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What is meant by the term “hospice care”?

A common understanding of what is considered hospice care for animals is still developing, as it is a fairly new field in veterinary medicine. Meanwhile, the term is being used in a wide array of meanings, so it is important in communications to clarify how it is understood by each individual. The sense in which we at SPIRITS in Transition apply the term hospice is rooted in what is already well known from modern human hospice. We work towards offering a similarly high level of care for our animal family members and their caregivers as is available to us humans during hospice.

Our efforts go towards helping to bridge the tremendous gap between what is currently available to humans versus companion animals when it comes to the end of physical life. This includes that our work is also based on the foundational human hospice principle that the process of dying is embraced as a part of life that does not need to be feared or avoided, nor postponed or hastened. We completely respect that there are other forms of end-of-life care and encourage all animal lovers to follow their own heart in any decision making process. We also understand that those who do feel drawn to giving their animal hospice care, may nonetheless encounter limitations that make a euthanasia decision the best available choice. This can for example be due to the fact that the field of animal end-of-life care in general has not yet caught up to the standard of human hospice. Other restrictions of various nature (including limited time, financial and other resources, but also situational factors as may occur in emergencies etc.) may make it impossible to create the circumstances for a companion animal to die peacefully in its own good time. While the focus of our efforts is oriented on modern human hospice, we support other forms of palliative and end-of-life comfort care for animals as well. This is also expressed in that our helpline volunteers neither advise for nor against euthanasia.

Given that we don’t know ahead of time what challenges may unfold in the process of caregiving, we highly recommend that anyone aiming to support their animal in dying peacefully on its own under hospice care has to be ready to elect, and able to provide for in-home euthanasia through a veterinarian when necessary. One explanation of the term animal hospice that is in strong resonance with our work was written by Guy Hancock, DVM, MEd, the director of the Veterinary Technology Program of the St. Petersburg Junior College. It is based on the philosophy of care to be found in human hospice care. To read Dr. Hancock’s explanation as posted on the website of The American Association of Human-Animal Bond Veterinarians, click on the different subjects on this page here.

I have children. Won’t it be too difficult for them to see an animal die?

Loving parents naturally have the wish to protect their children from having to go through difficult experiences. With this great intention, many over time have chosen to have a pet euthanized in the absence of their child, unfortunately often without preparing the child for the fact that they will not see their animal again. The child comes home from school, and the animal is gone. Sometimes, this happens unintentionally, for example when the animal feels sick. The parent takes it into the veterinary hospital while the child is in kindergarden or school, and agrees to a veterinarian suggesting to immediately euthanize as unexpected by the parent, a terminal diagnosis has been made.

This may seem like a “clean” solution, however in the years of our work we over and over have had adults take our courses who as children were not given the opportunity to say good bye to their beloved animal friend. They shared with us how extremely traumatic this experience was for them which left them with a sense of deep and unquenchable sadness. Then they took our course. To learn that euthanasia is not inevitably necessary when an animal loved ones life comes to an end, and also to be able to witness the unhastened and peaceful death of an animal as it is possible in our courses, allowed them to feel a much greater sense of completion.

What else is possible? In accompanying parents caring for a beloved dying animal we have been touched deeply by the remarkable ways in which children chose to participate. Due to the shorter life span of pets, their death is often the first time a child experiences death. Participating in the care of a terminally ill pet, can prepare a child for the fact that dying is a natural part of life, nothing feared nor to be avoided, giving it a natural outlet to apply its love for the animal in a practical way and prepare it gradually for the eventual Good Bye.
The age of the child of course also plays a role. If it is very young, it will not be able to fully grasp what is happening nor be as likely to retain a clear and formative memory. We had the great privilege to meet families taking on hospice care for their animal despite it overlapping with late stages of pregnancy, child birth and care for a newborn. They showed us what all can be possible in ways we would have hardly dared to suggest ourselves.

We are neither mental health professionals nor bereavement consultants and so can only share from our experience. Situational variability is so large that still every family will have to find their own way of facing the terminal illness of their animal. We can only speak to the wholesomeness of children taking part in caring for an animal dying on its own accord. To witness its life being taken in an instant is very different from that and this paragraph does not attempt to address that situation.
However if for some reason suddenly euthanasia becomes necessary, we do recommend to try to “buy time” whenever possible. I.e. when given the suggestion to euthanize by your veterinarian, to share with her or him that for you it is important that every family member gets to say good bye to the animal while it is still alive and, if ever possible, in the home setting. This includes allowing the animal to wake up after an exploratory surgery that revealed bad news. Especially if the animal walked into the clinic for the diagnosis that day, chances are it can be kept comfortable for another night, or even considerably longer, giving everyone some time to come to terms with the situation and extend their farewells. In many cases, your veterinarian has the practical ability to help you by providing the medications necessary to accomplish this while addressing evident comfort needs for your animal, and will, hopefully, understand just how important this is for your entire family.

A house call veterinarian would be ideal as long as the veterinarian is in support of your goal. Veterinary advances are such that they mostly can match human medicine, and high quality human hospice has become quite sophisticated. Only when it comes to hospice for companion animals the animal practitioner may be very used to, or even explicitly specialized in, fast endings which don’t require further care considerations. Heads up that hinting at you needing to “let go” (including at a moments notice, to immediately euthanize) is far more common than necessarily indicated for both, the animal’s and the family’s welfare. If you and your family have not said your good byes, chances are your animal also could greatly benefit from more time together, while being kept as comfortable as possible. You searching within yourself and being willing to take on challenging care needs is proof that you only want the best for your loved one, no matter what it takes. So if any doubts are there whether to authorize euthanasia or not, “buying life time” by utilizing professional comfort care (even if from a different veterinarian) is not an egocentric thing to do but is likely directly sourced by your deep connection with your animal family member.

In any which case, once the animal’s life is concluded, including the children also in creating a celebration of life and in funeral or also cremation arrangements (for instance by decorating a transportation box) can be very helpful to a healthful processing of their experience.

I am not sure if my animal is suffering- how can I tell?

Suffering is a really wide term, and also is a very individual experience. We all know from our own species that for example tolerance for pain differs widely between people, and this is true for animals as well. We want to also keep in mind that many of us can be in various levels of pain or discomfort without wanting to die. In addition and despite common notion, dying does not per se equal suffering. Nonetheless, certain terminal diseases can cause symptoms that require diligent treatment to keep the patient sufficiently comfortable, which is an important part of the work in hospice. Yet it can be challenging to identify the presence of such symptoms.
Depending on the underlying physical conditions, typical symptoms that require treatment towards the end of life (just as during life) may entail

  • a) pain
  • b) nausea
  • c) anxiety
  • d) difficulty breathing

In human hospice, each at–home patient has a comfort kit available that at a minimum allows the caregiver to immediately relieve a sudden incident of strong pain but also nausea and anxiety should they occur. Instant access to such medications is central just as much in animal hospice, as sudden changes can occur in the middle of the night and on weekends. Even when a veterinary service is responsive 24/7 as is required for hospice, it is possible that help cannot arrive in a timely manner when for example a sudden strong increase in pain levels were to occur. Pain medications that may have been used for some time are usually of mild to moderate action but from one moment to another may no longer be sufficient. This is the reason why a STRONG and FAST ACTING painkiller has to be in immediate reach of the caregiver, in a form that DOES NOT REQUIRE SWALLOWING. This is because the swallow reflex may weaken in a terminal patient, and at that point trying to give an oral medication can cause an additional crisis. Injections or sublingual or rectal application of urgent medications are therefore indicated.

When the comfort kit is given to the caregiver, written information as to the proper use of the medication has to be included, which states MINIMUM and MAXIMUM DOSE, expected time frame for ONSET OF EFFECT and regular as well as EARLIEST TIME PERIOD AFTER WHICH RE-DOSING is possible if necessary. The caregiver may be advised to call the veterinarian on duty for support over the phone before giving a new medication but in case the urgent call goes unanswered, the written information provided can still be used for guidance.

In certain circumstances it can become hard to distinguish whether a certain symptom is experienced by the animal or not.

a) Especially if pain comes on slowly, animals often do not vocalize to indicate that they are in pain. They may just become quieter or lose their appetite.

These may be conclusive signs of discomfort in an animal during it’s life, however, when it comes to the dying process, as the life energy gets low and the body’s strength naturally declines, usually so does the animals’ desire to move. Loss of appetite as well can be normal in a dying animal and does not necessarily mean suffering. Distinctly different from starving, we know from human hospice that hunger simply can cease to exist. When hunger is no longer experienced, to not eat is just a natural consequence and suffering is more likely to happen if one is forced to eat in spite of the body no longer being able to handle food.

As the increasing need for rest and the decreasing need for food may no longer serve as good guides to determine whether an animal is in discomfort, oftentimes the way it breathes can be a clue. Increased frequency of breaths and/or labored breathing can indicate the need to implement or increase pain control, whether with drugs and/or in alternative ways. In the very last stages of dying, a more and more enhanced exhale is typical of the body getting ready to complete it’s function.

Trembling of an animal can be caused by pain but can also be due to the animal’s increased need for warmth, as the body’s ability to regulate it’s temperature may weaken. Placing pre-warmed towels or blankets on the animal can help distinguish what is going on.

Unusual stiffness in limbs can be a symptom of strong pain requiring immediate attention.
Panting also can be a sign of pain but can also be due to multiple other not easily distinguished causes.

If uncertainty exists whether an animal is in pain, it can be indicated to do a medication trial by giving pain medication to see if the overall wellbeing of the animal improves. This requires medical guidance as not every pain medication is suitable to address every type of pain.

b) Nausea is often overlooked when it occurs without an incidence of vomiting. Some animals may exhibit slight drooling or just a smacking or licking of the lips when nauseous. If an animal walks up to food and then turns away without eating, it may either be mildly nauseous or it may be afraid of experiencing pain in the mouth when eating, as can occur with oral cancers. An animal experiencing nausea may also look like it has lost all interest in food. In doubt, just as with uncertain pain, a medication trial can be conducted with anti nausea medication to see if the animal’s interest in food returns or is simply part of the natural progression.

Certain health conditions have a high likeliness of causing progressing nausea, as for example liver cancer. In such cases it is important to treat nausea as consistently as one would treat the presence of pain and adapt to increasing treatment requirements as needed.

Nausea can also be an undesired side effect of medications the animal is receiving. A change in medications may be necessary, or anti-nausea medication can be given in addition. NSAIDS, non-steroidal anti-inflammatories commonly used to treat pain, unfortunately can at times cause nausea, loss of appetite and other GI symptoms as side effects. If that is the case it is critical to stop the medication and replace it with a different type.

c) Restlessness or agitation can occur in some terminal patients. This is why anti-anxiety medication is part of the comfort kit provided by the veterinary hospice service.

d) Difficulty breathing is likely to occur with certain conditions. Common examples are chronic heart failure and lung cancers. When the patient has a condition that makes difficulty breathing probable during disease progression, it is prudent to prepare for oxygen delivery in the home setting BEFORE an emergency arises. With chronic heart failure, the caregiver hopefully gets advised to log the resting respiratory rate (RRR) to catch needed adjustments in medications before a crisis occurs.

When implementing certain drugs or herbs, it has to be taken into consideration that their possible side effects can become more prominent when taken on an empty stomach by an animal which no longer eats and in general as the life force, including digestion, starts running low. That is when non-oral medications and other ways of soothing discomfort can become invaluable. Homeopathy, gentle body or energy work, warm towels and warm water bottles can do wonders when used in an effective manner.

As many of us are unfamiliar with the natural dying process, we tend to judge an animal’s situation from our very own perspective, concerned that we may let the animal suffer. Animals often have a very different point of view about suffering, and even if they clearly experience some level of discomfort they are often not interested in having their life be ended any sooner than it will on its own. To have the caretaker remain peaceful enough internally to perceive the animal’s needs and wishes is one of the most challenging aspects of providing hospice.

Some veterinarians suggest to use a Quality-of-Life scale to determine when to euthanize. Do you recommend a specific one?

Our simple answer would be “no”. Not only do we not recommend a specific QOL scale, but can share with you that the scales used in veterinary medicine generally are neither needed nor helpful when choosing hospice.

Opposite to human hospice, where QOL scales are utilized to evaluate therapy efficacy and needs for treatment plan adjustments, veterinary QOL scales are generally designed to determine when to euthanize. While it may still be used to end hospice care, euthanasia becomes unnecessary in most cases when proficient support is available to the caregiver and the animal.

If you are offered a QOL type scale, we invite you to evaluate it as to two factors:
1. Is the scale recognizing an individual’s will to live as being of prime importance?
2. Is the scale reflecting full acceptance of the symptoms of the normal dying process?

Whether presented as a form to be filled out by the animal guardian or, more commonly, just communicating its applicable points via a verbal conversation, many veterinarians follow certain guidelines that will be the trigger as to when to make a euthanasia recommendation to a client. Veterinarians generally have not learned how to keep a dying animal comfortable and euthanasia is a much simpler option. Mainstream focus has long been not whether but when to euthanize.

All Quality-of-Life scales we have encountered so far in the veterinary field have a couple things in common.

Re. 1. The will to live of an animal is not part of the equation. It is not noted as relevant, perhaps it is silently assumed to be reliably absent as soon as certain circumstances apply, such as immobility, lack of appetite, reduced interaction etc. But oftentimes this is far from reality.

Countless times an untimely euthanasia recommendation has been a source of tremendous stress for animal guardians who still sense the will to live of their animal companion despite their health challenges, yet feel obligated to have it’s life being taken.

“Relieving the animal from its suffering” is always well intentioned. Still, when reduced to hastening death rather than addressing a patient’s mounting symptoms, it completely sidesteps the scientifically intangible, yet ultimately most significant question: Does the animal still want to live?

Fact is that
• most humans CAN be kept sufficiently comfortable through their terminal illness, and we have tools in veterinary medicine to do the same.
• even in states with Death with Dignity Acts the available deathly concoction is only taken by a very small minority of people. Most people prefer to live out their lives despite all circumstances.
• when we asked animal guardians in surveys whether they believe their animal’s will to live is similarly strong as the will to live in humans, the answer to that question was a YES for more than 95% of the participants.

The will to live is not dependent on the ability to walk, and does not cease just because an animal no longer engages in play. Just like in people, the will-to-live can still be present when an animal hardly or no longer eats, including when it is sleeping a lot, and even when experiencing physical discomfort.

Re. 2. Latest once the active dying process begins, the dying individual (whether human or animal) will no longer interact in the ways we were familiar with and would always fail passing a QOL scale evaluation, as those are unaccepting of the normal stages of the dying process. So with or without the use of QOL scales, euthanasia then is likely to be elected unless the caregivers have been prepared for and are accepting of the phases of a normal dying process. Naturally arising, mostly anticipatory apprehension towards witnessing the dying process (especially when for the first time) is eased when the caregivers is well informed, is equipped with medications and knows how to apply them in case of emergency, and stays in the present moment.

PEACEFUL, the Quality of Dying Check list, is designed to determine acceptable quality of life for an animal in hospice care to continue the normal dying process. It is designed for animals who receive hospice care to maintain their comfort all the way through an unhastened death. It is informed by the experiences of dying humans, which taught hospice that certain symptoms, even though they can be difficult for the family to witness, are actually not causing discomfort to the patient.

My animal no longer wants to eat. What should I do?

There are many reasons why an animal may stop eating. If it happens while providing hospice, we want to be aware that antibiotics and other drugs can actually be causing the loss of appetite, as when an animals life force dwindles, it becomes more sensitive to side effects.

If the animal is only days or hours away from it’s natural end of physical life, it is just as in human hospice, normal for an individual to no longer experience the sensation of hunger. This makes perfect sense from the perspective that on one hand digestion is an energy consuming process. When the life force is low, the body spends it’s remaining energy on maintaining the function of the heart, liver and kidneys, rather than on digesting food. This is particularly true as a dying body has no use for the nutritional value contained in the food anymore.

If an animal declines food, one may offer more tempting items that also may be easier to swallow and are offered at room temperature or slightly warmer, and at times an animal may still take food when being hand fed. If it however keeps turning it’s head away, it is best, for dogs and cats, to remove the food, as the smell of it can be nauseating for their sensitive noses. You can always offer it briefly again later, to make sure the animal has not changed it’s mind.

Horses, dogs and cats can still live for several days without eating. The body can actually draw from its stored energy reserves, which often becomes visible in the animal losing weight.

My animal does not want to drink anymore. What should I do?

Inside the natural dying process it is common for both humans as well as animals to lose their interest in drinking, often preceded by a period of not wanting to eat. Just as the body at a certain point can no longer handle, nor has any use for digesting food, there also can come the time when drinking is no longer feasible. Many people react to that by trying to hydrate the body of the dying either by giving fluids into the mouth, or under the skin. This is a great thing to do when there is still hope for recovery, or to slow down the progression of an illness such as chronic kidney failure.

Inside of providing hospice care however, it can mean extending the dying process, which may not be desirable anymore once the individual is close to passing.

From human hospice it is known that being dehydrated can actually lower the pain threshold of the individual. This can go as far as being able to lower or discontinue pain medication, which in turn may allow the dying to experience less of the possible side effects of those drugs, including nausea, dizziness and indigestion.

If it can no longer reach water on it’s own, you still want to make sure to offer water to an animal, as it may change it’s mind. Some animals may still drink lukewarm water when it would refuse cold water. Particularly outdoors in cold climates we need to make sure the water offered to an animal in a hospice situation is warmed. Some animals may still want to drink, but need support to hold up their head to be able to do it.

Once an animal has stopped drinking entirely, it may be only hours to a day or so away from passing over.