Dr. Katherine Goldberg, is the founder of Whole Animal Veterinary Geriatrics & Hospice Services in Ithaca, N.Y. A decade of teaching humane sterilization techniques at Universidad de Colima in Tecomán, Mexico, led to her love of street dogs.
Wellness: Health Care
Palliative and hospice care making strides
March 10 2014
My first contact from Stryker’s family came via email: “He was just diagnosed with anal cancer and also has a lymph node that is affected. We don’t think we want to put him through two surgeries. Would it be possible to set up a time for you to visit him?”
Stryker, an exuberant eight-year-old chocolate Labrador, met me at the door with a stuffed manatee in his mouth. Tail wagging and full of energy, he was not what one might expect to see during a hospice intake exam. As his family and I gathered on the floor, Stryker vied for my attention. His caregivers’ eyes misted up as they told me about their goals for him and their fears about his diagnosis. Meanwhile, Stryker rolled around, tongue lolling, grabbing various toys. His expression said, Why are you sad? Let’s play!
My examination of Stryker confirmed that there was indeed a large mass occupying the space where his anal sac should be, on the inside left wall of his rectum. The only thing that made the process challenging was the vigorous side-to-side movement of Stryker’s tail. His people watched me, concern and love for this dog evident in their furrowed brows. Stryker’s only concern was my finger in his rectum.
Over the course of about two hours, I heard the family’s story. When Stryker was diagnosed, aggressive surgery was recommended in the same day. His family wasn’t sure they wanted to put him through the procedure, and they needed more guidance, more time to think. When they asked about other options, they weren’t given any, other than my least-favorite phrase in the veterinary vernacular: “Well, you can always do nothing.” Could those really be the only options, aggressive surgery or nothing? It seemed implausible. And fortunately for all of us gathered on the floor that day, it was.
The World Health Organization defines palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” In my work as a veterinarian exclusively dedicated to geriatrics, hospice and palliative care, I increasingly find myself mapping my own professional purpose to this definition.
Transitions between geriatric care, palliation and hospice are often blurry, to say the least. In an attempt to extract meaningful data, I maintain a spreadsheet of all the patients I have seen; in it is a column in which I try to categorize the nature of the case. I can tell you that it’s not always easy to assign a label. I can also tell you that when I started focusing exclusively on end-of-life care, I had no idea how desperately needed palliative care really was. It became very clear very quickly that people were euthanizing pets—beloved family members, according to more than 80 percent of Americans—because they felt they had no other choice.
These animals were in pain, I was told. I agreed. But when I asked what kind of pain-management strategies had been implemented, the answer was usually “none.” Attempts to alleviate pain and other physical symptoms such as diarrhea, incontinence or decreased mobility were woefully inadequate, or well-intentioned but poorly implemented, with little guidance or followup. I was meeting families who were at their breaking points, and who could blame them? No one wants to live with a vomiting, whining, confused animal who’s in pain and turns the living room into his favorite place to urinate.
But what if these symptoms could be minimized or eliminated? I am increasingly finding that people are willing and able to implement simple solutions to help their pets and preserve the bond they have with them when it is most threatened.
Examples of palliative medical interventions that can help pets with lifelimiting symptoms include:
• Antibiotics for chronic skin, dental or urinary tract infections.
• Anti-anxiety medications for psychological distress associated with limited mobility, nighttime pacing or signs of cognitive dysfunction.
• Pain medications in specific combinations for advanced multimodal pain relief.
• Skilled use of narcotic and non-narcotic medications for adequate pain relief. (This means that your care provider must have a current DEA license.)
• Physical-medical modalities such as heat, massage, physical therapy, laser and acupressure to improve mobility, comfort and muscle tone.
• Complementary therapies such as acupuncture, herbs and homeopathic remedies to address a wide variety of clinical signs. (A credentialed professional trained in these modalities should provide these services.)
• Appetite stimulants to boost caloric intake and improve overall well-being, if appetite is a primary issue and can be improved without undue negative consequences. (The pros and cons of stimulating appetite and an in-depth discussion of the goals of nutrition for each individual patient must take place. This is a tremendous source of stress for people, as well as an important philosophical conversation within hospice care.)
• Mobility aids, environmental enrichment and in-depth assessment of the home environment and other living spaces of the patient to identify areas that may have a negative impact on the animal’s quality of life, and developing strategies to improve them.
Stryker’s care plan involved all of these elements, plus counseling for his family regarding their goals, expectations and hopes for him. The psychosocial aspects of this type of care cannot be underestimated. With a comprehensive care plan, euthanasia is no longer such a low-hanging fruit.
I should say up front that I am not a fan of talking people out of euthanasia. As I make very clear when I lecture veterinary students about communication at the end of life, once people have made that decision, they have given it a tremendous amount of thought— more than they may let on during a traditional veterinary appointment. Once people have reached the place where they are willing to intentionally end the life of their companion animal, I think the best thing I can do is to support them through the process and provide bereavement support after the fact.
That said, this epidemic of euthanizing pets because of the perception that there is no other option breaks my heart a little each time I see it. Striking a balance between supporting people, not rocking the boat of a lifetime relationship with a family veterinarian and honestly responding to families when they look at me wide-eyed and ask “Is there anything else we can try?” is dicey. It’s something I’m becoming better at on the fly, as well as something that drives me with the determination of an Olympian-in-training to develop the best palliative care practice possible, and help others do the same.
As is the case with human hospice and palliative care, early provision of services is key to providing the most comprehensive care and enabling the entire family to benefit from it. People sometimes say, “Someone told me about you, but I’m not sure if my pet is ready for your services yet.” My response is, “If you are already asking the question, your pet is ready now, and likely, so are you.” We don’t have a specific timeline for pets as we do for people, largely because we don’t have a Medicare hospice benefit that will only kick in at a designated time. Far more practically speaking, the question is, what is “terminal” in a pet whose life we can legally end at any time? The definition is murky at times, and this complex ethical terrain is a source of great stress for many people. (Not to mention a fascinating and fulfilling career for me, as I help them navigate it.)
For Stryker’s family, a terminal diagnosis was the catalyst for seeking palliative care and hospice without really knowing what that would entail. Palliation became end-of-life care at some ill-defined point in our journey together. “Doing nothing” ended up being pretty involved, thank you very much. As a result, Stryker’s family reached their goal of giving him a birthday party and celebrating his life before facing his death. Stryker was also able to relax in a custom doghouse built into the deck (constructed while he was in hospice care).
During this fragile and personal time, I became part of Stryker’s family, honed my own clinical skills to provide the best care I knew how, and reaffirmed my decision to take the road less traveled in my professional life. Seven-and a half months after our initial meeting, we gathered again on the floor in the presence of a stuffed manatee, told Stryker that he was the best dog ever and said good-bye.
Culture: Stories & Lit
What We Do for Them.
January 8 2014
I should start by saying that my dog Sydney is not normal. She doesn’t sit or shake or play with toys. She only really likes to interact with other dogs to size them up. She interacts with people to discuss politics and existential suffering. She is a surprisingly picky eater, especially when you consider that she once maneuvered an entire deer head through the dog door and put it on my couch. Depending on the day, she will respond to you or ignore you in both English and Spanish. She came from the basurero (garbage dump) near Bucerias, Jalisco, Mexico, where she was nursing nine puppies in March of 2006.
Since then, I’ve spent a fair bit of time waiting for Sydney. Waiting for her to come back to the car after a hike, waiting for her to show up after she has run off to eat a carcass or kill a woodchuck (or run a town meeting, who knows). But never have I spent more time waiting for Sydney than the week of Monday, September 23, to Friday, September 27, 2013. She ran off from a friend’s house on Monday morning, which wasn’t in any way unusual. The unusual part was that she then roamed an area of approximately 10 miles for the next five days, ending up virtually where she started.
I waited calmly at first, then with worry, then with panic. Then I waited with meat. Lots of meat. The low point of this five-day ordeal was when I sat in the woods with a rotisserie chicken, crying like a toddler, screaming Sydney’s name into the air with a futility and a pitiful intonation that even I could recognize as borderline losing it. Camping out at the house she disappeared from, surrounded by smoking meat, pieces of my clothing in the woods nearby to scent the air, was a close second. The coyotes were loud, and when they would quiet down, I’d imagine them eating her body. A nice bottle of port helped, but not that much.
I set a trap, one of those oversized humane metal things that barely fit in the back of my Subaru. I thought it was absurd, but I did it anyway because I felt the need to be continually “doing something” while half of the community was out looking for her; by this time, my dog’s face was plastered all over town like a missing child on a milk carton. As a veterinarian, I was aware of the professional embarrassment this whole scenario represented, but by the time the flyers were up, I was already desperate enough not to care. Hence, I set a trap.
The assumption is that the animal will be hungry enough to be baited with food, walk into the trap and be waiting there for you in the morning. Sydney was too resourceful to be hungry, and I knew it. She was seen on day two of her journey tearing open trash bags, for crying out loud. The dog was fine. If she was hungry enough to be trapped, I figure she was just as likely to trot directly up to me in my tent where I waited like a meat-scented Unabomber. But I set the trap anyway, almost closing myself in the damn thing in the process.
Days four and five were scenes of increasing despair and decreasing function. Overwhelmed by calculations of how many years it had actually been since I’d lived without a dog, and preparing myself for that new reality, I was raw and just plain lonely. We take for granted the presence of a dog—even a quiet one who doesn’t do much and isn’t very soft.
Until there is no dog, it is hard to imagine how much space one actually occupies just by curling up on a small circular cushion that L. L. Bean calls a bed. Without a dog, the air is thin, like the decreased percentage of oxygen at higher altitudes. Without a dog, there’s nobody to check in with, out of the corner of your eye, just to feel a sense of “you and me, we are both here, now”—a sense that, as it turns out, is pretty damn important. Without a dog, days have less structure— no going home to let the dog out, or feed, or tend to—and while structure doesn’t always equal meaning, I think that with a dog, it does. Without a dog, being one person in one space is surprisingly lonely. With a dog, there is connection.
These thoughts about the meaning of “dog-ness” were swirling through my brain as I gazed at a glistening pile of canine feces. Glistening is important because it meant it was fresh, and I got excited when I saw it because it looked about Sydney-sized and -shaped. Some people will likely find this next part offensive and strange, but I don’t care; those people likely have never loved a dog. I touched it with my bare hand to see if it was still warm and broke it apart to check for evidence of Sydney’s hair. It was cold and there were some suspicious hairs, but nothing that clearly said, This is Sydney’s poop. It was something, though, and that was good enough for me.
With each day came Sydney sightings that ranged from mundane—“I saw her trotting down Lower Creek Road”— to proof of her resourcefulness—“She was seen opening trash bags”—to commentary that could describe no dog other than Sydney: “I saw her cross Route 366. She looked both ways before crossing and looked like she knew where she was headed.” A common theme in the sightings was the assessment that she was capable and fine, thank you very much. Meanwhile, I was rendered dysfunctional, perching in the woods yelling things like, “I’m eating your chicken, Sydney! It’s really good!” and “If you don’t come eat your ham, this is a lot of wasted pork!” Seems unfair, doesn’t it? I think so.
As Sydney was about to spend her fifth night away, and with no sightings for 24 hours, I received a phone call. “Hi, Katherine, this is Glenn Swan. I think I have your dog here. She is very happy on our dog bed, with my daughter brushing her …” The message went on, but I had already started to cry and put on my shoes. Glenn Swan, owner of Swan Cycles, is well known in the cycling community; he’s also a former employer of a close friend, and sold me my Fuji road bike in 2008.
I was greeted at the door by Glenn and his young daughter, who was wearing a pink tutu. Sydney was lounging on a pile of dog beds far nicer than the one she had at home, and while she did wag her tail briefly, she could otherwise barely be bothered to greet me. Hussy.
She looked fine; not thin, barely dirty, sporting no wounds or ailments that might have summoned some empathy from me. I asked her if she wanted to go home. She gave me a look that said, Um, hold on, let me think … I guess so, before slowly rising and following me to the door. I thanked Glenn and his family profusely and we walked outside. Glenn showed me the spot right near the door where she had been waiting to be let into his house. The whole time, I was thinking, Are you f—ing kidding me, Sydney?
As my friend Heather said, she could have at least had the decency to have a laceration or simple lameness. Even after I got her home, I still could not believe she was back. The mix of emotions, compounded by running on no sleep, spending five days in the same pair of meat-smoke-infused, brown Carhartt overalls, contemplating life without a dog, was intense. Do I kiss and cuddle her, or scream obscenities at her? It was a tough call.
One glass of red wine later, breaking my firm “no dogs in the bed” rule, I buried my face in Sydney’s dirty coat, speckled with vegetation and ticks, and breathed her in. It was the first time in five days that I was alone in my house without being lonely.
As I write this, Sydney is sleeping on her bed after a thorough brushing, tick-picking and bath. I wish I knew what she was thinking, but I suppose that is one of the mysteries of dogs. I breathe more deeply knowing that the air in my home is full of dog-ness once again, but I have no idea how we can love them so much. All I know is that I will probably love her more now that she is outfitted with a GPS device on her collar.
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