A Personal Struggle
led the way when our site came online in 1997. And, his
valiant struggle and loss to lymphoma helped us channel our efforts in more
healthful and holistic ways
more about how to do that at our important Polluted Pets page).
Yet, even with reduced vaccinations, filtered
water, a chemically-clean environment, organic foods, and more, we did not
escape a fibrosarcoma diagnosis with our
Golden Darcy in 2005. Their images, along with other Goldens who
have lost such
battles, are honored above.
Veterinary Hospice: An Evolving Field
According to Guy Hancock, DVM, MEd, at the
American Association of Human-Animal Bond
Veterinarians, "Hospice is a system which provides compassionate comfort care
to patients at the end of their lives and also supports their families in the
bereavement process. It includes comprehensive nursing care as well as
psychosocial and spiritual care for the patient and family. Hospice is built on
the nursing model, in contrast to the medical model of care. Hospice is not
about heroic medical interventions that prevent quality of life in a pointless
attempt to prolong it."
About 100 veterinarians nationwide offer end-of-life support as
part of their regular services, compassionately viewing dying as the final stage
of living. A few clinics, including the Argus Institute at Colorado State
University in Fort Collins, are dedicated solely to end-of-life treatment for
animals. Dr. Nancy Ruffing, a mobile hospice veterinarian in Pittsburgh,
Pennsylvania, feels that "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. You really have to be in tune with your pet, and that starts at the
beginning." Amy Souza's article,
Veterinary Hospice: Ways to nurture our pets at the end of life,
speaks well to the delicate issues in this emergent area.
"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
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
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. 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." ...
To end life or let life end?
"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 misinterpret the
term "pet hospice," believing that death without euthanasia is a fundamental
"Hospice is not about replacement of euthanasia," says Dr. Robin Downing,
owner of 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." ...
Dr. Jaime Glasser, who graciously
Live-Tweeted (Sept 5-7, 2009) from the
Second International Symposium on Veterinary Hospice Care at UC Davis, shared the following insights:
Sharen Meyers LCSW: Hospice in a nutshell is to Live until you Die. And,
Human Hospice needs Vet Hospice to get back to the center of our calling.
- A few speakers have all said we may deliver euthanasia to our pets to
alleviate our own fear of suffering and not the pet's suffering.
Ella Bittel: Hospice Care can walk people through the grieving
process so that when death of a pet occurs, gratitude and love remain.
- It is SO important to decide what you want done in the case of your
Pet's death BEFORE they are ill and where YOU are going to get support.
- I learned today that we can not fault any decisions we have made in the
past without the knowledge we have today.
Dr. Tom Wilson: In Hospice when we accept death, fear and powerlessness
are replaced with a continuum of care, and a strength emerges.
Dr. Tom Wilson: Hospice needs to be a part of a whole system of
wellness, and we must reevaluate our health model. We must recognize all
animals as conscious beings, and recognize our kinship with all life.
Dr. Tom Wilson:
We can not forget that we need to accept death and dance to
the end of the song with our animals as they live to enrich our lives. When
we dance to the end of the song with our pets, when death is eminent, we
will have sorrow but no regret.
Dr. Anthony Smith: In Hospice we have to have empathy, not sympathy.
Dr. Tina Ellenbogen uses Intra-Peritoneal injections for home euthanasia
so the pet dies slowly, gently in the owner's arms.
Ella Bittel: Are
we supposed to Euthanize an animal just IN CASE they are uncomfortable? What
if they want to live?
Coleen Ellis, who
Only Funeral Home in
the US, believes we need rituals to allow us to grieve the loss of our pet,
and is determined to educate our society that Pet Loss needs to be
are reminded to not assume what we mean by Hospice Care or Natural Death is
the same for everyone.
Veterinarians want to
relieve suffering but need to know Euthanasia is not the only solution.
Hospice Care is best done WITH a Vet's help.
- As Veterinarians we do not have a good education in death, hospice or
the grieving process. Veterinary Hospice Care may actually lead us to accept
death as a part of life and teach us how to live our lives better.
The newly created 2008 International Association for Animal
Hospice and Palliative Care (IAAHPC) is an interdisciplinary organization
dedicated to promoting comfort oriented nursing and medical care for companion
animals as they near the end of their life and as they die. It was founded by
Amir Shanan, DVM, who also founded the incredible
Veterinary Care practice. His Hospice Care work provides services,
primarily at home, that minimize the suffering of pets during the end stages of
their lives, and to provide information and support that minimize the suffering
experienced by these pets' owners and families. Learn more below about what
constitutes Hospice Care with Dr. Shanan.
Please check out our comprehensive listing of hospice related resources:
Veterinary Hospice Concepts and Applications
The first difficulty to be faced by veterinarians is making a
prognosis that the patient is terminal. The human hospice guideline of a life
expectancy of 6 months or less is probably too long for many veterinary
situations. Using the ratio of average human years to dog years, 6 months is
equivalent to approximately 1 month. While hospice care would certainly be
appropriate during the final month of life, it may be appropriate for much
longer in some cases.
The veterinarian must first recognize that the patient is terminal and that
hospice care is a better alternative then further heroic attempts at cure. This
step is complicated by the veterinarian's emotional investment in the case's
good outcome, which may make it more difficult to admit the true circumstances
as early as is optimal. In addition to determining the appropriate time to make
a switch to hospice care, a second problem is that there is no veterinary
hospice to which a referral can be made. The same veterinarian must re-evaluate
the patient care plan from an entirely different perspective.
Once the veterinarian determines that hospice care should be considered, the
primary caregivers (owners) must then be informed about the choice. In some
cases this will come as a relief to clients who have already recognized the
impending death of their pet. Other clients may not yet be ready to face reality
or give up hope for a cure.
Helping reluctant clients choose between ever intensifying medical treatment,
hospice care or euthanasia is a difficult task calling for much sensitivity and
care. It is important to thoroughly explore with the client all the options and
their medical and financial consequences as a part of this preparation. It may
be necessary to give the client time to think about the options and discuss them
with family members before making a decision.
A particularly useful idea is to have the client think through the issues and
describe their preferences long before they are faced with the real decision.
This might be termed "pre-need" counseling, and veterinarians might encourage
clients to complete a form similar to the advanced directive now required at
human hospital admission.
In terms of providing comprehensive hospice care, the veterinarian is most
prepared to fill the role of medical director. Pain management and relief of
signs are the major emphasis. Hospice care is becoming a specialty in human
medicine, which indicates the potential for advancement and new knowledge about
The veterinarian, veterinary technician and clients should jointly develop a
plan of care to address relief of pain and management of signs. Clients should
be made aware of various techniques which might be employed, and their
limitations. They should be advised of signs indicating pain, side effects of
the medical conditions and treatments, and anticipated complications as the
patient's condition declines. Clients may need to decide if euthanasia is still
an option, how the pet's remains will be treated after death, and other details
of care and memorialization.
Home nursing care and respite care can be provided by veterinary technicians and
hospital personnel, but veterinarians are probably not the best providers for
the other aspects of hospice care. Psychosocial services to the immediate family
should be provided by people with credentials in that field. An ideal veterinary
hospice care team would include employees and volunteers from the local human
hospice. Spiritual counseling is another critical aspect of hospice care, and
should be available to a veterinary hospice patient's family members. The
unexpected death of a much beloved pet can cause intense personal grief and
could precipitate a spiritual crisis as well. There are two cautions to
consider: first, the care must be provided by a team that is well coordinated
and has good communication. Secondly, the spiritual and psychosocial counselors
on the team need to be selected for both their professional competence and also
their sensitivity to the human animal bond. A blind referral to an insensitive
counselor could do more harm than good.
Dr. Ella Bittel's
Spirits in Transition
Spirits in Transition
was created by Ella Bittel, an Holistic Veterinarian who is on the board of directors
of the International Association for Animal
Hospice and Palliative Care (IAAHPC) and on the advisory board for the
Nikki Hospice Foundation for Pets (NHFP).
When her dog companion of 17 years, Momo, reached the end of her life, Dr.
Bittel came to realize that none of her training in traditional or complementary
veterinary care had provided any information on how to support a companion
animal dying naturally. This, of course, reflects our society's desire to want
to refrain from thinking about those topics of death and dying. Then left
unprepared and somewhat helpless, the common result is to employ euthanasia when
the end approaches.
Dr. Bittel's experiences with Momo passing naturally, and feeling that just like
birth, the dying process is of inherent value and an important part of an
individual's journey, led her to engage in animal hospice and create a
weekend seminar and
online classes for those desirous of such end-of life care. She also hopes
to build a worldwide network where people caring for a dying animal can
find support from
those who share their passion for hospice care.
Insight on these Frequently Asked Questions from Dr. Bittel:
1. I am not
sure if my animal is suffering—how can I tell?
animal no longer wants to eat. What should I do?
My animal does not want to
drink anymore. What should I do?
Villalobos Pet "Pawspice" Home Care Tips for your
Dr. Alice E. Villalobos, winner of the 1999 Bustad Companion Animal
Veterinarian-of-the-Year Award, was a founding member of the Veterinary Cancer
Society and 2005-2006 president of the American Association of Human-Animal Bond
Veterinarians. She has been in the forefront of the veterinary
hospice movement, coining the term
Pawspice to represent the animal
equivalent of hospice, seeing it as a viable alternative when pet owners are
coping with the problems and pain of their terminally ill pets. As noted in the
an option for pets facing the end, Dr. Villalobos does not see euthanasia as
the sole option, and believes clients become panicked when their veterinarians
have instructed them that this is their only option. She would like to see palliation
being a bigger word in a veterinarian's practice, especially with
terminal patients. "Palliation — that's what pawspice really is all
about: to make things better. I like the word palliation because it has pal
in front of it. We're doing something for our pal to make things better."
Dr. Villalobos' Quality of Life Care Program includes:
Individualized Quality of Life Care Program that considers both the pet care
giver's level of ability and participation, while addressing the pet's comfort
and medical needs.
Chemotherapy: Administration of the most current chemotherapeutic agents and protocols.
All necessary medical therapy with treatments such as blood transfusions,
electrolyte imbalance replacement, steroids, antibiotics and hormone therapy.
Nursing Care Instruction for Pet Caregivers:
Detailed instruction to pet care givers including administration of subcutaneous
fluids, injections, application of pain control patches and all aspects of at
home nursing care.
Effective Pain Management:
Pain control through means such as use of oral medications, injections and
Adequate Nutrition: Optimum caloric intake and nutrition through immuno-nutrition supplements,
feeding tubes and excellent quality food sources.
Fluid intake through increased fluid consumption or subcutaneous fluids.
Proper cleanliness through bathing, brushing, applying diapers and antibiotics
Maintaining muscle mass and healthy joints through walking, assisted swimming,
harnesses, slings and physical therapy.
Joy, mental stimulation, and interaction with their family through
socialization, grooming and activities.
|Conceptualized Hospice for a Pet's Last Days:
Pet "Pawspice" — Home Care Tips for your Terminal Pet
By Alice E. Villalobos, DVM
As pets get older, the bond between them and their
human caregivers grows stronger. In this millennium, cancer will touch one in
every three people and over half of their senior pets. Organ failure will claim
the lives of the other half of senior pets. It is time to rethink how the
profession will help pet owners face the final days with a terminally ill best
friend. Most pet owners have preconceived notions about cancer and its
treatment. Obvious biases and ingrained feelings regarding cancer may cause a
negative approach towards its treatment in geriatric pets. Case by case,
veterinarians and their professional staff must overcome the defeatist attitude
about cancer therapy by dispelling negative notions, one by one.
If the pet’s illness can’t be treated due to
financial constraints or a logistical problem, it is still a matter of good
professional service to compassionately provide advice and home care giving
instructions. When a treated pet’s cancer has recurred, if it is resistant to
further treatment or if the pet is in the terminal stages of cancer, in home
hospice care is a wonderful next step that keeps pet and caregiver comfortably
close to their nest. A well conceptualized, creative, palliative pet hospice (Pawspice)
for pet owners may be the very best care that medicine can offer to support the
people pet bond. Veterinarians and their staff can kindly and respectfully help
sustain a quality life for the terminal pet during the last days of the
When a pet is injured, gets sick, gets old, or has
arthritis the question of home care comes up. How much care is a pet owner
willing to provide to an ailing pet? From this author’s personal experience with
treating cancer patients in California for 30 years, it can be stated with
authority that the answer to this question is very personal and it may have no
limits. Each pet owner has unique personal life style and tolerance
considerations. After an initial consultation with the primary veterinarian and
a thorough consultation with a specialist regarding options for curative
treatment or palliation, the owner will struggle with finances, logistics, love,
guilt and grief. Then they either accept the challenge to treat their pet’s
illness or decline therapy. It is crucial that veterinarians refrain from being
judgmental at this touchy time. It is kind to continue educating and offering
options that may be more palatable for the owner to incorporate into their
routine. It is also important to refrain from suggesting or insisting on
euthanasia as the next best option if the pet is not treated as initially
recommended. Let the pet owner know that pain relief and ways to make the pet
more comfortable is available while they are trying to make a decision regarding
therapy. Many clients have complained that the initial veterinarian was too
quick to recommend euthanasia, or that the veterinarian seemed to insist things
be done as an “all or none” method because the pet’s prognosis was poor for
recovery or it was suffering or its disease was incurable.
Some pet owners feel that they would be unable to
handle the thought of giving daily injections of insulin to a diabetic pet or
giving a daily injection of fluids under the skin to a pet with failing kidneys.
The idea of using a feeding tube for nutrition during recovery from lipidosis,
or after an oral surgery or during radiation treatments to the oral cavity may
sound like heroics to one person and make perfect sense to another. It is truly
important to always speak to the caregiver in a tender, unhurried fashion as
that person is most likely under a tremendous amount of personal, financial and
Home care for a pet that can't walk or eliminate is
a task certain pet owners have chosen to tackle with the help of Pampers, pet
wheel chairs, egg crate mattresses and ramps. Families will even acquire
portable oxygen tanks for pets with compromised respiration. Some people react
with fear of medical procedures and needles. Others have great interest in
learning how to administer to their pets for convenience and needed financial
savings. The most important ingredient to look for in oneself, in the staff and
in the pet owner is willingness. Hold a staff meeting and ask the question if
being a compassionate veterinary care giving facility is truly O.K. with the
nursing staff. Put one special staff member as the appointed support person for
a certain pet and its owner. Ask the client to direct phone calls and concerns
to their designated staff member or support team. Staff can handle most of the
home care problems and the doctor can see the pet on regular rechecks to answer
major questions such as changes in prescription medications.
The nation is very impressed with the concern and
care that the Hospice across America program has provided for people who are
dying. Veterinarians can win the loyalty of their clients by emulating the
philosophy of the Hospice in honor of that special bond that connects people to
their pets. This may help keep our profession more celebrated in the eyes of the
public. Unlike the Hospice Movement for people, the veterinary profession won’t
be able to send in technicians with free bereavement counselors, hospital beds,
oxygen, free meals and wheel chairs. However; from exam room consultations,
veterinarians and staff can gracefully provide the education needed for the
efficient home care of ailing pets. Education that facilitates the control of
pain and the art of providing good nutritional and hydration support gives the
caregiver ability to care with expertise. They have more time to let go slowly
and carefully. Many tender private moments of quiet emotion and sweet
conversation are shared between the caregiver and the dying pet.
The most important factors to educate home
caregivers to confidently monitor are: quality of life, minimal pain, adequate
nutrition, hydration and respiration and detection of sepsis. With training from
the veterinary staff, home care may be almost like being in the hospital. Ask
the question, “If this pet owner were trained to take the pet’s temperature,
administer subcutaneous fluids and provide the proper medications and sufficient
food , can this pet have some well being and live longer at home?” If the owner
is instructed to create some frequent, routine fun (doing the pet’s favorite
things), the pet may even cheer up and look forward to the events. Ask the pet
owner if he/she is satisfied with the arrangement. It is also important to
determine with oneself and the staff if it feels rewarding or at least
satisfactory to help preserve the bond between this person and this pet. If
these ingredients are present, then pet hospice (Pawspice) is a good experience
for all involved.
Ask the pet owner if they have experienced the
amazing help that the American home hospice care movement has provided for a
terminally ill friend or family member.
Despite the lack of financial support from national
fund raising campaigns, the veterinary profession can emulate the concern and
care exemplified by the hospice concept. Veterinarians can win client loyalty by
respecting and preserving the special bond that connects clients to their pets
and keeps this profession so celebrated. If the veterinary team helps peacefully
to control pain and to provide nutrition in a hospice way, client-caregivers
gain confidence. They also gain courage for themselves.
Practical Ideas for Some Specific Disease Conditions
Renal failure patients fed special modified diets
such as Hill’s K/D or Select Balance, Modified Diet, may survive well if
supplemented with educated home care which includes: subcutaneous fluids, Tumil-K,
Pepcid, Amphogel, tissue salts, vitamins, fatty acids (safflower oil or fish
oils). Regularly scheduled recheck profiles can monitor renal function, acidosis
and anemia. Epogen may be used to bring low PCV levels back up to normal. One
cat in this author’s practice survived six happy years at home on daily
subcutaneous fluids passing away at age 22.
Diabetic pets who belong to reluctant, needle-shy
owners need the option of their veterinarian feeling comfortable about offering
oral hypoglycemic medication. One can expect good clinical results with oral
medication in one third of diabetics that have no ketones in the urine. Clients
feel that their veterinarian is trying to help the pet while prioritizing their
own concerns. If hyperglycemia is not controlled with oral medication, the owner
may be more inclined to try injectable insulin as a second choice.
Anorectic pets often need to be hand fed. People
need to learn the proper technique to best hand feed their ill pet. Cats like
their food warmed to body temperature. Squamous cell carcinoma of the tongue in
cats renders the tongue stiff and useless and causes early starvation despite
efforts to eat. When a pet can’t or won’t eat, the placement of a percutaneous
esophageal feeding tube may be performed under a short anesthetic with minimal
risk. The procedure has been described by Rawlings, JAAHA, 1993, 29: 562-530.
After the esophagosotmy feeding tube is in place, the pet needs to be fed
successfully a few times in the hospital. It is essential that a discharge
appointment be scheduled for a demonstration on how and what to feed the pet. If
a helpful nurse, whom the owner may call for further instructions, gives this
demonstration, the client is more at ease during the first few days with the
feeding tube. The diet and supplements for feeding must be spelled out to avoid
clogging the tube and to ensure the pet is getting enough calories and liquid to
maintain body weight. If the tube gets clogged, instruct the owner to use
Coca-Cola to dissolve the clog. Create a schedule that spells out the morning
and evening times for medications, chemotherapy, amounts of fluid, feeding
volumes and supplements on a written daily calendar. This written schedule helps
to clarify the day’s work order for the home caregiver.
Nasal cancer patients with facial deformity and
night stridor may be palliated with combinations of NSAIDS such as piroxicam or
carprofen and evening sedation with burtorphanol.
Osteosarcoma cases that are not amputated can be
palliated with walking casts to prevent pathological fractures, ramps to get in
and out of the car, into the house and on the bed. The use of piroxicam at
0.3mg/Kg once daily for pain control may actually yield a rare remission on a
sporadic basis as shown by Knapp and workers at Perdue. Carprofen with caution
about hepatotoxiciy in debilitated dogs may also help control pain. The cautious
use of Fentanyl patches may also be very helpful for in home end of life pain
Degenerative myelopathy or paralysis often includes
a wide range of resourceful home care items such as the above mentioned ramps
along with slings, chest and rump lifts, canvass suspension hammocks, wheel
carts, etc. Foot covers that are made with cloth or canvas help to prevent
abnormal wearing and ulcers of the metatarsals, pads and metacarpals.
Decubital ulcers are avoided in recumbent animals if
thoughtful planning ahead includes pads, waterbeds and egg crate mattresses, all
with washable covers. Frequent and complete cleaning of the pet’s coat and skin
is important if the pet is soiling itself with urine or feces. If the pet is out
doors, extreme caution must be taken to prevent fly strike and maggots
especially for the long hair breeds.
Transitional cell carcinoma cases will live many
months on therapy. It helps to put diapers or Pampers when the pet is in the
house and keep the bed close to the doggie door. This helps the family to endure
the problems of stranguria and pollakiuria. If the hematuria is severe enough to
cause extreme blood loss, measures to control the blood loss are in order. Mix a
1% solution of formalin with a vial of the topical ear solution, Synotic, which
contains DMSO, and instill into the bladder with a urinary catheter. Keep the
mixture in the bladder for 10 to 15 minutes and then void and flush out the
clots. This palliative procedure may reduce the hematuria for 7-10 days and it
may be repeated as needed.
Brain tumor patients that are having seizures may be
able to stay at home with confidence and with fewer emergency visits if given
instructions to use injectable diazepam introduced into the rectum as a
suppository for seizure control.
Severe vomiting may be controlled with Zofran
injections. On one rare occasion, this author dispensed injectable atropine to
help a Great Dane that had unresponsive vomiting and salivation and a low budget
owner. Care should be taken to provide liquid tears while using atropine in this
fashion, especially in breeds susceptible to KCS.
Severe pain may be controlled with injectable
nalbuphine. This drug offers pain control without the typical sedation effects
that accompany most powerful pain medications. Nalbuphine doses range from
0.5-1mg/kg SQ. every 3-4 hours in dogs and 0.2-0.5mg/kg in cats SQ. every 3-6
hours as needed. This pain medication is not under the controlled substance
regulations and may be of great value in pain control at home for end of life
“Chemoprevention” may be presented as palliative
care for pawspice candidates. According to Dr. Philip Bergman of M.D. Anderson
Memorial Cancer Center, chemoprevention involves the use of natural or synthetic
compounds that may reverse or suppress the process of carcinogenesis, metastasis
and recurrence. Nutritional advice and a nutraceutical supplementation program
that underscores cancer prevention for treated, untreated or terminally ill
cases may be professionally supervised. This service creates further client
confidence that the primary care veterinarian is helping as much as possible.
Animals that have received surgery or chemotherapy or radiation therapy that are
still considered to be at great risk for recurrence are definite candidates for
the pawspice concept because they are actually expected to die from their
disease within 4-12 months. Dogs with osteosarcoma, hemangiosarcoma,
adenocarcinoma, lymphoma and cats with breast cancer, vaccine associated
sarcoma, lymphoma, IBD, FeLV and FIV all fall into this category.
Technician house calls may be set up for those who
are unable to deal with administering injections and fluids to the ill pet. The
reception staff can be made aware of which pets are on Pawspice programs so as
to be sensitive to the owner’s calls.
Pet Loss Group Sessions can be very helpful for the
most affected individuals.
We recommend that the family read the new AAHA book,
Living With Cancer: A Pet Owner's Resource by Robin Downing, D.V.M.
Networking is also a big help. Give the phone number
of another client who is providing the same type of Pawspice care so they can
have the opportunity to share their experience with the newcomer. Dr. Kathleen
Carson and Christine Grey, both from this author’s facility, actively
participate in a Chat Room for Chronic Renal Failure cats on AOL (America on
Line). This informative chat room opens every Sunday evening at 5:00 p.m.
Pacific Standard Time. Tell clients to look for the private chat room, “CRF”.
This type of net working is very helpful and is a
staff time saver.
Day care for ill pets can be provided by the primary
care veterinarian. This service may be the key to sustaining a Pawspice for the
working pet owner. Convenient delivery and pickup times that revolve around the
owner’s schedule may be prearranged.
Euthanasia for the Pawspice Pet
Many pet owners want their beloved pet to pass away
at home. Unfortunately for them, the slow decline of a sick pet may be too
difficult for the family to accompany all the way to the end of the pet’s life.
There are many questions such as, “How will I know
when the time comes?” The answer to this question rests with the pet. Advise the
family that their pet will give a sign such as unrelenting vomiting, diarrhea,
crying, a moribund state or more bad days than good days. When the time
approaches for the pet to be humanely euthanized, the emotional pain for the
family may be softened if they know that the procedure can be performed at any
time of the day or night. Arrangements must be made that cover the patient’s
care 24 hours a day. Referrals for house calls, night calls and after hour
emergency room facilities need to be set so that the decision time for
euthanasia is made on behalf of the pet, not the doctor’s office hours. When the
time comes for the emotional pain of euthanasia, caregivers who are in a
Pawspice program are enabled to make the best decision for the pet. If they are
going to bring the dying pet to a facility for euthanasia, instruct them to
bring the pet’s favorite blanket and a candle and family or friends and other
pets to share in the final goodbye. It helps create a gentle atmosphere if the
overhead lights can be softened. One suggestion is to turn off overhead lights
and leave the x-ray viewer lights on in the exam room. The candles can also be
lighted at this time.
The next step is to sedate the pet in the presence
of the owner. This lets people relax while the pet gently falls into sedation. A
deep intramuscular injection of dormacetin or butorphanol-ace in the presence of
the owner is given. This allows that big first step to be an easy step for the
family to see their beloved pet falling into a relaxed sleep. At this time it is
kind to ask if each person in the room wants to stay for the final injection.
Many families are content to leave their pet in the sedated state with complete
trust that the next step is painless and fast. If family members are present
towel may be placed over the pet’s body covering the chest area up to the neck.
At this time it is this author’s preference to give the final euthanasia
solution I.C. while the family lovingly strokes the pet’s head. Many
institutions prefer I.V. euthanasia with I.V. catheters preplaced. However, it
seems somewhat traumatic to take near death pets away from their grief stricken
owners into the backroom in order to place indwelling catheters, which may
involve a struggle. Most near death pets are often anemic, hypovolemic or
hypotensive. If catheter placement causes any struggle or discomfort in the last
few minutes of life for the near death pet, it is honestly too difficult for
this author, let alone caring staff members, to repeatedly witness, even if the
owner is not present.
After the family members are gently assured that
their pet’s heart has stopped beating, it is appropriate and thoughtful to
encourage them to stay and view the deceased pet. Compare this special time to
the custom of having a little wake as they do for human family members. This
author feels that there is not enough reverence, service, ceremony or support
offered to the family on the occasion of death of the family pet by the
veterinary profession in general. As recognition of the overriding importance of
the bond that holds clients to veterinarians becomes common place across the
country, more hospitals will set aside softly lighted rooms for pet wakes upon
the occasion of a pet’s passing. This is the time to read poems and talk
compassionately about how important and sweet this dear beloved pet was. It is
highly recommend that the caregiver and children write a few words about who
this pet was and what was their special relationship all about. Often a small
lock of hair can be placed it in a windowed envelope with the date and the pet’s
name and given to the family as a souvenir. This author likes to read Rainbow
Bridge and a few poems from
ANGEL PAWPRINTS, the wonderful anthology of pet
memorials edited by Laurel E. Hunt, available from Darrowby Press, 3510
Thorndale Rd., Pasadena, CA, 91107. This book can be left in the room so the
family may have private time to read poems and grieve alone with their deceased
pet. Every five or ten minutes, it is wise to check in on the family and see if
they need any assistance. We again recommend that writing a story or a few
paragraphs about the pet would be helpful in the grieving and closure process.
This is also the time for making a plaster imprint of the pet’s paw (available
from the Argus Center at CSU).
Post Euthanasia Follow Up
We send one or two sympathy cards with staff notes
and signatures. It makes sense to ask for pictures of the pet and encourage the
bereaved clients to get back into the love cycle again and adopt a homeless pet.
A genuine invitation for the pet owners to come back and visit with cookies and
pictures is extended.
A call to the family a week later to ask how things
are going help the bereft family. If they are troubled, a very helpful tip can
be given that encourages tears and grief feelings to be limited to 30 minutes a
day preferably in the morning or the evening. It is good to tell person that
they are missed and to encourage them to hurry back into the people-pet bond and
adopt another loveable pet as soon as they feel up to it.
Sir Walter Scott: On a Pet’s Life Span
A favorite short poem by Sir Walter Scott can be
read to caregivers when they start a “Doggie Pawspice.” It is taken from Laurel
Hunt’s book. With one changed word it can include cats and other species of
pets. “I have sometimes thought of the final cause of dogs
(pets) having such short lives and I am quite satisfied it is in compassion to
the human race; for if we suffer so much in loving a dog (pet) after an
acquaintance of ten or twelve years, what would it be if they were to live
double that time?”
Bergman, P., Chemoprevention, Proceedings of the
1999 ACVIM Forum in Chicago.
Choen, S. P. and C. E. Fudin, eds. “Animal Illness
and Human Emotion.” Problems in Veterinary Medicine, 3, No. 1 (March 1991).
Downing, R., Pets Living With Cancer: a Pet Owner’s
Resource, AAHA Press, April 2000.
Hoskins, J., Feline ‘Triad Disease” Poses Triple
Threat, D.V.M. Newsmagazine, February 2000, p.4S-7S.
Hunt, L.E., Angel Paw Prints: An Anthology of Pet
Memorials, Darrowby Press, 1998.
Lagoni, L., Morehead, D., Butler, C., The
Bond-Centered Practice: The Future of Veterinary Care, Proceedings of the 1999
ACVIM Forum in Chicago.
Ogilvie, G.K., Hospice and Bond Centered Practice:
The Future of Veterinary Care, Proceedings of the 1999 ACVIM Forum in Chicago.
Ogilvie, G.K., Moore, A.S., Managing the Veterinary
Cancer Patient: A Practice Manual, Veterinary Learning Systems, 1995.
Rawlings, JAAHA, 1993, 29: 562-530, Percutaneous
Placement of a Midcervical Esophagostomy Tube: New Technique and Representative
Villalobos, A. E., Oncology Outlook, Those Stubborn
Cats That Won’t Eat, August 1999.
Villalobos, A. E., Oncology Outlook, Pet Hospice
Nurses the Bond, VPN, September 1999.
Villalobos, A. E., Oncology Outlook, On Bladder and
Prostate Cancer, VPN, January 2000.
Villalobos, A. E., Oncology Outlook,
Chemoprevention: Can Food Fight Cancer? VPN, March 2000, p. 48.
Villalobos Quality of Life
Veterinarians are often
asked to assess the various aspects that determine the overall quality of life
in terminally ill pets. Most older companion animals have one or more concurrent
disease conditions that worsen with time. One third of our pet population is
overweight and or obese. When pets become burdened with illness or cancer and
related treatment issues, their pre-existing conditions complicate the prognosis
for survival or may limit options for effective treatment.
The attending doctor is frequently asked, “When is the right time to euthanize
my beloved pet? How will I know?” You can respond with something like this, “
One day it will gel. You will know when it is the right time because your pet
will tell you with a look or a gesture, a sign or a series of bad days.” A
quality of life scale may help everyone, especially those who are in denial, to
look at issues that are difficult to face. Caretakers can use the proposed
Quality of Life Scale to ask themselves if they are able to provide enough help
to maintain an ailing pet properly.
More and more clients are requesting in home health care help for their ailing
pets. We must remaining sensitive to the caregiver’s wishes and provide end of
life care such as pet hospice or “Pawspice.” More information on Pawspice care
will be presented at the 2:30PM -3:30 PM session.
Animal patients have specific needs and desires that should be recognized and
Veterinarians must rise to accept the challenge of meeting these basic needs and
desires for terminal patients. If we can create or restore a satisfactory level
for our ailing companion animals, then we are justified in preserving the life
of the ill pet during its steady decline toward death. The goal in setting up
the Quality of Life Scale is to provide an easy guideline for assessment of the
pet so that family members can maintain a rewarding relationship and nurture the
human animal bond. This Quality of Life scale offers some objectivity while
remaining sensitive to the caregiver’s wishes. It will relieve guilt feelings
and engender the support of the veterinary team to actively help in the care and
decision-making for end of life, Pawspice patients.
The basic needs and desires innate to quality of life for terminal geriatric
cancer patients should not and cannot in good consciousness be ignored (McMillan
2005). It is up to the veterinary professionals and to the pet’s individual
caretaker to design an end of life program. The program needs to address each
factor that deals with quality of life openly and honestly. We can be very
proactive in helping pets achieve an improved score on their evaluations. The
scale for each factor runs from one to ten. 10 is the best and highest quality
rating for each factor. There are 7 basic factors in this proposed scale. A
score of 70 would therefore be perfect. (If the terminal geriatric cancer
patient scores at least 5 on each issue, the quality of life is considered
Use this proposed list of basic desires or factors. These factors are presumed
to be essential for quality of life. There may be additional factors for
individual cases which may impact the decision for the family. Each factor needs
to be monitored by both the attending doctor and caretaker with careful
attention. The proposed list can be named “HHHHHMM,” The 5 H’s and the 2 M’s are
easy to remember. The list includes the problems that every Pawspice program
should strive to satisfy: Hurt, Hunger, Hydration, Hygiene, Happiness, Mobility
and More good days than bad days. A score above 5 on most of these Quality of
Life Issues is acceptable in maintaining a Pawspice program. Each pet’s
situation needs to be customized, and each pet owner needs to be recognized as
an individual who needs a kind, supportive coaching approach to come to terms
with the decision to end a best friend’s life.
Pet caregivers can use this Quality of Life Scale
to determine the success of Pawspice care. Score patients using a
scale of 1 to 10.
Click here for a
handy PDF copy.
H: 0 - 10
HURT - Adequate pain control,
including breathing ability, is first and foremost on the scale. Is
the pet's pain successfully managed? Is oxygen necessary?
No hurt: adequate pain control is first and foremost on
the scale. This includes the pet’s ability to breath properly. Most
people do not realize that not being able to breath is ranked at the
top of the pain scale in human medicine. So attention to the pet’s
ability to breathe properly is a top priority. Cases with pulmonary
effusion need thoracocentesis on an as needed basis. Pet owners need
to be trained to monitor the pet’s respirations and comfort level
and to identify labored breathing so they won’t wait too long to
provide relief. Some families are willing to provide oxygen therapy
at home for their ailing pets. The veterinarian can prescribe oxygen
through a medical supply house. Pain control may include oral,
transdermal and injectable medications and be given preemptively.
H: 0 - 10
HUNGER - Is the pet eating enough?
Does hand feeding help? Does the patient require a feeding tube?
No hunger: if adequate nutrition is not being taken in
by the pet willingly or by hand or coaxing or force feeding, then
placement of a feeding tube needs to be considered. Cats do very
well with esophageal feeding tubes. Malnutrition develops quickly in
sick animals when the caretaker is not educated enough to know how
much their pet needs to eat to maintain body weight. Instruct owners
to use a blender or liquid diets to help their best friend maintain
proper nutritional and caloric intake. Many pets will live much
longer if offered wholesome, flavorful foods that are varied. My own
Great Pyrenees, Alaska, went from a life of consuming only dry food
to canned food to hamburger, fresh baked turkey, to chicken, to
various types of sausages, to venison (thanks to Dr. Jack Stephens),
pastrami, cheeses of all types and gourmet cut and marinated meats.
She liked parmesan cheese, smoke flavor, Alfredo sauce and cheddar
cheese soup mixed into her food along with lots of encouragement and
coaxing and hand feeding. It takes patience and gentle concentrated
coaxing to get some Pawspice pets to eat. It is hard not to be
disappointed when such specially prepared food is rejected. Just
come back with another offering with a different flavor a little
later and that meal may be more appealing to the patient.
H: 0 - 10
HYDRATION - Is the patient
dehydrated? For patients not drinking enough, use subcutaneous
fluids once or twice daily to supplement fluid intake.
No hydration problems. Educate the pet owner about
adequate fluid intake per pound (10 ml per pound per day) and to
assess for hydration by the pinch method. Subcutaneous (SQ) fluids
are a wonderful way to supplement the fluid intake of ailing pets.
It may take a few demonstration sessions for a pet owner to learn
how to administer SQ fluids. This helpful procedure saves the client
a lot of money and keeps the pet on a much healthier status. Giving
SQ fluids can make a huge difference in quality of life during
H: 0 - 10
HYGIENE - The patient should be
brushed and cleaned, particularly after elimination. Avoid pressure
scores and keep all wounds clean.
Good Hygiene is a must! Can the pet be kept brushed and cleaned? Is
the coat matted? Is the pet situated properly so that it won’t have
to lie in its own soil after eliminations? Pets, especially cats
with oral cancer can’t keep themselves clean, so they get
demoralized quickly. The odor associated with necrotic, oral tumors
can be offensive and cause social rejection by family members.
Instruct the pet owner to use antibiotics to help reduce foul
smelling infections. Dampen a sponge with a much-diluted solution of
lemon juice and hydrogen peroxide and gently stroke the face, paws
and legs of the patient. This action is similar to a “mother tongue”
and helps to clean the fur while soothing the unkempt cat. Dogs love
this type of facial and paw grooming too!
H: 0 - 10
HAPPINESS - Does the pet express
joy and interest? Is the pet responsive to things around him or her
(family, toys, etc.)? Is the pet depressed, lonely, anxious, bored
or afraid? Can the pet's bed be close to the family activities and
not be isolated?
Happiness is important for both caregiver and
receiver. Ask yourself if the patient has desires wants and needs
(Comstock 2001). Are these being met? Is the pet able to experience
any joy or mental stimulation? It is easy to see that our pets
communicate with their eyes. They know what is going on via their
senses and mental telepathy. Is the ailing pet willing to interact
with the family and be responsive to things going on around him? Is
the aging cat able to purr and enjoy being on the bed or in one’s
lap? Is there a response to a bit of catnip? Can the cat bat at toys
or look and follow a laser light? Can the ailing pet enjoy the
upbeat greetings and petting of loving family members? Can the pet’s
bed be moved close to the family’s activities and not left in an
isolated or neglected area? Is the pet depressed, lonely, anxious,
bored or afraid? Do you have a routine fun time that the pet looks
forward to? Mobility--- Score 0-10.
M: 0 - 10
MOBILITY - Can the patient get up
without assistance? Does the pet need human or mechanical help (e.g.
a cart)? Does the pet feel like going for a walk? Is the pet having
seizures or stumbling? (Some caregivers feel euthanasia is
preferable to amputation, yet an animal who has limited mobility but
is still alert and responsive can have a good quality of life as
long as caregivers are committed to helping the pet.)
Mobility is relative. Ask, is the pet able to get up and move around
enough to satisfy normal desires? Does the pet feel like going out
for a walk? Is the pet showing CNS signs, seizures or stumbling? Can
the pet be taken outdoors or helped into the litter box to eliminate
with assistance? Will a harness, a sling, or cart help? Is
The answer to the mobility question has viable and variable
scenarios. The scale score for mobility is acceptable anywhere from
0-10. I have met some utilitarian pet owners who are way too rigid
for their requirements in mobility of their pets. For instance, they
are regretfully but willing to sacrifice their pet’s life rather
than elect amputation of a limb. Some pet owners have the honest yet
teleological feeling that amputation is mutilation and not fair to
the pet. Instead, they allow the pet to bear a painful limb for
months before euthanasia. Then there are cases like the 12 year-old,
male, 90 pound, Golden Retriever, Krash Pancino of Orange County.
Krash’s mobility was compromised when he entered our pawspice
program with osteosarcoma of his left distal radius. His history
precluded amputation because of severe degenerative joint and disk
disease and degenerative myelitis. Krash had severe osteoarthritis
of both his knees along with moderate to severe DJD from bilateral
hip dysplasia. Krash’s cancer leg was splinted for visits to dog
park and at playtime to offset a potential pathological fracture.
His Pawspice was happy full of joy and love that lasted for 3
Dr. Robin Downing wrote thoughtfully about the mobility issue for
Murphy in her book, Pets Living With Cancer, A Pet Owner’s Resource.
She wrote, “ Because Murphy is such a big dog---150 pounds and very
tall---her ability to get up and down and to walk under her own
power are very important benchmarks in my personal “bottom line.”
She would be impossible to pick up and carry around. For the same
reason---her size---her ability to control her urine and stool
output is important.”
In my opinion, the mobility scale can have a variable score from 0
to 10. The need for mobility seems dependent on the species and
breed. Cats and small lap dogs can and do enjoy life with much less
need for handling their own mobility than large and giant breed
dogs. If the pet is compromised and is only able to lie in bed, is
there a schedule to change the position of the pet and rotate the
body at least as often as every two hours? Can the pet’s bed be
moved around the house to keep the pet entertained and in the
family’s company? Atelectasis and decubital ulcers must be avoided.
The nursing care of large immobile dogs is very demanding. Is the
bedding material soft enough? Can an egg crate mattress be used and
set up properly to avoid decubital ulcers? Is there a role for a pet
mobility cart or an Evans standing cart? These items really make a
difference in the Quality of Life for the pet that has limited
mobility yet is still alert and responsive.
M: 0 - 10
MORE GOOD DAYS THAN BAD - When bad
days outnumber good days, quality of life might be compromised. When
a healthy human-animal bond is no longer possible, the caregiver
must be made aware the end is near. The decision needs to be made if
the pet is suffering. If death comes peacefully and painlessly, that
Ask if there are more good days than bad days. When there are too
many bad days in a row, (or if the pet seems to be “turned off” to
life), the quality of life is too compromised. Bad days are those
filled with undesirable experiences such as: vomiting, nausea,
diarrhea, frustration, falling down, seizures, etc. Bad days could
be from a condition that worsens such as: cancer cachexia or the
profound weakness from anemia, or from the discomfort caused by
gradual tumor pressure or obstruction or a large, inoperable tumor
in the abdomen This was the situation with my own dear 111⁄2 year
-old Australian Shepherd, Alfie. He had a huge, undifferentiated
mass that rapidly expanded his liver. If the two-way exchange needed
to communicate and maintain a healthy human-animal bond is just not
there, the pet owner must reconcile or be gently told that the end
may be near.
It is very difficult for families to make the final decision to end
a beloved pet’s life by euthanasia. Coming to a decision about
ending a pet’s life is especially avoided when euthanasia is against
the pet owner’s gut feelings or if it against their religious
beliefs. Sometimes they are not sure about the quality of life
issues at the very end. It can be made more clear to them if a
standard scale for Quality of Life is explained and measured ahead
of time and re-evaluated every couple of weeks or every few days or
hours as the situation requires. If the pet is slowly passing on
with a peaceful tranquility, then that may be a satisfactory
What many pet caregivers really want is for their pet to pass on
naturally at home, in their arms or in their own bed. That is okay
as long as the pet is just weakening steadily and not ‘suffering to
death’. We as veterinarians need to accept the fact that it is a
very personal and natural wish when our clients request us to help
their pet to die naturally at home. We are the ones they turn to for
help and we have an oath “to use our scientific knowledge and skills
for the benefit of society through the protection of animal health
and the relief of animal suffering.” We can help our client’s pet
loss needs and at the same time guarantee that the pet has a pain
free passage by using the most powerful preemptive pain medications
during the last days and hours.
As part of a Quality of Life Program, or Pawspice program, we should
suggest the option of home euthanasia and refer the family to a
kindly house call veterinarian. Hopefully, using this conceptualized
user-friendly “HHHHHMM” scale for quality of life will facilitate
the heart wrenching decision that euthanasia truly is. Hopefully
your professional guidance and kindness can help relieve the angst
and regret about a beloved pet’s death that often haunts pet owners
for the rest of their lives.
A total >35 points
is acceptable for a good pawspice
Adapted by Villalobos, A.E., Quality of Life Scale Helps Make Final Call, VPN,
09/2004,for Canine and Feline Geriatric Oncology Honoring the Human-Animal Bond,
by Blackwell Publishing, Table 10.1, released 2006.
Dr. Anthony Smith: Compassionate Care
Anthony J. Smith, DVM, founded Rainbow Bridge Veterinary Services,
one of the only veterinary practices in the world devoted exclusively to
providing end-of-life care (hospice and euthanasia) to pets in their own homes.
Dr. Smith also serves as an adjunct professor in biology at Contra Costa College
and is a renowned author with over 20 professional journal and textbook