"I know my husband is dying. We have a little miniature poodle that is the joy of his life. He has asked to see her. Do you think I can put her in a cloth bag and sneak her into the hospital? I promise she'll be quiet."

A patient's wife made that request of Joy Shiller, RN, BSN, MS, CAPA, more than 30 years ago. The head nurse told her it was against hospital policy, so she had to say no to the woman.

"I will never forget the look of disappointment on her face," Shiller said.

"For the rest of the day and into the night, I pondered about a possible alternative plan."

She decided to try getting permission from the patient's physician to take him down to the door of the hospital, where his wife would be waiting with the dog. But when Shiller arrived for work the following day, another patient was in his bed.

"He had died during the evening shift," she said. "It was one of the most horrible moments in my nursing career."

The benefits of animal visits on patients have been recognized for centuries. The York Retreat in England, a home for mentally ill patients, used animal therapy as long ago as 1792, according to Erin Tompkins, RN, BSN, BFA, CCRN, a nurse in Kansas City, MO, who has done extensive research on animal therapy. And no less an authority than Florence Nightingale documented the benefits of animal therapy in her Notes on Nursing (1860, Harrison and Sons, London), Tompkins said.

But it wasn't until the last decade or so that many hospitals have changed their attitudes about animals, opening the door for animal-assisted therapy (AAT) and animal-assisted activity (AAA), which includes animal-assisted visitation (AAV).

Animals—mostly dogs—are now widely recognized as providing benefit to many patients, according to nurses who have worked with them.

A session is considered AAT when there's an actual therapy goal, such as improving strength or range of motion. AAA is an animal visitation that does not have a specific therapeutic purpose.

Patients who interact with animals have been shown to exhibit lower blood pressure, reduced stress, and improved emotional well-being, Tompkins said.

Tompkins quoted Dr. James H. O'Keefe from his book The Forever Young Diet and Lifestyle (2005, Andrews McMeel Publishing) in which he observed that many patients with serious heart trouble become lonely and depressed, which can only worsen cardiovascular health.

"From time to time, I send my patients home with a prescription that reads, 'One dog: to be taken for a walk once and hugged twice daily' as part of treatment," O'Keefe wrote.

A 1995 study called the "Cardiac Arrhythmia Suppression Trial" showed that patients who own a pet experience less anxiety, depression, and anger following a heart attack, Tompkins said. A 1992 study found that pet owners have lower systolic blood pressure than people who don't own pets, along with lower triglyceride levels. And studies in 2003 and 2006 found that adding a pet to a patient's social environment can lower blood pressure and stress response, she noted.

Useful in many situations

Katherine Connor, RN, BS, is an ICU educator and charge nurse in the cardiovascular ICU at Huguley Memorial Medical Center in Burleson, TX, and a volunteer with a Texas-based organization called Therapet. She has worked with numerous dogs, including some of her own, as part of that program.

Connor and her Therapet partner, Julie Miller, RN, BSN, CCRN, often take a dog to conferences when they go to talk about animal-assisted therapy. Miller's dog Huck, a 4-year-old golden retriever, accompanied Connor when she gave a talk at the American Association of Critical-Care Nurses' National Teaching Institute (NTI) in May in Chicago.

AAT can help a wide range of patients, Connor said. A UCLA study showed a 26% improvement in patient outcomes when therapy dogs visited them as part of their recovery program, she said—and she and Miller have seen it happen firsthand.

Miller told a story about a pregnant woman who was badly injured in a motor-vehicle accident and was unresponsive. After a volunteer brought a dog into her room, she was asked to scratch the dog. Even though she did not respond to anything else anyone said or did, she scratched the dog—and soon, she was stroking its fur.

"The next morning, she woke up and was able to talk to her family," Miller said.

Therapy with pets can be used in a wide variety of situations. Hospice care is one example. Connor told a story about a dog that was visiting a hospice patient named Barbara. "He knew what was going on," Connor said. "He stayed next to Barbara until she died."

Animals can inspire patients who otherwise refuse to participate in their own treatment, Connor said. She worked with a boy who had Down syndrome and had broken his neck in a car accident. The boy had no interest in physical therapy—until a dog was brought in. He started by throwing a ball for the dog, and eventually, he would participate in any physical therapy that directly involved the animal.

"He would reach out as far as he could reach to touch the dog," she said. "You could put weights on his arms, and he'd still do whatever you asked."

Therapy dogs can assist in many different tasks, from range of motion to memory loss to sensory stimulation to improving self-esteem and more.

A therapy dog named Pita was conditioned to bark when she heard the words "cow" and "squirrel," and that helped motivate a speech therapy patient to say the word "squirrel," Connor said. The woman showed great satisfaction at Pita's reaction to that word.

Patients who have had animal visits often relax and eat better, Connor said.

"It started just as a visitation program, and evolved as we discovered the fact that doctors and nurses can use a dog as a tool, just like they would any other kind of medical instrument."

Assisting children with surgery

Candise Flippin, RN, MS, CNOR, is the proud owner of a therapy dog named Barley, a golden retriever, in connection with her position as director of the medical program at Fresh Start Surgical Gifts in Carlsbad, CA.

Barley has helped patients with a wide range of tasks, but his main purpose in the program is to help calm people before surgery, Flippin said.

She told a story about a 13-year-old boy who needed reconstructive surgery because he was born without an outer ear. The boy desperately wanted the surgery, but some of his schoolmates had told him he would die if he were unconscious during the procedure.

"We were even unsuccessful at getting him to take his medication," she said.

So Flippin brought in Barley. The boy, who previously had been too nervous to even go near the operating room, was asked to walk Barley over to the pre-op area.

"He knew where he was going, so it's not like we tricked him," she explained. "We took a different route so it wouldn't trigger some of the negative thoughts, and he did it."

Barley sat with the boy while he went through his pre-op preparation, and Flippin could see him get nervous from time to time.

"He would reach over and pet Barley a little bit, and you could see he would relax some," she said. "We finally got him to the point where we could get him to agree to take the medication. ... He voluntarily walked back to the OR and was able to be induced."

Shortly after Flippin started doing animal-assisted therapy in 2005, an 8-year-old girl needed surgery for her cleft palette, and was having a hard time facing it. Her parents were nervous, too, and the little girl took her cues from them, Flippin said.

Enter Barley.

"As soon as she saw Barley, all that anxiety just melted away from her face," Flippin recalled. "Her parents petted Barley a little bit, and that relaxed them, too."

Barley was with the girl only a few minutes, but it was enough time to do the trick. The girl did get nervous again, but much less than before.

"She wasn't smiling really big, like she was when Barley was in there, but she wasn't back to that intense state," Flippin noted.

Clinical benefits

Tompkins told a story about a patient she called "Ronnie," who was not doing well after a transfer to the coronary care unit, following a six-week stay in the cardiovascular intensive care unit at Saint Luke's Hospital in Kansas City, MO.

Ronnie was an African-American male, 50 years old, with a history of nonischemic cardiomyopathy, diabetes mellitus type II, and chronic renal failure. He was withdrawn, depressed, and dependent on mechanical ventilation, and had acquired a sternal wound infection, Tompkins said.

He continued to require intensive care for continuous renal replacement therapy, as a result of an inactive, newly transplanted kidney.

"We introduced Ronnie to AAV shortly after his transfer to the coronary care unit, merely with the intent to boost his morale and cope with his depression," Tompkins said.

Ronnie got visits two to three times a week from four different dogs—a collie, a cavalier King Charles spaniel, an Old English sheepdog, and a mixed-breed dog.

"As a direct result of the first visitation, we found that Ronnie's recovery process dramatically improved," Tompkins said. "It was extremely exciting and uplifting to our staff to see the transformation that took place after Ronnie's AAV therapy that enabled him to become an active participant in his healthcare goal planning.

"He now smiled, was oriented to person, place, and time, became physically and mentally stronger at an accelerating pace, and was able to engage in self-care."

The animal visitation gave Ronnie something to look forward to, which had a positive impact on his physical and mental health, she said.

"Nearly three months after his admission, Ronnie was discharged from our hospital a much different person from the one who was admitted to our CCU. Ronnie attributes his successful recovery to having the desire to set goals, which was facilitated by the introduction of AAV."

Patients' personal pets

Some organizations are focused more on helping patients get visits from their own pets, rather than those trained for therapy.

Shiller, now a staff nurse and clinical mentor at Methodist Hospital in Houston, has seen the benefits of a group called PAWS (Pets Are Wonderful Support) Houston, a nonprofit organization that gives patients the chance to see their own pets when they are terminally or critically ill.

PAWS Houston was established in 2002, and that same year, Methodist Hospital adopted a policy to allow pet visitations. A representative from PAWS must approve each pet, after evaluating its temperament, medical history, and vaccinations. If a patient is near death, the process can be expedited, Shiller said.

All patients are eligible, except those in the bone marrow and gene cell unit, but the patient's physician must approve the visit. The visits are usually restricted to one hour and take place in the patient's room, when possible. If the patient is in a semi-private room, the roommate, along with the roommate's family and attending physician, must also approve the visit.

"The response to this program has far exceeded any expectation," Shiller said. "Every visit accomplishes a miracle. To see a patient's hands reach out to touch a loved dog or to watch a cat curl up contentedly with its owner is incredibly comforting—many times, even tearful.

"The stories related to the pet visitations at our hospital are compelling. A post-CVA patient who was left speechless saw his dog and spoke his name. A nonresponsive lady in the neuro ICU woke up and asked for a comb when she saw her dog."

Methodist Hospital's chaplain, the Rev. Sandra Londa, M.Div., BCC, told the story of an ICU patient who had grown increasingly unresponsive and was near death. One Friday, the patient's husband told Londa their boxer dog, Rosie, was coming for a visit, through the PAWS program.

"I missed Rosie's visit, but when I returned to work the following Monday, I saw the photograph that had been taken of the patient, along with Rosie and her husband," Londa said. "This patient, who was so near death on Friday morning, was smiling from ear to ear on Friday afternoon because of Rosie's visit."

In the photo, the patient's hand was on her dog's head.

"Such a picture of peace and serenity," she said. "The patient died two days later. What a testimony to the human-and-animal bond and the soothing presence offered by one of God's creatures!"

Benefits outweigh risks

Some administrators and other officials are reluctant to approve animal therapy because of the perceived risk of zoonosis, or transmission of disease from animals to humans.

"Good hand-washing techniques, meticulous animal vaccination upkeep, coupled with regularly scheduled veterinarian care, are recommended in preventing transmissions of diseases between animals and humans," Tompkins said.

Some experts even believe sibling visits are riskier than animal visits, because of the various childhood pathogens that may be lurking there.

"The benefits of AAT and AAV highly outweigh the controllable risks," she said. "This form of therapy is attributed to the decrease in mortality and morbidity rates following a serious illness. Animal therapy is beneficial across the health continuum and should be employed."

"In my limited experience with animal therapy, I have seen significant positive health outcomes in my patient population. Many healthcare providers did not think Ronnie would survive when he transferred to our unit. Animal therapy, along with holistic nursing care, benefits many lives daily—and allowed Ronnie to walk out of our hospital with his new heart and kidney, and a love of dogs."

Could your dog be a therapy dog?

Not every dog is cut out to be a therapy dog, according to Katherine Connor, RN, BS, a volunteer with a Whitehouse, TX–based animal-assisted therapy group called Therapet.

Dogs are selected based on their reliability, predictability, controllability, and suitability. The testing of those qualities is the main key to the success of any animal-assisted therapy program.

"If dogs flunk the temperament test, they are not meant to be therapy dogs," she said.

Therapet has never had an incident with a dog misbehaving in a hospital, and that's because they are so stringently tested before they go in, she said. The testing includes such things as brushing and back-brushing the dogs, yelling in their faces, pinching them, and approaching them with walkers and halos, just to make sure they will not overreact to any such situation in a hospital setting.

Connor has had four of her own dogs certified as therapy dogs, and has two others that will likely be certified soon. But she also has dogs that she knows will never be therapy dogs, because they don't have the right temperament.

Connor emphasized that dogs of any breed can be therapy dogs. She went through a few photos of the dogs Therapet has used, and focused on one in particular to make that point.

"This dog has a button that, if you press it, he'll roll over and want his belly scratched, and that button is basically the entire upper part of his body," she joked. "These dogs are selected based on temperament, not breed, and that dog is a pit bull."

"There are Dobermans, rottweilers, every dog you can think of as a 'mean dog,' in the program," said Troy Miller, MD, husband of Connor's AAT partner, Julie Miller.