What Is Animal Hospice?

New Animal Hospice Guidelines from the IAAHPC

The International Association of Animal Hospice and Palliative Care has just recently released their updated Animal Hospice Guidelines.  While the document is geared towards animal health professionals, I wanted to include a link to this paper for those who are interested in learning more about the field of animal hospice.  If your current veterinarian is not well-practiced in hospice and palliative care, please feel to pass these guidelines along to him/her. Animal hospice is still in its infancy in the US, so I believe it is important to spread the word amongst as many practicing veterinarians as possible.

Of particular interest to dog parents like you and me, is Section III, “Pain, suffering, well­being, and quality of life in the animal hospice and palliative  care patient.”  Of particular note was the information on Quality of Life Assessment, and this excerpt:

“They encourage us to ask “what is important to this animal in his  or her life?” and to remember that each individual animal has unique likes and dislikes. For  example, loss of mobility might negatively impact a dog who loves to play ball and Frisbee  more significantly than it would a dog whose favorite activity is sleeping in a sunny spot under a window. Individual animals also have unique capacities to adapt to change. A disabled animal may continue to enjoy his or her favorite activities if creatively modified to fit the animal’s condition. A disabled animal may also develop “new” favorite activities.”

This made me reflect on my recent experience with Scooby.  Scooby was a dog who lived to eat.  He enjoyed going on walks, being close to his people and getting his massages. At the end, when Scooby no longer wanted food, could not even stand to go for a walk without assistance and did not seem to register touch or he presence of our family very well, I knew that this was not the quality of life deserving of my sweet boy.  It was undignified that he could not defecate, except when lying down, and that sometimes, even with assistance to get out to urinate, he struggled and was unbalanced anyway.  This was how I knew that his quality of life had degraded to the point where I could not let him continue on this path.

In the end, Scooby was at home, where he loved to be, surrounded by the people who loved him most in the world, and even a few people who did not know him that well, but recognized how special he was.  He passed peacefully and simply, in a way that honored him.  I am proud that we could give that to him.

Source: WhenYourDogHasCancer.org

Do Animals Hide Pain?

Animals are designed to hide their pain. By the time we start to seriously consider the option of euthanasia, our pet would have appreciated getting relief long before we can bring ourselves to do the euthanasia. Most people wait way too long. Pets often suffer in silence way too long. And old pets are more painful than we realize.

They don’t cry, whine, or moan. They limp and pant, yet continue to eat and continue to wag their tail. So are they really suffering? Panting, falling, stiffness, difficulty getting up, difficulty laying down, and eliminating in the house are key signs of significant arthritis pain…and unnecessary suffering. The most ignored suffering is pain from debilitating arthritis and simple advanced old age. Our pets have the luxury of euthanasia available to them. They don’t have to linger in a painful body that’s not working for them. Waiting is actually cruel.

Pain meds work in early stages of arthritis. Eventually they stop working. Old age becomes too advanced and severe muscle loss occurs. Without a lot of muscle, the forces on the bones skyrocket. The level of arthritis pain goes way up once the pet becomes skinny. This is when pain meds are not enough and stop working. The reason why old pets eliminate in the house is because it has become too painful to posture and get into the position to eliminate outside. It hurts. So the pet holds their pee and poop as long as they can. And they end up leaking urine and going in the house.

It is very helpful to learn about signs of suffering. Pet Loss At Home veterinarians have a practical mindset for how to handle end-of-life decisions. Old age is very different than other stages in life. We need to be more practical and less aggressive and less invasive when it comes to old age. Almost all old pets (and people) have one or several types of cancer that don’t always show up on tests. It’s just a matter of…are these hidden ailments affecting quality of life yet or not? Organ failure and cancer are happening in all old bodies. It can be better to spend your money on planning a private and comfortable departure for your pet at home instead of testing for what we know is there anyway and not very treatable at all. How do you fix organ failure, cancer, and advanced old age? Euthanasia. Poking and proding and testing and treating illnesses in an old pet are often expensive and futile. Why put your pet through that torture?

Euthanasia is a valuable opportunity to give our cherished pet relief from terrible pain and suffering. Euthanasia is a loving escape out of a painful body that doesn’t work. Another word for euthanasia is relief or escape. And just like people want to die at home and not in a hospital setting, you can be at home to say goodbye to your pet. Ask for help with your particular situation. We can discuss what you are seeing with your pet via phone or email. You will become much more clear about what to do after hearing our advice.

 

When Is The Right Time?

By  | Pets – April 2013

By Dr. Andy Roark | vetstreet.com

Thinkstock

Just last week, while I was performing euthanasia for a critically ill patient, the pet’s owner looked at me and said, “I bet this is the hardest part of your job.” That gave me pause.

For me, putting animals to sleep is not one of the hardest parts of being a veterinarian. That’s because euthanasia is often a blessing and gift to a suffering animal. In my experience, the hardest part of being a veterinarian is telling owners that their beloved pet has a terminal illness and will soon be leaving this world. The emotions that pass across their faces, even if they have suspected the worst for some time, are heart-wrenching.

Related: The Hardest Decision a Pet Owner Has To Make

 

It’s Never Easy

I still remember the first person I had to share this terrible news with. He was a nice, middle-aged man with two small children and an 8-year-old Rottweiler named Stone. Stone was a member of the family, and when he started to limp, his owner brought him straight in to be checked out. Stone was a wonderful dog at home, but he was not a fan of the veterinary clinic. My best dog treats did nothing to warm his heart, and when I manipulated his painful left shoulder, well… that ended our chances of being best friends.

Even though Stone was not an admirer of mine, I liked him, and I really liked his owner. That made it so much harder to discuss his diagnosis: osteosarcoma. Osteosarcoma is a painful bone tumor that responds poorly to treatment. In some cases, treatments involving limb amputation and/or radiation therapy can be beneficial. In Stone’s case, these options were not feasible.

Together, Stone’s owner and I decided to provide him with the best palliative care we could, and we promised each other that we would not let Stone suffer. When the time came, we would do the right – if tough – thing and put him to sleep rather than allow him to live in increasing pain.

Stone’s owner was the first person I ever had an end-of-life discussion with, and he was also the first person to ask me a question I have heard hundreds of times since: “How will I know when it’s time?”

The most recent person to ask me this question was my own mother. Her Miniature Schnauzer has battled long-term health problems and was recently diagnosed with diabetes. Unfortunately, she initially responded poorly to treatment. She lost her love of food, began soiling her bed and was generally acting pitiful.

How to Decide

Over the past few years, I’ve heard a lot of veterinarians give wonderful advice to people who are wondering when it is time to give their pets the gift of a peaceful passing. Here are four of the best pieces of advice I’ve heard, and they are the same ones I passed on to my own mother for her consideration.

Every pet, illness and situation is different. There is no single rule that can be followed for when it is time to help your best friend “cross the rainbow bridge.” Getting input from your veterinarian on the specific medical conditions that your loved one may face is vital for doing what is best for your pet. You may also benefit from having a caring friend who is not as emotionally involved in the situation as you are to help you gain perspective and really “see” what is happening with your pet.

Related: Euthanasia – Why Some Pet Owners Choose to Stay and Some Choose to Go

 

Remember that pets live in the moment. One of the most wonderful things about animals is how they embrace the present. Every time I walk into my house, my faithful Vizsla throws a one-dog ticker tape parade. The fact that I have entered the house thousands of times before, or that I will leave again in a few hours, means nothing. All that matters to him is the joy that he feels right now.

When our pets are suffering, they don’t reflect on all the great days they have had before, or ponder what the future will bring. All they know is how they feel today. By considering this perspective, we can see the world more clearly through their eyes. And their eyes are what matter.

Ask yourself important questions. Sometimes, articulating or writing down your thoughts can make the right path more apparent. Some questions that help pet owners struggling with this decision include:

  • Why do I think it might be time to euthanize?
  • What are my fears and concerns about euthanizing?
  • Whose interests, besides those of my pet, am I taking into account?
  • What are the concerns of the people around me?
  • Am I making this decision because it is best for my pet, or because it is best for me because I’m not ready to let go?

Measure their quality of life. This is no more than trying to determine how good or bad our pet’s life is at this moment. Trying to assess this can be difficult, but there are some ways you can try and evaluate it. Let’s take a look at a few of my favorites in the next section.

Is Life a Joy or a Drag?

Our pets may not be able to talk to us and tell us how they are doing, but if we pay close attention, there are many clues that can help us answer that question.

The Rule of “Five Good Things”: Pick the top five things that your pet loves to do. Write them down. When he or she can no longer do three or more of them, quality of life has been impacted to a level where many veterinarians would recommend euthanasia.

Good Days vs. Bad: When pets have “good days and bad days,” it can be difficult to see how their condition is progressing over time. Actually tracking the days when your pet is feeling good as well as the days when he or she is not feeling well can be helpful. A check mark for good days and an X for bad days on your calendar can help you determine when a loved one is having more bad days than good.

HHHHHMM: Doctor Alice Villalobos is a well-known veterinary oncologist. Her “HHHHHMM” Quality of Life Scale is another useful tool. The five H’s and two M’s are: Hurt, Hunger, Hydration, Happiness, Hygiene (the ability to keep the pet clean from bodily waste), Mobility and More (as in, more good days than bad). Dr. Villalobos recommends grading each category on a scale of 1-10 (with 1 being poorest quality of life and 10 being best). If the majority of categories are ranked as 5 or above, continuing with supportive care is acceptable.

Pet Hospice Journal: Keeping a journal of your pet’s condition, behavior, appetite, etc., can be extremely valuable in evaluating quality of life over time.

A Tale of Two “Endings”

Thankfully, my mother’s Schnauzer, Zoe, eventually responded to her therapy. As a perpetual optimist, I like to think that she may be with us for some time to come. Still, the reality of having older pets is that we must be vigilant in their care and aware that every day is a gift.

In the case of my long-ago patient, Stone, with whom I first walked this path, I am glad to say that he did not suffer unnecessarily with osteosarcoma. His owner made a good decision, and Stone crossed the rainbow bridge while in the loving arms of his people. He was remembered by them as a strong, loving protector of the children in his family, and I will always remember his owner for having the strength and wisdom I hope we’ll all have when the time comes to say that final goodbye.

Is My Pet Suffering?

How Do I Know When To Euthanize My Pet?

The following could be signs that your pet is suffering, frustrated, or painful:

panting, falling, stumbling, hesitating, slow, licking wrists, biting, restless, shifting positions, anxious, unsettled, can’t get comfortable, can’t sleep fully on side for long periods, wanting to be upright all the time, tense or flinch with touch, stiff, eliminating in the house, dilated pupils, wide-eyed look, hiding, less time spent grooming, sleeping all the time, not interacting with the family, drooling, wet lips, chomping/licking lips, head hanging down, pale pink or white or blue tongue/gums, large belly, not eating, not moving, not walking, can’t get up, difficulty laying down, not using one leg or limping a lot on one leg, vomiting, third eyelids up and visible

Signs of Debilitating Arthritis (very valid, humane reason to euthanize): panting, falling, stumbling, hesitating, slow, licking wrists, biting, tense or flinch with touch, stiff, eliminating in the house, dilated pupils (pain), wide-eyed look (pain), old age weight loss and lack of muscle mass, skinny, bony, can’t get up, difficulty laying down, dragging toes, knuckled over, emaciated, laying in urine or feces

Signs of Unstable Chest/Lungs/Breathing: can’t sleep fully on side for long periods, wanting to be upright all the time, not laying flat out on side, laying on sternum/elbows/more upright, unable to sleep well or deeply, unable to sleep for long periods, panting, blue tongue, exhausted, coughing, restless, shifting positions, anxious, unsettled, can’t get comfortable

Signs a Cat May Not Be Feeling Well: hiding, less time spent grooming, unkept fur, sleeping all the time, not interacting with the family, 3rd eyelids elevated/visible, emaciated, weight loss, attracted to heat, finding warm places to rest/sleep

Signs of Nausea/Kidney Failure: drooling, wet lips, chomping/licking lips, head hanging down, not eating, eating less, only eating special people food, emaciated, vomiting, twitching

Signs of Hemangiosarcoma=ticking time bomb: pale pink or white or blue tongue/gums, large belly, not eating, not moving, not walking, weak, panting, slow when going outside to eliminate, restless, shifting positions, anxious, unsettled, can’t get comfortable, weight loss, skinny, bony

Signs of Osteosarcoma: obvious lysis or moth-eaten appearance on x-rays, not using one leg or limping a lot on one leg, head-bobbing limp, very large and very firm lump or tumor on leg, skin breaking open/splitting/oozing, pain may be manageable when still using the leg yet limping, pain often too great once not using the leg/holding leg up, don’t confuse it with torn ACL which is much less serious, much more manageable (younger dog, back leg, holding leg up, no lysis on bone scans/x-rays)

Signs of Old Dog Vestibular Syndrome: head tilted to one side, head cocked to one side, eyeballs jiggly/darting back and forth constantly, vomiting, drooling, nauseated, unbalanced, can’t walk, falling down, dizzy, doesn’t want to get up, (mild cases can recover in a few days, may take a few weeks to recover, symptoms may be too severe/too much suffering to let it go on that long so euthanize is humane option)

QUALITY OF LIFE FACTORS TO CONSIDER:

PAIN? – The worst forms of pain and suffering are breathing difficulty, bone pain (debilitating arthritis and bone cancer/osteosarcoma), and nausea (most commonly from kidney failure). Is your pet’s pain well managed? Can they breathe properly? Is there abdominal effort to breathe (bad)? Is there panting all the time or often (bad)? Can your pet sleep well for long periods (good)? Do they need to be upright (bad) to breathe, wanting to be on the elbows and chest and NOT on it’s side? Can they lay on their side (good) for long periods? Are the gums and tongue pale? Is the belly enlarged? Hemangiosarcoma is a very common fatal cancer of the spleen that can affect the liver and lungs as well. It’s a ticking time-bomb that can bleed without stopping. Don’t wait too long and get into a period where dog cannot breathe well. Drooling? Wet lips? Chomping/licking lips? Hanging head down? Cats in end-stage kidney failure feel like they are hung over or have to vomit constantly along with weakness. They definitely need relief once they stop eating or drinking, maybe even before that. Once dogs with osteosarcoma stop using the leg and hold it up all the time, the level of pain is too much. They are probably more painful than we think, even when they are still limping around on the leg.

NOT EATING? – Eating enough? Does hand feeding help? People food or canned food? Let your elderly pet eat whatever they like as long as it’s well tolerated/doesn’t cause diarrhea. Significant weight loss can mean serious cancer or organ failure that is not fixable. Still eating does not mean all is well. Some pets are suffering/painful inside, yet still eat very well. (Debilitating arthritis is a good example.) Remember, animals are designed to accept and hide their pain. They often don’t show obvious signs of pain like crying/yelping/whining/vocalizing even though they are feeling pain.

NOT DRINKING? – Is your pet drinking too much or not enough? Is there too frequent urination or not enough? Is the skin red, raw, and painful where continuous urine leakage has caused irritation like a sunburn?

CAN’T URINATE/DEFECATE IN THE APPROPRIATE PLACE? – Able to get outside often? And comfortably get into position to urinate and defecate? Fall when getting outside? Fall or shake when getting into position to urinate or defecate? Eliminating in the house because it’s too painful to go outside? Laying in urine or feces? Leaking urine often? Would a large flat container with low sides work better as a litterbox for old arthritic cats?

DEPRESSED/WEAK? – Expresses joy and interest? Responsive to family, toys, other pets? Depressed, lonely, anxious, frustrated, bored or afraid? Can your pet’s bed be moved to be close to family activities? Does your pet seem trapped in a body that doesn’t work or is painful? Some pets are suffering when their mobility is difficult and painful. Some pets are suffering even though they are still eating. Pale tongue/ gums? Periods of weakness that come and go?

CAN’T WALK/GET UP? – Get up without assistance? Feel like going for a walk? Stumbling, shaking? Do pain meds help (early arthritis) or make no difference (advanced arthritis)? Does it help to place rugs all over the house so pet can gain good traction and stability? Panting? Stiffness? Muscle mass gone? Skinny? Bony? Head, shoulders, spine/back, hip bones visible? Lost a lot of weight?

TOO MANY PROBLEMS? NO EASY FIX? – When bad days outnumber good days, or when your pet’s list of problems is long, quality of life is too compromised. Euthanasia is a very important opportunity to give our cherished pet the gift of relief from terrible pain and suffering. We are lucky that this option is available to our pets; we don’t have to watch them suffer through an often cruel and long, drawn-out natural death. You have the choice to be a little more comfortable and say goodbye peacefully and privately at home.

Does My Pet Have Poor Quality of Life?

QUALITY OF LIFE FACTORS TO CONSIDER:

PAIN? – The worst forms of pain and suffering are breathing difficulty, bone pain (debilitating arthritis and bone cancer/osteosarcoma), and nausea (most commonly from kidney failure). Is your pet’s pain well managed? Can they breathe properly? Is there abdominal effort to breathe (bad)? Is there panting all the time or often (bad)? Can your pet sleep well for long periods (good)? Do they need to be upright (bad) to breathe, wanting to be on the elbows and chest and NOT on it’s side? Can they lay on their side (good) for long periods? Are the gums and tongue pale? Is the belly enlarged? Hemangiosarcoma is a very common fatal cancer of the spleen that can affect the liver and lungs as well. It’s a ticking time-bomb that can bleed without stopping. Don’t wait too long and get into a period where dog cannot breathe well. Drooling? Wet lips? Chomping/licking lips? Hanging head down? Cats in end-stage kidney failure feel like they are hung over or have to vomit constantly along with weakness. They definitely need relief once they stop eating or drinking, maybe even before that. Once dogs with osteosarcoma stop using the leg and hold it up all the time, the level of pain is too much. They are probably more painful than we think, even when they are still limping around on the leg.

NOT EATING? – Eating enough? Does hand feeding help? People food or canned food? Let your elderly pet eat whatever they like as long as it’s well tolerated/doesn’t cause diarrhea. Significant weight loss can mean serious cancer or organ failure that is not fixable. Still eating does not mean all is well. Some pets are suffering/painful inside, yet still eat very well. (Debilitating arthritis is a good example.) Remember, animals are designed to accept and hide their pain. They often don’t show obvious signs of pain like crying/yelping/whining/vocalizing even though they are feeling pain.

NOT DRINKING? – Is your pet drinking too much or not enough? Is there too frequent urination or not enough? Is the skin red, raw, and painful where continuous urine leakage has caused irritation like a sunburn?

CAN’T URINATE/DEFECATE IN THE APPROPRIATE PLACE? – Able to get outside often? And comfortably get into position to urinate and defecate? Fall when getting outside? Fall or shake when getting into position to urinate or defecate? Eliminating in the house because it’s too painful to go outside? Laying in urine or feces? Leaking urine often? Would a large flat container with low sides work better as a litterbox for old arthritic cats?

DEPRESSED/WEAK? – Expresses joy and interest? Responsive to family, toys, other pets? Depressed, lonely, anxious, frustrated, bored or afraid? Can your pet’s bed be moved to be close to family activities? Does your pet seem trapped in a body that doesn’t work or is painful? Some pets are suffering when their mobility is difficult and painful. Some pets are suffering even though they are still eating. Pale tongue/ gums? Periods of weakness that come and go?

CAN’T WALK/GET UP? – Get up without assistance? Feel like going for a walk? Stumbling, shaking? Do pain meds help (early arthritis) or make no difference (advanced arthritis)? Does it help to place rugs all over the house so pet can gain good traction and stability? Panting? Stiffness? Muscle mass gone? Skinny? Bony? Head, shoulders, spine/back, hip bones visible? Lost a lot of weight?

TOO MANY PROBLEMS? NO EASY FIX? – When bad days outnumber good days, or when your pet’s list of problems is long, quality of life is too compromised. Euthanasia is a very important opportunity to give our cherished pet the gift of relief from terrible pain and suffering. We are lucky that this option is available to our pets; we don’t have to watch them suffer through an often cruel and long, drawn-out natural death. You have the choice to be a little more comfortable and say goodbye peacefully and privately at home.

 

 

How Do I Know When To Euthanize?

Here, I explain various end-of-life situations and how they may be handled.

When our very old pet dies in their sleep on their own terms, this kind of death is a little easier to handle. We knew it was coming, it happened painlessly during sleep, and we didn’t have to make the decision.

When our very old pet is diagnosed with an incurable disease that has no treatment, the choice can be quite clear. The pet has a very bad thing. They are very sick, very depressed, and not eating anything. We see and hear the facts and can proceed to euthanasia with relatively high confidence that we are doing the right thing. The pet had a long, good life. We had to fix their obvious suffering.

It gets confusing when our pet is very old and debilitated but still eating well. We expect them to stop eating if they are truly in enough pain to consider euthanasia. This is often not the case. Animals are designed to accept and hide pain. We need to look for subtle signs of suffering even when they still have that sparkle and brightness in their eyes. Even when they greet us and wag their tail every day. Look at how they can’t get around very well at all. They are stiff and have a very short stride and limping gait. They pant intensely for a long time after only a little exertion. They may urinate and defecate in the house and have a hard time getting up and laying down. They fall. They don’t like slippery floors.

This pet really is suffering with advanced, debilitating, painful arthritis daily. Our pets want to be functional, mobile, and comfortable. Once our pets get really old, their muscle wastes away to nothing. Lack of muscle can cause arthritis pain to become extreme. They can no longer tolerate the pain and their mobility and function become very poor. This pet wants relief and doesn’t want to live like this.

There is no right time to euthanize this pet. Simply a period of time when this pet would really appreciate getting relief from this nagging, daily, painful lack of function and mobility. Daily arthritis pain meds can help mobility for a while but eventually old age wins out and becomes too severe for any med to be effective.

Another situation to discuss is…do you invest in bloodwork and x-rays and ultrasound and biopsies when you have an older pet who has major weight loss and is slowing down and eating less? Some people really need to attempt to find answers or they feel guilty. They proceed with a workup, otherwise the decision to euthanize seems impossible to make without more concrete facts. (Remember, our medical advancements have limitations. There are still countless unknowns.) Some people don’t proceed with a stressful workup in a very old pet because they are not going to put them through extensive treatments like surgery or chemotherapy anyway so what’s the point? They try simple treatments like antibiotics and daily pain meds until quality of life is poor.

What about those “gray area” situations where things can get quite complicated, making a very difficult decision almost impossible. Phone discussions with an end-of-life expert like our Pet Loss At Home vets can help guide us when faced with more complicated and vague circumstances.

I think the bottom line is, discussions and resources about signs of suffering, quality of life and when to euthanize need to be a lot more available and mainstream. The more we know, the better we can do for our pets.

From “Euthanasia Guidebook For Pet Owners” written by Dr. Karen Twyning, DVM, founder of Pet Loss At Home, a growing national network of compassionate veterinarians dedicated to private pet euthanasia in the comfort of home.

Is It Ethical To Euthanize Your Pet?

Our pets are so incredibly lucky to be able to receive the medical fix of euthanasia. They don’t have to linger in malaise like we humans do. An older woman at a monthly grief support meeting made a profound impact on me recently. She described how her late husband struggled for years with leukemia. In his last months, he would wake up every morning cursing the fact that he woke up…and was still here. He told his wife, “Why can’t I be euthanized like my dog? I don’t want to live like this anymore!”

So many clients comment about this while I am at their house, “Gosh, I wish we could do this for humans!” While we cannot legally euthanize humans, hospice was developed as a band-aid to keep people “comfortable” while nature takes its course. And nature can be cruel. What kind of quality of life do these bed-ridden people have? So sad.

When we look back in history, medicine has come a long way in the past 100 years. We now know enough medically these days to be quite confident in assessing disease, degree of pain & suffering, and level of quality in our lives. I believe with pets, we need to focus on quality of life. In my opinion, they don’t want life at all costs. They want quality of life, as long as it lasts.

*A note about hospice care for pets. I feel it sometimes caters to people who cannot let go, enabling them to avoid the loss, to stay stuck, to not decide. I feel sorry for pets who have to linger in hidden pain and low quality of life. Natural death is often cruel and prolonged. Euthanasia is a very valuable opportunity to give our cherished pet the gift of relief from terrible pain and suffering. As a veterinarian, I am an advocate for pets. I believe our pets want to be functional and comfortable. It is my job to speak for pets and explain suffering clearly so that we all can feel a little more confident that we are doing what is best for our pets. Natural death often involves too much suffering. This could be why the vast majority of pets are euthanized and not left to die naturally.*

From “Euthanasia Guidebook For Pet Owners” written by Dr. Karen Twyning, DVM, founder of Pet Loss At Home: a respected and growing national network of compassionate veterinarians dedicated to private pet euthanasia in the comfort of home.