Written by Shannon Fujimoto Nakaya, DVM
In our modern world, doctors, nurses, and hospitals often provide an interface between the healthy individual and the dead one. Compared to our grandparents and great-grandparents, many younger people have not witnessed day-to-day, hour-to-hour care of a family member, human or non-human, who is seriously ill, convalescing, or dying. So part of helping someone decide whether they are going to choose a natural passing or euthanasia, is preparing them on what they might expect. Alas, every dying experience is unique to some degree, so there are no absolutes and no guarantees that predictions will actually come to pass.
I think of the body as a synchronized collection of organ systems with each system having a role in sustaining life. Maintaining life is about maintaining balance between all of the systems, supporting the one(s) having trouble and nourishing the others so that they might weather the extra burden. I actually visualize this in my head as a round ball of twigs levitating in mid-air. When all is well -- when the patient is balanced and aging gracefully -- that round ball just floats along. In my visual imagery, when one of the body's organ systems is fatigued, one of the twigs sticks out from the ball causing a deformity and and the entire ball will start to descend.
For me, graceful aging and graceful exits are about gently tapping on the twigs that are out of place, thereby preserving the roundness and balance of the ball so that it continues to levitate. At some point, the functional integrity of the ball is inevitably going to fail and implode, but the goal is for the patient to be able to be comfortable and able to enjoy life until that final implosion. When the ball of twigs maintains it's shape and then gradually descends and fades and dissipates without crashing, burning, trauma, pain, or suffering -- that is a graceful exit.
Graceful passings without intervention are possible, particularly when a caregiver is able and willing to support the patient's needs as presented in earlier chapters in this book. In cases where we have a diagnosis, we are better able to anticipate which system is most likely to become the biggest burden on the levitating ball, and we are better able to anticipate what symptoms might develop and then be better prepared to prevent or alleviate them.
Supporting a natural passing should NEVER be about allowing an animal to suffer. There are conditions and symptoms that are more difficult to alleviate and can complicate the process of dying gracefully without assistance. For example:
- Respiratory distress (as in cancers that metastize to lungs or end stage congestive heart failures).
- Bowel or bladder obstructions (cannot urinate or defecate).
- Broken and unstable bones.
- Intractable (not responstive to medications) vomiting.
- Intractable (not responsive to medications) seizures
- Intractable (not responsive to medications) physical or emotional pain.
Notice that the last three bullets on the list above are about intractable symptoms or those that cannot be relieved with medication or some other treatment. Most vomiting and most seizures and most pain can be alleviated, so that the patient can remain comfortable and enjoy life.
In a study of human patients with terminal illnesses who were asked -- hypothetically (as euthanasia is not a legal option in most of the United States) -- if they would prefer a natural passing or death by euthanasia, two themes became apparent:
- Humans with terminal illnesses and poorly managed pain would more often choose to die than to be in pain.
- Humans with connections and ties to other humans are less likely to want euthanasia. Put another way, patients with a reason to keep living bear their illnesses better.
If a patient can be kept comfortable and has a reason to keep living, then every good day is a gift.
Here, we walk a fine line. At the same time as we appreciate every good day as a gift, we also need to give our animal companions permission to die. Sometimes, the human-animal connection is so strong that animals don't let go and take many days and sometimes weeks to actually take their last breath. Sometimes, we need to let them know that however much we will miss their bodily presence, we understand that they need to go.
Sometimes, even when we give an animal companion permission to die, even hope that they die gracefully on their own, they just don't want to let go. Like humans, there are some individuals who are determined not to do down without a fight. These can be tough situations and it can be a tough decision to try to respect their fighting spirit without seeming to allowing them to suffering.
Even in the most graceful passings, death is rarely instantaneous (except in birds), where the animal is sitting up and conscious in one moment and dead in the next. For most species, dying is a process. In the final stages leading up to imminent passing, the dying often develop a far off look -- like they are "going towards the light." They are generally not very responsive at this stage, like they have gone on an inner journey, mentally preparing to leave their body. It is not uncommon for their breathing to become irregular at the very end of life. In fact, the last breaths may seem more like gasping than breathing. It is a process that has been happening for millions of years. Sometimes their bodies will become alternately tense and then relaxed. For people unfamiliar with the dying process, it can be disquieting, disturbing, even frightening. It is important not to panic. I get a number of phone calls when patients are in their final hours of life, "hurry, my animal needs to be euthanized." Usually I advise them to just be with them, reassure them that it's okay to let go. And often enough, the animals completes its passage before my arrival.
As with any self-help or do it yourself or guidebook such as this, there is always the potential for misinterpretation and/or misuse. There is always the potential for someone to extract a phrase from my work, apply it in a different context, and use it to justify an action that I wouldn't myself advise. At some level, the risk may be even greater because I do not tell people exactly what to do; I merely provide information and suggest things that they might consider. Empowerment requires a leap of faith that they who you empower will not use it inappropriately. In both Kindred Spirit Kindred Care and Graceful Aging Graceful Exits, I choose to empower the humans who truly do care about their animal companions and desire to make informed, thoughtful, and selfless decisions on their pet's behalf. I hope that my sincerity as an advocate for the animals and the human-animal bond comes through and that the cases where that tone is misconstrued and misused are rare events at best.
This text is by no means a substitute for veterinary evaluation, assessment, and treatment. This text is meant to help people provide supportive and nursing care for their pets. Particularly with middle-aged and older patients, however, I often enough meet people who assume that their dog is "old" and therefore, whatever is ailing them must be bad and incurable. It would sadden me to learn that someone has skipped over a professional assessment and unwittingly short-changed their animal companion a straight-forward medical solution.