What Happens After – Further Options

In my last post I talked about the most common ways to care for our beloved pets after they pass.  I’m going to continue that conversation here, by talking about some of the less-common paths that a family can choose to follow in choosing their pet’s aftercare.

Every family, and every person, is unique in their relationship with death and in their choices with regards to body care.  There is no one right or wrong path, and so many factors shape our beliefs, our wishes, and our decisions in this sphere – our previous experiences and those of the people around us, our faith, our culture, our bond with our pet and with other people in our chosen family, our thoughts and philosophy about the environment, and hopes and plans for the future.  The most important things to keep in mind are that your wishes are worthy of respect, within the limits of the law, and that communication with your veterinarian is critical.  If you have very specific wishes regarding your pet’s care after they pass, the earlier you are able to let your veterinary team know, the more likely they will be able to either help you accommodate them or, if they are not able, help you find someone who is able to realize these wishes.

With that said, what are some of the more specialized options available?

-Witnessed Cremation – I talked about private cremation in my last post.  Most crematories will also offer, for families that choose this path, an option for the family to be present and witness the procedure.  For some caregivers this can be a very sacred act of honoring their pet and bearing witness to their final transition from this life.

-Aquamation – Also known as “green cremation,” or alkaline hydrolysis.  This is a procedure where the remains are reduced to ash by chemical breakdown, rather than by heat.  It is often a choice pursued by caregivers who are concerned about the environmental impact of both burial and standard cremation.  At this time, aquamation is not available in Massachusetts, but it is legal in Vermont and Connecticut; if this is a path you wish to pursue it is important to discuss it with your vet early in the process of end-of-life planning.

-Taxidermy – This can be an option for people who want to physically retain either all or part of their pet.  The most important thing that I can stress, if this is a path that you choose, is to make sure that you find an artist who is experienced, skilled, and reliable; in Massachusetts the person in question also needs to be licensed by the state.

If you want to keep the likeness of your pet but do not want to pursue taxidermy, there are also businesses that will make plush replicas of your pet, such as Cuddle Clones or Grief Pets; these may be a way to keep a physical embodiment of your beloved pet without preserving their body.

Any list of options that I can make is going to be limited, of course, by my own experiences – ultimately, if you have a question, an idea, or a wish for your pet’s care after they pass, please discuss it with your veterinary care team.  They will do their best to work with you to find the best possible way to honor your wishes, and to care for your beloved pet with respect and compassion.

What Happens After – Choices

So far, my writing here has focused on caring for ailing pets, preparing for their passing, and caring for ourselves as we approach this journey.  There’s one subject that I haven’t touched on yet, though, and it’s a difficult one to talk about, but also incredibly important, so I’m going to focus on it for the next few posts.

It’s hard to think about caring for our beloved pets after they pass, but unfortunately it’s something that every caregiver needs to face eventually.  Many people have no idea what their options are when it comes to aftercare, and being confronted with this painful question for the first time when you’re also dealing with the immediate grief of having just lost your pet can make it even more traumatic.  Nothing is more tragic than regretting a decision made in haste, without the necessary information, time, and thoughtfulness to choose the best path to honor both your wishes and your bond with your pet.

With that in mind, I’m going to talk here about the most common paths available to care for your pets after they pass.  I’ll go into detail about specific choices, and some less common paths, in a future post, but it’s vitally important that all pet caregivers be informed about the choices available to them on this subject.

Here in Massachusetts there are a few pet cemeteries that veterinarians work with.  Many people have questions about such facilities; don’t be afraid to ask your veterinarian about the pet cemetery that they work with.  Your vet should be able to tell you the name of the facility, as well as discuss their practices, and answer any questions that you have about your pet’s care.  You can also visit their grounds yourself, if you want to see where your pet will be cared for and meet the staff – this can be a good way to address any concerns, as well as a beautiful way to honor the pets already cared for there.

Almost all pet cemeteries offer the following care options:

-Private burial:  Most cemeteries have beautiful grounds where you can have your pet laid to rest in their own private plot.  Because this does involve more preparation, as well as ongoing care, if this is what you wish for your pet you should discuss this with your veterinarian earlier in the course of your hospice relationship.  They should be able to help you get in touch with the appropriate staff at the pet cemetery, in order to make the necessary plans.

-Burial with other pets: If you are a member of a faith that does not permit cremation, or if such is not appealing to you, this can be a respectful way to lay your pet to rest without the concerns of arranging for a private burial.

-Cremation with other pets: When a pet is cared for in this fashion, their ashes are generally laid to rest on the cemetery grounds.  If you do not wish to have your pet returned to you, this can be a very thoughtful, respectful way to care for them.  Many crematories also allow for small personal items (letters, pictures, favorite toys, or blankets) to be cremated with the pet, which can be a beautiful final ritual or memorial.

-Private cremation: In this situation, the pet is cremated alone, and the ashes are returned to the family.  As above, most crematories allow the family to send personal items with the pets; they also can have many options for vessels to hold the ashes.  You can discuss this with your vet or the crematory staff, either before or after  – if you’re not emotionally ready for such questions at the time of passing, ashes can always be transferred later.  This may be a touching way to honor a pet’s memory, on their birthday or the anniversary of their passing.   Many crematories also offer scheduled private cremation, if you wish to be present.

The most important thing to keep in mind, when facing this decision, is that in every situation your pet will be handled with compassion, respect, and dignity.  Both your veterinarian and the staff of the facility that they use will treat your pet as the beloved being they are, whatever path you choose for their care.   If you have any questions about aftercare – about what’s involved, what your choices are, or how to handle the situation in the best manner for your and your pet’s wishes, please reach out to your veterinarian.  By considering these questions in advance, when it does come time to face your pet’s passing you can focus on the emotions of the moment instead of worrying about additional decision-making.

Garp

IMG_0580Garp was a character. He enjoyed being around people, even running to meet them at the front door, but he was also very particular about the way people should do things. This included everything from how exactly to pet him, when to feed him, when to let him in/out of the house, please never to pick him up, and so on. He would let you know in no uncertain terms if you were not living up to his standards!

 

 

 

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We enjoyed walking down the street together in the early morning to visit the community garden. Garp loved showing off, and would turn around to be sure you’d been watching after he’d done something particularly awesome (scampering up trees was one of his favorites).

He was fiercely proud and yet a sweet and affectionate love-bug too. I will always be grateful for the many years I shared with this sweet boy

 

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Bucket Lists

When coming to terms with a terminally ill pet, the idea of ‘bucket lists’ has started becoming popular – come up with a list of favorite things that you and your pet would want to do together, and make sure that you can do as many as possible in the time left.  This can be a beautiful way to create memories together, focus on the positive aspects of the time you’re sharing, and make your pet’s life as happy as possible.

A big challenge, though, is coming up with the list in the first place.  Sometimes people feel overwhelmed, or like they’re being silly, or they can’t see through the current challenges to think of what might be a source of happiness for them and their beloved pet.   So when a dear client started telling me about the bucket list they had put together with their cat, I was delighted to hear about it.  And with their permission, I wanted to share it here with you as an example of how we can make our pets’ final days special.  It’s a beautiful snapshot of shared love, making memories, and – if you’re struggling with how to make a similar list for your own pets – an excellent jumping-off point and source of inspiration for your own pet bucket list.


Mr. Brutus’s Bucket List   Mr B

1 try all flavors of temptations
2 treat taste test
3 lick wipped cream
4. Try rotisserie chicken
5 drink from water fountains when they are super cold and fresh and have ice in them
6 . open the window and enjoy fresh air
7  smother mom in kisses
8 scratch my favorite post
9 Have mom rename my scratchy lounge as “B’s throne”
10 scream in high places
11 scream about food
12  help unpack chewy order
13 enjoy new bag and box
14 break into the treat container
15 have a 5th adoption day party & birthday party
16 convince mom I need an extra can of fancy feast
17 lick the other kitties I live with
18 make a paw print with out making it too easy for mom
19 scream at Aunty D.
20 scream at Dr Becky
21 post pictures with my hashtag  #grumpBcat and get lots of likes on face book
22 take a cute pic for mom
23 get Dr Becky to write a prescription for extra  b belly rubs  both straight and circles
24 cuddle with mom
25  eat dry food fresh out of bag
26 eat from both of my other kitty housemate’s dishes

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

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.