For Makiki resident Joyce Tsuji, Toro was a companion and confidant, a reliable morning alarm clock and an occasional "bedtime hat."

The fawn-colored tabby, a stray who hung out under Tsuji’s car and eventually worked his way into her heart, was a beloved pet for more than five years.

"Toro became family from the moment he adopted me," Tsuji said.

When her cat was diagnosed with lymphoma about five years ago on top of a bowel syndrome, the animal was too weak for surgery, and Tsuji had to make the heartbreaking decision to euthanize her pet.

Losing Toro left a void in her life. She said she cried just as hard when she lost Toro as the day her grandparents died.

Five years later Tsuji still misses him.

"If you see a pet as family, the heartbreak is the same," she said. "Sometimes I think it may be even more so because, unlike with humans who can comprehend you telling them goodbye and ‘We love you,’ there’s a small bit inside of us that wonders if our pets know that we are letting them go so that they won’t suffer."

This kind of grief for pet owners is very real, according to Julie Ann Luiz Adrian, a veterinarian and assistant professor at the University of Hawaii at Hilo who co-authored a study last year on the emotional impacts of the loss of a pet.

Of the 106 pet owners surveyed at a vet clinic, about 20 percent said they experienced significant grief after the death of an animal companion, and about 30 percent said they still felt some grief or sadness over the loss for six months or longer. A smaller group, estimated at 5 percent, reported significant grief symptoms such as sleeplessness and bitterness, and possible post-traumatic stress disorder.

Such feelings can be even more severe for certain segments of the population, such as seniors, particularly if they have lost a spouse or are all alone, Adrian said.

"We think vets and psychiatrists should be aware there are some people out there who might go through some of the syndromes and might need help or therapy," she said.

In her own practice, Adrian has seen both sides of the spectrum — those who grieve deeply and those who are more stoic, unceremoniously dropping off their pets to be put to sleep.

For freelance photographer Luci Pemoni, the sense of loss over the death of her beagle, Phoebe, is still fresh.

Luci and Phoebe made the move together from New York to Honolulu, and for the last 10 years, they shared daily walks on Lanikai Beach. The beagle often went out on assignment with Pemoni — whether it was at a surf competition on the North Shore or on a hike up to Makapuu with President Barack Obama.

"She was a really quintessential faithful companion," said Pemoni. "She was pure love."

Just a month ago, Phoebe was euthanized after being diagnosed with an inoperable bladder tumor. It was one of the toughest decisions Pemoni ever had to make, but she said she didn’t want her pet’s suffering to worsen.

They took one last walk together at the beach before Phoebe jumped into Pemoni’s arms for the ride to the vet clinic.

Pemoni said she held Phoebe as the dog took her last breath and spent the night sobbing. Her advice to other pet owners facing a similar loss is to "send them off with love instead of sadness and grieving."

"Send them to the light. She had a very good life, and you kind of have to focus on that."

Susan Mirikitani, owner of the historical Bayer Estate on the Aina Haina shoreline, lost her two golden Labrador retrievers, Sammy and Max, a year apart. She called the two dogs her "babies."

"There’s this huge void," Mirikitani said of the loss.

Max was 15 years old when he was euthanized to ease his suffering from severe arthritis and a painful spinal cord condition. Sammy died more suddenly, at age 14, of a heart tumor.

Mirikitani said she was able to say goodbye to Max, comforting him with a soothing touch and voice while he was being euthanized. She said that when it was over, her dog looked at peace. "For some reason he was just glowing in that moment," she said.

When Sammy collapsed and went into cardiac arrest on a Saturday evening, the dog was rushed to the vet. Mirikitani was unable to go to the clinic the next day because it was closed. Then she got the dreaded phone call from the vet, saying her pet wasn’t going to make it. By the time she got there, it was too late.

Her grief kept Mirikitani awake at night, especially since the last time she saw Sammy alive, his head was pressed against a cage, as if imploring her not to leave.

Late one sleepless night, she made a trip back to the vet’s office and went through the motions of saying goodbye to her pet one more time. It was a sort of ritual that helped her get closure.

Every pet owner copes with grief in a different way, according to Rosemarie Grigg, who runs the Hawaiian Humane Society’s Pet Loss Support Group.

Generally, there isn’t as much help available for people dealing with the death of a pet as there is with the loss of other family members, so it’s important to seek out sympathy from those who understand, Grigg said.

Not helpful are insensitive remarks from others, like "Oh, get over it. You can get another cat," or "It was just a dog."

Grigg says she tries to create a safe, confidential space in the support group where pet owners can talk and share their feelings. She also makes referrals to professional therapists.

While group members might shed tears together, they also share laughter while reminiscing about the happy times with their pets.

Some ways to cope include writing an obituary, letter or poem for your pet, suggested Grigg, or putting together a collage of memories. Many pet owners also find it helpful to hold a funeral.

Sammy and Max were laid to rest in a special spot in Mirikitani’s back yard where she planted flowers and placed their leashes and favorite toys. Mirikitani said that during their short time on Earth, dogs can teach humans a lot about loyalty and love.

"You never lose that little space in your heart for them," she said. "If anything, I think the love of an animal expands your capacity to love."

For some, adopting another pet is helpful for moving on. However, the Humane Society recommends not rushing out to get a replacement pet while still grieving.

Grigg said the time needed to heal is different for everyone.

"What I always wish is that eventually the good and loving memories of their companion is what they remember more so than the event of the death," she said.

After coming home to a vacant dog bed, Pemoni adopted a 2-year-old English cocker spaniel named Hudson, who is bringing joy into her life. Pemoni said Hudson is not a replacement for Phoebe, but he does help fill an empty spot.

Mirikitani, too, has found new companionship — from a black Lab named Teddy, adopted from friends.

"The best path to recovery is to look around and still look for beauty in the world, and it happened to come in the form of a black Lab," she said.

CORRECTION: Rosemarie Grigg holds a master’s degree in psychology but is not a clinical psychologist as was reported in a previous verison of this story.