the people who love them. Veterinarians focused on hospice or end-of-life care aim to make the time before death comfortable for animals, teach owners how to administer medications and fluids, and help pet owners decide when euthanasia is warranted.
During more than 25 years as a general practitioner, Liz Palmer says she never had time to deal with end-of-life care properly.
“I was so focused on treating disease, spay/neuter, and primary care,” she says. “When I was trying to figure out what I was doing [with this new business] I was trying to find a word for it. It’s care in the end of life, but I also consider it ending life. I’m involved in the dying process.”
During an initial visit, Palmer conducts a thorough exam, particularly to detect pain, but believes it’s equally important to assess an animal’s environment.
“I really pay attention to how much an animal has to struggle to get through daily life. I like to go to homes, to sit on the couch and observe. I like to see the obstacles a pet faces and give the owners the ‘what are you going to do if?’ scenarios,” Palmer says. “I look at the quality of life of the owner, too. I don’t want the relationship to be a frustrating burden. That’s not good for the animal or the human.”
Making tough choices
As animal guardians we must make choices for our pets, but on the whole, the veterinary profession—while excellent at offering medically oriented solutions—is not well equipped to help people make end-of-life decisions that are wrought with emotion and that bring up all sorts of practical, ethical, and existential questions. What value do we place on life? Does that extend to animals, as well as humans? What constitutes suffering? How do we know when euthanasia is warranted?
The Argus Institute at Colorado State University’s veterinary teaching hospital has on-site counselors who are available around the clock to assist pet owners facing difficult medical decisions. Dr. Jane Shaw directs the institute and teaches veterinary communication at the school. Students often ask her what to do if someone doesn’t want to euthanize a pet.
“We ask questions of the client and can discover whatever barriers are there,” Shaw says. “There’s a subset of clients, mostly because of spiritual reasons, for whom euthanasia is not an option. For other people who desire a natural death for their pet, we walk them through what that death might look like. In many disease conditions, the death is not peaceful, and we have to have pretty frank conversations about that. Euthanasia is a controlled process, and done appropriately, is peaceful. Natural death is completely unknown, and that makes some vets uncomfortable. They’re worried about the animal’s welfare and the client’s welfare.”
In non-emergency cases, quality of life scales can help pet owners evaluate their animals. One widely used scale created by Dr. Alice Villalobos, an oncologist who coined the term “pawspice,” asks people to rate their pet from 1 to 10 in six areas: hurt, hunger, hydration, happiness, mobility, more good days than bad.
“Every member of the family should do the scale separately, because there’s always one person who has blinders on,” Villalobos says.
Dr. Nancy Ruffing, a mobile hospice veterinarian in Pittsburgh, Pennsylvania, supplements Villalobos’s scale with a handout containing her own words of wisdom surrounding end-of-life decisions.
“A lot of people don’t want to make it a numerical decision,” she says. Yet assessing a pet’s quality of life is crucial, and she considers it a large part of her job.
“Owners have to have some type of a mental plan for what to do at the end of life, but you have to look at your pet critically when they’re having a good day so you can recognize the subtle differences on a bad day,” Ruffing says. “You really have to be in tune with your pet, and that starts at the beginning of pet ownership.”
To end life or let life end?
Gail Pope—founder of BrightHaven, a residential hospice on ten acres in Santa Rosa, California—believes strongly in letting an animal’s life play out to the very end. It’s a stance she arrived at slowly. For many years, Pope worked at a conventional veterinary office and was schooled in conventional practices, including the idea that euthanasia constituted a normal end to an animal’s life. She and her husband started BrightHaven in 1996 with the simple goal of caring for elderly and infirm animals. When one of their resident cats, Mariah, began showing signs that she was about to die, Pope panicked. She was alone on the property and couldn’t leave the other animals, so she called the vet to come euthanize the cat—a notion that now makes Pope shake her head. “It’s the old thought of, she’s dying, hurry up, let’s kill her.”
Her veterinarian promised to send someone out during the lunch hour, and in the meantime Pope phoned a friend and animal communicator who instructed her to carry Mariah outside to an oak tree and sit with her in her arms. “I was terrified. I didn’t know what was going to happen,” she says.
Pope remained agitated, but Mariah was calm. The cat died quietly in Pope’s lap.
“My friend told me, ‘Mother Nature designed this,’ and that has stuck with me to this day.”
Over the next few years, as Pope moved toward alternative medicine, such as homeopathy and feeding animals a natural diet, she saw amazing things happen. Animals came to BrightHaven to die, but more and more of them instead grew healthier and livelier. Now, she says, her cats routinely live into their twenties; one lived to be thirty-five. And though Pope is not opposed to euthanasia in cases where she feels it is absolutely warranted, her philosophy and practice are to allow for natural death with few to no drugs other than natural remedies. Euthanasia is often employed too quickly, she says, and in an effort to relieve suffering, people actually may be ending their animals’ lives prematurely.
“While the body is expressing symptoms, that means it can still heal,” she says. “In fact, sometimes beings have to heal before they die. Often, they’ll have one or two really good days right before death.”
Pope’s position is atypical in the pet hospice community, but it is shared by some, including Kathryn Marocchino of Nikki Hospice Foundation for Pets in Vallejo, California. Marocchino thinks that in many instances people would rather not euthanize an ill animal, but they’re not presented with any other option, such as hospice care.
“There is intense debate in the community around what is hospice for animals,” says Marocchino, who helped organize a pet hospice symposium in 2008. “Hospice to vets means, I will do everything to help you, but I have a quality of life scale, and when the dog reaches a certain number, it’s time for euthanasia.”
At the symposium, Marocchino says only two veterinarians in attendance had ever witnessed the natural death of an animal. This fact suggests to her that euthanasia is used too frequently, and too readily, by veterinarians.
“They’re not giving death a chance,” Marocchino says. “Euthanasia should be a last resort.”
The majority of people working in pet hospice, however, do believe that euthanasia is a necessary—and humane—tool. Some of them worry that the larger veterinary community, and the general public, will misconceive the term “pet hospice,” believing that death without euthanasia is a fundamental tenet.
“Hospice is not about replacement of euthanasia,” says Dr. Robin Downing, owner of The Downing Center for Animal Pain Management in Windsor, Colorado. “In twenty-three years of practicing oncology, I have a fairly high conviction that the number of animals who die a natural death is few and far between. Most animals reach a point where they are actively in distress and we have an obligation to let them leave while they still know who they are and who their family is. The only time a client has expressed regret to me is the regret that they waited too long.”
The subject of death prompts strong feelings in most humans, and there are no easy answers for pet owners or doctors when confronting an animal’s final days. As the veterinary hospice field grows, it is crucial that practitioners remain open to divergent opinions and values, says Dr. Amir Shanan, who this year co-founded the International Association for Animal Hospice and Palliative Care.
“We must humbly accept that the subjective experience of dying is a great mystery,” says Shanan. “Also, we are acting as proxy for the wishes of a patient who is not of our species. It is very easy to err no matter what guiding principle we choose to follow.”
Hoping for a miracle
A few weeks ago during a walk at a nearby lake, Kramer became short of breath and had to be carried home. The Millers made an appointment with the vet, who x-rayed the dog’s lungs to see if the cancer had spread there. (It hadn’t.) Two days later at the same lake, Kramer acted like his old self, chasing geese twice his size. The next week, he followed the geese straight into the water.
“Animals don’t know they’re dying,” Carol says. “Toward the very end I think they might, but they don’t get anxious about it all the time like we do. Sometimes when I’m upset, he looks up at me like, ‘What’s wrong? What can I do for you to make you feel better?’”
Above all, the Millers do not want Kramer to suffer. One form of chemo made the dog violently ill and neither Frank nor Carol wants that to happen again. Their oncologists presented options for new treatments, and the Millers chose one that seems to be working.
“We are enjoying every precious day,” Carol says. “His spirits are high.”
But if the drugs lose effectiveness and Kramer’s cancer spreads, they’ve decided to stop chemotherapy and continue herbal treatments and prednisone until Kramer’s body gives out or he indicates to them that it’s time to go. They still hope for a miracle (who wouldn’t?), but the Millers are practical and know they must plan. They’ve contacted a mobile veterinarian, who, when the time comes, will perform euthanasia in their home.
SIDEBAR
What it takes to be a caregiver
Frank and Carol Miller live in a peaceful country neighborhood outside of Washington, DC. They are both retired, and they know how lucky they are to have the time and resources to care for Kramer, their beloved pet.
“When I’m at the vet, crying, sometimes I’m crying more for the people there who I know can’t afford the treatment their pet needs,” Carol says.
Treatment isn’t always expensive, especially if it mainly consists of fluids or pain meds, but cancer can be another story. To date, Kramer’s care has cost eight thousand dollars and counting.
“This dog has given us so much joy,” Frank says. “It’s worth every penny.”
The Millers have a file of papers and bills two inches thick, but record keeping is perhaps the least challenging part of caring for an ill or dying pet at home. Many people want to extend their pet’s life, yet some worry if they are cut out for the job. The medical care specifics depend on the disease, of course, but giving medications, shots, or subcutaneous fluids is not as daunting as people may think. The key is to find a vet or vet tech willing to train you.
“I’ve had people giving cats fluids for months with no problem,” says Dr. Liz Palmer of Charlottesville, Virginia.
Kramer’s treatments are relatively easy to administer. His prednisone and Pepcid come in pill form; the chemo treatments and homeopathic remedies are liquid, squirted into his mouth using a syringe a couple of times a day. The Millers call these shooters, and Kramer actually enjoys them. Getting him to take his pills was difficult until Carol discovered a pill pocket that doubles as a treat.
“We’re pretty busy with him,” Carol says. “There are four or five occasions when he gets medication each day. Psychologically, we do what people do for human cancer patients—keep him busy and cheerful and make sure his needs are met at all times.”
Dr. Robin Downing of Windsor, Colorado, says there are a few easy things owners can do to make ill—or simply geriatric—pets more comfortable.
“Bring them their food and water so they don’t have to walk to it,” she says. “Make it easier for them to get onto their bed. Make sure they’re not separated from you—even if they used to have a crate in another room, bring them closer to the family. Vets don’t think of animal patients as becoming depressed, but animals do experience an emotional life, and they want to be close to us.”
What if you work and are away for much of the day? Gail Bishop of CSU Pet Hospice points out that animals are often medicated and sleep a lot. Many of her clients arrange to come home at lunch or have a trusted friend check in on their pet. Dr. Ella Bittel of Spirits in Transition says people don’t realize how many resources already exist in their lives, or they have difficulty asking for assistance or accepting help that’s offered. Dealing with a serious illness takes its toll, however, and Bittel says that’s the time for people to turn to their support system. “It doesn’t even require having anything to do with animals,” she says. “You can have someone do the dishes, bring a meal over, take the kids to school, just to take a little bit of the burden off.”
Building a relationship with your vet is also a good idea. As your vet gets to know you, she will likely see how much you care for your animal. Still, it makes sense to express in detail what you are willing to do at home, and learn to do, in the case of a serious illness. In addition, pet owners should broach the heavy topic of end of life with their veterinarians, says Susan Marino of Angel’s Gate Hospice for Animals.
“It’s your responsibility to find out what your vet’s philosophy is early on,” Marino says. “You don’t want to wait fifteen years to when your animal is dying then find out your vet won’t do hospice. You’ve got to establish the relationship ahead of time and you’ve got to do your homework.”