When Should You Say Goodbye to a Pet?

When Jessamyn Kennedy began veterinary school, about twenty years ago, hardly anyone put their pets in day care or called them fur babies. Nobody brought dogs to brunch. Veterinary visits were for vaccinations and acute illnesses, not wellness checks. And, when pets suffered from cancer or heart failure or debility, conversations about what to do next were emotional but often straightforward. “We didn’t have some of the therapies we have now, but people were also more reasonable about what they were willing to put their pets through,” Kennedy told me. “They’d say, ‘Well, he’s a dog, so why would we put him through surgery that he doesn’t understand?’ ”

But, over time, Kennedy noticed, more people began to view pets as children or partners or therapists, companions who soothed them in a way that others could not. Pet birthday parties and TV shows for dogs started to proliferate; veterinary practice became increasingly subspecialized, populated by nephrologists, oncologists, and cardiologists. Pets now had access to interventions like dialysis and chemotherapy, which changed how long they could live, and introduced new uncertainty, for their owners, about how to recognize that they were dying. In the nineteen-seventies, hospice care evolved as more people resisted the compulsion to extend life at all costs, preferring instead to focus on dying comfortably, often at home. Now caring for a sick pet involved the same questions: What is a good quality of life? How much suffering is too much? And when is the right time to let go?

As a palliative-care physician, I was intrigued by the idea of pet hospice, which has burgeoned as people have struggled to answer these questions. I first heard of it in 2021, when a neighbor told me he’d used the service to care for his dog, who was experiencing kidney failure and laboring to breathe. His hospice veterinarian prescribed medications that eased the dog’s breathing, but what my neighbor most valued was what Kennedy described as the heart of her work: teaching people what the process of dying looks like for animals.

When Kennedy opened her own practice, in 2017, she offered in-home euthanasia, for clients who wanted their pets to die in a familiar place, rather than in the chaos of a vet’s office or emergency room. But sometimes people would call her because they weren’t sure if it was time for euthanasia, and she’d find that, with better pain control, some animals lived longer than anticipated. By clarifying the extent of a pet’s distress—a complicated task, given that animals often endure pain invisibly—Kennedy empowered owners to address suffering proactively. Local veterinarians quickly began to send her referrals for hospice and palliative care. “I kind of had to teach myself this art,” she told me. Aside from volunteering on a pet-loss hotline during veterinary school, she had received virtually no training on how to talk about death.

On a balmy October day, I joined Kennedy for a series of hospice visits in Plymouth, Massachusetts. Dressed in scrubs, with her hair pulled into a loose bun, she drove around town in a light-blue Subaru Crosstrek. In the trunk was a bag of euthanasia medications, intravenous-line kits, and patterned fleece blankets that she used to wrap pets after they died. “I choose one for each pet based on what I think they would like,” she told me. “It’s important that they have a soft place to land.”

When Sherri Hannan was twenty-seven, she adopted her first dog, a Labrador mix named Julio. She’d grown up with cats, and for many years dogs frightened her. “I thought they were scary and gross,” she told me. But when her husband, Ben, began to work overnight shifts for the municipal police department, Sherri wondered whether a dog could provide both company and security.

At her kitchen table, Sherri smiled as she recalled seeing Julio for the first time, in a shelter. “He was scrawny, pooping bloody diarrhea everywhere—you could see all his ribs,” she said. But he filled out quickly, growing rugged and broad-chested. Sherri began to call him Julio Suave, her “handsome man.”

Julio was an athlete. He jumped as though he had springs in his paws, and he became constipated without rigorous activity. But when he was around eleven years old, he started to struggle to climb the stairs. He paced at night, howling and drinking water excessively. One day, he stumbled and fell in the yard. “I began to ask myself, What kind of life is this?” Sherri told me.

For nearly two years, Ben and Sherri fought over how to care for Julio. Ben thought keeping Julio active was the best way to slow his decline. Sherri, who fiercely prioritized her pet’s independence, was terrified that another fall would mean not only immobility for Julio but a rupture for her marriage. “We finally agreed that we needed someone to guide us, someone objective and with experience,” Ben said.

Sherri called Kennedy, who had helped care for Sherri’s cat, Tango, a feisty tabby given to unravelling rolls of toilet paper. When Tango had been diagnosed with cancer, Ben and Sherri experienced a similar disagreement. Ben thought that, since Tango still enjoyed sitting with him and posing for photos, he wasn’t in pain. “But I was watching this vibrant menace to society just sit in a box,” Sherri said. Tango’s veins eventually collapsed, and the couple asked Kennedy to euthanize him at home. “The sounds he was making as he passed were so hard for me to take,” Sherri told me. “I really regret waiting too long to let him go. I don’t want to make that mistake with Julio.”

Kennedy told me that, when she meets a patient for the first time, she doesn’t assume that death is imminent. “Sometimes, I examine the pet and talk with the owners, and it’s very clear that it’s time for euthanasia,” she said. “Other times, the dog may be older, but there are ways to improve its quality of life. I always tell owners, ‘Getting old isn’t a crime!’ ”

In Kennedy’s view, Julio’s needs were analogous to those of a geriatric patient. “For dogs like him, I help make the home more hospitable for a big guy whose hips hurt and can’t move around,” she said. “So we raise food bowls and use nonslip toe grips on their paws, use little stairs to help them get onto couches.”

With Kennedy’s recommendations, Julio perked up. A low dose of pain medication improved his mobility, and that helped his constipation. He began to eat more. “He still sleeps under my chair,” Ben told me. “And he farts a lot.” A smell wafted through the air, and we all laughed. “God, Julio!” Sherri exclaimed.

Julio plopped down at my feet, licking the rust-red tips of his paws. Then he rose and joined his sister, a German shepherd named Peach, in a chorus of barking: the mailman had arrived.

The concept of pet hospice emerged in the eighties and nineties. In 1994, Amir Shanan, a Chicago-based veterinarian, was asked by a couple to euthanize their beloved dog at home. He started to advertise his work, and more people began calling. Their desire to give their pets a graceful end was so strong that they were willing to invite a stranger into their homes to do it. Shanan was astounded.

Eventually, pet owners began to tell Shanan that they needed his help well before it was time for euthanasia. “With euthanasia, the focus is on the time of death, and grief after the loss, but there is so much more that happens in the time between a bad diagnosis and death,” Shanan told me. He observed several gaps in veterinary care: animals with serious illnesses didn’t always receive proper symptom management, owners struggled to recognize the nuances of animal suffering, and people lacked the emotional guidance needed to make high-stakes decisions for their pets.

Shanan, who’d read about the profound impact that hospice could have on human patients and families, wondered whether a similar approach could be adopted for pets. In 2009, he founded the International Association for Animal Hospice and Palliative Care, which now has more than fifteen hundred veterinarian-members around the world. Shanan recruited a team that helped him develop guidelines, create a training program for veterinarians, and write an early textbook on the subject, which was published in 2017. The organization believes that dying is “a normal process,” and that its work allows pets and their families “to attain a degree of mental and spiritual preparation for death.”

Although pet hospice is modelled on human hospice, there are fundamental differences between the two. Human hospice, which is covered by most insurance, involves treating the emotional, spiritual, and physical suffering caused by a terminal illness as it unfolds naturally. Enrollment requires a prognosis of less than six months to live, and euthanasia is never considered. (Some states have legalized medical aid-in-dying, in which patients self-administer a life-ending medication, but euthanasia, in which the medication is administered intravenously by a health-care provider, is illegal in the United States.) Pet hospice, by contrast, is usually an out-of-pocket expense without clear life-expectancy requirements, and it can include the decision to euthanize an animal. An initial hospice visit can cost several hundred dollars; some veterinarians provide consultations over the phone or by Zoom, to gauge whether an in-person visit would be helpful. Humans enroll in hospice care for a variety of conditions, ranging from cancer to organ failure to stroke, but the veterinarians I spoke with told me that the majority of their referrals are for mobility issues and cancer, in dogs, and cancer and kidney failure, in cats.

Making decisions for a human with cancer and a dog with cancer can be similar—generally, there’s a desire to avoid pain and promote dignity—but assessing an animal’s suffering is, in some ways, far more complicated. Pets can’t tell us how they experience illness or treatment; we can’t explain to them the pros and cons of a surgery, or understand, at least fully, the depth of their discomfort. “When I started doing surgeries, back in the eighties, we wouldn’t even send dogs or cats home with pain medication, because they don’t always show that they’re in pain,” Shanan told me. “Cats hide pain really well,” Kennedy agreed. “It wasn’t until the two-thousands that we developed a pain scale for them, and it asks us to look at things as subtle as their whisker position.”

Cheryl London, a professor at the Cummings School of Veterinary Medicine at Tufts University, told me that pet owners always want more time. “But our pets have no concept of time,” she said. “They only know how well or badly they feel at any given moment.” At London’s office, people whose pets are enrolled in clinical trials are required to fill out a survey about their pet’s quality of life, which London relies on heavily. “I always tell owners that if I cannot improve the animal’s quality of life, then cancer therapy is not a good idea,” she said. Kennedy uses a similar survey, which tracks a pet’s ability to move, eat, drink, and eliminate, and provides space to write the things that pets enjoy doing and whether those activities remain within reach. “When one or two items fall off that list, that’s when you know it’s time to let go,” London said.

Many people believe that an animal’s ability to function independently is the best indicator of its quality of life, but Shanan wonders whether that’s too narrow a perspective. “I spent a few years asking myself about the difference between life having meaning—life being worth living for an animal, from their own point of view—and life being worse than death,” he told me. Couldn’t an animal’s sense of connection to its environment, rather than its ability to function, define its quality of life? Animals, like people, can adapt to disability or sickness, finding new meaning in what they’re still able to do. I thought about some of my own patients, who had insisted they would never want to live if they couldn’t walk without assistance, only to reconsider when facing those very circumstances. “When people say their dog can’t chase a ball, they may think the dog’s life isn’t good anymore,” Shanan said. “But I’ll look at the dog on the sofa and think, Maybe he just wants to hang out with you. And that is the greatest palliation in the world.”

We exist in an era of unprecedented human disconnection and loneliness. In the past few years, Kennedy has started to worry not just about her patients’ final days but about how their owners will survive the loss. “There are many more isolated and psychologically fragile people with pets as their only anchor,” she said. Kennedy works with a number of older owners who “have nobody left, and it’s like they’re looking their own mortality in the face when their pet is sick,” she said. “I worry that, without that pet, some people have nothing left to live for.”

Yet advocating for a pet requires separating what is human from what is humane, the suffering of the owner from that of the animal. “Pets will push on till the last minute and never complain,” Kennedy told me. “I tell people to take a minute and look your pet in the eyes. Ask them how they feel. They will tell you. Is your dog enjoying life, or just existing?”

I thought about these words when we visited a woman named Amy and her tiny black-and-white dog, Jingo. A petite blonde in dark slacks and a sweatshirt, Amy warmly welcomed us into her living room, where Jingo hobbled toward us, barking. “Just be careful—sometimes he leaves a trail of poop!” Amy said. A couple of years ago, Jingo had anal cancer, and surgery left him incontinent. Towels blanketed the couch and floor. “But it doesn’t really bother me, because it gave me two years,” Amy said.

Amy’s vet referred her to Kennedy because Jingo had been diagnosed with tracheal collapse. The rings of cartilage that held open his airway had weakened, and he’d developed a honking cough that could quickly devolve into gasping. Amy hated watching him struggle. “These near-miss moments happen and you wonder, Is this it?” she said.

“What are the main challenges you have with him?” Kennedy asked.

Jingo wandered the house at night, Amy said, getting lost and howling for help. He had chronic nausea, and the medication for it made him groggy. Amy, fearful about his breathing episodes, had begun to work from home, and installed a Ring camera to keep an eye on Jingo when she went out. She stopped joining her husband for road trips in their Airstream. Amy described herself as “overly attached” to Jingo; still, she didn’t want to prolong his agony.

Kennedy listened to Jingo’s heart and lungs, then suggested a few changes to his medication that might leave him less tired.

“So, here are a few harder questions,” she said, sitting down again. “Have you had to euthanize a pet before?”

Amy said yes, telling us about a golden retriever who had been dying of kidney failure. “I felt so guilty,” she said. “I knew she would have had life left, but it would be crummy. But now I don’t know—I mean, she was still wagging her tail, happy to see me at the door.”

“Kidney failure is so hard on dogs,” Kennedy said. “But a golden retriever will never show you how bad it’s doing, because it’s the ultimate people pleaser.” She paused. “It’s always better,” she added, “to let them go on a good day.”

Amy nodded, looking past us into her dining room. “It’s just so hard,” she said. “Nobody wants to feel like they’re playing God.” She told us about the recent death of her sister, who had suffered a cardiac arrest at work, lost consciousness, and been put on a ventilator. Amy’s brother-in-law told doctors that his wife would never want to live that way; she was taken off life support and died in the hospital. Amy worried that her sister hadn’t been given enough of a chance to recover. “I lost my absolute best friend,” she said, starting to cry. The thought of losing Jingo, too, was overwhelming.

The room fell silent. Amy pressed a tissue against her eyes. Kennedy gently asked, “If Jingo were to be in a serious situation right now, would you—”

“I would take him to the emergency room,” Amy said. “I wouldn’t even think twice. But I wouldn’t want him to be in the hospital. I think it’s a boundary now, but . . .” her voice trailed off. “I just wouldn’t want him to know what is going on.”

“So, if, let’s say, he had to stay there for three nights, just to get fluids or something?” Kennedy asked.

“Yeah, but not stressful stuff like X-rays. And it’s not a money thing, I would never want them to think I feel he’s not worth it,” Amy said, shaking her head.

“Have you talked about this with your husband?” Kennedy asked.

“He listens, but also says it’s too early to talk about this stuff,” Amy said. Kennedy handed her a quality-of-life survey. “Maybe the two of you could go over this together,” she suggested.

I looked at Jingo, who was sleeping on a purple blanket that complemented a bush of burgundy flowers just outside the window. It was an image of autumnal peace. I pointed it out to Amy, and she pulled out her phone to take a picture.

As I drove home, I marvelled at how Amy had rearranged her life around Jingo’s needs. I also wondered how others perceived her dedication, whether they thought that her efforts for an animal were extreme, or misplaced. I spoke with Laurie Levine, a Boston-based therapist whose practice focusses on helping people through pet loss and grief. “Many tell me that this animal is the love of my life, my soulmate,” she said. “It is a very physical relationship, a private one. Dogs are more public because of dog parks and walking, but especially with cats and birds and rodents, others may not have seen or known our beloved. They can’t understand what it is that we have lost.”

Given the absence of rituals to honor the animals we lose, Levine helps her clients create their own. One couple arranged a wake for their dog at an animal crematorium. Levine herself keeps photos of her deceased cats on her wall, and says good morning to them every day. “Much of my work is reflecting back to clients just how intimate, how worthy of commemoration their relationship with their pet is,” Levine told me. As she spoke, I thought about how Amy described her last moments with her golden retriever. “When it was time,” she’d said, “I just knelt down next to her and let her breathe my breath.”

Pets are witnesses and confidants, beings that understand us, and that we understand, in a distinct way. There are moments in my life that nobody knows about other than my cat. When my dog whines at a specific pitch, I know that he is hungry, not bored. Our love for pets can feel purer than our love for people, but the certainty embedded within all love is loss. Facing that loss, pet hospice reminds us, involves understanding the way suffering and joy can coexist.

Several months after Kennedy’s visit, Jingo had a rough night. Kennedy, who was occupied in clinic, told Amy to take him to his regular vet immediately. He died shortly thereafter. “I don’t know whether he was euthanized or died suddenly at home,” Kennedy said. She worried about how Amy was managing.

When I spoke with Sherri some months later, she told me that Julio seemed to have more energy. “At Thanksgiving, we went around the table and everyone said something about him,” she said. But, not long after, Julio could no longer hold himself up to eat. He became short of breath, and Sherri would stay up at night watching him, terrified that he might suffocate. Soon he struggled even to lie down. “Now he stands until he can’t, and he’ll kind of slope down, move his legs apart like frog legs, and drop his ass,” Sherri told me.

A sense of mystery imbues the experience of letting a loved one go: sometimes, even when nothing changes in their condition, we know, with sudden clarity, that it is time. Days after Sherri and I spoke, Ben came around. “He could finally see that it wasn’t about him being ready,” she told me tearfully. “It was about Julio’s suffering.”

Ben and Sherri’s close friends visited Julio on a Thursday night. They brought a homemade chocolate cake with cream-cheese frosting. The next morning, Julio ate two slices, along with some watermelon and bacon. He was still chewing when Kennedy began to sedate him. “Dr. K. said, ‘Typical Lab,’ ” Sherri told me. After so much struggle, Julio finally appeared peaceful. Ben picked him up and laid him gently on a wagon that he’d adorned with blue hydrangeas, scarlet gerbera daisies, and violets. Together, the couple buried Julio at the edge of their property, near the water, next to Tango, the cat. ♦