Making Choices

Recently, when I asked folks what topics I should write about here, someone asked, ‘When your vet prescribes a new diet or treatment for your pet, how long should you attempt it before you give up and go back to what you were doing before?’  And I realized that this question brought up something more important than the request itself – and that is the fundamental mindset behind it, and the difference between traditional Western medicine’s classical approach to treatment and the mindset of hospice medicine.  And this mindset is one that can get in the way of successful care for many patients.

The challenge with this question is threefold.  First, by phrasing it that way and considering treatment from that approach, it assumes that the treatment itself is difficult, challenging, unpleasant, and generally something the pet is going to dislike and the client is going to struggle with.  It sets the asker in a frame of mind where the automatic assumption is that the treatment is going to fail or be impossible to carry out, and the only question is how long to go through the motions before getting permission to stop, instead of considering the potential for easy treatment, positive experiences for the caregiver, and success.

Second, it frames the question of treatment into an either/or situation.  Either you are treating with one specific plan or you are doing nothing.  It creates a false dichotomy, instead of allowing for a spectrum of options including multiple levels and methods of treatment.

Finally, it is based upon a total absence of communication between the client and their veterinarian.  It sets forth a situation where, when a client undertakes a treatment path and then faces challenges along that path, rather than talking to their pet’s health care team to let them know they’re having difficulty, they decide to cease all treatment.

In hospice, communication and choice are two of the core concepts of our practice.  The most important tool we have, both as pet caretakers and as doctors, is communication.  If a particular treatment is suggested – whether that be a special diet, an oral medication, a form of physical therapy, or any other intervention – and that treatment is either too challenging for the pet or caregiver or isn’t improving the pet’s quality of life, it’s critical that we know.  While we as doctors have a wealth of knowledge, resources, and experience at hand to offer to our patients, none of that can help if we’re not aware that it’s needed.

Having these resources also means that, if one plan isn’t working, we can help form another.  That may mean suggesting a second diet if the first isn’t palatable, a different medication if the first isn’t effective (or a different formulation if the pet isn’t willing or able to take the first), offering assistance or training to help implement specific treatments, or making a decision as a team to discontinue a particular treatment.

And that last statement is, for me, the most critical one.  While it may seem like semantics, I honestly feel that there’s a difference between giving up and choosing not to continue.  Giving up carries a connotation of failure, which can also lead to guilt and blame – two emotions that can be incredibly damaging and undeserved for caregivers, especially in a hospice environment.  Making a choice, with cooperation and support, is an active decision that is still focused around the well-being of the patient.  Ultimately, when we’re facing an end-of-life situation, we know that eventually the patient is going to pass.  We can postpone that day, and we can make every day along the path more comfortable and peaceful, but we can’t delay death forever.  In that environment and mindset, I don’t feel that any considered and informed decision about treatment, or stopping treatment, is giving up – it’s just prioritizing different factors in the patient’s life.

So – I don’t think of my clients as giving up at any point in their pets’ care, and I hope sincerely that they don’t either.  It is my ultimate goal to create an environment where they feel comfortable communicating with me about any challenges they face and supported in any decisions they make.  And I hope that those of you reading this can take this mindset into your day-to-day experiences with traditional wellness care as well.

How Do You Do It?

“How do you face this sort of thing every day?”

“I don’t know how you do this job.”

“I could never do what you do – it would break my heart.”

“Isn’t that awfully depressing?”

I hear some variation on this almost every day – when I’m at an end-of-life visit, when someone asks me what I do, when I’m on the phone with a client calling to ask about how to handle an impending loss.  And they all boil down to the same thing – ‘how can you work around death and loss without being miserable?’  And the more I think about that question, the more I realize there’s a very simple answer.

My job lets me bear witness to some of the greatest acts of love that I can imagine, and reminds me every day of the goodness that people are able to hold within them.

Every person who calls me is doing so out of love, compassion, and hope.  Whether they’re looking for hospice care or looking to help their beloved pet pass peacefully, they are doing so out of kindness, and because of the deep bond that they share, and a desire to make things better – not for themselves, but for another living being.  Even knowing how hard it will be for them, they take this step because they want to make life better for another creature, or when that’s no longer possible, bring peace and an end to suffering.

Every time I step into a home I see selflessness, devotion, and love.  I see it in mattresses on the living room floor pulled up next to a dog bed so that an elderly pet who can’t climb the stairs won’t have to sleep alone.  I see it in heating pads and sun lamps arranged into nests in a cat’s favorite napping spot.   And I see friends and families coming together to support one another, sharing memories and comfort, hugs and laughter and tears.  A father lies on the floor with his daughter, telling her that it’s okay to feel what she’s feeling.  A best friend makes phone calls when the family is too broken up to speak.  A family plans to all share a toast to a pet’s memory at the same day and time, even if they can’t all be physically together.

 

Every death is different – and yet, the words I hear more often than any other, from person to pet?

“Thank you.”

“I love you.”

 

We live in a culture that does not encourage displaying or sharing our emotions – and yet every day I’m honored to share that closeness.  And right now, seemingly more than ever, we live in a world where news and social media seem to highlight the worst that humanity is capable of.  Hatred, violence, greed, selfishness, and anger are on display everywhere you look, and it can be easy to believe that this is the whole truth of the world.  But, while my job surrounds me with death, those deaths are the result of love and kindness, not intolerance, cruelty, or violence.  I am reminded every single day, with every family I help, of all the goodness in the world, the kindness that people are capable of, and the fact that every day people make decisions and take actions driven by love, compassion, and empathy.

 

How do I face this every day?

With gratitude for every family, every visit, and every moment of kindness I am honored to share.

Celebrating A Milestone

Today marks the one-year anniversary of Autumn Care & Crossings’ first patient, and my first official step on the path of being a hospice veterinarian.  While I had studied and planned and worked towards this in preparation, it was on this day last year that I formally became a hospice practitioner, and started stepping into people’s homes and lives to help them and their beloved pets in the final phases of their bond.

And I have learned so much in this year.  From my colleagues and the conferences I’ve attended, from the accountants and business folk who have helped me navigate the maze of small business ownership, and most importantly, from those very clients and patients.  I have learned more and nuanced details about targeted pain management and breakthrough pain and natural versus palliated death versus euthanasia.  I have learned how to reconcile Quickbooks and when not to trust Google maps.

I’ve learned to always keep treats and a spare pack of tissues in my bag, and that on a sunny day the dog park is an excellent place to finish a hospice call.  I’ve learned to never underestimate a child’s understanding or an adult’s devotion, when traditional medicine had always taught me to trust in the opposite balance.  I’ve learned that family is not defined by blood or by species, but by love – and that love comes in more shapes and manifestations than I had ever dreamed possible.  And I’ve learned that sometimes saying goodbye is the greatest and bravest act of love that a person can make.

It’s hard to write in a blog here when I sincerely don’t have words for how grateful I am to everyone who has been part of this year.  To my colleagues who shared their knowledge and experience with me; to the friends who helped make this practice real; to my patient and loving spouse who met the question of, ‘can I throw my career, our lives, and our home into chaos and turmoil for the sake of trying this?’ with more grace and support than I had any right to ask for, and most of all to the clients who invited me into their homes to be part of their pet’s care team.  Thank you all, more than you could ever know.

As a mark of that gratitude, and in celebration of the families and pets that I’ve been lucky enough to come to know over the past year, I’m starting what will hopefully become an annual tradition.  Autumn Care & Crossings will be making a donation to the MSPCA in honor of each pet in our care that has passed away over this past year.  It is my hope to celebrate each life passed by helping another animal become someone else’s beloved pet, and find a forever home as loving and caring as the ones my patients have been blessed to know.

Because I can’t say it enough times, thank you all again for being part of this amazing experience with me.  I look forward to many more years of laughter, tears, and learning as I help guide my patients and clients on their journey through this chapter of life.

Knowing When It’s Time

At some point in our relationship, almost every client that I’ve worked with – in both traditional practice and hospice practice – has asked me how to know when it’s time to euthanize their pet.  It’s a hard question – we want to have as much time as possible with them, but we also don’t want to allow them to suffer, and it’s natural to worry about making that difficult decision either too soon or too late.

I wish I had an easy answer here.  I wish there were an equation that we as doctors were trusted with – multiply the pet’s age by their weight, divide it by some numerical value assigned to their diagnosis, subtract a point for each day they don’t eat, and when you get to zero a timer sounds and you know.  Or, if not that, that there was some concrete point or incident that I could tell everyone to look for.  Unfortunately, that’s not the case.

Every pet is unique, and every person’s relationship with their pet is unique, and so the point of decision is going to be different for each family.  Some people want to be absolutely certain that they avoid any possibility of pain or suffering for their pet, and want to say goodbye sooner – and that’s okay.  Some people want to know that they’ve exhausted every possible treatment, and given their pet every possible moment of life – and that’s okay too.  And on top of that, every pet finds joy and happiness in different aspects of life, and so their quality of life is going to be affected by different things.

Quality of life is, ultimately, the most important factor in deciding when it’s time to help your pet pass.  And, as I said, it’s a very individual thing.   A 90-pound labrador retriever that’s used to being able to run and climb mountains with his family is going to be much more severely affected by joint disease and poor mobility than, say, a teacup chihuahua who’s used to being carried and cuddled for most of his interactions with his family.  On the other hand, that chihuahua (or an aloof kitty) is likely to be more negatively impacted by a need to take multiple medicines two or three times a day than the lab who will eat anything hidden in cream cheese or cold cuts.

One of the most important things that your veterinarian can help you do, as your pets age or confront chronic or terminal illness, is help teach you how to recognize their quality of life.  This is a deep collaboration between you, your pet, and the doctor – while they can talk you through what signs to watch for on the medical front, you know your pet’s personality.  You live with them every day, watch them, and know their favorite toys, treats, napping places, and things to do.  And it’s important to discuss these with your vet, and form a plan to pay attention to them and track them.

If your pet is seriously ill, your vet may suggest tracking their quality of life.  While there is no absolute equation, as I mentioned, there are factors that we can quantify and ways to track whether those details are getting better or worse.  If you’re having a hard time making a decision about whether your pet is suffering, having a way to look back over the past days or weeks and see objectively whether and how their condition is progressing can be a valuable aid.

There’s no way to make this decision an easy or painless one.  But by talking to your vet about quality of life, and paying attention to what your pet loves most, we can help you face this challenge with a little more confidence.

How To Help

Loss and death are always difficult, whether we’re the ones facing the loss of a beloved friend, pet, or family member ourselves or whether we’re trying to support someone we love through that process.  Every person approaches loss and grief with their own history, worries, and combination of emotions, and just like there’s no one right or wrong way to grieve, there’s no one right or wrong thing to say or do to support someone through grief.  There are, however, some things that can be generally helpful in most situations, and some that may seem helpful but can actually make things worse.

So – what should you NOT do to help someone you love through the loss of a pet?

*Don’t suggest that they get another pet.  While for some people getting a new pet may be part of their grieving and healing process, this isn’t true for everyone – and more importantly, the time to bring a new pet into the family (if they choose to do so) is different for everyone.  What may seem like a practical solution to you can come across as suggesting that pets are interchangeable and replaceable, which can seem dismissive of the pain and loss the person is feeling.

*On that same note, don’t try to reassure them by telling them it was ‘just an animal’ and that it could have been worse, by comparing it to other losses.  There’s no universal scale of loss or grief, and everyone is allowed to feel their own pain.  One person’s loss of a pet may be as traumatic to them as another person’s loss of a human.  Grief is not a contest or a zero-sum game.

*On the other hand, do not tell them “I know exactly how you feel.”  Even if you’ve been through a similar loss yourself, even if you feel that you have a deep understanding of their emotional state and want to be supportive, no two people experience grief and loss the same way.  Their emotional response is theirs and unique, just like yours was and is.  Don’t dismiss their feelings by suggesting that they’re the same as yours.

What CAN you do to be helpful?

*Listen.  This is the most important thing that a supporter and friend can do.  Let the person know that you are present, that you care, and that you’re able to be an ear and a shoulder for them.  If they want to talk, listen without judging or trying to problem-solve.  If they need reassurance, give it to them without straying into personal anecdotes of your own.  If they need quiet company, be present without pressuring them to behave in any particular way.

*Validate their feelings.  Let them know that it’s okay to grieve, and that you understand that their loss is significant to them.  While ‘I know how you feel’ is an unhelpful response, ‘I can’t imagine how difficult this must be for you’ or ‘I can only imagine how you must feel’ are open-ended, supportive statements that let your friend know that you empathize with their loss without second-guessing or hijacking their experience.

*Ask what they need or want.  What’s helpful to one person may not be helpful to someone else, and we run into the biggest problems when we assume that what we would want in a given situation would also then be best for another person in a similar situation.  Asking instead of assuming lets you give the most useful aid.  It also makes sure that the help you’re giving is focused on the grieving individual, rather than yourself.  Often in situations of caregiving we want to help in ways that will make us (the caregivers) feel better, but the most important focus should be on the person suffering the loss.  While we are hurting too, and are allowed to seek our own aid, the help we offer should be focused on those we’re helping rather than on ourselves.

*If the grieving individual isn’t able to focus enough to give you a specific answer to what they need or want, ask about specific ways you can help, but offer them as choices.  (“Would it help if I came over to keep you company?  Do you need someone to run errands for you?  Do you want me to return Smudge’s medicines to the vet so you don’t have to go back to that office so soon?”)  – and be prepared to accept whatever answer they give.  This empowers them to have some say in the help they receive while taking the burden of coming up with ways to be helpful off of their shoulders.

*Most of all, be patient.  Grieving takes time, and sometimes – as much as we want to help – there’s nothing we can do except be present, let the people we care about take the time they need to heal, and let them know that we’ll still be there, still care, and still be part of their life when they’re ready to engage with us again.

*Take care of yourself.  Even if you didn’t suffer the loss personally, having a friend or family member grieving the loss of a loved one (human or pet) can be stressful, challenging, and bring up memories of our own losses.  Make sure that you’re getting the rest and support you need – you can’t be a good caretaker and supporter if you’re not also taking care of yourself.

*If you’re concerned that your friend or family member is in danger, reach out to a professional.  Whether that’s a grief counselor, a religious leader, or a suicide hotline, if you’re seriously concerned that someone may be at risk of self-harm or falling into clinical depression or suicidal tendencies, don’t try to tackle that alone.  Encourage them to seek professional help, or if need be, reach out to a professional yourself.

Grief is something we all have to face at some point, both our own and that of our friends and loved ones – hopefully this can help make navigating that path a little easier.

Holidays And Loss

While the holiday season is meant to be a time of joy and celebration, for those of us who are dealing with a loss – either recent or historical – this time of year can be especially challenging in many ways.  The pressures and expectations of society and of friends and family, even if they’re well-intended or completely unintentional, can add stress and pain to a situation already heavy with memory and pain, and it’s incredibly important, in the middle of these challenges, to take care of ourselves and be aware of our own emotional health.

People facing loss and grief during the holidays are often drawn in two completely contradictory directions.  There’s pressure from society and our culture to celebrate, rejoice, and generally be filled with a spirit of love and good cheer that may not feel appropriate to someone mourning a recent loss or facing an imminent loss.  This may be even more acutely felt by those who have lost pets, as often many people may not regard that loss as being as valid or emotionally challenging as the loss of a human family member, or may pressure them to get a new pet as a holiday gift.

At the same time, at the other end of the spectrum, people facing loss can also be pressured to show their mourning in ways that outsiders feel appropriate – to grieve publicly and to abstain from any displays of happiness or celebration.  They may be told that it’s inappropriate to celebrate under these circumstances, or they may feel guilty for being happy when propriety tells them they should still be sad – it can feel like a betrayal of the individual lost to find happiness so soon after, or so close to their passing.

There is no right or wrong way to feel.  There is no one true way to grieve, and whatever you are feeling around your pet’s loss (or any other loss you may be facing) is right for *you.*  While it’s important to find support from the people you love and who love you, it’s also important to set boundaries, and to make it clear to them that your emotional path is your own, just as theirs is.  If it feels appropriate to grieve, to abstain from celebration, and to be present with your sorrow, then do so.  If it feels right to celebrate – to share tales of joy from a life together, to rejoice in the loved ones still present, to give your happiness as a gift to the world that gave you such a loving companion for as long as it was able, then do so.

You do not owe anyone either your sorrow or your happiness.  Not society, not your family, not the loved one who has passed on.  You have gifted them with your time, your energy, and so many other things, but your grief and your process through loss are yours to travel in your own way, at your own pace.

That doesn’t mean you need to walk it alone, though.  As I said, please reach out.  In this dark, chill, challenging time we can all feel lonely, especially if a beloved companion has passed or is facing terminal illness.  Please take advantage of the resources in your area.  Friends, family, veterinary staff, religious support groups, pet loss hotlines or online communities – whatever support you need to make it through this period.  Help is here.

Best wishes for hope, healing, happiness, and a bright new year.

Communication Conundrums

One of the most common questions I get, when I talk about hospice and end-of-life care, is how a person can discuss their choices regarding their pet’s care with other people who don’t understand or agree with the decisions they’ve made.  This is a challenging problem, in both directions – there will always be people who don’t understand a decision to invest time and money in a pet, and people who don’t understand a decision against aggressive care.

More and more, it’s actually becoming easier to discuss these decisions.  Our culture is coming to recognize the important roles that animals can play in our lives, and the strength of the bond between people and their pets.  From workplaces offering pet insurance to companies making greeting cards and thank-you cards for and from pets to the prevalence of pet-friendly hotels and vacation facilities, pets are being recognized as part of the family unit.  Still, that doesn’t protect us from the questioning and judgment of people who don’t – or can’t – understand the decisions and choices we make, or who accidentally hurt us with well-intentioned but ultimately hurtful advice.

(And for those of you who are friends or family to people facing pet loss, it can be hard to know what to say or how to help them.  That’s another complicated topic, that deserves its own post in the future.)

So – what do you say to someone who tells you that ‘it’s just a cat,’ or asks why you’re putting so much time and energy into what they perceive as a replaceable thing?  Or to someone who feels that your decision to stop chemotherapy or avoid surgery is giving up too early?

I wish I knew the way to answer this, in such a way that would lead to universal understanding and compassion.  Unfortunately, the best solution I’ve found is to politely establish your emotional boundaries, and redirect the conversation.  When it comes to issues around end-of-life care, grief, and loss, we all have so many emotions and so much personal history invested in these subjects that it can be impossible to change people’s minds – the best path I’ve found is not to try to create converts, but just to clarify one’s own position.

What do you say, then, to do that?  I’ve found that something along the lines of this can work:

“I appreciate your opinion, and respect you as a [friend/cousin/coworker] – but the human-animal bond is different for everyone, and this path I’ve chosen is the one I feel that best honors my bond with my pet.”

If they want to learn more, feel free to explain, or share some resources with them – some people have just never encountered the concept of hospice for pets before, or are unaware of the choices available when it comes to pain management and end-of-life care.  But if they persist in pushing their point of view, and don’t respect your decisions, it’s also okay to let them know that what they’re saying is hurtful.

Most people honestly want to help – sometimes you can deflect their well-intended words by giving them another way to help instead.  An offer such as “I understand that you mean well, but this is a very difficult time for me, and right now your words are making things more difficult.  If you want to help, what I really need from you right now is….”  And let them know what could be most helpful for you – whether that’s a hug, quiet acceptance, reassurance, a ride to the pharmacy, or anything else that may either ease your stress and emotional burden or help you face your current challenges.

The most important thing you can do, overall, when faced with challenges like this is seek out people who *do* understand.  Find a pet loss support group, either local to you or online.  Talk to your veterinarian or their staff.  And, ultimately, if you’re feeling overwhelmed or having trouble coping with either loss or the burden of caring for a chronically or terminally ill pet, talk to a grief counselor.  Regardless of what anyone else says, your feelings and your choices are valid – and you deserve to have the support of people who understand that.

Why Pain Matters

Pain.  It’s such a small word for such a large and complicated condition. Our culture surrounds us with so many different messages about pain, especially chronic pain, that it can be difficult to form a clear opinion about how to handle this condition, both in ourselves and in the pets that we love and care for.  How many times have we all heard these statements, or ones like them?

‘No pain, no gain.’

‘Pain is weakness leaving the body.’

‘A little pain never killed anyone.’

‘Just push through the pain.’

‘If it doesn’t hurt you’re not doing it right.’

These – and so many other philosophies – put forth the idea that pain is some kind of badge of honor.  That hurting is somehow proof that you’re working hard, or at the very least that pain in and of itself is harmless, minor, and not a problem that anyone should act on.  That, by treating pain, you’re admitting weakness.  And sadly, nothing could be further than the truth.

Pain is a disease in and of itself.  Pain causes physical damage to the body and permanent changes to the nervous system.  It slows healing.  And, in animals, it is one of the leading causes of death – as our pets reach a point where pain impacts their mobility so severely that they can’t stand or walk anymore, or diminishes their quality of life until they lose all interest in food and interaction, and the people who love and care for them choose to help them pass rather than either watch them suffer or face nursing care challenges that are beyond their capacity to manage.

It is true that some pain serves a purpose – but this is not true in most cases that we treat in medicine.  Ultimately, there are two kinds of pain: adaptive and maladaptive.

Adaptive pain is useful pain.  It is short, immediate, and serves the purpose of warning us that something damaging to our physical body is occurring, and that we need to act to correct that.  When you put your hand on a hot stove, and feel pain, you know to remove your hand before further damage occurs.  This is a normal function of our nervous system, and a way to protect ourselves.

Maladaptive pain is a very different thing – this is pain that serves no protective or helpful purpose.  This can be pain that continues after tissue heals, or pain that exists out of proportion to the stimulus causing that response.  Almost all chronic pain is maladaptive pain, and it can be very difficult to treat.

The problem is that these two forms of pain exist in a spectrum.  In particular, adaptive pain that is left untreated can and will progress to maladaptive pain.  When pain is untreated, there can be permanent physical changes in the neurological system.  Nerve pathways that help decrease or stop pain sensations cease to function, and other pathways that detect and transmit pain become more sensitive.  Other nerves not involved in the initial pain process are recruited and brought into the sensation and transmission of pain.   Once these changes occur, they cannot be undone.  Once chronic maladaptive pain exists, the best we can do is manage it.

There are several tools in our arsenal to manage chronic pain; I’ve talked about some of them in this blog before.  Chronic pain, if recognized and addressed, can be minimized and our pets’ quality of life can be maintained.  But the earlier in the course of a painful experience that we start treatment, and the more thorough that treatment is, the better the chance of preventing its progression to chronic maladaptive pain.  Treating pain early, and completely, is one of the most important tools we have in maintaining quality of life.

Pain is a disease.  We need to recognize it and treat it, just like any other.  Please, don’t let your pets – or yourselves – stay in pain.  Your bodies and your comfort are too valuable to suffer needlessly like that.

Treating Your Pet

When I asked for suggestions of what folks would find it useful for me to talk about here, one of the more common requests I got was for an explanation on how to give medicine to your pet.  Unfortunately, that’s not something I can easily describe in text-only, and it’s not a one-size-fits-all description.  Every pet is different, as is every person trying to treat them, and the best suggestion I can make is to ask your vet to demonstrate how give *this* medication to *that* animal – whether it’s pills, eye drops, insulin injections, or hairball paste.

But I did realize that there is one aspect of medicating (or treating in general) that I can talk about here, and that is how to find a medication form that works for you, your pet, and your lifestyle.  One of the most common problems I see – not just in hospice but in veterinary medicine in general – is people giving up on treating their pet because they feel it is difficult or impossible to give them medicine.  People get frustrated, pets go without treatment, and everybody suffers, because people don’t know that other options are available.  And if there’s one lesson I’d love to teach everyone reading this, it’s just that:

There are *ALMOST ALWAYS* more options available.

Not 100% of the time – some conditions demand to be treated only one way.  But in nearly every situation there are multiple options for getting medication into your pet, and your vet can work with you to find the one that works best.

So, how do you find the best way to treat your pet?  There are a lot of facets and steps:

1. Have confidence in yourself.

Yes, there are a lot of jokes out there about how to pill a cat, and yes, in general giving medicine is a skill.  But if you’re reading this, you’ve already mastered a whole lot of much more difficult and complicated skills.  I have confidence in you, and you can learn to do this.  It just takes time and practice.

2. Talk to your veterinarian.

As I said above, ask them to demonstrate how to give the medication.  Any considerate veterinarian should be able to either show you how to give a medication or have one of their nurses or technicians teach you.  If once isn’t enough, it’s okay to ask for another appointment when the next dose is due, for them to help walk you through it again.  We all went through this same learning curve, so we understand how challenging it can be at first.

3. Follow up with your veterinarian.

If you’re having trouble medicating, don’t just give up, or assume that this just isn’t going to work.  Let your vet know what’s going on.  They can’t help you, or suggest alternatives, if they don’t know there’s a problem in the first place.  On the other hand, if everything is going well, let them know too so they can note what types of treatment your pet tolerates for future reference.

Let’s say, though, that your pet is particularly challenging, and just won’t tolerate pills.  That’s not the automatic end of the road.  There are other ways to get medication – even oral meds – into your pet.

Compounding is an amazing tool for veterinary medicine.  It means getting medication custom-made for your pet.  This is very helpful in the case of super-small (or super-large) animals, because it means that we don’t have to worry about giving your 5-pound cat 1/16 of a tablet of something, or your Great Dane 5 pills three times a day.  It also means that, for pets who don’t want to take a pill, we can find something a little more palatable.

Compounded meds can be made up in a few forms:

-Chewable treats:  These are just what they sound like – chewy little treats that have medicine mixed into them.   They can be made up in several flavors, so let your vet know what kind of treats your pet tends to prefer.

-Flavored liquid: This is similar to other liquid medications, but instead of tasting like chalk or bubblegum, it can be made in flavors that are more appealing to pets.  (This is particularly common for cats, who may not always be as motivated to take flavored treats.)

-Unflavored capsules: For medications that taste very bitter, and whose flavor can’t be easily masked by chewables or liquid, we can hide the flavor by putting it into a capsule.  You still have to give this medication like you would a pill, but without the bitter taste, many animals take it a lot more easily.

-Transdermal:  Some (but not all!) medications can be made into a topical formula that is applied to the inner surface of your pet’s ear.  Be careful when requesting transdermal medications; not every drug can be absorbed through this route, so have your veterinarian double-check before requesting any specific medication be made in this formula.  Some pharmacies will compound any medication in any formula, regardless of efficacy, so having this option available doesn’t guarantee it will still work in every case, but for the situations where it does work, it can be a literal life-saver.

There are some things to keep in mind about compounding.  It’s not something your veterinarian can do at their own hospital (unless your veterinarian has a specialized compounding pharmacy on their premises), so they will need to call your prescription into an outside pharmacy.  Compounding takes time, so you’ll need to keep track of how much medicine you have on hand, and request your refills at least a few days before you run out of medicine.  And because the compounding requires special equipment and takes more hands-on time from the pharmacist, it is more expensive than just buying pills from your vet or a standard pharmacy.

However, if this is the best way to get medicine into your pet that will keep them alive or maintain their quality of life, it can be absolutely worth it.  And, most importantly, it’s free to ask.

And compounding medication isn’t the only alternative out there.  In some situations, medicine can also be given by injection, either at your vet’s office or, in some cases, with training at home.  Also, depending on where you live, you may be able to contact a traveling vet tech or skilled pet sitter to help medicate your pet.

Ultimately, the most important detail is that the first thing we try is almost never the only option.  Sometimes it takes trying a few different routes and techniques before we find the best way to treat a particular pet, to help maintain both their health and their positive relationship with their family.  Talk to your vet, let them know if you’re having trouble, and ask them to work with you to find the best way to treat your pet and their condition.  Together, we’ll find something that works.

When Should End-of-Life Care Start?

In his amazing book “A Dirty Job,” Christopher Moore describes hospice workers as “benevolent Valkyries, midwives of the final light.”  Since I’ve transitioned to practicing hospice medicine, this is a description that resonates with me more than ever.  My practice involves many facets of pet care, including (and often focusing on) end-of-life care, mostly because that’s the one part of home veterinary care that people are most familiar with, but even when it comes to planning for euthanasia, there’s a place for hospice medicine.  In some ways, preparing for and easing the path to death is at the core of what we do.

Many people have both the desire to have their pet pass peacefully at home and the foresight to reach out to a veterinarian that provides in-home euthanasia when their pet is first given a terminal or incurable diagnosis – but most of them don’t realize that having a visit with, and establishing a relationship with a hospice veterinarian can help make preparing for that inevitable final visit much smoother and easier.

All too often, I’ve had clients approach me by phone or email to discuss their concerns about their pet’s condition and their hopes for a home death, but decline any house calls before then, only to wind up in a crisis situation where they have to take their critically ill pet to an emergency facility instead of having the peaceful home passage they envisioned.

There are many reasons people may not choose to have their ailing pet evaluated by a hospice veterinarian.  Often they feel like there’s nothing we can do, medically, to treat the animal.  In other situations, they’re afraid to confront the severity and permanence of their pet’s diagnosis until they have no other choice.  And lastly, they may feel that they’ve already done everything necessary by ascertaining that home euthanasia is an option, and checking on prices and procedures.

When you’re hoping for, or planning on, having a pet pass at home, it can help immensely to make an appointment with a hospice veterinarian as early in the course of events as possible.  Medicine is only a small part of what we do – much of our practice involves education, support, and planning.

We can help you get a deeper and more thorough understanding of your pet’s diagnosis, and teach you ways to recognize their levels of comfort and quality of life.  We can help provide a tentative timeline – while no doctor can see the future, we can at least help come up with an idea of how quickly symptoms are likely to progress, and when intervention may be necessary.  We can help you plan their passing, show you what signs to watch for to know when the right time has come, hopefully without ending up in an emergency situation, and we can help you find both the emotional and educational support that a caregiver needs.

Even in situations where we can’t prescribe medicine to treat an animal, hospice caregivers can help both people and their pets in their journey before, during, and after death.  Medicine is not limited to diagnoses and prescriptions, and support is not limited to the patients themselves.  We are here for everyone involved – let us help.