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Quality of Life at End of Life: Pain Management

euthanasia

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Alice Villalobos, DVM, Fellow Emeritus NAP Pawspice 2019-07-22

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Southern California Veterinary Medical Association
End of Life Care Symposium
Thursday, August 27, 2015

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PEACEFUL PETS AQUAMATION
THE GREEN AND GENTLE ALTERNATIVE TO CREMATION

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Hill’s

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Zoetis
FOR ANIMALS, FOR HEALTH, FOR YOU

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WE CARE FOR YOUR BEST FRIEND
PAWSPICE

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Lap of Love
VETERINARY HOSPICE & In-Home Euthanasia
SoCal@LapofLove.com
(949) 310-0938

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ATLAS
Immune Systems Go!

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Rx Vitamins
for PETS
Professional Veterinary Formulas

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Valley Drug
And Compounding.Inc
16928 Ventura Blvd
(ONE BLOCK WEST OF BALBOA)
Encino, CA 9136
Tel 818-788-0635
Fax 818-386-2688
Toll-Free -1-877-482-6231

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Dr. Auuie Forslund. FVM
When it’s time to say goodbye…
Home Pet Euthanasia
Of Southern California
714-454-4080
www.homepeteuthanasia.com
IAAHPC

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AB SCIENCE
DIAMONDBACK
DRUGS

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SCVMA
End of Life Care Symposium
August 27, 2015
Houssel Theater, Long Beach Memorial Medical Center
Dedicated to the late:
Jeff Sanders & Sophia Yin, DVM, ACVB

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Quality of Life at End of Life
Pain Management
Decision Making:
Cases & Role Playing
Alice Villalobos, DVM, Fellow Emeritus NAP
Director: Pawspice & Animal Oncology Consultation Service
Hermosa Beach & Woodland Hills, CA
pawspice@yahoo.com
www.pawspice.com

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End of Life = 4th Stage of Life
- Can happen at any age!
- Often lasting a short time
- May extend: weeks, months, years
- Patient needs care to remain well
- Patient needs QoL assessment
- Patient declines toward death

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Dog being pulled in a cart

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Being Mortal
Medicine and what matters in the end Atul Gawande, MD 10-2014
-What are your PRIORITIES?
-What are your GOALS?
-What are your FEARS
-What TRADEOFFS are you willing to make for QoL longer life?

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Jack, 12 YO, Mx, Mal-shep Mix
STS: Several Sx’s
Recurrences
Mass enlarging rapidly
Difficulty walking
Still eating and active

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Dog with a tumor on his body

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Tumor being measured on a dog's shoulder

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LULU Mandl: June 11, at presentation

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LULU with a growing tumor on her shoulder

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Lulu mandl:
15 YO Fs Pit Mix
Presumptive Sarcoma
R axilla and P-S Node
Pawspice clinical trial
6-11-14 to 7-20-14
ST 6 weeks from start

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Validate the family’s Human-Animal Bond
- Ask how important their pet is in their life.
- Talk about the special HAB that they share.
- Talk to the patient.
- Reassure all concerned.

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Can Pawspice Give Hope?
- Hospice Helps us Redefine HOPE.
- The goals of end of life care are QoL.
- Apply this goal to actual hospice cases.
- Families feel it is a gift that bridges a gap.
- Cases: real life stories of love and hope.
- You, your practice, and your community can benefit from this emerging specialty.

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CASE Report: Savannah Rose:
12 1/2 YO F/S Basset Hound; Presented: 4-28-15
Hx:3 surgeries Recurrent CSA right rib cage with mets in her lungs
Rapid growth since last Sx only 3 weeks ago
Family: 80 YO couple, 2 deceased children 3 Basset Hound HH
QoL Discussions with family each visit
Progressive Disease
Home Euthanasia: 8-10-15

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The HHHHHMM Quality of Life Scale
- The acronym of 5h’s stand for:
- Hurt,
- Hunger,
- Hydration,
- Hygiene,
- Happiness
The 2 M’s stand for:
*Mobility
*More good days than bad days.

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Quality of Life Scale
- Proposed tool to assess patient QoL:
- Can be used on an “as needed” basis:
- Monthly
- Every other week
- Every Week
- Daily
- Hourly

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Score
0-10
Criterion
Hurt
Ability to breathe is top concern.
Pain Control is essential.
Is the dog breathing properly?
Is Oxygen supplementation necessary?
Is patient’s pain well managed?
Is there breakthrough pain?
Is pain being recognized?

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Coment Rome 10 YO Mx Chi
2-2-15 Presented Pulmonary CA Pleural Effusion
Pawspice
Palliative mCTx
5-26-15 Coughing Heart murmur
Pawspice Eol Palliative Tx for heart

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5-26-15 Coughing, suspected PD
PE: Detected advancing heart murmur
Palliative Medicine for heart disease

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Image

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#1 Ability to Breathe Properly: Outweighs All!
Oxygen Tx at home is very helpful Nasal Passage Cancer
Night Stridor: Managed by training dog to sleep holding a ball or toy in mouth to keep airway open as with panting.

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Image

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There are Many Pathways of Cancer Pain
!Perception!
Afferent
Efferent
Transduction
Transmission
Modulation
Projection
Noxious Stimulus
Mechanical
Chemical
Thermal
Neuroplasticity
Nociceptors
Nerve Fibers
Sensory
Experience
Tissue Damage
Osteolysis
Compression
Stress
Distress
Suffering
Severe
Acute
Chronic
Breakthrough
Somatic
Visceral

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Magellan Rhea: Multiple Myeloma: CTx for 2 years before onset of severe pain & disability. Pain controlled.

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World Health Organization Analgesia Ladder
This 3-Step WHO Approach is Simple.
Many c.a.’s need a more complex approach due to severe cancer pain.
NSAIDs
Pain
Non-opioid +/- Adjuvant
Weak Opioids (codeine)
Weak opioid */- non-opiods+/- Adjuvant
Pain Persisting or Increasing
Strong opioid +/- non-opioid +/- Adjuvant
Strong Opioids(Morphine)
Freedom From Pain

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Bisphosphonates Role in OSA Tx
IV: w 3-4 weeks Pami,
PO: Alendronate
Residronate

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CANCER PAIN AT PRESENTATION
*Severe
Moderate
Mild
*NEED REVERSE PYRAMID APPROACH

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Breakthrough Pain:
Bolus IV Fentanyl 2-3mcg/kg & CRI..
Microdose Ketamine Bolus IV 0.65mg/kg
CRI 2mcg/kg/min

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Analgesic Reverse Pyramid Approach
Multimodal
Pain
Tx
Use multiple classes of analgesics at diagnosis.
Once pain is reduced, then decrease Tx.

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Inflammatory Breast Cancer: Extremely Painful
Fentanyl Patch
Tylenol 15mg/kg BID x 5d
Oxycodone 0.3mg/kg PO BID x 3d
Dor Breakthrough pain
Recuvyna Q 7d

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“GAT” protocol
- Gabapentin:10mg/kg TID
- Amantadine: 3mg/kg/d
- Tramadol/Trazadone + NSAID + famotidine

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HUNGER
1-10
Is the pet eating enough?
Does hand feeding help?
Does the patient need a feeding tube?
Control nausea., vomiting.

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Lingual SCC: Grim PX. Most cats need feeding tube placement.

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Magic Reid: 6 YO Mix, E.coli Enteritis, IBD, Severe Pain, Anorexia Esophageal Feeding Tube saved his life

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Image

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0-10
HYDRATION -
Is the pet dehydrated?
For patients not drinking enough,
Teach family to give SQ fluids.
Control diarrhea, fluid loss.

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SQ Fluids help > QoL for dehydrated EoL pets.

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Quality of Life Scale
0-10
HYGIENE
The pet should be brushed and cleaned, particularly after eliminations.
Avoid pressure sores with soft bedding.
Keep all wounds clean.

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0-10
HAPPINESS
Does the pet express hoy and interest?
Is the pet responsive to family, toys, etc.?
Is the pet depressed, lonely, anxious, bored or afraid?
Can the pet’s bed be moved to be close to family activities?

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Image

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Sheila 11 YO GR: MxFacial FSA
Greg Pyeatt of HB & Cabo

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Image

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0-10
MOBILITY
Can pet get up w/o assistance?
Does pet need human or mechanical help (e.g., walking harness or cart)?
Does pet feel like going for a walk?
Is pet having seizures or stumbling?

[Some caregivers feel euthanasia is preferable to amputation. But a dog with limited mobility, yet still alert and responsive, can have a good quality of life as long as carers are committed to helping their dog with daily activities.] AV

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Amputation 5 years ago for CSA
OA is EoL problem

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Image

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Scott Rhea’s Magellan: Multiple Myeloma; treated with CTx/ImNTx for 2 years before onset of severe pain & disability. Pain was controlled and cart was helpful.

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0-10
MORE GOOD DAYS THAN BAD
When bad days outnumber good days, QoL might be too compromised.
When a healthy HAB is no longer possible, carers must be made aware that the end is near.
That decision for euthanasia needs to be made if the pet is suffering pointlessly.
If death comes peacefully and painlessly, that is okay.

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TOTAL
A total of 35 points plus represents acceptable QoL to continue Pawspice & EoL care for the patient.
If a low scoring criterion can be improved by 30-50%, the pet’s QoL may improve.
The HHHHHMM QoL Scale helps carers make the difficult decision to give their pet the gift of euthanasia as final act of love to assure a peaceful and painless passing.

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Age 22 years!
Retired Guide Dog, San Raphael.

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Decision Making
For QoL at the End of Life

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Image

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Being Mortal
Atul Gawande, MD
- What are your PRIORITIES?
- What are your GOALS?
- What are your FEARS
- What TRADEOFFS are you willing to make?

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Lazarus Davis 2008 Pawspice #1 stage five myeloproliferative disorder
WBC =659,500 end stage crisis from CLL
2010 severe suppurative cholangiohepatitis: Standard & PM Pawspice #2
3-2011: Hepatic Failure, Transcolonic Portal Scintingraphy Pawspice #3
BMSC-HGF + EPO +T-Cyte +3 TFx’s

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Often, carers feel alone.
They look on the Internet for answers.
Searching for positive options & expertise

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Do the Research and Think!
What do YOU want to know TODAY?
VETERINARY INFORMATION NETWORK
http://www.VIN.com
Do the Research and Think

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BMSC-HGF +EPO +T-Cyte + 3 TFx’s
Pawspice #3

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Sacrifice or Caring for pets
-Issues with: frustration, attachment, anticipatory grief, guilt, depression, resignation, hope & determination strum upon the fibers of the family.
-If the atmosphere at clinic is rushed, it boils down to a lot of dissatisfaction on both sides of the exam table.
-Carers may feel doctor is insensitive.

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Image

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Remove Barriers
- Front Desk Insensitivity, brisk attitude
- Telephone Insensitivity
- Rushed Office Visits
- Valuable words are left unsaid
- Client forgets to say something
- Doctor forgets to give best advice

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Conflict of Interest?
-The attending doctor struggles with many issues such as:
-Personal bias, personal ethics normative ethics]
-The practice philosophy
-Overall practice economics
-The client’s economics

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Avoid Dissatisfaction on Both Sides of Exam Table
- Fill the need for empathy & compassion.
- Schedule enough time to discuss options.
- Give recurrence & multiple comorbidities as much attention as your original level of care and attention.
- Foster doctor-client relationship

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Image

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Since 2008 to 2012,
Carolyn Davis, a film editor, went from being able to afford the best care for Lazarus
To at times owing us over $2.000 for long periods.
She was barely scraping by with maintenance Tx care for Lazarus.
Then another crisis!
October 3, 2012.

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Image

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Drs. Avoid bad News Talk
- Some serious consequences for patient s.
- “Patients lose good time with their families and for reflection and spend more time in the hospital and intensive care unit.”
- The avoidance of BNT can be neglectful.
- 50% lung cancer pts. in the USA are not offered hospice at 60 days before death.
- Bad news talks are potentially cost effective.

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Rufus Gleason at EoL: 3 year Pawspice with Nasal CSA

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Patient Centered Communication at End Of Life
- Effective communication is key to delivering quality care, avoid errors, save money and achieve better outcomes.
- Patient Centered Communication is effective and avoid the disparities that many veterinary facilities are facing.
- Communicating bad news and supporting your clients during end of life is an essential skill for Pawspice staff.
Clients need and expect us to be proficient in delivering bad information in a clear and compassionate way.
- The art of compassionate communication can be-mystify and de-stress the ‘bad news’ picture.

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Image

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Decision for palliation
- Medical comfort care (non-curative)
- Pain management
- Infection control
- Nutritional support
- Non-curative surgical procedures
- To make any condition less severe of complementary therapies, etc.
- To Improve Quality of Life!!

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Knowing Client Preference
There is growing trend of pet owners who want to keep their terminal pet at home.
They want sophisticated supportive care until their pet pass away at home on their own
Most want to provide their own EoL home care or Pawspice that will end with the final call for euthanasia when QoL declines.

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Image

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Patient Advocacy
- Patient Advocacy is a concept that most DVM’s think they understand, but probably don’t comprehend the scope.
- In its simplest terms, patient advocacy regards any activity that ultimately benefits a patient.
- It can apply to caregiving for an individual patient, to groups that develop policies and advice that help.
Patients, to government groups that develop legislation to improve systems for patients.
- This type of advocacy requires knowledge of the healthcare system and a medical background.
The veterinary nurse is in a key position to expand this field and its potential influence in VM.

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Image

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Decision Making Dilemmas
- Do advanced recurrence cancer patients get sent home with no hope and no supportive advice?
- Should one forego further treatment when a remission is unlikely?
- Can we enhance a geriatric patient’s quality of life with aggressive palliative care and mCTx?
- Daily chlorambucil at 2mg/M2 or lomustine at 4mg/M2 well tolerated; + NSAIDs + T-K-‘s; may achieve partial remission or stable disease.
- (Sophia Vallozzi: SCC, L z-arch, nasal sinus,Mx)

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Image

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20 YO, Missy Wayne

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How Far Is Too Far?
- Progressive or Minimalist DVM? PV or MV
- MV’s unwittingly practice their bias
- MV’s may avoid radical procedures
- MV’s look at old age as a barrier
- MV’s are “down to earth” practical
- The MV’s may be surprised when clients seek Dr.Google or second opinions.

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What Model Works Best?
- Patriarchal vs. Partnering for Decision making
- Situations of complexity and high client need
- Has the ba for care been raised higher than most DVM’s are prepared or willing or to offer?
- Can we trust pet owners to know what is best for their companion animal?
- Can we depend on the pet owner to make the proper decision for their pet?

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Framework for Ethical Decision-Making
- ethics.ubc.ca/upload/FrameworkEthicalDecision
- There is no perfect answer!
- Need: guidance & kindness during DM
- Options for kinder Tx & palliation appreciated.
- For me, it is caring for the HAB
- Each heartstring is plucked out at EoL
- These goals bestow a greater and sublime purpose to the art of veterinary practice.

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Decision Making
Decisions are often based upon the patient’s HHHHHMM Quality of Life score.
Euthanasia is elected if QoL score <35 points…..
Or
If QoL is dropping to a low point where life is not worth living.

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Any Questions?

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Book Resources:
Mcmillan, F.D., Mental Health and well-Being in Animals, Blackwell Publishing, 2005.
Rollin, B.E., Veterinary Medical Ethics: Theory and cases, 2nd ED., Blackwell Publishing, 2006.
Shearer et al, Palliative Medicine and Hospice Care, NAVC, Small Animal Practice, Vol. 41, No.3, May 2011.
Villalobos, A., Canine & Feline Geriatric Oncology: Honoring the Human-animal Bond,
Blackwell Publishing, 2007 (www.wiley.com)

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Canine and Feline Geriatric Oncology
Honoring the Human-Animal Bond
Alice Villalobos, DVM with Laurie Kaplan
www.wiley.com
Amazon.com
Help Your Dog Fight Cancer
So Easy to Love: So Hard to Lose
Laurie Kaplan
TheMagicBullet Fund.com

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PEACEFUL PETS AQUAMATION
THE GREEN AND GENTLE ALTERNATIVE TO CREMATION

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Hill’s

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Zoetis
FOR ANIMALS, FOR HEALTH, FOR YOU.

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WE CARE FOR YOUR BEST FRIEND
PAWSPICE

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Lap of Love
VETERINARY HOSPICE & In-Home Euthanasia
SoCal@LapofLove.com
(949)310-0938

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ATLAS
Immune Systems Go!

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Rx Vitamins
For PETS
Professional Veterinary Formulas

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Valley Drug
And Compounding.Inc
16928 Ventura Blvd
(ONE BLOCK WEST OF BALBAO)
Encino, CA 91316
Tel 818-788-0635
Fax 818-386-2688
Toll Free -1-877-7482-6231

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Dr. Auuie Forslund.DVM
When it’s time to say goodbye...
Home Pet Euthanasia
Of Southern California
714-454-4080
www.homepeteuthanasia.com
IAAHPC

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AB SCIENCE
DIAMONDBACK
DRUGS

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PAWSPICE
We care for your best friend
www.pawspice.com

HERMOSA BEACH
1580 pacific Coast Hwy
Hermosa Beach, CA 90254
562-493-5025

WOODLAND HILLS
20051 Ventura Blvd
Woodland Hills, CA 91364
818-712-0060

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