Ep 18: Hospice Care & Euthanasia with Dr. Sheilah Robertson of Lap of Love

What are the critical elements of providing compassionate end-of-life care for pets? Join us as we explore this profound topic with Dr. Sheila Robertson, the Senior Medical Director for Lap of Love Veterinary Hospice. With her extensive background in anesthesia and pain management, Dr. Robertson offers invaluable insights into proper sedation procedures before euthanasia, the emotional impact of these practices on pet owners, and the need for more compassionate approaches in veterinary medicine. 

Discover how alternatives to traditional sedation shots, such as gabapentin and the innovative pre-gabalin liquid Bonquat, can ease the stress of veterinary visits for cats. Dr. Robertson shares practical advice on managing chronic pain and hyperesthesia in feline patients using oral medications like buprenorphine. We also highlight the benefits of in-home euthanasia and the creative outdoor euthanasia practices adopted during the COVID-19 pandemic, aiming to provide a peaceful and familiar environment for pets and their owners.

Finally, we delve into the emotional aspects of saying goodbye to a beloved pet and the importance of respectful aftercare. From guiding pet owners through cremation or burial choices to understanding the concept of the peak-end rule, Dr. Robertson emphasizes creating comforting last memories. We discuss the balance between physical health and emotional well-being for pets and explore the rewarding yet complex role of veterinarians in this field. This episode is a heartfelt guide for pet owners navigating the challenging journey of their pets' end-of-life care.

Transcript

Kristiina Wilson: 0:00

Hi and welcome to Hiss and Tell. A cat behavior and more. Podcast hosted by me, Kristiina Wilson, animal behaviorist. Today's episode is all about end of life care, from hospice and palliative care to euthanasia. This is a topic that isn't talked about much but is a really important part of our pets journeys with us. So join me as I speak with Dr Sheila Robertson, medical director for Lap of Love Veterinary Hospice. Hi and welcome to Hiss and Tell. I'm Kristiina Wilson. I'm with my guest today, dr Sheila Robertson. She is the Senior Medical Director for Lap of Love Veterinary Hospice. Welcome, sheila.

Dr Sheilah Robertson: 0:46

Well, thank you, Kristiina, and it's really, really nice to be invited on your show, which I've listened to many, many times, but didn't expect to be a guest.

Kristiina Wilson: 0:57

Well, thank you so much. I'm really, really grateful that you're here. I've been doing, as listeners know and you may know, a real series on pet loss and grief and I really thought that getting into veterinary hospice would be a valuable part of that topic. So I'm really eager to have this discussion with you and to let our listeners know how they may kind of help ease their pets who are at end of life into a good ending into a good ending. So to just jump in, can you tell me a little bit about your background?

Dr Sheilah Robertson: 1:34

your education how you got into working with Lap of Love. So I actually I grew up in Scotland, in the United Kingdom, and graduated from Glasgow Vet School a long time ago, so I've been a veterinarian for over 40 years, and so my specialty up until recently has been anesthesia and pain management, and I've worked in academia, private practice, mixed animal practice, and then I did work in the animal welfare division at the AVMA for a couple of years as well, and then I joined Lap of Love almost eight years ago.

Kristiina Wilson: 2:10

I know you were telling me, when we were not recording, that the founders of Lap of Love were your former students.

Dr Sheilah Robertson: 2:16

Yeah, it's what comes around goes around, isn't it? So yeah, so, Danny McVitie and Mary Gardner when they were at University of Florida I was their professor for a lot of the pharmacology lectures- and then obviously anesthesia, and then obviously they both did clinical rotations with me and now they're my boss.

Kristiina Wilson: 2:41

I think that's actually quite a nice story. So because you have this special interest in sedation and anesthesia and analgesia, can you tell me a little bit about how that led you to be interested in veterinary hospice?

Dr Sheilah Robertson: 2:55

Yeah. So one of the things I've always noticed when I was going through my career is that the animals at either end of the age spectrum the little tiny ones and the pediatrics and the really old ones kind of always, you know, we didn't quite know what to do with them.

Dr Sheilah Robertson: 3:12

And then the veterinary profession has become so good with pediatric procedures and I'm also certified in shelter medicine and learned a lot about how to anesthetize tiny little things, and then I saw this huge gap where we're just not as good or as sure what to do with the much, much older aging population. So obviously, dogs and cats are living a lot longer because of good medicine and so on, and so they become. One of the biggest things to understand is they become frail, like people.

Dr Sheilah Robertson: 3:49

And they have often multiple diseases, so they can be a real challenge to anesthetize. And so I was really trying to investigate and work with people that worked and anesthetized very, very elderly people. You know what was so fragile about these patients. And then you know people think, well, you're an anesthesiologist and your patients are all supposed to wake up, and that is true. But then I realized that I call it the last appointment or the ultimate anesthetic, right it's?

Dr Sheilah Robertson: 4:25

the last anesthetic that they're going to have and they're not going to wake up for it and because of all the diseases that they may have at the time, which I've seen in clinical practice, you know, over the years, I felt that my skillset was, you know, maybe going to really help develop some better sedation techniques for euthanasia. And we at Lap of Love always, always do sedation or anesthesia prior to the actual euthanasia event.

Kristiina Wilson: 4:58

Of course.

Dr Sheilah Robertson: 4:59

And that's not a given in every appointment, really.

Dr Sheilah Robertson: 5:04

Oh yeah, that's not a given in in every appointment. There are really oh yeah. So, although the avma do suggest that that whenever possible we should um sedate and or and or anesthetize prior to euthanasia, um, we still hear from many, many clients that basically the appointment was they arrive, the pet cat or dog cat we're talking about cats is taken away, has a catheter place and when they come back it's a quick IV injection and it's all over very quickly. So I've done some recent surveys and I would say less than 40 percent of well, more than 40, probably about 60 percent of people now really get that sedation is a good idea, sure, but there's, you know, another 35 to 40 percent where they are not um doing pre-sedation that's horrifying very yes, it's very sudden and it's very abrupt and we get owners telling us that it was like they were there and then just very suddenly, very quickly, they were gone and we can get into all the reasons why sedation or anesthesia is so important in that final appointment with their pet?

Kristiina Wilson: 6:22

I think we should, but I first I'm curious to know cause. I have, unfortunately, you know, working with animals for so many years and I've personally had so many animals that I've, you know, gone through this. I have never, ever, had a an animal euthanized without the use of sedation. Um, and do these tend to be the kind of old school vets that also don't believe in pain management for animals? Because I be the kind of old school vets that also don't believe in pain management for animals? Because I have run into some old school vets who are like we don't give pain management for animals after a spay Like that, they don't need that, which I find insane.

Dr Sheilah Robertson: 6:58

Yeah, so I fought that battle. You know my entire career and on. You know when. You think, when I started out 40 plus years ago, we didn't have a lot of good um, pain medication right. But we were educated enough to know that a mammal is a mammal, like a human or a cat or a dog, and so the whole. Uh, you know, the neuroanatomy and pain pathways are the same.

Dr Sheilah Robertson: 7:25

So it wasn't that they weren't feeling pain, we just didn't recognize what the signs of pain were in those days, and now we have, you know, our toolbox is very, very full of really great things that we can give. You know, every year something great and new comes out for either acute pain or chronic pain, and that's been very, very active for cats just recently.

Kristiina Wilson: 7:51

Yes.

Dr Sheilah Robertson: 7:51

A lot of new products for cats, which has just been. You know, used to be, cats were always a second thought by drug companies, and that's no longer true.

Kristiina Wilson: 8:02

Let's just jump right in and talk about why we should be doing sedation when we're doing euthanasia.

Dr Sheilah Robertson: 8:08

Yeah, so a lot of the pets, as you know, have been struggling with their health issues up until the day that the owner, with probably a lot of advice and thinking and support from, hopefully, a lot of good support from their health care team, their veterinary team decided to say goodbye and so by offering sedation, which nearly always includes an analgesic.

Dr Sheilah Robertson: 8:36

It might be the first time in a long time that they've actually seen their pet at peace, like restful and calm and actually, and they're able to hold them and pet them, which they may not have been able to do up until that point, and they just see them in that, you know, really, you know, you can call it cloud nine, whatever you want to call it, but in that peaceful state. And then the other reason that we like to do heavy sedation or anesthesia is that we always try and either we try and step away and give the owner a very, very private moment so that they can speak to the pet pet because there's some people that really have.

Dr Sheilah Robertson: 9:23

They want to say something just as they would say to a person that they love that they know is is, you know, close to the end, but they may not want to say it in in front of us, and so we give them that moment of privacy, you know, and we encourage them to tell their pet, you know, that they love them and thank them, and and you know we step out and so if we've got them safely sedated or anesthetized, um, they have that really important moment of privacy alone with their pet. That's very important.

Kristiina Wilson: 9:57

So I know a lot of our listeners were asking is there an alternative to giving the sedation as a shot, or is that just something that we have to deal with right now?

Dr Sheilah Robertson: 10:08

Well, definitely giving them things like gabapentin ahead of time, which? A lot of people do in order to have a less stressful cat. You know, veterinary visit Right.

Dr Sheilah Robertson: 10:19

We now have Bonquat, the new pre-gabalin, which is a liquid, um that that just came on the market in march, so that's easier to give and make them, you know, a lot less stressed. Um, we can give them a little bit of buprenorphine in in their mouth because a lot of these cats are, um, you know, guts, are got painful issues, yes, often mobility, and just they're. They're very achy and that makes them hyper aesthetic.

Dr Sheilah Robertson: 10:49

So, even a small injection with a tiny little needle to them. It's real, because their pain threshold has been altered by their chronic pain Right. So often we will try and give something orally to take the edge off um, and then you know, we um. There's other things that we can do with the injection, a lot of the protocols that we've developed, um at lap of love, that all any veterinarian can have access to on our website. Uh, some of them they can be given sub-q and they work very well because, I mean, you know, when you have the little cat, that's like skin and bone and there is no such thing as IM right, there's no muscle.

Dr Sheilah Robertson: 11:32

So we have some protocols that work very well sub-Q, so this makes it a much smoother, you know, transition for the owner to watch and we usually explain we don't explain everything in detail- but we explain that. You know the general. This is, this is the plan and this is what's going to happen. This is what you'll see, and if we see something else while we're doing it, we'll explain. You know why Lily's doing that?

Dr Sheilah Robertson: 11:58

um, you know, as we go along, so I think that's a good way to do it, so we do, I, I would say I. I just actually looked at the data for our lap of love veterinarians and we're now, gosh, we're going. We're doing, like you know, almost 12 000 appointments, uh, a month now, wow. But most, you know, the majority of our pets are dogs, not not cats. But when I look to the cat data specifically, I would say about 50% of our veterinarians go in a vein and the other half are using the kidney oh, interesting. Under anesthesia.

Kristiina Wilson: 12:38

Yeah, of course it makes sense, Obviously under general anesthesia.

Dr Sheilah Robertson: 12:42

And the other thing is, if the cat is nice and sedate or anesthetized, it means we need fewer people, right? It could be just the owner and anyone that they want there and us right? We don't need someone helping us hold off the vein, we don't need someone else in the room. We don't need all that extra help, which is distracting for that important time.

Kristiina Wilson: 13:02

Sure for that important time. Sure so generally, just for for our listeners when a veterinarian from Lap of Love comes out.

Dr Sheilah Robertson: 13:10

It's just the veterinarian. It's just a veterinarian. We don't, we don't have, um, they don't have a technician or nurse with them. They're, they're on their own. Yes, yeah, okay.

Kristiina Wilson: 13:19

So I want to go back to that statistic that you touched on I know we talked about a little bit before we started the recording that only 10% of the animals that you see are cats. I find that really interesting. I know we talked a little bit about, of course, that it's. You know, dogs tend to be. Most dogs are larger than cats and more difficult to get to the vet. But I wish that more cat owners knew about the service and knew about in-home euthanasia. So are there any other reasons that you think that people who have cats are not taking advantage of the service or of in-home euthanasia?

Dr Sheilah Robertson: 13:56

No, because I mean we know as many homes in America have cats in them as dogs, so I think it is a lot of it is to do with the fact that they, they, they feel like, yes, I can get my cat in a carrier, um, and I can get them to the vet, although we all know people and cats often find that very, very stressful, um, but I think, uh, you know, cats really don't like strange places and to expose them to a very strange place at the very end is, you know, can be quite stressful for them, although there are I mean, I work with some fantastic, you know, top notch feline only practices that, do you know? Fantastic job with the euthanasia. They have a beautiful room. Do you know, fantastic job with the euthanasia, they have a beautiful room. Of course, during covid we were doing euthanasias outside um and a lot of.

Dr Sheilah Robertson: 14:51

Actually, one of my friends that I um, who has an amazing cat clinic, a brick city cat clinic in ocala, jenny solpeter. She started doing outdoor um euthanasias during covid and she hasn't really completely gone back to doing them indoors because they have a beautiful area behind their clinic that's got trees, it's got little gravestones from their local little cat community cats that are all there and it's very peaceful. They don't have to deal with, you know, other people in the waiting room. So she's actually some people have not gone back to going indoors and the owners quite like that privacy of a nice area behind the clinic and it's in nature.

Kristiina Wilson: 15:34

I guess we should talk a little bit about Lap of Love and the services you provide, and exactly what is a veterinary hospice for our listeners who may not know.

Dr Sheilah Robertson: 15:47

So what we? So we provide? Most of our appointments are in-home euthanasia but we also offer tele-hospice. So you know, we all. Obviously there's a lot of people that they, you know, they're not sure. Is this, you know, is there something that can be done, or is this euthanasia? And often on a phone, consult that can be. You know, you can help them, you know what's really going on, what's the next step, and so on. And then obviously we do hospice care as well that would be.

Dr Sheilah Robertson: 16:23

You know most people would understand in people palliative and hospice care. So I think the first thing to point out is that hospice is not a place.

Dr Sheilah Robertson: 16:34

So a lot of owners think that, well, if I choose hospice, they're going to go somewhere. You know like often people. But more and more people are having hospice care in their own home. So it's not a place, it's a philosophy of care. So this is when there's no curative intent for the disease. So this is, there's no longer diagnostics, and you know we're not trying any more treatments. We've decided either it's a terminal disease, it's not treatable, or the response to treatment was not optimal. Our owners can't afford the treatment and we never judge them for choosing hospice, and hospice is not about extending suffering.

Dr Sheilah Robertson: 17:23

It's about helping the cat live as well as it can for the time it has left and for the owners to witness that. And um, we we actually just had an internal discussion recently our average hospice patient.

Dr Sheilah Robertson: 17:39

We only have them in hospice for between uh two to ten days, so it's really, really short yep, because a lot of it's like they need to come to terms. Maybe family members need to come home because they want to. They don't want to say goodbye remotely, they want to come home. Kids coming back from college or something, um so and we don't do diagnostics. But once they enter hospice, um, we're not offering diagnostics or saying you know what, you know what more can we do. We're like then we um so if it is a hospice appointment, it's um usually quite a long appointment with the veterinarian, and then they write up the plan and then we're very, very lucky to have an amazing team of hospice nurses.

Dr Sheilah Robertson: 18:42

So it is a bit like the human system so the hospice nurses will get all the instructions and the information from the veterinarian, but they're the ones that will reach out to the owner with all the information that they need tips and tricks on. You know, if a medication has been suggested, how is the best way to give that? How do you keep your cat hydrated? How do you, you know, not force feed them. All the little tips and tricks and information and support is what they get from the nurses, and they're an amazing team.

Kristiina Wilson: 19:19

Can you describe the process that a pet owner goes through when they reach out to Lap of love for assistance? So let's say that they have a cat who's terminally ill. They reach out to you guys, um, let's say, for hospice, then leading to euthanasia. What is that process like?

Dr Sheilah Robertson: 19:34

yeah, so that if they, if they found us and a lot of them have either been sent or given the phone number by their veterinarian or they find us online.

Dr Sheilah Robertson: 19:44

So the first thing is is, and probably one of the most difficult things they're going to do is pick up the phone and make that call. And so we have a support center and we're very, very proud that our live answer rate is well over 95%. They're very well-versed in pet loss, grief and counseling, and probably the first thing they're going to say is you know what's your pet's name and is it a boy or a girl? And so these are key things, like you know, is a dog or a cat, what's his her name and what's going on. And a lot of them just sit there and listen.

Dr Sheilah Robertson: 20:27

And we have plenty of people in our support center that have sat and listened and talked with an owner for well over an hour, and the owner doesn't book an appointment and we don't mind, because we've done a sample. That's what they need, and often they'll say, well, I'll think about it. Or right there during that phone call, they book the appointment, and so we find out you know where's your zip code? Do we have someone in the area? You know when? You know what are we looking at. Is it urgent Is. Could it be in a?

Kristiina Wilson: 21:00

day or two, and then we're.

Dr Sheilah Robertson: 21:02

Obviously we have very, very simple pricing, because I think that's one of the things when people call a veterinarian and if they're not well set up for this type of appointment, they're saying, well, you know how big, you know like, and do you want this and do you want that? So we have a lot, pretty much, packages. So there's not all these like well, would you like this, would you like that? It's kind of a given, you know, and um, there's not an add-on, like I mean, it's a given that they're going to get paw prints and a hair clipping we don't even ask they, they're going to get that.

Dr Sheilah Robertson: 21:36

It's all rolled into one. And then the other, um, big, important question is, um, that they get asked is and what would you like to do with, let's say, it's Lily again, what would you like to do with Lily after you've said goodbye? And then that gets us into what the choices for aftercare, you know, are they going to. And then they might say, well, what do you mean? And they go? Well, would you like to? Are you know what? Would you like us to take care of? Her cremation or would you like to bury her?

Dr Sheilah Robertson: 22:09

And the way it's all scripted out, um, is, you know, everyone has very, very different beliefs and wishes.

Dr Sheilah Robertson: 22:16

Sure, some owners arrange that themselves, some owners bury their pet.

Dr Sheilah Robertson: 22:21

So, different religious beliefs and what happens, and you know, and, and I think one of the most important things is the, you know, the the final time that a caregiver sees their pet is really, really important, because that's seared in their mind.

Dr Sheilah Robertson: 22:41

It is, it's seared in their mind and we call it the peak end rule. So they may have been going through a rough journey with ups and downs, but if the very, very end is good, that really kind of like influences the whole experience that has come prior to that. So if it's a cat, after we've done the euthanasia and verified that you know death has happened, that the pet has passed, we leave again to give the owners another private moment to say what they want to do. And then we come back with a basket and a blanket and we place the and we never wrap or cover, we just pop them in a really soft you know, it's a little nice little wicker basket with a nice blanket and we tuck them in and if they have toys, or you know, sometimes owners have written a little letter that gets tucked in right.

Dr Sheilah Robertson: 23:37

That goes with them. Owners have written a little letter that gets tucked in, right, that goes with them, and then that basket usually gets strapped into the seat belt on the front seat and their head is never covered. And so all the way out to the car people are still looking at their pet and as they drive off, the last memory is the pet tucked in safely and then our vets obviously take care of it. But you'd be surprised, you would think, that owners never, would ever tell you this in this day and age, that they've seen their own pet put in the cadaver bag in front of them.

Kristiina Wilson: 24:12

Oh, I've had to do it myself, and that is that is something that was so traumatic to me about. You know, my best friend Kat's death that, like we had this. You know his whole illness was traumatic but we I made a plan, you know, we had this everything to give him a good ending. Right, it was this whole plan. And then obviously we had him euthanized and that went well. But then the service showed up to pick up his body and I had to put him in the cadaver bag and zip it and it was awful, and I have so much trauma around that I've had nightmares about it.

Kristiina Wilson: 24:48

It has just been it's just like yeah, it's like putting a family member into that.

Dr Sheilah Robertson: 24:54

It's terrible, that is something that owners should never have to witness.

Kristiina Wilson: 24:58

Yeah, that it's terrible, something that owners should never have to witness.

Dr Sheilah Robertson: 24:59

yeah, yeah, and if you talk to you know if you talk to people who have had the coroner arrive at a house because of a family member, you know, and they put them in the body bag. I mean, it's something that is so traumatic, so that is something that owners should never see. But we also, you know, we train and I do a lot of talks, like you know. We, we encourage, you know, people doing euthanasia in their clinic to up the game a little bit. So if the owner is leaving the clinic, um and the and it was done, you know in in a nice little room, either uh, you know a euthanasia room, or or in a clinical room that you know you turned it into, made it a little bit nicer and put out, you know, dimmed it down.

Dr Sheilah Robertson: 25:41

You can still place the cat in a lovely little basket and tuck it in and place a flower or you know something of the cat's, maybe its own blanket, Because owners 99% of the time as they exit and you should not, you know you should someone should be with the cat when they exit they always turn. Yes, look, and that last memory. If the cat is snuggled up in their basket, that's their last memory.

Kristiina Wilson: 26:09

Yeah, yeah, it's. I'm really happy to hear that you guys have have developed a work around for that, because it I think it is well even just thinking about it again. It is really so traumatic to have people go through that.

Dr Sheilah Robertson: 26:26

There's no need for owners to see that part, they just need to have the last top top.

Kristiina Wilson: 26:31

From a psych perspective, your last memory is your last memory and that's going to stay in your brain. And if it's unpleasant now you've kind of poisoned the well of all of that hard work that you've done to make this as good as you can.

Dr Sheilah Robertson: 26:47

Yeah, and we definitely try and help veterinarians do better. You know better you know in clinic euthanasia because we know we've interviewed a lot of our clients and they won't go back to their vet because of a bad experience. Of course you know what, what, um, you know what we want is people coming back to us, and what clinics want is someone that it has such a good experience I mean, at the worst possible moment with that pet that they have the courage to go back to that clinic you know, and you know we actually had.

Dr Sheilah Robertson: 27:23

it was actually a little girl, she was maybe 10. She returned to a clinic with her kitten and she told them she it was a friend of mine who was the veterinarian. She said this little girl came in all excited with her kitten and they remembered well, we euthanized their old cat, like less than six months ago. And the little girl said, well, thanks to you we had the courage to get a kitten.

Dr Sheilah Robertson: 27:47

you know because, you know it wasn't. You know they helped them through the process and helped them with grieving, and then that probably turns into another conversation about the support that owners need after the euthanasia. So it's not the minute we drive away. Our job is not done.

Kristiina Wilson: 28:07

Of course. So let's talk about that, yeah.

Dr Sheilah Robertson: 28:09

Yeah.

Kristiina Wilson: 28:10

So you know I've I've been talking a lot about grief and managing grief and pet loss, which is often so so disenfranchised, um and. I think people have only recently really been talking about how painful it is to lose a pet, um, and so I would love to hear how lap of love, and how you guys help support your clients after they go through this.

Dr Sheilah Robertson: 28:32

Yeah, so we we do tell them that um, you know, we don't know how they're going to react and usually we leave some leaflets about um, pet loss and grief and what our services are and um. So the services that we offer are there's a support group that is completely free and you don't actually have to have been a lap of love client to join the support group. So it's a group of people and it's on our website. You can sign up for a slot and it's basically led by um trained grief counselors, pet grief counselors, and people can talk about their recent loss and other people in the group can help them or relate to that. Then we have a one-on-one. If they want a private um conversation with a special, a special specialist. It's fifty dollars for an hour and then we have a pet loss journey course that they can take, which is like about a six-week course that um that they walk them through.

Dr Sheilah Robertson: 29:35

And then we have a facebook support group that they can join and they can talk about and post pictures about their pet and talk and ask other owners. Is this normal? You know? Six weeks later I'm still thinking I haven't picked up Lily's dishes, I haven't put away her toys. Is this, you know, and so we have a lot of things in place. And then you know, obviously, if we really think someone's struggling, we will suggest because veterinarians are not mental health providers we will suggest and give them you know numbers of people we think that they should reach out to and we just say you know, definitely um might find some help by reaching out to these professionals.

Dr Sheilah Robertson: 30:22

That can help you, um, and then we always do a check-in with the owners, like in either an email or a phone call, just to let them know we're thinking about them, and often, um, we do a year later, a year on the on the pets um anniversary of when they said goodbye.

Dr Sheilah Robertson: 30:40

We send out um a reminder and 99.9 percent of people really like that very few of course, actually don't like the fact that we, you know, they're like, wow, they remembered, right, yeah, we have a system and so it's like they're, you know. We'll just say, you know, we're remembering a year ago today, you know, whatever.

Kristiina Wilson: 31:01

So there's a year.

Dr Sheilah Robertson: 31:03

So there's a lot to do. But yeah, you're right, it's very disenfranchised. But yet, if you look at the data on well, on caregiver burden, so looking after a sick pet is just as difficult as it is taking care for an elderly parent with Alzheimer's, and so people start understanding that and then that the loss can be as great, if not more, than, when they lose a family member, just as you know the number of people that said, well, I've got to go back to work tomorrow, because if I say anything, they're going to say, well, it was just a cat right.

Kristiina Wilson: 31:43

Yeah.

Dr Sheilah Robertson: 31:44

That's just like and that's because people don't. If you haven't gone through it yourself, you don't understand.

Kristiina Wilson: 31:50

Yeah, how it feels. It's so tough. I mean, just personally, I had to take two weeks. I had to close my practice. For two weeks I was. I knew I was going to be of no use to anyone, so it's very difficult and I'm lucky that I could do that.

Kristiina Wilson: 32:05

But I want to talk a little bit about the tools that you guys have on your website. There's some really great tools, like the quality of life assessment that I think would be very helpful for our listeners who may have terminally ill pets. Can you talk a little bit about what that is and how people would use that?

Dr Sheilah Robertson: 32:20

Yeah, so it is actually interactive, the, you know lackoflovecom. And then we have the quality of life tools. So the owner can type in you know, I have a dog or a cat, his her name is, she weighs. She or he weighs x number of kilos and has been diagnosed, and they can, there's a drop down menu and they can, you know, choose a disease and obviously we're working on always upgrading it because a lot of cats right, collect, seem to collect comorbidities, right, so they've not just got one thing right, but the but the owner could choose. Let's say what's the common one Chronic kidney disease. So Lily is 15. She weighs four kilos, she's been diagnosed with chronic kidney disease. And then you click a button and it takes you into another page and you answer all these questions and it comes up with, uh, with a number, and we're we always err on the very, you know, very side of caution that we're saying. You know, lily's quality of life appears to be declining.

Dr Sheilah Robertson: 33:33

We highly recommend you reach out to your youtube, we, and we say your veterinarian, or reach out to a veterinarian and that could be us, it could be their own veterinarian, and then they can also click on the disease so chronic kidney disease, and they'll get a lot of information about what is this disease. You know how common it is in cats. Is it treatable? Is there, can we, how you know? So there's a lot of information on what can be done for the disease. But it's you know it. It tells them about the disease that they've chosen on the dropdown menu.

Dr Sheilah Robertson: 34:11

So they, so we have um those tools and you know, and if, um you know, owners can use those without having anything to do with us, if they because I highly recommend people start tracking quality of life in their past, in early age, and then download and write down that number, because as things progress you often don't see, because you're with them every day. You don't see that decline, but then you know little red flags should be coming up when the numbers are changing and you're getting different recommendations um and, and I think, doing quality of life assessments over time really, really help people make good decisions about saying goodbye.

Dr Sheilah Robertson: 34:55

I agree, I'm all for people collecting data across the board, just especially as a behaviorist, I would encourage people to keep and date stamp photographs because you know you don't you know, if you're not way you know the chronic kidney disease cat that you know, you don't realize that he's now or he or she's all skin and bone because you're not necessarily weighing them at home. But if you took a picture and you look at the picture from six months ago, it's like wow, you know. Or someone who hasn't seen the cat walks into the house and goes, oh wow, what's going on? And then you're like oh um, what do you think's going on? Because when it's just gradual in front of your own eyes, and then like we've got to admit, we've all been there ourselves and I'm guilty of it, we've all been on denial island or put on the denial goggles, yes, as Mary Gardner calls them, we don't want to face what's going on.

Dr Sheilah Robertson: 35:53

Right, of course. And so we need numbers and if we do a hospice visit um we always do the quality of life assessment with the owner to help them you know how to do it the first time. And sometimes we'll say really, um you, why did you choose that number? Because I would have chosen this number. And then obviously, as you're well aware, when there's a lot of family members, they're not all on the same page.

Kristiina Wilson: 36:22

Right.

Dr Sheilah Robertson: 36:23

And so we try and focus on the primary caregiver, because they're the one who gets exhausted first.

Dr Sheilah Robertson: 36:31

And just they're taking all the you know, they're seeing what's going on every day, whereas someone who's gone to work comes home and says, yeah, like what was your day like? They're like. No, I was just, you know, um, trying to get some food into lily. I've been mopping up her vomit. I've been doing this. So we try and focus on the, or you know, at least figure out who the primary caregiver is, because they need a lot of support absolutely they may not be getting it from the rest of the family.

Dr Sheilah Robertson: 36:57

The rest of the family are like no, when I come home she really perks up. So not everyone on the family members on the same page. So we try and have as many people there as possible and we go through it together and agree on what the number is or where we're at in the pathway. Yeah, and a lot of the questions and I need to emphasize I can't emphasize this enough um, they're not all focused on the disease or health.

Dr Sheilah Robertson: 37:27

It's yes, it's emotional health is what's so important and actually by, you know, really supporting the cat's emotional health when they're physically sick can actually do a lot to counterbalance. So the safe place to go and retreat, the you know the comfort, nice, warm place, the predictable interactions, the being, you know we prescribe. You know we might be prescribing medication, but we're also going to prescribe. You need to groom Lily two or three times a day because she can't do herself, but that's human, animal bonding time and she loves it and releases lots of you know nice hormones that make her feel good. So we're rxing drugs but we're rxing, you know, bonding time, grooming time, loving on your cat time. So I think everyone has to understand that quality of life is not about all about health. It's about mental health, emotional health, and sickness causes anxiety, and anxiety makes things you know, like pain, worse. So it's a balance between the two and they're equally important.

Kristiina Wilson: 38:37

Yeah, agreed. So I also wanted to ask you about the feline grimace scale and if you want to talk a little bit about what the feline grimace scale is and how that could be useful to people.

Dr Sheilah Robertson: 38:50

So the actually looking at facial expressions of pain. Actually, that's when I went back to my homeland, glasgow, for my sabbatical many years ago. We were working on a, an acute pain tool that was composite, um, so included lots of things. And that's when we well, my group at glasgow we figured out that the ears and the and the and the muzzle um change when they're in pain. But I have, I have to emphasize that the feline grimace scale is only validated for acute pain, right, not to say it's not useful in what we're talking about. So we published a couple of papers on using the ear position and then how tense the jaw was, which obviously alters the whiskers, right. Then Paolo Stigal's group came along and thought, well, wonder if we can do it all through facial expression. So then they spent years I mean since 2019, developing and validating the feline grimace scale. And we do know that owners can use that tool and they're going to be able to use it as well as a seasoned veterinarian, because it's all about pictures and the other great thing for people language is not an issue with that tool because it's all about face Because a lot of language, if it's in Spanish or English it doesn't quite

Dr Sheilah Robertson: 40:18

translate because a lot of language if it's in spanish or english, it doesn't quite translate. So basically, there is an app that you can put on your um on your smartphone and it literally you open it up and you look at your cat and number one, it says um, choose the position of the ears, and then you go to the next thing. It's the eye. You know the eyes open or they like, you know like this when they're painful, right, and then is there you. So there's five things that you mark and then you get a final score and if they score over a certain number, it's highly advisable that you seek veterinary attention because it's pain. But a lot of cats with chronic conditions have what we call acute on chronic pain. So the ones with inflammatory bowel disease might be going along just fine and then they have an acute episode, and so this is a nice tool for owners to have um to, to use um just to double check. You know like what's going on. Are we having a flare?

Dr Sheilah Robertson: 41:18

um is there an acute, you know? Are they having an acute pancreatitis? You know flare, so it's, it's a really good tool. Plus, it's, you know, on a phone app and it's um. So they, the feline grimace scale people and another group in calgary called sylvester AI, are developing actual, true artificial intelligence where you'll be able to actually just hold the phone up and it'll scan the cat and it's going to look for all those markers and then the algorithm.

Dr Sheilah Robertson: 41:51

You know, as you know, we know, we know, everybody's got to get the AI. You got to train the AI correctly. So the algorithm must be done correctly, but hopefully Sylvester AI, who are based in Calgary, and the Feline Grimascale group, who are Parvus Tagal's, now based in Hong Kong, there may be an AI app available, but it is still at the moment for acute pain right.

Kristiina Wilson: 42:20

Yes, that's really interesting about the app. Um, I wanted to talk to you a little bit about euthanasia versus natural death. I think a lot of people have an idea that a quote-unquote natural death is a good death or an. I don't want to say an easy death, but I think people have a lot of opinions about a natural death or an. I don't want to say an easy death, but I think people have a lot of opinions about a natural death that may or may not be accurate, so I would love to hear your thoughts on um, on this, this loaded topic.

Dr Sheilah Robertson: 42:50

Yeah, so so we, we do hear um a lot of people say, well, I, I, I just want them to have a natural death and what what we're here, what, what we all know and we all wish ourselves that your cat just goes to sleep one night and it doesn't wake up, right, yeah, but so when we, when someone says that they're, they would like a natural death for their pet, we usually just pause and we usually just say so what I hear you're saying is you want an unassisted death?

Dr Sheilah Robertson: 43:24

Right? So that's just changing their mindset a little bit. And then we say, you know, if we're, if we feel like it's really time for euthanasia, we say well, you know, euthanasia, which we can explain to you, is, is an opportunity for you to say goodbye, to lily in her home surroundings, surrounded by the people that love her, right, so it's all can be, can be planned. Now there are some people, because of their spiritual beliefs, or the religious beliefs um, you know, like budd, buddhists, they cannot euthanize, and so there may be some religious reasons, but we still tell them that it is an unassisted death, and usually what we say is that Mother Nature is not always kind at the end.

Dr Sheilah Robertson: 44:15

And most people have probably had a family member die in hospice and even with a lot of assistance, it's not always easy to watch. So, what we say is what we can help you with is to help. We can do a hospice assisted death, or we can call it, or we now have the terminology of palliated death. So we're going to ensure comfort until they pass on their own without euthanasia drugs.

Dr Sheilah Robertson: 44:49

So you know, and that might look like a lot of heavy sedation, you know sub-Q fluids, but we're going to be not. You know, we're trying to help them on their way but keep them comfortable. So the two new terms now that people are trying to give to owners when they ask about natural death, we, we first of all say what. What you're asking for is an unassisted death, um, and that's not always pleasant, so we can do a palliated or hospice assisted death and then we can explain to you what that might look like.

Kristiina Wilson: 45:27

You know, for this situation or that situation yeah okay I think often what people don't understand is that it's very rare for an animal to pass naturally in their sleep. That really almost never happens.

Dr Sheilah Robertson: 45:42

Yeah, it's only happened to me once yeah, and it was the night before I was going to euthanize my cat. Right, yeah, um, you know he he had he had. He was in heart failure, but not, you know, not drowning, right, um, and my husband and I had a big discussion on the Saturday evening. We said tomorrow's the day, and my husband got up early to spend some time with him and found him dead and so we assume he threw a clot, you know, because he had all.

Dr Sheilah Robertson: 46:15

yeah, Because he was just, you know, he was curled up. But that almost never happens. And so we do I mean sometimes we are pretty, we're as truthful as we can. So if it is heart failure, we do say well, you probably know about people in heart failure. They find it very, very hard to breathe and they struggle and they talk about like it feels like they're drowning.

Dr Sheilah Robertson: 46:42

And some people might say, well, that's not painful, because it's not all about pain. We say that's very, very scary. It's very, very scary. And you know our other and I'm sure everybody pulls this one out we always say you know, better a day too early than a moment too late. And then we have a lot of families that um choose euthanasia earlier as they become more experienced pet owners, because they know they left it too long with other pets and they don't want to do that again, right.

Dr Sheilah Robertson: 47:17

And the other thing is you know we often say you know, if you know the pet may die alone. If you don't choose euthanasia, they may be alone. You know, and struggle when you're not there and you didn't get the chance to say goodbye. So there's a lot of things that you know you need to explain to them, or we don't. We don't do 24 seven emergency care, right? So you know, we always tell them. You know you need to know where your nearest emergency room is, what the hours are, because if you leave it too late, you may be going there at two in the morning. You know, and you know, with meeting someone you've never met before and the journey and everything, um, and we, we just tell them this is how it might be.

Kristiina Wilson: 47:59

Right yeah, and I I think, to that end, encouraging people to make a plan um which is something I think you guys also do is so important.

Kristiina Wilson: 48:09

Um so I think it's very hard often for people to think about that and to really confront the idea that, like, yes, my, my pet is is going to no longer be with me soon, but making a plan for what do I think is is a good passing, and what does that look like and what am I going to do in an emergency? And and just having that all written down so that, as things get closer, there's no panicking, I think is sometimes leave what we call a comfort kit.

Dr Sheilah Robertson: 48:36

We don't, we don't leave controlled drugs in homes, but we can leave, um, something for you know, uh, to sedate if they realize they're in trouble, and um, we can leave things that are sedating, you know, or, or, if they, or if they just aren't ready for euthanasia. But it's close, you know, we can apply like we can give long-acting buprenorphine and some acepromazine to help them, you know, just be calmer before we leave that appointment. And we can leave like acepromazine can go transmucosally and help in cats and we have a lot more options in dogs to, you know, help them stay calm. We've got the pregabalin liquid, we've got gabapentin capsules if they can get them in. But we like to, you know, we sit and say you need to have a plan.

Dr Sheilah Robertson: 49:30

Yeah, If you know, if it's not, if it doesn't go the way you thought it was going to go.

Kristiina Wilson: 49:36

Yeah, and I think, unfortunately life likes to make things go the way that you didn't think it was going to go. I've seen that many times. So having a plan is difficult but, I think, ultimately worthwhile. So I just want to get to a couple of these questions from listeners. One of them was how do vets deal with the constant sadness of the job? So, especially because you're working in, you know a lap of love. How do you? Is that something that you confront? How do you handle that?

Dr Sheilah Robertson: 50:07

Yeah, so the so all of our veterinarians have a huge support group, they have each other, they have a lot of support and it's amazing to me, you know, because a lot of the published literature would say that one of the things that causes compassion, fatigue and burnout and maybe even suicide in veterinarians is you know this because we're euthanizing pets. Well, I would say that the lap of love veterinarians are a very content fulfilled group because they know why they're going to the home.

Dr Sheilah Robertson: 50:50

The people really are very grateful that they're there to help. All the discussion about price and everything's all been discussed before you get to the home. We know the appointments are 45 minutes to an hour, so we find a lot of our veterinarians are very fulfilled and feel a lot, get a lot of professional. I would be doing euthanasias right because people are grateful. So they're not, you know, they're not in a busy practice seeing patients every 10 minutes and then people saying I don't want this test, I want that test.

Dr Sheilah Robertson: 51:25

You're you know, there's none of that yeah stress going on and then they then they pack up and then they drive to another appointment. So it you know they're working on their own and then they drive between appointments so they have a time to decompress. Um, they have a lot of support from their colleagues, so I would say that a lot of them are very fulfilled. Um, and a lot of owners say to them, every time they leave, this must I don't know how you do this every day and they go. You know, it's an honor to be able to do this and I think that's how they genuinely feel.

Kristiina Wilson: 52:07

I think that makes a lot of sense.

Dr Sheilah Robertson: 52:09

Yeah, I mean, I think it would be nice to do a study between people in general practice and people that do all in-home euthanasia and job satisfaction, because I don't believe that it's. It's just the euthanasia and you know that is causing a lot of the issues with people with burnout and so on. It's it's more yeah, in context, I think you know I I do talk to er doctors who are doing these horrendous shifts and they're euthanizing eight pets but a lot of that is the owner didn't have the money to treat, even though and it was cute, you know they could have fixed it, but they didn't have the money.

Dr Sheilah Robertson: 52:51

So it's a young animal, you know, had parvo, you know, and and the vets thinking why didn't you?

Dr Sheilah Robertson: 52:58

you know, and it's just, like yes, whereas this end of life care is is, even though we do sometimes euthanize younger pets because they have bad diseases. It's quite, quite different and it's not that I would say it's a. It's a good job for someone who's maybe a little introverted and just likes to be work autonomously, right there you know. You work from home, you've got your day organized, you get in your car, you do your visits, you do your paperwork, you drive to the next appointment and you've got grateful people a lot of love.

Kristiina Wilson: 53:33

Vets all tell me they've never received so many gifts until they just sure because people are so thankful to them for coming yeah, I would think a huge piece of it is that that the people are self-selecting in right, like the clients are self-selecting in that are really people who love their pets right, which is sometimes something you don't see in in practice, as you see. Like you said, you see clients are self-selecting in that are really people who love their pets right, which is sometimes something you don't see in practice. Like you said, you see people who didn't vaccinate, or you see people who you know. You just see a spectrum of people who can be upsetting in a myriad of ways. And then also you're not feeling devalued, which I think is something that does happen a lot in general practice also with, like, nitpicking about money or nitpicking about whatever, um and I think that leads to so much burnout is just feeling devalued when you're giving. You're in a caregiving role. So another question was how can I entice my hospice kitty to eat?

Kristiina Wilson: 54:28

Oh, wow, oh that's a tough one, I know.

Dr Sheilah Robertson: 54:30

It's like you need a whole other uh guest A whole other podcast on that right, yeah, so I mean I'm going to go with. The most important thing is that you must not force feed a cat that doesn't want to eat. That is the fastest way to break the human animal bond or the cat owner bond, because the cat will. If the cat is feeling nauseous and doesn't want to eat and you are trying to force feed it, they will run away from you. That that breaks the the bond very, very quickly. The other thing is, if a cat really is feeling nauseous and doesn't want to eat and you try and give it like you think oh, it's got to love like the best deli turkey that you know that I went and bought for you they're going to associate that food with being sick. Right, the association is very quick. You all know that if you've ever had food poisoning, you cannot step inside that same restaurant without yes.

Dr Sheilah Robertson: 55:25

Yeah, so that happens. Very, very food aversion happens very, very quickly. So they need help from their veterinarian because we need to find out. Is it because they have chronic kidney disease and they have nausea? And if it's nausea, then we have good medication to give for nausea. Is it that they're vomiting everything up? Then we have good medication, right? We have serenia. We have angiotron.

Dr Sheilah Robertson: 55:50

We've got drugs that can help with that. Is it that they're the picky old chronic kidney disease cat? Then we have two medications right to stimulate or support appetite. We have transdermal metastasis, which owners love because it's not a pill, it's not an injection, you rub it on the ear with a glove on. And then we have capromiralin, which is an appetite stimulant that goes orally.

Dr Sheilah Robertson: 56:18

So there's lots of things we can do, but the key is not to force feed them and not to think that because you went to the deli and bought the most expensive delicious turkey, because they will, you know they're just.

Dr Sheilah Robertson: 56:32

And if you do lay put down food and hope that they voluntarily, if they haven't eaten it within 15 to 20 minutes, pick it up, right, if you are feeling nauseous, are you going to stand in front of the buffet? No, no, you're not. It's going to make you feel worse, you know, because people put out the buffet right, hoping they'll choose something. If it's not gone and they're showing it, just take it away. But one of the things and actually it's being published one of the things that in old cats, if you heat their wet food usually wet food if you heat it to body temperature, they will consume more calories, because a lot of times they can't smell very well, and so that's another thing to check. You know, but a as they age, their sense of smell goes down. But they might also have something, you know, crusty nose or something.

Dr Sheilah Robertson: 57:23

Right Heating heating food is good, and then you know. There is a place for feeding tubes.

Kristiina Wilson: 57:29

Yes, I was going to say that the E-tubes.

Dr Sheilah Robertson: 57:32

And so an E-tubeube I always say sooner rather than later when they're still robust, and it well not robust enough to, because they have to go on dranesease for that, even though it's a quick, good procedure. And the other thing is, once it's in, they can still choose to eat. You don't have to use it, they can be there for if they need more calories, more fluid, whatever. But the other thing is, once the e-tubes in oral medications are not even an issue anymore, right? Because?

Kristiina Wilson: 58:00

they go in the e-tube yep, right.

Dr Sheilah Robertson: 58:02

So that is something is why people opt for the e-tube. Um, if we think this is truly euthanasia and this cat only has, you know, it has no chance of recovery or only has a few days to live, that's a different discussion, right? But you know, I've looked after cats with eTubes, you know well, and my own, my own, for months same, and they can choose to eat or not, you know, if they don't eat, then we need extra hydration, you know is, you know it's a great tool in the right cat with the right disease.

Kristiina Wilson: 58:38

Yeah, it is, and I think a lot of people think that it's this big procedure and that it would be so terrible to have a tube, and the cats really don't seem to mind them Well, not with the new, yeah, not with the new.

Dr Sheilah Robertson: 58:50

You know the little, exactly with the little, the, the little, the little cool collar and yeah, they get cool collars and patterns.

Kristiina Wilson: 58:57

Profile tube yeah it's.

Dr Sheilah Robertson: 58:59

It just requires educate. You know, educating the owner like what can?

Kristiina Wilson: 59:03

go, yes, the tube.

Dr Sheilah Robertson: 59:04

How to prepare the tube, you know yeah so that, but that's all.

Kristiina Wilson: 59:07

I mean that, that's all another story once you've made it it is so E-tubes aren't a terrible thing.

Dr Sheilah Robertson: 59:17

I think there can be a very, very positive thing.

Kristiina Wilson: 59:21

Yeah, I agree. My one cat who was up here in the middle of our discussion. She has GI lymphoma and she's had it for many years and every once in a while she'll have a flare up. That's so bad that she can't't eat because her throat gets so irritated, and so we've had to do an e-tube a few times and she actually she seems to love it. Like she'll get so excited when it's time to like put the food in. She'll just kind of be like, yeah, put it in the tube. Like she's, yeah, she doesn't mind at all.

Dr Sheilah Robertson: 59:48

Like she gets jazzed, so it's if you do everything around that moment with positive reinforcement oh, yeah, exactly. Then you know you're, you're off on a win-win, right right there.

Kristiina Wilson: 1:00:02

Yes. And then the last question was when my cat was nearing his end, his vet was still suggesting treatments. Why would they do that? And I guess this cat did not have cancer. So this person is just wondering why are vets continuing to push treatments on a terminal cat?

Dr Sheilah Robertson: 1:00:19

Yeah, I personally don't understand that, but when I was in academia I would see it a lot with the very young veterinarians. Because the know, as in people, the default is always to treat more, try more, try something else. You know that's the default and luckily we've got amazing people like Atal Gawande you know who's now yes, wrote the book being mortal and medicine and what matters in the end. Saying that you know the default to more and more treatment is what's caused so much suffering in people, especially in the United States. Right, because that's you're going to end up dying with lots of tubes in a hospital, you know, and that's not. You should be able to choose how the end is.

Dr Sheilah Robertson: 1:01:09

So I think a lot of that is that during vet school there needs to be a lot more comprehensive courses on end of life care and difficult, or what I call tender conversations around. You know death and that we cannot cure and fix everything. You know death and that we cannot cure and fix everything, and and often some owners, maybe it is something we could cure but they can't afford the treatment and we must never make them feel guilty about choosing not to treat um because they have budgets right they have a financial budget.

Dr Sheilah Robertson: 1:01:51

They have an emotional budget, they have a time budget to do this. So our goal is to support them through the end. But why so? There are some very, very nice publications on futility of care in veterinary medicine and what the definition of futile care is. And that's just what you've said. And you know, most veterinarians admit that they have actually provided care that they feel is futile and that's because the owner wanted everything to be done.

Dr Sheilah Robertson: 1:02:27

But I think that's where we need to really shore up the veterinary education, in teaching people how to have these um, very, very difficult conversations around death and dying. Um, just as atal goandy has a training system called the um, the difficult medical conversation and you can go and train like how do you tell a patient they're you, you know they have a terminal illness and what we? The data shows that if you're trained in having those conversations, your stress level goes down. Your satisfaction with dealing with the patient goes up. You feel a lot more confident. But the patient benefits they want 100%. For us that it would be the owner, but if it's a human they want to know.

Dr Sheilah Robertson: 1:03:16

you know how long do I have? You know what should I do in the time I have left? So I think we need to work on getting you know robust end of life courses into every veterinary curriculum, and a lot of that's going to be about communication and accepting a person was like you know. I've said I don't want any more treatment and the veterinarian needs to now switch to supporting that decision and helping the owner and the cat or the dog until the end either euthanasia or the end happens.

Kristiina Wilson: 1:03:58

Yeah, I think you're right, I think it's about education, and I think for human doctors and veterinarians it's very difficult to be in a caring, curative profession and then, you know, admitting defeat even though it's not admitting defeat but admitting a natural process is going to happen yeah, I used to say to my um residents, and not just because I taught anesthesia, but to all the residents, because obviously I'm working with medicine and, sorry, I said you know that euthanasia is a treatment option right that can be laid on the table when you're talking to an owner.

Dr Sheilah Robertson: 1:04:33

Yeah, um, because it's always a treatment option in in a very difficult situation or a complex disease. And I always used to tell them I said you know, euthanasia should not be looked at as a failure, but we can fail at performing good euthanasia but it shouldn't yes treatment option. It shouldn't be looked at as a failure and we should be so grateful that, as veterinarians, we have that tool in our toolbox the euthanasia that we can perform euthanasia unlike our medical colleagues.

Kristiina Wilson: 1:05:09

Yes, you are so right and I think that is the perfect note to end on. Okay, so I want to really thank you, Dr Robertson, for taking this time out of your busy schedule to talk with me about this really important issue. I think we covered a lot and I'm really really grateful for your time. So thank you so very much, thank you.

Kristiina Wilson: 1:05:31

Thanks for listening. If you enjoyed today's episode or any of the episodes, please like and give us a rating. Also, feel free to share with your friends. We'd super appreciate it if you shared on social media or really anywhere. For cat behavior consultations go to catitude-adjustmentcom. You can follow us on social media at Hiss and Tell Podcast Music provided by Cat Beats.