Death and the road to 'One Health'
Jessica Vogelsang, DVM
Over and over again, we veterinarians hear it from our clients: Our pets die better than we do. In many cases, theyre right.
My time in veterinary medicine has taught me that our ingrained fear of death can be overcome, that comfort with the transition can be taught, and that experience and steady support can make all the difference during a time of grief. (Shutterstock.com)I think we forget as a profession that we're unicorns when it comes to being comfortable with death. We're stuck in a corner with the coroners as we make the morbid jokes and view death with an ease the rest of Western society lacks. Even MDs don't get it-in their world, euthanasia is a grave sin, not a moral obligation, even when one is suffering a terminal illness.
Like many aspiring veterinarians, I thought euthanasia would be the hardest part of my job. It wasn't-not by a long shot. I hated surgery, I was ambivalent about endocrinology, but I really excelled at death. Not in the sense that it hastened a pet's demise, but that when it was time, I could help pet owners manage the complicated emotional landscape that accompanies the decision to euthanize. Veterinary hospice and home euthanasia barely existed when I graduated, but over the years they developed into an area of interest and specialization. And I was all on board.
My time in the field has taught me that our ingrained fear of death can be overcome, that comfort with the transition can be taught, and that experience and steady support can make all the difference during a time of grief. Why then, I reasoned, don't we give ourselves credit for our role in helping people prepare for other deaths in their lives? If more people were actively involved in end-of-life decision making for their pets, perhaps they would be more inclined to talk about death and dying with their human family members when the time came.
Our pets die better than we do
“Futile care”-that scene in the ICU where physicians crack the chest of a 90-year-old in multi-organ failure who just arrested-plays out every day across the United States. The older you get, the more likely you are to die in a hospital. According to the Centers for Disease Control and Prevention, 73 percent of people over the age of 65 die as inpatients.
I took to heart Ken Murray's seminal 2011 essay “How doctors die,” which describes physicians who get bad prognoses and never set foot in a hospital again, instead maximizing their time out in the world with loved ones.
I didn't want to be one of the 73 percent. It sounded like a horrible way to go. Over and over again, we hear it from our clients: Our pets die better than we do. In many cases, they're right.
I decided I wanted to share this message. Such was my fervor that I started speaking publicly about the lessons we can take from our pets' deaths, presenting to other veterinarians as well as the general public. I was on fire! I was the Death Fairy, come to teach children that death is something we face, not something we stuff into an ICU and hide behind a hospital room curtain. I was lit from within by a persistent certainty in my bones that I would affect someone out there who desperately needed to hear those words.
As is so often the case in life, I was right in all the wrong ways.
‘I don't want to go back to the hospital ever again'
My mother, who dutifully attended all my talks and clapped the loudest at all of them, had been experiencing what we laughed off as “senior moments” for several months. Two months into my Death Fairy World Tour, she was diagnosed with a grade IV glioblastoma-the same kind of tumor that had taken the life of Brittany Maynard the year before.
Mom was an RN, and I was a hospice veterinarian. The neurology physician assistant didn't screw around as she wheeled in the machine to show us the results of her CT: It was a big bad tumor, too big and deep to do anything about surgically.
“Oh my God,” Mom whispered. “I'm going to die.”
As everyone around her held her and told her it was going to be OK, I stood silent-because she was right, of course. I sat in the room while the radiation oncologist told her about the six-week protocol for radiation, and as the other oncologist laid out the chemotherapy protocol. She was so stressed at the idea that she had a five-minute seizure in the car on the way home from the hospital. When I called the doctor from the side of the freeway to ask if we should come back to the hospital, she said, “Why would you? That's just the way it's going to be from now on.”
So we sat in a parking lot as she thrashed and I fumed.
Death and other client kindnesses
Is an outside hospice veterinarian the answer to a busy general practitioner? What should you focus on in client communication at the end of a pet's life. Dive into those topics in this companion piece by Dr. Vogelsang.
Every time we went back to the hospital for followups, she receded into herself a little more. It took several days before it occurred to anyone-in this case, my sister-to ask my mother what she wanted out of all of this.
“I don't want to go back to the hospital ever again,” she said. So we didn't.
I fielded calls from the doctors to explain why we were withdrawing from their care, receiving reactions that ranged from incredulous to understanding. I needed permission from her neurosurgeon to get a hospice consultation.
We stood on that muddy, pothole-filled road of a cancer diagnosis with a big beautiful gate off to the side that no one thought to point out to us until we asked, and then there it was. So we left the road.
The truth is, you need to fight like hell to get off the merry-go-round of aggressive care, and I completely understand why so few people do. It's unrealistic expectations on the part of patients, their families and the doctors; it's our culture; it's the need to win; it's the fact that many people don't even know that getting off is an option until it's too late. When we're overwhelmed with life-or-death diagnoses, we go along with whoever's in charge because it's the path of least resistance. We forget that we're the ones in charge.
When I told the oncology resident we didn't want to do chemo, he was angry.
“You could double her lifespan!” he said.
“From what to what?” I asked. “Be honest.”
His eyes flicked over to Mom and then back to me. He didn't want to say it out loud.
“With treatment, six to eight months,” he conceded. “What is it you do again?”
“I'm a hospice veterinarian,” I replied.
“Oh,” he said.
That was the last thing he said to me. When we left the hospital that day, we never went back, and my mother never had another seizure.
When people said, 'I wish we could do this for people,' tears would well in my eyes
While my mother was in hospice, I continued to see hospice and euthanasia appointments for work. When people said, “I wish we could do this for people,” tears would well in my eyes. I was petrified of what might happen to my mother in the end stages of her cancer, and I wondered what I would do if she felt her medications weren't managing her symptoms. To my relief, she was very well-managed. I understand this is not the case for all cancer patients. I still wish that, had she needed it, the choice to end things sooner would have been available. Even though we didn't need it, the fear of helplessness is a terrible feeling.
Several months after Mom's death, California joined Colorado, Oregon, Vermont and Washington in enacting a Death With Dignity Act. I attended a local meeting of Compassion & Choices, an advocacy group for patients wanting choice in end-of-life care. I was surrounded by doctors who were seen as rebels and traitors to the profession for thinking it was ethical to allow terminally ill patients to hasten their own deaths. Euthanasia is a dirty word furtively whispered, hence the verbiage “death with dignity” versus “assisted suicide.”
The doctors were fascinated by my job and by the idea that veterinarians on the whole consider the relief of suffering a moral obligation, that euthanasia is the norm and not the exception. In veterinary medicine, “natural death” is the dirty word furtively whispered, and clients who wish for it often report feeling pressured into choosing euthanasia before they feel ready.
With MDs and DVMs at such polar opposite ends of the spectrum in terms of how we view both death and the doctor's role in it, is it any wonder that patients struggle so hard with these decisions? If physicians tell families they're equipped to manage a dying patient's symptoms adequately-if that's the human standard of care-then we have to be understanding when those people come to us requesting the same for their pets. As we finally open conversations and bridge the gap, doctors are warming to the idea of death with dignity just as veterinarians are starting to aggressively manage terminal patients with palliative care. We're both walking toward the middle while realizing that every death is different. Truly, it's One Health at its finest.
In my mother's case, she lived two months past her diagnosis. A far cry short of the six to eight she might have had otherwise, but I would choose the short and pleasant walk over the long and painful one any day.
She had two beautiful, quiet, loving months, with my children on her bed every day and the Harry Potter films on replay in the background. With milkshakes instead of hospital pudding and a golden retriever to sleep on her feet.
I never would have been able to fight for what she wanted had I not been doing this very same thing already for dogs and cats. So, yes, when I say our work makes a difference, I mean it. Because I lived it.
I mourn the loss of my mother every day, but I've never once regretted the way she died: on her own terms, surrounded by family. How many people get to say that?
We veterinarians still have work to do.
Jessica Vogelsang, DVM, is a certified veterinary journalist, a regular contributing writer for a number of publications, author of the memoir All Dogs Go to Kevin, and creator of the popular blog Pawcurious.com.