Life, love, loss

LORA COHN STOOD IN THE DOORWAY OF HER department chair's office listening as he described a complicated assessment form he hoped she would complete. Tears began to show in her eyes.

Main photo: photodisc; leaf photo ©iStockphoto.com/Ben Walker

"I'm sorry," she said, waving a hand. "I know I'm not supposed to be like this. I know I'm supposed to be stronger. But I had to put my 15-year-old kitty Dagwood down yesterday, and I just can't concentrate on anything today."

What Cohn needed most at that moment was to communicate her feelings with a human. She needed to sit down and tell Dagwood's story. She needed to mourn.

Alan Wolfelt, Ph.D., in his book, When Your Pet Dies: A Guide to Mourning, Remembering, and Healing (Companion Press, 2004), draws a critical distinction between grieving and mourning. "Mourning is the outward expression of grief," he says. The problem: In modern society it's natural to grieve, but it's not acceptable to mourn—much. People don't like to think about death, let alone talk about it.

As Wolfelt points out, we have established the pursuit of happiness as an inalienable right. And, if we have little tolerance for mourning human death, we have less tolerance for those who mourn the death of their pets.

Dr. Melissa Rose, Cohn's veterinarian in Parkville, Mo., sees first-hand the reluctance people feel to mourn. "A lot of people I see are embarrassed by their feelings," she says, "even though some people feel closer to their pets than they do to their family members."

It's inevitable that most of your clients will stand in a doorway someday holding back tears. You know—better than any other health professional—the helpless feeling you get watching a person mourn the loss of his or her best friend. However, the experts say that you don't have to feel helpless. You know you can help dying pets out of life; you can also help their companions through the loss.

Let mourning happen

Cohn holds a doctorate in communication studies. She cites research suggesting the helping power of telling "the story" of those we lose. Cecilia Bosticco and Teresa Thompson summarized the literature last year in The Journal of Family Communication: The very act of telling stories, of putting loss into words, they say, helps people understand their grief. Listening, providing the space and time for them tell the story, is one important way you may be able to help your clients.

Sharon DeNayer, practice manager at Windsor Veterinary Clinic in Windsor, Colo., knows how important it is for her clients to share their stories. "Veterinary medicine is the only medical profession where we actually see the patient from birth to death," she says. "That's great, but it also puts a lot of pressure on veterinarians and their team members. As a practice, we knew we needed to offer a lot more pet loss support."

"It was a beautiful thing to me"

DeNayer learned about end-of-life issues through coursework at Wolfelt's Center for Loss & Life Transition in Fort Collins, Colo. And when Windsor co-owner, Dr. Robin Downing started "The Downing Center for Animal Pain Management"—a referral practice within the clinic—DeNayer took on the title of Bereavement Companion.

DeNayer follows Wolfelt's philosophy that the best strategy is to offer people friendship through their journey. "That's really what we're doing," she says. "We're helping people arrive at the point they can say it's time for euthanasia, and we're serving as companions through the process."

Guiding clients

The key to helping people through euthanasia of a beloved pet is to "walk with" them, in Wolfelt's terms. Support their decision, give them a quiet comfortable place to be, and, in some cases, cry with them, DeNayer says. She says veterinarians and their team members see many people today genuinely wrenched by the loss of a pet. And for some, she says, it's their first experience with death.

"That's why we like to set up a time for the whole family, including the children, to come in and talk," says DeNayer. "We answer their questions and talk about what's happening with their pet. We say, 'Here's what will happen when it's time.' We think talking about death and helping children understand more about what will happen makes it easier when the time comes."

At this early stage in the process, the Windsor team takes the client through each step in the practice protocol for euthanasia. They begin with the details, such as whether the client wants to be with the pet during euthanasia and whether the client wants private cremation or general cremation.

DeNayer also likes to have the legal papers signed in advance. Windsor Veterinary Clinic even offers clients the option of writing advance medical directives, as some people do in human cases. "We want the family to be able to just concentrate on their pet when they come in," she says.

When the time has come

Of course, knowing the time for euthanasia is perhaps the most difficult issue in helping people deal with the death of a pet. DeNayer thinks the first step in easing people through the process is to begin talking about the end early—months or even years before the time arrives. "We should begin to educate before the decision point," she explains. "We should begin the discussion when the doctor makes a diagnosis of a serious or terminal disease or illness. That's when you plant the seed: 'At some point we will decide when enough is enough.'"

Team training to provide closure

Kim Albert was not sure the time had arrived the Saturday morning she brought her beloved dog Punkin to the Windsor clinic from her home in Greeley, Colo. Dr. Downing, Albert remembers, was patient with her misgivings. She remembers sitting on the floor of the comfort room with Dr. Downing, DeNayer, and Punkin. The more she looked at Punkin's distinctive black-and-white face, the closer she was to the decision. The extra time to decide helped her come to grips with this difficult choice, she says, and prevented her from being nagged by it later.

In Parkville, Mo., Dr. Rose remembers her most difficult euthanasia. In her case it was the lack of an owner's decision that nagged. She was still a veterinary student at the University of Missouri-Columbia. "The owner wasn't ready and I was beyond ready," she recalls. "This older dog had cancer that had progressed to the brain. It couldn't walk or eat. It automatically regurgitated everything. It could not even raise its head to see. I had to tell the owner, who was not there to see it every day, I thought the pet should be euthanized."

Dr. Rose thinks the decision is often complicated because people know how much they will miss their companion. "Some people keep their pets alive for themselves rather than for their pet's well-being," she says.

Cohn says she was comforted by the way Dr. Rose explained the situation to her when she was faced with the decision about euthanasia: "She said, 'Sometimes our pets are trying to tell us it's time, but we can't listen.'"

Putting it into words

Dr. Cindy Adams, Ph.D., points to a body of research supporting the notion that the quality of conversation between the veterinarian and the pet owner is critical to the euthanasia process and to end-of-life grieving. Her research as a professor of communication and epidemiologist at the University of Calgary, Veterinary Medicine, focuses on "client-centered" conversations. She employs a methodology in which practitioners are taped discussing two cases of euthanasia designed to facilitate end-of-life discussions. One involves a cat with a behavior elimination problem and the other a dog with severe arthritis. "It's quite fascinating," she says, "to listen to the tapes and realize just how difficult it is for a veterinarian to shift gears and talk about ending the life of an animal."

Dr. Adams thinks the key to helping pet owners with that final decision is listening to the client receptively. "Until you can get your hands around what the client wants, the conversation is difficult," she explains. "One way to clarify the issue is to say, 'What I hear you saying is ...' That will help you get to the decision." A collaborative decision, she thinks, is essential to the well-being of the client in the grieving process.

She calls for veterinarians to both "inhale and exhale" in the conversation. By inhale, she means, "The person needs to be seen and heard and for you to absorb what's going on." By exhale, she means, "You must exhale some sort of response, even if it's just a head tilt or a gesture of empathy. For some practitioners," she says, "giving a response is really uncomfortable. But it's like learning to ski. You are uncomfortable at first, but if you keep trying you will eventually learn."

Understanding grief

Listening and reacting to people in this moment of stress can be difficult for you and your team. To understand the true import of this thorny decision, and the grief that will follow, you need a better understanding of the nature of grief so you know what to expect and how to interpret your clients' reactions.

Kathleen Ruby, Ph.D., opened the Pet Loss Hotline at Washington State University as a teaching tool to introduce veterinary students to the nature of grief. Ruby says many of them don't appreciate the level of grief people feel when their pets die.

In fact, it was on the hotline where she witnessed one of the most dramatic student transformations of her career. One night a male student picked up a call from a Vietnam veteran. He told the student how he had suffered from posttraumatic stress disorder when he returned from the war. He lost his wife and his family, and he turned to alcohol, which drove him even lower.

One day someone gave him a kitten. That kitten changed his life. He could see he needed to be sober to care for it, and the desire was enough to drive him up from the bottom. When he called the hotline that night, he had just lost the cat—then quite elderly—who had rescued him from the bottle and "put his life on a different course." Then, the veteran started sobbing.

"I'll never look at an animal, or pet loss, the same way again," the veterinary student told Ruby. "He said, 'Dr. Ruby, at first I thought the stuff you were teaching was hokey. Until I talked to this guy, I didn't get it,'" she recalls.

"My concern is we're sending veterinary students who don't 'get it' out to work in practice," says Ruby. "One of my findings is that many veterinarians struggle to handle problems concerning grief when they first come into practice. That's a major issue because they'll see four to five times more death and grief than a human physician will."

Ruby says learning to see the loss through the clients' eyes is a challenge. Practitioners tend to downplay the experience of grief in clients because they navigate through loss and death on a daily basis. But that's not clients' reality.

The educational community, she contends, owes both potential veterinarians and potential clients better equipped practitioners for those inevitable times when the joy of the human-animal bond turns to grief. Research, Ruby says, suggests approximately 30 percent of pet owners experience levels of grief they are willing to equate with losing a mother, father, or spouse. "We must do something to help them through. Both ethically and morally, the profession needs to take responsibility," she says.

However, the idea of taking responsibility, she cautions, can bring its own pitfalls. One pivotal issue in her grief and bereavement class is the difference between empathy and detachment. She describes the middle ground as "compassionate detachment." The key to maintaining professional health and a healthy staff, she says, is to learn to "experience enough to care but not so much that you destroy yourself." And the danger of the strategy of shutting down emotionally has been demonstrated in psychology literature repeatedly: "It's difficult to numb out one part of your life and not another," she explains. "You can wind up also being numb at home."

Complicating the picture even more, euthanasia may be as difficult for team members as for pet owners, says Mandy Finnell, RVT, with Cherokee Animal Clinic in Overland Park, Kan. "When a person and a pet have visited us for years, our team gets to know them," she says. "You grow close. Sometimes you can't help it; you break down with them. You know you have to be strong for them, to keep some kind of structure in the room and help them know they're making the right decision. But there are times when structure goes out the window. And it's hard to know when that will happen. When a grown man cries or when there are children in the room, it's almost impossible not to shed a tear."

Give space for mourning

In addition to being strong, Finnell says, it's also critical for the team to maintain decorum in the facility. At Cherokee Animal Clinic, a flag goes up when a euthanasia is planned. The practice doesn't have a soundproof comfort room, so team members encourage lower voices and curtail conversation while the client is in the clinic.

Before they will euthanize

When Windsor Veterinary Clinic expanded from 2,100 square feet to 5,700 square feet, the owners added a comfort room to create an atmosphere conducive to euthanasia. The room features a couch and adjustable lighting and provides calm space away from examination rooms and clinic noise.

DeNayer may light a candle in the room and turn on music. She sits with the client until Dr. Downing is free for the procedure. Typically, a technician places a catheter in the pet's leg in advance, and a staff member places a colored bandage cut in a heart shape over it. When possible, the team schedules the procedure at the end of the day when traffic is light in the clinic. "We can let them take as long as they want, either before or after we euthanize the animal," says DeNayer. "If a client needs to spend several hours with us afterward, fine. We would never think of rushing anyone through this process."

Team members always offer clients who come alone a ride home. The team will bring them back the next day to get their car. "The last thing we want," DeNayer says, "is somebody emotionally vulnerable on the road."

Later, the practice offers a variety of reminders, from clay paw prints to a single rose in a bud vase and a copy of When Your Pet Dies. A sympathy card on which each staff member who knew the pet contributes a memory is sent. A local artist may provide a portrait of the pet. Memorial rocks are available for backyard burial. Decorative wooden shelves by a local craftsman are also available, in addition to a picture frame with a place for the pet's ashes. In each case, a donation is made to the Morris Animal Foundation.

This month, Windsor Veterinary Clinic will hold its first annual remembrance ceremony. Based on the idea that telling the loved one's story helps heal the loss, the ceremony will encourage clients to talk about their pets. DeNayer plans a tree-lighting ceremony in which clients will hang favorite ornaments on the clinic's holiday tree. "They might hang an ornament in memory of their pet or maybe an ornament from their tree that their pet liked to bat to the floor," she says. "One of our goals is to help people understand that we realize their animals are really important to them—and to us."

Myth 1: Grief proceeds in predictable stages

No two people grieve and mourn in the same way. There are no set steps through the healing process. Each person will experience a range of unique feelings and thoughts. Just when we feel our journey through grief is softening, something may trigger a particularly fond memory and we will regress. The grief experience will naturally unfold over time.Each person's relationship with a pet is different, too. We may grieve differently for each of our pets when they die. It will help if we allow others to walk beside us on our grief journey, but we should not let them design our road map.

Myth 2: Following the death of a pet, the goal is to "get over" your grief

Grief never truly ends. We don't "get over" it. We're changed by our journey through grief. We can reach reconciliation with our loss. The pain we feel as we acknowledge the reality of our pet's death is strong, but it does soften with time. We realize that our life will be different without this pet. Our feelings of loss won't completely disappear, but our intense grief will lessen. The pet will not be forgotten.

Myth 3: Children are too young to understand

Any child old enough to love is old enough to grieve. Children may not have an "adult" understanding of death, but they do understand loss. Infants and toddlers recognize absence. Preschool children may think of death as temporary or reversible. As children mature, they develop a clearer understanding of death, often at the same level as adults.

As adults, we must be honest with children and answer their questions concretely. They can deal with what they know, but they can't deal with what they don't know. They can handle the truth when they are supported with understanding and love.

—Sharon DeNayer

Veterinary Economics Special Assignments Editor John Lofflin is a freelance writer in Kansas City, Mo. He teaches writing and editing at Park University in Parkville, Mo. Send your comments to ve@advanstar.com.