Guiding Clients Through End-of-Life Care

As Serissa, my 13-year-old Samoyed, neared the end of her life, I promised her that her quality of life would remain good, she would not suffer, her end would be peaceful, and she would not die alone. These promises sound easy and are what many would want for their own pet, but with the exception of not dying alone, they are highly subjective.

What is a good quality of life? What does suffering mean to me and what did it mean to Serissa? What qualifies as a peaceful ending? 

Veterinarians are constantly asked, When is it time? Too often owners are told, You will know or They will give you a look. The problem is that owners do not always know and pets will not always give a specific look. Even trained veterinary professionals find it difficult to know when the time has come, so how can families be expected to know, especially when they are also dealing with anticipatory grief ? They rely on the veterinary team to guide them through the decision process. (See Resources.)

Beginning the Discussion

When discussing end-of-life options, the first factors I consider are the disease itself, its signs, and its presentation during the end stages. Clear benchmarks help clients understand what to expect and begin the discussion on how equipped (eg, emotionally, physically, financially) they feel to manage their pet’s quality of life. Are they able to continue with the disease stressors, the anticipatory grief, the guilt, and the judgments from others? Are they prepared to say goodbye?

Or are they managing everything like a well-oiled machine ? Do they have a wonderful support system? They may never be ready to say goodbye, but are they prepared to release their pet from his or her struggles?

Three Stages

Breaking the end of life into these 3 stages often helps the decision process.

Stage 1

Things Are Good The pet has a good quality of life, his or her symptoms are well managed, and the family can adequately handle the pet’s care.

Stage 2

Stable but Subjective Most clients and patients fit into this longest stage, during which most clients will seek advice. The pet has limited time but everything is manageable. (Palliative care and euthanasia are options.)

Stage 3

Euthanasia Is the Best or Only Option Try to prevent a pet from entering this stage whenever possible. At this point, the pet’s welfare is jeopardized, he or she is suffering, and the family may not be able to properly care for the pet. Aim to guide families well before this point.

When a pet is given a terminal diagnosis or advanced aging is affecting quality of life, I place the pet in the Stable but Subjective stage. From that moment, I consider euthanasia an acceptable option, and I let families know I will support their decision to say goodbye at any point.

Final Thoughts

The Stable but Subjective stage is ambiguous, and every day I help clients make the best decisions given their unique circumstances. I believe it is acceptable to allow a client to say goodbye sooner rather than later, or to wait longer, so long as the boundaries are not pushed too hard and the opportunity for a peaceful passing is not put at risk. Defining a peaceful passing is also a matter of debate.

For Serissa and me, a peaceful passing meant Serissa would never know what suffering was, she would be beautifully sedated and dreaming of her favorite things, I would hold her paw and tell her how thankful I was to have her in my life, and she would gently fall asleep forever. (See Figure 1.) It was hard, but I kept my promise. Some may think I did it too soon, but I believe a week too soon is better than a day too late. I preferred to suffer with my sadness than allow Serissa to suffer.

Figure 1

 Dr. Mary Gardner and Serissa. Photo courtesy of Mary Gardner, DVM

Conclusion

Managing an end-of-life case is not easy and requires more skill than I ever imagined. Exploring the family’s needs, concerns, and wishes and ensuring the pet is being cared for properly are most important. This sounds simple, but end-of-life care is not black and white—like most veterinary medicine.

Case Report

Dixie, a 12-year-old mixed-breed golden retriever, had been diagnosed with osteosarcoma. Her euthanasia was scheduled to coincide with the depletion of her pain medication.

When I arrived at Dixie’s home, a smiling dog bounded toward my car. I could see the swelling on her leg, but I could also see she was happy. I rubbed her head and said, “Hey, pretty girl.” Then I looked at her crying owner, who said in a weak voice, “Yes, that is Dixie. It is difficult for us to make this decision because she is so happy, but will you still euthanize her today?”

I smiled warmly and said compassionately, “Yes, I will.” 

I know some veterinarians would have adamantly refused, and I fully respect that. In this case, 2 veterinarians had previously refused to euthanize Dixie. I also would have been just as comfortable if the owners had decided on more hospice and palliative care, but I knew they were emotionally ready to say goodbye.

Figure 2

 Saying goodbye to Dixie. Photo courtesy of Mary Gardner, DVM

We went inside. Dixie plopped down on her bed and was handfed about 2 lb of turkey breast. I said to the grieving family, “Unfortunately, Dixie has a terminal disease that will take away her happiness at some point. It may be this week, it may not be for a few months, but it will happen. What you are doing today is preventing Dixie from ever suffering, and I fully support you in that decision.”

Those words gave them such comfort, and I could see the guilt finally releasing from their hearts. Would I do the same if Dixie were mine? I cannot say. Maybe I would have waited a bit longer, but maybe not.