Caring For The Caregivers

When I talk to people about animal hospice, whether it’s to potential clients, other doctors, or people curious about the field, the biggest assumption I have to face is that what I do is primarily about prescribing medications.  There’s a belief that, because this is a field of medicine, it must obviously be focused around, and limited to, using drugs to treat symptoms.  And I’ve addressed many facets of that fallacy here.  I’ve talked about the importance of nutrition, of environmental modification, of emergency planning, and supporting quality of life, all of which are important, non-prescription-related facets of hospice and palliative care.

But one of the most important roles of animal hospice, and one of the most unrecognized ones, is something that I haven’t talked about yet – and that’s our role in taking care of the people who take care of their pets.

When a family brings a hospice and palliative care veterinarian into their care team, that doctor isn’t only stepping in to help the animal.  The human family members are as much part of the patient unit as the pet is, and the focus of care is directed equally at them.  Caring for a pet with a terminal or life-limiting illness is stressful, exhausting, scary, time-consuming, and something that most people’s day-to-day life experience neither prepares them for nor gives them the time and resources to manage, and the animal hospice team is there to help them through this process.

Caregiver support can take many different shapes.  Education is a large part of it – knowing more about your pet’s diagnosis and the signs they’re likely to show will help you provide better care for them, but it can also help you prepare for emotional hurdles, plan and budget your resources of both time and finances, and face upcoming decisions with more confidence.  Pairing caregivers with resources is incredibly important as well – helping a family find a skilled and trustworthy person to care for their ailing pet when they’re not home, finding a pharmacy that can make more palatable medications, interpreting a specialist’s instructions or recommendations, or providing references to a therapist or counselor who is sensitive to their specific needs are all services that hospice vets can provide.

Above and beyond this, every family has their own unique, special needs and challenges.  Some individuals have physical challenges that make caring for their pet difficult, and a hospice vet can help navigate these, finding ways to modify a pet’s care to accommodate visual, physical, or situational challenges.  Other families may need help communicating among themselves, or coming to consensus as different individuals have different priorities or concerns about their beloved pet’s care.  And many people may simply need the support of a compassionate and understanding person to talk through as they face the incredibly difficult challenge of taking responsibility for making life and death decisions for another being, to reassure them that the path they’re choosing is a fair, ethical, and loving one.  Lastly, a hospice veterinarian will help make sure that any care plan focuses on your own priorities, concerns, and needs – there is no ‘one size fits all’ hospice plan.

So often, people believe they and their pet aren’t candidates for hospice and palliative care because they believe there is nothing that can be done for their pet.  While this is almost never true, the equally important fact is that hospice can help them as well.

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

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.

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.

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.

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.

What Is Normal?

Facing the loss of a pet brings so many challenges to the people going through that experience – but the longer I work in hospice and end-of-life care, the more I realize that one of the most difficult parts of this loss for many people is just the fact that we live in a culture that doesn’t give us a guideline for how to navigate such a tragedy.

While everyone experiences grief differently, for most forms of loss there are standard procedures and behaviors that we can look to, that help shape our reactions and let us know that what we’re going through is normal and accepted.  We cry, we hold funerals, we send flowers, we partake in rituals that are given to us by our faith, our families, and our communities.  But very few of those resources exist for the loss of a pet, and so often people don’t know quite how to behave or react in the face of that pain.

So many times I hear clients ask me, ‘Is this normal?’ or ‘Does everybody do this?’  Or, even more tragically, they hesitate to ask for things that may comfort them or aid them in their grieving process because they are afraid that it will seem strange or silly.  And I want, more than anything, to help dispel that fear and reassure everyone reading this that, whatever shape it takes, your path through loss is the right one for you.

First, grief is universal in the face of loss.  Different people may express it in different ways – some people cry, some are quiet, some tell stories; some people need company and others need to be alone; some need to take action and others need time for introspection – but those are all reactions to the pain and heartache of losing a living being that you shared your life with.  It is entirely normal to hurt, to feel sorrow, and to mourn that loss.  You are not alone or unusual in loving, caring, or hurting, and there is nothing wrong with having such love and compassion in your life that you grieve when that part of your family is no longer with you.

Secondly, for all that grief is universal, mourning and memorializing are incredibly unique and personal.  We all bring our own beliefs, history, and experiences with us to every relationship in our life, and to the passings that happen when those relationships end.  As tragic as death is, every loss is in some way a celebration of the bond shared between the being that passes and the person or people who loved them, and a final chance to act to honor that bond.

If there is something that feels like an appropriate way to honor your pet’s passing, or that would comfort you in the face of that loss, please tell your veterinarian.  I promise you, it is not silly, you will not startle or offend us, and if anything we will be grateful for the trust you are showing us and the chance we have to help you and your beloved pet.  Whether it’s making them a favorite meal first, singing a favorite song or reading a prayer or poem, having pictures of family who can’t be present nearby, saving a lock of fur, sending them with a favorite toy, treat, or symbol of faith after they have passed, or any other act that may feel right to you, please do tell us.  This is part of why I describe what we do as end-of-life care, and not just euthanasia – there is so much more to saying goodbye to a beloved pet than just the act of helping them pass, and both you and your pet deserve to be cared for with compassion, respect, and kindness throughout that experience.

I’ve said before that there is no one right or wrong way to grieve, and that holds true for the process of letting go.  It seems paradoxical to say both that grieving is normal and that each person’s grief process is different and special, yet both are true, and worry and self-consciousness have no place interfering in such a challenging time.  Your bond with your pet is unique, and it is our job (and our honor) as hospice veterinarians and caretakers of that bond to help both you and your pet navigate this final chapter of their life in the best way possible.

Memorials

Most of the time here, when I write it’s about how to take care of our beloved pets through the course of chronic or terminal illness, and how to take care of ourselves as we face that process.  But it’s important to remember that our relationships with the animals that share our lives don’t end when those animals pass away, and that hospice and end-of-life care also encompasses honoring that bond and supporting the caregivers after a loss.

Our culture has many commonly accepted ways to honor and remember the loss of people in our lives, but often I’m faced with clients who want to find some special way to remember a beloved pet but don’t have an idea of how.  So I thought I’d put together a list of some ways to celebrate the memory of a pet that has passed.

  1. Create a photo pillow – You can take a favorite picture of your pet and make a pillow.  If your pet had a favorite blanket, you can use that fabric for the pillow as well.  http://inhabitat.com/how-to-make-personalized-photo-pillows-for-your-friends-and-family/
  2. Make a keepsake box – this can be a way to save treasured items in a special place. http://www.countryliving.com/diy-crafts/how-to/g432/memory-boxes-0704/?
  3. Sponsor a service dog in their memory – So many animals out there serve as much more than pets for the people who depend upon them.  Helping someone get the service dog they need can be an incredible way to honor the bond you had with your pet.  http://www.guidedogsofamerica.org/1/help/sponsorship/
  4. Take part in a charity walk or other event to help support pets in need: Here in Massachusetts the MSPCA runs an annual charity walk; similar events take place around the world.  https://www.mspca.org/featured_events/walk-for-animals/
  5. Write: Tell the story of your pet and your life together.  This may take the form of a blog post, poetry, a story, a childen’s book, or whatever form seems most appropriate to you.  Whether you share it with friends, the world, or keep the words for yourself, creating the story can be an incredible act of celebration and memory.
  6. Hold a memorial service: invite your friends and family who also loved your pet to come together and celebrate their life.  Ask everyone to share a favorite picture and memory of the pet, and celebrate your time together.
  7. Memorial jewelry: This can be anything from a pawprint necklace to a bracelet charm made from their collar or tags.  There are also necklaces that can be made to hold a small amount of ash, if you have your pet privately cremated.
  8. Make a memorial garden: Plant a tree, a flower bush, or if you don’t have an outdoor space, a house plant in honor and memory of your pet.
  9. Commission a painting: have a portrait made from your favorite picture of your pet, to hang in a place of honor in your home.
  10. Make a memorial stone: Even if you are not able to bury your beloved pet, an engraved stone can still help remember and honor them.  You can make one yourself and decorate it with family members, or order one custom-made for your pet.

These are just a small handful of ideas – there are so many other beautiful ways to honor and celebrate those who have passed from our lives – but I hope they can act as inspiration for those of you facing the challenge of how to create a fitting memorial for a pet that you have lost.

National Pet Memorial Day

Today is National Pet Memorial Day – a day for celebrating and remembering all of the special animals who have made our lives better with their presence. AC&C is hosting an online memorial today; we invite everyone to comment here andpercy share memories, pictures, and stories here in honor of our beloved pets.

I have been lucky enough to share my life with so many amazing and beloved pets, but most of all today I want to celebrate Percival. My best friend, constant companion, study buddy all through vet school, and the cat who taught my current kittens how to be cats. He crossed half the country with me, slept on my pillow every night for over a decade, and his presence is still felt in my life every day.

Thank you, Percy, for so many years of love. I still love you, I miss you, and you made my life better with your presence.