Features January 2002 Issue

Making Peace With Death

Not everyone can provide hospice care for a terminally ill dog, but proponents say a natural death may be kinder than euthanasia.

One great and inescapable sorrow awaits all of us who share our lives with dogs: Sooner or later we shall have to face the decline and death of our beloved companions. Painful though it is to contemplate this loss, ask yourself the following question: If it were within your power to provide it, what sort of death would you wish for your dog?

Chances are, you would wish him the same death as you would wish yourself: to die when he is ready, peacefully in his sleep, at home, in bed, surrounded by loved ones.

However, very few dogs actually die this way. For the vast majority, death will come in the form of euthanasia at the veterinarian’s office. Although in most circumstances this experience is mercifully quick and painless, it’s not what anyone would call ideal.

People may debate whether the dog experiences discomfort in the veterinary hospital setting – the dreaded odor of the clinic, the steel table, memories of recent painful treatments for a terminal illness, strangers coming and going. This setting is unquestionably uncomfortable for the grieving human, and may even leave her with the lingering feeling that she has in some indefinable way failed or betrayed the trust of her beloved canine friend.

However, conventional veterinary clinic-based euthanasia may one day be the exception rather than the rule. A small but growing number of veterinarians and animal guardians are beginning to challenge the way we typically deal with our animals’ terminal illnesses and are developing a compassionate alternative: veterinary hospice care.

Hospice history
The concept of hospice is not new; it was originally introduced more than 30 years ago by the British physician Dr. Cicely Saunders. In her work with terminally ill human patients, she came to realize that what her patients feared most was not death, but pain. By effectively controlling their pain, she was able to give back to her patients a vastly improved quality of life, even though their days were numbered.

Dr. Saunders’ work was expanded by others, including Dr. Elisabeth K bler-Ross, internationally known author of On Death and Dying. Eventually, the hospice philosophy has come to embrace several key concepts:

• Care for a terminally ill patient should neither prolong the patient’s life, nor hasten his death, but allow him to live as fully and comfortably as possible until death comes. Those who work with hospice patients accept with equanimity the fact that death is approaching, and seek to allow it to arrive as naturally and painlessly as possible.

• Once a patient enters hospice care, the particular diagnosis of his disease is no longer of central importance. Heroic efforts to effect a cure cease and the focus shifts to meticulous attention to the well-being of the patient, with a strong emphasis on pain control and the maintenance of comfort and dignity.

• Death is not a circumscribed event, but a process whose course is unique to each individual. Therefore, the care of each dying patient must be responsive to that individual’s needs.

• The emotional and spiritual needs of the dying patient and his loved ones strongly color the way they experience the patient’s death, so spiritual and emotional support for the patient and his family is one of the cornerstones of hospice care.

Also, the patient and family are regarded as a single unit, and care is delivered by a team which addresses the many different (and sometimes conflicting) needs of this unit as death approaches. Nor does care cease with the death of the patient; grief and bereavement counseling and the emotional support of the family may continue for many months after the death.

Hospice for animals
Veterinary hospice care is closely modeled on its human counterpart. Hospice care is usually chosen only once it becomes obvious that the animal’s disease has ceased to respond to conventional treatments and that its progress can no longer be held in check.

Typically, this point is reached only after a succession of visits to the veterinarian’s office, during the course of which the guardian has of necessity become very familiar with the various therapies and procedures the veterinarian has been using to control the disease. It is usually not too great a step at this stage for the veterinarian to hand over some of the basic supportive measures to the guardian to begin implementing them at home. With the use of available pharmacology – fentanyl patches, for example, or morphine – pain can quickly be brought under control and the patient made comfortable.

Of course, not every dying animal is a candidate for veterinary hospice care; there are circumstances, for example, where there is overwhelming trauma, or where quality of life is so very poor that your veterinarian will justifiably lead you toward the swift release of humane euthanasia. Other considerations must also be taken into account when weighing whether hospice care is an appropriate choice. For example, the animal’s guardian must be able to devote the considerable time and financial resources that may be necessary to sustain a dying pet through his last illness. Can the guardian be at home full- or part-time to monitor the patient?

Hard though such questions may be, they must be faced squarely at the outset, for no veterinarian will be willing to embark on the hospice journey with a client who cannot make a full commitment to see it through.

In some cases, the guardian may receive assistance from a veterinary technician. With the objective of avoiding the need for office visits altogether, the veterinarian might arrange for a vet tech to visit at regular intervals both to monitor the patient’s status and to provide support and assistance to the guardian. If the vet tech finds anything amiss or needs to change or add medications, she can do so after consulting by phone with the veterinarian. The vet tech also assumes responsibility for instructing the guardian in nursing skills such as rehydration, dealing with incontinence and avoiding pressure sores, etc.

Many holistic veterinarians also integrate alternative or complementary modalities such as flower essences, aromatherapy, color therapy, and/or homeopathy into their hospice care regimes, in some cases avoiding the need for the traditional opiates.

Eric Clough, DVM, of Merrimack, New Hampshire, is one of the hospice movement’s founding members and most enthusiastic advocates. He feels strongly that hospice is a more humane way of dealing with dying and death. “As a clinician, when you accept the hospice philosophy, you take on a different set of expectations in terms of disease management,” he says. “You no longer focus on increasingly intrusive diagnostics, frequent blood tests, etc. Instead, you turn your attention to what I call ‘Aggressive Comfort Therapy.’ The goal is to make death into a safe, loving, comfortable experience, rather than viewing it as a terrible defeat.”

Euthanasia and hospice
This is not to say that euthanasia is shunned by practitioners of veterinary hospice. Euthanasia has its place in veterinary hospice care and remains an option throughout the progress of the patient’s final illness. However, the hope of many who choose the hospice route is that euthanasia may never be needed, and that with careful nursing and effective symptomatic relief, patients may be able to find their own way, peacefully and without pain, to a natural death.

The rationale of euthanasia is unquestionably a noble one: to spare animals pain and suffering. Those who advocate hospice care do not dispute the compassionate basis of euthanasia; they do, however, question its timing, and even its inevitability. They also tend to view the disease process in an uncombative manner, accepting the approach of death without a sense of impotence or defeat. Instead, they channel their energies into addressing the patient’s pain and providing symptomatic relief on a day-to-day basis. If, however, the efforts of the animal’s guardians to provide comfort and relief from pain are fruitless, they may still decide to employ the option of humane euthanasia. Ideally, this would be delivered peacefully, at home, if possible.

Criticism of veterinary hospice
Hospice care is not embraced by all veterinary medical practitioners. Medical teaching – both human and veterinary – tends to reflect the larger culture and ours is a culture that is deeply uncomfortable with death. The military metaphor pervades medical thinking; we speak of fighting disease, beating infection, waging war on cancer. We train our physicians and veterinarians to view death as something to be conquered at all costs, and when a patient dies, we speak of that patient as having lost his battle.

Sadly, this has the unintended effect of making our doctors feel as though they have somehow failed when confronted with a life-limiting disease that will no longer respond to treatment. In the veterinary context, euthanasia can become in a sense a surrogate for treatment; it gives the veterinarian an additional treatment to administer – one more thing they can offer to “help” their patients. This may explain why some veterinarians guide their clients toward euthanasia – with what can often feel to the animal’s guardian like indecent haste – almost as soon as they diagnose an animal’s incurable illness.

“Vets are first and foremost medical thinkers,” comments Guy Hancock, DVM, Director of the Veterinary Technology program at St. Petersburg Junior College in Florida and an advisory board member of The Nikki Hospice Foundation for Pets. “This can make the transition from conventional treatment to hospice very tough for them, since in hospice care the medical aspects are secondary to the psychosocial aspects.”

Interestingly, the strongest criticism of the growing veterinary hospice movement has come from some who, professing to advocate for animal rights, find the notion of withholding immediate euthanasia from dying animals both unethical and abhorrent. They see it as yet another example of humans willfully subordinating the needs of animals in order to gratify needs of their own.

Hospice proponents counter this argument by pointing out that the raison d’être of hospice care is the relief of suffering, and that euthanasia is not by any means the only (nor even at times the best) way to accomplish this goal. They see such objections as simply another manifestation of our generalized cultural squeamishness about dying, and point to the example of Japan, where reverence for the elderly and a more dispassionate attitude toward the process of dying are strongly enshrined culturally – and where, correspondingly, the practice of veterinary euthanasia is extremely rare.

Even so, many who are dealing with terminal illness in their animal companions find themselves in the unenviable position of being pressured, sometimes none too subtly, by family and well-intentioned friends who don’t understand the concept of hospice or palliative care, and who feel that sustaining life in a dying animal is fundamentally cruel. Such pressure can induce agonies of self-doubt and confusion in the mind of the unfortunate pet guardian at a time when emotional resources are already stretched to breaking point.

Those who choose the hospice route will need to rely heavily on an experienced, sympathetic veterinarian and her staff for reassurance that they are indeed doing the right thing. A skilled veterinarian who knows her patient well can often tell from the look in the patient’s eyes whether his life is still worth living. It helps enormously to know that one’s veterinarian will blow the whistle if she honestly feels that the animal’s condition has reached a point where pain control can no longer be assured or quality of life is untenable.

It is also worth remembering that although animals assuredly do feel pain, they do not necessarily suffer quite the way we do. Although an animal may have pain, we can never know with certainty whether that animal is able to interpret the meaning of its condition, to have expectations or to worry and fret about impending death the way humans typically do. Those who know animals well and have studied them extensively often remark on the “philosophical” way in which animals seem to approach death, as though they both understood it and had no fear of it.

Different hospice approaches
Dr. Hancock, a staunch proponent of veterinary hospice care who is also deeply involved with the human hospice movement, believes strongly that the psychosocial tenets of the hospice movement are paramount. Just as with terminally ill human patients, he says, no animal should die alone.

“The family is the unit of care, and grief counseling should be available both before and for up to a year following the death.”

Debbie Mallu, DVM, a holistic veterinarian with a practice in Sedona, Arizona, is another hospice advocate who draws on human hospice ideology. Dr. Mallu says she no longer performs euthanasia, but even when she did, she would not euthanize an animal without its human guardian present.

Dr. Mallu’s growing interest and respect for the Buddhist philosophy has guided her in her veterinary practice, and she has incorporated some of her Buddhist beliefs into her hospice work. She encourages her clients to participate fully in the death process of their pets. As she sees it, her clients need help with their feelings almost as much as they need veterinary help for their pets, and their fear of death must be addressed before all else. “I try to teach them to let go of the outcome of the illness,” she says.

Although Dr. Mallu does on occasion make use of the full pharmacological battery for pain control, she uses mostly holistic modalities of treatment. “I prefer not to ‘dope up’ my patients if I can possibly avoid it,” she says. She teaches her clients to hold their dying pets, to stroke them in calming, comforting ways as the death progresses, and, as she puts it, “to be mindfully there, minute by minute, with a loving heart.”

Christina Chambreau, DVM, a holistic veterinarian from Sparks, Maryland, finds less and less reason to euthanize animals; she says she has euthanized only 10 animals in the past 10 years. “I operate on the assumption that the spirit goes on after death,” she says. “One can let go of the fear of death by realizing that only the physical body dies; the spirit lives on.”

Although Dr. Chambreau says she takes her patients’ pain very seriously and treats it aggressively, she reminds her clients that animals live in the moment, and don’t reflect on the significance of their symptoms. “People are apt to project their own fears of various symptoms onto their pets,” she says, “whereas the animals themselves may not find those symptoms overly troublesome.”

For some people, the most valued gift of hospice is its offer of a precious interval of time, however limited, in which the animal’s guardian can begin to say goodbye to her friend and the difficult but essential task of grieving can begin. As Rita Reynolds puts it in Blessing the Bridge, a wonderful book on the subject of animal death:

“My friend and teacher joined me in this lifetime in the form of a honey-colored terrier named Oliver. Through his living and dying, he taught me there is no such thing as life versus death, or success versus failure. Love given and received, moment by moment, is all that really matters.”


Also With This Article
Click here to view "Advocating for the Veterinary Hospice Movement."
Click here to view "Hospice: Not the 'Easy Way Out' and Not for Everyone."
Click here to view "Being Prepared: Understanding Medical Euthanasia."

-by Louise Kehoe

Louise Kehoe is a writer and garden designer who lives in New Hampshire. The author of a memoir, In This Dark House (1995, Random House), Kehoe has written for numerous publications including the Sunday Times (London) and the Chicago Tribune. This is her first article for WDJ.

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