Pets in Palliative Care

Abstract

Although human interaction with domesticated animals has existed since time immemorial, it has recently been in the spotlight to make it a candidate for improving health. This is a chapter dedicated to reflecting on what characteristics of the human-pet nexus can constitute new and better ways to care for patients in palliative care. We review basic concepts in animal-assisted interventions and therapies and reflect on the characteristics of pets that serve to incorporate palliative care integrally into health. Observations and recommendations are mentioned to be considered in future studies.

1. Introduction

The reason for writing this chapter is to analyze what role the human-animal relationship plays in palliative care. In these pages, we will review the different roles that animals occupy and the different ways in which pets can be seen from the point of view of palliative care.

First, one could ask, “What do pets have to do with Palliative Care?”

Palliative care as a philosophy has existed since humanity became aware of the importance of caring for a vulnerable partner, attending to the sick or helpless with dignity, and accompanying the terminally ill in solidarity with them through the process of dying.

Later, palliative care as a discipline in the field of health was objectified to ensure the interdisciplinary quality of life of human beings affected by diseases for which there is no cure, considering physical, psychic, social, and spiritual contexts, while at the same time addressing pain and other symptoms that cause severe suffering in the health system.

I will review what things in this human-animal nexus can be instruments in palliative care. The writer is a pediatrician who is in daily contact with patients in palliative care and who approached the world of therapies assisted by dogs rescued from the street that now keep company with patients and staff in palliative care.

2. Background

2.1 The relationship of humans with animals

The hominid species, by virtue of its superior brain power owing to the shape of the skull, evolved towards ever more sophisticated neural functions. Among many other abilities, humans can organize thoughts and share them with others.

Pets, which are the subject of this chapter, also have a level of neural sophistication. Phylogenetic characteristics and instinct, among other factors, brought dogs, cats, and other species into domestication [1]. The ability of pets to survive, coupled with their innate ability to learn, led humanity to regard dogs, cats, and the like as life partners.

The search for food, shelter, and companionship, which are merely basic biological functions, are particularly similar in mammals. Evolution, seen as a dynamic process, would sooner or later make humans and their pets co-workers.

In recent years, attempts have been made to include pets in the solution of health issues [2].

The integration of animals to solve health problems is a concept that today offers both opportunities and challenges. The One Health concept recognizes the link between animals and human beings in the same survival environment [3].

2.2 The dog and the human

Interactions between companion dogs and humans date back to the Ancient Neolithic period. Dogs were the first domesticated animals [4].

The dog in particular for its physical capabilities (its smell allows it to snoop and search with purpose; its muscular strength allows it to fight to defend its territory) and neuronal (ability to learn and distinguish) can be trained for the benefit of human work from the beginning of man-animal coexistence. In today’s times, man should also think about updating the defense of the quality of life of our animal co-workers.

For the ancient Egyptians, it was the god Anubis, a companion of souls and bodies during their passage to the afterlife. In this civilization, they gave the divine characteristic to the qualities of companionship, protection, and fidelity that the dog has [5]. The deity who watches over health, the healing of diseases, funeral honors, and life beyond death has the head of a jackal.

2.3 Horses as healers

Since the Pleistocene, horses and humans have worked together, in transportation and cargo, in hunting and in war, in sport, in the commonplace of life, and in occasions of greatness.

Now let’s fast forward in time to ancient Greece, the time of Plato, where long horseback rides were used to heal people suffering from incurable diseases to lift their spirits and restore their self-esteem [6].

The latter confirms what modern equine therapists know that the horse is a creature that is evolutionarily sensitive to the sensations of other living beings, captures the entire range of emotions, perceives different moods, and is capable of communicating with the other being [7].

2.4 Cat ownership and its effect on the health of the most vulnerable patients

Owning pets, specifically cats, is related to a decrease in stress levels and secondarily to a decrease in the risk of strokes. Cat purring can be a factor that lowers blood pressure, and catecholamine levels, and facilitates relaxation in humans. This may have an evolutionary explanation because purring is part of the natural sounds that cats produce to communicate that they are happy [8].

Cats require relatively less care than dogs or horses, they do not need to be taken for a walk, their size makes them fit on the lap, and they are agile, which makes them a good candidate to accompany an elderly person, someone who is ill, or a child.

With the company of the cat, the human being in a state of vulnerability and who feels alone learns to accept the other as they are. The cat is an animal that does not make value judgments when it seeks company, and this makes its presence special.

In palliative care, we find a universe of patients who feel alone, are marginalized, and for whom communication with their fellow human beings is difficult or impossible. Some examples are advanced dementia, degenerative neurological diseases, frail elderly people, and children with seizures or problems that affect their behavior and socialization. In these cases, the cat, as a companion animal, offers its tameness, its ease of care, and its portability.

2.5 The birth of animal-assisted goal- oriented Interventions with animal

Biophilia: Product of evolution and development that proposes that human beings deserve to affiliate with other forms of life [9].

Vernooij did an analysis of Human-Animal Interactions (HAI) following psychoanalytic theory and conceptualized that the function of the animal is to identify, protect, motivate, and serve as a catalyst in cases where humans encounter emotions that are difficult to handle [10].

When the initiative arose among the different associations interested in promoting the concept of visualizing animals as part of the range of therapies that should be at the service of health, it became clear that they should work on the definitions [11, 12].

Animal-Assisted Interventions (AAI) are interventions structured to achieve a goal, in which a service animal is intentionally incorporated. Achievements can be in the fields of health, education, social, or any area that promotes the improvement of life. The AAI is subdivided into three categories [13]:

Animal-Assisted Therapy (AAT) are structured intervention whose purpose is to achieve recovery, rehabilitation, or improvement of a health problem by increasing the patient’s quality of life through the intervention of a professional human and animal team and includes documentation and acting in the management of this health achievement.

Animal-Assisted Education (AAE): these are activities whose objective is to achieve the acquisition of knowledge or skills that can be used in the service. The achievement that uses the presence or interaction of animals.

Animal-Assisted Activities (AAA): unlike the previous ones, they are informal activities. They have in their favor spontaneity in achieving achievements under the condition of pleasure in the company of an animal.

Pet therapy: It is synonymous with AAI. Which pets are used when defining pet therapy? It usually refers to the following species [14] (although they are not the only ones) the dog (Canis familiaris), the cat (Felis catus), the rabbit (Oryctolagus cuniculus), the horse (Equus caballus), and the donkey (Equus asinus). There are experiences with dolphins and birds used for AAI, but for the purpose of this article, we will discuss dogs, cats, and horses.

2.6 The one health concept

Before analyzing what role, animals play with people in palliative care; we will take a pause to discuss the One Health concept.

The One Health concept identifies the human-animal bond as a way to improve mental and physical well-being. The AAI is a set of interventions that incorporate a human-animal team whose objective is to contribute to the health of the patient (IAHAIO.IAHAION White paper). One Health proposes that the work of the human therapist with the animal therapist for global quality of life is a low-cost wellness alternative in this world where procedures to augment health are expensive. Thus, the relationship can result in sustainable benefits in time [15].

However, due to the recent arrival of animal-assisted interventions (AAI) in the health field, it is a subject of study. A determination must be made as to the true reasons why animals can cooperate with the healing process. Specifically, what type of patients will they best serve and what is the best way to integrate them into conventional therapies to provide advantages for both parties? The novel issue is to study how and why the presence of the animal can be in some ways beneficial for the recovery of people’s health. This is how AAI emerged as a subject of study, protocolization, indications, and contraindications. In short, to discover if it fits into all the categories that other treatments do [16].

The advantages provided by the presence of an animal in an AAI are mental, physiological, social, and neurological, and probably modulated by a common neurological pathway that involves emotion, memory, reward, and affiliation. That is connected to the production of oxytocin in both the animal and the person [17]. Researchers are looking for the common factors that should be investigated to try to reach conclusions in a standardized and repeatable way.

2.7 Pets in palliative care: the topic of this chapter

Palliative care, given its holistic approach, with the help of pharmacology to treat symptoms, makes use of therapies that have a lot to do with psychological and personal well-being, drawing from disciplines such as mental health and social sciences [18].

The early contributions from parts of the medical community such as nursing, psychology, and social work, from the moment of diagnosis of an incurable disease result in improvement of the quality of life and initiate the healing process.

In addition to sciences such as physiotherapy, respiratory therapy, occupational therapy, and sensory conductive psychological therapy, there are alternative therapies such as music therapy, meditation, mindfulness, art therapy, and what is featured in this chapter, a therapy in which animals participate.

Let’s look at some properties of our relationship with pets that help us incorporate the philosophy of palliative care into health care.

2.8 Pets as significant beings

Living with pets allows us to better understand the nature of all beings, and our pets provide us with significant life lessons. Many of us have memories of our years of raising a pet, which endured the passage of time.

As part of the education of children in the principles of behavior, fables are used in which the protagonists are animals. This makes animals wise and special beings within the teaching and understanding of existence.

Many times, in my experience as a pediatric and palliative oncologist, hospitalized patients have wished to return home for the company of their family, and that includes pets. For a patient who is going through a process of resilience, a pet accompanying them can be a factor that increases resilience. A beloved dog or cat, unconditionally giving affection, is a source of joy for a patient.

It is worth mentioning that, in the survey on which palliative care professionals base our management plans, we consider family members and significant pets; a fact that makes a difference in the management of the emotional, mental, and social aspects of the families we serve.

Animals have had symbolic meaning in different times and cultures, as we have seen.

Those of us who work with patients in palliative care might inject into our conversations with them narratives featuring animals that are enshrined in personal beliefs, in the current social reality, or in traditions.

For example, to explain to a child the different stages of life, we often refer to dogs that started as puppies and then grew up. In fact, the rapid reproductive cycle of rodents used as pets, such as hamsters, illustrates to children the dynamics of life in just a few weeks. Spiritual themes closely linked to palliative care are illustrated with natural metaphors, such as the metamorphosis of butterflies.

An event that recently occurred in Colombia [19] in the aftermath of a plane crash, in which children survived in the jungle. An army dog that put the search teams on alert played a fundamental role in the rescue. Fortunately, the children were found alive, but the Belgian shepherd was never found. With a moving story, the aborigines who are natives of that Guaviare jungle explained the loss of the dog according to their aboriginal worldview: “the dog’s being is really a warrior guardian and he has gone with his mission accomplished”. This ancient narrative relates to what often helps us as palliative care professionals and that is to reach the most symbolic part of our patients.

2.9 Pets as a reason to reflect physically psychically and spiritually

A wound or infection heals because the living organism has the ability to regenerate. And health science practitioners give the best of themselves to initiate or facilitate this process. Healing in palliative care is more than a physical process. Complete healing includes awareness of vulnerability, resilience in the face of adversity, and the realization that we all value our inner selves above our material body.

Experiences that have left their mark on the psyche also help this process of healing in palliative care. Also, of such great importance are relationships with other beings that have contributed to our lives; our human and animal companions.

The presence of a pet has healing value in that it can lower blood pressure and alleviate glycemia. Also, a pet that remains sitting next to the bed of a sick person is company, love, and presence. In a word, it is healing.

The concept of the “Wounded Healer”, is one in which every person who works caring for the sick, through their lived experience as a human being and their compassionate companionship, can help a patient who cares, to find their own healing. This is both a spiritual and a scientific concept.

Animals can also be “wounded healers”. I remember a teenage amputee whose company was her amputee dog.

An article by a medical colleague entitled “The Death of My Dog: Lessons Learned from the Palliative Care of an Animal” reminded me that I had learned a lot from my own experience of the death of my cat, Ursula. She suffered seizures at the end of her life. Because of my beloved pet, I have a better understanding of the subject of the approach to death of patients with terminal neurological disease, such as the author says in his reflections about his canine friend [20].

2.10 Could pets sense when death is near?

There are numerous cases in which a cat or dog literally detects death through its sense of smell. In the well-studied and described case of the cat Oscar, it is hypothesized that the feline, due to its natural sensitivity to changes in body temperature, “predicted” with better than clinical accuracy, which patient had a few hours left to live, and this was useful to the hospital/hospice staff in complying with getting notices to family members [21]. The case of Oscar is well known, a cat who lived in a hospice and who took long naps next to the beds of patients who were in their final hours of life. This phenomenon was observed and described by the hospice geriatrician and was the subject of a medical article in the New England Journal of Medicine [22].

After repeated and methodical observations, the hypothesis was raised that the feline could perceive the lack of heat in the patient’s body and thus know that death was near. The cat’s approach to the human being, as if it were its feline way of giving palliative care and individualized attention to those for whom the end was near, was the subject of an episode of the series “Dr. House” (18th episode of the 5th season) [23].

In any case, Oscar the hospice cat gave rise to serious medical discussions about the role of an animal in the search for high-quality palliative care.

Ethology, which is a part of zoology that studies animal behavior and its relationship with biological evolution, may have an explanation for that pet’s uncanny ability. During the evolution of the species, canids and felines developed their sense of smell not only for hunting, reproduction, and survival but also as a way to detect which member of the pack was weak or sick.

The mammalian sense of smell can perceive ketones, which are biochemically derived from cells undergoing cell death.

2.11 Do dogs have a place in palliative care?

A dog that serves as a stimulus to perform therapy is not only a therapeutic incentive but a healing presence. There are physiological benefits for humans in interaction with dogs: it decreases the level of stress and blood pressure, and in diabetic children, the blood sugar level. In the field of mental health, it has been found that pet ownership is related to decreased stress levels in owners especially if they take them for walks and engage in physical activity.

At a time when the world was under the effects of the pandemic, interesting experiences were published such as an article based on observations in rural populations of Sri Lanka, where it was observed that dog ownership is related to family behaviors that promote their health and that of their communities [24]. Rathish et al. conclude that it is essential to have background information on the effects of a pet dog on personal and family health to implement One Health via human-animal interaction.

Despite the benefits, biosecurity and infection prevention precautions must be ensured in all interventions involving animals. In addition, there is much to study in terms of the characteristics of patients that can actually benefit (Dalton, 2022) [25]. At the forefront of these challenges is the concern for potential exposure to and spread of infectious disease agents, which was particularly relevant during the COVID-19 pandemic.

Human–dog interaction improves the mental well-being of participants as suggested by [26]. Prefrontal brain activation in healthy subjects increased with the rise in interaction and closeness with a dog. In their controlled trial, the observations suggest that interactions with a dog can activate stronger attentional processes in palliative care with animals.

More and more experiences are published in terms of animal-assisted therapy. Diabetes, post-traumatic stress, physical and emotional rehabilitation, and Alzheimer’s are some pathologies with published articles in which the benefits of the presence of pets during therapy are evaluated. However, it is still a challenge to see a pet as a member of the palliative care team.

Palliative care units for symptom control have modified their policies so that significant beings for patients, including pets, can spend time with them, yielding improved quality of care, improvement in the patient’s functionality scale in palliative care, and significantly better results on the Edmonton Symptom Assessment [27].

Schmitz et al., nursing professionals, published a publication on patients with advanced and incurable diseases in Dusseldorf at the Center for Palliative Medicine of the University of Dusseldorf [28].

In June 2014 at the Interdisciplinary Centre for Palliative Medicine of the University Hospital Dusseldorf, they performed animal-assisted therapy sessions and to date only very limited scientific data is available. In the field of Palliative Care, future research should focus on its possible benefits. In this study they described AAT in the company of dogs, recalling the writings of Florence Nightingale who wrote in her Nursing Notes that a small pet was excellent company for a chronically and long-ill patient (Nightingale) [29].

The indications for AAT were: severe tension, adjustment disorder, depression, demoralization syndrome, terminal delirium, and anxiety of fear. The AAT was determined by the doctor, or by the psycho-oncologist. Contraindications were patients allergic to animals, fear of the animal, or severe psychological distress (Table 1).

1. Greeting of the Patient

2. Introducing the dog and motivational conversation. Opportunity to observe dog

3. Patient-dog activities: games, giving treats, physical activities

4. Farewell ritual, arranging for another therapy

Table 1.

The content of the AAT was.

In the observations, it was notable that during the observation of the therapy dog, when they verbalized, they showed mirrored behavior and some individuals reflected their own emotions.

The most observed achievement in well-being was achieving relaxation, inducing an environment of good humor, and increasing the patient’s rapport by allowing him/her to pet the dog. The authors make a recommendation for future studies to better formulate therapeutic indications and also to video record the sessions for monitoring purposes.

Since March 2020, the world of health services has experienced changes in the way it provides its services. There was an experience in Panama to be published as a poster in the SIOP Congress, that focused on the role a dog’s company could have during the pediatric palliative care home visit [30].

The team visited pediatric patients in their homes during the COVID-19 pandemic. Two female dogs rescued from the street and rehabilitated, who were the pediatrician’s pets, were incorporated into the team that made the visits. The author observed that the pets entertained patients and family members, facilitated the spontaneity of conversation, and let two dogs, one per visit, accompany them to the patients’ home. The observations were documented in order to make a list of activities that would make these visits an organized health service.

There was 99% compliance with routine activities programmed by the basic team, which were:

• Examine the child-patient

• Talk to the caregiver about the child’s activities, health issues, or caregiving education

• Do procedures that do not require anesthesia at the patient’s bedside

• Collect emotions and mental state of the patient and family members at home

This experience concludes that when visiting a child who is severely ill with a terminal illness, the presence of properly trained pets within the health team adds novelty to the family environment, can contribute to rapport between the team and the family, and can even promote an environment for conversation. On palliative care issues such as disease progression, limitation of efforts, and grief for the loss, since the animal fulfills its role as a catalyst, and while the pet is accompanying the child; the other members of the team may be interacting with the animals. Caregivers.

A detailed work from the Barretos Hospital in São Paulo, Brazil gives us details about the characteristics of the animal and specific care, it also mentions some cases in which this therapy is not indicated [31].

2.12 Characteristics of therapy animal

1. Docile in character and trained in obedience and socialization

2. That it has approval given by a veterinary professional and/or trainer

3. Have your vaccination and deforming card up to date

4. Have a bi-annual laboratory examination (hematological and biochemical) reviewed by a veterinarian

5. That it is a pet in good nutritional status and that it eats only animal food

The handler must have AAI training (Table 2).

Stress, fatigue, agression

Estrus

Immunodepression

Infections

Open wounds

Episodes of diarrhea and/or vomiting

Fecal or urinary incontinence

Table 2.

Rule out the following circumstances in the animal.

2.13 Basic requirements for AAI

1. If present, contact a veterinarian and suspend contact with patients until the veterinary authority orders it.

2. The animal should not enter the kitchen or areas where food is prepared.

3. 24 hours before the presence of the animal in the AAI, it must: bathe, brush, groom, and cut nails, approval of the absence of ticks, fleas, lice, and other ectoparasites. Their paws will be disinfected with 70% alcohol before and after the session (Tables 3 and 4).

Regarding which patients should not be visited by an animal, and therefore would not benefit from AAI

1. Patients with isolation precautions

2. Patients with complications of surgical wounds

3. Patients with ostomies

4. Patients with neutropenia of 1000/mm^3 with the possibility of dropping even further

5. Patients who are scheduled for surgery in the next week

6. Patients with sepsis or severe infection

7. Patients with the presence of resistant bacteria

Table 3.

The human-animal team must comply with biosafety standards.

1. Patients who verbally do not want the presence of animals or are scared and have expressed this in the presence of an animal

2. Patients with severe mental disorders can cause stress or harm to the animal and this could trigger unfortunate situations

3. Allergies to animals

Table 4.

Other exclusion categories include.

2.14 The presence of animals that assist in therapy not only benefits patients, but health personnel, as well

A study held at the Central Military Hospital in the Czech Republic observed nursing staff that had the opportunity to play, feed, or give water to a dog that was already working as a therapeutic pet in the long-stay ward and in the internal medicine room.

Salivary cortical levels and perception of stress were measured and it was observed that both showed a decrease with a single intervention. The recommendation is to consider including the interaction of health personnel with animals as a means of mitigating the consequences of work stress [32].

2.15 Equine therapy: how it helps patients live better

There are some basic concepts of equine therapy that are important in the field of chronic patient health.

Equine therapy or equestrian therapy is the set of treatments aimed at improving the quality of life of people suffering from some type of disability that affects their motor, cognitive, and emotional function. In this type of therapy, horses intervene as directed by health professionals or equinotherapists to apply the natural qualities of horses to help the patient regain their health [33].

Horse riding is an activity that requires neuromuscular coordination. The horse’s back in contact with the pelvis, and its components, the lower extremities, which are the parts by which the riders support themselves, produces a neurological, sensory, motor, and psychological interaction [34].

In the time of Hippocrates, he recommended in his medical and academic texts the practice of horse riding to cure physical disabilities and mental pathologies (460 BC).

Chaisaignacc (1805–1895) described how muscle strength, voluntary control of movements, and coordination improved in neurological patients with the help of horseback riding [35].

The study of the Horse-Patient relationship began as a modern science after World War II, in Scandinavia and Germany. In 1953, Max Reichenbach carried out the first studies with numerous patients in Germany, developing the method of equine therapy [36].

In modern times, patients who congenitally suffer from neurological pathologies or their sequelae live for many years, with a good quality of life, as long as complications are avoided, rehabilitation begins early and the patient and their caregivers are mentally empowered in self-care.

This is why horse therapy has a lot to do with palliative care and health in general.

2.16 Helping to dispel doubts about the methodology of AAI and future recommendations

In the past, AAI has been criticized for its “inaccurate methodology, dubious analyses, conclusions that leave questions” [37].

In this regard, Holder and collaborators made a recent systematic review of the different therapies in which animals participated. These included activities facilitated by animals, pet therapy, and equine therapy in pediatric patients. They sought to summarize the information and compare conclusions [17].

This review proposes three mechanisms through which AAI obtained results in terms of the perception that it did improve the patient’s quality of life. The mechanisms are:

1. Compatible Animal Personality Mechanism

2. Distraction and Entertainment Mechanism

3. Physical Touch Mechanism

4. Increased Human Interaction Mechanism

They concluded that AAI has an important place in improving the quality of life, but that theoretical frameworks are still at the forefront of the discussion since mechanisms often overlap. However, they do agree that everyone acting in coordination offers substantial well-being benefits.

2.17 Working mechanism of AAI and the planning of study questions

A systematic review published in Frontiers in Psychology, by authors Wagner et al. (2022) points out that in previous research on AAIs, the question to be answered was, “Do AAIs work?” However, the matter of, “How do they work?” has been practically ignored and to this day there is no answer [38].

This systematic review used well-known databases (PsychINFO, PSYNDEX; ERIC; MEDLINE; Embase, PubMed, Cochrane; Scorpus, Science, CINAHL, PTSDpubs) to identify 2001 reports and scanned 1893 abstracts on AAI.

The factor most mentioned in the citations found in the database is Human-Animal Interaction. This is what researchers most frequently point to as an AAI mechanism of action. What is it about this interaction that can reduce human stress or anxiety and increase oxytocin levels?

The next most indicated element is Movement by Animals. What is it about the dynamics of the movement of a horse during equine therapy that is beneficial for humans riding the horses?

The factors can be divided into specifics such as the presence of the animal, or the interaction with an animal, or non-specific such as the social interaction of a human with other humans when the animal is present. For each component, it is necessary to determine how it functions socially, psychologically, biochemically, and maybe even in some ways we have not considered to improve the condition of the patient in different ways.

The authors suggest that future research will establish which of these hypothetical factors can be clearly observed and measured.

2.18 Zoonosis and AAI

You must always consider the risk of diseases whose contagion cycle occurs between animals and humans.

Of course, the first thing that must be taken into consideration is the characteristics of the patient that make them vulnerable to infections. As in any therapy, a balance must be made between the risks of infection and the benefits. Strict control of conditions is necessary to avoid infections [39].

One Health analyzes this and warns that in all cases in which you plan to involve an animal in therapy, biosafety measures must be taken. Not all animals can participate in AAI and we already mentioned clinical situations where it is risky to interact with animals (neutropenic patients, with complicated wounds and drainage) those suitable must be subjected to an evaluation to consider whether the veterinary standards of biosafety, vaccination, grooming and compliance with import requirements [40].

3. Conclusion

Animal-assisted interventions have been used since their formal beginnings as an alternative therapy, to improve chronic conditions, restore mental health, and reduce cortisol levels. In other words, they aid in reducing stress, strengthening the musculoskeletal and neuronal systems, and treating mental illnesses.

Consider that the range of palliative care spans children with neurodegenerative pathologies, patients with cerebral palsy, patients with sequelae of surgeries to remove tumors or those who live with tumors, children, and adolescents who go to school under the stress of knowing that they have or have had cancer. As caregivers, whose lives are subject to caring for people with diseases that cannot be cured, the topic of animal-assisted interventions, activities, or education is of great interest to us.

They have their place in complementary therapy for incurable patients or those who live with chronic illness, by providing benefits such as stabilization of the disease, regulation of stress, and social improvement. All of this has its roots in people-to-animal contact that has never ceased to amaze us since the first human domesticated the first animal.

Our relationship as providers of palliative care working side-by-side with companion animals as we strive for the best quality of care has been harmonious, inspiring, and respectful and has been destined to endure since prehistoric times because animals have occupied the imagination of all peoples in all periods of history. As we look towards the future of this human-animal nexus that began when both species met, we propose taking it as an opportunity to view life with true and sincere Biophilia: working together for life and with respect for everything created, while not abandoning or fearing death, but rather accompanying it.

Thus, we will say in future years that by respecting our animal co-therapists, man is that much more human and the animals turn out to be true healers (Figure 1).

Figure 1.

The author with her dog Tosca visits a patient.