Hospice and End of Life

older Labrador retriever gently panting at the beach

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Preventing and relieving suffering in pets is important all life stages, but particularly during end of life care. Hospice veterinarian, Dr. Mary Gardner, co-founder and chief information officer of Lap of Love Veterinary Hospice, joins this episode to tell us about a sweet golden retriever named Bogey, bucket lists, palliative care, and euthanasia or “good-byes.” If your dog or cat is an older animal, your geriatric pet could benefit from this discussion on how to identify ways to improve your final time together while relieving caregiver burden, and what to expect when it’s time.

Dr. Mary Gardner, Lap of Love hospice veterinarian

Mary Gardner wraps her arms around the shoulders of her two dogs

[00:01:05] Dr. Lancellotti: Welcome, everyone, to today’s episode of Your Vet Wants You To Know. I am very excited to have a special guest with me, to talk about hospice care for our geriatric pets. For Dr. Mary Gardner, there is nothing better than a dog with a gray muzzle or a skinny old cat. Her professional goal is to increase awareness and medical care for the geriatric veterinary patient, and to help make that final life stage as peaceful as possible, surrounded with dignity and support for all members of the family. She is the co-founder and chief information officer of Lap of Love Veterinary Hospice, which has over 300 veterinarians around the country, dedicated to veterinary hospice and euthanasia in the home. Dr. Gardner has published two books on caring for geriatric pets. It’s Never Long Enough is a book on geriatric dogs and Nine Lives are Not Enough is for geriatric cats. Welcome to the show, Dr. Gardner.

[00:02:02] Dr. Gardner: Thanks for having me!

[00:02:04] Dr. Lancellotti: I’m so excited that you’re here. I remember you speaking to our class at Western University, when I was a student, and I was just so inspired by the passion and the care that you showed for these older animals at the end of life.

[00:02:15] Dr. Gardner: Oh, I do love it. Gosh, that was a long time ago! Clearly, I’m still addicted to the weak and the wobbly, the bumpy and the skinny, and the families that love them.

A Beautiful Goodbye to Bogey

Golden Retriver Christmas ornament hanging from branches of a Christmas tree

[00:02:25] Dr. Lancellotti: The goal of this show is to connect with pet owners, providing them with some information about specific topics, in terms of an animal that they can relate to. I would love for you to tell our listeners a story about a pet that you’ve connected with, that helps to represent hospice care and how we deal with these animals.

[00:02:44] Dr. Gardner: Okay! I have so many stories! I have laced a lot of them throughout my books- and even my own personal stories (with my own pets in their hospice care). One of my favorite hospice patients was this Golden Retriever named Bogey that was diagnosed with lymphoma. A couple of years ago in Southern California, at the beginning of December, the family reached out to me. He’s already seen oncologists and his general practitioner, and they just wanted to get some hospice care. I remember knocking on the door and I could hear his little nails on the tile. He was just a typical, happy, loving golden retriever- which they are so well known for. He was struggling with some inappetence, diarrhea, and the things that come along with end-stage diseases. And the family was really struggling with, “How will I know when it’s his time?” It wasn’t time right then, but we knew it was going to be time in a couple of weeks (or maybe months), and they wanted to make sure that he was as comfortable as possible and that they lived every day as fully as they could. One of their questions for me was, “Will he make it to Christmas?” I said, “I can’t guarantee that. It’s really going to be up to him and his disease progression.” They didn’t know if they should put him on their Christmas cards or not, and I said, “He should absolutely be on the Christmas card, even if he’s just your Christmas angel, this year. We said goodbye to Bogey on New Year’s Eve, so he did make it through Christmas. The pictures I got were lovely. Even the videos they took of him at the beach for the last few weeks were just amazing. They really felt supported through it. They had no regrets. Even if he couldn’t make it to Christmas, they knew they would do right by Bogey. We just made sure he was comfortable and that they could handle the caregiving- an 80 pound golden retriever is not the easiest to care, at that size, so I gave them tips and tricks on how to manage his ailments. The family in the case was very typical of what we see, and I loved that I could be a part of that. You know? We gave him a big kickoff for his next journey.

[00:05:03] Dr. Lancellotti: That sounds really beautiful, that you’re able to give the family those special holidays together with him. That’s really nice.

[00:05:08] Dr. Gardner: Yeah. We never want to say goodbye anytime, but certainly during the holidays, it just adds a level of emotion. This Valentine’s Day will be two years since I let go of my girl. She was my heart and I will always remember her on Valentine’s Day.

What is Hospice for Pets?

[00:05:22] Dr. Lancellotti: You mentioned hospice care and it’s kind of a broad term. Can you break down hospice care into specific topics that you consider, when discussing what this means with owners?

[00:05:34] Dr. Gardner: Oh, absolutely. We all practice medicine a little bit differently, so every hospice veterinarian have different elements that they focus on or add to this. So many people have this idea that hospice is about prolonging suffering. It’s absolutely not. It is about support and care for the pet (and the owner) during the final stages. Dare I say, if we don’t do hospice, we’re actually allowing suffering to happen. I break it down into five major components of hospice. The first part of hospice care is the medical side for palliation. Palliative care is just a fancy word for making sure that the pet is as comfortable as possible, whether that’s pain, anxiety, nausea, etc. And for palliative care, that could come with or without curative treatment. Palliative care can be a younger dog going through something, but with hospice, we’re near the end. So we’re not seeking curative options. For Bogey, they were not continuing chemotherapy in hopes for curative outcomes. With hospice palliative care, we’re just making sure that they have the proper pain management, anxiety management, appetite stimulants (if needed), and proper hydration. That’s paramount to making sure that they’re comfortable. 

Changing the Environment for Older Dogs and Cats

Dr. Gardner: The next part, which I really enjoy, is going to families’ homes and setting them up for success. All of the Lap of Love veterinarians have the benefit of going into a home. We could see where the food bowl is, where the younger dog or kitten is, who could be jousting them for position on the couch. Can they get up on the couch? Can they get on their sunny spot still? We really set the house up for safety, ease of mobility, ease of cleaning, etc. – because many times these guys are in incontinent. What products could we recommend to make it an easier experience for the family, and more comfortable for the dog or cat? If you do not have a veterinarian that can come to your home, take videos! They are golden! If we, in the clinic, can see how the house is set up, or how the pet might be struggling, we could do a better assessment. When any dog or cat goes into the clinic, they’re different, so I encourage everybody to take videos and pictures. But making sure the environment is set up for success is key.

[00:07:59] Dr. Lancellotti: That’s fantastic! That’s the area where the animal’s spending the most time and we want them to be comfortable there. I can remember back to my dog Molly, who we said goodbye to this past summer. Toward the end, she had a lot of intervertebral disc disease and a lot of arthritis in her hips, so we made a lot of changes to our home, making it easier for her to get around. To give her more grip on the floor, my brother-in-law came out from New Jersey and he polyurethaned with some sand on top of the step, to give her extra grip on that step, so that it would be easy for her to go up and down. And it just made a huge difference in her being able to go out and lay in her sunny spot in the backyard.

[00:08:40]Dr. Gardner: When you’re in the veterinary hospital, we do tend to focus a lot on the medicine. There are wonderful veterinarians that could speak to all of the medicine, but not as much about what products to recommend. Like the polyurethane in the sand. It’s so easy to do. How can we set the house up so that a visually impaired dog or cat is safe or not as nervous? The worst thing ever is cognitive dysfunction. Owners suffer with that too.

Caregiver burden leads to depression and stress

Dr. Gardner: My girl, Sam, had spinal lymphoma, so she had major mobility issues. One of my biggest problems was her fecal incontinence. She would just poop on the rug and then she would fall in. It would get an in her fur and it was just a nightmare, so I learned how to have her poop on demand. I won’t go into details, but it was massive for me, as a caregiver, to be able to not have to clean up her poop in the house three times a day. And it’s not about finances, because if they can’t afford a certain harness, what’s the cheaper alternative? It’s about what they can physically manage. Even smaller dogs or cats have these issues, where you have to clean up after them and things like that. What can a family physically do? How much time can they invest? On average, for a geriatric or terminally ill pet, it’ll take three hours a day for the care that you give them.

[00:10:11] Dr. Lancellotti: Wow!

[00:10:11] Dr. Gardner: That’s a lot. Right?

[00:10:13] Dr. Lancellotti: Absolutely!

[00:10:13] Dr. Gardner: You could have two kids, yourself, a job, you’re not home for 10 hours, etc. If we can’t manage that, then they get caregiver burden, caregiver fatigue, and burnout. And that’s what I want to avoid! Is there respite care in their area? Are there good mobile groomers that could help? Are there wonderful technicians from our industry that will come and help? Let’s say it’s during the weekend and you want to have a weekend off. It’s okay to be tired and stressed and to need a day away. And I want to support families because they start to become isolated- and you just don’t leave because you think you can’t.

[00:10:48] Dr. Lancellotti: Yeah, caregiver burden is a very real thing and there’s lot of amazing research that’s being done. I think that’s something that people don’t often recognize when they’re caring for their own pet. It can truly be exhausting, isolating, and really hard (not just for the pet, but) for the owner, as well.

[00:11:08] Dr. Gardner: A hundred percent! And that is one lecture I give actually to veterinarians because I don’t know if we all recognize the struggles that a family has because we just don’t see it. Again, I’m in homes, so I see it a little bit more and I see what they go through and how they’ve set up their house and what they’re dealing with and the smells, etc. And they’ll keep doing it, but it can be stressful. And all that research that you’ve mentioned, Dr. Mary Beth Spitznagel, she’s done a lot of research on this. She has a great website. And it’s got some good, support tactics and things like that. But it basically has shown that the stress, the depression, just knowing for those listeners that are going through it, like I get it. I empathize. Like I know, and that’s why I want to make sure that we can make it easier for them because it is stressful.

[00:11:53] Dr. Lancellotti:Dr. Mary Beth Spitznagel is a fantastic researcher and I think that’s a great resource for people to look at.

Talk about your pet's quality of life

Dr. Lancellotti: I want to talk about quality of life because we’ve talked about some ways that animals may struggle. But how do you talk to pet owners about quality of life? What are you typically evaluating in terms of what the animal’s going through?

[00:12:18] Dr. Gardner: This is probably the most impactful part of my hospice visit. It’s usually at least a half hour because this is the worst decision you’ll ever make. Quality of life is so subjective. When you make that decision is subjective. It’s personal. I may do more and keep my pet longer than other people. It’s not that I’m right or wrong, but it is what I can handle. And it’s okay if somebody couldn’t handle that and they want to say goodbye sooner. It’s quality of life for the pet- which also extends to the family. And I don’t mean that in a selfish way. If the family can’t manage the pet, and then therefore hurts the pet’s quality of life, that’s a problem. So, what are the ailments the pet is dealing with? There are some that are, dare I say, worse than others. Anxiety is horrible. That’s the worst ailment to have. So if you’ve got a pet that has respiratory distress, that’s worse than, let’s say, being in incontinent, or drinking a lot and peeing a lot. That’s horrible for the family to deal with, but it’s not so much for the pet, so whether it’s mobility issues and they can’t get up, or the cat can’t get on any of their favorite spots, that’s bad. But anxiety always ranks #1 for me, so if that dog can’t get on the couch and that’s making them anxious, then that’s not good either. I have a dog that has separation and anxiety, so I know that when I leave, I can’t stand watching his reaction. He gets a lot of medications for it. So, the ailments they’re having is the first thing I talk about. The second thing is the pet’s personality and how well they’re managing their problems- like Bogey. Not that the tail is the indicator of quality of life. I need to make sure I state that clearly, but he was still happy. The family knows what makes Bogey happy, even when he started to decline in his appetite and stuff like that. So are they taking their medications? Are they running from the family? I don’t want them running away because they hate it. My current dog, who has anxiety, couldn’t go to physical therapy. He couldn’t go to get some treatments. He wouldn’t be able to benefit from some of the things that my other dog Sam did, because her personality allowed her to take part in things. The next thing is the family’s beliefs. Every single one of us, even Dr. Brittany and I have a difference of opinions? We all have a different opinion and I have to respect that. So if a family says, “You know what? We know that he will only get worse from now. Today’s a good day, and every day is only going to be a little bit worse, and we want to say goodbye today,” I’ll support that decision to say goodbye, today. And that’s really hard because you know that they could have a good day tomorrow, but what you’re preventing is bad days from ever happening. There are some families that could do that more than others, and I support that decision. I also support if we need to wait a little bit longer, as long as there’s palliative care. It’s very complex and you have to have somebody help guide you through the quality of life discussions with no judgment. There are a lot of scales out there- I have my own personal one. At Lap of Love, we have one. It’s really just a guide for us to start thinking about some of the things that we might not have thought about, which do address quality of life. Regarding Bogey’s family, I wanted them to go get the videos. I wanted them to do a professional photo shoot. I wanted to make sure that he was okay for the Christmas card and that they had no regrets. Boy, they were sad! And they still are today. But they will have no regrets. There’s a place that I lovingly call “Denial Island,” and I’ve been there myself. We never want to say goodbye. And that’s why I named my book, It’s Never Long Enough because we never get enough time. And I get it. You may not see the struggles that your pet is having because you’re on “Denial Island” or wearing denial goggles, and that’s where some of these quality life scales can be very helpful, to be a little bit more objective for something that is so subjective.

[00:16:21] Dr. Lancellotti: Yeah. I think you’ve brought up a couple of really good points there about that quality of life discussion. Every veterinarian has a different discussion. There are lots of different resources that are available for helping you to gauge what your animal’s quality of life is, but what it comes down to is you and your family, and having that conversation with the people that love the animal more than anything else. And because everybody’s coming with a different background and different beliefs, that decision can only belong to you and you alone. I encourage everyone to have a veterinarian that they trust to have that conversation with, but you’re absolutely right- “Denial Island” is a real place.

[00:17:03] Dr. Gardner: A lot of times, there will be arguments between family members (moms, dads, partners, teenagers, etc.) and they struggle. It’s a huge dynamic. What I think is important for people to do is recognize that none of us want our pets to suffer. The question is, “What is suffering?” If my dog sits in their poop, that’s suffering. If they don’t eat for three days straight, that’s suffering. And I think that helps open the discussion because the partner may say, “Well, I think five days is the day.” And the other may say, “Okay, let’s draw a line in the sand.” And I think that’s what helps- drawing that line in the sand and literally writing these things out. Make a diary. I love calendars where I just put a big X on the bad days because everyone says, “More good days than bad.” But if you don’t monitor what you’re measuring, you won’t do it well. So, because you’re on “Denial Island,” all of a sudden they ate finally, and you’re like, “Yes! He’s doing better!” But he didn’t eat for five days before that and you lose track. So, monitor what you’re measuring.

What happens when a pet is euthanized or put to sleep?

[00:18:08] Dr. Lancellotti: Because hospice care involves providing the pet good quality of life, it typically involves a conversation about the end of life. Can you tell us a little bit about how you discuss end of life with pet owners?

[00:18:22] Dr. Gardner: I always want to talk about it sooner than later because I want them to know that I am there to support their decision. I want to have that discussion early on, and I also want to discuss what euthanasia is. There are a lot of families that don’t even know what it really means. They they think we’re giving a heart attack. I want to talk about how I do it with sedation. At Lap of Love, we do it all in the homes, backyards, boats or wherever they want to be. We can plan that goodbye, and I think it’s very helpful for families not to be scared of the process. The last place I ever want a euthanasia to happen is in an emergency room. It’s just the worst place to be, and sometimes that’s where we are. If a family is opposed to euthanasia, I want to talk about palliative care for natural passing because we should never just let our pets just die on their own, without making sure that they are not experiencing pain. I lost my sister this summer and she was on a lot of morphine. And I think that’s very needed for our pets. I don’t ever want them to pass having any form of suffering. There are many people who are adamantly against euthanasia, but they are also adamantly against the pet suffering. You’re not always present for natural passing. You could be gone shopping and then you come home and they’ve passed. And that’s very jarring! I always say that I’m not ending life. I’m ending the dying process. They’re already dying. If we could make sure that they die well, then that would help with some of the regret. The two pets that I mourn the most are the ones that died on their own- my own pets. I wasn’t there for my Doberman Neo, to hold his paw and thank him for all that he’s given me, and my cat was an accident- and those are the ones that I still mourn over, because I couldn’t say “I love you” and I couldn’t make sure it was a good goodbye.

[00:20:11] Dr. Lancellotti: Yeah. I think “goodbye” is the word. It’s not supposed to be something that is traumatic. Of course, it is sad and heartbreaking, but for these animals it is a “good” bye. I want to have you discuss, very briefly, what that process involves, so that people will understand how euthanasia typically progresses?

[00:20:33] Dr. Gardner: I’m so glad you asked me about this because I want everybody to understand what the euthanasia process is. I’ve dedicated a whole chapter to it in my book. Oftentimes, people are scared, and I think that when we remove that mystery, we could set expectations and not be scared. We could still be sad, but not scared. Minimally, it is painless. That’s important to know. The majority of veterinarians here, in the United States, do something that we call pre sedation- usually, a shot under the skin, like a vaccine- and it just provides pain relief so that they start to feel really good. I love it because owners can see the pet relax after they’ve been tense or painful. Or maybe the anxiety has washed away. Then, there’s a sedative. After I give it, they’re still eating a cupcake, they’re still getting loved on, and they slowly start to fall asleep. So it’s a beautiful passage. It’s not an abrupt sudden thing that happens. And usually they’re snoring. I have to tell you, probably 30% of the time someone will say, “This is the best sleep he’s had in weeks.” That’s what I want. I want them to remember that. Then, the final medication is simply an overdose of anesthesia. However we administer that, it will travel to the brain, and when that goes away, everything else starts to follow. That could take 30 seconds. It could take a few minutes. It’s all dependent on blood pressure, circulation, or on the ailment the pet has. No single passing is the same. My main point is that there is no suffering happening. They’re sleeping, there is a massive overdose of anesthesia, and then they pass in their sleep. That is what we want for natural passing. When someone says, “I want them to die on their own,” what they really want is for them to die in their sleep- and we guarantee that. I think everyone can tell that I’m very passionate about that. I have had people crying in my arms because they did not do the good goodbye. The two things I always prepare an owner for is that their pet will relax their bladder (and may urinate) and their eyes don’t close all the way. That could startle some people, but it’s okay. The eyelids are a muscle. Everything shuts down and relaxes. I love to make memorial items afterwards, so I always make paw prints in clay or ink. I do nose prints. I take a fur clipping. But if a family doesn’t want those things, that’s okay too. There’s no judgment. Some people are like, “Nope!” and I have also shaved an entire dog because they wanted to make a pillow out of them. Usually, I’m up for anything, so if I can, I’ll do it. There are some special ways that we can memorialize our pet, and some amazing artists that do some great things to help honor that pet, even after they’ve passed.

[00:23:28] Dr. Lancellotti: Yeah. Every family’s a little bit different, as far as what is special to them about their pet and how they want to remember them, but there are a lot of different ways that you can do that.

What should pet owners remember about hospice care?

Dr. Lancellotti: I am just amazed and thankful for all of the information that you’ve given to pet owners, today, about caring for these older animals with terminal illnesses and that end of life discussion. What are some of the big takeaway points that you’d like pet owners to remember about hospice care?

[00:23:58] Dr. Gardner: I think the big thing is to not focus on the goodbye, but literally to live every single day because the one thing you’ll regret is that you didn’t say “I love you” enough. That goes for human goodbyes, too. We always want to say, “I love you.” And I adore bucket lists. I’m addicted to them. They could be as silly as you want. Even for my dog, Duncan, one of his things was to pee on the neighbor’s plants. It was just so much fun to make a bucket list for his older age. He couldn’t run a mile, but we could certainly bark at the mailman or whatever it may be. I had such a wonderful time making it and checking them off, whether it was steak dinner in bed or whatever. I just really encourage families to take pictures of it and send them to me. And you know what that does? Is it helps to counteract disenfranchised grief- which is to say “Oh, he’s just a dog,” or “He’s just a cat.” And you know what? He is not just a dog and she is not just a cat. They are a part of our lives. They’re a part of our families. They are my children. They are a being in the home, a sense of security, a sense of friendship, and so much more. When we can honor them and show what a wonderful life they’re having before they pass, it will certainly help after they’ve become angels.

[00:25:18] Dr. Lancellotti: Yeah. I think those good memories really help to heal the grief that’s in people’s hearts when the animal’s no longer with them. Making sure that you’re making all those good memories is a really special way of honoring the bond that you have with your animal. I want to give people some more resources- www.drmarygardner.com. And then Lap of Love, to find a veterinarian in your area. There are some great resources on there, as well. There’s also a link to find a veterinarian through the International Association for Animal Hospice and Palliative Care, if you would like to find a veterinarian in your area there. We also have a Facebook group that you can join and tell us about your experience with hospice care or end-of-life care for your pet. There’s a really amazing community there. It’s a great group to be a part of.

Scratching the Itch

Dr. Lancellotti: Dr. Gardner, at the end of each one of our episodes, we have a segment called Scratching the Itch. This is a short segment that is designed to highlight something- a human interest story, a product, or a website. Essentially, it’s something that just provides relief or makes you feel good. Hence, scratching the itch. I was wondering if you had a ‘scratching the itch’ that you would like to share with our listeners, today.

[00:26:41] Dr. Gardner: Gosh, I have tons of itches that I could scratch. I love it. This is amazing! I’ll share one thing that I’ve come across, recently. I met this amazing vet in the United Kingdom, Dr. Jade, and she started something called Street Vet. Now, there are over 400 volunteers in her network, all over the United Kingdom. They focus on and give care to homeless people who have dogs. It’s just such an amazing, heartwarming story. I plan to go help and volunteer with her organization, but there are some here in the United States, too. I was talking to some of the homeless people and it was just so amazing to hear their stories. They’d mention how important their pets were to them and how they wouldn’t even go into shelters, or go get medical care for themselves, because they couldn’t bring their dog inside with them. So, Dr. Jade is not only providing medical care for these dogs, but also providing some shelters (so they can take their dogs in with them), or even just day shelters so that person could go get help themselves. And it just warmed my heart when I talked to her and the people that she was helping. I think it’s wonderful that we not only care for those that may have some difficulties and struggles in life, but also share the love of a dog.

[00:28:14] Dr. Gardner: Absolutely!

[00:28:15] Dr. Lancellotti: Thank you very much, Dr. Gardner, for coming on the show and joining us, today. I am so grateful for your time and your expertise and the passion that you bring to veterinary medicine.

[00:28:25] Dr. Gardner: Aw, thanks for having me! I hope this is helpful for a ton of families that love their older pets too.

[00:28:30] Dr. Lancellotti: Absolutely! And for those of you who are listening, I look forward to your next visit with Your Vet Wants You To Know.

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