Signs Your Dog Is Dying

There’s No Expiration Date

If you’re reading this article, you are likely wondering if you are seeing signs your dog is dying. We are sorry that you have to read this article, and we hope it will help you to understand your dog’s situation better so you can get the assistance you need.

There is no expiration date for dogs, even though we use numbers like the median survival time to guess at how long you have left with your dog.

However, survival rate and prognosis (the likely outcome of the disease) are not perfect measurement systems but rather an approximation to aid in planning and expectations for dogs with cancer (or any health problem). Different diseases often follow patterns, so we can estimate how your dog will do based on how all of the dogs before her responded to their disease and treatments.

While prognosis and estimated survival time are helpful, they cannot provide exact death or disease progression dates. Because of this, it is beneficial to have broad expectations about how certain diseases generally progress.

This will help you answer questions like, “How long do I have with my dog?” and, “What will the decline in health look like over time?”

Ask Your Veterinarian What to Expect

Your veterinarian can advise you about whether your dog’s cancer is one that typically moves fast or one that generally progresses slowly. Knowing the approximate trajectory of illness can help empower you to actively provide comfort care and prepare and plan for a peaceful death with as little suffering as possible.¹

The rate of progression is different for every patient, and if your dog has multiple diseases, this can complicate the outcome.

Don’t Think of a Date

Part of the challenge of end-of-life care is the uncertainty. Despite our improving tools, no one can tell for certain when your dog’s last day will be. Veterinarians and veterinary oncologists can give a prognosis based on their findings, median survival time estimates based on their diagnosis, and thoughtful, well researched feedback on what your dog’s disease progression might look like, but none of us has a crystal ball.

If you hear “two weeks,” please do not think your veterinarian means “two weeks from today.” A vaguer but perhaps more helpful way to state a two-week time frame would be “weeks, not months.”

There Is No Test

There is research in human and veterinary medicine that suggests we may be able to examine biomarkers in DNA for clues. Still, no diagnostic test is available to know exactly when your dog will die.

Below are links to two studies that discuss some promising ways scientists are examining parts of human DNA to predict lifespan:

• DNA methylation strongly predicts lifespan and health outcomes in humans in this study- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6366976/
• Epigenetic clock and methylation studies in dogs (not yet peer reviewed): https://www.biorxiv.org/content/10.1101/2021.03.30.437604v1.abstract

Our advice? Listen to what your veterinarian says to expect when your dog is diagnosed with cancer, but don’t get hung up on that number. It is an estimate, not a guarantee.

Palliative vs Hospice Care

Palliative and hospice care are both meant to provide comfort, reduce stress, and offer symptom relief for the patient. The goal is not to try to cure, but instead to provide excellent quality of life during the time your dog has left with you, whether that is a long time or a short time.

The difference between these two terms comes down to whether or not any curative treatment option is going to be pursued.

Palliative care is often implied as end-of-life care in conversation, but it can actually take place at the same time as curative interventions. Palliative care is any care or treatment that you pursue at any time throughout your dog’s life to relieve symptoms of pain or illness.

Hospice care specifically refers to end of life care for a pet with terminal illness with no intention to try for a cure.³

Listen to Your Dog

In the absence of a diagnostic test, veterinarians and veterinary oncologists rely heavily on pet parents to observe and report changes they are seeing at home.

You know your dog best, and you are your dog’s best advocate. You know their subtle behaviors, routines, and body language. You also know the things they love best and how they typically react to the things that bring them the most joy.

Guardians are most often the first people to notice early signs of illness or distress. However, when faced with painful realizations and decisions, challenges can arise. Dogs are often very stoic and may mask signs of declining health as a survival tactic, every pet has a different threshold for pain and discomfort, and all disease processes have different progressions and expressions in unique individuals.⁴

You and your veterinarian can use pain assessment tools to evaluate how your dog is feeling. The pain assessment tools currently available in veterinary medicine are very useful but have their limitations because these patients cannot self-report – they depend on our observations. These tools will continue to be updated as more information is gathered about assessing wellbeing in nonverbal patients.^5-6

Even with thorough study and reliable pain assessment tools, humans have to be trained how to assess signs of decline accurately. In a study with a visual scale used by owners to measure chronic arthritis pain in dogs, researchers demonstrated the need for training of owners to recognize their dog’s behaviors as signs of pain.⁷

What does this mean for you? It means to listen when your veterinarian describes aspects of your dog’s behavior or physical state that concern them, and then apply that information to your own observations.

Try to look at your dog with an open mind and be honest about what you see and what your dog’s actions tell you.

Warning Signs a Dog is Dying

Warning signs are often subtle changes at first. Small changes to energy level, eating and drinking habits, breathing patterns, and behavior are clues to take seriously and to discuss with your veterinarian. Early intervention may improve these signs and overall quality of life.

If you notice severe changes or decline despite intervention, your dog may be telling you their body is reaching its limits. It is also possible that your dog may pass naturally while sleeping.

Here is a helpful framework used in human palliative care in the UK and Australia that refers to phases of illness as a system:⁸

• Stable – In this phase, problems and symptoms are adequately controlled, no new issues are showing up, and there are plans in place for future treatment interventions as needed. The patient moves out of this phase when the patient or caregiver’s needs increase.
• Unstable – This phase is associated with a higher level of pain in human patients. The patient is in this phase when an urgent change in the care plan or emergency treatment is needed because the patient has a new problem, or a current problem becomes more severe. This phase is also associated with a sudden change in caretaker circumstances that impacts patient care. When a new care plan is in place, the patient exits this phase, but that patient may be stable, deteriorating, or dying.
• Deteriorating – This phase is associated with the highest family and caregiver support needs in human medicine. Here, the patient experiences a gradual worsening of problems or a new but anticipated problem. Additionally, the caretaker(s) may be experiencing gradual worsening distress that impacts patient care. This phase is left behind when a patient hits a clinical plateau (stable), requires emergency treatment (unstable), or death is likely within days (dying).
• Dying – This phase is associated with the worst function in human patients. Death is likely within days. The patient only moves out of this phase if death is no longer likely within days, and they happen to transition to a stable or deteriorating phase.

The movement between these phases is not necessarily linear and consecutive. The stage designation is also not necessarily reliant upon a patient’s disease stage and prognosis.⁸ Your dog might jump between these stages throughout the course of her illness and treatment.

It is important to recognize that many of the signs a dog is dying are associated with modified, decreased, or absent natural functions such as energy, movement, drinking, eating, breathing, and going to the bathroom appropriately. Let’s look at some of those signs more closely.

Lethargy that Just Won’t Quit

Lethargy is a common finding in cancer patients, and it is a word commonly used to describe ill patients in veterinary medicine.

It can also be a confusing term for those not in the veterinary field. Differentiating between true lethargy and a tired dog is important for understanding illness. True lethargy involves an unusual level of inactivity and a lack of interest in rising and doing the things your dog normally does.

This is different than being tired because a dog that is simply tired may be sleeping a lot but can be woken and tempted by things like the mention of a walk or treat.

Lack of Interest in Food and/or Water

Dogs might not want to eat for a variety of reasons. These can include:

• dental disease
• cognitive or mental decline
• mobility issues
• pain
• vision loss
• anxiety
• nausea
• fever
• other systemic illness

Nausea can be seen with vomiting and diarrhea, but also with more subtle signs like lip licking and increased drooling. If your dog drinks water but won’t eat, it may be secondary to nausea, stress, or mouth pain.

As you can see, lack of interest in eating and drinking has a long list of possible causes. Some of these causes can be a part of cancer as an illness, but they should be addressed no matter what the underlying cause is. In many cases proper treatment will restore your dog’s appetite.

Loss or decrease of appetite is common in the final days of many illnesses but is not always a sign of impending death. If your dog is experiencing compromised appetite or desire to drink, please seek veterinary care promptly.

Movement Problems

Decreased mobility is very common in aging pets, and loss of mobility can cause extreme anxiety in pets.

Compromised movement may present as:

• slipping on tile and wood floors
• stumbling or falling
• inability to posture to urinate or defecate
• difficulty getting up or laying down or inability to get up/down without assistance
• no longer willing or able to go on a walk
• loss of stamina on walks
• challenges on stairs
• not jumping up on surfaces that were previously desirable (couch, bed, etc.)

Mobility challenges may lead to your dog not being able to stand. This is undoubtedly painful and can also be very stressful for dogs. Signs of anxiety associated with anything, including mobility challenges, are whining, heavy panting, restlessness, other vocalizations like barking, and fear responses in unusual contexts.

If challenged mobility goes unchecked, it may progress to bed sores, urine scalding, breathing abnormalities, and abnormal fluid accumulations in the body.¹⁰

Incontinence

Incontinence is the loss of ability to urinate and/or defecate at the appropriate time and in the appropriate location, and it has many potential causes.

Urinary incontinence can be confused with inappropriate elimination caused by cognitive or mental changes, anxiety, pain, UTIs, urinary stones, increased drinking of water caused by kidney disease, endocrine diseases, or some drugs (steroids). True incontinence can be secondary to spinal cord disease or damage to the bladder sphincter.¹¹

Differentiating inappropriate urination and incontinence can be difficult. Incontinence can present as unexpected leaking or dripping of urine while awake or asleep. Sometimes, it is first noticed after finding areas of irritation on skin near the genitals from urine scalding, or a dog continually licking their penis or vulva.

Fecal incontinence has two main types known as reservoir incontinence and sphincter incontinence. Reservoir incontinence is the result of disease of the rectum. It can be seen with any gastrointestinal disease (including cancer) where the pet is aware of going to the bathroom but cannot control the urge to do it. With this, you may find diarrhea with blood or mucus in inappropriate places.

Sphincter incontinence refers to disease of the anal sphincter where it cannot close properly, and feces leak out. This can be seen with a wound or mass on the anal sphincter as well as with nerve damage to areas that provide function to the sphincter. Dogs are unaware that they are dropping small amounts of feces, may drop feces when barking or excited, and may lick at the rectum.¹²

Urinary and fecal incontinence is common late in the process of dying and can be very stressful for a dog who has been housetrained their entire life.

It also makes it challenging to maintain hygiene, comfort, and overall quality of life when pets are soiling themselves.

Note, however, that not all terminal cancer patients will experience incontinence and not all incontinence is associated with a terminal disease.

Labored Breathing

Signs of difficulty breathing, or increased work of breathing, include:

• Extending neck out
• Open mouth breathing (not regular panting)
• Increased movement of the belly with breaths (abdominal breathing)
• Unwilling to lie down because it is easier for them to breathe standing

Respiratory distress is an emergency. Seek veterinary care immediately. It is reported as very painful and frightening for human patients.

Other breathing changes we can see during the final days of life include louder breathing, slower and deeper breaths at rest, and faster and heavier breaths when standing up and walking.¹²

Behavioral Changes

Behavioral changes can be associated with common end-of-life changes including anxiety, pain, and cognitive degeneration or changes in mental sharpness. It can be very difficult to differentiate between various underlying causes, but sometimes medication trials are useful to determine the cause and can offer some relief.

Behavior changes commonly associated with anxiety are whining, pacing, crying, panting, and overall restlessness.

Behavior changes associated with pain can be similar but also include sleeping more than usual, sleeping or resting in new areas, trembling, hiding, and new or worsened aggressive behaviors.

Behavioral changes associated with cognitive degeneration or mental decline include wandering the house, appearing to get lost in familiar places, and unexpected nipping or growling directed at well-known family members.

Unfortunately determining the cause of behavioral change can be difficult because some of the very different originating causes can look very similar to the guardian.¹³

Some dogs become less social and isolate themselves from family members as they approach death while others become more interested in staying near family members.

Any unusual behavior or changes in behavior are worth mentioning to your veterinarian. When thinking about end of life or declining quality of life, ask yourself questions like, does your dog express joy and interest? Are they responsive to their favorite toys, foods, places, or people?¹⁰

What You Can Do if You Think Your Dog is Dying

The first thing to do if you are concerned that your dog is dying is make an appointment with your dog’s veterinarian.

They may suggest diagnostic testing, a medication treatment trial, or non-pharmaceutical interventions that could drastically change your decision-making process. You don’t have to consent to any tests or treatments they offer, but you may not know all of your options until you explore them with a vet who understands your goals and has done a thorough physical exam and medical history review of your dog.

Even if you know that you do not want to take any drastic measures, consulting with your veterinarian can help improve your dog’s quality of life and ensure you have the best information to make the most informed decisions.

Many different perspectives may help you gather information about all the options for treatment and end-of-life care. Talk to your primary care veterinarian and/or your veterinary oncologist. Talk to a veterinarian with a special interest in hospice and end-of-life care. Talk to an integrative medicine veterinarian. Know your options so that you are the best medical advocate for your dog.

Here are specific interventions you can talk to your veterinarian about, and some changes you can make at home to support your dog.

Hydration

Methods for monitoring hydration status at home:

• Mentation or attitude (dehydration is associated with lethargy or lower energy)
• Mucous membrane color (gums should be pink in a healthy animal unless pigmented with black or brown). Pale gums or very dry gums can indicate dehydration.
• Skin tenting is a reflection of how fast the skin will return flat against the body when gently lifted. When the skin remains lifted or is delayed returning to its normal position, your dog may be dehydrated.
• CRT (capillary refill time) involves placing pressure on the gums to blanch them. The color should return in 1-2 seconds. If delayed, this may indicate dehydration
• Heart rate can be determined with stethoscope or by feeling the chest wall. The pulse may be felt by feeling the inner aspect of the upper thigh with very gentle pressure (femoral artery). This is best felt while your dog is standing. A heart rate greater than 160 beats per minute is high and can indicate low hydration status.
• Extremity temperature can be used to detect severe dehydration. If the room is warm but your dog’s feet are cold, that may indicate dehydration.¹⁵
• Note if your dog’s water intake and urine output are normal. If not, is it increased or decreased? If there is decreased intake, this may be a sign of dehydration.
• Increased drinking and urination can also result in dehydration.
• Steroid use and kidney disease can cause increased drinking and urination.
• The consistency of stools can also reflect hydration status. Is your dog’s stool quality normal, firm, or loose? Hard stools can indicate active dehydration. Soft to liquid stools (diarrhea) may indicate increased water losses from the GI tract and a need for supplemental hydration to prevent dehydration. This also applies to dogs that are actively vomiting.

Ways you can help increase fluid intake at home:

1. Transition to canned diet.
2. Add water to kibble.
3. Move water bowls to an easy to access location and have multiple water bowls around the house for easy access.
4. Use a syringe to gently wet the tongue to keep your dog comfortable in the later stages of the dying process. Symptoms of dry mouth may be more important to address than dehydration itself in final days according to human clinicians.¹⁴

NEVER force water or food down your pet’s throat. This can cause discomfort, anxiety, or aspiration of food or water into the lungs and lead to severe complications.

Your veterinarian may restore hydration with extra fluids in a vein or under the skin. This often depends on severity of the disease, the level of dehydration, and whether or not your pet will be hospitalized. You can also learn to give subcutaneous fluids at home.

IV or subcutaneous fluids may not be advised for your pet in the end stages of the disease process depending on what disease(s) your pet has. When misused, extra fluid supplementation can cause edema, tissue swelling, and fluid overload.

Please ask your veterinarian if fluid supplementation is warranted in your dog. They will help advise you on the best route for your dog’s individual scenario.

Support Appetite

Interventions to improve a compromised appetite will depend on the phase of illness. Earlier in the disease process, a complete and balanced diet is recommended.

Later in the disease process, nutritional considerations are different. Sometimes getting calories into your dog NOW is more important than making sure she is eating a healthy diet. Once she is feeling better and eating more regularly, she can be transitioned back to a diet more appropriate for long-term feeding.

When appetite is compromised in very ill patients, there are some medications that can be used to improve appetite and/or decrease nausea.

There are injectable and oral versions of anti-nausea medication. Maropitant (Cerenia^®) and ondansetron are commonly used medications in this context.

There are also medications specifically designed to increase appetite, such as Entyce or mirtazapine.

There is also some research suggesting a potential benefit to appetite from certain acupuncture techniques. Ask your veterinarian if this would be appropriate for your dog and if the service is available in your area.

Ways you can help stimulate appetite at home:

1. Adding canned food to the diet is a great option because it is often more tasty and can be easier to eat for pets with generalized weakness or dental disease. It is also a nutritionally complete option.
2. Add water or low sodium chicken broth to kibble to soften.
3. Warm canned food or moistened kibble to increase aroma. This may increase palatability for your dog or stimulate improved appetite. Use care when warming so that food is evenly heated and not too hot.
4. If there are other pets in the house, feed your dog in a kennel or separate room to decrease stress at meal time. Make sure food is in a highly accessible location with good floor traction.
5. Consider hand feeding your dog.
6. Add a small amount of a tasty treat such as cooked meat or whipped cream to the top of your dog’s food to get her started eating.
7. Try feeding off a plate so your dog thinks she is getting “special” human food.

Ask your vet about diet changes and their recommendations for prescription diets, over the counter highly palatable and digestible diets, or home cooked diet options for your dog.

Assisted feeding using feeding tubes may be of limited benefit in end-stage human cancer and is used with extreme caution and in limited circumstances in veterinary medical cancer patients due to serious considerations for quality-of-life vs benefit. If you are considering this, discuss the risks and benefits in detail with your veterinarian to determine if this is appropriate.¹⁸

NEVER force food or water down your pet’s throat, as this can cause discomfort, anxiety, or aspiration of food or water into the lungs and lead to severe complications.

It is important to consult with your veterinarian about nutrition and medication with end-of-life care and how to weigh the cost-benefit analysis of different dietary changes and medications.

Safety

Mobility and mental function may decrease with end-stage cancer. This can result in an increased risk for falls, episodes of collapse, and injury.

Ways you can help:

• Improve traction for better mobility by using rugs, bathmats, yoga mats, or adhesive carpet squares on tile or wood floors to create accessible paths around the house. Some dogs will tolerate adhesive pads for their paws or booties. Dogs with lots of fur between their paw pads may benefit from having the excess fur trimmed carefully with electric clippers to help expose their paw pads and improve their traction.
• If you have a multilevel home, set up your dog’s food, water, and toys on the ground floor to avoid stairs.
• Baby gates or pet gates can be used to block off potentially dangerous areas, stairs, or other pets that may want to play rough when you are unable to supervise play.
• Consider putting your dog in their kennel when you need to leave them unattended or at night.
• Remove furniture your pet could knock over or jump up on/fall off. Depending on how mobile your pet is, stairs or ramps onto couches or other furniture might improve comfort and safety with easy access to a favorite place.
• Use a harness/sling to support walking when needed and support posturing to urinate and defecate. You can use a towel under the abdomen in this way.
• Take your pet out more frequently to urinate and defecate to decrease the risk of soiling themselves. If possible, provide an indoor area that is ok for them to use like puppy pads or artificial turf near the door, so they don’t have to go as far.
• Keep fur around the genital area clean and dry to prevent urine scalding and infections.
• Keep bedding clean and dry.
• Monitor with a pet sitter or a “nanny cam” if appropriate.

Ask your vet about products they recommend that support mobility. These can include harnesses, wheelchairs, adhesive pads for paws, etc.

There are also some interventions that can be used to support cognitive or mental function. These include omega fatty acid supplementation, some prescription diet recommendations, selegiline, propentofylline, cognitive enrichment, and acupuncture.¹⁹

Pain Management

Pain management is extremely important and goes hand in hand with anxiety management. It is not always clear if pain or anxiety is the primary problem, and one can exacerbate the other.

Common signs of pain include:

• Decreased activity
• Avoiding stairs and avoiding jumping onto surfaces
• Difficulty standing after laying down
• Decreased appetite
• Licking or overgrooming an area
• Restlessness
• Vocalizing at unusual times or in a dog that is often quiet
• Hiding

Here is a link to a detailed pain checklist:

https://ivapm.org/wp-content/uploads/2022/07/IVAPM_2020-Is-Your-Dog-in-Pain-Handout_WEB-8-10-20.pdf

Here is a brief inventory checklist that may be more user friendly for assessing pain: https://www.vet.upenn.edu/docs/default-source/VCIC/canine-bpi.pdf?sfvrsn=6fd20eba_0

Sometimes pain can be difficult to diagnose explicitly and trying a pain medication can be extremely useful both in a treatment and diagnostic context.

It is important to understand that it is best to anticipate and prevent pain in animals rather than treat it in its advanced stages. The use of multimodal pain management (a combination of drugs and/or other therapies with different mechanisms of action) is often most effective, and using non-pharmacologic interventions to manage pain is extremely useful and often reduces risks associated with any individual single treatment.

DO NOT give over-the-counter pain medications or your own prescription medications to your pet. Many NSAID medications for humans can be deadly to pets, and dosing instructions and efficacy may look very different in prescription medications in animal patients.

Consult your vet for medication recommendations that are safe and effective for your dog. There are excellent combinations of prescription and over the counter medications and supplements to provide pain control while limiting side effects for your dog.²⁰

Pain management options for dogs include:

• Veterinary specific NSAIDs
• Gastroprotectants and antacids
• Opioids
• Gabapentin
• Amantadine
• Methocarbamol
• Local anesthetics
• Low dose ketamine injections
• Glucosamine/chondroitin supplementation
• Certain prescription diets
• CBD oil
• Omega 3 fatty acid supplements
• Cryotherapy and thermotherapy
• Therapeutic ultrasound
• TENS (electrical therapy)
• Therapeutic laser
• Acupuncture
• Manual therapy
• Shockwave therapy
• Platelet-rich plasma or stem cell therapy
• Massage
• Range of motion exercises
• Physical therapy (including therapeutic exercise like underwater treadmill or swimming)

Your vet can also advise you on the use of a “pain vacation.” This is often a one-day in-home hospitalization using IV pain meds to facilitate humane euthanasia at the end of a very good and pain-free day.

The use of an emergency injectable dose of medications or oral medications can be used if your pet has an emergency and needs short term pain relief, anxiety relief, or sedation to be transported to an ER or to your primary vet’s office for further care or humane euthanasia.²¹

Life Quality

There are many quality-of-life questionnaires and assessments available that can help you and your family assess your individual needs and your dog’s overall health and wellbeing.

Framework of The Five Freedoms associated with quality of life may be helpful in assessing overall welfare:¹⁷

• Freedom from hunger and thirst
• Freedom from discomfort
• Freedom from pain, injury, or disease
• Freedom to express normal behaviors
• Freedom from fear and distress

In many ways, you are evaluating pain, a ratio of good days to bad days, appetite, control of body function, enjoyment of previously loved things or activities, limitations on treatment options, and your own comfort and feelings about euthanasia.

One technique that can help you simplify your thinking is to use a wall calendar and put an X through bad days and a star or heart on good days. Seeing that there are more bad days than good over time can simplify this very difficult decision-making.

Your veterinary team can help you create an end-of-life plan that gives you and your dog the comfort and kindness you both deserve. Your veterinarian is also an excellent resource for helping you answer questions about your dog’s quality of life. It can be hard for a guardian to recognize some of the compromises in quality of life and this is normal.

Here are other resources for evaluating quality of life:

1.  The Ohio State Quality of life Assessment is Extremely useful and accessible https://vet.osu.edu/vmc/sites/default/files/import/assets/pdf/hospital/companionAnimals/HonoringtheBond/HowDoIKnowWhen.pdf
2. https://www.lapoflove.com/how-will-i-know-it-is-time/lap-of-love-quality-of-life-scale.pdf
3. https://www.lapoflove.com/quality-of-life-assessment
4. https://veterinarypartner.vin.com/default.aspx?pid=19239&id=4951966

Manage Your Grief

Anticipatory grief is experienced while your pet is alive. This is very common. Signs can look different than grief after the loss of a beloved pet, but are still valid. Those grieving prior to a pet’s death are deserving of help and are welcome in pet loss communities.^9,16

Managing your grief in a healthy way can help you to balance your emotional needs and distress with the care that you still need to provide for your dog. It is OK to be sad that your dog is ill and to acknowledge that sadness. But also try to take time each day to focus on the joys of still being with your dog.

Sit by your dog in her favorite spot and just be with her. Think about the good things in that moment and engage her in any activities that she still enjoys. And if you need to cry, cry.

There are many grief resources such as support groups, counselors, and memorials to treasure your dog’s memory.