Ways to nurture our pets at the end of life
By Amy Souza
Kramer, a black poodle/terrier mix with warm brown eyes, has silky black ears and a slightly tousled tuft of hair above his triangular face that makes him resemble his Seinfeldnamesake. 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, and a slight thickening around the waist from taking 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 pinpoint exactly what type of tumor Kramer has, they know it’s an aggressive immune-cell cancer. Because of the tumor’s location, radiation was not an option, but vets estimated that with surgery and chemotherapy, Kramer could live for one more year. The Millers were told not to expect a cure.
Seven months and many treatments later, it’s unclear whether their beloved pet will make it to another September. Whatever happens, the Millers are determined to do everything they can to keep Kramer healthy, happy and by their sides for as long as possible. So, they are taking his care into their own hands.
In a small room bordering the sitting area of their Maryland home, near a small refrigerator holding Kramer’s medications, Carol maintains a calendar to keep track of Kramer’s treatments. She has filled in each day of the month: “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.
What is veterinary hospice?
Veterinary hospice has existed for more than a decade, but it is far from mainstream. That appears to be changing, however, asmore and more practitioners begin to focus on end-of-life care and discover a huge demand for their services. It’s not surprising: An increasing number of people with pets are willing to give subcutaneous fluids or learn how to inject pain medication, especially if it means a few more months, weeks or days with their pets. Dr. Liz Palmer of Charlottesville, Virginia, opened a mobile end-of-life care practice a year and a half ago. Though she has never marketed her services, Palmer has an extensive clientlist.
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 receive 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 for more than 10 years in his Chicago general practice. “Pet owners don’t ask about hospice services, and veterinarians don’t offer information because, they say, pet owners aren’t asking about it.” Part of the reason is that neither general-practice vets nor the general public know 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 loving, appropriate manner, while also supporting the pet’s family. Many people agree 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 by teaching people how to administer medications and fluids, and helping them decide when euthanasia is warranted. During more than 25 years as a general practitioner, Palmer says she never had time to dealwith 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 she 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 choicesAs 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. These decisions are fraught with emotions and 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 people facing difficult medical decisions about their pets. 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 people evaluate their animals.
One widely used scale,created by oncologist Dr. Alice Villalobos, asks people to rate their pet from 1 to 10 in six areas: hurt, hunger, hydration, happiness, mobility, and 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 about 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 big 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.”
To end life or let life end?
Gail Pope, founder of BrightHaven, a residential hospice on 10 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 officeand 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 theirresident cats, Mariah, began showing signs that she was about to die, Pope panicked. She was alone and couldn’t leave the other animals, so she called a 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. She says, “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 administering 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 20s. Though Pope is not opposed to euthanasia in cases when 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. Pope’s position is atypical in the pet hospice community but it is shared bysome, 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 andtoo 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 themworry that the larger veterinary community, and the general public, will misinterpret the term “pet hospice,” believing that death without euthanasia is a fundamental tenet.
“Hospice is not about replacement of euthanasia,” says Dr. Robin Downing, ownerof the Downing Center for Animal Pain Management in Windsor, Colorado. “In 23 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 doctors or people with pets 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 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,” Shanan says. “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.
“Animals don’t know they’re dying,” Carol Miller 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 don’t want Kramer to suffer. One form of chemo made him 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. “Kramer’s spirits are high.” But if the drugs lose effectiveness and his cancer spreads, they’ve decided to stopchemotherapy 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, 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.