Grain-free Diets Are Potentially Linked to Heart Disease in Dogs

By Abigail Messina, DVM: Veterinarian at Vet At Your Door, P.C. and
Deirdre Frey, VMD: Owner, Veterinarian at Vet At Your Door P.C.

The problem: As you may or may not have heard, this past July the FDA administered a warning that some diets may be associated with Dilated Cardiac Myopathy (DCM) in dogs.  Specifically, the diets in cases reported to the FDA frequently list potatoes or multiple legumes such as peas, lentils, other “pulses” (seeds of legumes), and their protein, starch and fiber derivatives early in the ingredient list, indicating that they are main ingredients. 

DCM is a heart condition where the heart muscle gets thin and flabby, and the chambers of the heart become dilated, causing the heart to be weak and unable to beat properly.  As of now, it is thought that many of the ingredients in several “fad” diets block the adequate absorption of taurine - an amino acid that is integral to heart health.  Taurine deficiency is proven to be related to DCM.

More specifically, the incidence of DCM has increased in dogs eating boutique, grain-free, or diets with exotic ingredients such as kangaroo, lentils, duck, pea, fava bean, buffalo, tapioca, salmon, lamb, barley, bison, venison, chickpeas, potato, or other legumes/beans/seeds. It has also been seen in pets being fed vegan, raw, or home-prepared diets.  It is unclear at this point whether there are certain breeds that are more likely to develop DCM, however there seems to be higher incidence in Golden Retrievers and Cocker Spaniels.

Why is there such a higher incidence now than before?  Many more pet owners are feeding grain-free, boutique or exotic ingredient diets because they are portrayed, via excellent marketing, as more natural, or healthier than traditional diets.  These companies’ marketing messages also often imply that grains cause many health issues with pets.  In fact, the actual incidence of grain allergy in dogs is less than 0.5%.  Moreover, there is no scientific evidence that feeding these types of diets is healthier than any other diet.  Additionally, many of these food companies do not have veterinary nutritionists on staff, nor do they perform long-range peer-reviewed studies on their food. As demonstrated by this DCM issue, this can be very dangerous.

Here are some FAQs:

1. How do I know if my dog’s food falls into this category?
Overall, grain-free, exotic, or boutique brands seem to be the biggest culprits.  Look at the ingredients of your dog food.  Are potatoes or multiple legumes such as peas, lentils, other “pulses” (seeds of legumes), and their protein, starch and fiber derivatives in the first four or five ingredients? Are there exotic proteins in the first few ingredients (buffalo, bison, alligator, etc.)? If either of these questions are yes, your dog may be affected.  If you’re still not sure, you can email us at and we can tell you if your food may be one of those affected.

2. OK so what do I do if my dog may be affected?
The safest thing would be to test a taurine level (about $170) and have us assess your dog’s cardiovascular status.  If the taurine level is below normal or we notice any cardiac abnormalities on our exam, a supplement should be started immediately, the food switched, and ideally an echocardiogram (ultrasound of the heart) should be performed. 

3.  What are signs of DCM?
Decreased energy, cough, difficulty breathing and episodes of collapse.  Unfortunately, there may be no symptoms until the DCM is end-stage.

4.  What if I can’t afford the blood work or diagnostics?
We know this can add up. If you can’t afford testing, we recommend switching your dog as soon as possible to a safe, nutritious food with a proven track record (see below for ideas).  Supplementing taurine without diagnostics can be dangerous so it isn’t recommended.  It’s possible that switching the food can be enough to reverse the course of asymptomatic DCM. 

5. Are cats affected too?
There hasn’t been as much research done on cats and at this time, there doesn’t appear to be a correlation between these types of diets and DCM in cats. 

6.  What if I am feeding my dog one of these foods and I can’t afford blood work or diagnostics?
We recommend switching them as soon as possible to a safe, nutritious food (see below for ideas).  Supplementing taurine without diagnostics can be dangerous so it isn’t recommended. It’s important to note that there is a risk that there is DCM happening in your dog that you won’t know about, but it’s possible that switching the food can be enough to reverse the course of the DCM. 

 7. My dog’s skin and/or GI system are now so much better after switching to one of these diets.  What should I do?
There are true food allergies that can be helped by these foods due to their limited ingredient and/or exotic protein nature.  However, now that DCM is a risk, you can either find another brand (see below) and slowly switch to that food to see if skin / GI issues recur.  Alternatively, you can test your dog’s taurine level. If it’s normal and you’ve been feeding that food for awhile, it is likely ok to continue feeding. 

8.  What are brands you recommend switching to?
There are about forty bajillion brands out there so this is a difficult question.  REST ASSURED, we are not paid by any company to endorse them and we are not “brainwashed” by them either.  We recommend foods made by companies that do top-notch food trial studies on animals for LONG periods of time (i.e. years) and who have veterinary board-certified nutritionists on staff.  Namely, Purina Brands - ProPlan, Merrick, Chow, ONE, etc.; Hill's brands: Science Diet, Healthy Advantage, etc.; or Mars brands: Royal Canin, Iams, Eukanuba, Nutro, Pedigree, etc.

9.  Where can I read more on this topic?
We recommend looking at Tufts School of Veterinary Medicine’s article and UC Davis School of Veterinary Medicine’s article on this important topic.  These are board-certified, unbiased, veterinary nutrition specialists talking about this problem. 

We know this is a scary topic, and that many of our clients feed grain free foods.  We promise to stay abreast of this topic as the research becomes more available and more scientific facts are brought to light, and we will continue to keep all of you in the loop as well.  As always, please don’t hesitate to reach out and ask any questions you may have about all this. 







Giving the Gift of Peace

By Abigail Messina, DVM: Veterinarian at Vet At Your Door, P.C.

 Sweet Emmy

Sweet Emmy

“Goodbye, sweet friend” she said as she planted one last gentle kiss on her beloved dog’s forehead.  Emmy was an adorable little Lhasa Apso, who had helped more people in her 17 years than most humans do in a lifetime. Her owner was a social worker who used to bring Emmy along to her appointments, and she witnessed first hand the amazing healing ability of four paws and a wagging tail. As veterinary professionals, euthanasia is a very common, very normal part of our jobs.  Most of us are able to push through the grief of the families involved, and focus on the good that is being done with this hard task.  The peace, the comfort, the respect, the dignity that is being given to these furry little family members.  It is without a doubt one of the most emotionally conflicting aspects of our jobs; knowing that after you are done this family will have to cope with a huge hole in their household, but also knowing that you are helping this pet in the most compassionate way possible.  However, there are certain euthanasias that break through that calmness, that professionalism.  Those ones that hit you like a sucker punch in the gut, and you carry that sadness around with you for days.  Sometimes they are patients or clients we have grown close with throughout the years, sometimes they are ones we have just met that day.  We get to see first-hand the bond between owner and pet in it’s purest form, and sometimes the raw emotion and love experienced in that moment is overwhelming. 

 We become a counselor to the family in dealing with and working through the loss. 

We become a counselor to the family in dealing with and working through the loss. 

I have always gravitated towards hospice care and euthanasia - which I know sounds horrible on the surface, but hear me out.  There are so many times throughout your career as a veterinarian where you feel as though you don’t know enough, can’t offer enough, can’t help enough.  Veterinarians and their support staff are some of the most empathetic and selfless people out there, and we are also perfectionists. That makes several parts of medicine difficult - as nothing in life is perfect, and despite your best efforts, not everything always turns out the way it should.  In euthanasia, I can be more helpful than I will ever be at any other time in that pet’s life.  Their pet is declining, it’s body is failing and I can help. I can help the family have peace and comfort with the decision they need to make.  I can help the pet pass with the love and dignity that it deserves.  I can help give them a level of comfort and happiness that no medications in this world could bring.  And I can be there for that family even after their pet is gone, and be a source of healing for them.  My clients expect me to be honest in all situations - but especially when it comes to end-of-life care and helping them determine when it’s time to say goodbye.  They trust me most, with this.  It is a huge responsibility and an honor to be the one to help them; to not only be their vet, but to be their friend, their counselor, their lifeline.  

 Helping owners make the end-of-life decision is one of the most important things we do. 

Helping owners make the end-of-life decision is one of the most important things we do. 

Since becoming a house-call vet, I have grown to cherish these appointments even more.  Home euthanasias are so much more intimate and relaxed, and while it is still understandably a sad appointment, it is also the most beautiful one.  Everything is more natural and at ease - the family is in their own home, the pet is on their own bed surrounded by the people and the things and the smells that they love and are familiar with.  We have the time to sit and share stories about their pet when they were younger, or the struggles and changes they helped their owners through.  There is oftentimes laughter as well as tears.  We are able to focus on the family and their beloved pet who is about to say goodbye; there are no distractions, just the quiet beauty that is that last act of love.  It is by far the most real, most emotionally honest appointment we see, and I am so privileged to be a part of that.

I had never met Emmy and her mom before, but the sweetness and the love that I witnessed that snowy morning was so impactful that I couldn’t help but be affected by it.  It is times like this that I am grateful for what I do, and I love my job; and I am so thankful to those past, present, and future families that allow us to help them through this part of their pet’s life.  

Making Bailey Walk Again

By Abigail Messina, DVM: Veterinarian at Vet At Your Door, P.C.

As we rode the ferry over to Peak’s Island, we were thankful for the morning fog, as it gave us a temporary reprieve from the hot August sun.  We wondered what waited for us at the other end of the ride, and were packed and prepared for anything.  We had received the call yesterday, from an owner who was desperate for us to help her beloved old Dachshund named Bailey.  He had become suddenly paralyzed a few weeks prior without explanation - no trauma, no injury, just woke up one morning paralyzed and exquisitely painful.  He had received veterinary care prior to our visit, but the pain meds didn’t seem to be cutting it, and he continued to be uncomfortable and frustrated by his inability to walk. Unfortunately, this is all too commonly seen - especially in Dachshunds and other breeds that are longer than they are tall.  They are predisposed to Intervertebral Disc Disease (IVDD), a condition where the cushioning discs between the vertebrae of the spine bulge or burst (herniate) into the spinal cord space.  The herniated disc material puts pressure on the spinal cord and nerves causing pain, nerve damage, and paralysis.

 Bailey when we first met him, nestled in his blankets!

Bailey when we first met him, nestled in his blankets!

As we walk up the steps into the house, we see an adorable, little old Dachshund snuggled into a pile of blankets.  His eyes were clouded with age, his velvety brown fur speckled with gray, and his short little legs were folded up beneath him.  His mom had called us out to help relieve his pain - with medications if possible, but if we thought his comfort was unattainable, she was prepared to have us euthanize him, so that he could pass with dignity and be at peace.  As I began to evaluate Bailey, I found him to be significantly painful over his neck and lower back, he couldn’t move his neck side to side without it hurting, and 3 out of 4 legs were unable to support him, making it impossible for him to stand or walk on his own.  The disc herniation had affected the nerves for his front legs, his back legs, his bladder, and his rectum; however, he was able to feel all his feet when I pinched them, he was able to weakly wag his tail, and he was able to pull his feet away when I tickled his toes - all great signs! The fact that he could perform those small tasks showed me that his spinal cord damage was not severe, and the possibility existed for him to recover.  

Having been a veterinary acupuncturist for about 5 years now, I have seen it do amazing things.  The goal of acupuncture is to promote the body to heal itself by correcting energy imbalances in the body.  It enhances blood circulation, stimulates the nervous system, relaxes muscles, releases endorphins, and relieves pain by stimulating anti-inflammatory hormones.  The most impressive responses to acupuncture are those patients I’ve seen exactly like Bailey (or even much worse off!); and I have lost track of how many have been able to walk, run, and regain a completely normal life thanks to this ancient art.  The typical medical response to a pet with a herniated disc is to rush them for an MRI followed by spinal surgery; and while this is 100% a medically appropriate treatment, it is not financially feasible for many owners, with the average cost being $8,000 - $10,000.  And even with surgery, recovery is not guaranteed, and your pet may come out of the operation fully functional or still paralyzed.   

 Bailey being a champ for his acupuncture (he is actually staring at the treat bag).  

Bailey being a champ for his acupuncture (he is actually staring at the treat bag).  

Bailey’s mom and I had a long discussion about his condition, our short term goal: get his pain under control and make him comfortable, our long term goal: get him walking again.  I was confident we could attain both of those by adding in some other medications and acupuncture.  We immediately added in a medication called Gabapentin and increased the dose of his anti-inflammatory medication to help with the pain and muscle spasms he was having.  Because they live on Peak’s Island, we had to be strategic in our acupuncture schedule, and decided to meet in the ferry terminal in Portland for his treatments. Ideally a dog in Bailey’s condition would get acupuncture on a daily basis for the first week or so, however this was not feasible from a financial or scheduling standpoint, so we agreed to meet once a week. Every week Bailey comes over on the ferry in his cozy travel bag and gets fed an entire bag of treats while he gets his acupuncture.  He always snarls a bit at first, but then accepts the needles and sinks into it, sleeping for the majority of the 20 minute treatment.  Week by week as we watch the green leaves turn to the colored array of fall, we watch Bailey get stronger and stronger, with small victories at first - a stronger tail wag, a kick of the foot, a full neck movement to reach his favorite treats. I teach mom some physical therapy, massage, and water therapy she can do at home to help strengthen his muscles and keep him limber.  Over time, we were able to back off on his medications as his pain disappeared, and bit by bit we increased the time between acupuncture treatments (once a week, to every other week, to every 3 weeks, etc). 

Then, the day we have been waiting for comes.  We walk into the terminal as we have for months now, and see Bailey’s mom smiling with anticipation.  We haven’t even put our bags down before she says “You HAVE to see this!”, she opens the door to the travel bag, and out runs Bailey!! He takes off across the floor (albeit still a little wobbly) of the terminal and back again, standing up on his back legs to solicit pats and treats. Here is part of the video! 

I almost cried!  This fragile but feisty little dog who was once paralyzed is now not only pain free, but running again; thanks to acupuncture and his mom, who never gave up hope. 

I love my job...finally!

By Deirdre Frey, VMD: Veterinarian, Owner of Vet At Your Door, P.C.

When he sees my car pull up, the graying golden retriever grabs the nearest tennis ball and runs to my car door, tail wagging and eyes smiling.  “Hello Tomkins!” I say as I get out.  I throw the ball he had dropped at my feet.  “He loves you!” says Jean, his owner.  I smile, grateful for another moment in the day when I say to myself, “I love my job.”

Rewind to two years before. “I don’t know that I can do this job another day,” I remember saying to my husband when I came home from work. Mind you, I had a good job doing general practice at a veterinary clinic with really nice clients. I was only working 4 days per week.  I had wanted to be a vet since I was seven years old and I was doing it! Why was I so burned out?  

People are surprised to learn that burnout is a very big problem in the veterinary profession. We are all die-hard animal lovers, a nurturing and smart folk. Upon graduation, we are chomping at the bit to finally get to better the lives of animals. 

But then stressors await us out in the real world.  Real ones: ones that make veterinarians susceptible to high rates of depression and anxiety.  Ones that make us four times as likely to commit suicide than the average population, which is twice as high as any medical profession.  It’s an awful statistic. 

So you might wonder what are these stressors? To name a few:   

1. Economics: Veterinarians have the highest debt load relative to their salary than any other medical profession. We have to work and often feel “trapped” in a job we don’t like because it pays the bills.

2. Our nature: People in the veterinary profession are perfectionists and emotional people. We hold ourselves to a high standard.  We take any complaint or misstep very personally and have trouble getting over it.

3. Our “typical workday”: A typical day consists of 15 to 20 minute appointments from 8am-6pm.  Three to four times an hour, you’re supposed to get a medical history, examine the animal, perform diagnostics, make a diagnosis, and explain the plan to the client.  Rinse and repeat. There is no time to spare for emotion and good communication.  No time to witness the human-animal bond. Detachment between client and practitioner inevitably occurs. Then, communication breaks down.  Unhappy clients and mistakes occur which is bad for our perfectionist emotional selves (see #2), not to mention the animals and clients we care for.

4. Client and animal stress in the hospital: It’s a rare animal that loves to come to the vet. Alongside owners who are often stressed if their animal is sick, it’s hard to enjoy caring for an animal when they would rather try to kill or run away from you. The chance to build a relationship with the pet parent and their pet is doomed from the start. 

5. Lack of work/life balance:  This is an increasing problem, as 90% of veterinary graduates are women who are traditionally tasked to manage the family as well or at least traditionally feel the “pull” of wanting to spend more time with their families (of course men feel this too).  Trust me, it’s hard to connect with a child and find pleasure in the “nightly routine” after a long day of work.  You end up feeling like a failure in both work and life.

6. High exposure to grief:  There is rarely time to help the owners how we want to, or to adequately partake in the grief when you are thinking about a million other things or just feeling burned out in other ways.  But we do grieve and often don’t have outlets or time to process it personally.  

This paints a bleak picture and honestly, it was starting to make me mad!  Why are there so many caring smart people who feel so burned out?   “There must be another way,” I thought. 

What if I could re-establish connection with that human-animal bond I fell in love with as a child? What if I could work around my schedule and not feel like I was burning the candle at both ends? What if I could work with a staff that was also happy with their work/life balance? What if I could really get to know clients and animals by being able to take more time with them in a less stressful environment? 

I knew in my heart of hearts that the best medicine is practiced when veterinary staff is happiest.  I have always believed that when (a) there is true interest in getting to know a pet and their owner and (b) there is enough time to listen, we can start to nurture and protect and see the human-animal bond that made us as veterinary professionals want to do this in the first place. And that is a win-win for everyone!

Then it came to me: I was going to be a house call vet!

And let me tell you – this is the best job ever!  In the past year and a half building Vet At Your Door, I have re-discovered my love for this profession. This is thanks to the incredible people and pets I have had the time to get to know. I have more time to spend with my family and more time to take care of myself. 

 A happier Dr. Frey!

A happier Dr. Frey!

As a result, a happier and more emotionally available veterinarian is appearing at your door. I am a better veterinarian now because I really get to know the owner and pet and am able to develop a medical plan that makes sense for both. The “brain cloud” that accompanies burn-out is gone. Typical stress felt by owners and pets alike that often accompanies a visit to the vet's is largely gone.  What a beautiful thing!  And I have hired another veterinarian and a veterinary technician who are absolutely amazing and who also enjoy a well-balanced life.  We feel like a true family. 

And clients have noticed this too.  We have had so many people tell us “I am so happy we found you and had you come to the house!” For any service we offer, from wellness visits to acupuncture to sick visits to euthanasia, there is such intimacy in the home environment.  We feel honored to be able to be fully focused on the pet and owner in front of us, to be able to nurture the bond that exists there. 

It’s been a long and bumpy road to get here but I now feel fortunate to be fully present, available, and focused when I pull up my car into someone’s driveway.  And when a dog like Tomkins is just as happy to see me as I am to see him?  Well, it doesn’t get much better than that.  It is a childhood dream come true. 

Do you want to give your pet the gift of at-home veterinary care? Contact us today!

Acupuncture - is it for my pet?

By Abigail Messina, DVM: Vet At Your Door Veterinarian

The goal of veterinary acupuncture is to promote the body to heal itself.  From a Traditional Chinese Veterinary Medicine (TCVM) perspective, veterinary acupuncture encourages healing by correcting energy imbalances in the body.  A treatment involves the insertion of very fine needles into multiple acupuncture points, where nerve bundles and blood vessels come together. Acupuncture enhances blood circulation, nervous system stimulation, muscle relaxation, endorphin release, and anti-inflammatory and pain relieving hormone release.

What can veterinary acupuncture do for my cat or dog?

 One of Dr. Messina's patients benefitting from acupuncture treatments.

One of Dr. Messina's patients benefitting from acupuncture treatments.

  • Stimulates the release of the body's own pain relieving and anti-inflammatory substances
  • Relaxation of muscles at the site of needle insertion and more distant locations creates both a local and generalized pain relieving effect
  • Improves tissue blood flow, oxygenation, and removal of metabolic wastes and toxins
  • Lacks potential side effects for your pets internal organs
  • Medications or supplements will not adversely interact with veterinary acupuncture treatments, therefore it can be safely used to treat a variety of illnesses.

What conditions are best treated by acupuncture?

  • Arthritis and degenerative joint disease
  • Trauma
  • Allergies
  • Spinal disease including disc disease and paralysis
  • Incontinence
  • Neurologic disease

How frequently does my pet need acupuncture?

Dogs and cats start with more frequent treatments which are then tapered off to a less frequent interval for maintenance.  Most patients benefit from one to three sessions per week during the initial few weeks.  Each pet's maintenance interval is different, some need acupuncture every few months, whereas others are able to have their conditions resolved completely to where they no longer even need maintenance acupuncture.  The goal is to achieve the longest interval where your pet experiences maximum comfort between treatments.

Want to see if your animal can benefit from this therapy?

Contact us to book an appointment!

Death & Dying: A Veterinarian's Perspective

By Deirdre Frey, VMD: Vet At Your Door Veterinarian

I had only spent maybe an hour with Violet before this day.  She was referred to me for my hospice care services.  I saw her for a couple of appointments discussing how we could disguise her failing joints with the best cocktail that modern medicine had to offer.  And it worked.  Until it didn’t. 

Today I am with Violet and her Dad, Ron, on the front porch of their house.  I see a defined circular area where the deck stain has worn off.  “That is her spot”, Ron says, tears already spilling down his cheeks.

“She fell down the stairs last week, she can’t squat to pee.” 

“It’s time”, I agree. 

As a house call veterinarian, I have become an expert of sorts on death and dying. Now don’t get me wrong, I still love (and need) a healthy puppy visit thrown into my day.  But I can also say, and I know this sounds strange, that I enjoy performing euthanasia.

Now, before you write me off as a weirdo, hear me out. Like other veterinarians, I grew up feeling a deeper connection with animals than with people. After graduation, I was chomping at the bit to start improving the lives of animals.  Their owners were an afterthought.

Ironically, I have found that through doing euthanasia, I have nurtured my love of human beings. The bond people have with their animals; the deep soul-wrenching struggles they have making decisions for their animals; the raw emotion that erupts from people surrounding their pet’s last moments.  In bearing witness to this hidden, beautiful, unfiltered side of humanity, which breaks down to the simplicity of a man loving his dog, I feel deep gratitude for unearthing something that was not visible to me in my earlier life.  It affirms my yearning to be part of the human race.

Atul Gawande’s book “Being Mortal: Medicine and What Matters in the End” highlights the growing chasm between the increasingly sophisticated diagnostic and therapeutic options available in human medicine and what patients themselves actually want. The option of having a good death and electing not to put oneself through those other options is often ignored and looked down upon, much to the detriment of the patient.

It is exciting that in veterinary medicine, we also have more technologies, procedures, and treatments at our fingertips than we ever have had before.  When I make a diagnosis such as cancer, I consider it my job to go through all options and their associated risks, benefits, and costs. Euthanasia, while not fancy or advanced, is an option that I always include in the conversation. If I don’t, then pet owners may feel guilty for thinking it or may go somewhere else to discuss it.  Or worse, they may actually go through with an option they don’t believe in, and they, their pet, and/or their wallet suffer as a result. Choosing death is often portrayed in our society as “giving up” and it shouldn’t be.  Suffering is overrated.

I find it fascinating and supremely disappointing how in my four years of veterinary school, which boasts one of the most intense curriculums one can find in graduate school, that there was not one mention of how to perform euthanasia.  I remember entering my internship after graduation and being petrified of this task.  There are so many facets of the whole process: Guiding people through the decision of euthanasia, end-of-life hospice care options, how to best explain the process, sedating vs. not sedating, what drugs work best, what to expect during the process, how to deal with the remains of an animal, how to give the owners a lasting memory of their animal, how to deal with a person’s grief, how to deal with your own grief.  None of these topics were taught! And I can tell you - there is much to learn.

I believe mastering the art of euthanasia is a huge part of being a great vet.  Most animals have a much shorter life span than humans so dealing with death will inevitably be a part of our practice.  If the end-of-life experience isn’t good, that pet owner will have a negative association with that vet forever.  Talk about pressure!  Just as we study about diseases and treatments, so should we study how to best provide a peaceful loving death to our patients.  

I feel there is a great calling for veterinarians who specialize in end-of-life care.  Most veterinarians went to veterinary school to learn how to heal animals.  I can therefore understand how on paper, end-of-life care may seem like a bummer.  But I can tell you, relieving suffering and providing a peaceful way to leave this earth is the most gratifying thing I do both for the animal who is dying and for the loved ones surrounding them.  It seems counterintuitive but the lasting reminder of a good death is truly a gift that keeps on giving. 

I get an IV into Violet’s wiggly, dehydrated vein.  That is the hardest part, both for her and me.  The rest is easy, and that is the beauty of it. 

Violet looks at me with eyes that are bright, which belie her failing body.  She clumsily but earnestly circles around twice and nestles right into her spot.  As her Dad scratches behind her ears, his body heaving from sobs, he says “I love you my sweet Violet”.  I inject the solution.  I feel the familiar lump in my throat. She drifts off to sleep.  I listen with my stethoscope; her heart has stopped. No more life but no more pain either and that is the deliberate and loving choice which we have made for her.

I put my stethoscope back in my bag and hear “Thank you so much, Deirdre.  Thank you.”  It fills my heart every time.  These are the words that keep me going.