It is a typical Thursday afternoon. I’m finishing up a new puppy vaccination and reviewing diagnostics from the vomiting dog, and I have several callbacks yet to do. My tech tells me the 4 PM is waiting in the car. It is Sadie, a 12-year-old Golden Retriever, with a complaint of peeing in her bed.
I’m thinking maybe if I’m lucky a bit of Stilbestrol will be all this old girl needs and I can still dash out the door at 4:30 PM to pick up my kids from daycare.
I step into the appointment and quickly realize Stilbestrol isn’t going to be the solution for this family. Sadie is knuckling and stumbling, leaking urine in the exam room, and barking in a disoriented manner, and occasionally she has a bout of profound coughing. She is accompanied by a family of adoring kids and she happily takes all the cookies offered. This is not a euthanasia appointment; the owners want me to fix their dog. I’m thinking to myself I don’t have the time to fix this dog! So I do my best to have a conversation in my allotted time, which luckily at our practice is 30 minutes, and hand over some medication that will hopefully “do” something and talk about coming back the next day for further work up. I then dash out the door, making those callbacks on my cell phone while I drive like crazy to pick up the kids. I’m sure this is a familiar routine for some of you.
Is that good care that I just provided to a family with an elderly, frail dog who has numerous geriatric issues? Nope. Is that even good medicine? I’d say probably not. So how do we, as very busy veterinarians, especially in BC when we have a veterinary shortage, deal with hospice/palliative care for our senior patients? The World Health Organization defines palliative care for humans as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” That is a lot to assess, think about, and implement, and it can’t be done in one 30-minute appointment.
On my drive home that night, I thought about Sadie and her family, and what I could do to help them. The light bulb went on somewhere between thinking about what I was making for dinner and listening to the kids tell me a story about their day. I flashed briefly on some lectures I had attended at a conference in San Diego late last year. There was a series of lectures with titles such as, “Doc, How Will I Know It’s Time?,” “Euthanasia under Pressure: When the Sh*t Hits the Fan,” “Living Well and Being Old: Practical Care for Geriatrics in the Home,” and “The Old and the Restless: Caring for Grey Muzzles in Your Clinic.” These aren’t nearly as snazzy as things like “21 Tips from the ER,” or “Thoracic Trauma—What Lies Beneath,” but nonetheless the speaker herself, Dr. Mary Gardner, made an impact. Dr. Gardner is one of the founders of Lap of Love, an American country-wide company that practices home euthanasia and hospice care. She brought humour and compassion to these topics, and at the time of the conference she made me think again, or maybe just think for the first time, about how we deal with our senior patients. Sadie, a beautiful grey-muzzle dog with her many complaints and loving family, would fit into the spectrum of needing such special care, so I brought up the lectures and reviewed what I had learned.
Assessing quality of life is a big piece of the puzzle. I think owners want us to assess the quality of life for them, which is hard to do in a clinic setting. Dr. Gardner put it this way: “The goal is not to evaluate the quality of life for the family (although I feel owners want and deserve my opinion) but rather to help them uncover their own thoughts, feelings, and boundaries for their pet surrounding end-of-life decisions.” She went on to describe the questions she asks that help determine the family’s time, emotional, physical, and financial budgets as well. This is where I think we fail as veterinarians. We often only look at the disease and not at the whole picture. Often I find it hard when I know there are more treatments that could help an aging pet, but the family is unwilling to pursue those treatments. Dr. Gardner explained that “if the pet is declining in health and there are no additional diagnostics or treatments the family is either willing or able to explore, then quality of life is either an imminent concern or will be some point soon. If the family’s emotional, time, physical, or financial budgets are being drained there is a subjective time period in which euthanasia is an appropriate decision to make.”
I’m sure many of you, like me, get the dreaded question all too often . . . “Doc, when is it time?” How do we answer that question when we haven’t explored all of the variables with the family? I know that when I’ve had my five-minute conversation about quality of life or making THE decision, I’ve seen the agony on the owner’s face. I think we’ve also all faced this same question with our own pets. Dr. Gardner’s comment about this situation was succinct: “It is our duty to assist owners with end-of- life decisions and to help end and prevent suffering of animals. There are many ways to help families explore quality-of-life questions, but the one way that is an injustice to our profession is if you simply say, ‘Call me when it’s time.’ Owners need more than this, and animals deserve more.” I wholeheartedly agree with Dr. Gardner’s assessment of the situation, but once again to do this properly we need a commodity that is in short supply—time. There are many quality-of-life assessment tools available and not every one will work for you, but maybe now is the time to find one and implement it in your practice. So I printed out some assessment tools to bring to work with me the next day to share with Sadie’s family.
Geriatric home care is another piece to consider. It has never really crossed my mind to do a home visit for senior pets, mostly because of the time constraints once again. However, I ask owners all the time to film coughs or limps, and making use of technology could also help with home assessments. Dr. Gardner pointed out the benefit of seeing where the dog lives, as mobility is one of the major issues facing senior pets. She referred to slippery floors as “the ice rink of death for a dog with mobility issues,” which gives us a pretty good mental image of what the dog might be facing. Using simple things like bath mats or yoga mats around the house to create a path for the dog to follow can give the dog a sense of freedom and improve their quality of life. Other ideas are harnesses, scent stickers, or “halo” bumper devices to help blind patients navigate better. Traction booties are another tool that owners should investigate to allow the dog more freedom in the movement. Sanitation is a huge issue for many older patients, and recommending diapers or waterproof bedding or assisting with shaving the perianal area could go a long way to helping a dog like Sadie.
These are practical solutions for the dog and owner. However, the other aspect of home care for aging pets is caregiver burden. I recognized this with my elderly lab in his last few months of life. He couldn’t walk very far without collapsing. He got stressed out every night around 5 PM and tried to dig his way out of the house. He was anxious with loud noises. We worried about the interactions with our young children, who were two and one. We didn’t want them to accidentally cause him any pain. He defecated on the couch regularly. My stress level was very high at the time, and it was causing me to resent my beloved “first child.”
When I ultimately decided to euthanize him, I faced immense guilt. Because of the burden he had created for me, his last weeks weren’t necessarily full of the love I knew I had for him. Dr. Gardner normalized some of my emotions when she talked about a study that examined the toll of caregiving on pet owners. The results found that caregivers of terminally or chronically ill pets had a greater level of caregiver burden and stress, greater perceived stress, greater symptoms of depression and anxiety, and a lower score on indicators of quality of life and enjoyment. So the lesson that I learned is that we can’t forget to check how the owner is doing, and we have to have realistic expectations of what anyone can handle and what else is going on in that person’s life. I’m a lot more empathetic about owners’ home situations after facing my own dog’s end-of-life struggles in our home. Dr. Gardner’s lectures reminded me of this, and I wanted to make sure Sadie’s family had resources to access to help them on their journey forward.
Caring for the geriatric patient in the clinic is another key piece to greymuzzle medicine. Dr. Gardner pointed out that “The clinic can be a scary place for a pet—especially a fragile one. Making sure that they are physically and mentally safe, handled well/carefully, and treated respectfully is key.” I’ve noticed that some owners tend to brush everything off as “He’s just getting old” or “She’s just slowing down” and often don’t appear concerned about the declining health of their older dogs, not because they don’t love them, but because they may not be aware we can do something to help them. We aren’t seeing these older dogs, so we are missing out on helping a significant part of the pet population.
Dr. Gardner suggested that clinics need to consider giving more time and marketing to the older patient, similar to what we do for puppies. Some of her suggestions are making the senior version of “puppy packs,” or having a designated parking spot for senior pets. Why not post pictures on social media about the senior patients we see?
All too often we post the cute puppies only. How about making sure there are specific geriatric policies in place at your clinic? Some of the practical takeaways were things like, don’t tie geriatric animals down under anesthesia as it cripples them, use memory foam on the surgery table or during recovery, recover these patients with a harness to help them stand and balance, and be mindful of their heat loss and drug calculations. Clinic floors are also very slippery, so many of the home care tips also apply to the veterinary hospital. Keeping these in mind while Sadie was visiting our clinic the next day was going to be important.
After reviewing these lectures, I now had a list of things I wanted to discuss with Sadie’s family, and I felt that I could try do a better job to make her and her family more comfortable. However, in a busy veterinary practice, as much as we may want to support our clients in all of these ways, sometimes we still can’t do it all. To that end, there are veterinarians in our province who have decided to dedicate their entire practice to this type of medicine or to provide home euthanasia, and finding one of these veterinarians in your corner of the province may be a great resource. Dr. Bryanne Leuenberger has a home euthanasia practice on Vancouver Island, and she says she started her practice after seeing the need in her general practice. When asked what her clients think about her service, she said, “My clients have been exceedingly grateful to have this type of service available. For most clients it is a great relief to be able to be at home with their pet and not have to stress them in their last moments by taking them into the vet clinic.” Another such veterinarian is Dr. Jeff Berkshire who runs Lifting Stars Pet Homecare in Vancouver. Home euthanasia is clearly gaining momentum as evidenced by a recent article in Modern Dog magazine that highlighted this topic. The article talked about Dr. Berkshire and the services he provides. The article quotes Dr. Berkshire as saying, “More and more people are waking up to the fact that this is a service that we can do . . . It’s a very intimate, personal and emotional time and now we can facilitate this in a home setting where you can select who is there.” I suspect moving forward, many more clients will expect to have these services available.
For veterinarians who are interested in learning more about hospice or palliative care, there are many resources available. This list isn’t exhaustive, but these are some of the things I came across while sitting in the lectures in San Diego, while researching for Sadie, and also for this article. The International Association for Animal Hospice and Palliative Care has a veterinary certification program as well as an annual conference.
So even though I’m sure I can’t change the way I practice overnight, or carve out as much time as I need for these beautiful old patients, I can try to do better. As Atul Gawande said “Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.”
WAYS TO REMEMBER
- Make a scrapbook
- Plant a tree in your backyard
- Plant flowers yearly in a flower bed and take that time to reminisce and remember the pet
- Make a tribute table
- Have all family members wear something that reminds them of the pet
- Make each family member a small pillow out of the pet’s favourite blanket or bandanna
- Hold a memorial service
- Make a donation in the pet’s name and let your child choose the charity; Morris Animal Foundation or the OVC Pet Trust Fund are options
- Have all family members write a letter to the pet to express their feelings
- Keep a list of all the things your pet did that made you smile or laugh
- Order keepsakes such as jewellery made of ashes
- Make ink paw prints in the clinic
- Create clay paw prints like Peartree Impressions
- Offering a memorial page on your clinic website
RESOURCES
- International Association for Animal Hospice iaahpc.org
- Lap of Love lapoflove.com
- The Pet Hospice Journal pethospicejournal.com
- Treatment and Care of the Geriatric Veterinary Patient, Edited by Mary
- Gardner and Dani McVety
- Hospice and Palliative Care for Companion Animals, Edited by Amir
- Shanan, Tamara Shearer, and Jessica Pierce
- AAHA End of Life Care Guidelines
- Ohio State Veterinary School Pet Loss Library
- Gardner’s Amazon shopping list: www.amazon.com/shop/drmarygardner
- Vetgirl Podcast “Caring for Geriatric Patients”
- Palliative Medicine and Hospice Care, Veterinary Clinics of North
- America: Small Animal Practice Volume 41, 2011
- Blunt Dissection podcast, “Episode 16,” focus on geriatric anesthesia
- Atul Gawande’s books, such as Being Mortal
SUGGESTIONS FOR RESOURCES TO HAVE FOR CLIENTS
- Disease sheets of common geriatric disease
- Daily diaries to help assess overall quality of life
- Quality of life scales
- Other services you support, such as acupuncture, massage, grooming, in-home pet sitting, etc.
- Pet loss groups or grief counsellors
- In-home hospice and euthanasia services
- Emergency clinics in the local area
- Specific euthanasia information
Written by Kathryn Welsman, DVM