The Hardest Decision: Knowing When to Let Go

Trying to decide when can be the hardest thing ever. image: from the poster for “Our Loving Companions.”

As a veterinary internist for more than 35 years, I have helped thousands of people make one of the hardest decisions they will ever face: when to stop treating and assist a beloved animal to die.

Surprisingly, that decision has become more difficult over time. Not because veterinary medicine has failed us. Quite the opposite. It has succeeded across a range of ailments and treatments. But that success has made the decision about when to let go even harder.

Forty years ago, the human-animal bond certainly existed, though most people wouldn’t have even had a name for it. But today, our pets sleep in our beds, accompany us on vacations, have insurance policies, and increasingly occupy a place in our emotional lives once reserved almost exclusively for other people. 

In fact, this bond with our pets has been demonstrably good for us. Studies have found that companion animals are associated with their owners’ increased physical activity, social interaction, and social support, as well as lower levels of loneliness and, in some studies, reduced anxiety and stress. One study I’m particularly fond of counted the number of interactions people had with others while walking around a block in New York City with or without dogs. I’m sure I don't have to tell you which group had more interactions, but it's nice to know it's been documented.

Over the past 40 years, our world has changed, too. We’ve become busier, more isolated, and less certain. In this chaotic world, our animals have increasingly become a refuge for many of us. After all, nothing abates stress quite like burying one's face in a warm flank of fur.

At the same time, veterinary medicine has improved. When I began practicing, there were things we simply could not do for our pets. But today, veterinary medicine offers CT scans and MRIs, as well as sophisticated surgeries, chemotherapies, and treatments for diseases that once meant certain death. When I was a young internist, giving an owner a diagnosis of Feline Infectious Peritonitis felt like the end. Now, in many cases, this disease can be successfully treated and often cured. 

Of course, there is enormous joy in being able to save a life. But every new advance in veterinary medicine creates another question: how much longer should we keep our animals going?

I have known countless clients who sheepishly admitted that losing a pet was harder than losing a parent, sibling, or friend. They often feel guilty saying it, and I understand why. But a 2021 systematic review found that grief following the death of a companion animal can be comparable in importance to grief following the death of a human. Researchers identified profound loss, disruption of daily life, and difficulty adjusting to a world without the animal - just as most of us would feel after losing a human loved one.

Actually, this level of grief shouldn’t be surprising. Unlike humans, animals don't judge us or hold grudges. Their love is pure love. And we are responsible for them - entirely.

That combination of love and responsibility complicates the emotional decision-making about when it’s time to let them go. Love, like tears, can cloud our judgment. Sometimes love makes us want to do everything for a beloved pet. But sometimes love requires us to stop.

BE THERE LIVE in Berkeley
Oct 22-25

Dr. Alan Stewart spent his career caring for animals. Now a playwright, he has begun to explore and honor the human-animal bond through that medium. Our Loving Companions, an immersive theater project co-created with Elizabeth Coplan, founder of Grief Dialogues, will be performed at The Marsh in San Francisco on October 15–18 and The Marsh in Berkeley on October 22–25. For tickets, visit themarsh.org

When I graduated from veterinary college, my job seemed simple: cure disease and keep patients alive. But somewhere along the way, I realized I was thinking too narrowly. I wasn't just treating the dog or cat. I was treating the relationship between that animal and the person who loved them. My job wasn't simply to maximize the length of my patient's life. It was to maximize its quality and protect the bond that made that life meaningful.

I didn't want a cat spending its final days hiding under the bed because every interaction had become a battle over medication. I didn't want a dog undergoing procedure after procedure simply because there was one more test we could run. Most of all, I didn't want an owner to look back and say, “I waited too long.”

I have heard those words many times. I have said them myself. So what can I counsel?

First, don't wait for your pet to tell you they're ready. They may never tell you. Animals are remarkably stoic.

Second, pay attention to appetite. Most animals love to eat. When that changes significantly, it may be a sign they’re ready to let go.

Keep a quality-of-life calendar. Each night, give your pet a number from 1 to 10. Ten is a wonderful day. One is terrible. Write it down and watch the trend. This can help provide some objectivity when your heart cannot.

And look into their eyes. Ask how they feel. Then be willing to hear the answer. The hardest lesson is also the simplest: don't wait too long.

We imagine death as a peaceful moment when an animal closes its eyes and drifts away. Sometimes it is; often it isn't. There may be pain, anxiety, seizures, or difficulty breathing. 

You can make the end less frightening. Ask your veterinarian for help. There are also wonderful veterinarians who will come to your home and help you make the decision, and, when the time comes, help your loved one cross the rainbow bridge. Then you can grieve.

Our grief should never be colored by guilt; it should be evidence of our love. Our relationships with animals are worthy of mourning, remembrance, and ritual. 

Throughout my career, I have had the extraordinary privilege of seeing what animals do for us. They make us laugh. They comfort us. They give us routine and purpose. They sit beside us when we're sick. And they love us without asking us to become someone else first.

Perhaps this is the bargain we make when we bring an animal into our lives. We agree to love them. We agree to care for them. And eventually, we should agree to let them go. 

It is a heartbreaking bargain. But it is one I would make again and again.