The position pets occupy in our lives strongly influences our decisions, as owners, about end-of-life care. Although, legally, our pets are property, it is now common to view our animal and human families as one and the same, and the role pets play is rapidly evolving. Healthcare by proxy—making decisions for those who cannot speak or decide for themselves—is increasingly a facet of modern human medicine, although it has always been a part of veterinary medicine. The questions surrounding how much to do and how far to go for our pets are equally relevant to the choices we must make for our human loved ones. With an aging population and advances in healthcare that can prolong life further than at any other time in history, we confront the same decisions for our parents, grandparents, spouses, and partners who are no longer able to influence the course of their care at the end of their lives.
The often-wished-for fairy-tale ending of passing away peacefully during sleep, is, in my experience, a rare reality. The death I’ve witnessed has not been so considerate. The terminal consequences of the diseases I treat include uncontrolled bleeding, seizures from end-stage liver or kidney disease, and suffocation due to fluid accumulation in or around the lungs, none of which result in a quiet, clean, passive death. Euthanasia, on the other hand, with the careful administration of sequential drugs through a securely placed intravenous catheter, can provide the pain-free, dignified end so many of us seek, not only for our pets but also for ourselves. The pain from euthanasia stems not from the process itself, but from the decision to pursue the course.
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While Bagheera continued to maintain his kidney function without exhibiting the dire symptoms that hypertension predicted, Monty continued his inexorable decline. We approached and hovered just above the line I’d set for Monty’s quality of life—when he no longer wanted to eat, when he couldn’t use the litter box—and he continued to move parallel to it, never crossing over. How long can we live like this? I wondered.
These were questions I was able to avoid with Bagheera’s owner. His blood pressure remained stable, he’d called a truce over receiving medications, and his appetite was good. For now, we could expect to measure his life in months to years, but my old black cat was down to weeks or days.
The morning Monty was too weak to get off his bed was no easier because of its inevitability. I brought him a bowl of Fancy Feast, the go-to kitty comfort food that could usually entice the most reluctant eater. It had been his staple diet for the past few months, but that morning he wasn’t interested. I lifted him up, acutely aware of his fragility—the hollowness of a body barely occupied.
Rob drove us to the hospital. I cradled Monty on my lap, running my hand over and over his body. Memories swirled around me:
Carrying Monty home down Baltimore Avenue, the sound of his meow filling my ears.
The half-eaten mouse I’d found in the closet in my tiny room in Philadelphia.
The tears his coat had absorbed and the loneliness he’d eased when a solitary weekend in an unfamiliar city stretched before me.
The road trips we’d taken with him screaming his discontent from the backseat.
I felt the weight of his body on my shoulders when he would wrap himself around the back of my neck like a scarf. He was so light now on my lap.
It was easier to think of everything that had been rather than to contemplate what was to come.
For the first time I stepped into the hospital as a client and checked in at the front desk, registering Monty as a patient. I skipped the waiting room and took him directly to the treatment room, Rob walking a pace behind. The ER vet on duty knew we were on our way, and the catheter setup had been arranged. I noted the familiar fringe of tape attached to the edge of the treatment table when I calmly handed Monty to Sylvia. It was a small comfort that she would be the one placing his catheter. She would be careful when probing his fragile veins.
Rob and I sat in an exam room. I couldn’t stem the flood of thoughts of Monty. The smell of his breath, the leathery softness of his paw pads, his peculiar likes and dislikes. He’d been the one constant in my life since my arrival in America—and soon he would be gone. There was a surreal distance that separated my love for him—which should’ve protected him from anything—and the blue vinyl bench we sat on. I couldn’t see beyond my memories, and I didn’t want to.
Sylvia brought Monty into the room. He was wrapped in a fleecy blue blanket, and his catheterized leg was hidden beneath the fabric.
“Would you like some time with him?” Sylvia asked. A question I’d asked more times than I could count.
I looked to Rob for an answer. I felt paralyzed and unqualified. “It’s up to you, honey, whatever you prefer,” he replied to my silent question.
“Just a few minutes,” I said, the knot of grief I’d been holding tightly unraveling with the words.
Sylvia nodded and handed Monty to me with the reverence of a religious relic, but he felt awkward and foreign in my arms. I’d lost an essential part of him, of the reference point between us, when I registered him as a patient. I was not a doctor, and I didn’t know what to do.
I trembled with the effort of keeping my emotions contained. I was shy and embarrassed in front of Rob and in this exam room that had remained separate from my personal life, until now. Rob was the person who knew me most deeply, but there was something different I’d shared with Monty that I was about to lose.
When the ER vet entered the room, the minutes I’d spent with Monty felt insubstantial even though they’d seemed unending when they were passing. I wanted to change my mind, pretend there was a misunderstanding, but I knew I would do neither.
“Are you ready?” the vet asked. I nodded, tears now dripping from my chin and rolling down Monty’s faded coat like they’d done so many times before. I told him I loved him and kissed the back of his head, burying my face for a moment in his neck. I shifted him more comfortably on my lap. I couldn’t breathe.
I knew the technicalities of what was coming. First, flush the catheter with saline, then administer an anesthetic, and finally, when Monty was asleep, deliver the euthanasia solution. He would likely stop breathing once the anesthetic had been given, and his heartbeat would fade to silence while the euthanasia solution was administered. I’d heard the moment of death; the faraway sound of each pulse getting fainter and fainter until a muffled silence, and maybe the crackle of fur against the stethoscope diaphragm, was all that filtered into my ears. Like a train passing down a tunnel into the distance.
I continued petting him and telling him that I loved him. Willing his passing to be peaceful, racked with a guilt that now, at the end, the life we’d shared had not been good enough. I panicked at the thought that what I’d given him was insufficient compared to what he’d given me. That in this final moment I’d failed in the reckoning.
When the vet stood up from kneeling on the floor before me, Monty was gone. I didn’t need her to listen to his chest to tell me so. His weight was flaccid. He felt like he would melt through the blanket and onto the floor. There was nothing holding him together.
“Would you like a few minutes?” she asked.
“Just a few,” I said, unable to look up.
I gripped Monty tightly in the blanket, scared I would drop his body.
I’d made the right decision.
I hadn’t let Monty suffer because I couldn’t bear to let him go.
But this did nothing to ease my sorrow.
I’d never experienced this deep a loss before. And I saw, for the first time, the full expanse of the gulf I’d stepped across when I transformed from veterinarian to owner.
Epilogue
JULY 2016
I’ve dedicated the last twenty-six years to the anatomy, physiology, pathophysiology, and medicine of dogs and cats. I can tell you the receptor a steroid binds to and what it does in the body, why lilies are poiso
nous to cats and chocolate toxic to dogs. I know which cells do what in the kidney, liver, and intestine. If I close my eyes I can see them through the eyepiece of a microscope—the villi protruding from the intestinal border, a coral reef caught in paraffin; the tessellating perfection of blue hepatocytes; the stout, soldier-like uniformity of the kidneys’ glomerular membrane, the cells standing shoulder to shoulder.
I’ve diagnosed cancer of almost every organ; bacterial, fungal, and viral infections; diabetes, kidney failure, liver failure, heart failure. I’ve prescribed antibiotics, chemotherapy agents, pain medication, and hundreds of other drugs. I have listened to stories, so many stories. Stories of life and stories of what is soon to be death; stories of tiny kittens grown into old, frail cats; rambunctious puppies grown into arthritic geriatrics.
I hear myself saying, “Dogs are so bad at telling us when they are sick. Often, by the time we know something is wrong, there’s nothing we can do.”
I have held people’s hearts, hopes, and fears when I gently described a diagnosis, prognosis, and options.
I’ve held hands while delivering the news There is nothing more we can do, and the advice When the bad times outweigh the good, then it’s time.
I have held my breath and held back tears while administering euthanasia solution to a beloved companion, knowing in that instant that the moment has become a waypoint in the life of that family. I’ve experienced time and time again the deep, inexplicable bond we have with our pets.
I have always—almost always—had an answer for the seemingly unanswerable. A solution to the riddle, a diagnosis to piece the puzzle of clinical signs together. We were at the park yesterday. She ate her breakfast. He seemed fine, and then: What could I have done differently? What am I going to do now? The house will seem so empty. How can this piece of my heart, hidden inside the coat, skin, and bones of a cat, be gone?
I’ve been heroic, optimistic, pessimistic, and realistic. I’ve cried for my patients and their families while my own pain was softened by the sterile words of a diagnosis.
I have been a veterinarian in every waking and sleeping moment—in the hospital, in my car, in my home—my brain rattling through lists of patients and their problems, my anxieties infiltrating my family. Yet, when I lost Monty, and then a year later, Fred, and then, two years after that, Harry, my veterinary experience did nothing to dissolve the crystalline hardness of my grief.
On a typically glorious San Diego day two years ago, I took Emma to our local dog wash. We walked, Emma dawdling to smell every inch of pavement and greet everyone we passed, way more interested in the humans than their canine companions. Emma preferred life at a slow pace. The back right leg she’d had surgery on years earlier—the reason for our first meeting—had never fully recovered, and she still had that slight limp. The scar on her right thigh was still visible when the light hit her fur at the right angle.
Over the previous year, her face had grayed, and she now had the white muzzle and eyebrows of age and wisdom. Even the tips of her toes were white, a snowy fringe around each paw pad. She didn’t particularly enjoy baths, but given that her favorite place to sleep was snuggled on the couch between Rob and me, an occasional scrub to remove the carpet of hair she shed around the house and freshen her up was required.
On arrival at the dog wash I lifted Emma into the tub, swearing that she’d gained ten pounds since the last time I’d picked her up. Once she was safely deposited into the deep basin, she hung her head and fixed me with a look of disgusted displeasure that could only be described as “hangdog.” I turned on the water, adjusted the temperature, and began spraying her body, watching the droplets shimmer and roll off her oily coat like she was a seabird.
I ran my hand over her back and legs, encouraging the water to penetrate her thick outer coat. I gently directed the stream over her head and neck and worked backward toward her front legs and shoulders. Music was playing through the shop speakers, an eighties channel, and the air was filled with the pungent humidity of wet dogs and shampoo. It was satisfying and soothing to see the water blacken her fur, to feel handfuls of hair shed from her body. When a-ha’s “Take On Me” came on the radio, I smiled, reminded of when my sister had bought the album on cassette tape and listened to it over and over.
I sang along in my head, absently washing Emma’s neck and shoulders, and while I thought of the music we listened to in the backseat of our red Vauxhall Astra on family holidays, my palm passed over a hard irregularity in front of Emma’s left shoulder. A perfect drop of fear slid into my stomach. The music stopped. I ran my hand over the region again, slower this time, more cautiously. The fear curdled and grew, like egg white in boiling water. There was a mass. A firm, fixed glob of tissue, the size of half a lime, was stuck to the muscle of her shoulder, under her skin. I looked around. Had anyone noticed? A-ha was still playing. I turned back to Emma. Her expression was the same.
But everything had changed. How had I not noticed the mass sooner? Now, under her wet, slick coat, it was obvious. My fingers instinctively palpated the area over and over, gauging the mass’s size, texture, and adherence to other tissue. Maybe it’s a lipoma, I tried telling myself—a benign fatty tumor that could be ignored—but I knew it wasn’t. It felt malevolent, aggressive, cancerous.
At the clinic the next day I performed an aspiration, sinking a needle into the mass to obtain a sample of cells, a procedure I’d never imagined I would do on my own dog, regardless of its relative simplicity. I warily eyed the sample under the microscope before submitting the slides to the lab. The cells had large, violet-hued nuclei in a smattering of different sizes, and the cytoplasm swirled into a deeper blue pool seeming to flow from one nucleus to the next, making it difficult to distinguish individual cells. I didn’t need a textbook; this was a sarcoma—a malignant soft-tissue tumor—locally aggressive but rarely to metastasize.
That same day we performed a CT scan of the area to gauge the extent of the mass. I didn’t call Rob to get his permission, even though this had not been part of the plan we’d discussed that morning before I’d left with Emma. It was a quick procedure that could be performed under sedation, and it was what I needed to do. I hadn’t forgotten the terrible night after she’d been sedated for her blood donation years earlier, but this was different. This was for her, to help her. Wasn’t it?
The CT showed that the mass originated under her shoulder blade, and the hard half a lime I’d found was the tiny manifestation of a tumor that had burrowed its way from underneath her scapula to reveal itself when it was already too late. I was a specialist in hidden disease. I examined the function of internal organs sequestered deep in the body, diagnosed cancers invisible to the naked eye. This was what I did every day. This was what I had trained a lifetime to do.
There were three options, I explained to Rob later that night while Emma whined and paced the living room floor, groggy and anxious while the sedation from her CT scan wore off: limb amputation, palliative radiation, or do nothing. I looked at her graying face. Was I brave enough to do nothing?
We made the decision that night, quickly and decisively ruling out amputation—the only way to surgically control the cancer. I doubted she’d walk again if we pursued that route. Her right hind leg was too damaged to carry a third of her weight; it was already carrying significantly less than a quarter most of the time, judging by the wasting of her right thigh muscle.
I called the radiation oncologist at a local practice the next morning. “What would you do if she were your dog?” I asked, already knowing the answer. Radiation therapy, he replied without hesitation, a palliative course, five days of treatment, to slow tumor growth and improve prognosis. “This is what we should do,” I told Rob later that day, talking to him like a client. “She can come home every day and she’ll only need a short anesthesia.” That she hated being in a cage, and being alone, that she’d always handled anesthesia poorly, were negative
s I was willing to accept, and, I suggested, Rob should, too. He didn’t question my decision; I was still the one to choose when it came to our animal family.
The following week we drove her an hour each way, for five days, to receive radiation therapy. She whined and barked when she was put into her run after treatment each day until she secured a spot under the lead technician’s desk where she quietly napped. When we got her home she wouldn’t eat, and we had to coax her with rice and cottage cheese, sweet potatoes, and canned tuna. The area of hair clipped over her shoulder was so much bigger than the small mass we could see—the hair took a long time to grow back, and when it did, it was the gray-white of her muzzle.
But then life pretty much returned to normal. And it stayed that way for a year or so. We didn’t notice, at first, that we’d stopped walking everywhere with her. Or that her left front leg would tremble every time she squatted to urinate. Or even that the muscles of her right hind leg were melting away.
By the time her radiation therapy had faded to history, the tumor was growing again, wrapping its fingers of cancerous cells around her scapula, edging up toward her spine and forward along her neck. We had to make another decision. Should we try to repeat radiation therapy? Try again to slow tumor growth and buy extra time? But the outcome was now less certain, the probability of side effects higher. Radiation was not the right choice this time, we decided.
We started pain medications, adding more when the efficacy of the first waned. We limited her walks and our expectations. There had been a time when taking her on a walk annoyed me. Her attitude toward a neighborhood outing was always so lackadaisical; she wanted to spend too long sniffing the grass; she couldn’t make up her mind where to pee. But then, when her collar chafed against the mass and she no longer pulled on her leash, when she would stop with her head down, panting, waiting for the pain or exhaustion to pass, I missed those walks with her that had once been so exasperating.
My Patients and Other Animals Page 28