List of Contributors xxi
Acknowledgments xxiii
About the Companion Website xxiv
Part I Core Concepts 1
1 Introduction 3Pierce, BA, MTS, PhD
References 5
Further Reading 5
2 What Is Animal Hospice and Palliative Care? 6Amir Shanan, DVM and Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVM
Introduction 6
History of Animal Hospice 8
Scientific and Philosophical Roots 8
Early Beginnings 9
Organization and Recognition 10
Animal Hospice and Human Hospice 12
Ethical and Legal Differences 12
Economic Differences 13
Summary 14
References 14
3 The Interdisciplinary Team 16Tammy Wynn, MHA, LISW, RVT, CHPT and Amir Shanan, DVM
Interdisciplinary Teams in Human Hospice and Palliative Care 16
Interdisciplinary Teams (IDT) in Animal Hospice and Palliative Care 17
Operating a Successful Interdisciplinary Team 18
Common Mission and Vision 18
Team members, Their Roles, and Responsibilities 19
Effective Communication and Collaboration 22
Summary 25
References 25
4 Quality of Life Assessments 26Jessica Pierce, BA, MTS, PhD and Amir Shanan, DVM
What are Quality of Life Assessments and Why are they Important in End- of- Life Care? 26
Definitions of Quality of Life 26
Quality of Life and Well- being 27
Quality of Life Assessments and Euthanasia Decisions 28
The Importance of Context in Quality of Life Assessment 28
Quality of Life and Patient- Centered Care 29
Physical Discomfort, Emotional Distress, Pain, and Suffering 30
Coping and Adaptation 32
Measuring Quality of Life in Animal Patients 33
A Variety of Approaches to QOL 34
McMillans Affect Balance Model 35
Weighing Positive and Negative Affect at the End of Life 36
Quality of Life Assessment Tools 36
Quality of Life Assessment Over Time 38
Summary 40
References 40
Further Reading 42
5 Recognizing Distress 44Emma K. Grigg, PhD, CAAB, Suzanne Hetts, PhD, CAAB, and Amir Shanan, DVM
Stress, Distress, Emotions, and Suffering 44
The Stress Response 44
What Is Distress? 45
Behavioral Needs of Dogs and Cats 46
Assessing Quality of Life in Nonhuman Animals 47
Relevance to Animal Hospice and Palliative Care (AHPC) 48
Are Humans Adept at Recognizing Emotional States in Animals? 49
Body Language of Fear, Anxiety, and Pain 49
Fear- and Discomfort- Related Body Postures Commonly Observed in Dogs and Cats 49
Pain- Related Facial Expressions Commonly Observed in Dogs and Cats 51
Relevance to Animal Hospice and Palliative Care (AHPC) 52
Changes in Behavioral Patterns as Indicators of Pain and Distress 53
Do Animals Hide their Pain? 53
Decreased Response to and Engagement with their Surroundings 54
Unusual Patterns of Movement or Positioning 55
Focused Attention to One Specific Body Part 56
Displacement Behaviors 56
Can Sick Animals Suffer from Boredom? 56
Relevance to Animal Hospice and Palliative Care (AHPC) 57
End- of- Life Decisions 57
Conclusion 58
References 58
6 Balancing Efficacy of Treatments Against Burdens of Care 62Kristina August, DVM, GDVWHM, CHPV
Establishing the Goals of Care 63
Assessing Efficacy and Burdens of Medical Treatment 66
Assessment of Treatment Efficacy 66
Appetite and Hydration Needs at the End of Life 66
Emotional Well- Being 67
Animal Individual Preferences 67
Do- Not- Resuscitate and Advance Directives 67
Assessment of Treatment Burden 68
Assessing Diagnostic Procedures 69
Adverse Events: Treatment- Related Consequences 70
Steroids and End- of- Life Care 71
Adverse Events: Indirect Consequences of Medical Care 71
Assessing the Burdens of Caregiving 72
Conclusion 73
References 73
7 Ethical Decision- Making in Animal Hospice and Palliative Care 76Jessica Pierce, BA, MTS, PhD and Amir Shanan, DVM
A Method for Moral Decision- Making 77
Part 1: Clinical Considerations and Their Moral Dimensions 77
Part 2: Patient Considerations: How the Animal Feels and What the Animal Wants 78
Understanding What Animals Want 79
Will to Live 79
Respecting What Animals Want 80
Suffering 80
Part 3: Human Factors Influencing Moral Decision- Making 83
Providing Adequate Information 85
Guiding Client Decision- Making: How Much Is Too Much? 86
Guiding the Choice between Euthanasia and Continued Palliative Care 88
Societal Ethics and the Role of Cultural Values 90
Ethical Business Practices 91
Moral Stress, Decisional Regret, and Mental Health 91
Conclusion: Finding the Path of Least Regrets 92
References 93
8 Supportive Relationships: Veterinarians and Animal Hospice Providers Nonmedical Roles 95Amir Shanan, DVM and Laurel Lagoni, MS
Defining the Nonmedical Roles of Veterinary Professionals and Other Animal Hospice Providers (except licensed mental health professionals) 98
The Role of Source of Support 98
The Role of Educator 100
The Role of Facilitator 100
The Role of Resource and Referral Guide 101
Resources 101
Extended Services 102
Limiting the Role of Animal Hospice Veterinary Professionals and Other Providers (except licensed mental health professionals) 102
Know Thyself, Healer 105
Conclusion 105
Grief Support Resources 106
Memorials and Grief Support Resources 106
Counselors and Grief Support 106
Grief Support Training 106
Books for Caregivers 106
Books for Veterinarians 107
References 107
9 Management and Administration: Business Models 108Kathleen Cooney, DVM, MS, CHPV, CCFP
Guidelines for Animal Hospice and Palliative Care Practice 108
Service Delivery Models 109
Model 9.1 Hospice in the Veterinary Hospital Setting 110
Model 9.2 Hospice with Specialized Mobile Veterinarians 112
Model 9.3 Animal Hospice Case Managers 113
Model 9.4 Animal Hospice Sanctuaries/Rescues 114
Practicalities of Starting an Animal Hospice Service 114
Telehealth as a Bridging Component for all Models 117
Conclusion 118
References 119
Part II Patient Care 121
10 Cancers in Dogs and Cats 123Alice Villalobos, DVM, FNAP and Betsy Hershey, DVM, DACVIM (Oncology), CVA
Approach to End- of- Life Cancer Patients 124
Tumors of the Skin and Soft Tissues 124
Canine Lymphoma 125
Head and Neck Cancer 126
Oropharyngeal and Neck Tumors in Dogs and Cats 126
Nasal Passage Cancer 127
Brain Tumors 127
Cancer of the Skeletal System 128
Abdominal Tumors 129
Hemangiosarcoma in Dogs 129
Transitional Cell Carcinoma 129
Hepatic, Pancreatic, Intestinal, Adrenal, and Renal Cancer 130
Chest Cavity Tumors 130
Palliative Cancer Medicine 131
Advances in Noninvasive Technology for the Diagnosis of Cancer 134
Summary 135
Conflicts of Interest 135
References 135
11 Integrative Therapies for Palliative Care of the Veterinary Cancer Patient 138Betsy Hershey, DVM, DACVIM (Oncology), CVA
Nutrition and Food Therapy 138
Herbs and Supplements 141
Herbal Supplements 141
Antioxidants 143
Medicinal Mushrooms 143
B Vitamins 143
Digestive Enzymes 144
Probiotics 144
Vitamin d 144
Omega- 3 Polyunsaturated Fatty Acids (PUFAS) 145
Curcumin 145
High Dose IV Vitamin C Therapy 145
Acupuncture 146
Manual Massage Therapies 147
Energy Therapy (Biofield Therapy) 148
Sound Therapy 148
Reiki, Therapeutic Touch, and Healing Touch Therapies 148
Ozone Therapy 148
Hyperbaric Oxygen Therapy 150
Cannabis and Cannabidiol (CBD) Oil 151
Essential Oils 154
Homeopathy and Homotoxicology 155
Chiropractic 156
Photobiomodulation Therapy (PBM) 157
Summary 158
References 158
12 Chronic Kidney Disease 163Shea Cox, DVM, CHPV, CVPP and Christie Cornelius, DVM, CHPV
Description of Disease 163
Disease Trajectory 163
Clinical Manifestations of Disease 163
Management 164
Management of Factors that Accelerate Chronic Kidney Disease Progression 164
Dehydration 164
Nonregenerative Anemia 164
Systemic Hypertension 165
Proteinuria and Activation of the ReninAngiotensinAldosterone System 165
Renal Secondary Hyperparathyroidism 165
Symptomatic, Supportive, and Palliative Therapies 166
Oral Ulcerations and Uremic Gastritis 166
Nausea/Vomiting 166
Constipation/Obstipation 167
Loss of Appetite 167
Urinary Tract Infection 167
Hyperphosphatemia 168
Hypokalemia 168
Seizures 168
Dietary Considerations 168
Other Comfort Measures 168
Conclusion 168
References 169
13 Congestive Heart Failure 171Shea Cox, DVM, CHPV, CVPP and Christie Cornelius, DVM, CHPV
Description of Disease 171
Disease Trajectory 171
Clinical Manifestations of Disease 171
Palliative Management 172
Pulmonary Edema/Cardiac Function 172
Diuretics 173
Ace Inhibitors 173
Positive Lonotrope, Vasodilator 174
Calcium Channel Blocker 174
Pleural and Abdominal Effusion 174
Hypokalemia 174
Prerenal Azotemia 174
Balancing Renal and Cardiac Disease 174
Coughing 175
Respiratory Distress 175
Aortic Thromboembolism 175
Dietary Considerations 176
Heart- Gut Interactions in Heart Failure 176
Other Considerations 176
Conclusion 176
References 176
14 Respiratory Distress 178Cheryl Braswell, DVM, DACVECC, CHPV, CHT-V, CVPP
Airway Collapse 178
Description 178
Trajectory/Prognosis 179
Manifestations 179
Management 179
Pharmacologic 179
Physical 179
Nutritional 180
Surgery 180
Brachycephalic Airway Obstruction Syndrome 180
Description 180
Trajectory/Prognosis 180
Manifestations 181
Management 181
Pharmacologic 181
Physical 181
Nutrition 181
Surgery 181
Airway Inflammation 181
Description 181
Trajectory/Prognosis 182
Manifestations 182
Management 182
Pharmacologic 182
Physical 183
Nutritional 183
Pneumonia 183
Description 183
Trajectory/Prognosis 183
Manifestations 183
Management 183
Pharmacologic 183
Physical 184
Nutritional 184
The Suffering of Dyspnea: Palliative Care 184
References 185
15 Gastrointestinal Conditions 186Shea Cox, DVM, CHPV, CVPP and Christie Cornelius, DVM, CHPV
Inflammatory Bowel Disease 186
Description of Disease 186
Disease Trajectory 186
Clinical Manifestations of Disease 186
Palliative Management 186
Medical Support 186
Immunosuppressive Therapy 186
Antibiotic Therapy 187
Additional Support Therapy 187
Nutritional Support 188
Fecal Microbial Transplantation (FMT): The Ultimate Probiotic 188
Pancreatitis 188
Description of Disease 188
Disease Trajectory 188
Clinical Manifestations of Disease 189
Palliative Management 189
Medical Support 189
Analgesia 189
Antiemetics 189
Antibacterials 189
Immunosuppressants 189
Subcutaneous Fluid Therapy 189
Nutritional Support 189
Cholangitis/Cholangiohepatitis Syndrome 190
Description of Disease 190
Disease Trajectory 190
Clinical Manifestations of Disease 190
Palliative Management 190
Medical Support 190
Antimicrobial Therapy 190
Immunosuppressive Therapy 190
Analgesia 191
Antiemetics 191
Support Therapy 191
Subcutaneous Fluid Therapy 191
Nutritional Support 191
Conclusion 191
References 191
16 Musculoskeletal Disorders 193Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVM
Osteoarthritis 193
Description 193
Trajectory/Prognosis 194
Manifestations 194
Management 195
Cranial Cruciate Ligament Pathology 197
Description 197
Trajectory/Prognosis 197
Manifestations 197
Management 197
Medical Management 198
Surgical Management 198
Strains, Sprains, and Myofascial Pain 199
Description 199
Trajectory/Prognosis 199
Manifestations 199
Management 199
Coxofemoral Luxation 200
Description 200
Trajectory/Prognosis 200
Manifestations 200
Management 200
Fractures 201
Description 201
Trajectory/Prognosis 201
Manifestations 201
Management 201
Conclusion 201
References 202
17 Nervous System Disease 204Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVM
Intervertebral Disc Disease 204
Description 204
Trajectory/Prognosis 205
Manifestations 205
Management 206
Cervical Spondylomyelopathy 207
Description 207
Trajectory/Prognosis 208
Manifestations 208
Management 208
Fibrocartilagenous Embolic Myelopathy 208
Description 208
Trajectory/Prognosis 209
Manifestations 209
Management 209
Vestibular Disorders 209
Description 209
Trajectory/Prognosis 210
Manifestations 210
Management 210
Laryngeal Paralysis/Geriatric Onset Laryngeal Paralysis Polyneuropathy 211
Description 211
Trajectory/Prognosis 211
Manifestations 211
Management 211
Degenerative Myelopathy 212
Description 212
Trajectory/Prognosis 213
Manifestations 213
Management 213
Disorders of Micturition/Urination 214
Description 214
Trajectory/Prognosis 214
Manifestations 214
Management 214
Bladder Is Difficult or Cannot Be Expressed 215
Bladder Can Be Expressed with Effort 215
Straining to Urinate with Spurts of Urine Produced 215
Bladder Easily Expressed with Continuous Leakage 216
Urine Leakage when Urine Accumulates 216
Ancillary Therapies for Micturition Disorders 216
Conclusion 216
References 216
18 Cognitive Dysfunction 219Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVM
Description 219
Trajectory/Prognosis 220
Manifestations 220
Management 221
Client Education and Prevention 221
Behavior Modification and Environmental Enhancement 221
Diet Modification 222
Supplements 222
Alternative Care 223
Pharmaceutical Interventions 223
Conclusion 224
References 225
19 Pharmacology Interventions for Symptom Management 227Shea Cox, DVM, CHPV, CVPP
Introduction 227
Pain 227
Clinical Signs of Pain 227
Behavioral Indicators of Pain 227
Pharmacology for Pain Management 228
Nonsteroidal Anti- Inflammatory Drugs 228
Glucocorticoids 229
Acetaminophen 229
Opioids 229
Tricyclic Antidepressants 231
Serotonin- Norepinephrine Reuptake Inhibitors 232
Anticonvulsants 232
N- methyl- d- aspartate Receptor Antagonists 232
Monoclonal antibodies 233
Pharmacologic Protocols 233
Assessing Response to Treatment 234
Anxiety 234
Dysphoria 236
Weakness or Fatigue 237
Respiratory Symptoms 237
Dyspnea 237
Cough 239
Nausea and Vomiting 239
Anorexia and Cachexia 240
Dehydration 241
Constipation 241
Oral Health 242
Ulcers 242
Dry Mouth (Xerostomia) 242
Conclusion 242
References 242
20 Physical Medicine and Rehabilitation for Hospice and Palliative Care Patients 245Tamara Shearer, MS, DVM, CCRP, CVPP, CVA, MSTCVM
Physical Medicine vs. Physical Rehabilitation 245
Considerations for Physical Medicine with Hospice and Palliative Care Patients 245
Assistive Devices: Priority in Hospice Care 247
Slings and Harnesses 247
Straps and Bands 248
Protective Footwear 248
Support of Joints: Orthotic Devices 249
Support for Paralysis/Pararesis: Carts and Drag Bags 250
Four Simple but Important Manual Therapies and Therapeutic Exercises 250
Range of Motion 250
Assisted Standing and Walking 251
Proprioceptive and Balance Techniques 251
Massage and/or Tui-na 252
The Role of Acupuncture for Hospice and Palliative Care Patients 252
Innovative and Noninvasive Techniques 254
Kinesiology Taping 254
Extracorporeal Magnetotransduction Therapy: EMTT 257
Extracorporeal Shockwave Therapy 257
Targeted Pulsed Electromagnetic Field Therapy 258
Other Therapeutic Modalities for Hospice and Palliative Care Patients 259
Thermal Modalities 259
Photobiomodulation Therapy (also known as Laser Therapy) 260
Pulsed Signal Therapy 261
Electrotherapy 261
Therapeutic Ultrasound 262
Manual Therapy/Medical Manipulation/Chiropractic Care 262
Conclusion 263
References 263
21 Integrative Medicine in Animal Hospice and Palliative Care 265Kristina August, DVM, GDVWHM, CHPV
Terms 265
Going Mainstream 266
Safety and Adverse Reactions 267
Healing Philosophies 268
Nutritional Supplements 269
Herbal Medicine 269
Essential Oils 271
Other Therapies 272
Ensuring Quality of Life 273
Reliable Choices and Client Education 273
Conclusion 274
Educational Opportunities 274
References 274
22 Nursing Care for Seriously III Animals: Art and Techniques 278Shea Cox, DVM, CHPV, CVPP and Mary Ellen Goldberg, CVT, LVT, SRA-retired, CCRVN, CVPP, VTS-lab animal-retired, VTS-Physical Rehabilitation-retired, VTS-anesthesia/analgesia-Honorary
Introduction 278
Nurses Medical Roles 279
Intake 279
Planning of Care 279
Ongoing Monitoring and Assessments 279
Frequency of Assessments 279
Parameters of Assessments 279
Assessment of Pain 280
Pain Scales 280
Assessment of Other Signs of Discomfort 282
Assessment for Dehydration 282
Assessment of Medication Administration 282
Assessment of Mobility 282
Assessment of Mental and Emotional Status 283
Delivery of Care: Nursing Care Considerations 284
Comfort for the Patient 284
Oral and Ocular Comfort 284
Nutrition 286
Hydration 287
Treating Fluid Deficit (Dehydration) 287
Maintenance Fluids Administration 288
Calculating Fluid Deficit 288
Hygiene 288
Bedding 288
Environment 289
Mobility 289
Range of Motion (ROM) 289
Transitions 290
Standby Assisted Standing 290
Weight Shifting Exercises 290
Assisted Standing Exercises 290
Aids for Assisted Standing 290
Mobility Carts 290
Nursing Care for Recumbent Patients 290
Urination 291
Defecation 291
Respiration 291
Skin Care 292
Mobilizing the Recumbent Patient 292
Nurses as Advocates and Educators 292
Nurses Role as Advocates for Patient and for the Caregiver 293
Nurses Role as Educators 293
Awareness of Signs of Pain 294
Hygiene and Safety 294
Death and Dying 295
Conclusion 295
References 296
Further Reading 298
23 Comfort Care During Active Dying 299Gail Pope and Amir Shanan, DVM
Natural Death and Euthanasia 299
Goals of Caring for the Dying Patient 301
Advance Preparation and Education of Caregivers and Hospice Team 301
Desirable Environment of Care 302
Prognostication 303
Changes During Early and Late Stages of Active Dying 303
Available Information 303
Changes During Early Stages of Active Dying 303
Physical Changes 303
Behavioral Changes 304
Indications of Pain 304
Changes During Late Stages of Active Dying 305
Behavior, Sleeping Pattern, Responsiveness 305
Respiration 305
Eyes, Mucus Membranes, Jaw, and Extremities 306
Muscle Twitching, Stretching, and the Agonal Position 306
Odor 306
Summary 306
At the Time of Death 306
The Different Types of Active Death 308
Managing Clinical Signs During Active Dying 309
Management of Pain 309
Management of Anxiety and Agitation 310
Fatigue and Weakness 310
Loss of Ability to Swallow 311
Respiration 311
Cardiac Dysfunction and Renal Failure 311
Diminished Skin Vitality 311
Mucosal and Conjunctival Care 312
Incontinence 312
Administration of Medications, Fluids, and Food 312
Administration of Fluids 313
Administration of Food 314
Administration of Medications 314
Summary 315
References 315
24 Euthanasia in Animal End- of- Life Care 318Kathleen Cooney, DVM, CHPV, DACAW
Decision- Making for the Animal Hospice Patient 318
Advance Preparation and Education of the Professional Team 319
Advance Preparation and Education of Caregivers and Family 321
Euthanasia Setting: Desirable Environment of Care 323
Euthanasia Techniques and Criteria 324
Intravenous Injection 325
Intracardiac Injection 325
Intraperitoneal Injection 327
Intrahepatic Injection 328
Intrarenal Injections 329
Variability and Unpredictability 330
References 331
Part III Caregiver Needs: Providing Support 333
25 Caregivers Emotional Burden: Understanding, Acknowledging, and Addressing Caregivers Emotional Burden 335Amir Shanan, DVM
Caregiving Experience 336
The Mental Health Impact of Caregiving 339
Supporting caregivers Emotional Needs 340
The Role of a Licensed Mental Health Professional 343
Qualified Mental Health Professionals 345
Summary 346
References 347
26 Caregiver Burden in the Companion Animal Owner 349Mary Beth Spitznagel, PhD and Mark D. Carlson, DVM
What Is Caregiver Burden? 349
A Word About Research Data, the Terminology Used, and this Articles Audience 349
Caregiver Burden Is Present in Owners of Seriously Ill Companion Animals 350
How Caregiver Burden Differs from Other Client Experiences in this Context 350
How Does Caregiver Burden Affect the Veterinary Client? 351
Impact of Caregiver Burden on the Client 351
Impact of Caregiver Burden on the Patient 352
Research- Based Suggestions for Interacting with the Burdened Owner 352
Understand the Owners Perspective 352
Collaborate on the Care Approach 353
Lighten the Load 353
One Size Does Not Fit All: Toward Individualized Client Interactions 354
Interacting with the Distressed Client 354
Interacting with the Resilient Client 355
Interacting with the Non- Distressed Client 355
Interacting with the Other Influences Client 355
More than Compassion Fatigue: When Client Burden Transfers to the Clinician 355
The Burden Transfer DANCE 356
Conclusions 357
References 357
27 Addressing Spiritual Needs of Caregivers 360Carol Rowehl, LVT, MAR, STM
Spiritual Needs of Caregivers 361
Spiritual Distress 362
Taking a Spiritual History 363
When to Call in the Experts (and Who Are the Experts?) 364
Spiritual Questions Unique to Veterinary Practice and Hospice and Palliative Care 366
Including a Chaplain on the Interdisciplinary Veterinary/Hospice Team 367
Resources 370
References 371
28 Factors Contributing to the Decision to Euthanize Pet Dogs and Cats 374Nathaniel Cook, DVM, CVA, CVFT, CTPEP and Beth Marchitelli, DVM, MS
Introduction 374
Pet Factors: Symptoms and Clinical Signs that Affect Quality of Life 374
Appetite and Weight Loss 375
Appetite 375
Weight Loss 377
Elimination Disorders 377
Impaired Mobility 379
Sensory and Cognitive Decline 380
Dyspnea and Respiratory Compromise 381
Perception of Pain 382
Pet Factors: Severe Illness Diagnosis 382
Cancer 382
Organ Failure: Congestive Heart Failure 383
Endocrine Disorders: Diabetes Mellitus 384
Pet Owner Factors: Psychosocial Factors of Caregiving 384
Conclusion 385
References 385
29 Supporting Other Needs 389Shea Cox, DVM, CHPV, CVPP and Mary Ellen Goldberg, CVT, LVT, SRA-retired, CCRVN, CVPP VTS-lab animal-retired, VTS-Physical Rehabilitation-retired, VTS-anesthesia/analgesia-Honorary
Caring for the Caregiver: Addressing Emotional and Physical Needs 389
Maintaining Self- Care 390
Maintain Personal Nutrition and Sleep 390
Engage in Exercise 390
Make Time for Relaxation 390
Time Considerations of Hospice Care 391
Managing Time Commitments of Care 391
Tips for Balancing Caregiving with Ongoing Responsibilities 391
Understanding the Physical Labor of Care 391
Utilizing Proper Body Mechanics During Delivery of Care 392
Environmental Considerations of Hospice Care 393
Assessment of the Physical Space 393
Household and Environmental Modifications 393
Financial Considerations of Hospice Care 393
Cost of Medications 394
Cost of Diagnostics 394
Cost of Other Healthcare Providers 394
Cost of Environmental Modifications 394
Cost of End- of- Life Care 394
Helping to Defer Costs of Hospice Care 395
Pet Health Insurance 395
Equipment Rental, Recycling, and Reduced Cost Programs 395
Creating a Memorial Fund 395
Creating a Donation Bank 395
References 396
Further Reading 396
30 Aftercare 398
Coleen A. Ellis, CT, CPLP
Hospice Options and Accompanying Rituals 398
Emotional Support: Honoring the Journey 401
Assisting Children, Other Pets, and Family Members in Their Journey 402
After- Death Care Options 402
Summary 406
References 406
Index 407
