Pawspice (pet hospice) care for cancer patients (Proceedings)

When a pet is diagnosed with cancer, the bond that is shared between them and their human caregivers grows stronger. Cancer kills one in four of dogs over the age of two and it kills half of our senior pets. It is time to rethink how the profession will help pet owners face those final days with a terminally ill best friend. Most pet owners have preconceived notions about cancer and its treatment. Obvious biases and ingrained feelings regarding cancer may cause a negative approach towards its treatment in geriatric pets. Case by case, veterinarians and their professional staff must overcome the defeatist attitude about geriatric care and cancer therapy for pets by dispelling negative notions, one by one.

If the pet's cancer can't be treated due to financial constraints or a logistical problem, it is still a matter of good professional service to compassionately provide advice and home care giving instructions in a palliative Pawspice program. If a pet's cancer has recurred, if it is resistant to further treatment, if the pet has anemia or cachexia, or if the pet is in the terminal stages of cancer, in home pet hospice care is a wonderful next step. Pawspice keeps pet and caregiver comfortably close to their nest. A well-conceptualized, creative, palliative pet hospice for pet owners may be the very best care that medicine can offer to support the people pet bond. Veterinarians and their staff can kindly and respectfully help sustain a quality life for the terminal pet during the last days of the people-pet bond.

How Much Care at What Cost?

When a pet is diagnosed with cancer, the pet owner worries about how much care their pet will need and how much it will cost. How much care, devotion and money are pet owners willing to provide for their ailing pet? From this author's personal experience with treating cancer patients in California for 30 years, it can be stated with authority that the answer to this question is very personal and it may have no limits. Each pet owner has unique personal life style and tolerance considerations. After an initial consultation with the primary veterinarian and a thorough consultation with a specialist regarding options for curative treatment or palliation, the owner will struggle with finances, logistics, love, guilt and grief. Then they either accept the challenge to treat their pet's illness or decline therapy. It is crucial that veterinarians refrain from being judgmental at this touchy time. It is kind to continue educating and offering options that may be more palatable for the owner to incorporate into their routine. It is also important to refrain from suggesting or insisting on euthanasia as the next best option if the pet is not treated as initially recommended. Let the pet owner know that pain relief and ways to make the pet more comfortable is available while they are trying to make a decision regarding therapy. Many clients have complained that the initial veterinarian was too quick to recommend euthanasia, or that the veterinarian seemed to insist things be done as an "all or none" method because the pet's prognosis was poor for recovery or it was suffering or its disease was incurable.

Practical and Physical Considerations

Some pet owners feel that they would be unable to handle the thought of giving daily injections of insulin to a diabetic pet or giving a daily injection of fluids under the skin to a pet with failing kidneys. The idea of using a feeding tube for nutrition during recovery from lipidosis, or after an oral surgery or during radiation treatments to the oral cavity may sound like heroics to one person and make perfect sense to another. It is truly important to always speak to the caregiver in a tender, unhurried fashion as that person is most likely under a tremendous amount of personal, financial and emotional stress.

Home care for a cancer patient that has trouble rising or can't walk or eliminate properly is a task certain pet owners have chosen to tackle with the help of special harnesses, Pampers, pet wheel chairs, egg crate mattresses and ramps. Families are willing to set up portable oxygen tanks for their pets with compromised respiration. Some people react with fear of medical procedures and needles. Others have great interest in learning how to administer to their pets for convenience and needed financial savings. The most important ingredient to look for in oneself, in the staff and in the pet owner is willingness.

Seek Staff Agreement

Hold a staff meeting and ask the question if being a compassionate veterinary care giving facility is truly O.K. with the nursing staff. Put one special staff member as the appointed support person for a certain pet and its owner. Ask the client to direct phone calls and concerns to their designated staff member or support team. Staff can handle most of the home care problems and the doctor can see the pet on regular rechecks to answer major questions such as changes in prescription medications.

The nation is very impressed with the concern and care that the Hospice across America program has provided for people who are dying. Veterinarians can win the loyalty of their clients by emulating the philosophy of the Hospice in honor of that special bond that connects people to their pets. This may help keep our profession more celebrated in the eyes of the public. Unlike the Hospice Movement for people, the veterinary profession won't be able to send in technicians with free bereavement counselors, hospital beds, oxygen, free meals and wheel chairs. However; from exam room consultations, veterinarians and staff can gracefully provide the education needed for the efficient home care of ailing pets. Education that facilitates the control of pain and the art of providing good nutritional and hydration support gives the caregiver ability to care with expertise. They have more time to let go slowly and carefully. Many tender private moments of quiet emotion and sweet conversation are shared between the caregiver and the dying pet.

Important Factors

The most important factors to educate home caregivers to confidently monitor are: quality of life, with minimal pain, adequate nutrition, hydration and respiration and detection of sepsis. With training from the veterinary staff, home care may be almost like being in the hospital. Ask the question, "If this pet owner were trained to take the pet's temperature, administer subcutaneous fluids and provide the proper medications and sufficient food, can this pet have some well being and live longer at home?" If the owner is instructed to create some frequent, routine fun (doing the pet's favorite things), the pet may even cheer up and look forward to the events. Ask the pet owner if he/she is satisfied with the arrangement. It is also important to determine with oneself and the staff if it feels rewarding or at least satisfactory to help preserve the bond between this person and this pet. If these ingredients are present, then pet hospice (Pawspice) is a good experience for all involved.

Ask the pet owner if they have experienced the amazing help that the American home hospice care movement has provided for a terminally ill friend or family member.

Despite the lack of financial support from national fund raising campaigns, the veterinary profession can emulate the concern and care exemplified by the hospice concept. Veterinarians can win client loyalty by respecting and preserving the special bond that connects clients to their pets and keeps this profession so celebrated. If the veterinary team helps peacefully to control pain and to provide nutrition in a hospice way, client-caregivers gain confidence. They also gain courage for themselves.

Re-evaluation of Attachment

Caregivers must also face how they feel about their attachment for their pet's compromised status. They need to deal with feelings of guilt, their sense of duty and remorse as their geriatric pet encounters problems and the disability progresses. How they feel about participating in a treatment protocol now may be different after the pet encounters side effects from treatment. Caregivers often find themselves re-evaluating their commitment with the changing status of the Pawspice patient.

Many pet owners don't even know that they are cheating themselves out of enjoyment with their pet because they are so upset. They don't know how to deal with their own emotions and anticipatory grief over the pending loss of their pet. Based upon their personality type, their marital and financial situation, family commitments and other issues going on in their life, pet owners may respond with a wide range of emotions from panic all the way to shut down. It is a good idea to suggest professional pet loss counselling for your deeply bonded caregivers who need help facing their emotions.

All pet owners weigh their specific issues. They either accept the challenge to treat their pet's illness with your recommendations or they decline. When they decline an aggressive treatment plan, the battle is not over. Many pet owners seek the very palliative therapy that has not been wholeheartedly offered at your practice. Many others will sneak away from your hospital and pursue alternative treatments without your knowledge or guidance. Some reasons for this may be: they don't want to hurt your feelings, they are embarrassed, and they think you will be angry with them or that you may disapprove.

Resourcefulness with Options

It is crucial that veterinarians refrain from being judgmental at this touchy time. It is kind and proper to continue educating and offering options that may be more palatable for the owner to incorporate into their routine. Even though you might feel that you have to downplay your high tech medicine toward the level where you are only able to offer their pet comfort and support, you are doing the right thing for the pet. If you create a protocol for supportive care, it becomes a very palatable and viable option while keeping your client's confidence during the entire Pawspice.

It is also important to refrain from suggesting or insisting on euthanasia as the next best option if the pet is not treated on the high tech road or as you had initially recommended. Let the pet owner know that pain relief and ways to make the pet more comfortable are important to you and readily available at your facility, while they are trying to make a decision regarding therapy. Many clients have complained to me that their initial veterinarian was too quick to recommend euthanasia if their pet's disease was incurable or because their senior pet had other concurrent conditions, or was "too old".

Some clients felt dismissed when their veterinarian seemed to insist that the recommended procedures be done as an "all or none" policy. Some felt pressured to comply with procedure A or B, even though the pet's overall prognosis was poor. They complained that their veterinarian did not give them alternative choices, and if procedure A or B were not followed, their pet would suffer and need to be euthanatized. Yet somehow the consultation ended and their pet was discharged from the clinic without being offered adequate pain control and supportive care for the pet's ongoing condition at home. Pet caregivers felt abandoned, unsupported and disappointed.

Aversion to Caregiver

When the patient shows aversion to the caregiver's attempts at medication time, we run into a big problem that may erode the home care equation. This very problem hit me broadside when Alaska, my aging Great Pyreneese, started avoiding me during her Pawspice. She no longer greeted me with her usual cheer because she knew that I might have a pill, a syringe, or some SQ fluids for her. It only took one week to solve this problem. One of my assistants came every day to our home to give Alaska her injections and SQ fluids. Alaska was happy to see me all the time, once again.

Mr. Citron told me that he just could not torture his 14 year old cat, with pills or injections. Her mesenteric lymphoma responded well to the first chemotherapy treatment but he could not justify her reaction to him when he approached her to give the prednisone tablets. She would not accept any liquids or compounded medications or transdermal preparations. He called to quit treatments in frustration. We offered the option of visiting his local veterinarian once every two weeks for SQ injections of L-asparaginase and Cytosar-U and Depo-Medrol. We also recommended the option of the attending doctor giving her a 10 mg capsule of lomustine every 6 weeks following an acceptable CBC. Mr. Citron felt that Midge would have a much better Pawspice with this plan. He was very grateful to pursue the option for Midge to be treated periodically at the veterinary hospital without perturbing her a home.

Emma's Case

Emma Moon, a 14 year-old F/S Shepherd mix: One day, a very upset man entered our busy reception room. He asked our receptionist, Jennifer, if we had time to give him a second opinion. Mr. Moon and his wife had been told to euthanize their beloved dog, Emma, that day by two different specialists. Both an internist and a surgeon told them that Emma had two kinds of cancer and was very old and needed to be euthanized. He said that they had no children and were very attached to Emma. Jennifer comforted him. She told him that she would ask me to see if we could do anything to help.

I asked him to tell me what was going on. Mr. Moon was sitting on the floor with tears running down his cheeks. He managed to tell me that Emma had been diagnosed with bone cancer a few months ago and that she had rapidly developed a big huge tumor in her groin. It was diagnosed as mast cell cancer. He said that today's x-ray of her diseased leg looked like the bone cancer would fracture. Both specialists agreed that Emma should be put to sleep ASAP if not today. Mr. Moon said that he and his wife were tormented over this advice. They were not ready to let her go because Emma still wanted to eat and be with them. The clients in our waiting room and my staff empathized with his distress. I emphatically told him, "Your dog does not have to die from euthanasia today if you are not ready." I told him that we could enter Emma in a palliative Pawspice program. I said something like this, "If you are this conflicted and not ready yet, then it is not right for you." We told him to bring his wife and Emma and all the medications she was on, so we could evaluate her at the end of the day.

Sure enough, Mr. Moon returned at dusk with his wife. He carried Emma on a big soft pad into exam room #3. Emma's paws never touched the ground. She had pink mucous membranes and a pleasant interested look on her face. Mrs. Moon was puffy eyed and looked at me with hope. We examined Emma. She was breathing comfortably and had no heart murmur. She had a large swelling of her left humerus that had been diagnosed as osteosarcoma. Referral x-rays showed a large osteosarcomatous lesion with lysis and erosion of cortical bone.

The lesion appeared to have a hairline fracture present but there was no displacement. A huge, bright pink soft tissue mass extended along Emma's left caudal mammary chain. The mass was 16 x 8 x 8 cm. Fine needle aspiration cytology diagnosed mast cell tumor earlier that day. Emma's abdomen was normal on palpation with no organomegaly. The couple said, "Look at her, she isn't ready to die yet; she still gets up to do her business and she eats and wags her tail and likes being at the center of things. We want help to keep her with us until we feel she is ready to go."

It is important to inform the family that a pet's pain responses are often missed. I told the Moon's something like this, "Dogs and cats don't exhibit their pain in ways that can be completely understood. Dogs by their very nature want to stay with their pack and will fake wellness despite their pain. That is why a pet's pain may not be appreciated by their caregivers, even when they think that they know their own pet very well." I defended Emma's doctors regarding their opinion and verified the fact that Emma indeed had pain. The sheer volume and location of the mast cell tumor warranted a poor prognosis for any dog. Emma's mast cell cancer added a negative factor to the bone cancer. The pathological fracture, the fact that she was on NSAID's for the bone cancer yet needed steroids for the mast cell tumor, compounded with her advanced age, all added up to a very poor prognosis for Emma.

Essentially, I had no disagreement with her doctors' opinions yet could not disagree with the Moon's, viewpoint either. Emma was bright, alert and responsive, and she seemed to be quite content. We offered palliative Pawspice care. I said, "Look at Emma with your questions and she will tell you in some way when the time is right."

We designed a special homecare calendar with scheduled preemptive pain control for the bone tumor and palliative treatment for the mast cell cancer. We started Emma on Duragesic pain patches every 72 hours for osteosarcoma pain control. We administered IV dexamethazone and vinblastine for the mast cell cancer along with famotidine and Benadryl injections, and SQ fluids with vitamins B, C and B-12. We reviewed the calendar schedule with its specific instructions for oral prednisone, chlorambucil, Benadryl™ and pepcid along with supportive supplements from our chemoprevention and immunonutrition protocol. The Moon's were instructed to discontinue all NSAID's and recheck with us weekly for vinblastine injections and to assess Emma's quality of life. To our amazement, Emma's mast cell tumor regressed completely. She survived with a good quality of life in her loving home for an additional 8 months in Pawspice care.

Pawspice Care for Some Specific Conditions

When cancer patients have multiple conditions, we advise caregivers that if we can improve each poor condition by 50- 60%, we may be able restore or improve quality of life.

The next hour of lecture time will discuss using the Quality of Life Scale which enables hospital staff and family members to assess the pet's status.

Anorecticpets may respond to oral appetite stimulants such as mirtazapine every 72 hours. They often need to be hand fed or force fed. Caregivers need to be taught the proper technique to hand feed their ill pets properly and safely. Cats like their food warmed to body temperature. Squamous cell carcinoma of the tongue in cats renders the tongue stiff and useless and causes early starvation despite efforts to eat. When a pet can't or won't eat, the placement of a percutaneous esophageal feeding tube may be performed under a short anesthetic with minimal risk. The procedure has been described by Rawlings, JAAHA, 1993, 29: 562-530. After the esophagosotmy feeding tube is in place, the pet needs to be fed successfully a few times in the hospital. It is essential that a discharge appointment be scheduled for a demonstration on how and what to feed the pet. If a helpful nurse, whom the owner may call for further instructions, gives this demonstration, the client is more at ease during the first few days with the feeding tube. The diet and supplements for feeding must be spelled out to avoid clogging the tube and to ensure the pet is getting enough calories and liquid to maintain body weight. If the tube gets clogged, instruct the owner to use Coca-Cola to dissolve the clog. Create a schedule that spells out the morning and evening times for medications, chemotherapy, amounts of fluid, feeding volumes and supplements on a written daily calendar. This written schedule helps to clarify the day's work order for the home caregiver.

Severe vomiting may be controlled with Zofran injections. On one rare occasion, this author dispensed injectable atropine to help a Great Dane that had unresponsive vomiting and salivation and a low budget owner. Care should be taken to provide liquid tears while using atropine in this fashion, especially in breeds susceptible to KCS.

Severe pain may be controlled with injectable nalbuphine. This drug offers pain control without the typical sedation effects that accompany most powerful pain medications. Nalbuphine doses range from 0.5-1mg/kg SQ. every 3-4 hours in dogs and 0.2-0.5mg/kg in cats SQ. every 3-6 hours as needed. This pain medication is not under the controlled substance regulations and may be of great value in pain control at home for end of life care patients.

Renal failure patients fed special modified diets such as Hill's K/D or Select Balance, Modified Diet, may survive well if supplemented with educated home care which includes: subcutaneous fluids, Tumil-K, Pepcid, Amphogel, tissue salts, vitamins, fatty acids (safflower oil or fish oils). Regularly scheduled recheck profiles can monitor renal function, acidosis and anemia. Epogen may be used to bring low PCV levels back up to normal. One cat in this author's practice survived six happy years at home on daily subcutaneous fluids passing away at age 22.

Diabetic cancer patients that belong to reluctant, needle-shy owners need the option of trying oral hypoglycemic medication including APF Drops™ by Auburn Labs. Many cancer patients do not utilize insulin normally; however, one can expect good clinical results with oral medication in one third of diabetics that have no ketones in the urine. Clients feel that their veterinarian is trying to help the pet while prioritizing their own concerns. If hyperglycemia is not controlled with the oral medications, the pet owner may be more inclined to try injectable insulin.

Chemoprevention and Immunonutrition may be presented as palliative care for all pawspice candidates. According to Dr. Philip Bergman of M.D. Anderson Memorial Cancer Center, chemoprevention involves the use of natural or synthetic compounds that may reverse or suppress the process of carcinogenesis, metastasis and recurrence. Nutritional advice and a nutraceutical supplementation program that underscores cancer prevention for treated, untreated or terminally ill cases may be professionally supervised. Dr. Doug Herthel, President of Platinum Performance, Inc., calls the wellness supplements and minerals found in his formulations, "immuno-nutrition." These supplements are intended to promote healing and activate the immune system to keep animals in remission or promote remissions. Hill's promotes n/d and b/d for these very same results. The nutritional diets and the support supplements designed for ageing pets and pets with cancer universally contain antioxidants and omega-3 fatty acids.

Offering immunonutrition results in a very positive consultation and offers a great service for cancer patients with a poor prognosis. Immunonutrition counselling creates further client confidence that the primary care veterinarian is trying to help them keep the quality of life up as much as possible. Most animal cancer patients that have received surgery or chemotherapy or radiation therapy are still considered to be at great risk for recurrence. These animals are definitely excellent candidates for immunonutrition and the pawspice concept because they are actually expected to die from their disease within 4-12 months. Dogs with osteosarcoma, hemangiosarcoma, adenocarcinoma, lymphoma and cats with breast cancer, vaccine associated sarcoma, lymphoma, IBD, FeLV and FIV all fall into this high risk category and may benefit with extended survival times with immunonutrition and chemoprevention.

Technician house calls may be set up for those who are unable to deal with administering injections and fluids to the Pawspice pet at home. The reception staff can be made aware of which pets are on Pawspice programs so as to be sensitive to the owner's calls.

Day care for Pawspice pets can be provided at the primary care veterinary hospital. This service may be the key to sustaining a Pawspice for the working pet owner. Be sure to set up convenient drop off and pickup times that fit the owner's schedule.

Networking is also a big help. Give the phone number of another client who is providing the same type of Pawspice care so they can have the opportunity to share their experience with the newcomer. Dr. Kathleen Carson and Christine Grey, both from this author's facility, actively participate in a Chat Room for Chronic Renal Failure cats on AOL (America on Line). This informative chat room opens every Sunday evening at 5:00 p.m. Pacific Standard Time. Tell clients to look for the private chat room, "CRF". This type of net working is very helpful l and is a staff time saver.

Pet Loss Group Sessions can be very helpful for caregivers who are suffering from anticipatory grief and for those who feel lost after their pet passed away. Some pet owners will sink into the depression associated with maladaptive grief after they have lost a dear pet. It is very important to introduce them to a professional pet loss counselor.

Books to Recommend to Your Clients which educate them about the care for their Pawspice pets can be very helpful. Help Your Dog Fight Cancer by Laurie Kaplan, JanGen Press, Briarcliff, NY, 2008 and Pets Living With Cancer: A Pet Owner's Guide, AAHA Press, by Robin Downing, D.V.M. are two excellent resources for the pet owner. Many intelligent pet owners who are breeders or highly attached to their pets want to read more advanced works which can inform them scientifically as well as practically about cancer in dogs and cats. For these individuals, this author's book, Canine and Feline Geriatric Oncology: Honoring the Human-Animal Bond, may be of tremendous value in gaining a deeper insight into the field of veterinary oncology and their own pet's specific type of cancer.

Euthanasia for the Pawspice Pet

Many pet owners want their beloved pet to pass away at home. Unfortunately for them, the slow decline of a sick pet may be too difficult for the family to accompany all the way to the end of the pet's life. There are many questions such as, "How will I know when the time comes?" The answer to this question rests with the pet. Advise the family that their pet will give a sign such as unrelenting vomiting, diarrhea, crying, a moribund state or more bad days than good days. When the time approaches for the pet to be humanely euthanized, the emotional pain for the family may be softened if they know that the procedure can be performed at any time of the day or night. Arrangements must be made that cover the patient's care 24 hours a day. Referrals for house calls, night calls and after hour emergency room facilities need to be set so that the decision time for euthanasia is made on behalf of the pet, not the doctor's office hours. When the time comes for the emotional pain of euthanasia, caregivers who are in a Pawspice program are enabled to make the best decision for the pet. If they are going to bring the dying pet to a facility for euthanasia, instruct them to bring the pet's favorite blanket and a candle and family or friends and other pets to share in the final goodbye. It helps create a gentle atmosphere if the overhead lights can be softened. One suggestion is to turn off overhead lights and leave the x-ray viewer lights on in the exam room. The candles can also be lighted at this time.

The next step is to sedate the pet in the presence of the owner. This lets people relax while the pet gently falls into sedation. A deep intramuscular injection of dormacetin or butorphanol-ace in the presence of the owner is given. This allows that big first step to be an easy step for the family to see their beloved pet falling into a relaxed sleep. At this time it is kind to ask if each person in the room wants to stay for the final injection. Many families are content to leave their pet in the sedated state with complete trust that the next step is painless and fast. If family members are present towel may be placed over the pet's body covering the chest area up to the neck. At this time it is this author's preference to give the final euthanasia solution I.C. while the family lovingly strokes the pet's head. Some attending veterinarians prefer intrarenal or I.P. injections of the heavily sedated pet for the final injection. These routes avoid the hassle of trying to place IV catheters and their potential malfunction at critical moments.

Many institutions prefer I.V. euthanasia with I.V. catheters preplaced for the attending doctor's convenience. However, it seems somewhat traumatic to take near death pets away from their grief stricken owners into the backroom in order to place indwelling catheters, which may involve a struggle. Most near death pets are often anemic, hypovolemic or hypotensive. If catheter placement causes any struggle or discomfort, in the last few minutes of life for the near death pet, it is honestly too difficult for this author, let alone caring staff members, to repeatedly witness, even if the owner is not present.

After the family members are gently assured that their pet's heart has stopped beating, it is appropriate and thoughtful to encourage them to stay and view the deceased pet. Compare this special time to the custom of having a little wake as they do for human family members. This author feels that there is not enough reverence, service, ceremony or support offered to the family on the occasion of death of the family pet by the veterinary profession in general.

As recognition of the overriding importance of the bond that holds clients to veterinarians becomes common place across the country, more hospitals will set aside softly lighted rooms for pet wakes upon the occasion of a pet's passing. This is the time to read poems and talk compassionately about how important and sweet this dear beloved pet was. It is highly recommend that the caregiver and children write a few words about who this pet was and what was their special relationship all about. Often a small lock of hair can be placed it in a windowed envelope with the date and the pet's name and given to the family as a souvenir.

This author likes to read poems to the family after the pet has passed. Rainbow Bridge and a few poems from ANGEL PAWPRINTS, the wonderful anthology of pet memorials edited by Laurel E. Hunt, and Dr. Johnson's Apple Orchard by Edward C. Martin, Jr. are available from www.amazon.com are favorites. These books can be left in the room so the family may have some private time to read the loving poems and grieve alone with their deceased pet. Every five or ten minutes, it is wise to check in on the family and see if they need any assistance. We again recommend to the bereft caregiver that writing a story or a few paragraphs about the pet would be helpful in the grieving and closure process. This is also the time for making a plaster imprint of the pet's paw (available from the Argus Center at CSU). We also make "arrangements" for cremation or burial at this time. It is time to omit the word "disposal" from our billing slips and our vocabulary as veterinary healers who must deal with euthanasia of pets.

Post Euthanasia Follow Up

We send one or two sympathy card s with staff notes and signatures. It makes sense to ask for pictures of the pet and encourage the bereaved clients to get back into the love cycle again and adopt a homeless pet. A genuine invitation for the pet owners to come back and visit with cookies and pictures is extended. A call to the family a week later to ask how things are going helps the bereft family. If they are troubled, a very helpful tip can be given. Tell them that you encourage them to shed the tears and experience the grief feelings but to limit the grief to 30 minutes a day preferably in the morning or the evening. It is good to tell the pet's owner that they are missed at the practice and to encourage them to hurry back into the people-pet bond and adopt another loveable pet as soon as they feel it is possible. Extend them a warm welcome for a visit with you around lunchtime and tell them to bring cookies or candy for the staff.

Summary

Pawspice is the best way to provide time for pets to give an extended farewell to their families.

As long as the pet's best interests and quality of life are respected, Pawspice care can be a very rewarding experience for all involved. A favorite short poem by Sir Walter Scott can be read to caregivers when they start a "Doggie Pawspice." This profound poem was featured in Laurel Hunt's book. With one changed word it can include cats and other species of pets.

"I have sometimes thought of the final cause of dogs (pets) having such short lives and I am quite satisfied it is in compassion to the human race; for if we suffer so much in loving a dog (pet) after an acquaintance of ten or twelve years, what would it be if they were to live double that time?"

References

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Butler, C. and Lagoni, L., Eds., American Association of Human Animal Bond Veterinarians Winter Newsletter, 2002, p 1-12.

Choen, S. P. and C. E. Fudin, Eds. "Animal Illness and Human Emotion." Problems in Veterinary Medicine, 3, No. 1 (March 1991).

Downing, R., Pets Living With Cancer: a Pet Owner's Resource, AAHA Press, April 2000.

Hoskins, J., Feline 'Triad Disease" Poses Triple Threat, D.V.M. Newsmagazine, February 2000, p.4S-7S.

Hoskins, J., Feline 'Triad Disease' not Breed or Sex Specific, D.V.M. Practice Builder, October 2000, p. 31-35.

Hunt, L.E., Angel Paw Prints: An Anthology of Pet Memorials, Darrowby Press, 1998.

Lagoni, L., Morehead, D., Butler, C., The Bond-Centered Practice: The Future of Veterinary Care, Proceedings of the 1999 ACVIM Forum in Chicago.

MacEwen, E. G., Withrow, S. T., Small Animal Clinical Oncology, Third Edition, W.B. Saunders Company, 2001.

Martin, E. C., Dr. Johnson's Apple Orchard, The Story of America's First Pet Cemetery, 1997, Image Graphics Inc., Paducah, KY.

Ogilvie, G.K., Hospice and Bond Centered Practice: The Future of Veterinary Care, Proceedings of the 1999 ACVIM Forum in Chicago.

Ogilvie, G.K., Moore, A.S., Managing the Veterinary Cancer Patient: A Practice Manual, Veterinary Learning Systems, 1995.

Rawlings, JAAHA, 1993, 29: 562-530, Percutaneous Placement of a Midcervical Esophagostomy Tube: New Technique and Representative Cases.

Shearer, T., Hospice and Palliative Care, Ch. 30, Handbook of Veterinary Pain Management, Gaynor & Muir, Mosby/Elsevier, 2008.

Villalobos, A., Kaplan, L., Canine and Feline Geriatric Oncology:Honoring the Human-Animal Bond, Wiley-Blackwell Publishing, 2007.

Villalobos, A. E., Oncology Outlook, Those Stubborn Cats That Won't Eat, August 1999.

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Villalobos, A. E., Cancer: Early Diagnosis Offers Hope, D.V.M. Practice Builder, October 2001, p. 10-14.