As a veterinarian, I know it is the client who has lost a pet and wants our professional counsel that stretches our abilities to the limit; we haven't been trained to treat a broken heart. When the Delta Society was formed in 1981, I was one of the first in line; I knew I needed the knowledge they networked concerning the human/companion animal bond. I have been at most of the annual meetings of the Delta Society; their meeting has always given me a recharge that rejuvenates the soul. I am also a charter member of the new American Association of Human-Animal Bond Veterinarians, and watch their e-mail board for activity, which is not too frequent. But what is a practice to do?

The survey used in the introduction of this text allowed us to evaluate 156 retired (over 50 years of age) military families, identify their specific values toward their pets, and compare them to the survey population in total (n=961). In comparing the results of the older retired family to the total populations, some trends become evident. It was reported that 24.5% usually celebrate their pet's birthday, (about 10% less than the general population surveyed) and when asked about display of their pet's picture, 58% displayed pictures in their home. These rates reflect more pictures but less birthday celebration than the total population surveyed, an indication of increased pet importance with less desire to "count the days." In reviewing the names of that the elderly respondents gave their pets, a subjective review of the surveys reflected 48% of the pets had "people-type" names, 31% had been named after "things or physical traits," and 21% were given "animal-type" names. When compared to the total population of respondents, which reported that 23.4% were named after physical characteristics, 11.7% were named after TV show/movie/cartoon/or book characters, and 9% were named after a person and 7.7% were named after a previous pet, the "belonging" status of the pet became far more evident. This was reinforced when the elderly were asked about reasons for selecting their companion animals; they rated, in order of priorities, the reasons as follows: pleasure (36%), companionship (35%), and protection (10%).

Many traits or attributes are credited to the companion animal during daily conversations, so the survey asked specifically what special characteristics the pet displayed with the family. The responses were placed on a line scale from "great" through "some" to "none," with the following results shown in Table 1.

When asked directly to evaluate how important their pet was to their life, 50% reported "extremely important," 34% reported "very important," 14% reported "important," and 1.9% reported moderate to no importance. To better evaluate the importance of the companion animal, respondents were asked to rate the importance of their pet to them, in specific situations on a line scale from "great" to "some" to "none," with the following results:

It was interesting to note that while the intensity of feelings concerning the importance of the companion animal was often more polarized in the elderly than the population in general, the significance of death of the animal to the elderly was over 20% less (73.1% vs. 94.4% important to extreme loss). This is thought to be due to the greater acceptance of the death process by the elderly.

Besides questions concerning the importance of the pet to specific situations, other questions were posed to evaluate the respondents' anthropomorphic tendencies. When asked how the companion animal fit into the family group, 71.9% stated that the pet had full family member status, 23.9% had friend status, and 3.2% of the pets were considered possession/owned property. While these responses reflected a greater value to the elderly retired population, 99 percent of the families surveyed felt children should have pets. Later in the survey, the question was rephrased and the respondent was asked if the pet was afforded "people" status in the family. A line scale was used and the respondents were asked to rate the status from "always" through "usually" and "sometimes" to "never." The survey indicated 78.4% of the elderly felt their pet was usually to always afforded "people" status, while only 2.6% stated they never gave their pet "people" status; this rate was about 10% higher than for the total surveyed population.

Utilization of companion animals to reduce feelings of loneliness, depression, or boredom has been well documented in recent literature. Individuals have also exhibited dramatic improvements in their ability to interact and communicate with other residents and staff. These behavioral effects, whether subjectively or objectively proven, have resulted in a decreased staff workload, as well as an improved cost-benefit ration. This animal facilitated communication benefit could assist the hospice team at any point in the loss phenomenon shown below.

Kubler-Ross Loss Phenomenon
in Death/Dying Bereavement
(Stress Mediated)

Denial - Anger - Guilt - Depression - Acceptance

The rising costs of health care, especially hospital services, have been common concerns in the health care literature. The resources available for health care have become increasingly constrained. Health car must be considered a commodity.

The proportion of elderly in the nation's population is rapidly increasing; the challenge of meeting the long-term care needs of the elderly over the next 20 to 50 years is enormous. It is apparent that this is the age group that will have the greatest impact on health planning, healthcare provision, and healthcare costs over the next several decades. We must come to the realization that resources available to meet healthcare needs are limited, and these resources constraints will make stricter allocation decisions inevitable. This is especially evident in the care of the terminally ill elderly. Although technology has brought great changes in the delivery of health care; not all persons will be able to benefit from this contemporary medical technology. This factor is especially true with the dying child, where "quantity" care is often detrimental to the child's mental health, as well as their personal rights as a patient.

The hospice approach is offered as one alternative in the production and delivery of medical services to the terminally ill regardless of age. Attention is focused on palliative care rather than curative, offering death with dignity. In addition, several elements of care usually not found in the acute care system are part of the hospice; family and patient as one unit, continuum of care available, symptom management and pain control, use of the interdisciplinary team, utilization of therapy extenders or facilitators, and bereavement counseling. Many of these benefits are difficult to measure, such as the effects of using the companion animal. While the literature is full of articles about the role of animals with the elderly or with children, death is seldom mentioned.

Table 1

It has been well documented that the elderly with companion animals perceive less loneliness and less emotional isolation, as well as being provided something to care for, to keep them busy, to watch in idle times, or to provide a stimulus for exercise. The importance of the companion animal in life review, or reminiscence, cannot be understated in the hospice program; the animal provides a sense of security, as well as a dependence that often anchors the hospice patient to the realities of daily life.

Networking for Resources

Okay, so you join the Delta Society (Renton, WA, 800-869-6898) and get their resource list for grief counseling. You join the American Association of Human-Animal Bond Veterinarians (request your application on www.avma.org or www.VIN.com). You buy the books, get the journals, and become astute at the "first aid" level of counseling; learning to listen and ask questions that allows the client to discover the solution for themselves. But what of the practice team?

The American Animal Hospital Association (1-800-252-2242) released a VCR three-tape series on Pet Loss and Bereavement. The first 45-minute tape discusses pet loss and the grief process, while the second 45-minute tape reflects on methods that the practice team can use to counsel and console clients. Each of these tapes come with a unique workbook that is veterinary practice specific; they allow the practice to tailor their approach to fit the practice philosophy. The third VCR tape in the AAHA series is designed to be sent home with the client and has a brochure for the client to review. It is a great aid during those anticipatory grief times, when you first discover the cancer, or when the family must relocate and leave the pet behind, or when the congestive heart failure first becomes symptomatic. These tapes are a must for any practice that wants a team approach to client bereavement and wants to help the client to decide to return to the practice. The "new" AAHA study replicated (with an eighty percent smaller sample) the same family values we published in the text "Pet Connection", a 1983 Delta Society Proceedings text. The Latham Foundation published, "Universal Kinship, the bond between all living things", in 1991, and shares additional viewpoints and tools from multiple authors about the human-animal bond. In the Chapter on Grief, we explained the stages of grief, from anticipatory to crisis to crucible to reconstructive, which include certain practice actions which should be considered:

In most family pet loss situations, the grief is severe. The pet was a member of the family and is lost. The pain felt is the price paid for the love shared; but that doesn't reduce the pain. In most people, the grief process is a series of natural reactions, as explained by Kubler-Ross in the landmark textbook, Death, Dying, and Grief. These are seen in each of the client stages shown in the previous chart. But in some cases, certain people "get stuck" in one of the stages of grief; this is beyond our "first aid" counseling capabilities. The practice team generally cannot be effective at this time of crisis; the client isn't listening to anyone. What can you do.......where can a practice go for help?

In every community there are psychologists, social workers, and other professionals who are trained to communicate with people who are stuck in some phase of grief. How do you find these skilled professionals that are needed by your clients?

Compassion Fatigue - A Veterinary Staff Syndrome

On a caring healthcare delivery team supporting the clients of a companion animal practice, some staff are going to succumb to the pressures of euthanasia; this is most common in animal shelters, where euthanasia rates are exceptionally high for unadoptable animals. If you are experiencing compassion fatigue, you will probably recognize some of its classic symptoms:

 Avoidance behaviors

 Thoughts of "I don't care" and sensations of "emotional numbness"

 Withdrawal from previously pleasurable activities

 Indifference to or withdrawal from relationships

 Intrusive thoughts and images about work-related traumas

 Sleeping and eating difficulties

 Episodes of high anxiety

 Physical ailments (i.e. chronic pain or gastrointestinal symptoms)

 Less tolerance for problems and others' stress

 Depersonalizing those who are in need of help

 Feeling unable to "recover" after a patient's death

 Feeling trapped by responsibilities and victimized by your job

 Feeling that personal life intrudes on work life

 Feeling enormously drained by even small changes

 Loss of meaning and feelings of excitement about work

 Feeling overwhelmed by the "residue" of emotional suffering

 Experiencing acute emotional pain (feeling neglected, misunderstood, sad, vulnerable and hopeless).

Compassion fatigue in veterinary medicine is a particularly tricky problem because the stressors contributing to it are inherent in your work. As a veterinarian, you experience death five times more frequently than your counterparts in human medicine. Drs. Kathy Mitchener and Greg Ogilvie were the first team to take this subject on the road, they covered USA and International markets, and found that it is the same world wide - we have a caring profession, and many enter a compassion fatigue syndrome.

Factor in your own unique blend of responses to patient death and you're sitting on a possible powder keg. Particular emotional reactions to look out for that can increase compassion fatigue include:

 Guilt arising from patient death

 Powerlessness over disease; having no ability to cure but only care

 Emotional investment to a patient that dies

 Illness or death of very young patients

 Fear and guilt of letting down patients and clients

 Sadness when a patient does not have a "good death" (however defined)

 Difficulty establishing emotional boundaries.

When you add all these elements together, you may feel like a lamb to slaughter. This is not the self-help program offered by Home Depot - this needs outside help from skilled professionals. In shelters, we schedule the professional counselors into the practice about once every six months, so the contact points the shelter endorses are well known by all staff, managers, and the practice leadership. Don't get burnt out, get help!

Selling the Concept Locally

Many veterinary schools have developed a fully coordinated grief counseling program at the Veterinary Teaching Hospital; some VMAs have programs that link the veterinarians with the grief counseling professionals in the community (e.g., Denver Area Veterinary Medical Society). This allows both professional teams to use the resources of the other. The Pet Loss cohort groups start monthly, at an economical cost for the client who has lost their pet. The group meets for eight weekly sessions and then it disbands. If any individual still has a critical need, the group facilitator has the resources available to refer the client to individual sessions. But how do you start such a interprofessional team, in your own community?

To make it work, regardless of the community size, talk to your colleagues and use your local veterinary medical association; at a meeting, show an extract from the AAHA VCR tape(s) and share the excitement of the DAVMS program. Armed with the Delta Society resource list and the AAHA Pet Loss tapes, seek out a few local family counselors and sell your concept. These professionals understand the dynamics of family loss and have a professional group that can also network a support system; the profit motive can be addressed at this time to make the excitement really happen. Use the concepts of the DAVMS success story and offer to work for developing the same interprofessional system. Your local veterinary association makes the economies of scale workable and keeps it cost effective for all concerned. A joint meeting should be scheduled with key players from each group to outline the mechanics of the referral system. The DAVMS has developed a client brochure that is in most veterinary reception areas in the greater Denver metroplex; often the program sells itself.

There are many facets to bereavement, and many start in the stress of daily life. Developing a bereavement counseling capability within a veterinary practice will generally extend the same team skills to daily activities, such as the hit-by-car crisis or the pampered poodle's panicked owner. It doesn't matter. The people skills we learn to use in bereavement situations are identical to those we must use in stress situations; this includes the Saturday morning practice rush. You owe it to your team to develop these skills; it will enhance client relations as well as staff relationships.

Resources

1.  Catanzaro, T.E. 1984. A Study of the Human/Companion Animal Bond in Mobile Military Families in the United States. In The Pet Connection: Its Influence on Our Health and Quality of Life, ed. R.K. Anderson, B.L. Hart, and L.A. Hart. Minneapolis: Center to Study Human-Animal Relationships and Environments (CENSHARE), University of Minnesota.

2.  Kubler-Ross, E. 1997. (Reprint edition.) On Death and Dying. Collier Books.

3.  Latham Foundation. 1992. Universal Kinship: The Bond Between All Living Things. R&E Publishers.