 It's great to see you all. I know that it's really a challenging topic. I'm sure that for each of you, there are probably several other people that really thought they should come and just couldn't quite bring themselves to do it. Always in awe of the people that call me, especially when they don't know me, and leave a message on my voicemail where they're struggling to get the words out because it's such an emotional topic. So it can be a big deal. I think that it's a really beautiful time of life also. It's a time where we can really connect with our pets. And it's very meaningful, but it does not necessarily easy. So I graduated from veterinary school in 2001. I came to Central Vermont in 2002. I was at Union River Animal Hospital as a family practice veterinarian until 2013. And then I started a house call practice. And I did that as a general medicine family practitioner until two years ago when I decided to focus my practice solely on acupuncture, which I do mostly out of a little office in Berlin. It's not a vet clinic. It's just an acupuncture office for pets and end-of-life care for pets, which I do pretty much exclusively with house calls. Although sometimes in acupuncture appointments, we're having conversations because it's relevant to a lot of people. When I have always been drawn to end-of-life care, I feel like it's a little bit of an unusual thing to be interested in, and yet it's always been really meaningful to me. As a student, I was the student head of the Pet Law Support Hotline at Tufts. And we used to sit there. We had a room and a phone, and we would sit in the room and wait for the phone to ring on our shift, which was six to nine p.m. And we had different students covering each weeknight. And one night, someone called, and she said, all right, I know you will have the answer to this question. And I'm thinking, I'm a veterinary student. I don't have the answer to any question. She said, my priest couldn't tell me and my vet couldn't tell me. And I thought, uh-oh. And she said, but you'll know, is my dog going to heaven? Hey. Well, I said to her that I believe that if there's anybody that belongs in heaven, it's dogs because, and cats too, there's no more pure love than the love that we have with our animals and that they're innately good beings. And I also stole, I think, something from Will Rogers. I said, it wouldn't be heaven to me if dogs weren't there. So she said, I knew you would know. She said, all right, all right. So, but there's actually a lot we don't know. And there's a lot we're forced to guess. It's really challenging to try to figure out what pets want, what we want, how that can fit together. And we're trying to guess not only what somebody else wants who can't talk to us, but actually somebody else who's a different species. So what is a good quality of life and how do we know that? And in our struggles to try to figure that out, this is George and she has voluntarily crammed herself into this little box, which is the size of a table, paper napkins, but I like this picture for this slide because I feel like we often feel like we're crammed into this little box with all these conflicting feelings that we often feel the whole gamut of all of this stuff, love, anger, joy, sadness, anxiety, relief, confusion, guilt, acceptance, frustration, the pain from other losses comes back to us and I have lost humans that I've loved and pets that I've loved and I've never experienced a loss that didn't come without a pretty significant hunk of guilt which is obviously hard to deal with. So those are all totally normal feelings going through all this. It really is where the rubber meets the road and it forces us to confront a lot of issues that maybe we would rather not think about which is why I bet for every one of you that's here there's probably three more people that couldn't make it, just couldn't bring themselves to do it. So what I do as an end of life care that varies, sometimes people call me for euthanasia when they've already made a decision, other times people call me because they're trying to figure out the quality of life that their pet has and how to assess that and how to make end of life decisions, maybe they feel like they're close to euthanasia decision or maybe they're just trying to help their pet have a better quality of life because they're struggling with all these issues. And these are just as relevant for animals that maybe are not old but that are dealing with terminal illness as they are for animals that are older. So these are the kinds of questions that I'm asking or waiting to hear the information while people are telling me. And by the way this format is really kind of weird for me like I don't in my appointments lecture to people I'm gonna try to actually breeze through these slides relatively quickly because I wanna have more time for your questions. So if we go through something and you feel like I didn't spend much time with there and you wanna hear more or talk more about it, that's what I'm trying to do so that you will have a chance to ask me questions afterward. So when we're assessing quality of life, I'm looking at how they're eating, drinking, peeing, pooping, how are they sleeping? Are they restless? Can they get around okay? Do they understand what's going on? How's, what's their attitude like? How are they, do they seem happy? Do they seem bored, sad? How are they interacting with the family? Are they doing the kinds of things that they normally would do? And are they in pain? And ways to kind of address this in a more, I wanna say like defined, clear objective. Way, maybe a little bit, are there's questionnaires. I printed out some of them and we can print out some more. But these are geriatric questionnaires. It comes from the LAP of Love website. LAP of Love is a franchising organization that franchises veterinarians to do end of life house calls. And so the geriatric questionnaire is really useful because it goes through all of these things and gives you boxes to check off. So if you're gonna go for an appointment with a veterinarian, it's really handy to have that beforehand so that you have some basis on to ask all your questions and you'll forget all your questions when you get in the vet clinic. There are also quality of life scales and some people like to fill these out for their pet as they're going through the end of life process, maybe daily, weekly, monthly. It just helps to be able to look back, especially in a process that can be very gradual and where the new normal becomes something different every month or two to look back a few months ago and see, oh, I used to rate his mobility at five and now I'm consistently rating it at three. That kinda helps you get a sense of where you are. It's easy to lose track. There's actually an app on the LAP of Love website which I have not tried but I would love to hear about it if any of you guys try it. It's called the Gray Muzzle app and it's basically just a way to track quality of life measures for your animals every day or periodically on the app. And that's free on their website. And then I put bright lines up there because sometimes when I'm talking to people they have a sense that there's something that if that happens that will be the place where their decision is made. Like if he can't get up the stairs anymore I know that's really gonna be hard for him because he loves to be in our bedroom at night and if he can't do that then that's, and I can't carry him because my own back is bad or he loves to eat so if he stops eating and I have to coax him to eat then I know that's where my line is. Sometimes you think these things and then you change your mind but it's all helpful to have that thought process. So pain is a really big thing and it's often quite hard to assess because we can't talk to them. This list is all things that you might see with pain but you can see these things with other things. So they're not half an amonic. Like somebody who's panting and pacing might be doing that because they're painful especially dogs but they might also be doing that because they're confused and when dogs are old and they have dementia that it can get really hard for them to just settle down. So that's not necessarily physical pain but it might be an indication of distress from being anxious. Snapping or growling when you touch them, being irritable when you touch them, flinching when you touch them, hiding, being less responsive, not sleeping well, not eating, body tension, trembling. I tried to find a picture on the web of a painful animal. This guy looks, you know he looks not quite there and he looks, he doesn't look peaceful. When I say the inward turned attitude and the thousand yard stare, you could sort of imagine yourself just sitting on a chair in chronic pain like the pain deep inside your belly that's always happening. You're not gonna vocalize. People are often looking for signs like somebody crying out because oh I know he's in pain if he cries out but we only do that when we have acute pain. If you stomp on my foot I'm gonna yell but if my belly hurts and it has hurt for days I'm not yelling but I am gonna sit there just kind of hunched up. I'm not really gonna be looking at things. I'm not gonna be as responsive. It's a lot of work for me just to exist in that moment just to be there because I'm painful. So you can see that especially if you've had more experience if you're not sure I think it's good to have a veterinarian or a veterinary technician if you know one or you can corral one. It's best to be at home because obviously when you go in the clinic things really change a lot but that can help just learning to assess that. So when we have someone with a terminal illness regardless of how old they are we're looking at sleep, eating, activity, pain and then disease specific conditions like if somebody has kidney disease they're gonna be drinking more and peeing more that might affect how long they can go without going outside to go pee or how quickly their litter box fills up. With liver disease they can have neurologic signs they can have vomiting. So it's good to get a good sense from your veterinarian of what you could expect with that specific disease. And then when we have older animals this is my own kitty, Ike who lived to be almost 22. We have all those things for terminal illness plus things that are really specific generally to being older like hearing and vision loss and having trouble getting around having trouble regulating your temperature and also continence issues, peeing, pooping, accidents and just cognition, dementia that Ike actually got pretty darned demented and she was very helpful for me to understand how dementia works in cats because I really didn't know how subtle it could be until I went through it with her. So I'll talk more about that later. And mobility issues that the two major things that my older patients deal with are mobility problems and cognitive dementia type problems. So with the mobility the primary thing that I'm always looking to first try to relieve is pain because again we talked about chronic pain and how dogs and cats don't cry out when they're painful. They just may or may not look uncomfortable but we often don't know if they have pain until we try to relieve pain and then if we can see that that's actually helpful to them then we know okay there was pain. I'm always a fan of a pain medication trial for a couple of weeks or so to see how much better somebody might feel if they have pain meds going on. When we have mobility issues often I mean every older animal has this cats are a lot less obvious about it because they tend to just hunker down dogs tend to keep trying to do everything that they used to do and it becomes more and more obvious that they're not able to do that anymore. And it's usually a combination of these factors. We've got pain from arthritis or other nerve issues and then we have stiffness. If you have arthritis and you have a joint that doesn't move the full range of motion and it's your elbow and you're stuck like this which many dogs that have elbow arthritis are kind of stuck like this. You're going to limp even if you're not painful because your joint can't go through the normal range of motion. Neurologic deficits very often in the back end especially in large old dogs will see things like walking on the tops of their feet or crossing over a very narrow stance or a very wide stance kind of a drunken sailor gate in the back end. This isn't painful but it makes it really hard to get around especially when you have these other things going on. Then we get muscle wasting. We actually have loss of muscle mass in legs because they're not as active as they used to be so they're not moving to keep their muscle mass up plus these neurologic deficits when the nerve messages aren't going back and forth from the brain to the muscles that alone is a cause of muscle wasting. So then you lose muscle mass, then you get weaker. There's more stress on your joints and then you just have generalized weakness which can be a result of many of these things. Often somebody looks really weak but then if we give them pain medication that actually seems stronger because they're now able to do things comfortably that they couldn't do before. And cognition stuff, this affects dogs and cats. I think it's a lot less obvious in cats. Maybe that's because dogs have facial expressions that are more similar to people facial expressions probably because we domesticated them what like 50,000 years ago whereas cats have only been domesticated maybe 3,000 years. Cats are more close to wild animals than many dogs are. And their faces, you know, they always get, people talk about how they're inscrutable. I think that's mainly because the way their faces express things and we're not so used to reading that doesn't quite look like ours. The other part of it is that cats that are confused do tend to just kind of do less whereas dogs that are confused, it can be more obvious because they'll go to the wrong side of the door when they're trying to go to get out or they ask to go outside and then they don't really know why they're out there and then they come back in and then they want to go out again or they forget that they've eaten or they wander off down to the neighbor's house when they never did that before or they no longer seem to enjoy the things that they used to enjoy. I was just talking to someone today whose dog has pretty significant dementia and she used to spend all day outside and now she doesn't want to be out there. She goes outside, she comes back in and she wants to go out and come back in. It's very clear to them that she's not enjoying things the way that she had. So not knowing what's going on, having a day-night inversion, this is really common for people with dementia, it's also common for animals with dementia so we'll have yowling cats all night long or we'll have dogs that are sleeping all day because there's nothing going on at home and then up all night in the middle of the night asking to go out at three o'clock in the morning like I need to go out now. Okay, you must have to pee, go outside. And then we're like, oh, wow, it's really nice out here. Oh, I could pee, I guess. And you're like, it's three o'clock in the morning, I need to sleep. So it's really challenging with animals with dementia. It's a lot to manage. People are hard to manage when they have dementia. Pets are hard to yowling, agitation, eating and drinking changes. Maybe they don't remember about eating. Maybe they don't really seem to want to eat or maybe they feel like they always need to eat because they forgot that they just ate. I see both of those things. So there are some very awesome, fabulous cats. This is Teaser and Sammy. And I chose this picture for this slide because there they are so comfortable and happy in their cat beds, you know? And we get to this stage and our veterinarians are telling us about all the tests and procedures that we might choose to do. We as veterinarians are trained to give you all the options. I think we're really good at giving you the options of technology and intervention because those are clear to us. And we're not so good at talking about the options of what if you don't do that? But that's equally important because like these guys illustrate to me, everybody would probably rather just be home in their bed than going to the clinic and some hate it more than others, you know? But this is really a personal question because I sound very non-interventional and as a veterinarian I tend to be and that's how I've ended up where I am instead of being some super high tech that practices all this cool medicine. I don't dislike that cool medicine. I think that it's really useful and I want people to have it. I'm really glad that we have access to it. I just feel like it's much easier for veterinarians to kind of go with that because it makes sense the way we're trained and we don't really have as much training in how do we approach end of life care without those things. That having been said, they're really helpful, you know? Even if we're just doing palliative care, palliative care, the definition of that is that we're trying to treat the symptoms that somebody has without actually correcting their underlying disease process. So that is, palliative care can be done really usefully with tests. If we know, for example, that someone has changes in their blood work and certain values, we can actually target that palliative care to try to help them be more comfortable with that. So it's a discussion to have with your vet and to go in, I think, kind of having a thought process beforehand about how much intervention might be comfortable to you. Maybe you have a sense from experience with other family members or previous pets that you've had where you might feel like, you know what, I really kind of am a low intervention kind of person. Or, well, I would consider surgery, but only if it's likely to extend his life by at least whatever, six months, a year. To have those kind of thoughts when you are asking these questions at your veterinarian's office is helpful. Often, though, you're in there suddenly facing a diagnosis that you didn't know about. So don't feel like you have to get everything figured out then, you can always come back or ask more questions. One intervention that I think is really beneficial to consider kind of early on in the aging process is dentistry. A lot of old animals have trouble with their teeth and some of that may develop in old age, but some of that might have actually been going on for a while. So if you can get a dentistry done before they get old, you know, this may be about eight to 10 years of old age, depending on species and size of your critter, they will bounce back from that better. It's hard to wanna do dentistry when somebody is old because we know that even if it's really beneficial from the medical point of view, it's still a lot to recover from. There's the stress of hospitalization. There's the stress of anesthesia. There might be extractions. That's a significant procedure. And I've seen older animals go both ways. I saw a 17-year-old Chihuahua who was really uncomfortable and not doing great, come in, had terrible teeth. He had all his teeth extracted, and he bounced back and did fantastic for another year and a half after that, like super great quality of life. To me, that was worth it. But I've also seen situations where someone's taken weeks to bounce back, or it's a rare but actual complication of anesthesia that someone can actually go deaf. I think that happens more to older animals. And sometimes people say to me, you know, he was just never the same after that dentistry, which doesn't surprise me because going through that at an old and vulnerable age is like going through a serious illness. You know, it's a lot to have to recover from. So we weigh those things carefully. And we can talk more about interventions about specific cases or diseases if you want to. So you guys might know this dog. That's Charlie and Cap, and they're local Montpelier folks. Cap is no longer with us, but I chose him for this slide because Charlie did an absolutely tremendous job of feeding Cap. Cap belonged to his dad who passed away, or actually first had to go to a home and then passed away and Charlie took on his care. And Cap was just as elderly as Ron, his person. And Charlie did an incredible job of making beautiful home-cooked meals for Cap. Eating can be really an issue. It can be hard to get older animals to eat. And home-cooking, at least some portion of what they're eating, if not all of it, can be really helpful. If you're gonna home-cook all of it, it's really best to do that to a recipe made by a board-certified veterinary nutritionist because we can have deficits and even in a relatively short term, that can become an issue. But if you're just feeding regular food and you're gonna add in home-cooked food on top, one easy way to do that is to make a patty of ground meat with some vegetables that you chop up, maybe in the blender, and just make a bunch of patties of these and bake them all in the oven at the same time. Then you can freeze them and heat them up one by one. And I've seen really significant differences in how animals do based on getting some more home-cooked food. And you can replace about a third of their food with home-cooked food if the two-thirds that's left is commercially prepared food and not really have to worry about nutritional deficits. So that's a great thing to do. And there's ways to increase their appetite. Medication ways. Can we go back to one quick second for what we can do? Yep, and oh, by the way, if you guys want these slides, you can just, I'll have an email sign up and you can give me your email and then I can just email you the slides so you don't have to worry about copying down anything. What's something, what is in types? It's a brand name prescription medication for appetite. Yeah. So on there is, the list also is pain relief because one of the things that can cause someone to not eat well is to be painful. So I'm always thinking about pain relief whenever something's going on. Could that be at the bottom of it? And then here's a lovely short-faced dog, brachycephalic means short-headed and he has the most beautiful pains but also some significant airway compromise just due to his adorable anatomy. And so especially when they get old, airway narrowing can be really a significant issue. The other problem that we have, especially with older dogs is laryngeal paralysis. This is seen in older labs. There are those dogs that make that dark vaidery sound like when they're excited or exercising or in hot weather we really have to try to avoid overloading their airways with too much heat and too much breathing because it can actually become a life-threatening crisis and there is a surgery to correct that but it's hard to wanna go to surgery as for reasons we've already discussed when somebody is old. However, people that have opted to do that surgery have ended up being really happy that they did and I know a dog who's got right now still going probably another year and a half longer than he would have without that surgery. So avoiding hot temperatures, exercising midday, hot cars, having air conditioning fans, damp towels to cool these guys down can be really helpful. They now make beds that are cooling so that can be useful too. And getting around, pain meds is my number one mobility aid and if I've tried that and it hasn't helped enough then slings can be handy either just for very short-term use to help toss a sling under somebody to help get them up the stairs or that's the ginger lead because that's just like a hammock that goes under their belly that has two handles so we can help pick up their back end without having to lean way over and hold them and then the help them up harness has two parts. It's got a chest part and a back end part and they both have handles on them and you can actually wear that around inside the house so that when you need to be helped up someone can pick you up with those handles. Ramps can help, ramps have to be wide enough, stable enough, grippy enough, most ramps are not and then even when they are we have to train dogs gradually to use them by putting delicious treats on them and getting them associated with the ramp and then maybe putting the treat a little higher up it takes a while to train many dogs to ramps so just make sure it's big enough and then rubs and yoga mats, a lot of dogs have trouble with slippery floors and so one solution to that is just to put a pathway of cheap runners all around your house or yoga mats and the dogs will choose to stay on that pathway so that they can stay up and it helps them to get up and then finally you can make their feet more grippy. There are toe grips which go on their nails themselves and then there are these socks from Woodrow Wear that have little rubber grips on the bottom and that can be super helpful too but all of this stuff requires attention to make sure that it's working. We don't wanna have somebody go outside in their fancy socks and then leave those socks on all day because they're wet so any of the stuff that we use on the dog itself we have to be careful that it's working for the dog and carts, these are helpful if somebody really could go for a walk except for how their back end is not working. If their front end is significantly better than their back end then that's useful but unfortunately what many of my patients by the time I see them the issue is really that both ends are having trouble and that just getting up and moving around inside the house is hard which a cart is not gonna help you inside the house but it really could help somebody have a longer better quality of life if their front end is okay. So Dementia is so challenging and we talked about some of the ways that it's challenging especially at night. There's not a lot that we can do to make somebody less confused. We do have supplements, there's some evidence that a lower starch diet that's high in medium chain triglycerides like from coconut oil can be helpful. I think that that probably is only useful really significantly if we start early and many of the early signs we miss. So hey, if you have an older dog start those things now why not? Anapryl is a medication that's been used for canine cognitive dysfunction with mixed results. Mostly what I'm doing with my patients with Dementia is trying to help them relax if they're anxious. Our cat that had Dementia was not flipped out about it. She just slept all day long. She still knew how to find the cat box. She still knew how to find the feed. So that was okay. But for those that are anxious and distressed or for the dogs that are pacing and up all night trying to help them calm down and help them sleep is really important for them and for you guys also. One way to help them with a day night inversion if we can increase their daytime activity like if we could take them to work with us where it's just a more lively environment. They don't have the wherewithal or the strength to do a lot of stuff but just being somewhere where stuff is happening as opposed to home sleeping all day could really help them be more awake during the day and more asleep at night. And just like you've probably experienced if you have humans in your life with Dementia when things change for them like the living environment changes or people change it can be really unsettling. So even just moving the furniture around in your house is unsettling. I say this not to say don't make any changes but so that you know that when they have a hard time it's not your fault. Like it's just the process of the disease of having dementia it's the way it is for them. So many times people talk to me about wanting a natural death. And often pretty much every consult that I have people will say something like I wish that he would just not wake up in the morning. You know that that would be a peaceful way for him to go and they're recognizing that already life has become something of a struggle for their animal and that also it's a struggle for us like that we're trying to figure out what they want and you know how they feel and that we know that things are going to get worse for them and we wish them just a peaceful end. And people would like to have their pets end be as close to that as possible and yet we're really often challenged by the fact that much of what goes on in the end of life for pets is not immediately life-threatening unless it's really uncomfortable and that a lot of the time what happens with them most of the rest of them works okay and there's this one thing that doesn't. So if we have a really arthritic dog who can't even really get up but his liver and his heart and his lungs and his kidneys are all fine he's not gonna go for natural causes. If we have I just saw this dog today who's actually in pretty great shape physically but cognitively she's really having challenges and she's very agitated about that. So life already has some really serious quality of life issues but there's nothing there that's going unless I mean she's an older lady like in people years she's about 80 to 85 so anything could happen but it isn't necessarily likely that she'll just go like that's why I'm saying not choosing is choosing because we can't just hope that they'll go we have to be there and recognize that what is going on with them and can we make that better and if we can't make that better then maybe we have to make some decisions. Hospice care is basically it can eventually include euthanasia but generally we think of it as being sort of the opposite of end of life of euthanasia like the goals of hospice are to help somebody have as comfortable an end to their life as possible and as natural of a death as they can although there are all these pain medication interventions but we don't try to make them eat if they're not eating we don't try to make them drink if they're not drinking we try to be guided by their process and also add in pain relief. It's really hard to do that with pets because there's no support network for people to have hospice care for pets there's no visiting nurses there's no hospice volunteers and so all of that care falls on the shoulders of the person or people who are home who are the owners or guardians or pet parents or however you want to say that it's just a ton of responsibility and care to shoulder and it can get really hard. So I think most of the time people do end up making euthanasia decision even if they'd rather not and that can be really hard. It's comfortable for me to think about euthanasia as the end of life but for a lot of people it feels very uncomfortable. I've had people say to me more than once I feel like I'm murdering my dog. They have spent this whole animal's life caring for them and loving them and protecting them from harm and helping them be as healthy and comfortable as possible and then we get to this place where they now essentially they're saying to me okay that this is it I order the death of my dog. Like that can feel so bad. I respect and understand that and it can be a very anguishing struggle to think about euthanasia when you feel that way about euthanasia and it's again totally normal. This is just a gamut. Everybody feels different ways and this is not right to feel that euthanasia is right. It's just at this stage the way we have veterinary care, the option that ends up making the most sense for quality of life for most animals at some point. And sometimes I feel like we can overlook problems that they're having in our wish not to deal with the fact that they're at the end of their life. I never see anybody not thinking about this but I do sometimes see people a little bit I think in denial about how much pain their animal might be in or how uncomfortable they might be because maybe they don't have a good solution. I mean there does come a point in a lot of animals' lives where they are so uncomfortable that the only way to make them comfortable would be to sedate them to the point that they're not aware of their discomfort. Like maybe they're having a lot of trouble breathing and that's stressful or their body isn't a lot of pain. You know it's challenging. If somebody wanted to do that and have me work with them on that I would do that. I respect and appreciate that so I'm not ruling it out but I think most people feel like the work of it and the cost of it is just like the financial cost is too much. So euthanasia just really simply the options are being at home, being in a vet clinic. You may plan ahead on this or you might find yourself taken by surprise and meeting this urgently. The more urgent it is the harder it can be to make arrangements to be at home so that's worth thinking about. At this stage most veterinarians do euthanasia pretty much the same way we give sedation first. Most of us give that injectively because it's quick and it's very reliable and very thorough sedation and then once we have them to the point where they're not feeling anything anymore then we give the second injection which is the euthanasia solution which actually stops their heart. And the way I do that is all designed to try to make it as comfortable and peaceful for everybody as possible and I have never met a veterinarian who doesn't feel that way but each of us has different training and maybe different techniques. So it's worth asking how will this go beforehand if you're wondering about that. And then afterwards you have the option of burial at home or some other location if you have a friend that you can bury at their house or cremation which you can have the ashes return to you or you can choose not to have them returned. And when I do home euthanasia I offer the service of taking the pet with me for cremation and then bringing the ashes back home to people but I also am fine with people wanting to make their own arrangements. There's a pet crematory in Northfield that I work with and that most of the vets around work with that's very reliable or one could call up a local veterinarian's office and ask them to take the body for cremation and they would do that and then you would come to the office and pick up the ashes afterward. And people are often wondering what happens if I'm getting these ashes back are these really my pets ashes? How can I know that? I think that's very reasonable to wonder about we've all heard those awful stories when it's not the case. The crematory that I work with here I've been working with for years and I trust them that they're doing a good job. And they, I can explain more in detail but they set things up so that what you're getting back truly is the ashes of your pet. And I'll tell you more about that if you have questions. So here's Mombo, he's a lovely boy and as far as I know he's doing fine so I don't mean this slide to be pretentious for his life, but he's so beautiful with his crazy little face and his 11 year old pup cake. Underbite, yes, exactly. Yeah, and this is the burning question that everybody is wondering when I'm talking to them. How do they know when it's time? Most people I'm talking to are making a euthanasia decision so that's what this question is about. And there is no simple answer and I don't pretend to have the answer. I don't think anybody knows, no veterinarian knows. But some of the things that helped me when I think about this are to imagine life as this kind of this shape where early on we're born and then we do all this stuff and all this interesting things happen. We do all these things, this is our mid-life and then we get to this family where things really narrow down and then we just come to this little tip and instead of going out and hiking or doing all the things that everybody does, hunting for mice, whatever it is that they're doing that they love to do. I think of my kitty Ike when she was about 20 years old she just pretty much stopped doing anything but sleeping and all day long she was just sleeping and that was when I started to think, how is this for quality of life for you? Like is this good enough? How do I know it's good enough? Are you satisfied and I would pick her up and I don't think she knew anymore who I was, who she was, what being a cat meant, but I would pick her up and she would purr and I thought, okay, I don't know, cats can purr for many reasons, they don't always purr because they're happy, but my thought was it may be that she knows that we love her and it may be that in her IUA that she loves us and like here I am just holding her and I feel like she can feel that and I decided that that was enough for me at that point because she wasn't obviously suffering in some other major land. But there we were at the end of this little tip and when we are thinking about when to make a euthanasia decision we get really focused on the right time and we start parsing every little thing that happens because you know there's ups and downs and we're thinking like okay today was a better day but then he didn't eat in the evening and then we're really trying to figure out when do I do this and I totally get that because it's a really weird job to have to try to make a decision that is a life and death decision for someone you love in the middle of a process that is not linear and is ongoing and is gradual. Like what makes today worse than last week in that way that now he should be dead? This is, it's a really hard question and yet to me when we get to that point we're actually in the sort of gray area I often call it where it's not obvious that we shouldn't do this and it's not obvious that we should. Like it's okay to make that decision at any point in this gray area and we haven't yet got to the point where it's an absolute no brainer where there's nothing left that's good in that pet's life and we know that it's absolutely no question time. And people are ready at different times. This is a bell curve which is just the normal distribution of data in any given situation and so some people are gonna be ready earlier in this process of decline. Most people are gonna be ready somewhere in the middle of this process decline and some people aren't ready until later on in the process of decline and I respect all of that because I think that I've never seen anybody not wrestling with this question, not feeling intensely committed to the good life of their pet and wanting to do the right thing for their pet and wrestling with those questions of guilt and am I being selfish and how do I make this decision for him? So I do not have an easy answer to this question but I do feel like you can't make the wrong decision. The right time is there is no one right time. It's just a place of time where it is an appropriate decision. So I hope that takes a little pressure off because the thing is that we're just people. Like we don't know anything, you know? We are so limited in what we can actually know about what goes on and we're just trying to do a good job to make somebody happy and as comfortable as we can and we have to just kind of be okay with the fact that we can't know. We can't know how these meds affect them other than what we can see and observe. We can't know what they want. We can't really know how they feel. You know, I just hope it's comfortable in some way or comforting to know that we're doing the best that we can and that's all we can do and that it's love. Ultimately at the end of it, it's really just about love. I had someone once ask me about interventions like have me come to the house and here's what I'm doing and these are all the supplements I'm giving and here are the meds and this is how I feed and I cook this food this way and then I do this other thing and at the end I said, you know, you're really doing everything. There's nothing for me to change about what you're doing. You're doing a beautiful job but all that you really need to do is just to spend time with her and for some reason this person found that really revelatory in a beautiful way. It was like, oh yeah, you know I thought I had to figure out everything about all these meds and all these supplements and do everything right and you're saying that the most important thing I could do is just sit down here on her bed with her and be with her. Oh, what a relief that was to this person and I think it's very true. I think we can get caught up in all the minutia and all the tracking and challenging stuff and can forget that what is really the most important thing for us to do is just to be there with them which can be really hard. Like a lot of the time we're anticipating, you know, we're grieving right then and there and then we're also thinking about how awful and painful it's gonna be when we actually lose them and sometimes we're not really there with them because we're so stuck in that place of grieving our grief now and also grieving our grief that we're gonna have and it can be really hard to sit with them but if we can open our hearts a little bit to do that more I think that's really the most useful thing. So in trying to figure out when is a good time, the quality of life tracking that we talked about is useful. Some people find it really helpful to plan ahead because they have a time, I've had people set a euthanasia date with me two or three weeks in advance and then they feel like that's really great because they have this time to go do the favorite things that they always liked to do and to have people come and say goodbye and that it can be like a person's end of life when we know a person is going that they can have all these meaningful interactions. I am not a person that's really comfortable with that myself. I'm totally fine. I think it's great if clients can do that. I can't do that. Like once I have decided, I have decided and I can't wait anymore at that point. So I fully respect how hard it can be to plan ahead but the more you can plan ahead, the more choice that you can have about how things go. If you can get a house call that to come to your house that does take usually some level of planning ahead. So just bear that in mind. So I often find that kids are involved in this situation and depending on their age there can be a lot of involvement for them or not much. Usually I think at around the age of about six or so is when they start to understand enough that they might actually be comfortable being present at euthanasia. I always advocate for people to ask their kids about what they want. I think kids are very good judges of what they actually are prepared for. It's really good to have conversations in advance. Many of us have had the experience where a beloved pet was euthanized and we had no idea that that was gonna happen and we came home from school and our pet was gone. And that was very hard for me when that happened. And I feel like looking back, I totally could have handled it. And there are now some good books. I have a book list on one of my slides that has some useful books. This one is a little tricky. I always recommend people read the book before they read it to their kid. But some people really like this book and other people don't. And what the book is about is that the boy feels more comfortable that his dog has passed away because he told her he loved her every day. But the two other kids in the family didn't do that. And some people feel like when they're reading this to their kids that this is not the kind of message they wanna send that, oh, you should feel guilty or bad in any way about the end of life of your pet. So on the other hand, this concept of being with your pet every day and telling them, being with them and telling them that you love them is really valuable. But only if we know about it in advance, right? Other things that can be useful, visiting favorite places beforehand or sometimes afterwards to schedule, to scatter some ashes there. Having a memorial service for your pet can be a really great thing to do. Having a memory box, there's one of the kids' books that I have on my book list that talks about making a memory box for someone who's lost that we miss and love to remember things about them. Sometimes kids are afraid that they're gonna forget somebody that they love and this can help reassure them that they won't. Memorial Jewelry, Evie has a little bone shaped piece of jewelry with the ashes of our dog in it. And that means a lot to her. And some of that stuff, I mean, there's memorial jewelry in every style. And some of it's really beautiful. Tennis Ball Valhalla, this is the thing that I came up with once on the way home from an appointment where I thought, you know, the people had done a lot of their grieving beforehand and so the appointment was actually almost like a wake. You know, they were able to talk about how much they loved their dog and all the things that he loved. And, you know, he really liked chasing the squirrels and at the end, one of them said, he just really liked bananas. And they had a whole story about how he loved bananas and how he would beg for bananas every time anyone was eating them. And I thought, it's so beautiful and wonderful. Like, this is it, this is the meaning of his life. Just the little things that he loved and how he liked being at home with them. And I thought, well, Valhalla, right, is the place where all the Norse warriors go where they have drinking and fighting. And, you know, like what happens in your pets, Valhalla, is it full of tennis balls? Is it full of bananas? I think it's a great way to just really write out and appreciate all the things that they are. A photo book you could make. And I saw one time in a catalog this really great frame. It was just a picture frame. I had a picture of a dog and it's smiling. And on the top it said, thank you for everything. And on the bottom it said, I had a wonderful time. And when I looked at this, I thought, that's what we need, we need to remember that. Like sometimes at the end of their lives we're so consumed with the stress and struggle and difficulty of the end of their lives. And then once they're gone, it's really so helpful to remember that feather image. Like most of their life was this wonderful great thing where they had a great time and you loved them and they ate bananas. And like they really did have a wonderful time. And I wanted to incorporate that into my sympathy cards for a while but I actually haven't been sure that everybody would feel about it the way that I do. So I have hesitated to do it. But if it does mean something, try it. Just give it a try. Take a picture of your pet and put that little frame around it and just see maybe it's helpful. And the 10th Good Thing About Barney which is a great kids book by Judas Beorst and it's about a cat who dies and the family talks about all the good things about Barney. And I totally recommend that one. But remembering all the good things. It's just all the ways you can do that. So here's my book list. And then I've got a website list. It's just two websites that I think are useful. The top books are for adults and the bottom books like the last five of them are really aimed at kids. But I find that kids books, books that are aimed at kids are super helpful for adults too because they really boil things down into these very simple ideas and they make us all cry when we read them. I really like being mortal. That's by a human surgeon about human end of life but it really made me think a lot and it's beautifully written. And then the last walk is about animals. And some of that stuff I didn't really like so much but the parts where she talks about the actual like what it is like day to day to take care of her aging dog and all the difficulties that he has. They're so true and it's so common. I think that's worth it just reading that for that alone because you get the feeling like I am not alone. Everybody goes through these things. So those are my books and I can send you this list and these are the websites. The International Association for Animal Hospice and Palliative Care is primarily for veterinarians but they do have resources for lay people and they have a hotline list and Laugh of Love has a ton of resources for lay people not for veterinarians but for pet owners, guardians. And they've got that gray muzzle app and the geriatric questionnaire which I have copies of. I have talked a lot. You guys have questions. You talked a lot about dementia. Yeah. How common is that? Super common. Is that because they're really longer than? Yeah, maybe. I don't know. I mean I think dementia is more common in humans too and we don't necessarily know why that is but I think many, many, many, many, many older animals have early stage dementia that may be not that noticeable or not that problematic but I would say probably a quarter of the animals that I see for end of life consultations are having some significant dementia issues. What are some of the early signs? So I think we attribute hearing loss and vision loss to hearing loss and vision loss but sometimes it's actually about not knowing what the meaning of the things you're hearing or the things you're seeing are. Being a little bit more withdrawn or just not acting like their normal self, not interacting like their normal self. I don't know. I would bet you that there's early signs that we totally miss that I don't even know what to tell you they are because the things that happen with people are so subtle in the beginning and we wouldn't know if a dog is forgetting those things or if he's telling us the same story four times in a row or a year, right, exactly? We're going to use that bone. Talk a little bit about the money issue in terms of, I know we have a lot of animals and then we always get to this point where you're in that gray area and you go into that and then you know, well, we could do this, we could do this, we could do this and now it would be 750 and this would be 650 and that would be, and I love my pets. Can you talk maybe about what, I don't even know, what kind of questions are appropriate to ask? Like I asked, what will this give my animal basically? Like are there other questions? Because it seems like that's what we all get hit with in the face, right? There's not a lot of health insurance unless you were smart and you bought it when they were kittens and so now you're just faced with a lot of money and a pet that is probably not going to get better but could seamlessly live a lot of medical, what do you ask? Yeah, I think that's a really good question and I think that no one should feel uncomfortable about asking that question because like you said, insurance is thin on the ground and it really matters so you should feel totally comfortable asking that question and you should, I would ask about, well, what are we gonna learn from this test and how is that gonna affect decisions that I might make, you know, sometimes we're gonna get more information but you might not actually do things that differently so if the purpose of the test is to get a definitive diagnosis about exactly what type of cancer we think is going on but you won't find that too useful because you're not planning on pursuing chemotherapy or radiation or surgery, you just wanna treat palliatively and maybe you just wanna treat palliatively based on symptoms, that's a worthy question to ask so what are we gonna learn from this? How is that gonna affect our decision-making, like what is the benefit of that information to us? Do I need that information to help keep him comfortable and if so, how? You know, and in the case of a procedure, how likely is it that this is gonna have a definitive good effect versus is it gonna extend his life and on average maybe how long? You know, what are the potential negative effects of this thing, like if you're gonna go for some biopsy, you know, is there a possibility that he's gonna, what's gonna happen with anesthesia, what's the recovery time, does that help? Okay, does anyone else have more questions related to that one thing? Cause I don't know that I answered that, you? Yeah, I have a question, and then with the other way around I think it is really important for anybody who has an animal, which needs care, to ask always, which I once didn't do and they have lost my dog, it was really painful, is this medication possibly damaging the animal? Because when we have rescued animals, we don't know what happened in their formalities and if an animal ever had a little problem or if a horse went through a starvation period and it was nicely recuperated, there are so much more sensitive to medications and this nice visiting that from what she had said, he didn't ask us, so our dog got killed but the medication was supposed to help the dog because he had a liver sensitivity and the liver shut down. Yeah. And it was so painful, we took weeks and we finally was dead on IV, and they were all living on animals, it was really expensive and the vet was not in any way feeling guilty about it or bad or anything because she had justified it by saying, well, I thought we wouldn't wanna have a test. We never had before, had no choice. Right. Which is because we didn't think about asking, dude, does this medication possibly kill the dog? That is a test necessary, you know. Yeah. You're talking about a really rare side effect but something that's really significant and serious. And the owner of the animal always asks, is this medication having any possibly damaging side effect? Can we test it before? Yeah, I think that's it. A good question to ask is in any situation what's the potential negative effects here and how likely are they to happen because you need to be informed in order to make those choices and that should be your choice about whether you're gonna have testing beforehand or whether you're gonna use a certain medication. This is changing the side effect of the animal. Okay. And I'm not exactly sure how to word it but at a geriatric animal, quite old, relatively healthy, do you see dogs that just drift off in the night? Very often, 50, 100 times, is there any other discussion? Yeah, what can you give us there? I don't know if there's any, but I think. Can we try? Yeah, you know, there's a kind of a thing about in veterinary medicine that I feel like there's a little bit of a presumption that everybody's life should end in euthanasia and that if it doesn't, that someone has suffered too much and I don't agree with that. I have seen animals go very peacefully. Rarely does it happen overnight, suddenly, but I've seen them go into a decline, a very significant decline over a period of just a couple of days where it's very clear that they've stopped eating and they've stopped drinking and they're just lying in their bed and they're not really interacting but they look peaceful. It's hard to predict how the end of that will go and sometimes there is some agitation toward the end or some vocalization or some breathing patterns that could be uncomfortable if you weren't prepared for them, although they don't necessarily mean that someone is genuinely distressed. It can be just something that the body is doing without conscious awareness and I do think it's entirely possible to die peacefully without my help. But that having been said, I feel like that, I don't have a percentage for you because a lot of them I'm not hearing about. Sometimes I go to someone's house and they say, oh, my cat passed away and he just went very peacefully. No veterinarian has ever heard that so it's not hard to see why we kind of have perpetuated for us this idea that we need to be there to help. But often people do call me about that. They're wondering maybe how is this gonna go? Is my pet gonna go peacefully? Do I need you to come out here and help him go or can he go on his own? And so then we have a conversation about what you're seeing so far. Do you think he's comfortable and how much that person can handle the sort of uncertainty of what might happen if it does start to look a little funky and are they prepared to zip off to the emergency clinic if they feel like that's what they need to do because it is hard to reach one of us to come to the house at the last minute. So I don't know a percentage. It's entirely possible and I think that I've certainly been called to euthanize animals that I think probably would have gone peacefully on their own but that's a pretty small number also. But you're saying also if you preach like let's just let this go peacefully and then at the last something could be happening at the end that you would make it that you'd have to go off to the emergency clinic? Yeah, because it depends how comfortable people are with not knowing exactly what's happening and can we watch somebody who's breathing changes or the breathing sounds very hoarse or they're breathing very rapidly or are they actually vocalizing? Can we feel okay with that and not knowing whether that means that they're in distress or not? They may well not be but it's just hard to know and so a lot of people's decision making at that point is based on I don't know what's going on but I don't wanna worry that it's something that's uncomfortable so I'm gonna step in here. It's possible to have a sort of crisis kit for that situation and to give some sedation at that point that could be helpful because that's certainly what they do with people if they're having that issue as they're approaching them but it's tricky because then either it's gotta be oral meds that you have to somehow get into them or injectable meds that you have to be comfortable giving or sometimes we can give it like rectally kind of as a suppository or as just an injection without a needle kind of just squirting something up the rectum but all of that stuff can be stuff that people just don't want any part of but if people are comfortable with that they can do that. I can't give a whole lot of that for someone to have on hand for obvious reasons because most of those things are controlled drugs that we have to regulate pretty closely. Did that answer that? Absolutely. Okay, cool. Yes. What are the thoughts about the expression of the owner's emotional state during the dead dying process? Sometimes I wonder if too much expression adds to their anxiety. Right, yeah, people often worry about that. They'll tell me like I'm really trying hard not to cry in front of him because I want this to be as peaceful for him as possible and I know that animals are really sensitive emotional feelers that I had that situation in my own self and many people have these stories where I had just adopted these two cats, they didn't want anything to do with each other and I'm on my bed crying and they both came up to me and touched their noses to my face like this like right here and then when I was over my upset they went back to not speaking to each other for the next two weeks. So they can tell that when we're feeling things we could probably tell a lot more if we weren't so thanky with our big brains but I don't think that they fear death the way that we do and I don't think that they necessarily even emotions are straightforward for them I feel like our emotions are always overlaid with other emotions about our emotions and that gets so complicated for us and I wonder if just the simply our being sad is not stressful to them necessarily but our being anxious about being sad and trying really hard not to be sad might be more stressful than our sadness and I also feel like we can't not be sad like this is a really sad time so to try to put pressure on ourselves to not be sad is really hard and if we can instead open our hearts and feel that sadness and be there with it and be with them and recognize that our sadness is coming out of our love for them maybe that can be an expression of love and not distressing to them but they do take on care of our feelings I feel like that's actually the job especially of cats do it too but dogs have been domesticated by people for a long time and we made them the way that they are because we wanted them to do jobs for us and now we've taken away most of their jobs but they're still there to help us that's their reason for being a lot of dogs and they will take on our emotional well-being as their task because that's the job that they have now there's actually a book by John Katz I think it's called The New Work of Dogs that talks about that I haven't read it but I really yeah I feel like that's totally true so there's just an inherent nature of dogs to do that and there's nothing we can do about that I don't know, what do you think? So. Can we talk a little bit about this is something that I was told when I was dealing with in two subsequent years of the dogs were just a year prior that animals in general and particularly cats have a drive to survive essentially and that's sort of in them evolutionarily to not show their weak or that they're in pain or that they're distressed and that that can make it hard to tell what's going on because they're gonna cover it up or not show it not show that have you discovered in your work things that you find to be true as indicators of distress and stuff that go beyond because I know when you said the bright line thing I made me think of I had this idea with my dog if she loved to eat that if she didn't show interest in food that would be a clear indicator she never stopped liking food the last thing we did together was your chicken and so that was never an indicator but what I did learn was that she was incredibly restless couldn't settle, didn't stay down long that that was an indication of pain that she couldn't get comfortable she didn't cry, she wouldn't whine she didn't do any of those things but she just circled and paced and so on and so forth and I just wondered if there were other signs that you've come to understand to be indicators like of pain specifically well pain and or distress of some other sort yeah I mean I would say looking not relaxed panting, pacing, circling being touchy and irritable being withdrawn, hiding, wandering off like you know disappearing not eating did I say not interacting normally with the family it can be subtle though I think it's less so with predators like dogs and cats than it is with prey animals prey animals seem extra good at hiding what's going on with them but the signs can be kind of subtle you know like a cat in distress with breathing difficulty often doesn't look as bad to the people as it looks to me because of my trained eye and some of that is just that it just doesn't look as you know it's a cat that's not moving a lot and it's actually visibly breathing like a visibly breathing beyond I mean we can see our cats breathe all the time but you know if they're putting just a hair more effort into that than they normally are that can be such a subtle thing but when they come in and I see that I'm like this cat is breathing with great distress so some of it I think is just something that you pick up over time or with exposure I've seen so many cats with respiratory distress that I can see it and someone who hasn't seen many cats like that won't necessarily pick it up that's my lead in I have a cat with respiratory distress he's a 14 year old Persian he's got that Persian name and so that's his stem ball and I've just had him for about a year there in the head and I think he kind of felt like he could come to me and fall apart because it's kind of what he's done and so I'm trying to learn to breathe him does your acupuncture help that? Maybe? Or how do you, it's a breaking how do you say that? Breaking cephalic Cephalic? Yeah The short nose Right Shortheaded? Yeah Does it help with that? Maybe? It's hard to say some of it is anatomically based and there's nothing we can do about that and then some of it might be inflammation based so acupuncture could help with that some of it might be allergy related that could be helped sometimes they've had upper respiratory infections as a young cat that caused scarring in their deep kind of fine nose bones that are way back there so it's not just a compromise of shortened airway but also of damage that occurred in Kittenhood so I don't know if it would help or not it's worth a try but I can't tell you for sure Yeah Oh The glucosome comes right in Do you think it makes any difference if it can give a dog human glucosome? Yeah you can A lot of those supplements are not tested or because they're nutritional supplements they're required to be safe as a food stuff but not necessarily required to have the activity that they claim so I have concerns about a lot of supplements because there was a test not that long ago in the journal of the AVMA that tested I don't know 15 different supplements and found that one of them actually had what it said it had so I tend to recommend the same two brands all the time because I know I feel like I can trust them I'm sure there's other trustworthy brands out there and you know at one point they did some testing on I think it was the Walmart brand and it was actually good but you know it's a generic and they get it from different suppliers and so it may have changed I feel like I can rely on stuff from Nutramax which they make Dasequin which is one of the and a whole host of other supplements in that family and then also Vetri Science which is a Vermont company that actually makes their products in Vermont and they're like a flex and they have Vetri Flex which is supposedly only available from veterinarians but I think their products are good too so those are the ones I tend to recommend If it says it's standardized, do you trust it then or not? No. It's still not I know that it says house calls does that, have you ever met anyone like on a trail or do you look at a trail map or something for the United Asia? No I haven't but I would Yeah. You have a question? I have a question. This is my husband. What is your question? One thing I did hear you talk about I was going to speak about the interest What is it like when you go to someone's house like how long are you there? What is the procedure sort of that happens? Like just for euthanasia? Yeah or they made the decision to call you out what does that process look like? Right. Well I will actually talk about a consult because that's useful to know too sometimes people really just don't know where they are and they know they have to think about end-of-life stuff but they don't know how to think about it or they got stuck because their pet is somewhere where no pet of theirs has previously gone and they don't know how to deal with that or maybe this pet is like their heart dog and they just can't or maybe they've never had a pet before and they don't know where to go with it so having a consult I would come out and it usually takes about an hour to an hour and a half and I do a physical exam and the person tells me all about the medical history and all about what's going on and all the challenges they're dealing with and then we talk about the various options that could address those challenges and we also talk a lot about sort of end-of-life philosophy and where they are and how much intervention they're interested in and how they view end-of-life and other end-of-life experiences that they've had with others that they've loved people, humans just so I can get a better sense of them and mostly it's about me trying to help them figure out how they feel and then sometimes at the end of that the person is actually ready other times they're not sometimes they want a prescription for a medication that we've talked about that they've decided they wanna try so we do that sometimes they call me back a few weeks later and I come out and do the Eucanasia then other times two years go by and every now and again I text him and I go how's he doing and they go he's doing pretty good and I go all right if I'm prescribing something in order to keep prescribing I have to see someone at least annually but I sometimes turn into people's regular vet for a couple of years although if they want something like tests or procedures or interventions I will refer them back to a clinic but for the Eucanasia visit what happens is we can be anywhere that's comfortable so that can be outside or in whatever room take a little time to get to know the people and to say hello to the animal and often people even if they're pretty sure still have questions or they still wanna confirm with me that I think what they're doing makes sense so they might want me to do a physical exam or just explain what's been going on and so we talk about that some if people want that but if I don't require anybody to justify their decision to me I've never seen anyone make this decision lightly or in such a way that I feel like I should question them very, very occasionally I get to somebody's house and their main problem is pain and they haven't tried any pain meds and I will ask them some questions to see if they might possibly be interested in pain meds I don't, I truly try not to act like they should be interested in them because I completely respect that somebody may not be interested and they may feel like that's just postponing something inevitable or they're not sure what the side effects would be or they just don't wanna go there so I really try not to make people feel like they should do that but I also want them to know that there is this option and that it might be useful and I try to give them a good idea of what the potential side effects might be but most of the time that's not the conversation because much of the time people have done in the case where they call me knowing that they want euthanasia they'd also know most of the time that they've already gone through the things that they can go through and tried the things they can try or sometimes they ask me that question so we will have whatever level of conversation people want to have that might be nothing or that might be 45 minutes it's just whatever works and then the actual procedure is for me to give sedation mostly I do that by injection and mostly with cats it's an injection under the skin of a small amount of stuff that's about half the size of a vaccination often with dogs it's either that or if it's a big dog it might be a two step process if they're especially sensitive to pain because the injection that goes in the muscle and some of the stuff that can go in that can be stingy in and of itself so if somebody seems like they're gonna be super sensitive to that I might suggest that we break it up into two steps but sometimes people really prefer not for it to take that long because the subcutaneous injection maybe takes about 15 minutes to take effect and then if they're not fully asleep and we want to give another injection in the muscle at that point that might take another 10 minutes sometimes people are fine with that and actually prefer if things take longer because it helps them sort of get used to what's going on other times it's about as much as people can do to be there for this process and it just needs to go as quickly and smoothly as possible and I just try to read people or ask them if I need to ask them how they feel about that but the sedation part usually takes about 10 to 15 minutes and then once they're fully sedate I give the euthanasia injection for cats I just tend to give that into the abdomen they don't feel anything at that point and that takes maybe depending on where it ends up and how much blood supply that place has might be as quick as just a couple of minutes to absorb but more commonly is usually about 10 to 15 minutes maybe 20 minutes to absorb fully which is a very peaceful process especially because they've had the sedation beforehand they just gradually start to breathe a little bit less often sometimes and then very slowly the breathing the brain stops first and then the breathing and then the heart if it's a dog, if it's a very small dog I'll do that injection in the abdomen like with cats if it's a larger dog I'll give the injection in the vein and so I have a tourniquet and a little clipper to clip over the vein and the injection goes usually very smoothly but again I really like to make sure that they don't feel anything before this in case their blood pressure is not great so sometimes I need to use the second vein I want them to not know about any of that and I want us to know that they don't know about any of that because I think that helps us have our minds at ease too and so in all cases the brain stops first and then the breathing and then the heart and so I just listen to the heart and let people know that it stopped and then most of the time people want to have some time with their pets privately so I usually go out to the car and put things away or sometimes if I'm gonna be taking the pet for cremation I'll make a little space for them in the car so that we can carry them out and then I just tell the people I'm gonna carry these things out to the car and I'll just wait there for you and you can come into the door and wave and I'll come back in when you're ready and once someone asked me to go away for longer they said could you give us an hour and I said sure I could go away and come back I had to charge them a little bit more but they were very happy with that extra time and it was fine to do that so mostly we've been at people's houses I would say all the time I've had some clients that were just my clients for regular like general medicine house calls that really didn't actually want to euthanize their pet at home they just didn't want to be thinking about that when they were at home I mean I've known clients who had to change veterinarians not because they didn't like anything that the veterinarian had done but just because they could not face going back to the clinic where their pet had died so everybody is different about those things and some people feel like they can't be present and I understand that too I not had anybody not want to be present at a house call but I would totally respect that if they did and in the clinic I've had some times where people just said I just have to say goodbye to him and go and I understand that it's really hard so oh gosh guys and because I feel like that's a really heavy note to end on yeah and I can I more of a sort of question yeah sure do you have an experience or have you heard anything about the use of CBD with the animals? I think I am legally not allowed to advise people about that but I think I am legally allowed to tell you that I have known people that have used it for agitation and anxiety for it's been used for seizures with varying degrees of usefulness there's a lot of trials and people for seizures there's currently trials going on in veterinary medicine at Colorado vet school there for both I think I mean definitely for pain and I think also for epilepsy so I've seen people using it and thinking it's helpful for pain, agitation, anxiety appetite issues it seems more variable so I think that's about all I'm okay to say but it does seem like it can be helpful yeah just a quick comment I don't know if people are aware but the new hospital is not clear that where the broken death was they're not clear that they do acute care off hours so you don't have to go to the religion if that should go in yeah you may still need to go they don't have a full service emergency clinic hospital full on after hours but they have vets and they do seem willing to see you in the middle of the night but they may still refer you on if that you have something for example I had some clients that went there with a dog that had bloat and they said we can't do this surgery here you could go up to Burlington but we actually think that he might well not make it and then the people ended up deciding to euthanize him there and they were very grateful that they have been able to have that here instead of having to go up so it's not a full service hospital but I do think they actually will see you in the middle of the night and people have been happy with their service and if it's something you know like porcupine quills or something maybe Phil so it's not where is the it's the old formerly Berlin vet clinic now Montpelier veterinary hospital yes no it's different people Steve Carey used to run the Montpelier the Berlin and it's been bought by a couple that's fiance is the husband to be is a veterinarian he's from Morrisville his grandfather and great-grandfather were vets they met in vet school in Indiana she's from Indiana she practiced in Texas until recently but so there it's like a husband wife or almost husband wife they're not going to be there yet yeah yeah yeah you're welcome thanks for coming in