- Email: [email protected]
Client Services for Geriatric Pets
Geriatrics and Gerontology
0195--5616/89 $0.00
+
.20
Client Services for Geriatric Pets
Guy Hancock, DVM,* and judy Yates, MAt
The previous articles focused on the physiologic and pathologic processes common in geriatric dogs and cats and the latest knowledge about diagnostic and therapeutic techniques. This article offers practical ideas and insight into the emotional interactions between the veterinarian, the client, and the pet during the medical treatment of a geriatric animal patient.
HUMAN-ANIMAL BONDING AND LIFE CIRCUMSTANCES There is much evidence linking factors such as marital and job status, social network, and other life circumstances to health or illness. 2• 8 There is also evidence that certain groups, by virtue of their social conditions, are predisposed to a greater impact from the grief associated with pet loss. 4• 5 • 10 The following bonding relationships represent examples of situations that may have implications for the veterinarian who is treating a geriatric pet. Families with Children Living at Home The pet in question may be older than the eldest child. This child may have known the pet his or he r entire life and have a very deep bond. 3 The depth of the bond with a pet can vary greatly among the various family members. It is, therefore, very important for all members of the family to take part in the discussions and decisions about medical treatme nts, terminal illness, and whether to euthanize a pet. It is not in the best interest of the veterinarian to decide which family member is best equipped to make a life or death decision regarding the pet. Instead, the veterinarian should ask if the entire family has participated in the decision and advise or encourage that participation. It would be helpful to expand the records that most veterinarians keep on addresses, phone numbers or work place to include information on the family and the human-animal bonding pattern *Chairman, Veterinary Technology Program, St. Petersburg Junior College, Health Education Center, St. Petersburg, Florida tCounty Extension Director, Pinellas County Cooperative Extension Service, IFAS/University of Florida, Largo, Florida Veterinary Clinics of North America: Small Animal Practice- Vol. 19, No. 1, January 1989
187
188
Guy
SANDRA
NAME: RELATION:
HANCOCK AND JUDY YATES
HUSBAND
WIFE
DAUGHTER
PET NAME: (DOG)
(CAT)
(RABBIT)
ARROW SIZE INDICATES STRENGTH OF BOND
D
SINGLE ADULT
PSYCHOSOCIAL STRESSES, DATE OF OCCURRENCE
D
COUPLE WITHOUT CHILDREN
_
LOSS OF PET
D
COUPLE WITH CHILDREN
_
LOSS OF FAMILY _
_
SERIOUS ILLNESS IN HOUSEHOLD _
D
ELDERLY IN HOUSEHOLD
_
DIVORCE/SEPARATION _
_
OTHER_
D
ELDERLY ADULT
NOTES & COMMENTS _ _ _ _ _ _ _ _ _ _ _ _ __
_
_
LOSS OF JOB _
Figure 1. Chart indicating strength of bonds between family members and their pets.
that exists within the family. Figure 1 presents one way to obtain and arrange this information to help the hospital staff anticipate the multitude of bonds present in a household with several pets. One of the veterinary professions's obligations must be to communicate to the decision-makers in the household the importance and implications of these bonds. In many instances, the decision-maker, head of household, or person who brings the pet to the hospital for treatment is the least bonded person and may not realize or understand t~e ;deep feelings of other family members. This person may be motivated mote by economics or by other factors and may not appreciate the consequences of excluding the family from the decision or the actual procedure. This pe rson must be encouraged to understand the negative consequences of trying to "protect" the other members from the decision-making process or the emotion and the potential grief of the situation. Veterinarians must help the decisionmaker or appointed person or "drawer of the short straw" to see the larger picture . The loss of a pe t during childhood may have lifelong effects, especially if the child feels powerless and excluded from events surrounding the animal's death. 4 • 5 • 8 The euthanasia or death of a family pet is not an ordinary, unpleasant task, like emptying the trash. It is a significant life experience that should not be downplayed, belittled, or short-changed. 5 In some emergency situations, time is short and the veterinarian may anticipate difficulty in calling the family together or arranging for the m to go through this process. In this case, the owner present with the animal might be encouraged to telephone the family, discuss the situation, obtain their approval, and at least ask if they want to be pre sent for a final farewell.
CLIENT SERVICES FOR GERIATRIC PETS
189
Adults with Elderly Family Living in the Home Again, the bonding to a pet can be very different among members of a household. Elderly people may become dependent on the companionship of a pet. 9 This pet may not technically be theirs, but they may spend a lot of time alone with the pet while the family is working or involved in life's many activities. The elderly person may take on the responsibility of caring for the pet as a way to feel useful in the household and to be of value instead of being a burden. The subject of how the elderly are treated in our society could be the topic of another entire book. Many elderly feel alienated from their families, relying, in turn, on a pet to provide the unconditional love that may help the person cope with rejection and the losses associated with aging. Elderly people may draw many parallels and conclusions between the care of a geriatric pet and their own situation. Many clients will mention that their pet has the same health condition or problem as they have. Consider the psychological implications if the condition of the pet is terminal or has a discouraging prognosis. When an elderly person with cancer must have an only pet euthanized because of the diagnosis of a malignancy, it can be very traumatic for several reasons. The loss of a pet can have negative impacts on the health of the owner5 ; this alone should cause veterinarians to give considerable thought to treatments that may prolong the life of a pet with cancer or other terminal disease. Secondly, the implication is strong, even if erroneous, that what is true for the pet is true for the person. A person with an incurable disease may empathize closely with a pet in the same condition. Many terminal diseases of pets can be managed effectively, prolonging the animal's life while also maintaining the hope and quality of life for the person. These considerations should be discussed when an elderly relative or friend may be affected by the family's decision to euthanize a pet. Single Adults, Couples Without Children, Elderly Living Alone These groups may share smaller households and support networks and have fewer opportunities to nurture another person. In some cases the pets serve as a child-substitute for childless couples or single adults and for parents of grown children when the children have left home. 1• 2 Studies have shown that nearly all pet owners talk to their pets as they would to another human. A psychosocial factor is involved in this human-animal bond. 2 The people who fall into these groups may want their pets to play a much larger role in their lives than do persons with multiple "significant others." Activities and emotional support that evolve around the pet may be much more critical to the pet owne r when there are no children or other family members in the household. Household members and a social network are important in helping people cope with any loss. If the social network of these types of pe t owners should be smaller, they may be more vulnerable to the negative consequences of a pet's illness or loss. Also, the presence of a pet is a factor associated with positive health benefits. 6 Clients should be made aware of these health benefits so they can at least give some consideration to having more than one pet. A second pet reduces their dependency on a single animal and can provide comfort during the grief process. It is certainly appropriate to suggest getting another pet
190
..
GUY HANCOCK AND JUDY YATES
during any office visit, and it is especially relevant after a single pet has • survived a life-threatening illness.
EUTHANASIA OF GERIATRIC PETS Because owners of geriatric pets must be faced with the possibility of choosing euthanasia more frequently than the owners of young animals, the veterinarian will often have to decide between recommending euthanasia or suggesting possible alternatives. The following are offered as criteria for consideration when choosing euthanasia for an older pet. Grave Medical Prognosis Euthanasia may be the only alternative, especially if the prognosis is associated with pain or suffering for the animal. The prognosis may, in fact, be less than grave. But the treatments required may be heroic, dependent on technology that is not readily available or be expensive beyond the owner's means. Even with such a seemingly obvious need for euthanasia, there may still be strong grief reactions and guilt for the owner. 5 The most mentioned question that seems to remain with the pet owner is "Did I do everything possible for my pet?" Guilt is a normal part of the grief reaction, so the owner needs reassurance that he is not to blame for the pet's death. Reduced Quality of the Pet's Life This is a relative factor that can be determined by either the owner or the veterinarian, but most often the pet owner will seek veterinary advice in making the decision. Oftentimes the owner is aware of the pet's problems in the home environment and seeks the veterinarian's approval for consensus. The veterinarian must be sensitive to providing as much help and information as the client desires so that, in turn, the cH~ntJeels comfortable with whatever decision is reached. From the owner's p~r$p~ctive, a critical need will be for the veterinarian to care and to' empathize with the pet owner as the decision-making process proceeds. Change(s) in the Owner's Circumstances That Make It Difficult or Impossible To Keep the Pet This rationale is more troublesome to many conscientious veterinarians because it creates personal and professional conflict for the veterinarian. A decrease in the pet owner's physical ability, a lack of mobility, or dependence on othe rs may cause the person to request euthanasia for a pet. Not only is this a very stressful time for the owner, because of having to give up personal independence, possessions, and family, it can be a particularly bad time to also be forced to give up a beloved pet. It can become an even harder, more traumatic decision if the owner has to consider euthanasia of a healthy pet simply because of a lack of alternatives. If the client is moving to a nursing home, there is a remote possibility the nursing home also may accept the pe t, because nursing homes are becoming more cognizant of the therapeutic benefits of resident pets and pet visitation.
CLIENT SERVICES FOR GERIATRIC PETS
191
The Pet No Longer Fulfills the Role of a Companion Euthanasia may be requested when the owner's quality of life is adversely affected because of the medical care or personal attention required for an aging pet. The owner may be deeply bonded to the animal, but can no longer derive pleasure because it is unable to fill the role of a companion. The pet owner may view euthanasia as the only way to resolve the situation. The veterinarian can expect from the owner a great deal of guilt and grief to be associated with euthanasia when it is done for this reason .
PET LOSS AND OWNER GRIEF Anticipation of Pet Loss The veterinarian and hospital staff are able to identify geriatric pets, but they also should be even more aware of the implications of aging and pet loss. Most pet owners can be expected to grieve the loss of a pet they have had for many years, but some owners are predisposed to more intense grief than others. The intensity and consequences of grief may also be increased by a number of social conditions. 4• 5 The loss of a pet may be especially difficult with the concurrent loss of another pet, a spouse, or other family member. Other contributing factors include living alone, retirement, loss of income, or divorce. 11 Planning for Pet Loss It is a professional responsibility of the veterinarian to help owners prepare for the inevitable separation from a pet. How can this be done, and what specific steps can be taken? The first step might be to suggest that the person with a single geriatric pet obtain a companion pet for the benefit of both the pet and the owner. Dogs especially are social animals and could be expected to benefit from more social contact with their own species. Many pet owners can provide evidence of the animal-animal bond that develops between some of their pets, both within and across species. A second step could be to have the owners think about the unthinkable. Have them take some time to reflect on the expected life span of their pet and, in turn, what the pet's death would mean to them. By doing this, they start preparing for the grieving process before the loss happens, taking the loss in small increments, which may lessen the impact of the actual event and make it somewhat easier to bear. They may consider the circumstances of a previous pet's death and decide if they want to do anything different with this pet. As the projected life span becomes shorter and shorter, have the owners ask questions about euthanasia and disposal. If the hospital staff will do a little prompting and show a willingness to take the time to listen, clients will be able to get some of these dreaded questions answered in advance. Some clients have misconceptions based on previous experiences. They may need to ask questions such as, whether they can be present, if the procedure hurts, and what options are available for disposal. The veterinary staff should be well informed about disposal
192
..
GuY HANCOCK AND JUDY YATES
options and supportive of the client's choice. Perhaps we can borrow some techniques from life insurance sales representatives who are in a similar situation, forced to bring up a topic no one wants to think about. This type of thinking centers on emphasizing the positive aspects of planning for a family's needs. In the veterinarian's situation, emphasis can be put on how the pet depends on the owner for everything. This includes providing geriatric medical care and deciding if and when to administer a painless death. If the client cares enough about the pet's welfare to be in a veterinary office, he also cares enough to plan ahead for the various circumstances that occur as a pet reaches the end of its life. Clients could be given a planning brochure or questionnaire that would ask a number of pertinent questions. It should be completed and returned to be kept in the client's record folder. By taking the brochure home, the client could have the time to define goals and plan how the goals could best be achieved in a number of hypothetical situations. There are several benefits to this advanced planning brochure. First, communication between the client and the veterinary staff may be enhanced. Second, the staff and client will be acting as a team to plan for the care and welfare of the pet. The veterinarian's contributions would be to raise the questions, provide information, and offer professional expertise. The client's role would be to answer the questions and make the decisions. Both parties have the animal's welfare as the primary goal and can be more objective because they are planning well in advance. This planning process may reduce the risk of being in an adversarial relationship with the client during a very emotional and traumatic time. Finally, the advance planning may help the client to prepare for and cope with the grief reaction of losing a pet. Dealing with Grief Grief is initiatedby a loss, and there is no doubt that the loss of a pet can trigger a significant grief reaction in almost. an5f:fatriily member.5 The intensity and duration of the grief is extremely variable and is not necessarily predicted only by the strength of the person's bond' to the deceased pet. One researcher reports the average duration of grief over the loss of a pet to be 10 months. 4 Thus, there is no "normal" grief reaction, only each individual's personal reaction and process of resolution. The generally accepted stages of grief are (1) denial, (2) anger, (3) guilt, (4) depression, and (5) resolution. 7 These do not occur necessarily in the order listed, and a person can experience pathologic grief and remain in one of these stages. It is entirely possible that people experience all these feelings, not in a linear fashion, but repeatedly. Each repetition may be a step toward eventual resolution. The stages may be emphasized to a very different degree and duration in many individuals. Also, it is necessary to understand that grief over a current loss may reactivate grief over previous losses. Sometimes the veterinarian will witness an apparently excessive display of grief, which is in fact, the combined grief of the pet loss and the previous loss of a spouse, family member, or another pet. Very possibly the pet was there to help the owner through the loneliness and depression caused by the first loss or previous problems. Now the client is grieving both losses
CLIENT SERVICES FOR GERIATRIC PETS
193
and has no pet to assist in the process of resolution. Another situation that may lead to a very strong reaction to pet loss is the client with a spouse who has contracted or succumbed to the same or a similar illness that caused the death of the pet. A final problem for clients is the lack of social approval and rituals for dealing with grief caused by pet loss. 5 With human loss, we expect our social network to be sympathetic and understanding, willing to listen and to provide help through the difficult times. We also have public rituals such as funerals, memorial services, and burials to help validate the worth of the departed, convince us that they are really gone, and allow us to express our bottled up rage, loss, sadness, guilt, and love. All these things help us work through the grief to resolution, yet all or most of these are lacking or they are socially unacceptable in the event of a pet's death. We are likely to be ridiculed by our social peers if we express any sense of grief more than a few days after a pet dies. The veterinarian and hospital staff are very important at this point because the client can freely express grief and receive acceptance and understanding from compassionate persons. Specific Steps the Veterinarian and Staff Can Take l. Consider all alternatives to euthanasia. The veterinarian's role in these situations will be to help the owner make these hard decisions, taking care at the same time, not to judge or condemn. In the case of a client who must go to a nursing home, the vast majority of health-care facilities have not yet made provisions for new residents to bring their pets with them. However, it is a good policy to ask or suggest the idea to a nursing home near your practice; that is, if you are willing to offer veterinary assistance to the home's resident pets. Because the veterinary community is too small to meet the needs for charitable medical care (it would result in bankruptcy for most practitioners), one alternative to charitable care might be to shift the burden of providing care for pets of indigent owners to the public. In human medicine, insurance and governmental assistance programs help people cope with human medical bills that they cannot pay out of their normal incomes. In veterinary medicine, pet insurance is beginning to succeed in some states, but the impact is small. In addition, the pet owners who may need a companion animal and financial assistance the most are the least likely to be insured, even where insurance is available. The ideal alternative to euthanasia when the owner can no longer care for a healthy pet is to find another person to take the pet. The pet's new owner might even be kind enough to visit the former owner periodically. Any assistance by the veterinarian in finding a new home can help the owner both emotionally and physically. The grief reaction over a significant loss can have detrimental effects on a person's physical and mental health. People experiencing grief have higher morbidity and mortality rates from all causes. 5 • 8 The person's sense of loss can sometimes be decreased by helping provide a suitable new home for the pet. The establishment of a pet fostering organization to match people needing help with foster homes willing to help both a pet and its owner would be an excellent way of
194
...
Guy HANCOCK AND JuDY YATES
providing this alternative. Such an organization exists in England, but these authors are not aware of any such programs in the United States. The Pinellas Animal Foundation is currently attempting to start this service in Pinellas County, Florida. Another solution may lie with help from the general public, providing the donations and support to pay for veterinary medical assistance to needy owners. This support could be tax money administered through governmental assistance programs or through voluntary contributions to private foundations established for this purpose. The public may one day choose to support veterinary care for pets of needy individuals. The public currently supports humane societies' efforts to shelter, relocate, or dispose of unwanted animals. This benefits society, but fails to deal with the breaking of significant human-animal bonds. Consider the greater benefit of preserving the existing bond between owners or family and a pet. The best intervention would help both the animal and the people bonded to it. 2. Be sensitive to the client's bonds with pets. Refer to Figure 1, which can be used to record information about the human-animal relationships within a household. 3. Be active in assisting clients to plan their pet's final years and the inevitable loss of the pet. Try to be of assistance while the owner decides how much to be involved. The veterinarian and staff can take the opportunities that arise during routine visits to ask clients to answer questions such as those posed in the brochure referred to earlier and encourage clients to consider an additional companion pet. 4. Be flexible . Give clients the opportunity to see their pet before it dies, to be present during euthanasia if they desire, to spend a few minutes alone with the body where they can express their grief in privacy and compose themselves if they must return to the reception area. If possible, allow grieving owners to leave through a private exit and avoid waiting at the reception counter. J3e willing to do a house call toex<~,mine a moribund pet and to perform euthanasia in the home, if that is thth)\~tier' s preference. Many veterinarians have been reluctant to perfoi:m'{mthanasia in the presence of owners, but veterinarians were serving themselves instead of their clients. The justification was to "spare the client," but the reason may have been that the veterinarian was more comfortable in the private setting. Now there is a way to easily serve the client and the patient. The technique is to administer a large dose of tranquilizer by the subcutaneous or intramuscular route. The pet may object, but will soon recover from this mild distress. The client can then hold the pet as it slowly becomes more relaxed. Clients are reassured with the pet comfortable and relaxed in their arms. When the pet is nearly unconscious from the tranquilizer, it will not vocalize or be distressed by the actual euthanasia injection. No muzzling or struggle is necessary. The pet's last conscious activity will be to be held and petted by the owner. Truly, "euthanasia" means a good death. 5. Let owners know that it is okay to visit with their gravely ill pet, to
spend some moments alone with the dying pet, or to bring a friend for moral support. Make them feel at ease about doing these things during the crucial final days and hours of an animal's life. 6. In the days after a pet's death, consider sending a sympathy card,
CLIENT SERVICES FOR GERIATRIC PETS
195
a letter, or flowers. The only guideline to follow is that it must be personal to be meaningful. A form letter is too cold to be comforting and sends the wrong message about your compassion and sympathy. Be sure the deceased pet's vaccination reminder cards are pulled from the files. A history sheet in the client's folder that lists all previous pets and some notes about the date and circumstances of each one's death will be helpful in future relations. 7. When billing for services performed on a pet that has died, consider presenting the statement in advance of the euthanasia, or mail it to the client a week or two later. If possible, encourage the pet owner to come to the office before the pet is actually brought to be euthanized. It seems insensitive to demand payment for a bill during the client's emotional confusion and turmoil at the time of euthanasia or death. If clients offer to pay the bill at that time, then take care of it if the bill is ready. Do not leave them standing at the reception counter in tears while the charges are added up.
SUMMARY Some veterinarians have been reluctant to discuss the prospect of the death of a pet because of a sense of discomfort and a lack of understanding about how to respond to the client's grief reaction. It is essential to take the time for this important communication and help clients deal with fears about the process, any feelings of guilt and helplessness, and judgments about the medical aspects of a case. Clients must be encouraged to express grief over the loss of a pet, particularly a geriatric pet that has lived with them many years and to which they are deeply bonded. Veterinarians need to counsel clients about obtaining additional pets or another pet. The phrase "replacement pet" must be stricken from the veterinarian's vocabulary. One does not "replace" a deceased spouse, mother, father, or child. It is possible to have another child or find another spouse, but it is not possible to replace a person. Neither can a pet be "replaced," because each pet is a unique living being. It is disrespectful to the memory of deceased pets to belittle their uniqueness by suggesting that they can be replaced. Instead, the veterinarian has the capability and responsibility to help pet owners maintain fond and happy memories of an irreplacable pet, while finding room in their hearts for another new pet to create happiness for the future. Once the grief is resolved, clients will be thankful for having had the privilege of sharing their life with an animal and experiencing the joy of the bond between two unique individuals.
REFERENCES 1. Albert A, Bulcroft K: Pets, families, and the life course. J Marr Fam 50:543- 552, 1988 2. Beck AH, Katcher AA: Between Pets and People. New York, Putnam Publishing, 1983 3. Blue G: The value of pets in children's lives. J Assoc Childhood Ed Inti, pp 84- 90, Dec 1986 4. Jamie W (ed): The Lat;Jam Letter. Winter 8:1, 1986-1987
196
Guy HANCOCK AND JUDY YATES
'·
5. Kay WJ, Nieburg HA, Katcher AH, et a!: Pet Loss and Human Bereavement. Ames, Iowa State University Press, 1984 6. Kidd AH, Feldman BM: Pet ownership and self-perceptiohs of older people. Psych Rept 48:867-875, 1981 7. Kubler-Ross E: On Death and Dying. London, Macmillan, 1969 8. Lynch, JL: The Broken Heart: The Medical Consequences of Loneliness. New York, Basic Books, 1977 9. New JC Jr, Wilson CC, Netting FE: How community-based elderly perceive pet ownership. Calif Vet 40:22-27, 1986 10. Quackenbush J, Voith VL (ed): The human/animal bond. Vet Clin North Am 15:2, 1985 11. Rynearson EK: Humans and pets and attachment. Br J Psychiatry 133:550-555, 1978
SUGGESTED READINGS Berryman JC, Howells K, Lloyd-Evans, M: Pet owner attitudes to pets and people: A psychological study. Vet Rec 117:659-661, 1985 Chastain CB: Managing the guilt of companion pet euthanasia. Fe! Pract 12:7-11, 1982 Diamond B: When the cat lives on. Cat Fancy 30:4, 1987 Harris JM: A study of client grief responses to death or loss in a companion animal veterinary practice. CalifVet 12:17-22,1982 Hart LA, Rivero CA, Mader B, et al: A pet loss support group: Evaluation of the first year. Calif Vet 41:13-15, 26, 1987 Rosenberg M: Clinical aspects of the grief associated with the loss of a companion pet. Can Prac 8:6-17, 1981 Swift WB: Coping with pet loss. Cat Fancy 30:3, 1987 Thomas C: Client relations: Dealing with grief. New methods. J An Health Tech 5:19-24, 1982 . Thomas GP: When a pet dies (How to deal with the grief of clients). Mod Vet Pract 63:273277, 1982 St. Petersburg Junior College Health Education Center P.O. Box 13489 St. Petersburg, FL 33733
0195--5616/89 $0.00
+
.20
Client Services for Geriatric Pets
Guy Hancock, DVM,* and judy Yates, MAt
The previous articles focused on the physiologic and pathologic processes common in geriatric dogs and cats and the latest knowledge about diagnostic and therapeutic techniques. This article offers practical ideas and insight into the emotional interactions between the veterinarian, the client, and the pet during the medical treatment of a geriatric animal patient.
HUMAN-ANIMAL BONDING AND LIFE CIRCUMSTANCES There is much evidence linking factors such as marital and job status, social network, and other life circumstances to health or illness. 2• 8 There is also evidence that certain groups, by virtue of their social conditions, are predisposed to a greater impact from the grief associated with pet loss. 4• 5 • 10 The following bonding relationships represent examples of situations that may have implications for the veterinarian who is treating a geriatric pet. Families with Children Living at Home The pet in question may be older than the eldest child. This child may have known the pet his or he r entire life and have a very deep bond. 3 The depth of the bond with a pet can vary greatly among the various family members. It is, therefore, very important for all members of the family to take part in the discussions and decisions about medical treatme nts, terminal illness, and whether to euthanize a pet. It is not in the best interest of the veterinarian to decide which family member is best equipped to make a life or death decision regarding the pet. Instead, the veterinarian should ask if the entire family has participated in the decision and advise or encourage that participation. It would be helpful to expand the records that most veterinarians keep on addresses, phone numbers or work place to include information on the family and the human-animal bonding pattern *Chairman, Veterinary Technology Program, St. Petersburg Junior College, Health Education Center, St. Petersburg, Florida tCounty Extension Director, Pinellas County Cooperative Extension Service, IFAS/University of Florida, Largo, Florida Veterinary Clinics of North America: Small Animal Practice- Vol. 19, No. 1, January 1989
187
188
Guy
SANDRA
NAME: RELATION:
HANCOCK AND JUDY YATES
HUSBAND
WIFE
DAUGHTER
PET NAME: (DOG)
(CAT)
(RABBIT)
ARROW SIZE INDICATES STRENGTH OF BOND
D
SINGLE ADULT
PSYCHOSOCIAL STRESSES, DATE OF OCCURRENCE
D
COUPLE WITHOUT CHILDREN
_
LOSS OF PET
D
COUPLE WITH CHILDREN
_
LOSS OF FAMILY _
_
SERIOUS ILLNESS IN HOUSEHOLD _
D
ELDERLY IN HOUSEHOLD
_
DIVORCE/SEPARATION _
_
OTHER_
D
ELDERLY ADULT
NOTES & COMMENTS _ _ _ _ _ _ _ _ _ _ _ _ __
_
_
LOSS OF JOB _
Figure 1. Chart indicating strength of bonds between family members and their pets.
that exists within the family. Figure 1 presents one way to obtain and arrange this information to help the hospital staff anticipate the multitude of bonds present in a household with several pets. One of the veterinary professions's obligations must be to communicate to the decision-makers in the household the importance and implications of these bonds. In many instances, the decision-maker, head of household, or person who brings the pet to the hospital for treatment is the least bonded person and may not realize or understand t~e ;deep feelings of other family members. This person may be motivated mote by economics or by other factors and may not appreciate the consequences of excluding the family from the decision or the actual procedure. This pe rson must be encouraged to understand the negative consequences of trying to "protect" the other members from the decision-making process or the emotion and the potential grief of the situation. Veterinarians must help the decisionmaker or appointed person or "drawer of the short straw" to see the larger picture . The loss of a pe t during childhood may have lifelong effects, especially if the child feels powerless and excluded from events surrounding the animal's death. 4 • 5 • 8 The euthanasia or death of a family pet is not an ordinary, unpleasant task, like emptying the trash. It is a significant life experience that should not be downplayed, belittled, or short-changed. 5 In some emergency situations, time is short and the veterinarian may anticipate difficulty in calling the family together or arranging for the m to go through this process. In this case, the owner present with the animal might be encouraged to telephone the family, discuss the situation, obtain their approval, and at least ask if they want to be pre sent for a final farewell.
CLIENT SERVICES FOR GERIATRIC PETS
189
Adults with Elderly Family Living in the Home Again, the bonding to a pet can be very different among members of a household. Elderly people may become dependent on the companionship of a pet. 9 This pet may not technically be theirs, but they may spend a lot of time alone with the pet while the family is working or involved in life's many activities. The elderly person may take on the responsibility of caring for the pet as a way to feel useful in the household and to be of value instead of being a burden. The subject of how the elderly are treated in our society could be the topic of another entire book. Many elderly feel alienated from their families, relying, in turn, on a pet to provide the unconditional love that may help the person cope with rejection and the losses associated with aging. Elderly people may draw many parallels and conclusions between the care of a geriatric pet and their own situation. Many clients will mention that their pet has the same health condition or problem as they have. Consider the psychological implications if the condition of the pet is terminal or has a discouraging prognosis. When an elderly person with cancer must have an only pet euthanized because of the diagnosis of a malignancy, it can be very traumatic for several reasons. The loss of a pet can have negative impacts on the health of the owner5 ; this alone should cause veterinarians to give considerable thought to treatments that may prolong the life of a pet with cancer or other terminal disease. Secondly, the implication is strong, even if erroneous, that what is true for the pet is true for the person. A person with an incurable disease may empathize closely with a pet in the same condition. Many terminal diseases of pets can be managed effectively, prolonging the animal's life while also maintaining the hope and quality of life for the person. These considerations should be discussed when an elderly relative or friend may be affected by the family's decision to euthanize a pet. Single Adults, Couples Without Children, Elderly Living Alone These groups may share smaller households and support networks and have fewer opportunities to nurture another person. In some cases the pets serve as a child-substitute for childless couples or single adults and for parents of grown children when the children have left home. 1• 2 Studies have shown that nearly all pet owners talk to their pets as they would to another human. A psychosocial factor is involved in this human-animal bond. 2 The people who fall into these groups may want their pets to play a much larger role in their lives than do persons with multiple "significant others." Activities and emotional support that evolve around the pet may be much more critical to the pet owne r when there are no children or other family members in the household. Household members and a social network are important in helping people cope with any loss. If the social network of these types of pe t owners should be smaller, they may be more vulnerable to the negative consequences of a pet's illness or loss. Also, the presence of a pet is a factor associated with positive health benefits. 6 Clients should be made aware of these health benefits so they can at least give some consideration to having more than one pet. A second pet reduces their dependency on a single animal and can provide comfort during the grief process. It is certainly appropriate to suggest getting another pet
190
..
GUY HANCOCK AND JUDY YATES
during any office visit, and it is especially relevant after a single pet has • survived a life-threatening illness.
EUTHANASIA OF GERIATRIC PETS Because owners of geriatric pets must be faced with the possibility of choosing euthanasia more frequently than the owners of young animals, the veterinarian will often have to decide between recommending euthanasia or suggesting possible alternatives. The following are offered as criteria for consideration when choosing euthanasia for an older pet. Grave Medical Prognosis Euthanasia may be the only alternative, especially if the prognosis is associated with pain or suffering for the animal. The prognosis may, in fact, be less than grave. But the treatments required may be heroic, dependent on technology that is not readily available or be expensive beyond the owner's means. Even with such a seemingly obvious need for euthanasia, there may still be strong grief reactions and guilt for the owner. 5 The most mentioned question that seems to remain with the pet owner is "Did I do everything possible for my pet?" Guilt is a normal part of the grief reaction, so the owner needs reassurance that he is not to blame for the pet's death. Reduced Quality of the Pet's Life This is a relative factor that can be determined by either the owner or the veterinarian, but most often the pet owner will seek veterinary advice in making the decision. Oftentimes the owner is aware of the pet's problems in the home environment and seeks the veterinarian's approval for consensus. The veterinarian must be sensitive to providing as much help and information as the client desires so that, in turn, the cH~ntJeels comfortable with whatever decision is reached. From the owner's p~r$p~ctive, a critical need will be for the veterinarian to care and to' empathize with the pet owner as the decision-making process proceeds. Change(s) in the Owner's Circumstances That Make It Difficult or Impossible To Keep the Pet This rationale is more troublesome to many conscientious veterinarians because it creates personal and professional conflict for the veterinarian. A decrease in the pet owner's physical ability, a lack of mobility, or dependence on othe rs may cause the person to request euthanasia for a pet. Not only is this a very stressful time for the owner, because of having to give up personal independence, possessions, and family, it can be a particularly bad time to also be forced to give up a beloved pet. It can become an even harder, more traumatic decision if the owner has to consider euthanasia of a healthy pet simply because of a lack of alternatives. If the client is moving to a nursing home, there is a remote possibility the nursing home also may accept the pe t, because nursing homes are becoming more cognizant of the therapeutic benefits of resident pets and pet visitation.
CLIENT SERVICES FOR GERIATRIC PETS
191
The Pet No Longer Fulfills the Role of a Companion Euthanasia may be requested when the owner's quality of life is adversely affected because of the medical care or personal attention required for an aging pet. The owner may be deeply bonded to the animal, but can no longer derive pleasure because it is unable to fill the role of a companion. The pet owner may view euthanasia as the only way to resolve the situation. The veterinarian can expect from the owner a great deal of guilt and grief to be associated with euthanasia when it is done for this reason .
PET LOSS AND OWNER GRIEF Anticipation of Pet Loss The veterinarian and hospital staff are able to identify geriatric pets, but they also should be even more aware of the implications of aging and pet loss. Most pet owners can be expected to grieve the loss of a pet they have had for many years, but some owners are predisposed to more intense grief than others. The intensity and consequences of grief may also be increased by a number of social conditions. 4• 5 The loss of a pet may be especially difficult with the concurrent loss of another pet, a spouse, or other family member. Other contributing factors include living alone, retirement, loss of income, or divorce. 11 Planning for Pet Loss It is a professional responsibility of the veterinarian to help owners prepare for the inevitable separation from a pet. How can this be done, and what specific steps can be taken? The first step might be to suggest that the person with a single geriatric pet obtain a companion pet for the benefit of both the pet and the owner. Dogs especially are social animals and could be expected to benefit from more social contact with their own species. Many pet owners can provide evidence of the animal-animal bond that develops between some of their pets, both within and across species. A second step could be to have the owners think about the unthinkable. Have them take some time to reflect on the expected life span of their pet and, in turn, what the pet's death would mean to them. By doing this, they start preparing for the grieving process before the loss happens, taking the loss in small increments, which may lessen the impact of the actual event and make it somewhat easier to bear. They may consider the circumstances of a previous pet's death and decide if they want to do anything different with this pet. As the projected life span becomes shorter and shorter, have the owners ask questions about euthanasia and disposal. If the hospital staff will do a little prompting and show a willingness to take the time to listen, clients will be able to get some of these dreaded questions answered in advance. Some clients have misconceptions based on previous experiences. They may need to ask questions such as, whether they can be present, if the procedure hurts, and what options are available for disposal. The veterinary staff should be well informed about disposal
192
..
GuY HANCOCK AND JUDY YATES
options and supportive of the client's choice. Perhaps we can borrow some techniques from life insurance sales representatives who are in a similar situation, forced to bring up a topic no one wants to think about. This type of thinking centers on emphasizing the positive aspects of planning for a family's needs. In the veterinarian's situation, emphasis can be put on how the pet depends on the owner for everything. This includes providing geriatric medical care and deciding if and when to administer a painless death. If the client cares enough about the pet's welfare to be in a veterinary office, he also cares enough to plan ahead for the various circumstances that occur as a pet reaches the end of its life. Clients could be given a planning brochure or questionnaire that would ask a number of pertinent questions. It should be completed and returned to be kept in the client's record folder. By taking the brochure home, the client could have the time to define goals and plan how the goals could best be achieved in a number of hypothetical situations. There are several benefits to this advanced planning brochure. First, communication between the client and the veterinary staff may be enhanced. Second, the staff and client will be acting as a team to plan for the care and welfare of the pet. The veterinarian's contributions would be to raise the questions, provide information, and offer professional expertise. The client's role would be to answer the questions and make the decisions. Both parties have the animal's welfare as the primary goal and can be more objective because they are planning well in advance. This planning process may reduce the risk of being in an adversarial relationship with the client during a very emotional and traumatic time. Finally, the advance planning may help the client to prepare for and cope with the grief reaction of losing a pet. Dealing with Grief Grief is initiatedby a loss, and there is no doubt that the loss of a pet can trigger a significant grief reaction in almost. an5f:fatriily member.5 The intensity and duration of the grief is extremely variable and is not necessarily predicted only by the strength of the person's bond' to the deceased pet. One researcher reports the average duration of grief over the loss of a pet to be 10 months. 4 Thus, there is no "normal" grief reaction, only each individual's personal reaction and process of resolution. The generally accepted stages of grief are (1) denial, (2) anger, (3) guilt, (4) depression, and (5) resolution. 7 These do not occur necessarily in the order listed, and a person can experience pathologic grief and remain in one of these stages. It is entirely possible that people experience all these feelings, not in a linear fashion, but repeatedly. Each repetition may be a step toward eventual resolution. The stages may be emphasized to a very different degree and duration in many individuals. Also, it is necessary to understand that grief over a current loss may reactivate grief over previous losses. Sometimes the veterinarian will witness an apparently excessive display of grief, which is in fact, the combined grief of the pet loss and the previous loss of a spouse, family member, or another pet. Very possibly the pet was there to help the owner through the loneliness and depression caused by the first loss or previous problems. Now the client is grieving both losses
CLIENT SERVICES FOR GERIATRIC PETS
193
and has no pet to assist in the process of resolution. Another situation that may lead to a very strong reaction to pet loss is the client with a spouse who has contracted or succumbed to the same or a similar illness that caused the death of the pet. A final problem for clients is the lack of social approval and rituals for dealing with grief caused by pet loss. 5 With human loss, we expect our social network to be sympathetic and understanding, willing to listen and to provide help through the difficult times. We also have public rituals such as funerals, memorial services, and burials to help validate the worth of the departed, convince us that they are really gone, and allow us to express our bottled up rage, loss, sadness, guilt, and love. All these things help us work through the grief to resolution, yet all or most of these are lacking or they are socially unacceptable in the event of a pet's death. We are likely to be ridiculed by our social peers if we express any sense of grief more than a few days after a pet dies. The veterinarian and hospital staff are very important at this point because the client can freely express grief and receive acceptance and understanding from compassionate persons. Specific Steps the Veterinarian and Staff Can Take l. Consider all alternatives to euthanasia. The veterinarian's role in these situations will be to help the owner make these hard decisions, taking care at the same time, not to judge or condemn. In the case of a client who must go to a nursing home, the vast majority of health-care facilities have not yet made provisions for new residents to bring their pets with them. However, it is a good policy to ask or suggest the idea to a nursing home near your practice; that is, if you are willing to offer veterinary assistance to the home's resident pets. Because the veterinary community is too small to meet the needs for charitable medical care (it would result in bankruptcy for most practitioners), one alternative to charitable care might be to shift the burden of providing care for pets of indigent owners to the public. In human medicine, insurance and governmental assistance programs help people cope with human medical bills that they cannot pay out of their normal incomes. In veterinary medicine, pet insurance is beginning to succeed in some states, but the impact is small. In addition, the pet owners who may need a companion animal and financial assistance the most are the least likely to be insured, even where insurance is available. The ideal alternative to euthanasia when the owner can no longer care for a healthy pet is to find another person to take the pet. The pet's new owner might even be kind enough to visit the former owner periodically. Any assistance by the veterinarian in finding a new home can help the owner both emotionally and physically. The grief reaction over a significant loss can have detrimental effects on a person's physical and mental health. People experiencing grief have higher morbidity and mortality rates from all causes. 5 • 8 The person's sense of loss can sometimes be decreased by helping provide a suitable new home for the pet. The establishment of a pet fostering organization to match people needing help with foster homes willing to help both a pet and its owner would be an excellent way of
194
...
Guy HANCOCK AND JuDY YATES
providing this alternative. Such an organization exists in England, but these authors are not aware of any such programs in the United States. The Pinellas Animal Foundation is currently attempting to start this service in Pinellas County, Florida. Another solution may lie with help from the general public, providing the donations and support to pay for veterinary medical assistance to needy owners. This support could be tax money administered through governmental assistance programs or through voluntary contributions to private foundations established for this purpose. The public may one day choose to support veterinary care for pets of needy individuals. The public currently supports humane societies' efforts to shelter, relocate, or dispose of unwanted animals. This benefits society, but fails to deal with the breaking of significant human-animal bonds. Consider the greater benefit of preserving the existing bond between owners or family and a pet. The best intervention would help both the animal and the people bonded to it. 2. Be sensitive to the client's bonds with pets. Refer to Figure 1, which can be used to record information about the human-animal relationships within a household. 3. Be active in assisting clients to plan their pet's final years and the inevitable loss of the pet. Try to be of assistance while the owner decides how much to be involved. The veterinarian and staff can take the opportunities that arise during routine visits to ask clients to answer questions such as those posed in the brochure referred to earlier and encourage clients to consider an additional companion pet. 4. Be flexible . Give clients the opportunity to see their pet before it dies, to be present during euthanasia if they desire, to spend a few minutes alone with the body where they can express their grief in privacy and compose themselves if they must return to the reception area. If possible, allow grieving owners to leave through a private exit and avoid waiting at the reception counter. J3e willing to do a house call toex<~,mine a moribund pet and to perform euthanasia in the home, if that is thth)\~tier' s preference. Many veterinarians have been reluctant to perfoi:m'{mthanasia in the presence of owners, but veterinarians were serving themselves instead of their clients. The justification was to "spare the client," but the reason may have been that the veterinarian was more comfortable in the private setting. Now there is a way to easily serve the client and the patient. The technique is to administer a large dose of tranquilizer by the subcutaneous or intramuscular route. The pet may object, but will soon recover from this mild distress. The client can then hold the pet as it slowly becomes more relaxed. Clients are reassured with the pet comfortable and relaxed in their arms. When the pet is nearly unconscious from the tranquilizer, it will not vocalize or be distressed by the actual euthanasia injection. No muzzling or struggle is necessary. The pet's last conscious activity will be to be held and petted by the owner. Truly, "euthanasia" means a good death. 5. Let owners know that it is okay to visit with their gravely ill pet, to
spend some moments alone with the dying pet, or to bring a friend for moral support. Make them feel at ease about doing these things during the crucial final days and hours of an animal's life. 6. In the days after a pet's death, consider sending a sympathy card,
CLIENT SERVICES FOR GERIATRIC PETS
195
a letter, or flowers. The only guideline to follow is that it must be personal to be meaningful. A form letter is too cold to be comforting and sends the wrong message about your compassion and sympathy. Be sure the deceased pet's vaccination reminder cards are pulled from the files. A history sheet in the client's folder that lists all previous pets and some notes about the date and circumstances of each one's death will be helpful in future relations. 7. When billing for services performed on a pet that has died, consider presenting the statement in advance of the euthanasia, or mail it to the client a week or two later. If possible, encourage the pet owner to come to the office before the pet is actually brought to be euthanized. It seems insensitive to demand payment for a bill during the client's emotional confusion and turmoil at the time of euthanasia or death. If clients offer to pay the bill at that time, then take care of it if the bill is ready. Do not leave them standing at the reception counter in tears while the charges are added up.
SUMMARY Some veterinarians have been reluctant to discuss the prospect of the death of a pet because of a sense of discomfort and a lack of understanding about how to respond to the client's grief reaction. It is essential to take the time for this important communication and help clients deal with fears about the process, any feelings of guilt and helplessness, and judgments about the medical aspects of a case. Clients must be encouraged to express grief over the loss of a pet, particularly a geriatric pet that has lived with them many years and to which they are deeply bonded. Veterinarians need to counsel clients about obtaining additional pets or another pet. The phrase "replacement pet" must be stricken from the veterinarian's vocabulary. One does not "replace" a deceased spouse, mother, father, or child. It is possible to have another child or find another spouse, but it is not possible to replace a person. Neither can a pet be "replaced," because each pet is a unique living being. It is disrespectful to the memory of deceased pets to belittle their uniqueness by suggesting that they can be replaced. Instead, the veterinarian has the capability and responsibility to help pet owners maintain fond and happy memories of an irreplacable pet, while finding room in their hearts for another new pet to create happiness for the future. Once the grief is resolved, clients will be thankful for having had the privilege of sharing their life with an animal and experiencing the joy of the bond between two unique individuals.
REFERENCES 1. Albert A, Bulcroft K: Pets, families, and the life course. J Marr Fam 50:543- 552, 1988 2. Beck AH, Katcher AA: Between Pets and People. New York, Putnam Publishing, 1983 3. Blue G: The value of pets in children's lives. J Assoc Childhood Ed Inti, pp 84- 90, Dec 1986 4. Jamie W (ed): The Lat;Jam Letter. Winter 8:1, 1986-1987
196
Guy HANCOCK AND JUDY YATES
'·
5. Kay WJ, Nieburg HA, Katcher AH, et a!: Pet Loss and Human Bereavement. Ames, Iowa State University Press, 1984 6. Kidd AH, Feldman BM: Pet ownership and self-perceptiohs of older people. Psych Rept 48:867-875, 1981 7. Kubler-Ross E: On Death and Dying. London, Macmillan, 1969 8. Lynch, JL: The Broken Heart: The Medical Consequences of Loneliness. New York, Basic Books, 1977 9. New JC Jr, Wilson CC, Netting FE: How community-based elderly perceive pet ownership. Calif Vet 40:22-27, 1986 10. Quackenbush J, Voith VL (ed): The human/animal bond. Vet Clin North Am 15:2, 1985 11. Rynearson EK: Humans and pets and attachment. Br J Psychiatry 133:550-555, 1978
SUGGESTED READINGS Berryman JC, Howells K, Lloyd-Evans, M: Pet owner attitudes to pets and people: A psychological study. Vet Rec 117:659-661, 1985 Chastain CB: Managing the guilt of companion pet euthanasia. Fe! Pract 12:7-11, 1982 Diamond B: When the cat lives on. Cat Fancy 30:4, 1987 Harris JM: A study of client grief responses to death or loss in a companion animal veterinary practice. CalifVet 12:17-22,1982 Hart LA, Rivero CA, Mader B, et al: A pet loss support group: Evaluation of the first year. Calif Vet 41:13-15, 26, 1987 Rosenberg M: Clinical aspects of the grief associated with the loss of a companion pet. Can Prac 8:6-17, 1981 Swift WB: Coping with pet loss. Cat Fancy 30:3, 1987 Thomas C: Client relations: Dealing with grief. New methods. J An Health Tech 5:19-24, 1982 . Thomas GP: When a pet dies (How to deal with the grief of clients). Mod Vet Pract 63:273277, 1982 St. Petersburg Junior College Health Education Center P.O. Box 13489 St. Petersburg, FL 33733