On Death And Dying…And Dogs

*** One live-in therapy pet’s influence on hospice patients’ quality of life ***

Abstract

The purpose of this study is to examine the effects of pet therapy visits on hospice patients’ perceived quality of life during end-of-life care, as measured by self-report. Specifically, we will look at the effect one particular dog (trained as a resident therapy pet for an 18-bed hospice home in Bakersfield, CA) has on a group of terminally ill hospice patients’ ability to find peace, meaning, and closure in their final days. The self-administered and self-scored McGill Quality Of Life Scale (MQOL) will be used to measure patients’ physical and psychological symptoms and existential and spiritual well being, both before and after visits from the hospice home’s resident therapy dog.Patients sampled in the study will represent a diverse cross-section of the hospice population; they will range in age from five to ninety five years old, such that the inclusive and far-reaching nature of the benefits of animal-assisted therapy interventions across age, race, and gender is evident. Dependent variables potentially affected by the live-in presence of, and regular visits from, a therapy dog might include mood, anxiety and energy levels, emotional stability, sense of loneliness, faith or fear with regard to death, and physical pain. We suspect that patients who engage with the dog on a regular basis will report a lessening of negative physical symptoms and an increase in positive thoughts and feelings, including increased acceptance of their impending fate. The MQOL questionnaire was chosen because it reflects existential concerns, which are of great importance to patients with life-threatening illnesses, but which were not included in the majority of QOL assessments that came before it. The existential domain includes concerns regarding death, freedom, isolation, and the question of meaning (Cohen, et al., 1996). Because of the inextricably linked nature of humans’ and dogs’ co-evolutionary relationship, we suspect that palliative care involving dogs will bear strongly on terminally ill patients’ quality of life; we project the dog will provide a sense of existential connectedness in circumstances that might otherwise be predominantly defined by pain, loneliness, and/or fear.

Literature Review

In her iconic 1969 publication, On Death And Dying, Swiss psychiatrist Elisabeth Kubler-Ross wrote, “Death is not painful. It is the most beautiful experience you will have”. While this bold declarative statement cannot be scientifically verified, empirical evidence supports the claim that certain types of physical, emotional, and spiritual enrichment lend positively to a person’s experience as he or she lay dying. Kubler-Ross’ sentiment makes the most sense in context of a “good death” versus a “bad” one. Conceptually, notion that a death can be good is one that has varied throughout history, and is different across cultures. In the real world of life (and death) in hospice care, care providers face the unique challenge of designing palliative care practices that contribute to a “good death” for each patient. This means not only helping to reduce physical pain, but also to create an environment that effectively addresses each patient’s individual needs and desires. According to a 2006 article from the American Journal of Critical Care, suggestions for affording patients the opportunity to experience a good death include facilitating dying with dignity; not allowing patients to be alone while dying; managing patients’ pain and discomfort; knowing, and then following, patients’ wishes for end-of-life care; promoting earlier cessation of treatment; and communicating effectively as a health care team (Beckstrand et al., 2006).

The challenge of enriching quality of life for patients and families in the depths of emotional upheaval is immense. The standard way in which this is addressed is through the use of complementary and alternative therapies. In 2011, the U.S. Department of Health and Human Services reported on the widespread use of complementary and alternative therapies (also known as complementary and alternative medicine, or CAM) in hospice care. These are products and practices that are not part of standard care. As of 2007, 41.8% of hospice care providers offered CAT services (Bercovitz et al., 2011). Some of these services include massage, support groups, music therapy, guided meditation, and animal-assisted therapy. Animal-assisted therapy is an intervention that brings animals together with persons with physical and/or emotional needs as a way of meeting those needs (Barba, 1995). Hospice patients’ needs pertain to the type and quality of care they receive, which lends to (or detracts from) their quality of life as they approach death. Of the many issues hospice care providers address with complementary and alternative therapies, stress is the most prevalent (Turnbach, 2014). Stress leads to adverse outcomes and affects patients’ quality of life and well being on both physical and psychological levels. For terminally ill adults, animal assisted therapy (AAT) is a natural form of pain and stress management and emotional support, improves side effects of mood disorders, reduces drug dependency, decreases loneliness, and increases socialization with elderly patients. The presence of an animal, or even the mere observation of animals, can buffer physiological and psychological responses to stress and anxiety (Cirulli, Borgi, and Berry, 2011).

Studies of the human-companion animal bond reveal many physiological and psychological benefits (Velde, Cipriani and Fisher, 2005). Interactions between people and dogs are known to decrease physical pain and increase the “feel good” chemicals dopamine, oxytocin, prolactin, and serotonin in both parties. According to Odendaal (2000), the physiological effects dogs have on people are as follows: Pets can decrease anxiety and sympathetic nervous system arousal by providing a pleasant external focus for attention, promote feelings of safety and provide a source of contact comfort. They can decrease loneliness and depression by providing companionship, and by promoting an impetus for nurturing (Odendaal, 2000). Parents of terminally ill children report that therapy dog visits were effective in creating a positive, de-stressing experience for their children as well. Caprilli and Messeri (2006) concluded that dogs work successfully with terminally ill patients and that infection rates can be kept under control as a minimum threat (Turnbach, 2014). A 1984 study by Ruth J Mushcel revealed evidence for the benefit of pet therapy on terminally ill cancer patients. Patients’ feelings of depression and despair with regard to their impending deaths were recorded both before and after several visits from a therapy dog. After exposure to the animal, anxiety, stress and depression were reduced, due to the comfort and natural empathy the therapy pets provided. Overall, pet therapy increased the comfort and adaptation of the terminally ill patients (Turnbach, 2014).

Many of the known positive health effects inherent to the human-canine bond lend to the parameters of a “good death”. With regard to helping patients die with dignity, the following applies: Patients who are body conscious and feel unappealing to others, such as stroke patients, cancer patients, and patients with AIDS, can improve their self-esteem and self-acceptance by associating with animals, who are nonjudgmental (Strickland, 1991. Reviewed by Barba, Beth, 1995). With regard to making sure a patient does not go through the dying process alone, and has a sense of closure with family and friends, which includes openly discussing feelings: Improved social interactions and communications can be achieved by participation in AAT activities. The presence of an animal, particularly a dog, is able to act as an “ice breaker”: it catalyzes communication and enhances opportunities for social exchange and shared interests which, in turn, can promote a feeling of social integration (Cirulli, et al. 2011). Animals can also serve as transitional objects in efforts to improve communication between withdrawn and isolated patients, caregivers and family members. Animals give families something to focus on besides the stress they are experiencing (Barba, 1995). According to Steinhauser’s study (2000), participants confirmed the deep importance of spirituality or meaningfulness at the end of life. Pets have the power to incite deep meaningfulness in people’s lives, as their presence increases feelings of happiness, security and self-worth, and reduces feelings of loneliness and isolation on a daily basis, and during separations or transitions such as bereavement. Conrad Lorenz equated a need for the companionship of his dog to a bond with nature, and saw pets as helping us to maintain psychological equilibrium (Sable, 1995). With regard to dying patients’ need to be recognized as whole and complete individuals, dogs’ dependence upon them for care becomes a therapeutic element that further lends to a good death.

Participants

Approximately 100 patients coming through the doors of Hoffmann Hospice’s state-of-the-art, 18-bed hospice home over a one-year period will be asked to participate in the study. To qualify, patients’ have to be within six months of (predicted) death, but still in good enough physical and mental condition to participate lucidly. Participants will include adults and children (Hoffmann is the only hospice in Kern County that admits pediatric patients). If necessary, children’s parents will be able to help them understand what’s being asked of them, and assist them in filling out the MQOL questionnaire. When making decisions about who to include in the study, hospice staff and researchers should work together to determine who might not benefit from animal assisted interventions, including those who are allergic to pet dander, those who do not care for animals, and those with limiting physical or physiological conditions.

The dog used in this study will be three year-old rescue dog, papillon mix “Maggie”, who is being trained specifically to work as the resident therapy pet in this facility. Maggie weighs approximately fifteen pounds, and has an extremely gentle and calm temperament. She will be a live-in pet, certified for therapy work both at the hospice home, and in the greater community through Marley’s Mutts Dog Rescue’s therapy dog program, Miracle Mutts. Maggie will have earned fifty hours of community service in pursuit of her certification by the time she begins working in the hospice home. The management team at Hoffmann’s goal in adopting a dog is to illuminate the theme that a dog is what makes a house a home. Her presence is meant to bring comfort and light to patients, families, staff and volunteers, who deal with the weight of illness and loss on a daily basis.

Procedure

The study will measure alterations in quality of life as measured by the MQOL scale. Participants will be given the MQOL questionnaire upon entering hospice care, and will fill it out once a week thereafter, notating how many times Maggie visited with them that week, and for how long. Participants will be encouraged to journal about their experiences with Maggie, specifically as they recognize her effect on their quality of life according to the items on the questionnaire. Evaluation of the data after one year will reveal whether or not Maggie’s effect on patients’ QOL was statistically significant. We believe that patients’ reflection in self-scoring of the tests, in addition to journaling exercises, will itself have a positive impact on patients’ experience in their final days.

Discussion

With regard to hospice patients, for whom the focus has shifted from curing disease to preserving quality of life, providing end of life care that affords individuals a good death is the optimal goal. While pets may not be a cure for all that ails us, often, they are the best medicine. Dogs have the power to bring dying patients into the moment, such that they can fully, and with a sense of openness, experience the profound right of passage at hand. While all animal lovers know this is true from an internal perspective, scientific evidence backs up the anecdotal. Studies prove that a dog’s presence not only offers emotional support, but has the power to improve a person’s physiological state. In hospital settings, therapy dogs effectively decrease blood pressure and lower heart rate, offer distraction from pain and anxiety, diminish depressive symptoms, and increase production of oxytocin, dopamine, and serotonin.

While the positive effects of AAT on hospice patients is clear, there is room for improvement in the research methodology that surrounds its objectification. Although many descriptive reports of AAT stress positive effects with some evidence from controlled studies of its effectiveness, there is a need for more controlled studies in the quantitative paradigm on AAT, including those that collect data on any negative effects (Velde, et al. 2005). Despite the methodological weaknesses of some of the existing studies, the current evidence is promising and a growing body of research is starting to address the mechanisms behind the human-animal bond (Cirulli et al., 2011). Not only are physiological benefits recordable, and self-perceived benefits notable by patients themselves via survey, but outward behavioral manifestations of physiological enhancements are observable, and therefore measurable. Some of these might include talking to the dog or about the dog, petting or stroking the dog, smiling, laughing, or crying that indicates emotional openness in the dog’s presence.

While Hoffmann Hospice currently has a visiting therapy dog program, and that program produces positive results in patients’ quality of life based on observation and general assessment by volunteers and staff, we believe a resident therapy dog’s effect will be different – and even address some concerns discussed by researchers who feel that research methodologies in this field could stand to improve. Cirulli (2011) states that future standards for animal-assisted activities and therapies will rely upon a critical need to document the whole activity/therapeutic process from start to finish, and to understand which techniques work best with individual patients on a case-by-case basis. While our research aims initially to collect data from multiple patients via questionnaire, we envision the future development of qualitative research by case study, to delve into the intricate personal details of individuals’ experiences as affected by and related to their interactions with Maggie. Furthermore, we feel the fact that Maggie’s presence will combat the sterile nature and feel of a hospital-type facility, replacing it with a feeling of home, which will further improve morale for patients and their families, staff, doctors, nurses, and volunteers. Animals make acute care units seem more homelike, and enhance family perceptions of the institution (Barba, 1995). Maggie’s live-in status also offers the potential to integrate different palliative and occupational therapy activities together into altogether new modalities. For instance, the chaplain might include Maggie’s presence in prayer ceremonies; walking Maggie might become part of daily physical therapy and/or outdoor enrichment time connecting with nature, to stave off worsening physical symptoms of illness and inject healthy and enjoyable activities into patients’ days. Training Maggie and eliciting behavioral responses, such as tricks, might be incorporated into entertainment options for pediatric patients.

Elisabeth Kubler-Ross wrote, “Those who have the strength and the love to sit with a dying patient in the silence that goes beyond words will know that this moment is neither frightening nor painful, but a peaceful cessation of the functioning of the body.” She never qualified whether the strong, silent, loving being she described was necessarily human…or not.

References

Beckstrand, Renea L. et al. Providing a “Good Death”: Critical Care Nurses’ Suggestions For Improving End-Of-Life Care. American Journal of Critical Care, Volume 15, No. 1, p. 38-45. 2006.

Cohen, S. Robin. Mount, Balfour M., Tomas, Jon J.N. and Mount, Lauren F. Existential Well-being Is an Important Determinant of Quality of Life. American Cancer Society, Volume 77, no. 3, p. 576-586. February 1, 1996

Velde, Beth P. Cipriani, Joseph and Fisher, Grace. Resident and therapist views of animal-assisted therapy: Implications for occupational therapy practice. Australian Occupational Therapy Journal, Volume 52, p. 43-50. 2005

Bercovitz, Anita. Sengupta, Manisha. Jones, Adrienne and Harris-Kojetin, Lauren D. Complementary and Alternative Therapies in Hospice: The National Home and Hospice Care Survey: United States, 2007. National Health Statistics Report, Volume 33. January 19, 2011.

Cirulli, Francesca. Borgi, Marta. Berry, Alessandra. Francia, Nadia and Alleva, Enrico. Animal-assisted interventions as innovative tools for mental health. Ann Ist Super Sanita, Volume 47, no. 4, p. 341-348. 2011.

Wlodarczyk, Natalie. The Effect of Music Therapy on the Spirituality of Persons in an In-Patient Hospice Unit as Measured by Self-Report. The FL State University DigiNole Commons, Electronic Theses, Treatises and Dissertations. October 6, 2003.

Field, Marilyn J. and Cassel, Christine K. Approaching Death: Improving Care at the End of Life. National Academy of Science. Committee on Care at the End of Life, Institute of Medicine. 1997.

Odendaal, J.S.J. Animal-Assisted Therapy – Magic or Medicine? Journal of Psychosomatic Research, Volume 49, p. 275-280. 2000.

Sable, Pat. Pets, Attachment, and Well-being Across the Life Cycle. Social Work, Volume 40, Issue no. 3, p. 334. May, 1995.

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