Preparing to say goodbye

There is never an easy time for euthanasia. No matter how much time we are granted, there is never enough time to spend with a loved one. There is a fine line between rationally seeing that no more can be done, and emotionally accepting it as fact. Along with all the emotions that accompany this twilight comes the doubt that possibly more could have been done. These are all perfectly human emotions.

As difficult as it may seem, making these arrangements with some clarity before the final decision is made, can actually decrease the anxiety and stress of actually seeing it through. Some things to consider:

• Create special memories. We hold many dear memories of our beloved pet throughout his/her lifetime but there are some things that might help preserve those memories over time. Making a family video, taking special pictures, going on a car ride to a special place or out for some ice cream, casting a paw print in clay, clipping some fur...these are some ways of preserving special times. They give us something palpable to cherish forever, and help bridge the gap between the physical loss and the emotional connection that never ends.
• Where will this take place? For many, the comfort of home surrounded by friends, family and familiar surroundings is extremely important. Contacting your vet in advance and arranging for a final home visit will eliminate the stress of traveling to the vet clinic. This is particularly important to do in advance if there are logistic issues about traveling with the pet, such as the dog's weight, ability to move independently, whether or not assistance is needed to place the dog in a vehicle, etc.
• When will this take place? For some people, a specific time can be chosen, depending on very personal and individual issues. While there is finality to making this last "appointment", for many people it is looked upon as the time to offer a final gift to the beloved pet... a time when the dog will be set free.
• What if there is an emergent need for euthanasia? There are times when unforeseen emergencies happen, when the dog suddenly and inexplicably takes a turn for the worse, or a complication develops without warning. In these circumstances, struggling to find an emergency facility can be devastating and extremely stressful. Knowing in advance where the nearest emergency facility is and having those contact phone numbers can be extremely helpful during this difficult time.
• After the fact: deciding on how to proceed with your pet after the actual euthanasia has taken place is difficult and emotionally draining. Having some kind of plan in advance helps to clearly direct the next steps and decreases the emotional burden of making the decision on the spot. Some people prefer home burials, if their local laws permit. Some choose cremation, so it is important to establish this information in advance with your veterinarian. Others choose not to keep the remains. These are very personal decisions.

In some cases, an autopsy may be possible, especially if the pet was cared for at a veterinary teaching hospital. This is also a very personal decision, but if it might be a consideration, plans should be made in advance. In other cases, if the pet was participating in a clinical research trial, autopsy may be included as part of the learning experience, to help veterinarians understand more about the cancer and pool their resources towards finding a cure.

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The Six Criteria to Consider before Euthanasia

These are taken directly from the book "Merle's Door" by Ted Kerasote. These criteria are from Dr. Bernard Hershhorn (a veterinarian), who adds that chronological age, in itself, is NEVER a criterion.

1. Is the condition prolonged, recurring or getting worse?
2. Is the condition no longer responding to therapy?
3. Is your dog in pain or otherwise physically suffering?
4. Is it no longer possible to alleviate that pain or suffering?
5. If your dog recovers, is he likely to be chronically ill, an invalid or unable to care for himself as a healthy dog?
6. If your dog recovers, is he likely no longer to be able to enjoy life, or will he have severe personality changes?

Hershhorn goes on to say that if one's answers to all 6 questions are "yes", the dog should be euthanized. If the answers to questions 3 and 4 are "no", then perhaps the dog should be allowed to die naturally. However, one must answer 3 more questions:

1. Can you provide the necessary care?
2. Will such care so interfere with your own life as to create serious problems for you or your family?
3. Will the cost involved become unbearably expensive?

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Oncology Outlook for VPN June 25, 2004 By Dr. Alice Villalobos

"HHHHHMM" Quality of Life Scale helps decision-making.

There is a real need for assessing various levels of quality of life for aging, ailing and terminally ill pets. Most geriatric animals have one or more abnormal conditions that appeared in their senior years and these conditions generally worsen with time. One third of them are obese. Additionally, half of our nation's companion animals, over the age of ten, become burdened with cancer and its related treatment issues. Veterinarians are frequently asked, "When is the right time to euthanize my beloved pet? How will I know?" A quality of life scale may help everyone, especially those in denial, to look at issues that are difficult to face. Caretakers can use this itemized scale to ask themselves if they are able to provide enough help to maintain an ailing pet in the proper fashion.

Every animal has certain desires that should be recognized and respected. If we can meet these basic desires at 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 a guideline so that pet owners can maintain a rewarding relationship that nurtures the human animal bond. This scale 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 desires that are innate to the quality of life for sick pets should not and cannot in good consciousness be ignored. It is up to the veterinary profession and to the pet's individual caretaker to design an end of life program (Pawspice) or pet hospice that encounters each factor and deals with it openly and honestly with an achievement of quality of life scale from one to ten. Ten is the best. Below is a proposed list of the basic desires that need both healer and caretaker's attention.

I have christened this scale with the name "HHHHHMM", so it is easy to remember the desires we want to satisfy: Hurt, Hunger, Hydration, Hygiene, Happiness, Mobility and More good days than bad days. A score above 5 on most of these Quality Issues is acceptable in maintaining a pet hospice, pawspice or end of life program. Each pet's situation needs individualization and a kind, supportive approach.

The HHHHHMM Quality of Life Scale

Hurt: 0-10

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 so attention to the pet's ability to breath is a top priority. Some families are willing to provide oxygen therapy at home for their ailing pets and the veterinarian can prescribe it through a medical supply house. Pain control may include oral, transdermal and injectable medications.

Hunger: 0-10

No hunger: if adequate nutrition is not being taken in by the pet willingly or by hand 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. Instruct owners to use a blender or liquid diets to help their best friend maintain proper nutritional and caloric intake.

Hydration: 0-10

No hydration problems. SQ fluids are a wonderful way to supplement the fluid intake of ailing pets. It may take a few sessions for a pet owner to get the hang of this helpful procedure. It makes end of life care a very special event.

Hygiene: 0-10

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 owner to use antibiotics to help reduce foul smelling infections. Using a sponge (dampened with a very dilute solution of lemon juice and hydrogen peroxide) the gentle stroking action of a "mother tongue" on the face, paws and legs helps to soothe and clean the fur of cats. Dogs love this type of grooming too!

Happiness: 0-10

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?

Mobility: 0-10

Ask, is the pet able to move around enough on its own or with help in order to satisfy its 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 or a sling or a cart be helpful? Is medication helping?

The answer to the mobility question has viable and variable scenarios and the scale score is acceptable anywhere from 0-10. I have met some utilitarian pet owners who are way too rigid in the mobility area. 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 bear a painful limb for months before euthanasia. Then there are cases like 12 year-old, male, 90 pound, Golden Retriever, Krash Pancino of Orange County. Krash's mobility was already borderline when he entered our pawspice program with osteosarcoma of his left distal radius. His history precluded amputation because of severe DJD, degenerative myelitis, and severe arthritis of both knees and hip dysplasia. Krash wears a splint to offset a pathological fracture.

In my opinion, the mobility scale can be variable from 0 to 10. The need for mobility seems dependant on the species and breed. Cats and small lap dogs can and do enjoy life with much less need for mobility ability 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.

More Good Days Than Bad Days: 0-10

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 filled with undesirable experiences such as vomiting, nausea, diarrhea, frustration, seizures, etc. Bad days could be from the profound weakness from anemia, or from the discomfort caused by an obstruction or a large, inoperable tumor in the abdomen This was the situation with my own dear Australian Shepard, Alfie, (VPN, Dec., 2004) who had a huge, undifferentiated mass rapidly overtake 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 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 with euthanasia.

This is especially avoided when euthanasia is against the pet owner's religious beliefs. Sometimes they are not sure about the very last quality of life issues. It can be made more clear to them if the standard scale for Quality of Life is set ahead of time and re-evaluated every couple of weeks or every few days as the situation requires. If the pet is slowly passing on with a peaceful tranquility, then that may be a satisfactory situation. People often do want 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. Home euthanasia with a kindly house call vet may be elected. Hopefully, the concept of a Scale for Quality of Life will facilitate the heart wrenching decision that euthanasia truly is. Hopefully our professional guidance can help relieve the angst and regret about a beloved pet's death that often haunts rest of a pet owner's life.

Oncology Outlook for VPN June 25, 2004 By Dr. Alice Villalobos

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Pawspice: An End of Life Hospice Plan for Pets

By Dr. Alice Villalobos

Animal Oncology Consultation Service dralicev@aol.com

As pets get older, the bond gets stronger. In this new millennium, cancer threatens the life of one in every three people and stalks over half the senior pet population. Organ failure will erode the life of senior pets that are fortunate enough to escape cancer.

Most pet owners and their local veterinarians 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, especially if the pet owner wants to challenge the cancer. The negative notions and bias must be dispelled one by one. Even when one supposes the pet's cancer can't be treated due to financial constraints or a logistical problem, it is still important to recommend the best consultation possible. So that at least the pet owner and the local veterinarian know what options are available and how best to approach them.

Pets that have had surgery or radiation therapy or chemotherapy may develop recurrence of their cancer. Some dogs and cats that have been on treatment for lymphoma may develop resistance to further treatment. These pets are good candidates for a pawspice program.

Because survival instincts are so strong, many pets don't show their illness until they are in the advanced and or terminal stages of cancer. Many animals with a poor prognosis may still feel well enough to enjoy their life and they do not have to be euthanatized because of the diagnosis. They do not have to be euthanatized prematurely. They can still have a quality time at home with compassionate and supportive care in the form of a "Pawspice" program.

Pawspice may be the only option that the pet owner and doctor can follow and this option is very good medicine. The pawspice approach is truly treating the human-animal love bond. At home pawspice care is a wonderful option that keeps pet and care giver comfortably close to their nest. To conceptualize and create a palliative pet hospice (Pawspice) program for pet owners to follow specifically for their pet is often THE only and best care that medicine can offer.

When a pet is injured, gets sick, gets old, or develops arthritis, the question of home care comes up. How much care would a pet owner be willing to provide to an ailing pet? From my personal experience with treating general practice and cancer patients for over 32 years in Southern California, I can with experience and authority say that the answer to this question is very personal and it may have no limits. Each pet owner has a unique, personal life style and variable 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, if it seems feasible, or they may decline therapy.

When a pet owner is facing anticipatory grief, they are often quiet upset. They may not comprehend the entire scope of the consultation. It is crucial that veterinarians refrain from being judgmental at this time. It is also important for the veterinarian to refrain from suggesting euthanasia too soon or insisting on euthanasia as the next best option if the pet is not going to be treated with the doctor's initial recommendations or referral.

Many pet owners have complained that their veterinarian was too quick to recommend euthanasia, because the prognosis was poor for recovery or a disease was incurable or there were too many interfering disease complications such as diabetes or heart disease, kidney disease or Cushing's disease on top of the cancer. It is important for the doctor to have patience and remain kind to the pet owner and furthermore, to continue offering options that may be more palatable to the pet owner's philosophy and or budget. It is truly important for the doctor to offer home treatment options such as subcutaneous fluids and feeding tube placement in a tender, unhurried fashion as the pet's caregiver is under tremendous stress. Pawspice is often the last option but it is the option that becomes quiet easy for a distraught pet owner to incorporate while struggling with the decision making process.

Networking is also a big help. If another pet owner, who is in a Pawspice with their pet, can share their experience with a client who is starting out on Pawspice, it can be very helpful.

Some pet owners cringe at the thought of giving daily injections to their pet. Some cancer patients need injections of antibiotics or pain medications or chemotherapy. Some pets need insulin if they are diabetic. Some pets need daily injections of fluids under the skin if they have failing kidneys or calcium and other imbalances.

We approach the fear of needles with cheerful teaching. We give demonstrations and ask the pet owner to actually give a mock injection until they acquire the skill. Most pet owners want to nurse their pet at home but they need their veterinarian and the nursing staff to teach them how to care and maintain hygiene for their pet while working with their own unique inhibitions and concerns.

Kidney failure patients that eat special modified diets may survive long periods of time if supplemented with educated home care that includes: subcutaneous fluids, tumil-K, pepcid, amphogel, vitamins and monthly BUN and creatinine recheck blood work. One cat in our practice survived six years on this type of home care before passing away at age 22!

The idea of using a feeding tube for nutrition during recovery from hepatic lipidosis, or after an oral surgery or during radiation treatments may sound like heroics to one person and make perfect sense to another. Feeding tubes have become quite routine in our practice to help animals get the nutrition they need! Placement of an esophageal feeding tube may be performed under short anesthetic with minimal risk. After the tube is in place and the pet has been fed successfully a few times in the hospital, a discharge appointment with a helpful nurse who can give clear instructions for feeding and tube care is essential. 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.

Proper nutrition is very important. In the past 10 years, I have focused on immunonutrition for my pawspice patients and we have had some amazing results. So my immunonutrition plan has actually become quiet well known and sought after. Please see the article on Immunonutrition. The article may be attached to this e-mail or a following e-mail upon your request.

We recommend using a special daily calendar with a schedule that spells out the morning and evening times you're your pet's medications, and chemotherapy. We like to use a separate calendar for all the immunonutrition supplements. If your pet has a weight loss problem, we write out the amount of fluids to be given and the intervals and the feeding volumes and supplements. Everything that is going into the patient should be shown in writing on the daily calendar. A written schedule helps to clarify the days work order for the home caregiver and family. It is important to always write down if the pet has had a good day or a bad day or if there was vomiting or diarrhea or lethargy or a fever. Keeping a diary helps, but it is easier for our staff to understand if the problem is related to one of the medications if the problem is noted on the calendar itself.

Home care for a pet that can't walk well enough to eliminate on their own is a task that certain pet owners have chosen to tackle. It can be done with the help of pampers and pet wheel chairs and soft bedding and good frequent bathing practices. Butt baths really help here! Some people react with fear of medical procedures such as wound care and handling bandage changes and needles. Others have great interest in learning how to administer medications and injections to their pets for convenience and needed savings. The most important ingredient to look for in your doctor, their staff and yourself is willingness. If you find that your local veterinary hospital is unaccustomed to helping clients with Pawspice care, ask the doctor to hole a staff meeting and ask the question if being a compassionate veterinary caregiver is truly O.K. with the nursing staff. Ask your doctor to put one special staff member as the appointed support person for a certain pet and pet owner. Then you can direct your phone calls and concerns to this team member and then to the doctor staff if needed.

The most important issues to educate home caregivers about Pawspice care are to be prepared to deal with THE FIVE H's.


• NO HURT
• NO HUNGER
• NO HYDRATION PROBLEMS
• NO HYGIENE PROBLEMS
• HAPPINESS, THERE MUST BE SOME!

We are looking for quality of life in pawspice. That means: good pain control, adequate nutrition and hydration and good hygiene. With training from the veterinary staff, home care may be a lot like being in the hospital yet more meaningful for the pet and the pet's family.

Ask yourself these questions:
• If this pet owner (ME!) was trained to administer medications, subcutaneous fluids, injections for pain control, keeping the pet on a good feeding schedule and keep up good hygiene, can the pet maintain a status of well being and live longer at home?
• Can some fun be created (doing the pet’s favorite things) for the joy in our bond to continue?
• Does your pet seem satisfied with the arrangement?
• Is your pet still able to experience some joy?
• Are you open minded about what quality of life is?
• Do you hold Quality of Life as being important to preserve the physical bond between you and your pet?
• Are you doing the pawspice out of guilt? (If the answer is yes, Get some counseling! Guilt is definitely not a good reason for entering this program!)
• Are you entering the pawspice out of a sense of duty?
• Do you want to share these last days or months together because you love your pet and know that he/she wants to live as long as there is some joy left between the two of you and because being together makes sense? There must be some happiness traveling between you and your pet in pawspice. Otherwise the bond that you share may place too much suffering on your pet to remain healthy and feasible.
• Are you able to keep your ill pet clean and odor free? Can you prevent decubital ulcers? These are nasty pressure point sores that result from lying on one side too long. Are you providing necessary wound care if needed?

If these ingredients are present, then pet hospice (Pawspice) is a good thing. Not all pet owners know where to draw the line about quality of life and they may need their doctor's advice and guidance on this important issue.

Pet owners can ask their veterinarians if they have experienced the amazing help that hospice care provided for a friend or family member. Veterinary Medicine can emulate the concern and care that the Hospice movement has made across America. Veterinarians can win the loyalty of their clients by respecting and preserving the 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 in the USA, veterinary medicine won't be able to send in free house call nurses and registered animal health technicians and free bereavement counselors. Your cancer patient pet won't be receiving free hospital beds, free oxygen, free meals and wheel chairs. However, on a consultation basis, veterinarians and staff can gracefully provide the education needed for the efficient home care of ailing pets.

When a pet is sick, we all suffer from anticipatory grief. Once you see that you can facilitate the control of pain and that you can provide good nutritional support in a hospice way, you, the caregiver, will gain confidence and courage. By providing care and documenting the condition of your pet you will have more time to let go slowly and carefully allow what is going to come in the near future. Mitzie Karsh's Mom, Roberta said, "You know the big hole is coming and that you will fall in it." Many tender private moments of quiet emotion and sweet conversation are shared between the caregiver and the dying pet.

It is normal to have questions such as, "How will I know when the time comes?" My answer is, "Your pet will tell you!" You will see your pet giving you a sign such as unrelenting vomiting, diarrhea, crying, a moribund state or more bad days than good days. I have been working on a special Quality of Life Scale that pet owners can refer to that may help answer this question more objectively. If you would like to help me with this Q of L Scale, please do so!

When the hour comes for the decision to be made, there is emotional pain. But if one knows that the word, euthanasia, actually means, "well death", the caregiver and family are more able to make the best decision on behalf of their pet.

I instruct people to bring a favorite blanket and a candle and family, friends and other pets to share in the sad goodbye. I prefer to soften the lights in the room and sedate the pet (with an intramuscular injection of an antiemetic and dormacetin or butorphanol-ace) in the presence of the owner. This allows that big first step to be an easy step for people to relax as they see their beloved pet falling into a relaxed sleep. Then we ask who wants to stay in the room for the final injection. We place a towel over the chest and I prefer to give the final euthanasia solution I.C. or I.P. while others may prefer I.V.

After we have gently assured the family members that their pet's heart has stopped beating, we genuinely invite that the family to stay and view the deceased pet in a "wake" type of service. I feel that there is not enough reverence, service, ceremony or support on the occasion of the passing of a beloved pet being offered to the family by our profession. So you may need to ask your veterinarian to allow you the exam room time for this special wake after the euthanasia is performed.

I like to read some of my favorite poems from ANGEL PAWPRINTS. This book is a wonderful anthology of pet memorials edited by Laurel E. Hunt, available from Amazon.com. We leave the room so the family may have private time alone with their deceased pet. After five or ten minutes, we'll check in on the family. We then talk compassionately about how important and sweet this dear beloved pet was.

We also highly recommend that the caregiver and children write a story or a poem or, at the very least, a few words about whom this pet was and how special their relationship was.

We'll often recommend that you cut and save a lock of hair from your pet's shoulder area (where you patted often. You can then place the lock of hair in a windowed envelope with the date and the pet's name as a memento. This is also the time for making a plaster imprint of the pet's paw (available from the Argus Center at CSU). Our staff will send one or two sympathy cards with notes and signatures. We also make a donation to the Peter Zippi Fund for Animals in honor of the passed pet's bond that they shared with the family. We look at pictures of the pet to help memorialize and give closure for staff and the bereaved.

We encourage people who have lost a beloved pet to get back into the "pet love cycle" again and adopt a (homeless) pet as soon as the "rinse cycle" of pet loss and grief is done.

We may call the family a week later and ask how things are going. We may encourage pet grief to be limited to 30 minutes a day preferably in the morning or the evening. We sincerely miss our clients after their pet passes and we tell them that we miss seeing them. We encourage adoption of another loveable pet as soon as you feel up to it.

Our favorite poem that we read to the caregivers at the time they enter into a "doggie Pawspice" is taken from Laurel Hunt's book. I'll adapt it to include our feline friends for they too often participate in "Cat Pawspice".

"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?"

Sir Walter Scott

FYI You can look at other ideas about pet hospice by going on line and checking the Argus Center at Colorado State Veterinary Hospital's Animal Cancer Center. They have set up a facility like a hotel where you can be living with your dying pet during the last few days.

csuanimalcancercenter.org go to the Argus center and read about their pet hospice program.

Pawspice: An End of Life Hospice Plan for Pets

By Dr. Alice Villalobos

Animal Oncology Consultation Service dralicev@aol.com

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