Peace of Mind for Pet Parents Episode 034: When Palliative Care Becomes Hospice: Knowing When to Shift Gears

Episode Transcript: 

Karen Wylie: Hello and welcome back to Peace of Mind for Pet Parents. I'm Karen Wylie here as always with Gail Pope. Our discussion today is going to focus on a gray area. One of those gray areas we've talked about many different times, but a particularly tender time, which is making a shift from when we're providing palliative care to our pets then to a more hospice oriented approach. There's no sharp dividing line between these two types of care. It's more like a softer curve in the road that you can't anticipate, where your pet's needs change. Therefore, your focus begins to shift from maintaining the stability of your pet's illness or condition to preparing for change.

So Gail, you and I have both walked this path many times with a variety of pets— you with so many of the animals at the sanctuary, me with my personal pets. So it seems like the first thing we should start out with is doing what we can to define what the two types of care really mean. Because it's not like there's a single day or a single diagnosis where it flips the switch from one to the other. It's a gradual transition but it seems like defining the difference would help.

For me, I guess the way to think about palliative care is that it is comfort care while still hoping for stability. So palliative care is definitely supporting living because we're still managing symptoms, we're adjusting medications, we're helping our pets feel the best they can feel even with a chronic condition or a difficult to manage condition, and even early stages of something that will ultimately be terminal. But hospice care is still comfort care when time is getting short. So how am I doing as I'm trying to pull these two apart a little bit? How would you add to that?

Gail Pope:  I think as the dynamic changes, and we are heading towards the end of life, my mind rests firmly here with human hospice care and human palliative care belonging together. But in the human world, because of insurance etc, it has to be very cut and dried. However, in our animal world, it isn't so cut and dried generally.

You understand what palliative care is. You understand what hospice care is. In order to do hospice care, palliative care just belongs there. It already sits under that umbrella, doesn't it? There doesn't have to be a particular time when you shift, It's more of a gradual transition. Just one of those transitions in life and living towards dying and death and transition.

Karen Wylie: And that, of course, I would completely agree with because as I was saying earlier, it's not like there's a specific day or time or one symptom that you see once. It's not like you immediately switch gears. It's very much just a gradual road that we go down. What would you say are some examples of conditions that pets have, that move from palliative to hospice care?

Where a pet owner is already providing palliative care on a day-to-day basis with some illness or diagnosis or condition that their pet already has but their pet is stable and, maintaining a very positive quality of life then at some point that can shift.

Gail Pope: The ones that we're all most familiar with obviously is cancer. The C word is the number one, renal issues, the main organs: the heart, the liver, the kidneys. It's all those diseases that have been so commonplace. 

However, also the other big one that sits firmly in there is aging. As we get older, these things become more important in our lives. I think particularly in the human world, if people selected hospice and palliative care for themselves or for their family members earlier than they generally do, then life would be so much better.

So much more beautiful are those end stages because when you are looking at the holistic approach of end of life for body, mind, and spirit— you're embracing all of that under the umbrella of hospice. Then it's just a beautiful time, and very often it's a time when we see healing as actually provided for new life, very often again, in the human world.

Humans, or people I should say, go into the world of hospice when they have a difficult diagnosis and eventually death is presumed to be in the future. When that new holistic approach is offered, they start to get better and sometimes they're discharged from hospice and they live longer, fuller, beautiful lives for a very long time. So it really is, I think, the body, mind, and spirit approach of hospice with palliative care as a layer that is just included rather than is separate. It's all part and parcel of this beautiful bubble that takes care of the whole family as well as the animal as a unit.

Karen Wylie: What you were just mentioning was making me think of Jimmy Carter. Because when he went into hospice care, of course the expectation from an insurance, Medicare insurance point of view is six months. That's when people are admitted to hospice because they have six months or less to live and he lasted a year and a half with wonderful hospice care. So I always think of him as someone who did a lot to illustrate what's possible with both palliative care and hospice care. Because clearly his conditions were being treated and he had more time than expected.

That's certainly true for so many of our pets and whatever they're dealing with. You're bringing up age -related conditions like cognitive dysfunction, the severe arthritis affecting mobility more and more over time, pain issues ... .diabetes would be another one. I would talk about how we start treating them at the beginning and they can be stable for a very long time but then they can start declining as well. Maybe different treatments or changes in insulin, etcetera, can restabilize but at some point we're not able to stabilize anymore.

So anyone who's listening dealing with kidney or heart disease, cancer, mobility, neurological or dementia— you're likely walking that path from palliative to hospice; that gradual transition. So it's not necessarily "I'll say it this way and let you say it your way."

It's not about doing less for your pet, it's more about doing it differently. Because when you're making that shift, it's more about peace of mind for you, peace for your pet and not focusing on procedures.

Gail Pope: Yes, I'm right with you on that. I think for most of us, the focus after a diagnosis is curing it. "What's wrong?" "What can I do?" "Let's do it. 

Let's make it better."

And sometimes that isn't the outcome and Mother Nature follows a different path. So I think we can become so focused on cure - until we finally realize that cure isn't going to happen. Then if people had a lot more education and understanding about how beautiful hospice is and how it relieves such stress, It would change the mindset to living in the moment instead of fighting something. I think it's just such a beautiful way to work through living.

It is all about living. That's what we are all doing most of our lives anyway— heading through one transition or another towards the final transition - in this lifetime anyway.

Karen Wylie: You bring up living, it's both living day to day and it calls to mind the “Living Quality of Life Care Assessment Tool” that we have available because shifting gears from a palliative approach when everything's stable, to hospice when you're not able to maintain that stability anymore. You're still providing comfort but the stability is the big change. One of the ways to know where you're at is to be using a Quality of Life Assessment Tool regularly so that you're seeing patterns because this isn't where one thing happens and you say, "Oh my God, it's hospice."

It can happen but 98% of the time that's not how it goes. It's not just one crisis that means you're in hospice care. So being able to regularly monitor what's happening with your pet lets you begin identifying when patterns change and what you can do about those patterns changing. Whether it is something a medication can be changed in some way to restabilize or not.

Gail Pope: I think one of the questions I'm asked a lot when talking about palliative care and hospice care, people have said to me "I'd prefer to treat my animals holistically, so I guess I don't fit under that umbrella."

Or they'll say "My doctor is not a holistic veterinarian. He's very conventional."

I think people worry about whether they can move into that hospice period with either kind of approach but of course, everything fits. We are talking about holistic medicine with an H but hospice care is a Wholistic approach, so it takes— Oh gosh, I'm getting tongue tied now.

It takes holistic thinking or holistic medicine, and it puts the W in front because it includes anything and everything. It's Wholistic care. It's what's best for that patient and the family.

Karen Wylie: Which makes perfect sense. I think people can find support, whether it's from a conventional vet or a holistic vet, because if that's who you've been working with, you've adapted to their style, their approach to care whether it's a holistic or conventional approach. You've chosen a track to go down and you can still get support from whichever type of care you have been focusing on.

I think another clue that you might be shifting gears from palliative to more of a hospice approach is when you find yourself wanting to take your pet to the vet more frequently for more tests or to be checked because something's changing and you don't know how to deal with it. When that starts happening a lot, that's definitely a sign that the stability that you had for whatever period of time— which sometimes depending on the condition or disease, could be many months or years even. So when there's that kind of change and you're needing more frequent veterinary support, that's usually an indicator that something is changing, something's no longer stable.

Gail Pope: Yes. That's fascinating because what I'm realizing now is that for many years I haven't switched from one thing to another. I've treated our animals the same all the way through. I'm known for hospice but even when I have a younger, seemingly healthy animal, they still fit under the umbrella of BrightHaven's Protocol for caring.

Everybody fits under it. It is a focus on living which eventually took me into the world of hospice. I went in there kicking and screaming because I thought hospice was all about death. I’ve probably told this story many times, I simply didn't know. I was brought up in England, obviously, when the word hospice meant death and dying.

So BrightHaven animals had taught me to care for them through life and to embrace dying as a part of that life. So without even knowing it, I had moved into the hospice space without knowing it, without labeling it, just doing it. So it was beautiful when I was introduced to what that word actually meant in life and caring for loved ones.

And it's, "Oh wow, this is what I've learned. This is what animals have taught me."

So I think it's beautiful. I like the way you expressed that. Thank you.

Karen Wylie: It is interesting that neither one of us understood we were providing hospice care when we were providing hospice care because long before we ever met, we were dealing with what we saw in front of us.

We were always dealing with the pet in front of us and just adapting day to day as needed to keep them on the planet as long as possible for both me to enjoy my babies and for them to enjoy their lives. But then when things would shift, I had to learn to accept that shift that they were showing me and increase my ability to know when it was happening. I certainly didn't know those signs for myself 30 years ago. I had to learn that.

I really hadn't focused on hospice care until I was going through human death doula certifications and focusing on providing support to people in hospice care and their families. Then suddenly it was like, "Oh my God, I've been doing that."

So it's really what, maybe 4, 5 years ago for me now at this point. It is interesting to think about because if you are focused on the pet in front of you it's a gradual road, and yet as we're talking about the medications starting to lose their effectiveness, you might find yourself headed to the vet a little bit more. You start seeing some indicators of decline, like progressive weight loss, the little bit of weakness where maybe they're not jumping up on the couch as easily as they used to or into the back of the car there, they could start being disinterested in food. I guess that part of this has to be our own intuition as pet parents.

Gail Pope: Exactly. As mothers, we know these things, don't we? We pick up on them, but I do think it's easy to get lost in everyday life and not pick up on the signs if you don't know about them. It's hard because I've cared for so many hundreds of animals that it's become just a normal thing for me to notice as things change.

I would imagine that most pet parents do notice. Maybe there's subtle ones they don't notice so much, but over a short period of time, then I think we all notice. Whether we actually take any action or figure out whether any action is actually needed, it's about making adjustments, and perhaps paying attention to a quality of life scale like ours.

Karen Wylie: Like ours, “Living” of course.

Gail Pope: Then it's in your mind as your animal is getting a little older or a little grayer, a little whiter. Pay attention to the little shifts and think about what more you should or could be doing and that would take you forward in baby steps to “healing for the highest good"

And letting go of whether the highest good for your being, your animals being not your being, or both maybe. Just making that determination, understanding what is the highest good, and sometimes that is for living a little longer and sometimes that is for transition to gently take place.

Karen Wylie: One of the things I do very much like about our Living Quality of Life Assessment is that we are very focused on the joy that each pet takes in their day-to-day life and their life with us. So that it's not solely or primarily focused on the physical, it's also on the more subtle moments of when, or how they're enjoying their life and the joy they're experiencing. Whether that's basking in the sunshine, whether it's going on a walk, whether it's maybe needing to shorten the walk but still enjoying the walk, and that's still enjoying life. So monitoring all that is important.

I think you had so many animals in the sanctuary that most of your day was focused on monitoring everybody. You had your record keeping, you had volunteers, you had staff, and everybody was focused on making sure everybody was okay. Everybody was stable today. I approached it that way too, especially when I had more animals, which is something we talked about in other podcasts.

Some things are easier to learn when you have larger numbers because you can compare. So I think it can be harder when you just have the one animal or maybe two and what's happening with that animal is a brand new, different disease or condition that you've never dealt with. I've had so many cats over the years, they get to that 15 to 18-year-old point and then kidney disease raises its head and we're monitoring the stages and what to do. But I haven't had that much experience with liver  disease, and so if I had a liver issue diagnosed with one of my animals, it'd be like, "Oh my God, what do I look for?"

It'd be a brand new thing for me to worry about. So I think that holds true for a lot of pet parents with just one, two, or three pets and all at different ages and stages and that sort of thing. 

One of the things that was interesting for me to think about was - “What are some ideas we could talk about for this episode or the next episode”? One of the reasons I was thinking of this topic for us is because of the conversations that come up at our weekly Cuppa and Conversation groups when, because we don't necessarily talk about it or label it as palliative care or hospice care, but the questions are more like "My cat or dog really doesn't want the Sub-Q fluids anymore. What does that mean?"

It could mean so many different things. It could mean maybe you can get better at giving the Sub-Q fluids. Maybe they don't need as much quantity of Sub-Q fluids. Maybe there's been a change in that or maybe the pet is starting to make that shift themselves and feeling "I don't think I need those anymore. I don't want those anymore."

Identifying what's happening can offer lots of different reasons, and that's why it's such a gray zone.

Gail Pope: It's all about finding balance to make each day the best it can be, and to be open to the physical and the emotional declines that we all go through as we age. At any age. We're changing all the time. Life is a transition in itself. Being open and aware and attentive to what's happening is important as is preserving the joy, the fun, and again it's all about balance. It's about bringing it all together to make life as good as it can be for your loved one today, whatever that involves.

Karen Wylie: Whatever it involves.

Gail Pope: I know I used to be so involved in the label, the disease that it took me away from where my focus should be. I know I've said it before but that's why I love working with classical veterinary homeopathy because we put all the symptoms into a pot. We work with the remedy and we accept and we see balance coming. We are not focused on medicalizing the journey. We're just focused on supporting it and working I guess with Mother Nature who is our ally on the other side, if you like.

Karen Wylie: The other doctor in the room. I think as you're saying, when we feel like we're managing decline more than maintaining stability, again, that's where we're starting. It's a sign that we're entering hospice territory and hospice is not about giving up. As we've talked, at other times it's just about changing what we give to our pet— which as I guess I said a little earlier, is more peace for them, peace of mind for us, instead of more procedures and more treatments.

Gail Pope: Exactly, it can be a beautiful time.

Karen Wylie: So let's begin thinking about how to bring this conversation to a close. I don't think we've talked too much about how each of us as the pet parent can reorient ourselves a little emotionally and practically when this shift may be happening for our pets. Is it a reframing of our goals? How would you suggest that a pet owner think about this process?

Gail Pope: I think understanding that it is a process but I think that it's a difficult question. I take it for granted. I know I haven't really thought about it in that way. I think that when we love someone, we adapt with them. Each day, each hour, each minute, if you like. But as we're attuned to our loved one, we step into the process and we move with it without necessarily verbalizing it sometimes, but we accept that our dog wasn't wanting to walk quite as far. We see and we know all these things and our brain stores them and compartmentalizes them all, and we go with the flow. Maybe some people don't but I think most of us do, don't you?

Karen Wylie: I think most of us when we do make these initial observations of the dog not wanting to walk the full length like it usually has, it's like, "Huh, that's weird." Then it happens a second or third time and it's "Oh my God, no."

I think there can be some moments of denial of not wanting to see it. But again, that's where keeping track every week or so looking for patterns and not getting upset for the one thing that happens lets you stay more peaceful in this process.

You're more on top of it. If you are doing that— letting your intuition be active, you listen to the guidance you're getting and the sense you have of what's happening, and you're keeping those weekly records so you're not trying to rely on remembering you're looking for patterns and not one time things. You don't have to wait for somebody else to tell you that your pet is entering hospice care because you have a good sense of what's happening as well as the observations you've been making. So you know, it's up to you to decide whether the comfort and connection with your pet is what matters more than going back to get new lab results.

Gail Pope: Yes, or medicine isn't working. Sometimes it will happen when there has been a difficult diagnosis. It doesn't even have to be a terminal diagnosis but very often if it's difficult, it can be a terminal diagnosis, and that means time to pause and reflect and remember some of these things, like a shorter walk and a little less energy.

"Oh, and that's been going on for a while now."

"He's certainly sleeping longer..."

And these things all start to come together and then it's looking at the medicine. Is it really doing anything? The diagnostics don't seem to have shown that we've had success. Maybe it's time to think about what else we can try. So those are the occasions to start thinking about a new way forward. Let's face it, it may not be about hospice. It may be about just making a few changes here and there and perhaps stepping into palliative care. Then going a little further. I don't think there are any cut and dried lines necessary, or sometimes there are particularly in more acute situations, perhaps.

Karen Wylie: Yes, but not in the ones we've been describing today. We started out talking about how this is a gray area. There are no black and white specific answers to this.

Gail Pope: Exactly. Yes, it's a long and winding road.

Karen Wylie: It is, and can be, and you can keep your pet with you longer generally by observing and adapting and doing all the things that we're talking about. Being more confident in yourself as a caregiver, with your own observations and not expecting your vet to know everything about what's going on in your home because that's just not going to happen. You're the primary caregiver and have the knowledge about your pet.

So if you are listening or watching today and wondering whether your pet might be nearing this stage… I guess one of the things that needs to be said is that hospice isn't a moment, a single moment. It's more of a mindset of how you approach the care of your pet when you're not giving up. Your focus is still comfort and giving peace to your pet, peace of mind for yourself and unconditional love in their last chapter. When we shift from prolonging life to enriching it that does mean we're walking the Hospice path. So Gail, is there anything you would like to say?

Gail Pope: No, I honestly think you've just said it. You said it with one word, enriching. Enriching— it made me go goosey when you said that. It really is a precious time and it's enriching life. Again, that comes down to what I always say, it's healing for the highest good of the being. Oh, beautiful. That's it— enriching. I love it.

Karen Wylie: There we go. It's a sacred time and doing everything we can for them and ourselves is all a part of it. If you are thinking you have a pet that you're on this path with, do think about what your pet needs most from you right now. Do they need more treatment, more tenderness?

And what would your day-to-day life look like if you focused on how they're living instead of how long they're going to live. I think that can change everything and that's the enrichment and why you got goosey. I always consider that a very good sign. Thank you all for being with us today. We hope you'll be with us again next week and bye-bye. Thanks.

Gail Pope: Thank you. Goodbye.