Saying Good-Bye

Palliative and hospice care making strides
By Katherine Goldberg DVM, March 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.

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.