Animal Hospice — We Need It, and We Need to Do It Right

Over the last several decades, attitudes towards pets and their role in our households have change dramatically, and in my opinion for the better. Many pet owners see their animal companions as family members rather than objects of utility and entertainment. Pets are brought to the veterinarian with goals and expectations more like those of a parent bringing their child to the pediatrician than of an owner bringing a broken car to the mechanic.

This change in attitude has supported progress in the quality of veterinary care. Better attention to pain control and quality of life, more and better therapies, and of course the expectation that veterinarians will follow the principles of evidence-based medicine that are the standard of care in the human medical field are all positive developments in the profession made possible by clients’ growing desire to have the best care for their animal companions.

And as pet care has improved and our pets have come to live longer, we are more frequently confronted with the issues associated with caring for geriatric patients. Older pets will often have complex and multifaceted medical problems. They may suffer from chronic diseases, including degenerative processes such as osteoarthritis and loss of hearing, vision, mobility, continence, appetite, weight, and even cognitive and behavioral functions. And ultimately our pets will come to the end of their lives, and an important part of our work as veterinarians is helping our patients and their owners through this part of the life cycle.

Because pets are more and more members of the family, owners may not simply wish to euthanize at the first sign of serious disease. Veterinarians can and should be able to support their clients through the process of accepting and grieving for the impending loss of a pet while still strongly advocating for the interests of their patients. Unfortunately, training and resources to help veterinarians do this effectively are scarce, and vets may not be aware that there is more they can offer besides steroids and euthanasia.

In human medicine, the hospice model has become the dominant approach to end-of-life care. While there are many different specific forms hospice care can take, in general the philosophy is to palliate the clinical symptoms of the dying person and also support the patient and the family through the logistical, psychological, and often spiritual aspects of the dying process.

The emergence of hospice represents a salutary change in cultural attitudes which more and more accept that death is part of the life cycle and need not be denied or hidden away. Dying people and their families deserve physical and psychological comfort, and if medical and allied health care personnel are accepting and comfortable with the dying process they can better provide appropriate care.

Of course, in general euthanasia is not an option for people at the end of their lives, and it is a common practice in veterinary medicine, and widely accepted as appropriate medically and morally. So the hospice model has been slow to gain acceptance in the veterinary medical community. However, there are veterinarians and others working to bring this practice to our pets. I think many of the attitudes and practices of hospice are desperately needed in the veterinary field. Like the rest of our culture, I think veterinary medicine would benefit tremendously from a more accepting attitude towards death and dying, and I think our patients and clients can and should receive better care and comfort from us even when we can no longer substantively influence severe disease processes.

However, I am also concerned that some of the people involved in this movement may be bringing irrational ideas and approaches to the process which may ultimately end causing rather than relieving suffering for our patients.

The International Association for Animal Hospice and Palliative Care (IAAHPC)  has recently been established, with the stated mission to promote hospice care and establish protocols and standards for such care. The organization was founded after a symposium on animal hospice held March, 2008 at the University of California Davis. The existence of differing, and sometimes incompatible philosophies regarding hospice care are hinted at on the IAAHPC website:

“IAAHPC is committed to being an organization that is inclusive in its philosophy; it will represent different professions and differing viewpoints of animal hospice/palliative care, end of life, and death and dying.

Some in the animal hospice movement see their own views as diametrically opposed to other views. But whether we like it or not, the animals and society will be best served by focusing on our common interests and by respecting our differences.”

A little investigating of the organization’s board of directors provides some insight into these differences. A number of the members are strong advocates of CAVM practices and critical of mainstream veterinary medicine. Dr. Ella Bittel is a “holistic” veterinarian with strong CAM credentials. She practices acupuncture, chiropractic, homeopathy, Bach flower therapy, and TTOUCH and other energy therapies. She is also an active member of a number of CAVM lobbying groups and has published in the  Journal of the American Holistic Veterinary Medical Association on the topic of hospice care. In her article, she is suggests that “holistic” veterinarians are more likely to embrace the hospice process and paints a rather bleak picture of mainstream veterinarians forcing euthanasia on their clients and “disenfranchising clients from their basic right to chose[sic] what they feel is best for the animal they have cared for throughout its entire life.”

In her other writings, Dr. Bittel frequently promotes the value of CAVM therapies for relieving discomfort or preserving function when “Western” medicine has failed. As I have discussed before, most of these assertions are unproven or outright false. Dr. Bittel  also makes frequent reference to an animal’s “will to live” and “dying wishes,” which she suggests owners and caregivers can intuit through a “hunch,” “tuning in with a calm mind,” and so on. She describes poignantly her loss of her own dog, and includes as a vital facet in making care decisions her inner sense of what her pet wanted.  

I respect the energy that Dr. Bittel is putting into promoting the hospice concept, and I agree with her that there is a need for better end-of-life care for our pets. However, I reject the cliché that she puts forward  that veterinarians who describe themselves as “holistic” are in any real way truly more aware of or interested in the welfare of their patients as whole beings. “Holistic” has strayed far from its literal meaning to become merely a shibboleth indicating a faith commitment to unproven or outright bogus medical approaches, often relying heavily on vitalism and a vague New Age mélange of spiritual beliefs. Homeopathy, Bach flower therapy, and “energy medicine” offer no real relief of suffering for our patients, and they offer only the limited comfort of placebo by proxy for our clients. I have seen many patients suffering clear and obvious pain because their owners refused to see that the faith-based medicine they were using was failing, and because they had irrational fear of real medical therapies. Cognitive dissonance and other forms of denial are powerful, and we do our patients no service by helping our clients to deceive themselves that their pets are comfortable and happy when they are in fact suffering.

Pet owners desperately want to hold on to their beloved companions as long as possible. Owners and veterinarians want the pets we care for to be happy and well, and we want our efforts on their behalf to be successful. It is all too easy to project these desires onto our pets and see what we want to see. Promoting subjective, intuitive methods of divining what our pets “true” feelings and desires are, and discounting the behavioral signs available to us, as Dr. Bittel sometimes suggests, is a dangerous practice that promotes such emotional projection and the mistaking of our desires and interests for those of our animal companions.

Examples of tragic harm that can be caused by such approaches abounds in human medicine, including the fads of Facilitated Communication and Repressed Memory Therapy. I have had numerous encounters with pet psychics or “animal communicators” who claimed to speak for the inner thoughts and feelings of some of my patients. They often provide vague, reasonable statements that could apply to any animal at any time. They certainly appear to comfort clients, and I have never seen one claim to intuit something from an animal that a clients really didn’t want to hear. But I have also seen the worst of them flagrantly pander to the client’s inability to accept the inevitable loss of their pet and continue to re-assure them their companion was content and did not want to be euthanized despite obvious and awful suffering. Such irrational methods for making decisions about quality of  life, palliative care, and euthanasia are not in our pets’ best interests and have no place in veterinary hospice care.

Other members of the IAAHPC founding board besides Dr. Bittel also promote a “holistic” or CAVM-based approach to veterinary care, including Gail Pope, who is affiliate with a “Holistic Animal Retreat” which promotes homeopathy and “animal communication” as part of its services. The philosophical and epistemological perspectives of other board members isn’t readily apparent, and I suspect from the reference to “difference” quoted above that some are strongly in favor of a science-based approach to end-of–life care.

Certainly, there is no need for absolute uniformity in clinical practice related to hospice care, and the IAAHPC statement is correct that the goal of improving end-of-life veterinary care is important enough to warrant attempts to find common ground and accommodation among veterinarians with different approaches. However, if the flagship organization for the hospice movement, the group setting the standards for the profession, is ultimately dominated by faith-based medicine and  misleading vitalist philosophies, then the standards that are adopted may very well do more harm than good.

Euthanasia should certainly not be the only or first recourse in serious terminal illness, but neither should it be shunned as “unnatural” or discouraged on the basis of “intuitive” methods of quality-of-life assessment that project the owners needs and wishes onto the patients. And while homeopathy or flower essences may give the owner the comfort of imagining they are doing something to contribute to their pets’ wellbeing, they should by no means be used in lieu of truly effective therapies for control of pain, nausea, and other discomfort associated with dying. Every attempt should be made to ensure that the methods of assessing the condition of the pet and the response to palliative therapy, and the therapies that are employed, are consistent with the best evidence and most sound scientific principles possible. No one should deny our clients the comfort of  rituals and spiritual practices that they may wish to invoke when their pets are sick or dying. But just as parents cannot legally or morally deny their children the best scientific medical care available on the basis of religious or other faith-centered beliefs, so animals who are dying should not be denied adequate palliation and euthanasia on the basis of such beliefs. I believe there is much of value in the hospice approach that can and should be brought into veterinary medicine, but I also believe that to do hospice the right way and truly improve the care we give, we must stick to science and evidence-based medical practices.

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11 Responses to Animal Hospice — We Need It, and We Need to Do It Right

  1. Rita says:

    Indeed – I often get the feeling that the terminally ill, who can’t get out of bed to brandish a zimmer frame at the reiki-flower-remedy-woo brigade, are the worst victims of these dubious practices. I’m all for soothing peoples’ – and animals’ – last moments, but I agree that there’s a fearful danger of CAM practitioners fobbing off pets’ guardians with “beautiful” sentiments whilst holding up or deflecting effective methods of relief.

  2. Bartimaeus says:

    I have a housecall practice, and therefore see maybe more than my share of old, sick pets that are difficult to get in to a clinic, and also euthanasias.
    Most people are pretty good about using multimodal pain relief when I explain it to them, and can do a lot with their pets. I have only had one or two cases where I thought people were victimizing their pets (unintentionally, but still) with some type of belief in alt med or strange new-age belief systems. In one case I ultimately had to tell an owner that I would not be able to participate in the pet’s treatment anymore, because I thought they were being cruel. They were not happy with me, but they had not been all that happy beforehand, and were dead set against “western” medicine from the start. At that point, I felt that all I could do for that pet was refuse to participate in their delusional course of action. It is unfortunate that some pets do suffer because of their owner’s ideology, and we can and should use science and evidence to reduce this as much as possible.

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  4. Manny Katz says:

    The link to Gail Pope is now incorrect. It should just http://www.brighthaven.org.

    Gail Pope knows more about palliative/hospice care than just about anyone else, having been involved with that and animal rescue for close to 25 years. Where have you been? She has taken care of sick, disabled and dying animals (mostly cats but several other species as well) and hardly ever chosen to use euthanasia. She started off that way (the mainstream way) but gradually changed rather completely. From what you write, I conclude that you have not really studied her writings on end-of-life-care, but have focused only on her methods which you disagree with almost entirely. Why don’t you look into her animal biographies and philosophies. When was the last time you had a 35 year old cat to treat? Close to 600 animals have been tended to very lovingly, (including one of mine) painstakingly by her, her husband and a limited staff and many volunteer vets all across the country. See what she writes about the circle of life. Also, she would be most happy to discuss any of this with you as she has with my current (MSM) vet.

    I have a beloved 22 year old cat right now suffering with two types of cancer: orall squamous cell carcinoma which has taken his tongue, and bladder transitional cell carcinoma which has made him almost incontinet. YET– he wants to live, eats still via syringe, gets palliative drugs, sleeps with me, interacts with me, shows a depressed mood at times but not any clear and obvious suffering. He bleeds sometimes from both ends but is indifferent to it. He is now almost 1/2 his original weight. All the vets did not want to even do a feeding tube (which I now regret highly) and wanted him put down months ago. His original prognosis last December was just a few weeks to a couple months–it is now almost 8 months since then…and that has required a huge amount of hospice care from us. Really huge. I’m in my 70s and have managed it, but it is very tiring. But I can’t kill my best friend…just can’t. Not when he himself has not shut down or given up. I feel that would be a betrayal of his trust.

    I share with you Gail Pope’s latest message to me here for all your readers. She was responding to my regret over not having installed the feeding tube when he was stronger:

    “I said once that hospice care is not for the feint hearted. It requires strength and courage and endurance from everyone. In fact I am using the same words in our seminar presentation this year:
    § Hospice care is not for the ‘feint hearted’. It will test you. It breaks your heart, and you find your courage, all in the same breath. You truly learn how to put someone else before yourself.

    § But, for all the tiredness and heartache, the bottom line is that someone who is dying, loves and trusts you enough to want you around during their last earthly experiences. They choose you to keep the sacred space for them. That is incredibly beautiful. It’s awe inspiring. It’s a testament to love. And it is a privilege. Not a burden, but an honor.

    § What you will learn you cannot learn anywhere else.

    § People most often are driven to euthanasia to be free of the pain – their own. They often become angry because they want their loved one to be well and not suffer, or die.

    § The trick is finding the love and meaning within that pain.

    You simply HAVE to stop apportioning blame to yourself. It is neither fair nor appropriate. It’s maybe time to accept Smokey as dying and “be” with him.

    Franny died recently and you will recall that she had a feeding tube. After her death, her owner blamed herself for all the things she might have missed along the way and tried to find out what SHE did to cause Franny to die.

    Please let go of your sense of failure, let go of the anger. You have done and are doing a wonderful job – filled with love. Please try to enjoy Smokey’s love and be with him now.”

  5. TearDrop says:

    Manny,
    I think you may be very mistaken about what your cat is going through. He is hiding his pain and suffering. You probably didn’t give the whole history, but I bet he has other problems with elimination and gait and overall strength.

    I don’t know about the feeding tube. Maybe doing it earlier would’ve been better, but vets are conservative, and they don’t like putting that stuff in terminal cats from my experience. I think that’s shortsighted myself, so I agree on that. It would have saved you a lot of trouble in the feeding.

    I guess being strong is a job for the both of you.

    Tears

  6. skeptvet says:

    I don’t see anywhere in my article that I suggested Dr. Pope was not a kind and caring person or helpful to her clients. What I said was that in addition to hospice care, which I support doing effectively, she advocates homeopathy and “animal communication,” which are unscientific nonsense that may bring some psychological comfort to owners but do nothing to help our patients. I think this raises a legitimate concern that these therapies, and the beliefs that underlie them, may compromise the welfare of some patients if they discourage use of effective palliative care and, when appropriate, active euthanasia.

    One of the great challenges of veterinary medicine is being responsive to the needs of clients and their pets. Sometimes, unfortunately, these needs conflict. I don’t think we can truly know whether or not our pets wish to continue fighting for life or to pass peacefully, but I think it is all too easy to project our own needs on them. This is a normal human behavior which arises in any loving relationship. But when we project onto other human beings they can often tell us directly that we are doing so and let us know what their own needs truly our. Our animal companions cannot do this. So part of my job as a vet is to advocate for the interests of my patients, even if the owner has a different view of these interests based, at least in part, on their own needs. I have to do this without psychics to tell me what the patients’ themselves think because I don’t believe such people have any genuine insight into animal thoughts. Sometimes, this means telling people that I fear they may be clinging to the idea that their pets wish to stay because it is so painful for the person to say goodbye.

    I agree with Dr. Pope that end-of-life care is not for the feint-hearted, but that applies equally well to choosing to let our pets go as to supporting them while they die naturally. I can’t say with certainty which is the right choice in a given case, and the decision always belongs rightly to the owner. However, I will say that offering fake solace, in the form of treatments like homeopathy and animal communication, does not truly help our animal companions, and these kinds of therapies do diminish the value of good hospice care.

  7. v.t. says:

    Manny Katz said: Gail Pope knows more about palliative/hospice care than just about anyone else, having been involved with that and animal rescue for close to 25 years.

    You are joking, right?

    Read the following, Manny, then come back and tell us they are truly helping hospice patients.

    http://brighthaven.org/animal-hospice/pain-palliative-care/

    Gail Pope obviously doesn’t have a clue in recognizing common signs of fatigue, pain, organ failure, and a plethora of other chronic or acute disease states, let alone know how to treat them effectively. Homeopathy is their “primary” care method, and from their very own words, only “rarely” do they ever employ real medical interventions in the event homeopathy or reiki do not help the patient (oh the irony, since neither homeopathy or reiki does diddly and both depend solely on faith, nothing more). She and her ilk are the very reason veterinary medicine needs common ground and guidance measures in hospice care.

  8. Manny Katz says:

    To v.t.,
    It’s easy to say after visiting one-page and seeing a list of treatments that are decried and derided as not being SBM or EBM, as the blog names them, that the entire enterprise is invalid and deserves ridicule and censuring. That would be a preposterous conclusion. Why don’t you read everything, especially the Philosophy and Animal Hospice section where pain, suffering, quality of life, etc. INCLUDING THE HISTORIES of several residents. There are many themes, practices and procedures going on there, many aspects like diet, environment, care and attention as well as medical interventions when needed.

    I had a cat at BH (Gingi) that had lost all excretory functions as a result of a car accident. I was told straight away by the first vet to euthanize–somehing that very much resembles the cookie-cutter, cookbook, recipe laden, one-size-fits-all recommendations based on vague guidelines and algorithms of so-called “modern” human and veterinary medicine.

    I disagreed with the vet, took her for an operation that had to remove most of the tail, but then had to manually express her. Couldn’t do it. Luckily, found BH, who accepted her. She lived at least another 10 years there, being manually expressed daily, undergoing surgery when her intestines got tangled, and other procedures as necessary, but mainly just the BH protocols. I visited regularly, saw many other cats with worse problems, yet happy. Gingi died on his own without any interventions from a respiratory failure; I was very close to him; he received personal attention the whole time.

    As I asked before, how many cats have you treated that were in their 30’s? Over 500 animals have spent their final years there in much better health than so called ‘normal” animals in “normal” homes, with “mainstream” treatments. There is a large cadre of vets always available by phone, from around the country and abroad, and each animal has his/own assigned vet. There is a built-in treatment and operating area, gorgeous, protected grounds, a large home specifically designed for animal hospice care top to bottom. You can read about it all at the BH website and through their publications.

    You can surely find things to complain about by skimming the surface, but go deeper. Science isn’t the answer to every ill and difficulty. And animals, their thoughts, sensations, minds, images are still very much a mystery, and the more we find out the closer they seems to us, and in some ways, smarter.

  9. v.t. says:

    I stand by my statement, Manny.

    I didn’t write their website or make the claims they make. Treating ANY pet with homeopathy and reiki is unethical, and downright criminal. All the caring in the world does not change that fact.

    I had a cat at BH (Gingi) that had lost all excretory functions as a result of a car accident. I was told straight away by the first vet to euthanize–somehing that very much resembles the cookie-cutter, cookbook, recipe laden, one-size-fits-all recommendations based on vague guidelines and algorithms of so-called “modern” human and veterinary medicine.

    That second sentence – there’s so much wrong with that, I’m asking myself if it’s worth the trouble to enlighten you.

  10. Manny Katz says:

    V.T.
    You think I’m nuts in my 2nd sentence that you mentioned. A bit overdone perhaps, but not far from what goes on in medicine and what goes on in the training of doctors. Don’t believe me…read the book “When Doctors Don’t Listen” by Drs. Wen and Kosovsky, two ER docs. Then you’ll see what I mean.

    The vets that I’ve seen locally have used some off-the-shelf, algorithmic, arbitrary QOL scale with points. That’s the cookbook, guideline approach. For a hospice pet, I’m interest not so much in QOL but rather in QODying. I don’t see euthanasia as a moral obligation except perhaps when the animal is in extremis. And that is often just an opinion, unless you believe in “communicators” which I don’t.

    No need to take the trouble to enlighten me.

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