What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Aine Seavers — Thu, 04 May 2023 01:10:53 GMT

Animal advocacy triumphs cultural views and we as Vets are first and foremost animal advocates so having a place for animals to die a protracted extended pre-death suffering doesn't do it for me. Just the separation alone at the very end of their lives-when they have never been more vulnerable and scared to be then handed over to strangers and only sight their loved owners from afar-that is not simply not fair to the pet. Over the years I have had many different religions/cultures address their concerns with me-and starting out as a deep seated religion believer myself-I knew the levels of concern and how -deep and entrenched they are-but often because the belief's interpretation of an issue is never questioned. Despite not being Hindu-I ended up having a long line of that faith members follow me and surrender their pets to me for a peaceful passing to their next life. The human beliefs in Singapore should not be used as a reason why their pets have to suffer when other pets don't but the error is with the Veterinary profession allowing this to be normalised. The veterinary profession needs to be educating for the animal not enabling tunnel vision. Pet Euthanasia is the giving of a gently death, it is not the same as the taking of an otherwise healthy human life yet Singapore has the death penalty-by drop hanging. Either taking life is condemned or it is not.

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Aine Seavers — Thu, 04 May 2023 00:57:25 GMT

[quote userid="25265" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/30625/what-do-you-think-of-the-blessed-sleep-protocol-for-pre-euthanasia-sedation/241463#241463"]Alfaxalone does not work reliably SC (we've tried).[/quote]

Agree- i tried the same with Alfaxan in dogs so as not to waste short dated bottles and it just didnt work.

[quote userid="25265" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/30625/what-do-you-think-of-the-blessed-sleep-protocol-for-pre-euthanasia-sedation/241463#241463"]oletil seems a good solution, but the refridgerated storage is impractical for our purposes.[/quote]

The resultant solution will contain 100 mg total Zoletil for Injection per one milliliter (50 mg tiletamine and 50 mg zolazepam per mL). Discard unused solution after 4 days when stored at room temperature or after 14 days when kept refrigerated.28 Feb 2023

So Zoletil doesnt need to be kept in the fridge-and certainly not an issue for a call out/house call, but most vets here have iceboxes to transport meds so not an issue re short time out of fridge.. Equally I would suspect the refrigeration is about sterility not efficacy so again not an issue in a euthanasia. I prefer taking Zol than taking S8s out on a housecall-for some of our area that was a safety issue getting known we that we carried s8s in the cars.

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Arlo Guthrie — Wed, 03 May 2023 09:00:57 GMT

[quote userid="25265" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/30625/what-do-you-think-of-the-blessed-sleep-protocol-for-pre-euthanasia-sedation/241463#241463"]Sorry for being so late to this thread - I just get the email digests![/quote]

Hi Ben Walker - You must mean the monthly digests. Coming soon are a new digest format which allows you to get a digest of new content either daily or weekly as you choose. Waiting for developers to have a slot, but hope this is within the next few weeks.

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

HannahGillian — Tue, 02 May 2023 23:55:02 GMT

Hi,

I’m no longer UK practising but when I moved to Australia the practice I’m in sedated Dom/torb/acp then gives propofol before the barbiturate. I was skeptical but no agonal gasping issues (no more than without sedation).

Propofol is cheap here as it’s the human version and no preservatives, so we keep unused stuff just for this purpose.

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Ben Walker — Tue, 02 May 2023 19:03:31 GMT

Sorry for being so late to this thread - I just get the email digests! I run a home euthanasia service, and am happy to share our sedation protocols if they are at all helpful.

We didn't want the hassle of storing and logging ketamine, so we don't use the "blessed sleep" mixture. It seems reasonable to me but a bit of a pain to draw up unless you pre-mixed. Zoletil seems a good solution, but the refridgerated storage is impractical for our purposes.

Dogs:
20-30mcg/kg medetomine, 0.2mg/kg butorphanol, 0.15mg/kg midazolam combined SC.
Midazolam reduces the twitching we sometimes see with medetomidine SC (less of an issue IM). We reduce the medetomidine dose with severe cardiac disease, half doses of everything if in respiratory distress. Large dogs (40kg+) and I usually just give the medetomidine and butorphanol. We don't see nausea in dogs with this and I don't believe the medetomidine has an important effect on venous access.

Cats:
0.15ml/cat midazolam (5mg/ml), 0.15ml/cat butorphanol (10mg/ml), 2mg/kg alfaxalone combined IM.
Largish volume, but given slowly in epaxial muscles with 23G it's well tolerated. If they are fractious then 200mg/cat gabapentin 2 hours before appointment. You can also give the midazolam and butorphanol SC first, then alfaxalone IM. Alfaxalone does not work reliably SC (we've tried).

[quote userid="7269" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/30625/what-do-you-think-of-the-blessed-sleep-protocol-for-pre-euthanasia-sedation/241247#241247"]I do always cannulate nowadays, I always used to go off the needle but it adds very little time and does ensure we don’t have any leakage which stings.[/quote]

Completely agree. If we can't place a cannula after a couple of attempts we go IP or IH in dogs. We use IP in cats by default.

[quote userid="8958" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/30625/what-do-you-think-of-the-blessed-sleep-protocol-for-pre-euthanasia-sedation/241244#241244"]I'll probably get shot down but for the past 4 years I have given dogs euthatal SLOWLY[/quote]

We do this too. Dose low and slow. We usually give 0.2-0.25ml/kg (40-50mg/kg) slow IV (~30 seconds). Very rare to see gasping. Another benefit of a cannula - you can give more if needed (it rarely is).

[quote userid="3685" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/30625/what-do-you-think-of-the-blessed-sleep-protocol-for-pre-euthanasia-sedation/241380#241380"]But, having my 17 year old cat taken away from me to place the cannula was by far the worst part of it. Standing there alone in that room waiting for her to come back, when I’d been with her for 17 years, is the one part of the process that I wish I could erase.[/quote]

I'm really sorry to hear that, Nicola. Thank you for sharing the experience though, for anyone doubting the importance of being part of the whole process.

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Lucy Fleming — Thu, 27 Apr 2023 12:11:47 GMT

I suspect, like most situations in vet med, the "right" way is some mystical combination of the method the vet is best at, the individual patient temperament and condition, and the needs of the owners.

I personally prefer to sedate most of mine (medetomidine/ butorphanol, though I'm interested to hear low-volume alternatives that have less associated nausea), unless they are particularly calm or quite debilitated - means they can "fall asleep" with the owner and makes it much easier for me to then get IV access in the room (like some others, I prefer not to take them away from the owners, but I don't really like placing IVs in unsedated animals in front of owners). A lot of older/ arthritic animals seem to find it understandably uncomfortable to have limbs manipulated for an IV injection or catheter placement.

Some owners seem to prefer the slower process of the animal falling asleep more gradually, some others would potentially prefer to be "in and out" once they've made the decision but you can't suit absolutely everyone!

Cats and small dogs I'll usually go off the needle, larger dogs I would be more likely to place an IV cath, especially if a large volume is needed - I don't tend to use huge syringes as I don't have the hand size or strength, so a catheter allows me to use two smaller ones more easily. Sedation also often means I can use a tourniquet and place the IV without an assistant - not really an advantage but makes a consult room feel less crowded especially if lots of family members have come in.

Personally don't tend to use intrahepatic or intrarenal just because I find a little tricky and I'm also never quite sure how owners will react to the idea.

Regarding hospice/ palliative care, I do think there may be a role for this in improving the QOL/ monitoring of those animals diagnosed with life-limiting conditions - not to extend their life but to improve management of pain, nausea, nutrition etc in the time up until euthanasia is indicated, which may not necessarily be immediately, but is likely some time before the client brings it back to you because it's eaten and drunk nothing for a week and not got up for two days and now they think "it's time" - being able to monitor these patients more closely might actually mean being PTS sooner than if the owners are left more to their own devices. I agree it doesn't require specialist knowledge (though I read the description of "specialist company" in a previous post to mean merely that this was the only service they provide, not that it was specialist in the RCVS sense)

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Kate Richardson — Fri, 21 Apr 2023 14:38:20 GMT

Don't know about dogs, but Alfaxan is brilliant in cats, IM, 0.5-1ml usually enough to sedate them with no to minimal unwanted effects. have had a couple go a little bit twitchy, but they were both very sick cats so suspect I should have just used a lower dose. Pretty sure it would work same in dogs.

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Sarah Wheadon — Fri, 21 Apr 2023 13:18:21 GMT

ie me . Love that butterfly!

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Neil Wheadon — Thu, 20 Apr 2023 14:30:14 GMT

[quote userid="3169" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/30625/what-do-you-think-of-the-blessed-sleep-protocol-for-pre-euthanasia-sedation/241385#241385"]I will say that in some old fragile veins a needle will sit where a cannula will blow. That can be a problem[/quote]

I do know vets that use a butterfly needle and also the back leg, so the owner can hold the head and aren't crowded out. If you can do this then this may be a better way

Neil

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Michael Woodhouse — Thu, 20 Apr 2023 14:26:31 GMT

[quote userid="8958" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/30625/what-do-you-think-of-the-blessed-sleep-protocol-for-pre-euthanasia-sedation/241354#241354"]

Placing catheters is tricky in some cases. Hand on heart, can anyone on here say that they hit a vein first time 100% of the time. I have witnessed animals brought out the back for euthanasia where nearly everyone in the building has tried to place one. (excluding the receptionist)

I go off the needle for 2 reasons

[/quote]

I agree with off the needle, in most cases. I find the younger vets much prefer a cannula. I guess for the same reasons - if it's in you know you have good access - whether skill from a needle or IV placed.

I will say that in some old fragile veins a needle will sit where a cannula will blow. That can be a problem.

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Nicola Cole — Thu, 20 Apr 2023 07:09:24 GMT

[quote userid="7615" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/30625/what-do-you-think-of-the-blessed-sleep-protocol-for-pre-euthanasia-sedation/241243#241243"]this is done away from the clients out back[/quote]

I had my cat put to sleep recently. I’m not currently in practice (due to family circumstances) so couldn’t do it myself. It all went smoothly, vet was lovely etc.

I had prepared myself for it and knew it was time.

But, having my 17 year old cat taken away from me to place the cannula was by far the worst part of it. Standing there alone in that room waiting for her to come back, when I’d been with her for 17 years, is the one part of the process that I wish I could erase.

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Miriam Lodewyks — Wed, 19 Apr 2023 17:10:38 GMT

[quote userid="6473" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/30625/what-do-you-think-of-the-blessed-sleep-protocol-for-pre-euthanasia-sedation/241376#241376"]pallative care human nurse [/quote]

Funny that: some of the worst cases of neglect I have seen was a human nurse and a couple of GP’s. They must get so used to just watching people suffer that they genuinely think it’s ok for the same to happen to their pet.

It is worth noting though that euthenasia is a cultural concept. A colleague I know has moved to Singapore where euthenasia is strongly condemned. Their hospital has an entire wing dedicated to hospice care… people literally visit every day watching their beloved pet die.

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Aine Seavers — Wed, 19 Apr 2023 01:02:04 GMT

I think we are talking about apples and oranges. I have no issue with home based short term pallative care and euthanasia. I do when an animal is shipped off at the end of its life-in misery to end it at a vet hospice for the sole benefit of the owner. Nothing can persuade me this is in the pet's best interest. People can be strong if you enable them. Tell them the truth-if they suffer less and the dog suffers more then that is a 100%wrong. Only once in 35yr did I fail to convince an owner-they were a pallative care human nurse and the abuse of that dog;s last few months left me wondering how anyone could watch such suffering and not act and hence my concern for her human patients. We got the usual lies-keep alive as so and so on way home from overseas-and when the date came-suddenly another child needing to come home... All the rest thanked me for a wake up call and also to have belief in them that they could walk this journey.-they ended up with no regrets and no traumatic memories of a horrible last few weeks and eventual death. Once you admit then its time to pts as animal in too much pain-you also realise it was in an awful lot of pain to get to that point-and its that realisation that stays with the owner for ever re that pet.

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Miriam Lodewyks — Tue, 18 Apr 2023 09:49:31 GMT

I don’t dispute the fact that there are cases where pets are left to suffer for longer than needed, and there are cases where earlier intervention may well have provided a pet with a longer and better life.
Over the years I’ve become wary of being too judgemental of people’s circumstances and life-choices, conscious that it’s often one’s own hubris talking. Hence I believe that a home-based service that focusses on understanding all the surrounding factors that may influence a pet’s well-being and guiding owners towards the best outcome for all. Maybe not a “speciality”, but a valuable skill and service, imho.

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Aine Seavers — Mon, 17 Apr 2023 20:48:21 GMT

Yep. Hold the same view. Taking a vital important, but in the end a basic daily skill to then make it more complicated than it is. The end result is keeping animals alive just existing not thriving and all for the sole benefit of an owner. We as vets are there to be first and foremost an Advocate for the patient not the owner. We have to speak on behalf of the animal. For those who argue euthanasia unnatural then I remind them that mother nature would have provided a swift albeit violent end to their pets suffering if the pet left to die as nature had it but humans create a shield around the pet that is unnatural and denies the pet the right to die as nature intended hence why vets see euthanasia as a noble gift to be able to give to the animal in pain. Losing a pet hurts that is an inescapable fact. Dragging out the pet's pain to delay or reduce the owner's pain is not in the pet's benefit and owners need to be told those cold hard facts.

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

David Mills — Mon, 17 Apr 2023 16:00:46 GMT

[quote userid="2457" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/30625/what-do-you-think-of-the-blessed-sleep-protocol-for-pre-euthanasia-sedation/241350#241350"]but I don't think you're discussing the same thing.[/quote]

I suspect this is the case.

My issue isn't with home euthanasia, or how or where people choose to do it.

My issue is with the concept of "hospice care" or "end of life care" and their elevation into the veterinary lexicon a few years ago. Hospice care is the care given to animals with a terminal disease for which there is no cure, and the animal is heading towards the end of its life. Palliative care is slightly different in that it aims to alleviate symptoms of a disease that may be curable (but that treatment course may not be pursued for a number of reasons). They are different.

What I rail against is a few years ago (pre-Covid) hospice/end of life care being pushed as some sort of speciality - there were conferences and groups and all sorts. I find it murky in terms of ethics. There were tales of animals being kept going on daily opioid injections/patches, and it stank of eeking out quantity over quality of life. It was designed, it seems, primarily for the owner who was struggling to let go of their animal. I don't think vets have any justifiable place giving weeks of high-grade analgesia to keep an animal alive because the owner wants it; the same as doing a highly invasive surgery on an old animal to give a few more weeks of life (e.g. malignant spleen removal).

Moreover, from an intellectual perspective, it elevates the mundane to a speciality which is completely unjustified. QoL assessments and recognition of suffering are part of every vet's skill set - there are no specialities here. But elevating this, making it a 'thing' allows a certain manipulation of owner emotions, and, of course, profit. It is a skewing of a human medicine branch - hospice care has its place in human medicine so that people can be given time to process, sort out affairs, etc, and crucially it is required because euthanasia doesn't yet exist. That doesn't hold in veterinary medicine because thankfully we can legally kill animals to prevent or end suffering.

Of course we will provide palliative care all the time, but only up until the point that the animal has a reasonable QoL. That I would say is for us to ultimately decide, not the owner, and it is a slippery slope if we in the name of 'shared decision making' or other human medicine concepts that don't map onto our patients, abrogate our responsibility towards patients at the end of their lives.

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Neil Wheadon — Mon, 17 Apr 2023 15:13:17 GMT

[quote userid="9448" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/30625/what-do-you-think-of-the-blessed-sleep-protocol-for-pre-euthanasia-sedation/241353#241353"] I understand how pushed and stressful it can be in practice, but have seen too much pet distress trying to fit a cannula away from its owners, restrained, unwell, frightened, possibly compromised.[/quote]

I think this is a key point

I go off the needle for 2 reasons

1) I am not confident in placing a cannula. It's just something that I can do 7 times out of 10 and it is THE most stressful thing I do in an animal. People assume vets can do this, well this one can't and I've been doing this for years. I've seen other vets that can't as well

2) I can hit a vein with a 23 gauge needle 98 times out of 100.

A euthanasia is one point where a vet will be judged. I can count on an America Football Teams fingers, the number of client with horror stories about a PTS and they often avoid missing that vein. That's why you do everything in front of the owner, in my case, one attempt, if I miss, I sedate, and I pre-warn clients of this. I won't routinely sedate as it just drags the whole thing out and animals die so well with a slow IV that there is no better way in my opinion

Neil

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Julie Turner — Mon, 17 Apr 2023 15:01:05 GMT

I have been providing euthanasia with pre-sedation in the home or garden for many years. I, too, baulk at keeping a pet alive beyond a decent quality of life, and have only had to deal with this issue when I am in traditional practice because people seek me for one reason. In the practice cases, if an owner refuses to PTS, then, unless an overt case of neglect, I defy any SA vet to withhold palliative treatment. In most cases, I find the owner soon after makes the decision, just needing some time to process. Extremes are thankfully rare nowadays.

The majority of patients I see for home euthanasia have loving homes with caring families, and I am convinced that a relatively painless s/c injection while the family cuddles (or whatever) their pet who then peacefully drifts off in their home, is a gold standard of end-of-life care. Additionally, pre- and post- informing and counselling the humans is also crucial for many reasons.

Also, unless the owner wants speed, I avoid veins, with that necessity to reposition the pet, and instead use a longer needle to aim intrahepatically. It takes a bit more Pentobarb and sometimes a bit more time. I ensure I am not on a tight schedule - ie I am not getting back to evening surgery etc. I understand how pushed and stressful it can be in practice, but have seen too much pet distress trying to fit a cannula away from its owners, restrained, unwell, frightened, possibly compromised.

When I am in practice, I still pre-sedate, and then give the owner a choice of whether they want to stay. I follow practice protocol after the sedation.

I don't feel that I am being exploitative to anyone, and practices around me actually give out my number to their clients. I am not superior, I just give more time. I would add that when you do this in practice, apart from it being hugely important to the wellbeing of the pets and the clients and their children, their experience will influence whether they can bear to return (to those memories) with their new pet.

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Gillian Mostyn — Mon, 17 Apr 2023 13:21:32 GMT

[quote userid="11901" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/30625/what-do-you-think-of-the-blessed-sleep-protocol-for-pre-euthanasia-sedation/241348#241348"]I disagree strongly with your view that hospice care = exploitation. The home euthenasias I have done are without exception much much nicer for the patient than the ones where they are dragged to the vet one last time[/quote]

I agree with David, but I don't think you're discussing the same thing. I may be wrong, but I think he is referring to 'hospice care' as being the normal palliative care that we all strive to provide, but possibly then extending a pets life beyond the point where most of us would have already recommended euthanasia.

The location of euthanasia, be it home or at the practice, is surely irrelevant to anyone other than the client and their wallet? Its the method and timing that matters.

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Miriam Lodewyks — Mon, 17 Apr 2023 12:30:32 GMT

I disagree strongly with your view that hospice care = exploitation. The home euthenasias I have done are without exception much much nicer for the patient than the ones where they are dragged to the vet one last time, so the animal is definitely NOT losing out, and what an adult choses to spend their money on is their own choice, be it a boob job, manicure or home euthenasia by a caring professional. Owners are quoted the fee at the time of booking so there are no surprises when the vet turns up. I feel your views are patronising to the clients, and with a distinct whiff of hubris, if I may be so bold.

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

David Mills — Mon, 17 Apr 2023 10:37:02 GMT

An oxymoron.

Euthanasing animals isn't a speciality, nor is "end of life care", even though some companies may charge it as if it was a speciality.

The other issue I have with it is that it a time of the owner's life where emotions are running high and it is being sold as superior - when in reality it rarely is. On the flip side, the use of drugs or whatever to unnecessarily prolong an animal's life (suffering) because owners ask you to, dressed up in the woolly notion of "end of life care", rather than having the difficult conversation - then charging £££ for such - doesn't sit well. It could be seen as exploitative, with only one loser - the animal (and owner's wallet).

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Aine Seavers — Mon, 17 Apr 2023 10:35:07 GMT

Totally agree. This ridiculous wastage must stop-aside from the wasted medication, the stockpile of half used containers is madness. If the data exists outside the Uk for the drug to work for longer and as the company will have a paper trail to show probably lasts even beyond that-then regulatory bodies need to insist the companies file for the longest,not the shortest shelf-life possible.

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Aine Seavers — Mon, 17 Apr 2023 10:31:45 GMT

I agree . I am of the belief the pet and owner should not be separated unless under extreme conditions. And no need for im. Zoetil s/c works fine as long as you use a fresh needle so zero sting,. I do not like the separation to place a catheter-and neiter do most clients if you asked them to choose.

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Miriam Lodewyks — Mon, 17 Apr 2023 09:12:39 GMT

[quote userid="12670" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/30625/what-do-you-think-of-the-blessed-sleep-protocol-for-pre-euthanasia-sedation/241339#241339"]After placing the IV catheter, ideally out of owner's sight in prep room[/quote]

This is how I have always done it too.
However, I recently did a locum for a Veterinary Hospice company where IM sedation is the norm, and was surprised how many clients were adamant that their pet should “not feel a thing” and “not be messed with” (ie. the placing of an iv cannula) prior to euthenasia.

RE: What do you think of the 'blessed sleep' protocol for pre euthanasia sedation?

Miriam Lodewyks — Mon, 17 Apr 2023 09:04:56 GMT

[quote userid="8991" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/30625/what-do-you-think-of-the-blessed-sleep-protocol-for-pre-euthanasia-sedation/241336#241336"]To be blunt - a con.[/quote]

A “con” is when you deliberately deceive someone for personal gain.

Just because you don’t understand the value of a service does not make it a “con”… I can’t see the point in paying someone to paint my nails, but that doesn’t make manicurists con-artists.
I have done a lot of home-euthanasias both as a routine service for a normal practice and for a specialist company. The difference between the aforementioned services is how much time you have to spend with the client when they are your only focus, as opposed to needing to rush back in time for afternoon consults. Naturally, that comes at a price, one that some people are happy to pay. My experience is that those who choose this service are extremely relieved and glad to have a compassionate professional to lean on in their time of need.