Hear beautiful stories about end of life. Dr. Bob and Veterinarian, Liz Fernandez, discuss how there are similarities in their end-of-life work that helps people, pets, and families who are dealing with end-of-life issues.
Note: A Life and Death Conversation is produced for the ear. The optimal experience will come from listening to it. We provide the transcript as a way to easily navigate to a particular section and for those who would like to follow along using the text. We strongly encourage you to listen to the audio which allows you to hear the full emotional impact of the show. A combination of speech recognition software and human transcribers generates transcripts which may contain errors. The corresponding audio should be checked before quoting in print.
Dr. Bob: Liz Fernandez is a doctor who makes house calls. She gets to know her patients and families intimately, and she frequently provides counsel and guidance as her patients head toward the natural end of their lives. In many circumstances, she lovingly administers medication through an IV that allows her patients to fall asleep and die peacefully usually in the arms of their loved ones.
What Dr. Fernandez does is legal and acceptable because she’s a doctor of veterinarian medicine and her patients are mostly dogs and cats. Although I don’t perform euthanasia which is illegal in this country, I am with many patients as they die peacefully after self-ingesting medication that allows them to have a quick and peaceful death. In many respects, Dr. Fernandez’s practice is very similar to mine. We both drive all over the place to make house calls, we both develop very intimate relationships with our patients and families, and we both help to guide and counsel as our patients approach the natural end of their lives.
In this episode, we share some of the beautiful and some of the challenging experiences that we’ve had, and we discuss how it affects us to be in these emotionally complex circumstances so often. I hope you find it interesting, informative, and meaningful in some way.
Liz, thanks for coming on the show, and I’m looking forward to having you share some of your insights from your really fascinating career. Can you just share with me a little bit what is it like? You have a unique model of practice for a vet, and what’s a typical day or typical few days for you?
Liz Fernandez: I practice in Ventura County. I work with small animals, and I do house calls, and most of what I do is Chinese medicine acupuncture, so most of my clients, my patients are older. I may see anywhere between three to six patients a day, and I drive all over the county. Sometimes I keep it localized in a smaller area, but my radius is about 60 miles from my house so it could be anywhere in that to give you an idea. Yes, I drive about 30,000 miles a year-
Dr. Bob: Which is kind of similar to me. It sounds like your work is in many ways similar to mine; going out and meeting with older patients and addressing the concerns that they and their families have and supporting them.
Liz Fernandez: Right, and so I have … Since I see them … I see them. I’ll spend an hour or so. Each appointment is about an hour unless it’s an initial appointment and it’s usually about two hours. I may be seeing them once a week, or once every other week, or once a month, so I get to know the clients quite well and as their animals, either dogs or cats, for the most part, start to age and get near to that point when they’re going to have to make some decision, we’ve already had probably at least a few discussions if not more; just some in general and some more specific. It’s nice because I do have that connection already with most of the clients that I work with, and that makes it a lot easier to move into that idea of now we may not be trying to get them better, we’re just trying to keep them comfortable.
Dr. Bob: Got it. So you have the conversations ideally upstream about what will happen when things change, and you’re looking now at a comfort-focused end of life scenario. It’s interesting because you have an option to help create a very peaceful end of life for your patients that we don’t necessarily have. Not necessarily have, we don’t have. We don’t have euthanasia. It’s not legal; it’s not available. Fortunately in California now we do have the medical aid in dying through the end of life option app, so there is another conversation that can happen when people are open to it, but everybody is aware that euthanasia is a viable and acceptable option at the end of an animal’s life.
Liz Fernandez: Yeah, and I find it fascinating because with the animals, we almost more often than not, people demand it for a multitude of reasons; the most common being, “I don’t want my pet to suffer.” That I totally understand and I agree with, and I support them in those decisions. It’s just fascinating that … And part of it I guess is with people we have more options in terms of supportive care to keep people comfortable and just have somebody there 24/7. That’s pretty very challenging for most people.I have had clients that have the ability to have somebody with their pet 24/7 offer doing whatever it is that they need to have done in a home situation. It’s not like they’re putting him in the hospital or something and not being with them, it’s just that they can manage all of those little things like if they can’t get up from by themselves that somebody can take them and help them to get up and go outside and if they’re not continent then they can take care of that in terms of changing the bedding and that sort of thing in helping them.But that’s not the norm. For most people, it’s just not an option. What do you do if you can’t be there or if don’t know someone who can be there or afford to pay someone to be there, what do you do? This other option is available especially when there’s no hope of improvement. And so that’s what happens.
Dr. Bob: It’s interesting to think about those scenarios because it’s just natural to make the comparisons, right? This is between people and animals, and if you have a person who needs care to manage their ADLs because they can’t get up by themselves, they can’t clean themselves. That’s not enough to justify having their life end. For some people, it may be that the complexities of creating care-
Liz Fernandez: The other part of that is that a lot of times, it’s emotional least distressful for the clients because they realize their own limitations whether that be physical, emotional, financial. All of those things factor in, and so they wind up making a decision because not that they think it’s what is necessary that the animal is that near to death that that’s what is appropriate, but because the entire situation is such that they can’t handle it.
If you have an 85-year-old woman who’s got 100-pound dog and she doesn’t have anybody else to help or take care of it, she may be healthy within herself, but to be able to meet all the needs of a big dog-
Dr. Bob: That’s dangerous.
Liz Fernandez: Yeah, it’s dangerous. Or even somebody who’s 50, but they have a bad back.
Dr. Bob: That part like knowing that the dog is not or the animal is not necessarily imminent, that close to death, or maybe it’s not even suffering that much, right? It may not be in pain, it may just have these limitations, and if the family was able to meet those needs even though the dog is not living its ideal life like a human being who’s 90-
Liz Fernandez: Right. A lot of people feel like if they can’t get up if they can’t do those things, that they are suffering, that it is not a life that they would want, so there is that. I would say that with most of my clients they do a really good job of trying to make things work, but on the other hand, most of them have co-morbidities that are … Like if their back legs aren’t working anymore, there’s a good chance that they probably have some other issues going on whether that be kidney disease or sometimes some underlying, whether it’s cancer or heart disease or other things that make it even more challenging. I honestly can say that I don’t find myself in situations where I feel that it’s inappropriate.
Dr. Bob: Well, imagine if you did then you would find other solution.
Liz Fernandez: Exactly. I mean, we each have to do what we feel in our heart is right or for us, but I also try and tell people that there’s not necessarily an objective right or wrong. There’s a right or wrong for you in this moment, but not necessarily a right or wrong that is somewhere posted in a book somewhere that says that this is the way you have to proceed. Because we have to be honest and compassionate with ourselves as well as in the whole situation.
Dr. Bob: Well, I read your book Sacred Gifts of a Short Life: Uncovering the Wisdom of Our Pets End of Life Journeys, and it’s really touching, it’s really well done and smart.
Liz Fernandez: Thank you.
Dr. Bob: It was great stories and as I’m reading it, I so often I’m finding corollaries to my life and my practice and my thought processes. One of the things that was really poignant for me is your … One of the stories, I think it comes up a number of times when people ask how they’ll know when it’s the right time. For me being a physician who assists some patients through medical aid in dying, there are times when people get a prescription for a life-ending medication, and one of the big questions that they have and that their families have is when will I know it’s time? When will I know that it’s the time to take this?
What their experience or if they’re struggling to go through is what your families are dealing with. The difference, I guess the difference in my situation with human beings is that they’re the ones making these decisions for themselves, no one can make it for them. And they recognize that when they do take this medication, they may be robbing themselves or … They’re clearly shortening their life, but they may be robbing themselves of some relatively reasonable time, and they don’t know. There’s no way to absolutely predict what the future is going to hold and sometimes they’ll be inclined to take the medication sooner because they’re afraid that things will change and they’ll lose their ability. They’ll lose their mental ability, the physical ability, so there’s this back and forth dialogue they have with themselves and questioning.
Almost every single time, I’ve told them, “You’ll know when it’s time. No one’s going to tell you it’s time. You’re going to know, and when you know it, you know it. There’s been a couple of people out of the many dozen who I have been with who have still been slightly, slightly, hesitant, reluctant questioning it and even to the last hours. What I recognize is those people are the ones who have younger children. No matter what they do, separating any moment sooner than they absolutely have to is a challenge. Those are the ones that tend to be a struggle. But like you said, they know when it’s time, sounds like your families come to a place where they just know now is the time.
Liz Fernandez: Yeah, and I have definitely tried to work with people and something that I do talk about in the book as far as just … Because even in our profession we have a tendency to, and as a profession, this is so, and I have tried to steer away from this, but we’re the ones that like to tell people when it’s time, and people like us to tell them oftentimes. What I have found throughout my career is that if there is not complete 100% choice that’s made by the person who’s involved with the pet, then they sometimes feel guilty, feel pushed, feel resentful that someone else told them that they needed to do something when they weren’t ready. I try to avoid that and make sure that they are comfortable and that they are listening to that place within themselves that we each have that I think it’s so important not just to listen in this situation but throughout our lives, that we start listening to that, that we begin to trust it, and then we can act on it.
This is a situation that really invites us to do this in a wholehearted way, and if we have practice doing that throughout our lives, it becomes much easier. What I ask people to do is to try and get very quiet and feel into their body and have someone else perhaps even present with them and feel into their body with the idea that, “I’m going to euthanize my pet today,” and then just feel what happens to them. The person who’s with them can watch whether there’s a tenseness that happens, whether there’s a clenching or a contraction, or if there’s a relaxation and opening up because the body is reacting to the deepest truth.
I think that can be very helpful. I had had a couple of situations where I’ve been with somebody as we move through that process and I’ve reflected to them what I have seen, and in one situation I said when you get your poll body relaxed when you thought about just going ahead and letting Sophie go today. Then we talked a little bit longer because it didn’t seem like she was ready to go ahead with that. But what I told her and what we talked about was that it really was okay that she felt that way. That it was getting really challenging and very difficult to take care of her. When she actually accepted the idea, so her body was just asking, inviting her to become okay with that as a possibility, and recognizing it and forgiving herself for having that feeling, for feeling like I can’t do this another day. And yet there were some things that we could try, and we wound up trying them.
And then would about two weeks later, things have deteriorated further, and she was very clear, and she had no question. But what her body actually was doing when she relaxed was not saying that it needed to happen today as much as it was saying that she needed to accept that as a possibility and that it was okay that she felt the way she did. Once she became okay with this feeling that, “I can’t do it anymore,” she actually found the strength to be able to go on a little longer. But he had to accept that within himself first. Very interesting. And the opposite happened. Both of these situations happened within probably two or three months of each other, and the other situation was that the lady just did not want to euthanize her pet. And she knew. I mean, there were all sorts of signs from the universe, and from her husband, and her husband had a dream, and all of these different things and she just knew, and he was really not doing well, but she just couldn’t let go.
I said to her because again when we went through the process, not doing it is what gave her the most relaxation in her body. And I said, okay. Consciously and in her brain, I said, “Be okay with that. It’s okay that you can’t do it today. Because sooner or later if you don’t do it for him, he’s going to do it himself.” And he’s not really suffering; he was just in a point of not really eating anymore, but just not moving. You know what I mean? He wasn’t in any kind of excruciating pain that we needed to address or anything. And once she could finally just say to herself that it was okay, she could forgive yourself for not being able to do what she really felt was the best interest of her pet. Because she just loved him so much and just, it’s like … When she completely surrendered to that, she sat with him for a few minutes and then she said, “Let’s go ahead.”
Dr. Bob: It’s beautiful.
Liz Fernandez: Yeah, it’s quite fascinating, but again if you start to listen deeply and can accept whatever happens or whatever wants to happen and trust it, then I think that we do have the answers within ourselves to make these difficult decisions.
Dr. Bob: Actually I appreciate that you shared that. Because on a couple of levels, I think what you’re sharing is so vitally important. On the one hand, I think that’s what we need. Everybody needs … Moving to the human realm, we all need to be able to go deep inside and become comfortable with the idea that one day we’re going to die.
Liz Fernandez: Yes, just have a good relationship with death.Dr. Bob: Yes. And not to say, “Okay, I’m ready to die.” Not to say that I’ve got everything prepared or that emotionally, financially, legally, or whatever. But to just understand and feel this sense of acceptance and a sense of calm about it, and if you can’t get there, then the work needs to revolve around figuring out why what is it that’s keeping you from feeling that sense of acceptance or calm about it. But once you can get there, then everything is a bit easier, I think it’s brighter, a little bit more … It’s almost like it’s bonus time. Now I’ve accepted this; there’s my ultimate endpoint, now let’s get on with life.
Liz Fernandez: Right. Part of why I wrote the book was not only just for clients, but for practitioners and then just the general public. Because the whole idea is what my book tries to talk about and what I’m passionate about is just that. It’s the idea of having a relationship with death that makes it less scary. Be able to embrace it, to dance with it, to recognize it everywhere. Things are dying all the time. We push it away so much we deny even the idea. No one wants to say the word. It becomes this big scary boogeyman and the big monster under the bed.
Dr. Bob: It does not have to be that way.
Liz Fernandez: That’s a cultural thing. It’s like can we just start just have a keep the conversation going.
Dr. Bob: And I think we are. I mean, that’s part of what we’re doing, right? That’s why we have this … That’s why I have a life and death conversation. There are people like us who are not only comfortable talking about it but shine when we’re talking about it. Because it’s like being part of a club where you understand where this is coming from, where this conversation comes from. Not because we’re morbid or want to talk about dying or don’t love life, it’s because we do love life. And we love life enough to say, “And one day this is going to end.” And that’s going to be okay too because that’s We can maybe by doing this, by having these conversations and people listen to it and they think, “Wow, that’s an interesting way of looking at it.”
Liz Fernandez: Broadening the perspectives because there is a sacredness to it. There is this deep sense of … I mean, it pulls us into silence. I had the opportunity a couple of weeks ago to speak to a group of high school students who are interested in veterinarian medicine, and this is the topic we talked about. We talked about … I just described the state that one gets into when one watches a sunset, and you’re just completely present. That’s kind of what meditation is, but it’s also what happens when we are communing with death if you will. I mean, if we’re present with someone who’s dying, and that silence, it’s just so full. There’s so much life and love there.
Dr. Bob: And sadness, right? There’s loss, there’s all of it, but it’s the whole continuum.
Liz Fernandez: It’s all of it, exactly. And that’s the other thing that I try and really focus on. It’s the idea that it’s not either or. You don’t have to deny anything. You don’t have to deny that you feel devastated or just horrible for whatever the experience is, and at the same time at some point, everyone who’s ever gone through a grieving process knows that there is this … All of a sudden flash will get in your head, and you’ll start smiling and laughing when you’re thinking of this person who you miss so dearly. You’re feeling it all. That’s what I mean I think it’s important. That we allow ourselves to feel all of that. It’s like clouds. They come, and they go, and your feelings and your emotions are going to be all over the map as part of the grieving process.
One of the [inaudible 00:26:09], a friend of mine recently who passed away. She was very aware, and she lived so fully. I have another client whose dog is … They called me a month ago thinking it was time and it’s not yet, and they’re just kind of writing with it. The idea to be able to live fully knowing very clearly because you have a terminal diagnosis, that your time is very limited, is … I’ve seen only either in animals because they don’t get all hung up, but in people, those that have really, really accepted the idea, they’re older, and they can live like you said, very fully because of that.
Dr. Bob: Yeah. For me that’s a big part of my mission, and it sounds like of yours, is to create this comfort to allow the loved ones who are part of this experience to have it be as peaceful and potentially transformative as possible, so they can go on the rest of their lives feeling a sense of peace about it, feeling a sense that they did everything right, that they did the best possible in support of their loved one. Yes, it’s important to make it comfortable for the person who’s dying and to reduce the fear and to reduce the struggle, but so much the loved ones go on for years or decades having to carry that experience with them. It’s a beautiful experience if it has been well explained and accepted, and the processing has been allowed to happen, it can be amazing what it opens up for them or allows them to experience.
Which is why it’s so it’s so unfortunate and challenging one when people die suddenly. Or animals when death happens suddenly, and people haven’t been able to prepare. You know what my solution for that is? Always be prepared. I think about that. I was in [inaudible 00:28:38] for 20 plus years. From early on in my career and in my adulthood, it became very clear to me how quickly things could change, how random things were, and so I guess I got comfortable with this idea that I could be just removed from life instantly or traumatized.
I made a very conscious decision to tell people what I wanted them to know. To not leave things hanging. I’m almost to the point where my kids when I would leave the house they, “I know dad, I know you love me. I know. Okay.” We have to hug again, and …
Liz Fernandez: They say when they’re 13, right?
Dr. Bob: Yeah, but I don’t care. This is my thing.
Liz Fernandez: They will appreciate it.
Dr. Bob: Let’s hope so.
Liz Fernandez: No, I absolutely agree. That is hard when people leave us suddenly. It is wise to be really authentic in your feelings and leave things … What makes your people know. I have always done the same. It’s like, is there anything I need to say to anybody that I know? I try and do that.Dr. Bob: Well, who knows. Maybe this is just a reminder for somebody just to do it a little bit more. I feel like people who … Well, anyone who has a pet certainly, or anybody who is interested in exploring the experiences in the mind and insights of someone like you who’s around death on a daily bases would benefit from getting a hold of your book. We’ll put a link to the book on our website, which is integratedmdcare.com. Once this episode airs, then it will be available.
I thought it was wonderful. I gained a lot of insights out of it. I’m sure many other people have as well.
Liz Fernandez: Well, great. I am so pleased to hear that and thank you for offering to put it on the website.
Dr. Bob: Well, Liz, thank you again for taking the time out of your day.
Liz Fernandez: And thank you. I really appreciate it. All right.
Dr. Bob: All right. Thanks, everyone for tuning in. We’ll talk to you soon.