Dr. Pachel: And that was the question that really allowed me to get into the details with those clients and say, well, what shifted? And then we could say, well, amazing. We can still attend to their needs, we can still watch, we can still do all of the things and still be responsible for providing structure and predictability within that framework. To allow your dog to take a breath, to be able to relax back into that directive role as a way of addressing the anxiety that existed for them when that relationship changed in ways they couldn't understand.
Dr. Venable: Welcome to the Veterinary Cancer Pioneers Podcast, the show where we delve into the groundbreaking work of veterinary professionals who are dedicated to advancing the field of veterinary oncology. I'm your host, Dr. Rachel Venable, and I'm thrilled to embark on this journey with you. This episode is produced and brought to you by ImpriMed, pioneers in an AI-driven precision medicine for veterinary oncology. ImpriMed’s Personalized Prediction Profile helps you make confident treatment decisions for canine lymphoma and leukemia patients by predicting how your patient will respond to multiple chemotherapy protocol options. Learn more at imprimedicine.com. That is imprimedicine.com.
Dr. Venable: Hello and welcome to the Veterinary Cancer Pioneers podcast. I'm Dr. Venable and today we have a really interesting show for you guys. And instead of just talking about oncology, we're actually gonna talk about animal behavior. So I'm really excited. We have Dr. Christopher Pachel on the show today. He's a board-certified veterinary behaviorist and entrepreneur. He is the owner of Animal Behavior Clinic in Portland, Oregon. He also serves as the Vice President of Behavior for Instinct, Dog Behavior and Training, and co-owns the Instinct Portland franchise, so he's also a widely recognized educator and speaker. Dr. Pachel teaches at multiple veterinary schools. He lectures internationally authored articles and book chapters. And if you've gone to any DVM360 conferences or even other conferences, I've heard him speak at several. He does an amazing job. So I'm so excited to hear just his opinion on behavior, especially as we talk about chronic disease and oncology. So Dr. Pachel, thank you so much for being on the show today.
Dr. Pachel: Thank you so much for having me. I know when we met and we kind of started to brainstorm this particular topic, my wheels were turning about ways to, to intersect with things from my perspective, from my specialty as it relates to yours as well as all of your listeners. So I am thrilled to dive in here.
Dr. Venable: Thank you. I am too, and you know, I always like to ask, just from the beginning, what type you into your specialty, whether veterinary medicine or also animal behavior?
Dr. Pachel: Yeah, I was, I say, destined to be a veterinarian, just from the standpoint of I don't ever remember having anything else on the radar. It was always the plan. From as long as I can really remember elementary school, I'm going to be a veterinarian. That's what my parents tell me. So that was always the plan. And also, while I got into veterinary medicine, because of a love for animals and a desire to be a helper and all of those sorts of things, I got into veterinary behavior because of my clients, and I didn't actually realize that at the time. But unlike some of my colleagues who got in because you know that special case that pulled them in and required them to dig deeper, maybe even for, you know, their own household? For me, it was my clients. When I was in general practice, when I had those clients who had a need, who were struggling in some way, shape or form, and I, in order to help them, had to dig deeper, had to do some additional education. And then once I started to peel back the layers on veterinary behavior, I was hooked. Never looked back.
Dr. Venable: That's awesome. And I love how just your experiences have led you to where you are today, and certainly doing a lot with behavior. And you know what? Would you. I'm just kind of curious, what is the most common behavior issue that people will bring to you? What do you see the most?
Dr. Pachel: Yeah. So probably the easiest way to answer that is to describe my patient population as dogs and cats with big feelings and inappropriate or unsafe coping strategies. Beyond that, certainly we can get into diagnoses and, you know, talk about noise phobia and separation anxiety and fear-based aggression and compulsive disorder. And we see all of those. But most of those patterns are driven by underlying emotional needs that aren't being met. And the animal doing the best they can to cope with those needs to try to navigate their environment, but often lacking the knowledge or the skill set or the emotional regulation, or even the control or agency to really do anything about it. And so when we tip into problem range, that's when we say, wait a minute, this animal needs help, we need help. What do we do?
Dr. Venable: And that's really interesting. And I like the way you framed all that. You know, just to instead of saying, well, it's just an aggressive dog, you know. Because it is much more complicated.So that is really interesting. Well, to kind of shift gears a little bit and what I really like to talk about, you know, oncology, right. It's usually kind of your chronic disease setting your caregiver dynamic. You know, how would you say, you know, you see the dynamic shifts during that care of pets with long term illnesses like cancer. You know what kind of patterns you see in the relationship, see what kind of things you see in those cases.
Dr. Pachel: Yeah, it's a great question to be able to ask and to dive into. And it absolutely can vary a lot from one situation to the next or one household to the next. But the thing that really caught my attention first in this particular topic of chronic disease, chronic illness, caregiver roles shifting, I had a couple of cases a number of years ago where the owners presented the dogs. Now, these were cases, not necessarily of cancer, not necessarily terminal illnesses, but other chronic diseases that required a shift within the caregiver role. And what was really standing out to me in those particular cases is that each of these particular owners said, you know what? I have a great relationship with my dog. We've always done a lot of training. We do a lot of things together. And when I looked at those relationships, they would say, yeah, I would give my dog some suggestions. We would use their cues, the dog would respond, I would reinforce the appropriate behavior. Life is good. And what stood out to me in these particular cases is that in the case of chronic illness, the role of sort of who's giving direction can shift. Now, I don't want to go down a pathway of saying, oh, it's about alpha or dominance or any of those sorts of things. No, no no, no, no, no, no. I'm really just talking about sort of who's in the driver's seat of what's happening within those interactions. And oftentimes what happens is we have a person who's now rather than being directive rather than creating structure and predictability for the animal, is hovering over that animal watching every little move, you know, tracking all of those data points in is now is responding to the dog as part of that caregiver role.
Dr. Pachel: And for some of my patients, especially those who may have more of a predisposition toward anxiety or a need for predictability and structure, the rules change. And those dogs don't know how to navigate that shifting role. And in those patients that really brought this to my attention, what we were seeing was a dramatic and prolonged uptick within their fear and anxiety behaviors that made me think, God, you know, not just what were they sick with, what was the diagnosis, but what was the functional significance of that diagnosis for your relationship? And that was the question that really allowed me to get into the details with those clients who say, well, what shifted? And then we could say, well, amazing. We can still attend to their needs, we can still watch. We can still do all of the things and still be responsible for providing structure and predictability within that framework. To allow your dog to take a breath, to be able to relax back into that directive role as a way of addressing the anxiety that existed for them when that relationship changed in ways they couldn't understand.
Dr. Venable: And that's really interesting, because a lot of people do, you know, once they know their pet has some kind of major illness, they do just kind of stare at them and then, you know, I'll hear these things where like, I don't know if this is normal, but now I'm seeing this, you know, whether it's like some kind of movement or even toilet changes, right? Like toilet habits changes. I feel like they give way more questions now. So that kind of what you're seeing is where just the owner, the family members are just staring at the pet so much that it's the roles reversed. That's what you're saying. And so it creates that unpredictability. That's so interesting. I never thought about it.
Dr. Pachel: Yeah. And I think a lot of times if we have a dog that is reasonably secure in their role and doesn't need a lot of direction, maybe this is irrelevant. But it really brought it out to me as a way of saying, let me continue looking at that. Let me continue to evaluate that when I'm seeing additional cases, whether it's because of chronic illness, whether it's because of end of life concerns for whatever's going on, or even just recognizing other social dynamic changes that may result in a changing role. Keeping in mind that for the dogs that live in our households, they're relying on us for direction, for structure, often to provide them with meals and walks and all of those things. They are dependent on us. If we change the rules, if we change the rules but didn't tell them that can be really confusing and anxiety producing.
Dr. Venable: You have those people do it because they, you know, they're almost accidentally staring at them too much. So what are some changes for them?
Dr. Pachel: Yeah. So typically where I'll start is asking them, you know, is there anything from your dog's perspective either in your daily routine, the exercise schedule, the feeding routines, things that often change across the board when we're navigating cancer and other chronic diseases, all of those things tend to change. And so I'll often ask the question from your dog's perspective, what shifted?
Dr. Pachel: You know, if I could just talk to your dog, leaving you out of the picture here for just a second. What do we do if we just ask the dog, what would they tell us about what looks different now? And oftentimes I have clients. You kind of go, “God, I don't know, but let me think about this for a second.” And usually within even just a minute or two of kind of troubleshooting, maybe giving them some strategies, they'll identify those things and be like, okay, maybe if your dog is struggling, let's say maybe their exercise needs have to change? Maybe we're not going for a four mile hike, but could we still structure an activity period twice a day the way we used to? Can we give them the structure even if the activity has changed? You know, if they previously were fed twice a day and now they're being fed small, frequent meals for some reason, could we go back to the way in which we used to feed them so the structure looks the same? Even if the schedule needs to be different, or the food itself needs to be different. You know, these are some of the things I'm trying to say from a practical, everyday scenario. What do we think your dog might have been, depending on as predictable cues that we could recreate in this new version of whatever it is that we're navigating now?
Dr. Venable: And it's interesting to me too. How, just maybe, we take for granted just the normal routines in your household. At least I do. You know, all the things you were bringing up. I was like, oh, I don't really thought about that.
Dr. Pachel: Most people don't, and most people don't have any reason to. And that's one of the cool things about dogs, is that they're often very adaptable to whatever we throw at them. But as is often the case with acute illness at that time of diagnosis, at the time, where they kind of tip that point where they're now actually showing signs of illness, things change really fast.
Dr. Pachel: And so we now understand why they've changed. But the dog may not, and especially if they're not feeling well, if their sensory perceptions have changed as a result of whatever it is that we're navigating, whether it's physical discomfort or other changes, that in and of itself can impact that anxiety and emotional regulation as well.
Dr. Venable: I honestly, I guess I should frame this, that I feel like a lot of pets that come into the vet clinic, even oncology, we usually can train them in a sense that they don't mind coming for chemo appointments. You know, we try to spoil them and we try to make it as positive as possible. But, you know, there's always dogs that don't really want to come.
Dr. Venable: And it can be a lot, you know, chemo protocols. We can be looking at weekly visits or every three weeks or blood draws, you know, a lot of things. And I'm always shocked how much they let us do in general. You know, often we'll put these dogs on trazodone. I find it as a way to take the edge off. Is that a good solution, whether it's chemo or diabetes, you know, they're just having to come to that a lot. But what do you recommend for those dogs?
Dr. Pachel: Yeah. You mentioned trazodone is a potential solution. And it's a great option to be able to trial. You know trazodone as an example of a pre visit pharmaceutical something that can be given typically 1 to 2, 1 to 3 hours prior to the vet or prior to transport to the vet. Something that helps just a little bit more of that relaxation, a little bit more with that comfort, a little bit more adaptability to changes that may be happening there. And I love that, especially when we look at trazodone, it does have an anti-anxiety effect. It does have a mild sedative effect that often kind of helps them be a bit more settled, especially if they need to be there for an extended period of time for a particular infusion protocol or anything else where it's not just a quick in and out appointment. Trazodone is a great way to help them settle in at a more of a resting baseline level of arousal. So I love it for all of those reasons, you know, and truthfully, depending on what they're coming in for, I do like asking the owners the caregivers, is this a dog that already has a preexisting love or avoidance pattern when it comes to the veterinary experience, and is there anything that your dog finds particularly enjoyable? Is it a massage? Is it certain types of treats? Is it a particular game or interaction? Is there something that your dog really enjoys? And then we try to put those things together in a way that helps the dog understand. I'm going to go to the vet, and hopefully I've got something on board that makes that less stressful. And then as soon as we get through, you know, even the initial portion of that procedure, basically something happens and then we immediately or as close as we can follow that up with, with whatever they're reinforcer is, we're getting an actual contingent relationship between stressor and reinforcer that helps them know it's not just I'm going to go to the vet and we're going to play ball the whole time we're there. No, no, no. They're going to poke me with needles. They're gonna require me to be still for certain things. But when I do that, amazing things happen. And that relationship is actually a really important thing that I find even in the veterinary side of things, we don't always think about the order of operations.
We're trying to rely more on classical conditioning, of saying if we just make it a positive experience overall, hopefully they'll have a good enough time that they can kind of let go of some of the negative stuff. And again, to their credit, so many dogs have the ability to do that. And if we are seeing any level of stress or if the owner says, yeah, we've tried that, going into the vet is still a pretty stressful experience, then it may be on us to create a little bit more of that relationship. We do some stuff and then follow up with the reinforcer. We do some stuff and we follow up with the reinforcer, and that's what starts to set that conditioning into the correct order to build that tolerance in expectation of something good happening.
Dr. Venable: I like that I never thought about the timing. You know, I'll be honest, I probably don't have enough background on behavior. So this is great for me. I clearly need a lot of education. So yeah, that's really interesting. So what if you tried to reward them before doing what you were going to do? Like do they just get all confused? What is the logic with the timing?
Dr. Pachel: Yeah a couple of things can happen there. One, if we have a dog who really enjoys whatever, let's say, let's say we're using food, we're using a licky mat. We're using something that's more of an extended duration positive experience. So best case scenario is the dog is so distracted by the food that they're not even really paying attention to the fact that we're getting a blood sample, we're giving an injection, and we're doing all of those things. That's the best case scenario. Maybe that's the second best, best case scenario. Maybe there'll be enough of a positive association. They go, yeah, come in here is the best place that could possibly be. So I love that a lot of dogs will have that experience. And I say that in case anybody is listening to this going, “Oh my God, we have to revamp all of our protocols. We're not paying attention to the order effect.” You're probably doing what you need to do for a lot of your patients, maybe even the majority of them. And also for some dogs, if the order matters and if we're doing it in reverse order, then basically what happens is the good thing. The treat in this case is predictive of a needle poke. The good thing is that it is predictive of a stressful experience. The good thing is that it is predictive of pain. And for animals who are not down for the actual experience themselves, what can happen is we bring out the food, we bring out the licky mat, and we have a dog that goes, I know what's coming next. I don't want any part of it. I'm out of here, I'm out of here. Or in some cases might respond more aggressively or defensively as a way to try to control that situation, to prevent the thing from happening. So we can actually teach those dogs by presenting things in the wrong order, that the good thing predicts the unpleasant thing, and they're actually learning to opt out rather than opting in.
Dr. Venable: That makes a lot of sense. It's like the reverse of Pavlov's dogs, right? The drooling dogs with the bells. So now what about cats? You know, we've been talking about dogs because honestly, I personally see a lot more dogs. But what do you think about cats? I feel like they're too smart. They're kind of tricky. What can you do with cats? Especially in a short clinic setting? You know.
Dr. Pachel: Yes. I think one of the challenges with cats is that, you know, while they're absolutely subjected to all of the same principles, we were just talking about the way in which they learn is exactly the same: the order effect, the conditioning, the pre pre visit, pharmaceuticals, all of those things. All of those are exactly the same. Even though there may be species-typical differences in kind of what happens next for those animals, I think one of the major differences for cats is that until they were sick, until they were ill, many cats in households don't go anywhere. They're really living a pretty homebody, sort of an existence that, even if they're accustomed to having visitors into the home, they're often not traveling. They're not in their carriers, they're not going to the vet repeatedly. Again, unless are until that's required. And so I find for a lot of our cats, the baseline level of comfort with the veterinary experience is often not as positive.
And so we're starting kind of further away from a place of comfort, which may make us more reliant on pre-visit pharmaceuticals, trying to just make it a, you know, a not a traumatic experience on the way to trying to make it a reasonably positive one. I think it's, it's often a steeper uphill based on where they're starting from.
Dr. Venable: And that makes sense too, because I do find it a lot harder to get cats to like the clinic. I feel like we have more success with dogs in general. And are there anything maybe in the veterinary environment, you know what you're talking about, things to do for the animals. You know, like rewarding them, like finding out what are things they like. But what about the clinic itself? You know, there's all different layouts and things, but what's maybe some layouts or behaviors you recommend in the clinic?
Dr. Pachel: Yeah, I have a couple of things here. I think, you know, utilizing pheromones support for both dogs and cats as a way to try to send a bit more of a chemical messenger that says this is actually a safe space. That's one way that we can modify the environment. I also try to be really mindful of noise, chaos, fast movements, the directness of movements versus if we are working with a patient, can we be a bit more oblique or softer with our our movement patterns, knowing that for all of us who work in the veterinary space, every single day, we are habituated, we are desensitized to what that actually looks like.
Dr. Pachel: And so we're doing what we do, and we're having cake for the birthday party, and we're doing, you know, we're celebrating somebody's chemo journey. And like, we're doing all the things. But if you're the patient for whom this is new or threatening, all of that chaos has the potential to add to that emotional arousal. So those are some of the things that we can focus on. But at the end of the day, what I'm really doing is watching the patient. If somebody does come into the room with a bigger voice, do we see any sort of change in body language? Do we see shrinking? Do we see if we're talking about cats? Do we see pillow erection or hair standing up? Do we see pupillary dilation? Do we see sort of re-situating themselves to move further and further back in their kennel? You know, do we see anything that goes on, “Oh, for you that was a stressor?” Okay. Let's see what we can do to modify that as best we can, knowing that the clinic environment isn't completely modifiable, but can we be more aware? Those are some of the things that come to mind.
Dr. Venable: Would you recommend having an area? I feel like a lot of clinics, you know, there's an area like the treatment area where there's a lot of cages. So you can, you know, all the staff, everybody can see all the animals, which I think is good because we know if there's any issue or anything, but I could see where that could be highly triggering for some of these animals. So would you recommend maybe, you know, and I've seen someplace where they have almost a quieter a room for cats or just a separate area where maybe you can't see them as much, but if they're, you know, not critical, that might not be as much of a problem.
Dr. Pachel: Yeah. You hit on something that's actually really important from a feline stress reduction standpoint is that in both in the veterinary environment as well as in the shelter environment, one of the things that has the biggest impact on feline stress is the ability to hide. Now that is sort of working against us, just as you said we're trying to keep an eye on. And oh gosh, what then is it possible to put up even, let's say, a little curtain on one side of the cage front where the cat can tuck behind? If they feel motivated to do so, we can position ourselves to still look at them when we need to. But for all of the other chaos, they can kind of sit behind a curtain a little bit. You know, those are some of the strategies where we can say, how can I give you what you need to allow you that chance to decompress a little bit, allow you the chance to to have a bit more acoustic as well as visual line of sight buffering. What would that look like without compromising my ability to provide patient care? And sometimes it's a delicate balance. And of course, when we need to prioritize patient care, of course we're going to do that. But I think sometimes there are things that we could do relatively easily that may make a difference for individual cats or dogs without negatively compromising our ability to care for them.
Dr. Venable: Yeah, I think that makes sense. And what's something that I don't know that maybe historically not just vets, but people have done with animals that you're like, this is if you have an anxious or maybe aggressive animal when it comes to the vet clinic, don't do this. You know, I don't. Is it muzzles? Is there something I'm sure there's something you guys have seen that you're like, why does everyone keep doing this?
Dr. Pachel: Yeah, I would say probably the number one thing is when we're pushing beyond an animal's comfort level for the sake of a short procedure, when we kind of say, it'll only take me seven seconds, just hold them still. Let's just get it done. That is probably the number one. Number two and number three mistake that I say because for that animal, it's I mean, yeah, it is only seven seconds. It's seven seconds of trauma. It's seven seconds of surviving in a way that may be more than what they can handle. Now, keep in mind, I'm not saying we shouldn't restrain. I'm not saying that we can't do things that may be stressful for them, but really being mindful about where that line is for the animal. If we are restraining and we can see the stress, anxiety, fear and defensiveness climbing, pause for a second, even a microsecond.
Is there something I could do differently? Could I ask John to keep his voice down? Could I change the way in which I'm holding for just a second? If, for example, being held and supportive was helpful, but then when I shifted position, I saw stress increasing. What can I do as my part of the conversation to try to stay within that reasonable comfort level, or if it's appropriate, is there a scenario where we say, let's try again with appropriate medication on board?
Let's go ahead and put you back into your holding area. Let's use some pheromones if it's appropriate to give a dose of trazodone or gabapentin, can we try again in two hours with an animal who's more amenable to that procedure? And if it's something we absolutely have to do at that moment, recognize that getting it done checks the box. But at what cost? So is there an option for sedation or some additional support or a different way of accomplishing that? That still checks the box, but without risking a worsening? And I say this especially using the example that we're talking about for animals who may need to come in multiple times for diabetes, for chemo protocols, for frequent re-checks, for whatever it is winning today and checking that box if it's setting us up for greater trauma, greater potential for failure later on, I want to see, is there something that we could do differently today to minimize that as a potential?
Dr. Venable: Yeah, that makes a lot of sense. I've certainly seen some animals that yeah, they just you can tell they're getting stressed, but it should just be quick. But you know, probably are making it worse. So I've been in clinics where they don't really like to sedate and you know, they try other things, you know, maybe try a bit more oral things, but not really injectable. And then I've been with other clinics where I felt like they IV injected everybody like everybody was sedated for every procedure. It was just automatic. Is there a happy medium? Do you have an opinion? Is it just depend on your practice and maybe the cases you see? What do you think about that?
Dr. Pachel: I think it depends on a lot of factors. I know that, you know, for my own personal take, I am advocating for sedating. And yet I am so far removed from actually being the one sedating patients at this point in my career that if you put me in a clinic where we're sedating anything, I'm going to be tachycardic myself until I get comfortable with that again. So it's, you know, I think some degrees it's our comfort and our familiarity with protocols and understanding what options exist, knowing that in the case of of acute or chronic illness, there may be protocol adjustments that we really need to, you know, let's phone up the anesthesiologists and say, what are my options here? So I think there's a comfort factor for us. I think in some cases there's a flow factor where we're concerned it's going to take too much time or I don't have the staffing resources. And so we kind of power or muscle through I think in other cases. And these are all valid concerns. I'm not meaning to minimize any of them. They're all absolutely relevant. I think in other cases we're worried, well, gosh, if we sedate that's going to add additional expense.
It's going to add an additional cost to the client. And they're already concerned about the cost of treatment. And so we withhold something without actually asking the question. If we were to ask the client to say, hey, I'm concerned, I'm seeing X, Y, and Z, you've mentioned that your dog or your cat already has a stressful relationship with the clinic, and we've got a whole course of treatment for the next three procedures.
Do we have your permission to proactively sedate or use anti-anxiety medications in hopes that it won't be needed in the long term? Can we do that? This is how it's going to affect treatment. Do we have your permission to go forward? And if the client says, “No, I'm out”, you know, no for whatever reason, no is a complete sentence.
Then, of course, then we'll do the best we can. But I think sometimes our own biases or limitations or obstacles get in the way of us actually presenting what we think may actually be the best treatment for the animal because of those biases that we hold. So as with everything, check our own biases. We all have them, myself included. Where are they showing up in our decision making process? And what can we do to kind of shine a light on those and see what we can address?
Dr. Venable: And there are so many good drugs out there, I think, anymore, you know, that all the different acting and reversals. So yeah, I think the drugs can be really helpful. But it is interesting because I've certainly ran into clients that just say no, you know, like you said, they're not interested. And then it's trying to figure it out. So it can be interesting. And you know, are there any you know, when we're talking about these chronic diseases that these poor pets have that are coming in. Are there any behavioral management techniques maybe for the frequent visits? I know we've kind of talked about it a little bit, but just in general, like what are some things maybe we could tell those owners to help, you know, just the experience from the beginning before the pet gets to the clinic.
Dr. Pachel: I love that. I think the greatest thing that comes into that conversation is observation. So what I'll often do when I'm meeting a client or an animal for the first time, especially if I recognize signs of stress, I may ask the client, do you ever? You know, this is what I'm seeing. I'm just getting to know Sparky or Fluffy for the first time, so you know them better than I do. Of course. Do you ever see this in other situations or today? Do you recall when you first started to notice Sparky's stress level starting to climb? Was it just when I walked in the room? Was it when you got to the parking lot? Was it when you got ready to get into the car? So trying to get a sense of where things start to kick up in terms of stress and anxiety allows me to get in front of that, whether it's with medication support or then recognizing.
Actually, Sparky got stressed right when he went to get in the car and came to find out, Sparky gets stressed every time he gets in the car. Maybe that's something we can address as part of making our veterinary experience less stressful. He may not be terribly stressed about us at all, but just getting here, maybe the stressor. Maybe there's a motion sickness issue that we can address through medication support, or asking people to drive more gently. You know, whatever the case may be, there's all kinds of solutions. But again, observation, what are we seeing? When are we seeing it? Can we get in front of it is probably one of the most informative things to at least then guide what's needed.
Dr. Venable: I know that makes sense too, because there could be lots of different triggers. It may not actually be the vet clinic like you said, maybe it's the car and then it just all goes downhill from there no matter where you're going. So I feel like and I think that's how it is for a lot of cats. I think it's just getting in the car like, and then we're just done. They're over it. So one thing I do want to shift a little bit. How much do you see? Just the human animal bond. You know that's a big topic. And you know looking at you know, again kind of maybe either aging pets or pets with chronic illness, you know, I feel like people are looking at different research with the human animal bond in those cases or just in general, what do you see or do you see behavior changes just even in those scenarios?
Dr. Pachel: I do. I think the human bond is a really important thing to factor in. And I also want to be cautious that when we're talking about something like human animal bond, it's really easy. And in my sort of scientific framework to talk about it as a singular thing, this is bond. And the reality is that bond looks completely and totally different for each client, for each pet, the relationship they have, the activities that they share, how they communicate. It's going to be incredibly different from one example to the next. And this is again, another place where I think my own biases can get in the way or can kind of filter what I'm seeing. If I'm someone who says, well, the best bond is the person who does obedience training and they do nose work and they do agility and all of those things, that's going to frame the way I'm viewing versus asking the client what's meaningful? What do you enjoy doing with Sparky? What do you enjoy doing with fluffy? What do you enjoy? What do they enjoy? How would your world change if you couldn't do those things? If we needed to change your feeding schedule, if we needed to change your activity schedule, if we needed to add in a weekly veterinary appointment. How does that potentially affect your relationship? Not the relationship that I can see, but how does that affect your relationship with them? Do you have any concerns that would be helpful for us to know on the front side that we might be able to incorporate into that overall treatment plan.
Dr. Venable: Because there's been some studies or surveys and things finding that clients, especially just sometimes the bond can get strained or just they have more anxiety. And yes, I hadn't thought about it, but you're probably right. Sometimes just coming to the clinic a lot or just, you know, how is that disrupting? How can we help with that? Like if it's like, well, you want to do this chemo and so you have to come this much. I mean, can you give some practical tips of how we can help those pet owners?
Dr. Pachel: Absolutely. I think, you know, for our purposes, even if this isn't the framing that we bring into the conversation, just recognizing that the ask that we're presenting, especially for clients who say, you know what, just tell me what to do, I will do everything. And I mean, I love those clients. I love their dedication. And also, even in that scenario, completing treatment carries with it a caregiver burden. We are asking them to modify their routine, their spending habits, their rituals. We are asking for those adjustments and depending on how much of a deviation that is from their existing baselines, that in and of itself can be really, really stressful. So I think even just again, even if this doesn't come into the conversation and labeling it as caregiver burden with the client, just being mindful that that is a lot. And if we recognize our clients or our pets that we're seeing, maybe the last three appointments went really smoothly, but today was a little rough. If we're seeing that as a trend that is worsening, I'm actually going to call that out, not as God. What's going on in your life that you're so stressed about? You know, nothing that might be perceived as judgment or anything like that.
But, you know, I recognize we're seeing a little bit more, you know, a little bit more panting. We're seeing that last time fluffy was, you know, maybe a little less interactive. Is there anything else that you can help us to understand that may allow us to provide better care for Sparky, for fluffy? And sometimes I think even just acknowledging that there are things that we can do creates that perception for the client of saying, actually, you know what's going on? I mean, I'm having this whole, you know, I'm having this whole thing. I'm also caring for my mom or my spouse and I, their job changed or whatever the case may be. And I say all of this with full awareness that most of us, myself included, are not marriage and family therapists. We're not trained as counselors. And so it sometimes feels like we're asking to be a little bit more intrusive, or asking them to be vulnerable with us in a way that we don't have the skills to know what to do with.
I'm not asking for us to be therapists, but I am asking us to bring empathy, kindness, and curiosity into the conversation and simply acknowledging this is hard. This is hard for a lot of folks. I don't know if it's hard for you. I'm not trying to project that onto your experience, but a lot of our clients do find that this is challenging. If you identify any elements within our treatment process that feel uncomfortable, feel more challenging, and you're thinking of ways that we might be able to do this differently. I can't promise we'll be able to do that, but please don't hesitate to bring that forward. And gosh, if that client gives me any little nugget to latch on to, I'm going to do my absolute best to make good on that promise of at least trying to do better as a gesture to create that perception of safety and open communication and trust within that relationship, so that if we do get into sticky territory later on, as often is the case when animals stop responding to protocols or things aren't working, or we might be reaching the end of our financial limitations. I want to have built a framework of trust through small, safe interactions that gives me something to lean on later on. If we can.
Dr. Venable: Trust this huge. I think when there's no trust, you know, even if we're talking about business relationships or clinic relationships, all those things, if there's no trust there, they don't trust you as the veterinarian, it's. Yeah, that's tough. And it is interesting. You bring up just having empathy, asking some questions like it's true. That can really help just with that bond and trust. Just, you know, as you're trying to do it. Because I think sometimes, you know, we know we want the best for the animal and we're doing all the medicine. But it can come off kind of sterile, I'm sure to a lot of people.
Dr. Pachel: Especially when we start getting into clinical conversations and we're talking about this type of tumor or that type of chemical, you know, it can sound very, very foreign. And God forbid, we're starting to talk about multidrug protocols. I mean, the clients, I mean, they get it. They catch up. I mean, it's amazing what clients do when they're motivated to understand. But those first conversations can be so foreign that again, coming in with kindness, do you need me to slow down? Do you need me to write any of this down? Would it be helpful to actually print out the discharge notes so we can run those through together, versus me giving you it all verbally and you're scrambling to catch up? What would be helpful for you? I'll do my best to accommodate.
Dr. Venable: Right. Yeah. Well, and you know, you also started to mention, you know, as things are starting to progress, maybe it's, you know, we're not responding to treatment anymore or just old age, you know, some of these pets, as they get older, whether it's really a disease or arthritis or dementia type things, you how do you find just animal behavior? And also with the client, like what's the best way to start approaching some of those difficult conversations?
Dr. Pachel: And yeah,I think it's one of the things that I try to do, I can and I have work to do in this area as well. We were all on this sort of growth journey, and every client brings with them their own experiences that we're trying to navigate and trying to meet in the middle somewhere. But I think one of the things that I try to do more often than not, especially the moment I have even a little inkling that, “Oh, those numbers don't look great,” or, “We're, you know, we're 12 weeks into a 16 week protocol. This would be the time that things could go sideways if they,” you know, anything along those lines, whatever the treatment happens to be, I try to bring a question into my conversations with the owners before I need it to say, you know, I'm I'm thrilled that everything is going as smoothly as it is with treatment.
And I hope, I hope that that's what continues. If we notice something that is not going according to plan, how would you like me to bring that to you? And literally calling it out as a question, knowing that for a lot of people they kind of go, well, I don't know, just just tell me. And yet there are a lot of our clients who know that I jokingly say, I'm in the Pacific Northwest. I previously practiced in Minnesota. So the Midwest very sort of everything has to be sort of couched in niceties and all of that. When I'm working with East Coast communicators, they're like, just rip off the Band-Aid. Just tell me as it is, I'm, you know, I want to know that because if they're looking for direct, rip the Band-Aid off communication and I'm defaulting to my sort of nice, gentle way, I'm not going to land with that client as positively as I possibly could. And absolutely the reverse could be true as well. If my default is a bit more. Yeah, we're dealing with hard things. I'm just going to shoot straight. We're going to do what we do. And this is a client who really needs to know that there's about to be a difficult conversation. I can ask the question and if they know their communication style, I'll do my best. So calling those things out ideally comes back to that trust relationship. Ideally, before I need their trust. I've built it before I need to communicate something challenging. I know at least somewhat of how to do that in a way that's likely to land in the easiest way possible.
Dr. Venable: It is interesting thinking about just kind of giving people that warning shot well in advance, you know, and we know it's going to come in that way. Just everybody kind of preparing themselves before it happens. So that is really interesting and kind of thinking about the end of life, you know, what do you see as animal behavior wise? Are there certain things that you'll tell people like, you know, when they get a lot of times with cancer, because people always ask, well, how is this going to end? And so I'll kind of go over some different things depending on their cancer that we might see. Or we're talking about quality of life, you know, things that I'll have them watch from your perspective on behavior. What are things maybe that you tell clients to watch or they might see.
Dr. Pachel: Yeah. So I really I love the open ended way in which you're presenting that question, because it can vary a lot from dog to dog, from cat to cat, from household to household and so, you know, kind of in the same way we were talking in the previous thread about bringing it up. Before we get there, I'll often do the same thing, just as you mentioned with this particular type of cancer, if things start to progress, these are the things we're likely to see. And I may add an additional statement to say. With that in mind, I'm just getting to know your dog or your cat. They've lived in your home for 15 years. You have a good sense of what they look like on a good day, on a bad day. And so keeping track of that and trying to create a sense of of agency and really empowerment for the client to observe those changes in their pet, to say, oh, you know, if this is a dog, for example, that as long as they're able to sit in the front window and watch the kids go by after school, that's a good day.
That's a very different quality of life from the dog, who needs to be able to run in the park and socialize and do things for four hours a day. Otherwise they're unfulfilled. Making decisions for those two dogs could look very, very different, and neither is inherently better or worse. They're just different. So asking, you know, as many of the validated quality of life scales do, asking those questions, what does your dog enjoy? What do you enjoy doing with your dog? And if we're reaching a point where those things are no longer possible or practical, then are we looking for signs of fear, anxiety, stress, depression or sadness? Social withdrawal? Defensive aggression? Are we seeing anything at all that suggests this is getting hard? And then what do we do about it?
Dr. Venable: And I really like all those. And I do want to switch gears just a little bit because my other question is what do you recommend for those really aggressive pets, whether it's a dog or a cat? And we are looking at, you know, whether it's cancer or maybe some kind of long term chronic disease, and the family wants to do something, but handling this pet is going to be intense.
Dr. Venable: Like it's not just, you know, a little bit of pills. It's no, you know, we can't do a physical exam. The pet's too aggressive. You know, I had one the other day and the owner couldn't get the muzzle on, like, it's just, you know. What are your thoughts? And I guess maybe even the behavior community, because sometimes I feel like personally when we're talking about chronic disease, like end of life, not just like this, is there once a year or every three years rabies vaccine, you know, like this is a long term thing. Is it fair to the pet? Is that that's how I feel? But what would you say? Yours or maybe just the behavior community for those really aggressive animals. But how do you recommend, maybe communicating or just approaching those pets?
Dr. Pachel: Yeah, I think as with so many things, it depends on a number of variables. And I think the one that really jumping out to me first and foremost is urgency. If we're talking about getting a three year rabies vaccine or an annual exam, and I can do an observational exam and keep everybody safe and we can, we can continue working. That's one thing. If it's a patient who needs twice daily injections, we've got you know, that's a different ask. And if we can't do that then the question as you said what are our options using muzzles? I'm a huge advocate for muzzles, especially when we have the time opposite of urgency, when we have the time to proactively train that animal, dog or cat to a muzzle or some other device that's going to maintain safety in the midst of treatment. If I can do that, so that the tool itself is not an added stressor to that treatment experience. That's what I'm looking for.
But the reality is, as you know, when we make a diagnosis that now requires treatment today, tomorrow, the next day, we don't always get the luxury of time. And so that's where we then look at some of the medication supports and really run down the list of what are the things that I can do on the behavior side that may allow you to feel better, more comfortable, safer while we're moving forward? And if that's not good enough, then I turn to the anesthesiologists and I say, I can't make you feel good enough that you're going to trust me enough to tolerate this. So is it an option to make you sleep? Can I make you sort of be unaware of what we're doing? Can I use trans mucosal sedation protocols that you can lick off a licky mat that provides that level of sedation, much as we would get from an injectable, but way more safely, you know, is that an option? Sometimes yes. Sometimes no. Sometimes it is an option. But maybe the budget is a limiting factor or there's something else. And that's the point for me where I come back to again, kindness, curiosity and empathy. What does it look like to have that conversation with the owner to say, here's what I would like to do. Here are the limitations that are preventing us at this moment from leaning into that gold standard.
How do you want to proceed? You know, I'm not trying to ask the client to do my job, but at some point, they are the ones who are ultimately going to decide, do I need to uplevel my commitment? Meaning I need to invest time in muzzle training. I need to invest financial resources into treatment. So what does it look like to uplevel their commitment or downgrade their expectations? And I'll often tell my clients in the scope of providing behavioral work, it is not my decision. What you choose uplevel or downgrade. It's not up to me. But if what we're doing is not achieving the outcome that we need, continuing on with the commitments or the expectations without making the changes is not going to change the outcome, we're going to have to change something. What do you want to do?
Dr. Venable: I yeah that's good. I'm sure you run into that. I mean, because I'm sure you see a lot of aggressive animals. So, I'm sure you run into how do we approach these guys. So that is interesting. And also just curious, you know, a lot of people try, like to try to do and and gabapentin, you know, the night before morning of, if that doesn't work. And I remember I'll admit I'm old enough. I remember the ace promising days like. And that could be a little sketchy sometimes. That drug always makes me a bit nervous. But what do you have? And I don't know if you're comfortable even saying, like, different drug combinations. Or would you just recommend talking to an anesthesiologist? Do you have any favorites?
Dr. Pachel: I do have some favorites, and I think it depends on what level of sedation we're looking for, what routes of administration are available to us. You know, for some of our patients, they're stressed, but we can administer injectables safely. Others that is not an option. And maybe it's an owner who can't place a muzzle safely or comfortably for the animal, in which case then our options do get a bit more limited. I love the option you mentioned with the gabapentin and trazodone, gabazone or trazo-pentin or whatever you want to call the combination of those two. I do love that as a starting point. And again, if I have a patient who just needs to feel a little bit more at ease, and that's the effect we get from that particular med. Great. I love being able to use other medications. I love my benzodiazepines, for example, which aren't appropriate for every scenario. And yes, we like to do a trial dose ahead of time to make sure we're not getting paradoxical excitation or any other side effects that may make treatment actually more challenging rather than less. But I find it for many of my patients, we're really concerned about adding in a benzo for some of the controlled drug reasons, or we're worried about behavioral disinhibition, or there are a variety of concerns, but I do love them as a trial.
If I have an animal who's panicking, there's almost no other drug category that's better at addressing panic than a benzo. So considering that option, I love my alpha twos as well, whether that's dexmedetomidine or, you know, any of the other options with oral clonidine is another option that we have available, keeping in mind that we do have some cardiovascular things to pay attention to with our alpha two, so maybe it's not going to be appropriate for every dog, for every cat, for every animal. But again, it's really sort of understanding the toolbox that's available. And I always tell folks, if you're not sure what to do and you're trying to make them more comfortable, by all means check in with a veterinary behaviorist. We've got tools up our sleeve that nobody even knows about. And if you want them to go to sleep, amazing. Call the anesthesiologist. They're your best resource, but also decide what you want. They're very different outcomes, and they're very different dog drugs or different drug doses to achieve those. And so really being mindful what am I trying to accomplish and who is my best resource if I don't already have that in my toolbox?
Dr. Venable: I love that, and I've learned so much during this conversation and definitely need to brush up on my behavior for sure. You know one thing, where is a good place for people to contact you if they, you know, need a behaviorist? I have clients that need a behaviorist. How can we reach out to you?
Dr. Pachel: So all of the information about reaching out to me or my team, there are four doctors on my team at the animal behavior Clinic in Portland, Oregon. All of that information is available on our website, which is AnimalBehaviorClinic.net. And if you go on that website and click on the services tab, you'll see all of the different services that we offer, whether that's vet to vet phone conversations in 30 minute increments, whether it's seeing clients directly, if they happen to be in our local area or working through their primary care team, and actually doing a lot of the heavy lifting through a telehealth consult to be able to do some of that, we can get them matched up. I've got an entire team of trainers on my team at instinct, Dog Behavior and Training Portland that we can work collaboratively with as well to not only get the assessment and the plan, but also the training and behavior modification support to move them toward whatever those goals are, whether it's muzzling, whether it's safe in safely giving injections, whether it's you name it, those are all things that we can do. So the Animal Behavior Clinic dot net is the place to start. And also if you're looking for more conversations like this one, this conversation, once it's released, will also appear on the media page for drpachel.com. And if you're interested in looking at other conversations as they've happened, that's another place to go beyond just the services that we provide in the clinic.
Dr. Venable: I love how you provide so many different options and not just here's one thing, but also the training, the, you know, the telehealth, the phone, whatever it may be. That's awesome. I think you've really thought about all the different angles. And before we wrap up, I always like to ask people, you know, who would you recommend to be a good guest on this show?
Dr. Pachel: Oh, that's a great question. And I think if I were if you haven't already explored this option, I know a couple of veterinary social workers who would love to dive further into the client side of these conversations about what it actually looks like to navigate long term critical conditions, potentially terminal conditions with our clients. And what does that look like? I will tell you, for so many of the suggestions that I provided today that are on the communication side, I've gleaned those from my conversations with veterinary social workers over the last 20 years. So, I've got a whole team of those in my back pocket. I think it will be a lovely angle to explore.
Dr. Venable: Yeah, I think that would be great. Certainly a big part of oncology is well, I'm really just veterinary medicine is communication. And I think there's so much we can always learn more. So that is an awesome suggestion. Well doc well thank you so much. This has been an amazing conversation and thank you for being on the show.
Dr. Pachel: Thank you so much for having me. I look forward to the next conversations if and when they happen.
Dr. Venable: Well, that's it for this episode of the Veterinary Cancer Pioneers podcast. If you enjoyed this episode and gained valuable insight, we would be so grateful if you could share our podcast with your friends and colleagues. And it would be even more wonderful if you want to give us a five-star rating, positive review, or any kind of feedback on Apple Podcasts or wherever you listen. The Veterinary Cancer Pioneers Podcast is presented to you by ImpriMed.