Anniversaries

Six years ago AC&C opened our doors, metaphorically speaking, and saw our first patient. Since then, things have changed in so many ways – for this practice, for me, and – especially in the past year – for the world.

This past year has seen so many challenges for all of us, as families, as caregivers, and as veterinarians. It was a year ago today that the American Veterinary Medical Association released guidelines that we should cease seeing all but the most urgent cases. Those guidelines have since been walked back, but for several months I was afraid that I wouldn’t be able to help my clients, and that house call medicine wouldn’t be able to survive.

But my clients and my colleagues are creative, wise, and compassionate, and the crises we’ve faced have given rise to so much ingenuity and collaboration. We’ve adapted in ways that I never would have imagined – telemedicine, borrowing empty apartments, even moving favorite chairs out onto back porches so a pet can still pass peacefully in his favorite seat while keeping the family safe.

Every year I try to find a way to improve and grow as as a doctor, to find new ways to help my patients and clients. In past years this has taken the shape of certification in hospice medicine, or training in Western herbal medicine. This past year, it was learning how to navigate a pandemic and continue to provide care while keeping families safe.

I have no idea what this coming year will bring, but I know that with the help of my amazing clients and the veterinary field in general, it will be better, and I will be both grateful and lucky to be part of it. May this year be better for all of you, as well.

Honoring A Pet As They Pass

One of the most important facets of having end-of-life care happen outside of the veterinary office, for me, is the ability to make that passing special for both the pet and the family.  Ritual and ceremony are incredibly important to us, and creating a personal, unique event to honor the passing of a family member can be both a comfort and a cultural touchstone.

Often, people aren’t sure quite how to do this for a belovet pet – our culture doesn’t have a framework for the passing of a pet, as it does for other humans.   There are so many ways to create something unique to yourself and your family, though.  Sometimes this can be as simple as reading a favorite poem or saying a prayer; other times I’ve attended parties or sat in as families shared honored memories at a passing.  Recently I was honored to be present at one of the most beautiful passings I’ve ever attended, though, and I’m going to share her story there for anyone wondering how to create a special last day and farewell.

 

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Bella started out the day with her favorite meal….

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Then she got to go for a drive around the city.

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When she got home, she was allowed to share a piece of chocolate (a stolen treat when she was a puppy!)

A toast was shared, to a life well-lived....

A toast was shared, to a life well-lived….

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Her brother and sister couldn’t be there in person, but her sister visited via FaceTime and her stuffed soldier stood in for her big brother….

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Finally, Bella curled up in mom’s arms and fell asleep listening to her favorite song, and passed from this life.

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And a much younger Bella, on her first day at home. Thank you so much, Princess, for a beautiful life and a memorable passing. You will always be loved and missed.

Hospice As Part of A Team

In many ways, veterinary hospice is greatly informed by, and based on, human hospice medicine.  We learn from our human colleagues, we adapt their priorities and focuses, and we strive to practice as they do, supporting comfort and quality of life for both the patient and the family.

There is one way, though, in which those of us who work with animals – and our patients – are luckier than our human counterparts.  In human medicine (in the United States, at least), a patient must choose between pursuing curative care and entering hospice; they can’t receive the benefits of hospice care while still receiving traditional medical treatment for their condition.  Our pets, thankfully, do not need to make this decision – a pet patient can begin hospice and palliative care while still also being treated by general practice vets and/or specialists, and often benefits significantly from this decision.

Hospice care functions best when it’s part of an integrative approach that includes a team of professionals to give the best, and most well-rounded, support to both the pet and the people caring for them.  Far from replacing your regular veterinarian, a hospice veterinarian is joining them, and adding to the resources you have at hand.

This teamwork can take many shapes.  Some pets have multiple chronic health conditions, some of which may be better managed at home by a hospice veterinarian while others are more easily handled with in-clinic care.  A pet diagnosed with a potentially manageable but progressive condition may benefit from seeing both a specialist (such as an oncologist or internal medicine specialist) to help manage the primary disease as well as a hospice veterinarian to make sure that, in the course of treatment, quality of life is still prioritized and the family gets the support they need.  And even for families who decide to avoid any further office visits, general practice vets are still part of the team, providing historical information, helping with medications, and being available for support.

Hospice cases are often complex, and demand a lot from the people caring for the beings in need.  Hospice’s greatest purpose, ultimately, is to make sure that you have the best possible team supporting you and your loved one along this journey.

Becoming An Apprentice

One of the most important things to me, as a hospice practitioner, is continuing to learn and find ways to better support my patients and clients.  Veterinary hospice is a field that is always growing and changing, and I want to make sure that I do my best to stay educated about ways to provide comfort and care in this critical time.

Because of this, I am incredibly excited to announce that I’ve been accepted into an Apprenticeship in Western Herbal Medicine, starting this fall!  This is an eight-month-long program, focusing on in-depth learning about veterinary herbal medicine, with a focus on traditional western plants.

So often, when we’re facing a terminal diagnosis, families want to turn to resources beyond mainstream medicine.  The primary challenge in doing this is a lack of education – about what herbs and supplements are safe and effective, how to properly dose them to be most beneficial, what their interactions with other treatments and other health conditions may be, and how to choose the right brand and formulation (since these products are not regulated by any government office).  By studying this subject in depth, I hope to learn how to use these plant-based treatments to help give my patients the best possible quality of life, as well as answer questions from their caregivers who are looking for complementary and alternative paths to support their beloved pets.

My apprenticeship will begin this September, and I can’t wait to share what I learn with my clients – and if you are a pet caregiver who is interested in herbal medicine for your pet, definitely discuss it with your veterinarian!  These treatments are frequently very helpful, but they still need to be approached with education and care to make sure that we’re helping our patients in a safe, knowledgeable way.

What Happens After – Home Care

We’ve come to my third and final post about caring for your pet after they pass; this is also the hardest to write because it’s one of the most sensitive topics to confront.  One of the most surprisingly difficult challenges we frequently face at the end of a pet’s life, these days, is helping a family that wants to bury their beloved pet themselves.  As our lives become more and more urban, what may have once been a simple and commonplace decision has become increasingly complicated.  If this is a path that you want to take, it is important to communicate clearly and in advance with your veterinary team.

As simple and comforting as a home burial for your pet may seem, there are many factors to consider, both legal and practical – I am going to go over the most basic and common of them here, but the most important thing to know is that the laws and requirements can vary widely by location; make sure to talk to your veterinary team, and to plan in advance.  With that in mind, if you want to lay your pet to rest yourself, here are the details that you need to keep in mind.  Be aware, I am going to speak in detail about care of remains here.

-You cannot legally bury your pet on public property.  While every jurisdiction may have its own laws about burial on private property, it is never legal to bury animals on public property, such as parks or reserve lands.

-The legality of burying pets on private property varies depending on local laws.  In Massachusetts, at least, this can vary by city and township.  If you wish to perform a home burial, you will need to contact your city’s town hall to determine whether this is legal in your area.  You will also need to contact DigSafe to make sure that the area you are planning to use is away from power, gas, and water lines.

-The physical effort of burying a pet at home can also be significant.  While our pets are often smaller than we are (but not always!), we still need to make sure to lay them to rest deeply enough to make sure that they remain safe and undisturbed.   This means making sure that their final resting place is at least 4 to 6 feet deep, and that they are covered by at least 3-4 feet of earth.

-If an animal is helped to pass by euthanasia, this process involves an injection of lethal medication.  This means that any other animal that gets access to your pet after they pass will also ingest these fatal medications.  Therefore, for any pet that passes by euthanasia, it is vitally important that they either be laid to rest in a casket or under a layer of rock as well as earth to prevent any risk of predation.

-The time of year can also affect your ability to perform a home burial – if the ground is frozen, it may be challenging to dig a resting place for your beloved pet.

Home burial is, for many families, a beloved tradition and a cherished honor, and it can be very important to hold onto this way to maintain a connection to your pet after they pass.  If that is true for you, then I absolutely encourage you to work with your veterinary team to plan in advance and help arrange a way to make this happen as smoothly as possible.

If it turns out that your township has laws preventing home burial, or that other circumstances prevent this from being a valid option,  your hospice veterinarian may be able to help you come up with alternatives.  Burial at a pet cemetery, cremation and burial of ashes, or creation of a memorial garden may all be options for having a physical location to visit and honor your pet’s memory.  The most important thing to remember is that you do not need to navigate this maze alone in your grief.  Your veterinary team is here to support you, and help you create the best possible end-of-life experience for you an your beloved pet.

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