Stand with clients on the path to 'The End'
Sharon DeNayer is a Firstline Editorial Advisory Board member and the practice manager at Windsor Veterinary Clinic P.C. in Windsor, Colo.
For us, veterinary medicine is a form of friendship, and caring for hospice and palliative-care patients is a team activity that asks for attention, care and skill from every single team member in our hospitals.
“A good man will take care of his horses and dogs, not only while they are young, but when they are old and past service.”
- Plutarch, c. 100 CE
In summer 1992, a young kitten was wandering around a parking lot in search of food, water and attention. A family rescued him to keep him from being hit by a car and brought him to us. When we couldn't locate his owner and no one was interested in adopting him, he became our clinic cat, Rooney. He lived with us until we euthanized him a few weeks before his 22nd birthday in 2014. He was a friendly soul who endeared himself to many.
Up until the day he died, Rooney continued to be a congenial host to all of our clients. (Photo courtesy of author)
We watched him grow from a frisky kitten to a curious teenager to a mellow adult to a senior and, finally, to a geriatric cat. Rooney dealt with chronic kidney disease for many years, but it progressed to a point that he became a palliative-care patient the last two years of his life. Because he lived at the clinic, it was easier for our healthcare time to give him subcutaneous fluids when he needed them. They watched his kidney disease progress and managed the fluids accordingly. Up until the day he died, Rooney continued to be a congenial host to all of our clients. After he died, it was difficult for us to have clients ask each day, “Where's Rooney?” Although that was painful, it also gave us the opportunity to tell Rooney's story and honor his life.
How we practice medicine as a form of friendship
Leon Bernard, a French physician in the 1800s, said, “Medicine should be practiced as a form of friendship.” Dr. Robin Downing and I chose to use this quote as the foundation of our practice culture.
This began 31 years ago with our Housecalls Unlimited mobile practice in Wyoming in 1986. With that foundation, building relationships with clients and patients was paramount to our work. In our house call practice, it was easy to work with older patients in places they were more comfortable. This set the stage for end-of-life care down the road, including what is now referred to as "hospice and palliative care." (But no one was calling it that back then.) Because you can't practice friendship if you don't treat others as individuals, we worked hard to understand our clients' individual relationships with their pets to offer services that fit their needs.
In 1991, we purchased Windsor Veterinary Clinic in Colorado, changing from a mobile to a stationary practice, although we occasionally made house calls after hours. Since we've been here more than 25 years, we've seen multiple generations of some families and have truly provided womb-to-tomb care for thousands of pets. Years ago we realized how important bereavement services were to our clients in practicing medicine as a form of friendship.
What NOT to say when a pet dies
“I know just how you feel.”
“Time heals all wounds.”
“You must get on with your life.”
“It was God's will.”
“God never gives us more than we can bear.”
“Everything happens for a reason.”
“You're holding up so well.”
“Think of all you still have to be thankful for.”
“You'll get over it.”
“Just be happy he's out of his pain.”
“At least she's not suffering.”
“Now you have an angel in heaven.”
“Aren't you over it yet?”
“You can always get another.”
“It's a blessing in disguise.”
When we developed The Downing Center for Animal Pain Management as a referral practice in 2006, we knew most of our patients would be closer to the end of their lives than the beginning, so we expanded our knowledge and skills in bereavement.
Hospice is a philosophy, not a place. Hospice and palliative care can take place in the home or in a veterinary clinic. Hospice care centers on the comfort needs of the patient, the wishes of the family caregivers and the skills of the healthcare team.
How we find hospice-friendly team members
As we fill vacant or additional positions on our healthcare teams, we look for specific skills, interests and attitudes. We require a two-day working interview. Once hired, all of our team members are cross-trained so they understand the importance of each position and can fill in as needed. That's especially important in hospice and palliative care, as we require a case manager for each patient. That person may hold any position on the healthcare team and serves as the liaison between the client and the hospital. We highly value the team members who are skilled in relationship building, communication, teamwork and teaching. Here's why they're necessary for the work we do, especially palliative and hospice care:
Relationship building. It's our job to help our clients deal compassionately with their pets' problems. That trust in us starts during their first visit to our hospital-whether the pet is a youngster, adult or senior. We must show respect for the client and the patient. We want the client and the patient to look forward to their visits and to be comfortable when they're here.
Communication skills. Listening is the most important communication skill. We ask open-ended questions to clarify and expand our understanding. We speak in laymen's terms and involve all family members present in the conversation (and that includes children).
For kids' sake, we don't 'put pets to sleep'
Because we serve many clients of all ages, we're careful with our words. For instance, we avoid the phrase “put to sleep.” (If a child needs surgery later, he or she may be shown the room by a doctor or nurse where they'll be “put to sleep.”) Before we perform euthanasia, we never ask, “Are you ready?” No one is ever ready for euthanasia. We ask, “May I proceed?”
Teamwork. Everyone on the team is cross-trained to be able to assist-or fill in-for others. We all speak with one voice to prevent mixed messages to our clients. We know each other's strengths. When selecting and delegating responsibilities, our clients and patients benefit from the strongest skills of all of our healthcare team.
Teaching skills. In working with palliative-care patients, the team must educate clients about illnesses and diseases. We often have to teach new skills-like wound care and how to administer subcutaneous fluids-to clients with hospice and palliative-care pets. We want those pet owners to feel comfortable and competent in their caregiving skills. The team needs to follow up regularly to see how these treatments are going as well as to find or develop client handouts that will enhance their caregiving skills.
(Editor's note: Check out this client handout from DeNayer on helping clients who've lost their best buddy. For more team resources, here's a client communication script on how to discuss the cost of euthanasia and 13 gentle gestures to help grieving clients.)
Anticipatory grief begins when the veterinarian diagnoses a life-limiting illness or disease. It's our responsibility to provide support throughout the bereavement process. (Shutterstock.com)
What to say when a pet dies
“I'm sorry for your loss.”
“I heard about your loss. I don't know what to say.”
“I've been thinking of you.”
“I'm here for you if you need to talk.”
“I remember the story you told me about ... ”
“I've been thinking about you and your family.”
“You're very important to me.”
“What can I do to help you?”
“You're in my thoughts and prayers.”
Anticipatory grief begins when the veterinarian diagnoses a life-limiting illness or disease. It's our responsibility to provide support throughout the bereavement process. This truly demands our most compassionate care. The support should also carry on well past the death of the pet. The website veterinarywisdom.com, from the folks who make ClayPaws, also has many excellent handouts for veterinary professionals and pet owners.
How we make hospice and palliative care a team activity
The entire healthcare team at any veterinary hospital should be involved with the hospice and palliative care services offered. That's how we do it, starting with the veterinarian.
The veterinarian 1) develops the individualized medical care plan for the patient and revises it as needed, 2) trains the team in medical procedures needed for hospice and palliative care, and 3) carries out the euthanasia procedure.
Then the veterinary nurses and veterinary assistants can carry out medical care under the doctor's direction. Those team members can also train the family caregivers in procedures to be carried out at home.
Each hospice and palliative care patient should have a case manager. The case manager choreographs all of the services offered to these patients and is the liaison between the healthcare team and the family caregivers. These tasks can be carried out by any trained healthcare team member.
Last but not least, your team needs a bereavement companion provides the major bereavement support for family members. This position can be filled by any team member with the proper training. (Read more about that here.)
In our practices, my position as practice manager provides me with the most flexible schedule of anyone on our healthcare team. My training, experience and passion allow me to regularly serve as a case manager and bereavement companion. These are my favorite-as well as the most personally rewarding-parts of my work.
Sharon DeNayer is a Firstline Editorial Advisory Board member and the practice manager at Windsor Veterinary Clinic P.C. in Windsor, Colorado.