Hospice and Palliative Care for Companion Animals: Principles and Practice

List of Contributors xxi

Acknowledgments xxiii

About the Companion Website xxiv

Part I Core Concepts 1

1 Introduction 3
Pierce, BA, MTS, PhD

References 5

Further Reading 5

2 What Is Animal Hospice and Palliative Care? 6
Amir 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 16
Tammy 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 26
Jessica 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

McMillan’s 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 44
Emma 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 62
Kristina 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 76
Jessica 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 95
Amir 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 108
Kathleen 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 123
Alice 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 138
Betsy 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 163
Shea 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 Renin–Angiotensin–Aldosterone 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 171
Shea 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 178
Cheryl 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 186
Shea 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 193
Tamara 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 204
Tamara 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 219
Tamara 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 227
Shea 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 245
Tamara 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 265
Kristina 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 278
Shea 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 299
Gail 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 318
Kathleen 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 335
Amir 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 349
Mary Beth Spitznagel, PhD and Mark D. Carlson, DVM

What Is Caregiver Burden? 349

A Word About Research Data, the Terminology Used, and this Article’s 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 Owner’s 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 360
Carol 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 374
Nathaniel 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 389
Shea 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