Hospice Part 2: The Six Symptoms
Welcome to Part 2 of my discussion on pet hospice! In Part 1 we discussed what hospice means — what it is and is not. In this segment we are really going dig in and get serious. This is where we start learning about the concrete, physical things you can do to provide for your pet’s needs in his or her final days and weeks. Be warned it's a long post, but we're packing a lot in. Hopefully you'll bear with me.
Before we start, though, I would like to set some expectations. My goal with this series is to help you understand the hospice process, give you an idea of the active role you can take, and emphasize the importance of partnering with your vet throughout the period of hospice care. Each of the topics touched on below and in the rest of the series could have a whole series of its own (and some will!). You may not come away with a list of things to do in every area, but you will hopefully have a better understanding of the underlying issues and be able to better apply the advice you get from your vet or in future posts.
In my mind, with my new-found appreciation of what exactly hospice care means, hospice begins at that moment when you decide, “Enough! My pet isn't going to get well. No more tests. No more diagnostics. I just want him/ her to be comfortable. I want to enjoy the time we have.” So what can hospice offer you and your pet when you find yourself in this (admittedly miserable) spot?
Let's start by breaking down some of the basic and most common symptoms to be addressed by pets in the end stages of disease. Then we will discuss each area in more detail. The symptoms we will be discussing are: pain, mobility, hydration, appetite, hygiene, and happiness.
Symptom 1: Pain
This is probably the most fundamental concern most of us have for our pets in the end stages of disease: Is he/she in pain? With that in mind, it is often difficult to tell! Our pets are stoic; they often don't give us outward signs of pain (what those signs might be when they DO exist, how pain works, and things you can do about them will definitely be an upcoming series). Often rather than showing obvious pain, a pet will withdraw and become less active—this is especially true of cats. We then must extrapolate from human diseases—if this would be a painful condition for a person, we can assume it likely would be for a pet as well.
It helps to group pain into three different types:
Physical pain: This is the typical pain we normally think of. Things like arthritis, fractures, or bone tumors would fall into this category.
Malaise/ pain of disease: While we generally don't think of things such as kidney disease or liver disease as classically painful, consider how you feel when you have a bad case of the flu. You are miserable. You may not be in pain, per se, but the malaise creates a type of suffering which is real.
Anxiety: In an emergency room, generally if you ask a patient who is suffering from a respiratory or cardiac event what their level of pain is, they will answer a 9 or 10. These are highly painful conditions in part due to the anxiety which results from being unable to breathe. This is true for veterinary patients as well; anxiety creates significant suffering and needs to be treated.
The point here is that pain may not always look the way we expect it to, and may not be obvious. However, you can generally see it if you know what to look for. Once pain is identified, it can be treated. There are many effective management strategies available for pets, including for those with serious underlying health conditions. Effective pain control is one of the most critical pieces of managing hospice care effectively. Proper consultation and partnership with your vet can help determine a path to take appropriate to the type of pain, which may include drugs, but also alternative and complementary therapies such as acupuncture, massage, or chiropractic care.
Symptom 2: Mobility
Sarcopenia. It's a big word, but kind of a nifty one (I think anyway). Sarcopenia is age-related loss of muscle mass. It's why senior dogs and cats (and people) become frail and weak even in the absence of other diseases. Regardless of activity levels and overall health, over time, we all start losing muscle mass.
Without getting into too much physiology, skeletal muscle fibers can be divided into two primary types: fast twitch fibers and slow twitch fibers. Fast twitch fibers are great for a sprint: they get you up and moving quickly, but they also run out of energy quickly. Slow twitch muscles don’t move as quickly, but they can store energy much more effectively—so they can keep you going for a marathon.
What does twitching have to do with any of this?? Well, the whole point is this: fast twitch fibers are lost more quickly and in higher numbers than slow twitch fibers in sarcopenia. This explains why so many elderly dogs are unable to get up without help, but can often get around fairly well once they are up.
So what can we do to help improve the mobility of a pet in the end stages of disease? Unfortunately, once sarcopenia sets in, we can't reverse it. What we can do is help them get around. Rugs and mats on hard floors can improve their footing significantly (hardwood floors look fantastic and are easy for us to care for, but can be very difficult for a pet struggling with mobility issues). Yoga mats work great for this! There are also booties available to improve traction, and slings which can make it easier to help you assist your pet with walking.
Symptoms 3 & 4: Hydration and Appetite
I will discuss these two areas together because they really are closely related when discussing hospice. At this point, however, I feel it is important to reiterate exactly who the patient is that we are talking about: this is the patient that we have accepted is dying. It is NOT a patient with a treatable disease or a client who is still looking to “try one more thing”. We are talking about a situation in which the client has accepted that the pet is in his or her final days or weeks. Maybe the family needs a bit more time to say goodbye. Maybe they want to spend every moment with their pet that they possibly can. This is a hospice patient. The discussion of managing eating and drinking would be entirely different for a patient in any other situation.
Okay. Now that we are all on the same page with that, appetite is a huge indicator of well-being for many pet owners. As long as Fluffy is eating, things are ok. So if Fluffy stops eating, we get scared! With hospice patients, within certain limits, in my opinion, all rules go down the drain. We really don't care if Fluffy gets a balanced diet. Not to be indelicate, but long-term nutrition really isn't a concern at this point. We don't want to make Fluffy sick, but if Fluffy would like to eat chicken or spaghetti, I say go for it!
At some point, it is very likely that a pet in the end stages of life may stop eating and drinking entirely. Sometimes an appetite stimulant can help for a while, but sometimes even that won't help any more. There is a common phrase in human hospice care—I remember it from when my father was in hospice care—and it is true for pets as well. The saying is this: “Food and water are for the living. The body will not take in nutrition for a future it knows it does not have.” Ceasing to eat and drink is part of the body’s way of letting go, and Fluffy telling you it's time to consult again with your hospice vet.
Symptom 5: Hygiene
Hygiene can sometimes be a real challenge for these patients. Urinary and fecal incontinence is common. Pair that with limited mobility, and skin infections, pressure sores, hair mats can all become issues. Accidents in the house can also put strain on the human care takers and relationships between family members.
Regular brushing will help stimulate the skin, prevent mats, and help find areas of irritation before they become more serious issues. Clipping hair away from problem areas, baby powder, and baby cream can also help protect the skin. Baby mattresses, water proof mattress pads, and “puppy pads” or “chux” pads can be valuable in keeping floors and bedding clean. It's not vanity in the same sense it is for us, but everybody feels better when they're clean. And the grooming assistance can be a great bonding experience as well.
Symptom 6: Happiness
Next to pain, happiness is probably the thing which most concerns pet parents when facing end of life decisions with their pet: Is my pet still happy?
There are some things to ask when considering the happiness of your pet. The first (and probably most obvious) is to consider the things your pet most loves and if he or she is still able to enjoy them. Less obvious is the things your pet hates. Perhaps your dog really hates when the UPS man comes. When the day comes when she no longer cares when that big brown van pulls up, you know she has become apathetic about her life!
So what can you do to improve your pet’s happiness once you begin hospice care? There are lots of things that you can do to cater to your pet. Here are a few ideas to get you started:
Massage: Massage is great not only to help your pet with achy joints and muscles. It also will release “feel good” endorphins and creates great bonding time between you and your pet.
Modified play: Your pet isn't able to play like he used to, but he can still do something! Try rolling a ball a few inches across the floor to him or hiding treats in his blankets for a game of “hide and seek”. Toned down versions of his favorite games can be fun for both of you.
Get outside: Long walks like you used to enjoy may be a thing of the past, but taking your dog for a ride in a wagon may be just the thing to let her reconnect with the neighborhood. Did your kitty love the outdoors? Just spending some time sitting together on the lawn may cheer both of you up!
Whatever works best for you and your pet, each member of the family should make a point of spending some quality time with your pet every day. After all: that's really what hospice is for: time to be together to say goodbye.
Hopefully this has given some helpful suggestions for managing the physical and mental well-being of your pet in the final stages of his or her life. Next time we will talk about the other half of the equation: you! The “hospice movement” has taken off not just because it’s good for pets. It’s good for their people, too. In Part 3 we will talk about how hospice helps you get through the final days, weeks, or months with your pet.
Until then, Peace out, yo!! <3