Certification

This has, paradoxically, been one of the hardest posts for me to write – I like to think of my blog here as being about animal hospice in general, and my patients in particular, and not about myself.  At the same time, it’s also one of the most important in its own way.

Last month I was honored beyond words can express to graduate as a member of the inaugural class of Certified Hospice and Palliative Care Veterinarians.  After a year and a half of studying and working together, hands-on seminars and techniques laboratories, extensive training, case studies, and more tests than I’ve taken in almost 20 years, I stood up with some 50 other veterinarians to be recognized as the world’s first formally trained and certified hospice practitioners.

This is important in so many different ways.  It’s important for me, and my patients and my community, because it means I have both the foundation and the network to provide the best possible care and support for them.  The friends and colleagues I’ve found as part of this journey will always be there for me, and we can share our experiences, knowledge, and training to practice even better medicine.  It also means that I have an obligation to share my own learning to help other vets in the community – the more I know the more I can help them, and improve the quality of life for pets and their caregivers across the board.

But beyond just my own patients and community, this is a huge milestone for the field of veterinary medicine as a whole.  Until now, animal hospice has been largely unknown.  Even most other vets have been unaware of hospice as a resource, and many who have heard of it haven’t understood what exactly hospice does.  It’s often seen as ‘just giving up,’ or dismissed as nothing more than pain medicine – a drastic mischaracterization of the complex and diverse ways that hospice can help both people and pets.

With this program, we now have an official set of standards for animal hospice.  We can point to our curriculum and say, “This is what hospice is, and what we do.  This is what a veterinarian who practices hospice medicine can be expected to know, to offer, and to do.  We are more than just providers of pain medicine and euthanasia.”  With this, we can – and will – reach out even further to both pet caregivers and other veterinarians, to make sure that eventually every pet has the option of choosing hospice care when the time comes and that every new vet tech and vet student is trained in this field as much as they are in surgery, internal medicine, and pharmacology.

So, far from being the end of a journey for me, becoming certified is just the first step.  My path from here is one of continued learning (I have already enrolled in an Apprenticeship in Herbal Medicine for 2018), but now it is one of teaching as well as I take on the role of educating others about what hospice is, and how we help.

And of course, I can’t write this without expressing my gratitude to my teachers, my fellow students, my family, and most of all my patients and caregivers – you have taught me (and continue to teach me) so much more than any lecture or class ever could, an

Longfellow

Longfellow was an amazingly, sensual, spirited, fun loving, sweet dog, probably spoiled—often told that he was an alpha dog.  He was like the neighborhood mayor—loved his walks, knew all the smells and moved fast, with a swagger, sometimes just with me, often with a neighborhood pal.  I am comforted knowing that Longfellow had a wonderful life—lots of fun and love and security—hamburg, chicken and liver treats—and ice-cream. I often  wished all children could feel as cherished and well-cared for as LF.    He was a lucky guy, but his gifts to me (and Adam) were  far greater than anything we could give to him.

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Planning Ahead

One of the biggest challenges we face when working with pets in a hospice situation is the fact that we are no longer dealing with curable diagnoses.  Because of this, we know that no matter what we do, over time their illness and their symptoms will progress.  Even pets that are stable and responding well to the treatment that we’re giving them today will eventually start to show more signs of illness, or develop additional problems or side effects.

Part of managing this challenging situation is keeping in close touch with your hospice veterinarian, and monitoring your pet closely – while it may seem unusual to ask for frequent check-ins, especially if your pet seems comfortable at the moment, such careful attention lets us stay on top of any subtle changes that may indicate a need to adapt our treatment plan.  But an equally important facet of hospice care is planning ahead for those changes and potential emergencies.

Sometimes the progression of symptoms can be slow and subtle – a pet’s appetite may gradually decrease, so that they need coaxing to eat; their arthritis may cause more discomfort over time, so that they get tired more quickly on their walks or start needing help on the stairs again.  But sometimes we can be confronted with sudden, drastic changes in a pet’s condition on an emergency basis.  The best thing you can do to help manage either of these situations is to talk to your veterinarian in advance, and plan for how you will manage in such potential situations.

The best plan will vary widely depending on your pet’s diagnosis, their temperament, your home environment, and your own resources and abilities when caring for them.  The first step in preparing, though, is always going to be talking to your vet about their specific diagnosis or condition.  Make sure that you have an understanding of what is going on in your pet’s body, how it is likely to progress over time, what signs to watch for, and what possible complications may arise.  The more educated and aware you are, the earlier you will be able to recognize changes – potentially preventing an emergency by acting earlier.  Also, being informed can help you feel more confident and prevent you from feeling panicked or overwhelmed in a challenging situation.

Then, based on your conversations and understanding, you and your vet can put together any necessary plans.  A plan for slow progression may involve discussing whether you can safely increase the dose or frequency of specific medications based on the severity of your pet’s symptoms; monitoring your pet’s vital signs and adjusting their care plan in response; keeping anti-nausea medication on hand for a pet with GI or kidney disease, or many other similar simple adjustments to their existing care.  Emergency plans can range from having an Emergency Kit on hand with single, pre-measured doses of anti-seizure medications or strong pain killers; having an oxygen concentrator and mask on hand in case of difficulty breathing; or having access to a 24-hour nurse or vet tech to help with care if you are unable to be present.

Each plan, of course, must be tailored to your own pet and your own situation, and your vet must be an active part of both planning and enacting it – while it should go without saying, never change your pet’s medication or treatment plan without consulting your veterinarian first!  While some medications can be safely increased or decreased, others can be very dangerous to change; your vet will help you decide what is best for you and your pet.  Whatever plan you put in place, make sure to keep it written down for your own reference, and review it with your vet at each visit to make sure that it doesn’t need to be changed or adjusted.

It’s scary and hard to think about our beloved pets getting sicker, especially when we’ve gotten them to a stable, comfortable point, and we can never be so thorough that we can be completely prepared for every possible emergency, but all the same, the more we can plan the better we can maintain the creatures that we love and care for in comfort for as long as possible.

Peach

It has been a while since I wrote my first memorial for Autumn Care & Crossings. Inpeach on quilt
March of 2015, we became one of Dr. Schoenberg’s first clients, needing her
assistance to help our 15-year- old cat, Fog, cross the rainbow bridge. She was one of
a pair—sisters from a litter of feral kittens born in March of 2000. After Fog died, I
memorialized her for this site, and in that post I wrote:

We think Peach still has a few years with us, so we’re going to save Fog’s ashes
and when Peach’s time comes, we’ll ask Dr. Schoenberg to help her pass as well,
and then we’ll mingle the ashes of the two sisters. We’ll place them in the
garden to nourish a special planting. The girls will, in the end, be together
again.

As it turns out, Peach had another two and a half years with us, for which we are so
grateful. Dr. Schoenberg’s care and guidance during those years made such a
difference, and when Peach’s time to leave us came in August of 2017, we knew the
drill. We knew exactly how hard it would be, and also how easy it would be. In-home
euthanasia, as we had discovered with Fog, is the compassionate end-of- life passage
that we humans deny ourselves but gift to our pets.saying goodbye

 
After Fog’s death, Peach became an entirely different cat. Yes, for about six months
she mourned her sister’s death, meowing plaintively as she searched for her in the
house or awaited her at the bottom of the stairs. It ripped our hearts out. But
eventually she…forgot. She adapted to life as a single cat, and to our tremendous
surprise, she blossomed. After 15 years of almost exclusively feline companionship,
she became more of a “people cat.” Always the beta, she’d spent a lifetime deferring
to her sister when it came to food and affection. She was skittish, and often hid when
people came over, leaving them to joke about whether we really had a second cat
because only Fog had the courage to show herself and cozy up to strangers.

 
It was astonishing the way Peach suddenly came out of the shadows, literally and
metaphorically. She began snuggling up with anyone and everyone. When clients
came to the house, she would not leave them alone, jonesing for caresses from
anyone who would have her. It was as if she were making up for all of the years that
Fog got the lion’s share of attention. We were grateful that in her golden years, she
not only survived the loss of her sister, but she thrived.
I’ll never forget the day I took my then-eight- year-old daughter Charlotte to pick up
the kittens from their foster home. The gray tabby that we later named Fog was
quite ready to go. The orange tabby, not so much. While Fog liked being held and
handled, Peach did not. We were told she’d need “extra work” to become more
friendly with people. The truth is that it never really happened, until the very end.

As a kitten, Peach was much smarter than her sister. She was aloof, but so much
more curious and active. A mouse could walk by Fog’s nose and she’d yawn, but
Peach? She was on it! Little escaped her notice. She even had an uncanny ability to
recognize cat species when she saw them on television. While Fog dozed obliviously,
Peach trained her gaze on the screen anytime there was a pet cat…or lion, tiger,
leopard, or other big cat performing in a commercial or being filmed in the wild.
Jackson Galaxy mesmerized her. She just knew!
Peach lived to be 17 and a half. It’s hard to remember what life was like before we
had the two cats. My daughter is now 25 and independent. I was divorced and
remarried, and we’ve moved twice. It’s the end of an era for sure. I blinked my eyes
and the kittens and my little girl grew up. March of 2000 feels like a lifetime ago, and
like it was yesterday.

 
Now we are catless. Over the past 20 years, I’ve had two dogs, two cats, many fish,
and even one pet snake. My husband Geof has had many of his own pets as well.
Now we don’t even have a houseplant. We’re going to see how it goes. If we don’t get
another pet, we may never see Dr. Schoenberg again, but we will always remember
and be grateful for what she did for us, and for our kitties.

 
We love you, Peach. And we love you, Fog. Soon we will mingle your ashes under a
new azalea bush in the back yard, and you will be together again. That was always
the plan. In that way, you will always be with us.Peach and Fog (1)

Adding And Subtracting

When we talk about, and practice, hospice medicine and palliative care, the primary focus is on maintaining a good quality of life for our patients.  When I talk to my clients and ask them what their goals are for their pet, while the exact details may vary, this is almost always listed as their top priority.  But it does raise the question of what, exactly ‘quality of life’ is, and how we maintain it.

 

So often, quality of life is defined by the absence of things – absence of pain, absence of hunger, absence of fear, absence of discomfort or distress.   Because of this, measures to support quality of life are often investigated and implemented by finding things that could potentially cause a pet to suffer these unpleasant conditions and removing or preventing them.

-I don’t want my dog to be in pain, so I won’t take her on walks.

-I don’t want my cat to have an upset stomach, so I can’t feed him this food or these treats.

-I don’t want my pet to be afraid, so I can’t leave them home alone.

-I don’t want my pet to injure themselves given their poor vision or mobility, so I can’t let them have free roam of the house.

-My pet gets short of breath easily, so I can’t go running with her anymore.

 

And these are all important things to pay attention to, absolutely.  But in a phase of life that already lends itself to a negative mindset, focusing on subtracting and taking things away – on what you and your pet *can’t* do anymore – can lead to an even more intense focus on negativity, pessimism, and loss.  It can become a daily reminder of what you and your pet used to have, but can no longer share.

 

Instead, or in addition, we need to find ways to reframe quality-of-life as a presence of positive factors.  While we can improve a pet’s well-being by removing suffering, we can also improve it even further by adding joy.   One of the best ways to do this, and one of the most uplifting ways to improve quality of life for both pets and their caregivers, is to think of what your pet loves and work with your veterinary team to find ways to continue including that in their life – or if you’ve been unable to do so, to reintroduce it.

-If your dog loves going for walks but gets painful or tired, can you drive them to their favorite park instead of walking there?  Shorter walks, or walks over flat terrain instead of hilly, can also help.  Small or toy dogs can also enjoy walks in a stroller.

-If your dog loves sniffing things but can’t walk far, can you ask friends with pets to bring their dogs to your neighborhood, so your pet can then have a short “sniff walk” around the area?

-If your cat loves sitting in high places but can’t jump, ramps or stairs can help them get to their favorite positions.

-If your pet used to love to chase toys but can’t run anymore, toys can be slowly rolled to them, or tossed gently a short distance.

-If your pet loves spending time with family but is limited in where they have access for any reason, can you either move family time to a place that’s safe for them or revise the family space to make it more pet-safe?  Baby gates, play mats, and puppy pads can be very helpful for this.

-If you cat loves napping in sunbeams but can’t reach their favorite window seat anymore, bright lamps can create a warm, “sunny” spot for them.

 

There are as many solutions as there are pets and families – it may require a little bit of creativity and ingenuity, but ultimately focusing on how you can add things to make your pet happier instead of limiting yourself to just eliminating sources of suffering can both improve their quality of life beyond just ‘not suffering’ and help sustain your bond with them by finding ways that you can continue to share time and favorite activities, even as they age or face chronic illness.

Creating A Community

One of the things that I love the most about house call work, and hospice in particular, is the sense of community that it creates.  Veterinarians have always played an important role in sustaining and supporting the human-animal bond, but caring for an aging or ailing pet often calls for, and creates, a strong bond between both the caregivers and their nearest and dearest – and going into their homes and helping through that transition lets me bear witness to bonds of family, friendship, and love that I am honored to witness and, on some level, share in.

Autumn Care & Crossings is dedicating this summer to community support and outreach.  The more people are aware of animal hospice, and the important role that senior pets play in our lives, the better the lives of both pets and caregivers will be.  We’re starting, as a culture, to recognize the emotional impact of caring for our pets, and this is amazing – it means that more and more, people will be able to find the support and compassion they need to help them through this emotionally challenging time.  And the more people are aware of options for improving their pet’s quality of life, the more we will be able to act to keep our pets comfortable and happy through the last chapter of their life.

I’ve already taken a few steps to reach out into the

community to spread the word about animal hospice and palliative care.  Boston Voyager has been gracious enough to reach out and write a piece about AC&C, and animal hospice.  I’ve also written an article for A-DOG, the Arlington Dog Owners’ Group, to follow on the talk I gave in the fall about caring for aging pets.

And lastly, AC&C is a sponsor for the 2017 Somerville Dog Festival.  We’ll have a booth at the festival, sharing information about senior pet care, animal hospice, and quality of life, as well as offering supplies for making memorial gardens – please come out and join us!

If you know of an organization or resource in your community that would like to learn more about animal hospice, or a place to spread the word, please let me know!   The more people are aware of this option, and the more caregivers learn that they’re not alone in this phase of life, the better we can make life for people and pets out there.

Silly Wizard

They hold our histories

Live only to love & be loved.Wizard
Each fills space in your heart
Creating a place for another
The too quiet house echoes remembrance
Silence ebbs, recedes, displaced by life
Stories shared, brief moments in time
Love will be heard through sadness
Promise grows and flows into light
“A feeling once had is never lost.”

Milestones

I suppose it’s a mark of success in and of itself when a milestone passes and you’re too busy experiencing the event to take time, at that very moment, to celebrate it.

Two weeks ago we celebrated the second anniversary of Autumn Care & Crossings.  What started out as a daydream has turned into a full-time practice, and such a core part of my world that I can no longer imagine what my life would be like without it.  The practice of hospice, the philosophies and teachings, and the mindfulness that comes with it have shaped and colored both the way I work with my patients and their caregivers and every other facet of my life.

In my first year of hospice practice I learned so much about what hospice means, and what running a business means – and those are lessons that I honestly believe will continue to grow and change as long as I’m alive.  This year has seen me take a more formal turn towards both teaching and learning – the former through community outreach and lectures on caring for senior pets, and the latter through the IAAHPC’s Certification Program in Animal Hospice and Palliative Care.  I am so honored to be part of that program – to be able to be present at the start of such an important phase of this profession, and to do my best to offer the highest quality of care to my patients and clients.

At the same time, this year has brought the passing of some of our first and oldest patients.  Saying goodbye to a beloved family member is never easy, and the closeness that hospice care brings means that I share, at some level, in the loss of those pets who have been in my care.  In their memory, and in honor of every pet that has passed while in our care this year, Autumn Care & Crossings will again be making a donation to the MSPCA.  I can think of no better way to celebrate the lives of all of these beloved pets than by helping another animal to become the beloved companion of a caring and loving family.

The longer I travel along this path of hospice and end-of-life care, the more blessed I feel to have been called to it.  And it is the pets and the caregivers themselves who make me feel so lucky – I am grateful beyond words to every family that has opened their home to me and trusted me to shepherd them and their beloved companions through this transition, for every hug, every smile, every tear, and every wag and purr.  This is a precious phase of life, and you honor me by letting me be part of your team.  Thank you.

Molli

Molli came into our lives 17 years ago brought to us from a dear friend.  As soon as Molli walked out of her carrier she knew right away that this was her forever home. She always walked around with her beautiful tail straight up in the air with that curious question mark at the end ready for her next adventure.  She was not a lap cat but always used your hip like a pillow. Whatever room we were in she would grace us with her presence.  She was a seasoned mouser and whenever a fly got into the house it was doomed right from the start.  She absolutely loved to help me “make theIMAG1878-1-1-1 bed”! She loved playing hide and seek! We have so many loving memories. I could go on and on but…

It was in August 2016 that Dr. Becky came into our lives. We knew we did not want to put Molls through surgery and chemotherapy when she was diagnosed with colon cancer. With Dr. Becky’s kind and supportive care we were able to give Molli quality of life through the end. Dr. Becky always helped us feel comfortable with our decision to provide palliative care and would prepare us to make that heart- wrenching decision when the time came.  So on January 20, 2017 Dr. Becky was there for us. She explained to us what to expect to help Molli have a peaceful crossing. From beginning to end Dr. Becky was there for us.

Bonding With Older Pets

As our pets age, we face many different challenges and changes in our relationships with them.  Part of this comes with the transition from companion to caregiver – older pets often require more support, medical care, and supervision, leading to a change in how we spend our time with them and how our pets behave around us.  But there’s also the fact that frequently older pets aren’t interested in, or able to, take part in shared favorite activities.  Dogs may be less interested in going for car rides or long runs; cats may not sleep in our beds or chase their toys anymore; and these changes impact our bond with them at the same time that we’re facing fear from difficult diagnoses, stress from changing care schedules, and frustration from struggling to medicate our pets or manage the symptoms of their illness or aging.

In times like this, it’s incredibly important to find ways to maintain and support that bond, and to engage with our aging and ailing pets in ways that make them happy and remind us of our love for them and the joy they bring into our lives.   Older pets can still be active parts of our families and our lives, and can still be incredible sources of love and happiness, if we’re willing to work with them.

Every pet is different, but there are almost always ways to adapt their favorite activities to fit with their current levels of energy, mobility, and strength.  For dogs with arthritis and mobility problems, the change can be as simple as adjusting your walking routines.  Shorter walks can still be fun and bonding – or, if your pet isn’t able to walk all the way to the park and back, it may be easier to drive to the park and walk around there, then drive home.  Adapting your route can help as well; walking on level ground instead of hilly areas or on surfaces with more traction can help an older pet still enjoy their time outside.

Dogs who used to love to chase toys but aren’t able to run anymore can still engage in their favorite toy by walking after a slowly rolled ball, or a toy that was gently tossed a short distance.  If your pet used to love car rides but now gets anxious in the car or can’t jump in anymore, mobility aids may help – a ramp or stairs to get into the car, and a seat belt harness once they’re inside, may help them enjoy this shared activity again.

Older cats may withdraw from family due to unrecognized joint pain – if your kitty isn’t hopping up onto the bed or sofa, talk to your veterinarian to see if they’re actually in discomfort and if there’s anything that can be done medically to treat them.  Also, stairs or ramps up to furniture can make it easier for an older pet with arthritis or limited strength to get back to their favorite perches.  Older pets also often have diminished senses; toys with brighter colors, bells, or scented with catnip may be more appealing and more likely to encourage them to play and interact – and just like dogs, a few shorter play sessions may be more fun for a pet that tires easily.

Ultimately, think about what you and your pet loved doing together, and talk to your veterinarian.  Together, you can put together a plan to keep that shared fun in you and your pet’s life, and keep your relationship with them positive and rewarding at this new stage in their life.