Peace of Mind for Pet Parents Episode 60: What If Your Pet Had a DNR? Planning for Peace When Crisis Hits

Episode Transcript: 

Karen Wylie: Hello and welcome to Peace of Mind for Pet Parents. I'm Karen Wylie here as always with my wonderful friend Gail Pope. Today we're going to talk about something that perhaps is a little unexpected in a conversation about pet care. It's a conversation that most of us have probably only had in human medicine and that's the DNR— the “Do Not Resuscitate” form.

Most of us know what that is, at least in a general sense. Maybe someone in your life— a parent, a grandparent or maybe even yourself has put one in effect. It's a document. It's a decision. An expression of a deeply personal wish that someone has about their body and a body that is maybe in the process of dying and you're saying, "Please don't pull back from that. Let me go in peace."

There are different levels of care that can be specified in a DNR and we'll get to that in a minute. In human medicine, it's one of the most loving things that a person can do, not just for themselves but for their family members to provide guidance about what they would like their end of life to be like. 

And yet I guess what I want to start with today it's also one of the most commonly overridden decisions in medicine. For reasons that are very human and ones we can all relate to as pet parents - just because we've thought one way a few months ago, we can change when a crisis is upon us. And humans do that all the time, especially when our loved ones are in crisis. 

So Gail and I see that same kind of thing happening all the time in the world of pet care and yet nobody's talking about this process of how we change our approach to the care of our pets when there's a crisis. So that's what we're going to talk about today.

Gail, I guess we should start with describing a little bit about how DNRs are put into place in medical care. I'll share my experience with my husband, Tim first, and then I'll ask you to share the same because although in some ways they're similar, in others, they're very different. 

About 10 years ago, my husband had an erratic heartbeat and that got us into an emergency room. At that point he was, I guess 71 or 72 and, of course, he was referred to a cardiologist right away. The first thing when we got to that cardiologist office was the question, do you have a DNR? Do you have advanced directives? At that point, we had wills that the lawyer had, but we didn't have anything because neither of us had any health issues at that point. We said no. So of course they gave us all the paperwork to begin reviewing and then as each healthcare practitioner came into the exam room, they would say, "Has someone spoken to you about A DNR? About advanced directives?"

So literally by the time we were leaving that first cardiologist appointment, we'd had five people talk to us about this. We got into the car to come home and had an hour drive back from Asheville. All we were really talking about was like, "Can you get over this?" 

It's really the erratic heartbeat that was the first sign that, "Hey, we're going to have to do these tests and these other tests and we're going to have to monitor you every six months. This is what it's going to be like and even though you're in good health now with just an erratic heartbeat, this is what we need you to be thinking about and we do need you to sign these and we do need to have these on file."

So that was our entry into the world of, I don't know, I want to say healthcare but really part of tsickness-care because every six months as we would go back for a routine appointment, it would start in every room with every practitioner. "Do you have a DNR in place?" 

So it was a very big deal for the human healthcare system because they're legally responsible to not override it themselves, not to do what they think is possible. Family members tend to override it all the time but as healthcare practitioners, they're legally prevented from doing it. They have ethics committees and patient advocates and all sorts of protective processes in healthcare. 

So that was my first exposure to DNRs and advanced directives. What about you? With Richard, was that your first experience with it?

Gail Pope: Oh, God, yes. Obviously I knew about them but I hadn't really done any research or really thought deeply about it. When Richard was first diagnosed with cancer, it was never brought up. It was much later in his journey, years later in his journey when he really started to lose weight. It was really clear. At that point, I think hospice would've been a great choice but nobody ever made that choice and Richard wasn't ready to hear the word other than in our animals’ lives.

I actually remember the day. One day at the hospital, after I think Richard had gone for a test of some sort, we were asked if either of us had a DNR. We were both like, "No". They gave us the forms and just said, "Take them home and have a look at them. It's worth thinking about." So that was our introduction to it. Then as time went on, it was raised a little more often but every time it was like, "Yes, actually we do have one." You could feel the relief, "Oh, good. That's important."

Perhaps not something that everybody wants to talk about but when the actual time came when Richard was at a point where the DNR would've been used. He had a crisis at home and initially I asked him if he wanted me to call 911. Fully expecting, knowing his wishes that he would say, "No, just stay with me. It's okay." But he said "yes"— call them right away.

Karen Wylie: Surprise.

Gail Pope: So, I did and the paramedics arrived and one of the first things they said when they came through the door was, "Do you have a DNR?" So I gave them his DNR and so they rushed him to the hospital and something broke down at that point. I'm not sure what, where, or why, but obviously the DNR— I don't know whether it went with us or it didn't. Actually, I think I know what happened because I did overhear part of the conversation. Richard revoked it. Basically, I heard them say, "Okay, Mr. Pope, do you want this? Do you want that?" So they went by his verbal responses. He could barely breathe and they kept having to lift the oxygen mask up for him to speak. He was basically saying, "Do whatever you need to."

So that was interesting to me because regardless of the fact that we'd had lots of family conversations about what we would all want or not want, and we were very focused on exactly that. When the time came, it all changed. So that was interesting to me. I haven't really had a chance to think about this very much because you sprang it on me like about an hour ago.

Karen Wylie: At least you got an hour. Come on now.

Gail Pope: But it's interesting in that hour I actually remembered that, look, here's mine.

Karen Wylie: Exactly!

Gail Pope: And they sit on my fridge and they explain what I would want and what I wouldn't want done to me. I think it's wonderful and when you first mentioned talking about DNR for humans and then moving into talking about whether we would have those same principles for our animals, I was like— and I still feel a little bit like I don't know how that would work. But yes, it does make an awful lot of sense.

You know, when an animal comes into hospice care, I think it is, although we don't call it a DNR, but we do think that through. We do think about what we would like their end of life to be and what they— obviously it depends on the animal too. They all have personalities and the kind of animal that would wish for this or would never want that. It varies from being to being and human to human too.

So I think these kinds of forms— you know what? Maybe you should actually create one because for somebody who's got an animal who is approaching end of life to be asked, maybe not all of these deep medical questions for emergency care but feeding, hydration, all of the things that start to decline towards the end of the life - things that scare people and they panic about. 

So having a form that not only gently explains but then says you could do this or you could do that. Think about this or that. It's starting to roll around in my head that maybe we should think more about what happens at the end of life. Because a lot of people end up in a veterinary hospital, an emergency hospital— obviously there's a rush. This happened and that happened, and they say, "It's okay. Leave him with us", and that's it. You don't see them anymore. You're not handing them a form. You then, generally will speak to reception and fill in some details, but you aren't really allowed personally into that situation.

So if we had one of these kinds of forms and could say, "You know, he collapsed and here's some instructions." Wouldn't that be wonderful?

Karen Wylie: I think it would be because we've both been through this so often with our own pets at the end of life. Where we're committed to providing comfort care, depending on what the original diagnosis was and we're working through. But then there comes a time when they begin actively dying, that someone who's not seen the process before could begin to panic and take their animal to the ER. Then even though the animal was in the active dying process where its body has begun to shut down normally, naturally. But it can be scary when that's actually happening.

So someone could have been committed to providing comfort care but really not understanding what it would look like and what they would want to do. So that's what I was reading a couple weeks ago about DNR in human healthcare. That's when it was like, for me, we need something like that. Not necessarily committing to all the levels of care and specificity that the forms you were asked to complete include. 

One of the things that actually was very helpful in the seven year process when Tim had his first erratic heartbeat to when he finally got a pacemaker, it was on one hand annoying that we were asked all the time but some of them would say, "Have you updated it? Have you looked at it recently?"

Then it was like "No, actually..." Because we had not looked at it and Tim signed it seven years prior to the pacemaker being implanted. The whole point with that is, it's one thing to have a feeling of how you want to handle things at the very beginning of a diagnosis but your feelings and your decisions could change over a period of time.

Gail Pope: Of course and you won't necessarily be able to speak. Richard was able to speak and say what he wanted at the end. But that was nothing like what was on his form. Had he not been able to speak, they would've treated him very differently.

Karen Wylie: Yes.

Gail Pope: It's fascinating. It's interesting.

Karen Wylie: So I think that the timing of it though, it's one thing that I think begins to be very important if we're going to consider this idea of what could we do that is like this in the care of our animals. The timing of it makes a difference because you really don't want to be signing something like this when you are in the ER and you're in the middle of a crisis with your loved one, yourself or the animal. 

The time to be completing a DNR or something like it, maybe a commitment to comfort care for animals or something, but the time to do that is when things are stable. When you can think clearly and your emotions are not overtaking your ability to think clearly. When you don't have immediate decisions that you've got to make.

Gail Pope: Ideally, that would be at the beginning of the hospice care journey but of course very often the hospice care journey for animals and people starts much too late. It's difficult to generalize but say six months before when the being is starting to decline and that's really when the comfort care should start beginning but it varies.

Sitting here remembering an incident that happened to me which actually was a huge learning experience for a number of people in the veterinary profession. 

It was an interesting time. I had taken one of our animals to the vet. He was getting close to the end of his life, not that close. It was difficult to tell and I can't remember the medical situation but there was something that I wasn't quite sure about. So I had taken him in and asked them to check him over and just see what was going on and see  if there was something more than we could do. I went back home and I hadn't been home long and the phone rang and it was the clinic to say that they needed my permission to euthanize him. I'm like, "Oh my God. Oh no, what's happened?" I didn't live far away, so I said, "Absolutely not. I'm on my way."

I drove straight there and they took me back. It was absolutely an interesting experience, I think, for all of us because there were two techs and then there was the veterinarian. There was somebody else— maybe a technician in the background. They were all clearly, "Oh my God. You are here at last, at last. Is it okay? Can we go ahead and…?" You could feel the *distress sound* and I looked at the table and there's my cat, who is very clearly in his dying process and very comfortably so, and I said, "It's okay. It's okay. Please just give me a minute."

So, I stayed with him and just really got a sense of whether I was right or wrong. The atmosphere in the room very gradually came down but there was still an awful lot of, "You want to go ahead now? Or whatever?" And I said, "No, it's absolutely fine. He is actually dying. It's okay." He passed away literally very gently while I was with him and they were watching and there was such a mixed feeling. There was an, "Oh my god." There was relief. There were so many different energies around that room at the time but it was a lesson for everybody in it.

I have to thank the cat for actually giving us all that lesson because again, it was partly my energy because once I was there, he was able to just let go. Thankfully he died really peacefully and really easily which was a really interesting experience for the veterinary staff to have experienced with him. That just came back to my mind. I hadn't thought about that for a long time.

Karen Wylie: You're describing the situation that happens for so many pet parents that if the animal is in the active dying process— a natural process, but they haven't seen it before.

Gail Pope: And won't know what is to be done.

Karen Wylie: And their animal could be an hour or two away from going on their own, but they panic and they bring their animal to the ER. What are our ERs and our vet clinic's supposed to do? They're supposed to fix things, treat things, make things better. So that cat being in that clinic that day, that may have been the very first natural death that the veterinary team saw. This is not something they teach in school. Depending on the age, depending on the disease trajectory, depending on— there are lots of things to consider but natural death is possible for many animals.

It would be great if more veterinarians were given exposure to that because then when pet parents might bring their animals to an ER situation and say, "Is there something to be done?" They could say, "No, not really because they're pretty close already on their own. If you want we can do X, Y, Z." 

But if people haven't thought through what they really want for their pet's death and what they don't want for it, then they can't answer. They can't in the moment of crisis, when they're crying and they're confused about what's happening and they're not sure if there's anything to be done and so they say, "Yes, do what you can." Even if there's really not much to be done.

You and I have talked about the fact that we each have had many peaceful natural passings. Part of that is because we go with the process. We let their body do what it's going to do naturally as it's shutting down, as they start to eat less, as they start to drink less and their hydration becomes less and their body, all the systems start slowing down and then shutting down. We don't intervene to stop that process and a lot of times it's that intervention that can cause the crisis.

Gail Pope: That's right, absolutely. I think it's something to really think deeply about.

Karen Wylie: I think it is, in terms of the timing of it because people can always change their mind. But if they can begin thinking about it early in the diagnosis process of their animal's life or the disease early in the disease trajectory as their veterinarian describes it to them, what they think is possible or what they think is likely, thinking through these kind of things before they need to make a decision on the spot would be—

Gail Pope: There's nothing worse than making an emergency decision especially if you've taken your animal to the vet for an emergency and the next thing you are faced with is a decision, do we do surgery? There's this or this and you don't have more than 30 seconds. It's "Come on, do you want to do this?" You know, they tell you something about the surgery and what the odds are and what do you do? You have to jump off that cliff one side or the other. Then if you say yes, you may regret it. If you say no, you may regret it. So you're in trouble either way.

Karen Wylie: You're in trouble either way. We work with so many people who, years later are reflecting on those decision points. Those situations where they were unprepared for the situation that came. So it just seems to me like we can all do a better job preparing pet parents. Certainly, our veterinarians and clinics could perhaps give some thought to helping their clients begin thinking through how they want their pet's end of life process to be and what their ultimate death to be like.

Somehow I think I have my marching orders to be developing something like this for our clients.

Gail Pope: I'm actually thinking about that now. I think it's the perfect task for you. Once you get your teeth into it, I think it's as simple as a little Q and A. It would be different for every animal. Some animals relish treatments and they're really good about it. Others, they would rather die than have something done to them. Especially some of the wild ones. They've come in as a feral cat and they're gradually acclimatizing themselves to human life but they've still got this feral streak. Sometimes they would rather die than have to endure, x, y, z.

Karen Wylie: Very true. That's where the timing issue makes a big difference, I think. Again, just reflecting on seven years of it with Tim at the cardiologist offices, every year or two someone's saying, "Have you updated yours? Has anything changed?" 

That is such an important piece that you can think how you want to care for a particular animal.

Months down the road or years down the road, depending on what's going on, you might say, "Okay, based on this new information, I think I've got to make a different decision. I've got to approach it differently. So it's not one time and that's it but I guess it's part of our process of monitoring quality of life.

Gail Pope: I was just here thinking that it really is just a step further forward because we've got a "Monitoring Quality of Life" and then we've got "Peaceful" monitoring the quality of actual death. Now we've identified a little gap in the middle here. So I tell you what, by next next Monday when we meet, you can introduce us to—

Karen Wylie: Our new checklist!

Gail Pope: Oh, how funny. I love that.

Karen Wylie: I'll do what I can. I'll do what I can. I'm really glad we had this conversation though because after reading it a couple weeks ago about humans and just starting to think that it's just something we don't do for ourselves in pet care. We don't do it for our clients. 

I think that's a missing piece of the end of life puzzle.

Gail Pope: You have to also realize that a lot of people would say, "Oh, I wouldn't want to do that." People shy away from the thought of aging, illness or dying and they don't want to make plans for the future. They don't want to think about what their decisions would be. So I think it's a baby step type of thing. It is stepping into it gradually and gently but just having people start to think about, "Do I know what I would want for the end of my life? Wow. Now let me look at my four-legged children. What would they...?" Because they're all very different and you can imagine they would all choose different interventions or no interventions.

Karen Wylie: Yes, like we were saying here just a few minutes ago, the timing of it can change. Everything can change over time. So asking the questions, answering the questions while your pet is healthy and stable would be the best time. Then revisiting those questions over and over and just adapting your answers as needed would be an easier way to go than finding yourself in the ER and not knowing quite what to do.

Gail Pope: Yes, exactly.

Karen Wylie: Anything you would like to say In closing, my dear?

Gail Pope: I'm still sitting here with it flowing backwards and forwards through my mind. But again, it's something at which love has to be the base. Love is the bottom line. If you love someone, then doing something like this for them is a blessing, isn't it?

Karen Wylie: Yes.

Gail Pope: It really is. It takes you to a deeper place that most of us don't even want to think about but on the other hand, it really is all about love.

Karen Wylie: It is and perhaps some love of yourself too because thinking ahead like this could be a great step towards self care as you give care to your pet all the way through.

Gail Pope: Beautiful. That's absolutely beautiful. Thank you.

Karen Wylie: And thank you for being with us today. We hope this episode was meaningful to you and if it was, please share it because this is a conversation all of us who love our pets should begin having. If you have any questions or a story idea or a topic you'd like Gail and I to address, please send it our way.

We'd be happy to consider that. You never know, we might take on your topic very soon. So until next time, take care of yourself and take care of all of your pets. We'll see you next time. Bye-bye.

Gail Pope: Goodbye.