I always assumed my experience as a veterinarian would serve me at some point when I needed to navigate the human healthcare system. The similarities between veterinary training and medical training, after all, lend themselves to a good number of similarities: how to read scientific articles critically. How to read an MRI. When to call the office and say, this prescription doesn’t seem quite right, is this what you wanted?
The similarities are all well and good, but I never understood, in the marrow of my bones, until recently that what would serve me best was our differences.
We MDs and DVMs are both given an ethical mandate to ‘do no harm’, which we as communities hold dear. Our duties to our patients are guided by this overarching principle; we look to it for direction in complicated cases, fall back on it when we feel conflicted about a request, and hold it like a flashlight when we shine a light into the cave of an uncertain future, looking for direction.
But oh, do those lights shine in very different spectrums.
As a veterinarian, I agree. We veterinarians occupy a strange place in the medical field in that most of us view it as not only an option but often a moral imperative to ease the pain of a traumatic death process through pharmacologic means. We are precise in our process, with the goal of minimizing stress and pain. We view it not as causing death, but as easing an uncurable pain. In this, we view our fulfillment to do no harm.
But in the human medical field, the prevailing attitude is by and large that hastening death is, indeed, harm, and anything we do to prolong a life is conversely fulfilling their requirement to do no harm, no matter what it does to a person or family in the process.
Even if it is multiple craniotomies.
Months of chemotherapy.
Daily radiation therapy with a bevy of ill effects. And you have to get screwed down to the table wearing one of these while they shoot brain shrivelling radiation beams at your head:
Not to cure a disease, but to make a patient breathe one more day, for better or for worse. It is the second most common utterance to me in my hospice work: we do better with our pets than we do our people when it comes to end-of-life decisions, and truly, friends, we really do.
I was recently-by invitation- listening to a doctor outline just such a series of events and possibilities to a patient who didn’t want to partake in them, who has been looking- without success- for someone to say, it’s ok to say no to months of hospital visits and yes to fewer days filled with this:
Plenty of people do want everything we have to throw at disease, and more power to them all. Thank God for modern medicine. But when did it become not only an unthinkable mistake, but an outright affront to the medical community to say, “thanks but no thanks”?
Searching for information on hospice and palliative care has been as challenging as getting bootleg rum during prohibition, furtive conversations in hallways and whispered hints at such necessary things as family support and respite care, secondary concerns far down the to-do list after scheduling yet another CT. I never knew how much of an afterthought the emotional wellbeing of the patient truly is in many medical decision making processes.
“So what if they don’t want to do this?” I asked.
“Well, this is the standard of care,” the resident responded.
“And if they choose not to do this?” I asked again.
“Why wouldn’t you?” he said, dumbfounded. He never did give me an answer.
I once worked in a very stressful place. It was an emergency hospital, always about 3 staff members short of a full crew and 25 people piled in the lobby waiting for treatment. It was a large staff of doctors, about 10 at the time, and as how things tend to happen in nutso environments the staff would get nutso a little bit as well. Stress does that to people.
You never sat still at that hospital; it was run run run, a dog bleeding out in room 1, a dyspneic cat gasping in room 2, five clients wanting updates on the phone. We didn’t catch up on things there so much as run as fast as you can so as not to fall further behind. The whole place had a surreal Through the Looking Glass feel to it, now that I think about it.
In the midst of this chaos, one or two of the more enlightened veterinarians managed to float above it all. Dr. Naidus was one of them. Needles would be flying and people screaming and papers falling to the floor, and he would be solemnly nibbling on some healthy snack or another, surveying the scene with an amused glance before going back to whatever it was he was doing.
The interns and newer veterinarians such as myself were drawn to him like an acolyte to a guru, trying to figure out the secret of his zen-ness. He’d laugh and tell us when we were old we’d be too tired to get worked up over the small stuff too. (He was right.)
Clients loved him as much as we did. Every Christmas, when I considered myself lucky to get a hand soap from the rare client who could remember my name, baskets would start showing up in the treatment area with his name on it. Baskets and baskets and baskets. He always shared.
Dr. Naidus got more gifts than the rest of us put together, including the owner and the boarded surgeon, and when we tried to figure out the secret of people loving him as much as they did it was simple: he gave them what they wanted. Treatment, or palliation if they didn’t want to pursue heroic measures. We were in an economically depressed area and people spent a lot of time confronted with estimates they couldn’t realistically afford.
He was always kind and understanding and worked with them based on what they could do. It wasn’t, as he kept reassuring us, rocket science. Be kind. Laugh, for goodness sake, it’s not that bad.
He took the same approach with the terrified interns, who were performing under a great deal of pressure without a lot of knowledge under their belts. We’d come up to him, all of us including him up to our eyeballs in paperwork, for advice or a ‘can you take a peek’ or ‘HELP!’ and he always did, with nary an eyeroll or a sigh or a ‘in a few minutes.’ In a place where people routinely lost their sanity trying to stay afloat, I never saw the guy lose his cool, like, ever. He surrounded himself with a bubble of laughter impervious to the anxiety around him. It rubbed off.
I worked with him only briefly, but have heard news of him through my friends who remained and considered him a dear friend. I knew he had been battling illness for a while, and had dealt with it with his characteristic humor. He did well for a very long time and went on to charm many more clients in the years since we sat side by side in that chaotic treatment area, watching the world swirl by.
In Through the Looking Glass, Alice happens upon the Red King, napping beneath a tree.
“He’s dreaming now,” said Tweedledee: “and what do you think he’s dreaming about?”
Alice said, “Nobody can guess that.”
“Why, about you!” Tweedledee exclaimed, clapping his hands triumphantly. “And if he left off dreaming about you, where do you suppose you’d be?”
“Where I am now, of course,” said Alice.
“Not you!” Tweedledee retorted contemptuously. “You’d be nowhere.”
Dr. Naidus was very much this type of quiet force in many lives. I am sure he was greeted today by many pets he has helped over his long career, as they welcome him home. Perhaps he and Kevin are sharing a brew; it’s been a long journey. Life, what is it but a dream?
Rest well, my friend. Thank you for being you.
PS This is not the hospital I wrote about in this post. ;)
It is one of the sad ironies of being a veterinarian in clinical practice that most of your clients are majorly unhappy to see you. (Retrievers don’t count, they’re always happy to see you.)
The reasons are obvious: vet clinics mean temperature taking, and shots, and cold tables. Trust me, I don’t much enjoy heading off to my doctor’s office either, nice as the staff is. Those awful half length hospital gowns they give you (ladies, you know the ones I’m referring to)- cold and humiliating. I’m here for something I’m not going to like.
One of the most common things I hear from clients at a home euthanasia appointment is, “I just couldn’t bear to do this at the clinic. My last dog was shaking like a leaf when we went in for the appointment and I felt so terribly guilty afterwards.” And who can blame them for feeling guilty? Who wants their last memory of their dog or cat to be them cowering in a corner? How awful.
Not all pets feel this way about the vet, of course, but for those that do, it just adds another layer of emotional trauma to an already challenging time. Is this the pet signaling they don’t want to die? No. As pain management expert Dr. Robin Downing says, “Pets don’t fear death. They fear pain.” They are telling us they don’t like the vet, but of course we are only human and it’s hard not to extrapolate that to a bigger message that isn’t there.
So what happens in the absence of the clinic and the coat, when a pet meets me outside the office? A pleasant hello, usually. Even when I am there to help them transition. Especially when I am there to help them transition. I will be honest, I wasn’t expecting that.
I was reminded today of a lovely Golden I met last year, who was winding down a battle with cancer. When I came to the family home, their sweet girl was almost nonresponsive. As I knelt down by her side, she opened her beautiful brown eyes and gave me a huge, enthusiastic wag. We all stood there in shock, as she had not been able to do much of anything in the hours leading up to that moment. She did not fear death, or me.
In the absence of a preconceived assumption of vaccines and thermometers, pets are free to judge me based on whatever it is they perceive I am there to do. I cannot tell you the number of kisses, licks, wags, head bumps I get from pets who by all rights should be past caring who is sitting next to them. It means something.
It’s not, “Oh boy! THE DOCTOR IS HERE!”
It’s not, “That blond lady sure does smell good, like bacon.”
“I’m never going back,” I have heard more than one pet owner say. They are talking about the office of their veterinarian, a person with whom they have built a relationship for years, someone they like and trust. But their pet died there, and the painful memories are too strong. So strong for some people that they go and find a new vet, even if they liked their old one just fine.
It’s one of the reasons I like having the option that I offer, of performing in-home euthanasia and pet hospice with Paws into Grace. Because I know more than anyone that as much as the client hated the office that one time, many pets hated it every time. That can be pretty upsetting for some families.
Which leads to the next concern, one I hadn’t thought of until a client voiced it to me. “I don’t want to go to the vet office, but I can’t euthanize my pet at home,” she said. “I can’t have that memory associated with my house.” So sometimes those clients end up decamping to a third party location, a park or a beach. And I respect that decision, though I would encourage those who feel that way to think on it a little while before making up their minds. Here’s why:
1. The precedent has been set in human hospice for staying at home.
The gold standard in human hospice, for those who have adequate support systems in place, is for people to pass at home whenever possible. That is by far the most comfortable place for a patient, in familiar surroundings. I was with my grandfather when he quietly died on a rented hospital bed in the living room he called his own for 40 years. He hated hospitals and I’m pretty sure had we put him in one, he would have haunted us all.
2. Moving an ill pet can be a challenge.
Pets who are very ill can be nauseated, painful, disoriented, and uncomfortable. This goes for people, too. How many times have we been down with the flu and known that we should probably go to the doctor but we feel too rotten to move? Same goes for pets. Add in mobility issues and it is just one more stress for owners, especially with very large pets or very upset cats- no matter the destination.
3. Your home is deafeningly, loudly, overwhelmingly a place of comfort.
This is the place Kekoa died:
But unlike a vet office where I might only have a handful of memories, I see this place every day and I don’t look at it as the place my dog died. I look at it as my living room, the place we opened Christmas presents, the place Brody plops down while I’m writing. It also happens to be the place Kekoa chose to settle down and leave this earth, because she knew as well that this is a happy place.
And you know what? It still is. I am glad she chose our sun dappled living room. At home, when I administer a pet’s sedation, they choose where they want to be: outside, in the kitchen, in mom’s lap. People find comfort knowing their pet selected the place they are most at home.
I’ve only been in this house a year and it’s had more than its share of sadness. I am looking at the floor where Kekoa died while sitting on the couch where Apollo died. I actually drove him home from the specialty hospital as quickly as I could- after he got lots of pain meds, so he could curl up on my lap after everyone got a chance to say goodbye.
But right now, it’s the place my dog is chewing up a toy and my son is doing his homework. This is our home, where life happens. And I feel good about that.
Want more info or to know if anyone in your area provides this?
Not all veterinarians even know this service exists, and information can be hard to come by. Here are two national databases of veterinarians that offer this service:
One year ago today, we said goodbye to Kekoa. After a month of bucket list indulgences going from kale to turkey and then, that day, chocolate chip bacon ice cream, I said I love you one last time.
We pet owners talk a lot about heart dogs, that dog who just ‘got’ you, the dog who changed you and will never, ever be replaced (you can substitute dog for any pet, of course.) And once you have a heart dog, once you lose a heart dog, you may wonder if you will ever have another one again.
I’m here to say yes, you can.
Emmett was my heart dog, the dog who taught me fierce love and how to be a family and how even the best of us were allowed our jealous moments but we’d get over them eventually. He taught me forgiveness. I loved the other dogs I had before him just as much, Taffy and Mulan and Nuke, but he was the dog who spoke to my soul.
Kekoa was brought into our lives furtively, a sneak adoption if you will. We were supposed to adopt a different lab, a younger one, one glossier and with better teeth, but as I didn’t realize until after she was gone, she spoke to my daughter’s soul, and there it was. She was the shoe that fit. That was a February as well. This is her month, the month of heart.
Kekoa lived without a spiteful bone in her body. I think she growled once in her life, when Apollo tried to steal a bite of her food, and even then it was more indignant than menacing. She loved food, almost as much as she loved us.
When she died, when I made the decision to euthanize her when her bone cancer was causing her pain I couldn’t control, I wrestled with the same emotions every pet owner struggles with: uncertainty. Is it the right time? Guilt. I’m acting too soon. Pain. I don’t like seeing this. She was bothered by none of this internal turmoil, choosing instead to just trust us and sleep in my daughter’s room at night. I was so busy thinking of my own distress I really missed the boat on thinking about how the kids would be affected, but Kekoa stepped in- completely unaware she was even doing it- to be there for them.
Many things happened afterwards as a direct result of her death. I began working with Paws into Grace. In the midst of my mourning, her story wrote itself into the book proposal I was working on, which will be a forever monument to her. I committed to getting certified in pet loss counseling, which I completed last week, in order to give a voice to those who are sad and suffering so they know: NO, you are not alone and your grief is real. They don’t call them heart pets for no reason. They take some of it with them.
She was a heart dog too, and I never even gave her credit for it until long after she was gone. This sad, head hanging little black dog with terrible head/chest proportions and bad gas taught me how to take care of others just by being true to yourself. If that isn’t love, I don’t know what is.
Yesterday, I was working on a homework assignment for a course I am taking on pet loss and bereavement. I was reading about the guilt so much of us feel after losing a pet, and one of the exercises they recommend we do is imagine a conversation with our pet. I decided I would try this with Kekoa, as I struggled- like so many people do- with knowing if it was the right time to say goodbye to her last year as she dealt with bone cancer.
Me: Kekoa, I’m sorry.
Kekoa: I love you.
Me: I feel like maybe I let you go too soon.
Kekoa: I love you.
Me: Do you forgive me if I made the wrong choice?
Kekoa: I love you.
I kept waiting for her to say something else, but that was all she ever had to say. It’s been almost a year, which is hard to believe. February 10th. A Valentine’s Day with a massively broken heart.
But now, I can think of no better way to reflect on this anniversary than to be with all of you, my friends, who can all relate to the special sort of sorrow this kind of loss rains upon us. The first- and hopefully not last- online pet memorial candle lighting ceremony is tonight, February 5th, 6 pm PST. I will be joined by several wonderful friends and we are so honored to be sharing in this event together.
How to Participate:
This ceremony, and this hangout, is for you and all you find meaningful. I encourage you all to participate to whatever degree you wish.
If you like, you can watch the Hangout right here, no special account required.
(Crying along at home is fine, by the by. I wish we let ourselves do that more often.)
Share a memory: You can click on the Q & A button and write a memory of your pet.
Share a photo: You can post a picture of your pet by clicking on the camera icon next to the “say something” box. If all goes as planned, I can incorporate those into the ceremony too.
Tweet a memory: If you post on Twitter using the hashtag #petcandle, I should be able to incorporate those tweets into the ceremony as well.
Above all else I want people to feel included. This is a group-owned event. Feedback after the fact is welcome as well. If you’re not up to watching, we’ll be sending much love to you. And if you know of anyone who might want to watch, I would love it if you could share this with them.
There is something vastly powerful about going through grief with friends. It validates, it resonates, it comforts. When it comes to losing a pet, too many of us are forced to endure the pain without that camaraderie of a circle of friends.
To that end, and because I know so many people continue to hurt and feel alone in their grief over the loss of a beloved pet, The Tiniest Tiger and I are hosting a Pet Loss Candle Ceremony next Wednesday, February 5th, at 6 pm PST.
What Will Happen
During this Google Hangout, we will be lighting candles to remember those who have left us, and to comfort those left behind. It’s open to all- kids can participate too!
How To Participate
1. Watch at home: at Google +, YouTube, or here.
The main Google + Event page is here. You do not need to RSVP to watch it, but if you do you will be sent a reminder through your Google account.
You can also watch at light your own candle at home without a Google + account. It will stream live, and also be up later as a recorded event, on YouTube. All you need to do is click on this link at the time of the hangout, or simply come back here and watch it here on this post.
If you would like to be online with us as a candle lighter, we will have a limited number of spaces. You will need a Google + account as well as a webcam- and a candle :). If you’d like to be a part of that, please contact me here or through my Contact Page and I can give you more information.
We are very excited to be doing this event as so many of us have known this sadness recently- or even not so recently. We hope you can join us!
I can’t believe Koa’s been gone over a month. Sometimes I still look for her around the corner or find some black fur stuck to a sock buried in the laundry pile. We are still adjusting.
I did a quick Google Hangout video talking about some of the lessons I’ve taken from my own dogs as well as my experience in the clinic. I hope it has some information people find useful, especially to those who have never been through the process before.
I do not profess to know what happens to us after we die. Even those who have strong faith in what will happen to us after we go are sometimes unsure of what happens to our beloved pets. And to them, I quote the great Will Rogers: “If there are no dogs in Heaven, then when I die I want to go where they went.”
When someone close to me passes on, be it person or pet, I have a dream about them a week or so later. I don’t know why, if it is a quirk of my subconscious or an actual visit or who the heck knows; the theologians can debate it all they want, but these particular dreams always stick with me long after I wake and give me a good deal of comfort. And yes, I had a dream about Kekoa a week or so ago, right before the funeral service in our backyard arranged by our daughter and very kindly attended by all four grandparents.
But last night I had a different dream, and regardless of what it means it really struck me because it’s the only time I’ve had one like it. Those of you who have been around for a while may remember me speaking about my grandmother Mary, who passed away several years ago and is the person, I believe, who most set me on the path I am on today as a veterinarian. You may also recall my grandfather John, who passed away just under a year ago. It was from him, I later learned, that I got my obsession with adventure and the dream of climbing Mt. Meru, which I accomplished last year.
So in this dream, I am driving around on a grassy hillside and I pull into a driveway, quiet and remote. Another car pulls up, and it’s my grandmother.
“Open the window so I can see your face,” she says. “It’s been so long.”
But I get out instead, and look in her backseat. And there is my dog Mulan, who died of melanoma in 2009, right before I started the blog.
Not Brody! This is Mulan and Emmett, in 2008.
“Is she doing better?” I ask, reaching in as she licks me.
“Of course!” Mary says proudly. “I know how to take care of animals. She is doing very well.”
I peer into the drivers seat. “Is my grandfather up there?”
“Yes,” she laughs. “But he doesn’t want to come out.” Which is typical.
I pat Mulan, and I start to cry.
“What’s wrong?” she asks.
“I just lost another dog,” I said. “She had bone cancer.”
My grandmother takes my hand, and says, “I’m sorry.” She kisses me and I wake up with a wet pillow.
You know how some dreams are. Some are bizarre flights of fancy, some dreadful chasms of dark worries come to fruition. And others, in those rare and brief moments, sweep you up in their elusive beauty and show you something that stays with you long after you wake. They feel real. And of all the people for Mulan to find on the other side, my sweet dog who was abandoned by an owner who didn’t feel like treating her flea allergies and wanted me to euthanize her instead, I’m so glad that at least in my mind, she found Mary.
I don’t know what it means, or if it means anything. But I am so glad it was a dream I got to have.
Scientists have long been fascinated with the concept of “muscle memory”, that subconscious part of our brain that controls movement without us having to think about it. It’s what allows us to do complicated tasks such as riding a bike or typing “the quick brown fox jumps over the lazy dog” without having to stop and say, OK, I need to contract my left hamstring while extending my right quadricep and all those tricky things that go into motion. It’s what allows me to tie a knot during surgery without the laborious thought process that takes place during learning “around the forceps from the front? or the back?” After a while, it just happens.
It’s funny how it pops up in the most unexpected places. For the past 3 years, Kekoa has been my footrest. I literally could not sit in the house without her wedging herself beneath my feet. Now, my feet head toward the floor, expecting a mass to bring them to a halt about 12 inches off the ground. I don’t think about it or calibrate their momentum, they just go with the intent that they will hit fur. Without her there, they crash repeatedly into the floor, each time a jarring reminder of what is no longer there.
It’s odd to me how strong those tangible physical reminders can be. For some reason, I can’t remember the exact timbre of my individual dogs’ barks- and I know they were all quite distinctive- but to a one I can tell you how their heads felt in my hands. Taffy, light as a feather, ready to nip at the slightest provocation. Nuke, needle-nosed and gently, resting into your palm. Emmett, like a solid football, sturdy and reassuring. Mulan, like a brick, wide and solid.
Kekoa’s head was disproportionately small compared to the rest of her body. She looked somewhat like an engorged tick, but in a nice way. She would lumber over and plop on your feet, her manticore tail smacking into the wall with such force you’d think someone was cracking a whip on the drywall. She never seemed to notice. Such was her excitement that she would hover over you, massive, looming, and then with the gentlest motion ease her tiny head into your hands and cover them with kisses. You’d try to push her head away when you had enough but then she’d kiss that hand too, so eventually you’d just give up. Her tail wouldn’t stop wagging the whole time.
She had a terrible wail. A piercing bark so heartbreaking and eardrum-wrenching that she lost two homes because of it. We used our baby monitor to listen in while we were away, and eventually I had to stop because it was too much to listen to.
That sound I can’t bring up. Already, I’ve forgotten it. But the sound of her tail hitting the cabinet, and the feel of her head in my hand- those will be with me forever.
Are there any strangely strong memories you carry with your pets who have moved on?