I hesitated. Was I withholding my suspicion about Bagheera’s true age to protect my client or myself? No, I reasoned, my honesty would change nothing. Bagheera’s kidneys would still be failing; his owner would still be confronted by the death of her pet sooner than was fair.
“You’re right,” I said. “Cats often live to be fifteen or older, but unfortunately some develop serious diseases at a much younger age.”
We continued to discuss the next steps, and with each turn of the conversation I was struck by how much Bagheera reminded me of Monty: The way Bagheera looked at me with an expression close to serious understanding. The snippets of information his owner told me about their life together that so vividly reminded me of my life with Monty. And there also, tugging at the sleeve of my white coat, rising like a palpitation, was the realization I couldn’t deny any longer. Monty was old, and I was going to lose him.
* * *
—
I became aware that despite the increasing life expectancy of pets in the States, the number of years an animal had been alive mattered less than the age their owners perceived them to be. And that perceived age, whether older or younger than time dictated, had a profound impact on an owner’s diagnostic and treatment decisions, as well as their expectations. In some cases, an owner’s belief that their pet was too old for “expensive testing and medication” would result in a terminal decision, despite my assertion that ten for a cat or seven for a dog wasn’t old.
The opposite, however, could be equally true and distressing. An owner with a firm belief in the exceptional longevity of their pet, and a refusal to realize that life is ultimately terminal, might demand aggressive diagnostics and treatment regardless of their pet’s actual age or prognosis. It was these geriatric animals, with nothing left but the dignity of a good death—hauled through invasive interventions because an owner “didn’t believe in euthanasia” or “wasn’t ready to let Buddy go”—that caused the most despair. My inability to advocate strongly enough for my patients and wrestle their owners from their denial was devastating. Leading their beloved companions down a futile and painful path was one of the failures I felt the sharpest and deepest.
My proximity to disease and my familiarity with its whims and cruelties did not breach the whisker-thin insulation that still protected me from the harshest medical truths. The good health of those I loved had insulated me from the darkest depths that illness could bring, and I viewed ethical dilemmas surrounding advanced care and euthanasia with the pureness of vision reserved for the most naïve. Although I’d cried over patients’ deaths, empathized with owners, and railed against the unfairness of lives taken too soon, the pain I felt had always been one step removed, muffled by the degree of separation that exists between doctor and patient.
By the end of 2009, the only personal losses I’d experienced were the deaths of my maternal and paternal grandfathers when I was a child in the United Kingdom.
My dad’s father died first, from a brain tumor. He spent his final days in a hospice I never visited. He’d worn thick glasses with yellowish lenses and had a bald spot that was fascinatingly shiny. Both my grandfathers had served in World War II, as most of their generation had, but it was my paternal grandfather who reminded me most of the soldier he’d once been. He was a BBC Dad’s Army–type of soldier—sergeant-majorish, but with a comic timing that sweetened the gruffness of his South London accent.
I remember marching in formation with my sister around his living room to his barking: “Left. Left. Left, right, left,” stopping only when he called us to “Attennnshun!” Years later, when I rummaged through my grandma’s cabinet, I discovered the relics of his life that she’d saved—Chinese checkers that really came from China, the musty khaki hat he’d worn in the Congo during the war—each artifact shrouded in the mystery of a man I’d never really known.
My mother’s father smoked cigars and used Brylcreem to slick back his receding metal-gray hair. Even now, these smells transport me back to his living room on a Saturday night. My grandmother would be filling green and amber cut-glass bowls with pickled beetroot, cheese, and sliced tomatoes and cucumbers for supper while we listened to ABBA (his favorite band) and the soundtrack to The Sound of Music. The voices of Agnetha, Benny, Frida, and Björn and Julie Andrews always echoed through my grandparents’ small council house—which they proudly paid off to call their own.
I remember nights when my sister and I slept over in their spare bedroom and woke to a breakfast of fried eggs, sausage, and bacon, with fried mushrooms and tomatoes on the side. But I don’t remember the agony of my grandfather’s final days—the colon cancer that left him yellow-tinged and hollow in the bed he’d shared with his wife for so many years. I can easily recall my grandmother’s searing sadness, and her anger at being left alone. But the texture of my grandfather’s death is vague, smoothed by my mother’s reluctance to speak of him and my youthful refusal to acknowledge such serious emotional matters.
When I traveled to the United States in 2000, both my parents and grandmothers were in vibrant health. Separated from my family by thousands of miles, I was distanced from the direct, progressive impact of aging. I missed the eightieth, and then ninetieth, birthday celebrations of my grandmothers. My mum’s and dad’s retirements. The funerals of distant relatives. Even when Rob’s family joined mine, we remained isolated in our San Diego bubble from the effects of familial aging: His mum lived thousands of miles away, in Florida, and his dad had died at fifty, before I’d had the opportunity to meet him. Although death and dying were a constant part of my work life, it was easy to think that they were something that would never touch me personally.
The holy grail of stopping or reversing the aging process has long been a topic of intense scientific research and pseudoscientific theorization. And in the past twenty years, longevity in our canine and feline companions has gained increasing scientific interest. Our pets’ shorter life spans allow for more rapid evaluation of the effect of individual factors on the biology of aging, with potential applications expanding to human medicine.
That our pets are enjoying longer, healthier lives is indisputable; a 2015 Science article reported that the average life expectancy of the dog has doubled in the past four decades, and that indoor cats now live twice as long, on average, as their feral counterparts.
The factors influencing the longevity of our dogs and cats fall neatly in line with those that influence our own. Vaccinations have decreased deaths from fatal infectious diseases such as distemper and parvovirus; yearly checkups catch problems at an earlier, more treatable, stage; and with highly tailored diet options, disease can be nutritionally managed to enhance quality of life. But the life span of companion animals differs from that of other species in one significant way.
Across nature it is accepted that larger creatures live longer than smaller ones; body mass is positively correlated with the number of years lived. Compare the elephant’s decades to the mouse’s months. Multiple factors influence this difference, including rates of reproduction, litter size, metabolic rate, and ecologic niche.
Our companion animals, however, break this rule. Cats and small-breed dogs—Chihuahuas, terriers, and multiple others—live significantly longer than larger breeds. As an example, the giant Great Dane and Irish wolfhound typically live a mere six years, while a 2015 International Cat Care study of English cats found that the average feline life span is around fourteen years. And when it comes to small dogs, sixteen-year-old deaf, blind, and crabby Chihuahuas with a grip on life stronger than their grip on my sleeve are not uncommon in my exam room.
The reason for diminished longevity in larger dogs has not been discovered. However, as with much of our pets’ lives, human intervention probably plays a significant role, and tailored breeding is likely to blame. Studies have demonstrated that purebred large and giant breed dogs begin aging earlier and at a more rapid rate than smaller breeds—hig
her growth hormone levels, the negative effect of rapid growth on the skeleton, and the pitfalls of breeding to the extremes of genetic malleability all shape the brevity of the lives of the biggest dogs.
Cats, on the other hand, age more homogenously. Feline body mass and physiology differ little between breeds, and the majority of pet cats are mixed breed or domestic short-haired with an average weight that differs by only a few pounds. For purebred cats, as for purebred dogs, genetic disease can negatively influence life expectancy. For example, polycystic kidney and liver disease in Persians and related breeds, and hypertrophic cardiomyopathy in Maine coons, can result in premature death.
* * *
—
Even with the best preventive care—yearly vet visits, up-to-date vaccination schedules, a nutritionally complete diet, and regular activity—the diseases my patients and their owners faced often disrespected the rules. There was no magic formula to guarantee longevity, just as there was no way to predict how an individual animal and its disease would respond to the treatment recommended in the literature.
When Bagheera and his owner left the clinic after our first meeting, with new diet recommendations, prescriptions to improve his appetite and directions for their recheck, I lingered in my office. My next appointment was waiting, but I needed a moment. Bagheera had given me a glimpse of my own pet through the dispassionate, analytic lens I reserved for the hospital.
I closed my eyes and saw Monty lying in the San Diego sun that patterned our kitchen floor: his coat the same deep rusted brown-black; his body slim, with the paunch of old age resting between his back legs, as if his fat had slid down and collected there. But in the flat light of my office, when I peered at my memory more closely, I realized that he’d become brittle and light, filled with polystyrene. His coat had a tufted, greasy quality that suggested he wasn’t taking care of himself, and it was littered with clumps of dead hair—small mats of fuzzy gray undercoat showed beneath the brown-black.
Sitting at my desk I analyzed the increased amount Monty had been drinking over the past months and the way he stumbled sometimes at the top of the stairs after he’d climbed up them, exhausted from the short trip. But then, I reasoned, he was always waiting in the kitchen with the other cats for the tinkle of dry food pouring into their ceramic bowls. He slept through the day, but that’s what cats do, I told myself, given that his housemates, over ten years his junior, were equally likely to spend hours napping on the back of the couch.
I needed to acknowledge that the years I’d once assumed were ahead of Monty and me, which I’d taken for granted, were dwindling to months. His signs of normal aging had slid into indicators of age-related disease.
The differentiation between old age and geriatric-related illness was a common topic of discussion in my exam room. It was a distinction that could be difficult to elucidate and challenging to understand. When did an old cat’s napping indicate lethargy? When did a geriatric dog’s confusion go beyond cognitive dysfunction and indicate a brain tumor or terminal disease? And if age-related disease was identified, how far should one go to treat it? Was “prolonging the inevitable” justifiable when euthanasia was a legal and humane alternative?
My patients’—and now Monty’s—quality of life remained steadily in my thoughts. The oath I’d taken upon graduation—Above all, my constant endeavor will be to ensure the health and welfare of animals committed to my care—was a continuing reminder of my duty as a veterinarian. But the purity of that promise was a more complicated and nuanced beast than journals, textbooks, and internal medicine conferences described. It was my patients and their owners who taught me the most about the limits of the oath I’d taken.
When pets become sick and parameters of testing, treatment, and the extent of intervention are considered, the ground becomes boggy. Social, economic, religious, and personal ethical pressures influence the decisions we make for our pets, and the veterinarians treating them are tasked with balancing these factors to ensure their patients’ quality of life. But even the quality of an animal’s life is subjective and difficult to pin down, especially when veterinarians must make assumptions based on an owner’s words.
* * *
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The human filter we apply to animals—whether they are our pets, those we visit at the zoo, or those who make headlines, such as Cecil the lion or Harambe the Cincinnati Zoo gorilla—influences the way we perceive their behavior and the decisions we make for them. Our desire for our pets to be part of the family, to be our “fur babies,” clouds our objectivity in assessing quality of life; what we want for our pets often supersedes the best medical and ethical advice.
The very nature of being an internal medicine specialist, and diagnosing and treating the sickest animals, means I consult with owners who have heightened attachments to their pets. I’ve met families who don’t take vacations, couples who won’t spend the night away, people who set alarms to get up in the middle of the night, every night, to care for their beloved companions. Do they make these choices because of the bond they share with their pets, or because of their own needs, or both?
I know owners who have slept on the floor or couch for years rather than leave a pet who cannot get upstairs alone. There have been times I’ve wanted to say “You don’t have to do this anymore; you deserve a better quality of life, too,” but I’ve held my counsel, knowing that the owner was as dependent on providing the care as their animal was on receiving it. The choices we make for the animals in our lives are a deep and entirely personal affair.
We choose our pets. We choose their names, what they eat, even what they wear. We choose if our cats live indoors or outdoors. We choose if our dogs go on hikes or are carried to the mall. And, when it comes to their health, we choose the care they receive and, in many cases, if they live or die.
* * *
—
At Bagheera’s next visit he’d gained a little weight, and his owner reported small changes in his behavior that suggested that his quality of life had improved—he was sleeping on her pillow again and greeting her when she got home. But with the news that Bagheera’s treatment plan was helping also came a common complaint. Administering the medications was becoming torturous for them both. Leslie dreaded giving the pills as much as Bagheera evaded receiving them. He hid whenever it was time for his medication, and if she did successfully administer them he would salivate and foam profusely, or spit the pills out after she’d wrangled them through his locked-tight jaws. He’d also figured out that medication might be hidden in his food, and he refused to eat anything his owner had used for drug administration—not a good move for a cat with a diminished appetite.
There wasn’t an easy solution. One of the best options was to compound medications into flavored liquids, tiny melting tablets, treat-like chews, or even creams for transdermal absorption. Some owners and their cats have tolerated subcutaneous injections better than pilling. But these options still hold limitations. For most compounded drugs there is little data regarding bioavailability or efficacy, which brings into question whether the desired therapeutic effect can be achieved. And cats might even refuse a flavored liquid or chew, only adding to the frustration. I’d seen owners who would not, or could not, medicate their pet at home, which, ultimately, resulted in potentially treatable diseases becoming fatal.
I’d occasionally had to medicate my own cats, and knew that their tolerance for human intervention varied wildly. Fred, my small, scatty cat, was averse to most types of human contact. The mere act of petting him usually made him recoil. Once I understood his temperament, I’d made him a promise that if he became sick I wouldn’t submit him to the same testing and treatment I recommended for my patients. To do so would only satisfy my need to keep him around. Harry, on the other hand, my rock-star cat, was the opposite. He would sit on my lap for hours, willingly submit to nail trims while purring, and allow me to administer oral medications without
raising a paw. I’d decided that I’d do whatever it took to save him if the time came.
For Monty, the parameters were blurry. He was beyond the age for the kind of intensive treatment I’d prescribed for Bagheera and other patients. I’d medicated him for minor ailments in the past, and it had been challenging. If he wouldn’t take the pill in a small amount of food—which he usually refused after he’d been fooled once—the only other option was to pry his mouth open and shove the tablet down his throat. Unless I hit it just right, which rarely happened, I would leave him cowering and gagging, and me guilty and sorry. Was the benefit of the medication outweighed by the nasty taste it left in both our mouths? My veterinarian answer was yes; my answer as his owner was no.
I talked with Bagheera’s owner about compounding medications, and tricks to make pilling easier, and for the time being, she was willing to persevere with the treatment that made him feel better. From the outset, however, there was no cure. The aim was to extend and improve the quality of Bagheera’s life, but despite feeding him the right food, administering medications, and, when the time came, giving daily fluids under the skin, his kidney damage was irreversible and progressive. When the best outcome was a life of daily treatment, the objective was less clear. Could I uphold my oath of maintaining my patient’s health and welfare while also abiding by an owner’s wishes?
The first sign that Bagheera’s disease was worsening came sooner than I’d hoped. One Monday morning, only a month or so after his first visit, I took a panicked phone call from Leslie. Her voice was high and tight.
“I’m really worried about Bhaggie,” she said. “He seemed a little off last night, but we’d struggled over his meds earlier and I thought he was mad at me. But this morning he’s disoriented and confused, and he didn’t want his breakfast, even though I gave him tuna, which he usually loves….”
My Patients and Other Animals Page 26