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.

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

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.