Animal Hospice 101

Because of my book The Last Walk and my work with The International Association for Animal Hospice and Palliative Care, I frequently get asked to describe animal hospice. I’ll usually answer with some general statements like, “it is a philosophy of care, where you focus attention on managing symptoms and providing comfort care, rather than trying to cure disease; it means trying to maximize quality of life, without necessarily trying to extend life; it means caring for the whole family as a unit, not just the pet in isolation." While these statements do describe animal hospice care, people will often persist and say, “But what does hospice care actually look like, in the day to day world?” To help answer this more specific question, I’m going to describe for you what an actual hospice visit looked like for me and my beloved dog Maya, because it is fresh in my mind. Just last week we had an initial consult with a hospice veterinarian.

Source: Jessica Pierce

As some of my regular readers will know, old age is finally catching up with my sweet pointer mix Maya. (She will be turning 15 tomorrow. Happy birthday, Maya!) Several months ago, she suffered from an acute episode of back pain and temporarily lost the use of her hind legs, which our veterinarian thought was a ruptured disc, a spinal embolism, or perhaps a tumor impinging on her spinal column. Although the crisis passed, Maya never regained full use of her back end and now walks with a wobble and a slight tilt to one side. She has arthritis in both front paws, has mostly lost her sight, and can’t hear much of anything. She has a slow-growing tumor on her jaw as well as a more ominous, fast-growing mammary tumor.

Until just a few weeks ago, Maya’s arthritic pain was well controlled with a combination of medications (including gabapentin, meloxicam, and CBD tincture), and her quality of life was definitely good. She seemed happy and engaged. Last week, though, she began refusing food, was less eager to walk, and seemed to suffer periods of anxiety or agitation where she would pace the house (usually in the middle of the night). Her challenges seemed to be adding up, and I felt less confident about her quality of life. I decided it was time to call in a veterinarian with special training and knowledge in palliative care and hospice.

Here are the reasons I decided to call the hospice vet:

• I wanted to know whether there was more we could be doing to keep Maya comfortable—because there almost always is.
• I wanted the unique skills and perspective of a veterinarian who specializes in providing end of life care.
• I wanted to add to Maya’s care team, because my feeling is the “more the merrier.” Maya now has her regular mobile vet, who has been following her medically for about 8 years and knows her well. The mobile vet also happens to be trained in acupuncture, which we’ve added (with excellent results) into Maya’s care regimen. Maya also sometimes sees a local veterinarian at the town clinic, if she has something that needs attention right away (e.g., we went there recently when Maya had an eye infection).
• I wanted to establish a relationship with a veterinarian who could provide euthanasia in our home, if we get to a point at which Maya no longer has an acceptable quality of life and we choose to hasten her death. (One of the common misperceptions about animal hospice is that always involves “natural death” for an animal, and never includes euthanasia. This is simply not true. On the flip side, some mobile euthanasia services will falsely advertise themselves as “hospice providers,” even though they only service they provide is euthanasia, with no palliative or supportive care prior as an animal declines.)
• I wanted to provide Maya care within our home. The expectation is that Maya will never again have to go to a clinic or hospital.

Here is what the vet did while she was here:

Stages of Care. She talked to us about stages of care and what to expect. We are in the “palliative care” phase, where Maya’s trajectory is unknown. At some point, we will move into early and then advanced hospice care, if Maya is expected to die within several days or weeks. (Of course, it is impossible to know what stage we are in… Maya could die sooner than we expect, or she could live for many months.) As Maya advances, her care needs will intensify.

Family support. She talked to us about who belongs to Maya’s caregiving village, and asked us how we were coping with the emotional and physical challenges of caring for an animal near the end of life. (Were we sleeping enough? Feeling okay about what was happening? Having any points of disagreement over the plan of care, etc.?)

Expectations for Maya’s life. She helped us articulate what it is that Maya most values and how we can best support her in maintaining activities and experiences that are important to her

Expectations and goals for death. She asked us to articulate what matters most to us, as we think about Maya’s death. (Do we have a strong commitment to natural death, or are we open to euthanasia? How would we feel if Maya passed away in her sleep?)

Wishes regarding aftercare. She asked us to think about what we would like to happen after death, with Maya’s body. (Would we like the veterinarian to take Maya’s body with her and arrange for cremation? Do we want water-based or traditional fire-based private, semi-private or communal? Would we like remains returned to us?

Maya’s physical needs. She educated us on identifying signs of discomfort and distress; gave us some handouts on behavioral indicators of pain; talked about what loss of appetite can mean (and that it isn’t always a sign of poor quality of life); reassured us that Maya sleeping all the time was okay (it means she is comfortable).

Maya’s emotional needs. We talked about whether Maya was still able to interact with us and our other dog? Were there any barriers to her being able to engage socially? Was she able to get out into the world? The vet encouraged us to keep taking Maya out for walks, even if the walks were mostly just a ride in the car over to the park so Maya can stand in the grass and sniff. We talked about trying to keep things interesting with treats, Kongs, etc. She cautioned us that our other dog, Bella, might show some new patterns of interaction with Maya, and that we should especially watch for signs of aggression.

Source: Jessica Pierce

Medications. This was already largely in place for Maya, but the hospice vet made a few alterations and additions. She upped the dosing of pain meds; provided an anti-nausea (just in case); and explained the range of options available to address pain, nausea, agitation, loss of appetite and other symptoms.

Nutritional support. She said we should try to keep things interesting for Maya and should feed her whatever she is willing to eat, as long as it doesn’t cause GI distress and diarrhea.

Daily monitoring. She left us with a daily health log and encouraged us to use it to track Maya’s progression. We might record things like appetite, drinking, defecation, urination, interest in favorites activities (play, park, etc.), pain, medications, and sleep patterns.

Environmental modifications. She walked around the house with us to assess the environment from Maya’s point of view, to see if there were additional physical modifications that might benefit Maya. We already have nearly all the wood floors covered with carpets, runners, yoga mats, and anything else we could find that would provide traction. But the vet identified two remaining slippery spots that needed attention, one right in front of Maya’s dog door and in front of her favorite dog bed. She looked to make sure that Maya would be able to comfortably access the backyard and suggested that we add an additional step or ramp outside the dog door, where the drop is likely to become challenging. She made sure that we were feeding Maya somewhere with good traction for her feet, and that she had water available and, again, in a place where Maya wouldn’t feel slippery. She suggested keeping the house a bit cooler since elderly dogs have trouble regulating their body heat and often feel too hot. (She thought some of Maya’s nighttime restlessness might be from being overheated.)

Maya's new ramp.

Source: Jessica Pierce

Comfort Kit. The hospice vet left us with an emergency “comfort kit”—a syringe filled with a combination of several drugs which will provide heavy sedation if Maya ever gets into a crisis and becomes extremely uncomfortable. The comfort kit can bridge the time it would take for the vet to reach our house or for us to drive Maya to an emergency clinic.

Finally, here is what it cost:

The initial hospice consultation—which lasted a full two hours—was $250. Each additional recheck visit will probably be between $100 and $150. For now, these might occur every month. But as Maya’s health declines, more frequent visits will become necessary. Of course, these visits are just a fraction of the larger cost of Maya’s care. We probably spend about $300 a month on meds; another $250 on acupuncture; $500 every six months for blood work; and then add in the cost of acute and emergency visits. It is impossible to put a number on how much end of life care will cost for a given animal, because it depends on what the animal needs, how long the animal lives, what interventions the vet recommends and the family chooses to pursue, etc. Providing good care for an aging or ill animal is costly, but hospice veterinarians are often quite skilled at balancing the medical needs of an animal against the financial limitations of the family and finding a comfortable path forward.

Although the hospice visit was difficult and sad, I felt good after the vet left our house. We have a solid plan of care in place, have thought carefully about what Maya needs now and have anticipated what Maya may need in the future. And, painful as it is, I have looked Maya’s mortality in the eye and reckoned with its reality. I will be walking these last miles with Maya with a greater sense of peace.