Hospice Care and Veterinary-Assisted Death

When “putting him to sleep” is not the end you choose for your dog.


by Denise Flaim

“Life is pleasant. Death is peaceful,” mused author Isaac Asimov. “It’s the transition that’s troublesome.”

Our culture’s ambivalence about death is no secret and no surprise. Leaving this mortal coil can be messy and exhausting, both physically and emotionally. So with our companion animals, we oftentimes beat death to the punch, scheduling it on our own terms by taking that teary-eyed ride to the vet’s office and saying a final goodbye on a tiled floor or steel table.

Susan Marino of Fort Salonga, New York, has devoted her life to helping companion animals go gently – and naturally – into that good night. A former intensive-care pediatrics nurse and a licensed vet tech, the 54-year-old is the founder of Angel’s Gate, the country’s first and only residential hospice for animals. More than 100 dying and disabled animals call Marino’s suburban Long Island ranch house home, from Rottweilers to Rat Terriers, calicos to cockatoos. And all but a handful have died there without euthanasia, in a home rather than a hospital setting.

“People think they may want to do hospice, but it’s not something that most people know anything about,” says Marino, who, with this writer, is the author of Getting Lucky: How One Special Dog Found Love and a Second Chance at Angel’s Gate (Stewart, Tabori & Chang, 2005). The same often applies to veterinary professionals: “Vets learned in school that when animals get sick with no hope of getting better, you don’t want them to suffer, so you euthanize them,” she says. “Many of them have never seen an animal die a natural death.”

Recognizing this emotional dissonance with the animals many of us love as family members, the American Veterinary Medical Association released its Guidelines for Veterinary Hospice Care in 2001. Less than a page and a half long, the 11-point document underscores that the hospice experience helps “the respectful closure of each unique human-animal bond” and stresses that “patients should be kept as free from pain as possible and in a sanitary state,” but does not offer many specifics.

And that is precisely the problem. Almost every day, Marino says, she fields a desperate phone call from someone who wants a terminally ill animal to die at home, but cannot find anyone to explain how.

Support at a difficult time
Jeffrey Krauss, 48, of Manhattan, is a case in point. In 2004, his 17-year-old cat, Babe, was diagnosed with kidney failure. When he told the vet he wanted to take her home to die, “I was scolded for being cruel.”

Krauss found the Angel’s Gate Web site and contacted Marino, who explained how to administer subcutaneous injections to keep Babe hydrated and comfortable. “She died a few days after we brought her home, which is what I was told would happen,” Krauss says. “But she didn’t die alone. I grieved, but was very comfortable with that decision.”

Last summer, when Krauss’s 8½-year-old black Lab, Mango, was diagnosed with kidney disease, he called Marino again. Mango needed to be hydrated with fluids. As problems arose – why was Mango shaking so much? – Marino gave suggestions: Mango can’t regulate her body temperature well, so make sure the IV fluid is warmed, and place heated towels around her.

Mango lived for five months after her diagnosis. She had bad days and good days, including “two miraculous ones that were real rare gifts,” Krauss remembers.

It’s memories like those that are the whole point of hospice, Marino says. “Doing hospice allows me to intentionally spend good, quality time with the animals I care about, to say goodbye in a gentle, loving way,” she says. “I get to write the final chapter in that animal’s life.”

But just as all writers have different tones, choose different words, and focus on different angles, so too will all those final stories vary. Some caretakers will see their animal to the end; others will choose a point beyond which they will not venture. Still others may decide to end the chapter before it even begins.

“There is no right or wrong. Hospice is a decision that needs to come from your heart,” says Marino. “It’s a matter of choices, and it’s important to remember that we have them.”

To that end, here are some questions to consider in making the commitment to provide hospice care for a companion animal:

• Will my vet support my decision?

Though it seems counterintuitive, this is a question you need to ask while your dog is still healthy.

If you wait until a terminal diagnosis before broaching it, “the conversation is going to be clouded and very difficult,” Marino says. “Like anything else, the outcome will be much better if you’re prepared ahead of time.”

Ask some questions about the vet’s policy on euthanasia. Is she willing to work with someone who wants to care for a dying dog at home? Are there any circumstances under which she would not be supportive of doing hospice?

Once you have the conversation, keep reinforcing it, suggests Marino. “Every time you have your dog in for a wellness exam, reiterate it to make sure he hasn’t changed his mind. It’s very easy for a vet to say yes when there’s nothing going on. But that way, he also gets to know you and gets to know what your heart is all about.”

As in any partnership, trust between you and your veterinarian is essential. Consider pain relief. Veterinarians can prescribe controlled substances such as Butrophenol and Valium to keep a dog comfortable, but many are reluctant to send those drugs home with a dog because of concern that the drugs may be misused. “Your vet has to know when he or she hands over that narcotic that you’re going to use it properly,” Marino says.

If you are truly committed to providing hospice, then you need your veterinarian to embody the literal meaning of the word “doctor,” which comes from the Latin verb docere, meaning “to teach.”

“A doctor’s responsibility is to educate you so you can make informed choices, not to make choices for you,” Marino says. “A lot of times, people don’t want that responsibility. They want their vet to say, ‘It’s time to give up.’

“You need to decide what person you are,” she continues. “Do you want to be in charge, do you want the vet to be in charge, or do you want a mix of what’s in the middle?” Once you are clear on your own comfort level, then you can find the veterinarian who will best help you reach it.

• What illness am I dealing with, and do I understand the course it will take?

“You need to really research what’s going on with the animal, and understand what the disease process is,” says Marino. “You need to ask your vet what the end is going to be like. Are there going to be seizures? Will the animal have difficulty breathing?”

With some disorders, such as kidney disease, dogs can have relatively good quality of life until the very end. “If you’re consistent with giving fluids, that hydration is a sort of mini-dialysis for the kidneys,” she explains. Often, as the end nears, dogs follow a similar trajectory: They refuse food for a few days, then around the fourth day refuse water, and pass soon after.

“On that third day, often they perk up and eat,” Marino says of the pattern she’s observed. “They seem brighter, and you might think things are going to get better. But soon after, they’re gone.”

Other diseases are more complicated. With degenerative myelopathy, an immune-mediated paralysis that begins in the rear and moves progressively forward, a dog can live for a year or longer, depending on diet and stress levels. But ultimately, as the disease advances, the diaphragm will be affected, making breathing difficult and opening the door to pneumonia and other respiratory problems.

Because it is so hard on an animal, compromised breathing is often a sign that hospice should be ended and euthanasia considered. Denise Juliano of Lake Grove, New York, eventually euthanized her Collie, Winston, when his breathing became labored from lung cancer. But six months earlier, when her veterinarian gave her the bad news and suggested euthanasia, she looked at her still-active dog and decided to keep him comfortable for as long as she could.

“I don’t regret those extra months with Winston,” Juliano adds. “More than anything it was a lot of messes; he would throw up a lot, and he became incontinent on and off.” But that was minor compared to the joy of having Winston in her life for a few more months.

• Do I have the time?

“Dying is an evolution, a process,” Marino says. “In the beginning, the dog may not mind being left alone, and it’s not going to be a 24-hour job. There might be some back and forth to the vet, but that can be done on evenings and weekends.”

Eventually, though, the time will come when your dog will need you in attendance pretty much every day. At that point, you may need to take a leave of absence from your job, or hire someone to come to your home several times a day to walk or medicate the dog.

Flexibility is absolutely essential. “If you’re a person who likes structure and rigidity, you may have a hard time with hospice care,” Marino says, adding that your social life will be essentially nonexistent. “Animals can go into remission, they can have really good days and really bad days, and you have to be resigned to that.”

During the last three months of Mango’s life, Krauss carried the 60-pound dog down from his third-floor brownstone triplex every two hours because she refused to soil in the house. “That wasn’t easy, and I didn’t get much sleep, but I did it,” he says. “I like to think that if I were the dog and she were the human, she would do the same for me.”

Krauss points out that it’s not just the sheer time devoted to hospice care that’s demanding, but the quality of the time itself. “You have to be present as the animal you love deteriorates, knowing she will not get better,” he says. “You cannot be emotionally absent.”

• Do I have the funds?

“This is not a cheap investment,” Marino says. While it might sound crass, “you need to ask yourself, ‘How much am I willing to invest?’ I know people who are willing to take out a second mortgage to give their dog another six months of life. But if you are a working single mom with three kids and you’re giving up your grocery money so your dog can be treated, you have to check the wisdom and practicality of that.”

Cancer treatments such as chemotherapy and radiation might prolong a dog’s life, but they cost thousands of dollars. Those too squeamish to perform simple procedures such as subcutaneous injections can take their dog to the vet daily, or hire a licensed vet tech to come over and give them – all at a steep price.

Certainly, the more work a caretaker is willing to do herself, the less the financial impact. But the expenses will mount up: time off from work, the cost of dog sitters when you cannot be home, and supplies “more than likely will run in the thousands,” Marino warns.

• Can the humans in my life cope?

For all its moments of deep connection and quiet joy, hospice is very stressful, putting a strain on your energy, finances, time – and relationships. If there is any friction in your family situation, hospice will inevitably bring it to the surface.

“It’s so important to have a family in agreement; I have seen an animal dying in a home cause absolute turmoil,” Marino says. “Every family member has to lay his or her cards on the table and present what part they want to play. Some want to be more involved than others, but no one should be criticized for something they can’t give, or if someone else gives more.”

Such honesty forestalls any resentment on the part of a more involved caretaker who might be tempted to accuse another of not doing enough. Speaking of that last word, caretakers need to be very explicit about defining it. “The family has to be in agreement on when enough is enough. For some people, the dog becoming incontinent would be enough. For others, it’s when the dog can’t get up,” says Marino. “‘Enough is enough’ varies according to what people are willing to tolerate.”

But for many, the strain and exhaustion are a small footnote to the experience itself. “We went through the dying process that you would go through if a family member was dying at home,” concludes Krauss.

“There are tremendous gifts and learning that come from that: That you can care for a dying animal that you love even though it’s hard. That you can release them to let them go on. And that you can show them that even in their sickness, they are lovable.”

The down and often dirty
“Life is messy,” says Marino. “It’s not neat and clean.” The same goes for hospice care. Incontinence and vomiting, unpredictable ups and downs in an animal’s condition – all can seem like insurmountable obstacles unless a caretaker is perfectly prepared for them. Here are some essentials you’ll want to have at the ready:

• Diapers. The baby (not the adult) kind are best. Shop around for a brand that is ultra-absorbent, and modify each diaper with a simple snip to allow for a tail opening.

Diapers also help protect against urine scalds by drawing the moisture away from the skin. “Make sure the diaper is as dry as possible,” says Marino. As with a newborn baby, she uses a diaper-rash product such as Balmex or Desitin to create a barrier so the skin doesn’t get raw.

With long-coated dogs such as Collies and Huskies, Marino sometimes shaves the whole perineal area, especially in summer. “Because the coat is so thick, the dog can get maggots and you don’t even know it,” she says, noting that the fly larvae can hatch within 24 hours of being laid, and will immediately begin eating away at any necrotic tissue.

• Bedding. For incontinent or immobile dogs, Marino recommends doggie cots made out of PVC pipe and mesh fabric. Elevated off the ground, the beds are comfortable for the dog and easy to clean for the caretaker. She places a hospital-type blue “chuck pad” under the bed, or a tray of cat litter to make the area easy to clean.

Speaking of cleaning, consider devoting an area of the house for providing hospice. “It should be a place where if the animal is incontinent or vomits, it’s not on your $10,000 Persian rug,” Marino says. “It should be a place where the animal is comfortable, and so are you.”

• Supplies. Among the items that Marino recommends obtaining from your vet are fluids and disposable needles to do subcutaneous injections, which will be required in nearly every dog’s final days. Pedialyte, an oral electrolyte solution for children, is also good to have in the cupboard to combat dehydration.

Diarrhea is a common problem with terminally ill animals, and Marino always keeps a tincture of slippery elm on hand to deal with gastrointestinal upsets. For vomiting, she often turns to the homeopathic remedy Nux vomica.

Instead of a heating pad – a big no-no – Marino uses a warming disc that can be heated in a microwave. You can determine whether the disc is too warm, refrain from putting it near the dog until it’s at a safe temperature, and then feel confident that it will slowly cool (rather than heating up to a temperature that can burn, like heating pads are wont to do). Warming discs stay warm for 10 hours, and are especially good for animals with kidney disease.

Another must-have is a rectal thermometer. “Learn what temperature is normal for your dog,” Marino advises. “Typically, it’s 101 degrees, but it can range from 100 to 102 for some dogs.” And while a muzzle might sound like an odd item to keep handy, she notes that some dogs can nip during unpleasant procedures such as a change of wound dressing, or when they are frightened or out of sorts.

• As for nutritional supplements, Marino frequently gives her hospice dogs Seacure, a biologically hydrolyzed whitefish supplement that is easy for the digestive system to assimilate (and whose fishy odor tempts many dogs with delicate appetites into eating). She also uses colostrum to support the immune system and help ward off secondary infections, and Pet Tinic, an iron-rich vitamin and mineral supplement, to help boost oxygen-carrying red blood cells.

• Faith. While it sounds basic, caretakers need to believe in their ability to do their best for their animal. Marino remembers the day that Krauss’s partner Deb called, distraught. On one of the dog’s very good days, Deb had taken her hiking, but the next day, she was noticeably worse.

“She was feeling guilty, like ‘Maybe it was something I did,’” Marino recalls. “But the key in all this is to live life and savor it. It’s very important to focus on the days that we go hiking rather than the days when things don’t go so well. Those are the days you want to remember.”

Also With This Article
“Canine Hospice Options”
“Death at Home: Is Veterinary Euthanasia Better?”

-Denise Flaim is a staff writer and companion-animal columnist at Newsday, the daily newspaper on Long Island. She is also the author of The Holistic Dog Book: Canine Care for the 21st Century and Getting Lucky: How One Special Dog Found Love and a Second Chance at Angel’s Gate (Stewart, Tabori & Chang, $19). Denise shares her home with her husband, toddler triplets, and two naturally reared Rhodesian Ridgebacks.