The following is a guest blog written by Katherine Goldberg, DVM. You can learn more about Dr. Goldberg and her practice, Whole Animal Veterinary Housecalls & Hospice Services, in Ithaca, NY here. Her practice is exclusively focused on geriatric support, hospice, and palliative care for animals.
Leading concerns mentioned by the (very few) individuals who sought out and utilized Oregon’s Death With Dignity Act in 2010 were: 1) loss of autonomy (93.8%), 2) a decreasing ability to participate in activities that made life enjoyable (93.8%), and 3) loss of dignity (78.5%). Fear of intractable physical pain has NOT seemed to be a central motivation under the DWDA. Patients are not exercising their legal right to choose physical-assisted death because they are unable to obtain good symptom management.
SO, what does this tell us about our animal patients?
Loss of autonomy can arguably be thrown out, since animals do not have autonomy (i.e., control over their own destiny & ability to make decisions about their care, life & death) at any time in their life. As emotionally evolved as many of us believe our pets to be, they still exist, for the duration of their lives, as complete dependents. Every need and event - from food, shelter, and daily attention, to complex medical procedures and interventions for management of chronic disease, to the timing and type of death – is controlled by humans. Arguably, our animal family members have no more autonomy in death & dying as they do in life & living.
If people are exercising their right to die under DWDA legislation because of a decreasing ability to participate in activities that made life enjoyable, then the importance of evaluating what makes our animals’ lives enjoyable cannot be overstated. Proponents of “natural death” in the veterinary hospice movement often state that just because animals can’t do what they used to, it doesn’t necessarily mean that they would choose to die. “Natural death” supporters point to many examples of disabled but otherwise happy people who are living rich & fulfilling lives, as rationale for not ending animals’ lives if they still have a “will to live.” But the truth is, we really don’t know about animals. I suspect that there is individual variation here, just as there is for people.
The fact that people overwhelmingly cite a “decreasing ability to participate in activities that made life enjoyable” as their reason for exercising their right to assistance in dying, I think, serves as even MORE compelling evidence that diminished daily activities for animals is a critical consideration in evaluating their overall quality of life – perhaps even more than physical pain. Additionally, since we are not typically evaluating our pets’ “will to live” at other times in their lives, I find it a bit artificial to introduce this as they are dying. What is to be made of dog breeds so rife with medical abnormalities that their daily living is negatively impacted? How about animals in long-term confinement in shelters? Would those dogs “want to live” if given the choice? What about captive marine mammals, or migratory species confined to zoo habitats. How about a veal calf, battery caged hen, or sow in a farrowing crate? Would they choose to live if given the choice? There are, of course, no answers to these questions. Just as we will continue to breed, confine, eat and interact with animals in all facets of society, we will be unable to really know WHAT they want. We can only do our best to speak for them and help them conform to the 5 freedoms. Or as Jessica Pierce aptly suggests, 6. (The 6th being the freedom to have a dignified & peaceful death.)
Loss of dignity for animals is a value judgment by people, and people who know the animal patient best can assess this. Loss of mobility, continence, and cognitive function are probably the categories of clinical signs that impact our animals’ dignity the most.
While people are not citing fear of pain or inadequate pain relief as a reason to utilize the DWDA, it is interesting to observe that the #1 cited reason for euthanasia of our veterinary patients (in my, and many others’ experience) is pain that cannot be controlled. I speak to a handful of clients each week, virtually all of whom express that they can’t watch their animals suffer anymore and they just “don’t think it’s fair” to let them continue. What is going on here? Are these patients truly suffering? Yes, often animals are not on ANY pain medications when I meet them. Some have tried medications which haven’t made a perceptible difference to caregivers, so they stopped giving them. Some have had undesirable side effects on medications and the meds were stopped – often without any consultation with a veterinarian about alternative strategies. All too often, patients are “on pain medication” but when I look at the dosages they are pitifully low. People feel that they have been doing everything they can, when in reality they are giving doses of medications that wouldn’t begin to touch the animal’s pain. By the time the clients call me, they are often so prepared for euthanasia because of the “pain & suffering” of their pet that offering an alternative would be worse for their bereavement process. These situations are tragic, and all too common. Sometimes people are hungry for an alternative, and I come up with one and we then work together to see if it is a reasonable plan for them. Euthanasia is always on the table if our efforts fail.
I would argue, however, that even with superb multi-modal pain management, sometimes we can not adequately control pain in our animal patients. We have to accept this fact. Sometimes the dosing schedule that would be required for effective pain management is incompatible with the work schedule of our clients. Oftentimes, this is the case. We may have the same toolbox available for our animal patients as our MD counterparts, but the logistics of their use for animals are vastly different. Round the clock dosing of ANYTHING for our pets is usually impossible.
Death with Dignity legislation can be hugely informative to the veterinary profession as we embrace hospice and palliative care for our animal patients. It may be argued that similarities, rather than discrepancies, will continue to evolve in terms of what is “allowable” for animals and people in death and dying. Consideration of what constitutes a “good death” as well as acceptable quality of life for all species will continue to be essential for this discourse. Some veterinary hospice care providers would cite companion animals’ “will to live” as reason to withhold euthanasia even in the face of physical and psychological suffering. Closer examination of Death With Dignity legislation serves to caution against such a conclusion. Consideration of life’s enjoyment, dignity, and pain management should be primary for animal patients. Quality of living must take precedence over mode of dying.
by Katherine Goldberg, DVM