Wednesday, November 20, 2013

Living and losing the last moments with your terminal dog.



My days are measured in tiny baby steps. Savannah, my beagle mix is 18 years old, and she is slowing down, losing her marbles, and challenging my ability to understand what she needs.

Together we are taking the smallest steps of backward and forward and keeping in mind the ever present looming fear of the slope that lies ahead and the finality of this journey.


She always hated baths.

Measuring Quality of Life;


Savannah is tired, I am tired. It is a battle between a ghost I cannot see who slips into the little cracks of a being that I used to know so well. She is still there in fleeting moments. I can pick her up, she buries her nose in my palm, breathes me in, and showers me with kisses. I am still here for her. For all of her little slips, for the days that grow darker and for the night that calls her.

Measuring quality of life is an intensely personal decision. As a veterinarian I try very hard to not suggest/suppose/presume, etc. what a family is seeing as they live with their ailing/failing pet. It is not my place, nor my ability, to tell you what your pets quality of life is..but I do try to remind clients that we are talking about their pets quality,,and not our unwillingness to be burdened. It is a fine line. If there isn't a pet parent to take care of a pet I can't offer anyone anything.

For me, and for the decisions that I make for Savannah, her quality of life is measured by the following checklist;

  1. Eating/drinking
  2. Peeing/Pooping...although butt baths are a daily routine,,she sort of slumps as she postures to poop.
  3. Wagging tail. A very primal act, but to me it means she is happy. 
  4. Sniffing. She is a beagle, this is primal too. If she is on grass or dirt, she is sniffing. Her brain needs to keep working.
  5. Sleeping..Well, we are working on this one. We both need to sleep.
  6. Happy. OK, this is a toughie. She has good and bad days. I am keeping her out of pain, and spending lots of time with her. 
Many vets use the old adage, "when the bad days out number the good ones it is time." I don't know if I believe this for myself, so I have a tough time using it as a measuring stick.

The decision to say goodbye is certainly one of the hardest moments in many peoples lives. I take it intensely seriously and I try to talk about their pets condition instead of providing benchmarks to use as a pros vs cons tally.



Home Life;


Her life is lived in the small safe places that she can't hurt herself in. The hallway, the front yard tie out, and the back yard at work. She is still happy to have the ground under her feet. To smell the footsteps of the critters that passed by, linger below, and elude my ability to perceive. She is still a beagle. Sniffing, eating, and wanting to live a pampered life.


Basic Hygiene:


But there are bathtubs, butt clean-ups, and pee pads. They are the inevitable landscape of every elderly hospice patient. It is a side of being a parent that not everyone chooses to take on. My husband thinks I am being to anthropomorphic. I remind him that he is entitled to his opinion, and that she is my responsibility, and that I will not choose to let her go because she is a burden.

And I remind him that she is still in there, a little harder to recognize, but still there. She is a different version of herself but she is eating, drinking, peeing, pooping, wagging, and walking. When one of those escapes her I may open up the floor to discussion with him about the next step that is right for her.


She has good days, and bad days, and I am watching her at every tiny step.

I can promise her, and only her, that I will say goodbye, and I will not let her suffer.

Joe dancing..with Charlie.
Can you see Savannah's tie out between the two trees?


Sleeping:


There have been nights where neither one of us get more than an hour or two of sleep at a time.

These almost broke me.

There is a reason that sleep deprivation is used as a form of torture. 

There were times where I got angry. Where I wanted to end it all right then and there. I get it. I understand my clients who give up here. I am not judging, nor am I trying to convince anyone that my way is the right, or the only way.

Sleep can come in waves of 10 hour stretches at 10 am and then be a fleeting uncapturable ghost at 10 pm to 6 am. I have battled back and forth about pinning a diagnosis on her.

My rule-outs;
  • She is not in pain.
  • She is not hungry, thirsty or in need of bathroom facilities. I know because I offer all of them at least twice.
  • She is losing it? Technically called cognitive dysfunction. (Sometimes I believe we are both losing it,,,no sleep does this to you).


Savannah has the best bed in the house..warm, comfy, and highly sought after by the puppies.

The run of nights that that stole any chance of sleep had to end. 

I tried exercising for hours to get her tired. We walked and walked and walked from 6 pm to 9 pm. And then she paced from 9 pm to 9:30, slept an hour and repeated this all night. I can't sleep through her anxiety.

So I tried the anti-anxiety medication alprazolam. It calmed her, but she still didn't sleep.



Ask Your Vet for Help;


So I tried Tramadol. BINGO! Tramadol is used primarily to treat pain. For Savannah it is providing her sleep. BUT! I am also considering adding back an anti-depressant, and/or a cognitive dysfunction drug. And both of these are contra-indicated if using tramadol.

So, here we are, sort of treading water, and sort of unsure which oar, or direction to go in next.

Other things to try; melatonin, and SAM-e, (both are over the counter more natural options), acupuncture, the b/d diet (Science Diet b=brain), 

I already keep her light on for her all night. This help immensely.


At 8:45 pm Savannah gets a half of a 50 mg pill, and she sleeps all night! It has been four glorious nights of sleeping from 10 pm to 6 am. She is happier, calmer, and I am able to function again.

Is she anxious? Is she suffering from dementia? Is it pain? Honestly, I am not sure. I am trying to address all of her needs and keep her eating, drinking, peeing and pooping as we navigate through these uncharted waters.


Eating:

I am offering anything and everything.

We are at the point where sustenance is more important than nutritional value.

Gone are the days of dry kibble and we have almost abandoned any hope of boring prescription food. We make two meals at every feeding. She likes variety, and her tastes change hourly. Lately the Honeycomb, spaghetti, and bread/rolls/buns is her preference. That's after she turns her nose up to chicken, ground beef, and hot dogs.


Maintaining Sanity;

 Yours and your pets. This is a hard one to access. It is a balancing act. Trying to keep track of your ability to make sound decisions for both yourself and your pet. How much time and attention do you have to give? How much does your pet need? They are hard questions to answer, fulfill, and follow through with. I have a very good friend who is taking care of her dog with chronic renal failure. She is sleeping only when her dog sleeps, losing full nights of uninterrupted sleep, and feeling like I am, that precious time is slipping away. We fear that day when we have to say goodbye, and yet we know its quickly approaching.



I told her that we need to move in together. And take shifts. It is a marvelous idea. We all need to band together and provide our own pet hospice support and care taking group.


Exercise;

Keeping the body active is keeping it healthy.

All pets will very quickly lose muscle mass if they are not using them. Encourage walks, make mental stimuli and environmental enrichment a priority. It is as important as eating.

Savannah paces. She has a head tilt so she circles. I can tell if she is pacing/circling because she is hungry, thirsty, needs to go to the bathroom, or is just bored. 

I don't discourage the pacing unless I think it is due to anxiety. And if it is anxiety related, I treat the anxiety.



My goal for her is the same it always has been.

I want her to be happy and healthy. The parameters around these evolve as her condition changes. 

The last few months with her have been some of the most memorable and rewarding. I wouldn't give up one single second of them.



 And I hope there are a few tiny little steps left.

Taken today.

And as a little footnote, I finally have a little dog that I can dress up. These two other pups of mine think they are farm dogs. They hate being dressed up, and they will promptly find a poop pile to embellish their new outfit with.

So everyday Savannah gets a new outfit. And everyday I remind her how beautiful she is!

UPDATE: December 6, 2013

Savannah is doing remarkably well. I have tried a few medications and had some limited success.
Here's whats working right now.

She is eating well. I offer at least three options three times a day. She seems to change her taste bud preference daily, so if something doesn't work today, it might work tomorrow. The options that I offer her are; canned dog food that varies between super expensive and junk food. Canned cat food, same guidelines as dog food. Dry cat food, and dry dog food. For some reason I can't explain she will eat a large T/D (Science Diet for dental disease), like a treat, but only about one a day. Ham, turkey, bologna, rotisserie chicken, hot dogs, ground beef. I have a wide assortment of these on hand and cook a little bit at a time. Tuna, rice, noodles (these are a big hit about every 4th day), cheese, peanut butter (always used to give pills, she is almost impossible! I have been bitten twice, which NEVER happens to me!). Soft rolls, she will always eat these, so I offer them whenever she hasn't eaten well. Cereal, Cheerios, and her personal favorite Honeycomb. But on days that she is especially picky I think outside the box and try junk food. The other night she ate white cheddar cheese crackers like they were the yummiest treat ever. When your pet turns their nose up at food and you are flirting with the cloaked death stalker, you offer anything and everything, try crackers and animal cookies, or something outside of their normal diet.

All of this food juggling has caused an increased amount of fecal output, and the consistency is no longer optimal in neither color nor firmness. The burden that an ever changing diet has had on her gi tract has caused gastro-intestinal pain in the form of cramping, gas distension and the discomfort that diarrhea causes. I know that when she is pacing and moaning at 9 pm after eating a good meal it is because her belly is bothering her. She, like most normal healthy pets, defecates about every 12-24 hours. The more meals I feed a day the more frequently she needs to defecate.


The nights were the big problem. She paced, cried, and would wake up for 45 minutes every 45 minutes. I solved this with 3 mg of melatonin, and tramadol. Tramadol is an opiate used primarily in veterinary medicine for pain. I have seen some pets get anxious on it, so always give it with a disclaimer to monitor closely. Tramadol lets Savannah sleep through the night. After 8 hours of rest she is less anxious, happier, calmer, more focused and clear headed. I should add that both of us are.

SAM-e is also given. It is helps to promote overall healthy brain function, and helps to balance emotions by acting as a mood stabilizer.

I also started her on selegiline. Used in human medicine for Parkinson's disease, dementia, and depression. I do believe it is helping her immensely.

She also get Neutricks, for cognitive dysfunction. These are large chewable tablets. She is not terribly fond of them, and because I have to pill her with all of the medications, the larger pills are significantly more difficult to give.


Last week we started acupuncture. After two treatments and the regimen listed above she is doing far better than she has in the last six months.




I looked at her this morning with my husband and said "Damn, Savannah-dog, you just might make it to summer!" She can bury her nose in the soft ground of 2014 and remind terra firma that there is still one mighty beagle left to reckon with.







Cognitive Dysfunction

'Joy Sessions' capture tender moments with owners and terminally ill pets.


If you have any pet related questions or comments, or hints to help an elderly dog live their life to its fullest please share them here, or you can find me at Pawbly.com, or on Twitter @FreePetAdvice.


18 comments:

  1. Krista, you are a wonderful doggie mom, Savannah must be so happy to have you. Thank you for sharing what you are going through taking care of your senior pet; it helps me to persevere for the love of mine.

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    1. Thank You Susan,

      Taking care of an elderly pet is not easy, but it is soo rewarding, and after 18 years of being by my side I owe her this.

      All my best
      Krista

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  2. What a lucky pup. Thank you for sharing for us and all the pet parents out there what giving pet a dignified and comfortable end of days looks like. In practice I'm continually astounded by how much better I can make the end of a pet's life and how many more happy days we can give them. Just this week simple anti-nausea medication made a world of difference for a kitty with GI lymphoma.

    When we were trying to decide whether to let Riley go when he had his stroke and could no longer walk, there were folks at our clinic who gave me "the look" that said they thought it was time. For us though, he was still comfortable, still happy to see us, and we could keep him clean and happy. We wanted to give him what happy days we could.

    When it got to be too much for him (he could not longer sleep or rest), we made the right decision. But if I had let him go when others thought I should, I would have regretted it, and we would have lost those last precious and happy days he had with us.

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    1. Hello,

      Thanks for visiting,

      I agree that this decision is one of the hardest to make, and that for each of us it is based on personal factors based on our unique relationships with our pets.

      Lucky for Riley to have had such devoted and intuitive observant parents.

      I am sorry for your loss, and I hope that I am as sure as you were when Savannahs time comes. I am only afraid that the slope is so gradual and so dimly lit that I won't truly know when that definitive moment arrives.

      But in the end I know I was true to her and her entire lifes needs.

      All my best to you..even on those tough days on the floor..

      Krista

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  3. Thank you. People like you make this world a better place! There is a poem I love and I wanted to share it with you. Hope it puts a smile on your face.

    LITTLE DOGS RHAPSODY IN THE NIGHT (PERCY THREE)

    He puts his cheek against mine
    and makes small, expressive sounds.
    And when I'm awake, or awake enough
    he turns upside down, his four paws
    in the air
    and his eyes dark and fervent.
    Tell me you love me, he says.
    Tell me again.
    Could there be a sweeter arrangement?
    Over and over
    he gets to ask it.
    I get to tell.

    From Mary Oliver’s “Dog Songs”

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    1. Dear Petra,

      Thank you so much for sharing that poem, it is so incredibly touching and I will remember it always.

      Thank You Again,
      Sincerely,
      Krista

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  4. This is heartbreakingly beautiful and so comforting to know that vets struggle with this too.
    My parents have never had peace with their decision to put their beautiful cocker spaniel, Mickey, to sleep. 12 years old and almost a year of renal failure, having tried everything the vet suggested, he had had 3 bad days in a row. Struggling to get up and crying when he lay down, he had stopped showing interest in food (before this time he was the most food-focused dog I have ever seen) so they decided it was time. My mum slept on the couch with him in her lap that night- his favourite place to be in the world- and my Dad took him to the vet in the morning. When Mickey got to the vet he perked up and wagged his tail. The vet asked my Dad was he sure, that they could maybe try some stronger pain meds (after saying the week earlier that there was nothing more to be done). My Dad went ahead, the decision had been agonising and had been made. He still blames himself though and feels like maybe he should have waited.
    It's a gift we can give our pets, to surrender gracefully at the right time but in some ways that makes it harder on us.

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    1. Hello,

      Oh, I am so sorry that your parents agonize over their decision. I have to admit that it is sometimes very hard to be the veterinarian and want to help both our patients and our clients as they make such a difficult heart wrenching decision.
      As a distant by stander with lots of experience with chronic renal failure pets it certainly sounds like your parents made a hard decision but with their pet in mind as the most important deciding factor. After that is done it is never the wrong decision. And maybe that little wag was for a final loving goodbye. How amazing to be loved so completely and given such a compassionate goodbye. Life for their dog was never going to be what it was before, and saying goodbye peacefully, without suffering, and in the arms of someone who loves you is all any of us can ask for.

      Your parents are amazing, loving people, who were so fortunate to have such a beautiful dog to share a part of their life with. I hope that they take great peace in knowing that.

      Forgiveness is a powerful (and difficult) thing I understand it completely, but It wont do anything but dull the wonderful memories that they should cherish.

      This vet believes they did exactly the right thing for exactly the right reasons. I hope they find a bit of peace in that.

      Here is a blog on my regrets..See I still grapple with this..but I am learning to try to forgive myself, believe in my heart that I made every decision with a kind genuine concern for both my patients and my clients, and to accept that I am a human being, I am not perfect, but my intentions are to always be kind.

      http://kmdvm.blogspot.com/2011/10/ones-i-left-behind-my-regrets.html

      All my best,
      and thank you for sharing.
      Hugs to you and your parents.

      Krista

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  5. Hi Krista, a lovely post that had me nodding all the way through! I too have an 18 year old dog - my staffy Isabel. And I struggle with exactly the same questions - but as long as she's eating, pooping & still enjoying her verrry slow walks then I figure her quality of life is still good. I was also struggling with seriously interrupted sleeps at night but that has totally stopped since making sure she has night lights and can find her way between her favourite beds.

    I keep hoping I'll be spared from making the final tough decision and will just come home and find her sleeping forever on her favourite bed - but who knows? Yes, it's extra effort to look after her & sometimes not so convenient but I think the benefits far outweigh any inconvenience. After her 18th birthday I wrote a blog post 'Ode to Isabel' exactly about this - http://www.vetanswers.com.au/blog/post/ode-to-isabel-the-18-year-old-staffy/166

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    1. hello Judy,

      I understand completely. It is so hard to say goodbye, but I am so grateful for each moment. I treasure whatever time I have left, as my heart prepares to say goodbye.

      We were so lucky to have soo many years together. i cling to that gratitude through the tears of the thought of not having her underfoot and by my side.

      XOXO
      Krista

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  6. Great post! I love all the pics too. I treat a lot of old timers and I am asked THE question all the time of when is it time. I use similar guidelines that you have but just broken down into 3 questions -
    1.Is the dog eating?
    2. Is the dog sleeping at least 3 hours at a time at least once a day, preferably 2 or more times?
    3. Does the dog still want to be part of the family?

    If those 3 questions are answered yes - quality of life in the eyes of that dog is fine.

    I think your guy does have some CCD - staring at walls, forgetting what it is doing at times and barking or restless at night (like your guy) are the most common symptoms. From a natural standpoint like you suggested I use melatonin and SAMe. However, I also use other antioxidants preferably OPC type and it seems to help.

    Good luck with getting sleep - you are a vet, in vet school we learned that sleep for us is overrated :-)

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    1. Hello!

      Savannah has been on melatonin 3mg bid for about two weeks. Also the SAMe SID for about as long. I tried Xanax, no difference seen, and low dose tramadol..but was concerned about over lapping and mixing..she has been on selegiline HCl 5 mg SID about a week. I also increased her tramadol to 50 mg (shes about 14 pounds) each night, and she is sleeping, walking, and interacting much better than she has in months.

      Can you clarify the OPC? antioxidants?

      My poor little guinea pig, (the consequence of being a vets kid). But so far the days seem to be brighter, and she is happy. What more could I ask?

      Thanks for your advice!

      Sincerely
      Krista

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  7. Dear Krista,
    There are many people that just won't understand why you are doing what you are doing. There are many that aren't able to find it within themselves to look after a human relative when they are in a similar situation. Reading your words made me weep thinking about my Mum and my beloved dog - I nursed both until the end. I gave everything I had and then more to do everything to ease pain, discomfort and surround them with love. While nursing my dying mother, I only managed around 2 hours broken sleep a night for the last 3 months of her life. With my beloved dog who died 7 months and one day ago, I woke every time she did - up to 7 times per night, every night to arrange her legs so she was comfortable and cover her with a blanket. I loved and cherished her; walked at her pace and permanently embedded the memories into my mind. I wanted her end to be peaceful. I guess it was, but I didn't get to say good bye to her - I had to let her go on the operating table. I did go in to be with her while she died and told her how much I loved her, kissed her and held her paw. I hope on some level she knew I was with her. To have brought her round would have been for me and not for her. It will haunt me for the rest of my life. I tried so hard and still failed. I hope she forgives me. If I'd have known what the surgery revealed, I would have never agreed to it and taken her home and let her go peacefully the next day. There was a chance she could have recovered and I had to take it.I wish I hadn't and we'd gone for that little walk instead. I'm glad it is me living with the pain though and not her. She was my soul mate.
    This life is cruel and so very hard. Some of us feel it more than others, but we are not alone. I carry permanent health issues as a result of the extreme stress, sleep deprivation and simply pushing myself above and beyond what I should have been capable of. Would I do it again for a loved one? For sure, in a heartbeat.
    Remember this when the dark desperate moments envelope you: love never dies and your compassion and commitment is a true gift to those you love.
    Wishing you and your beloved girl only the very best. xxx
    P.S. Please don't waste your precious time leaving a reply as you have for some other comments - go kiss your sweet girl instead. x

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    1. Hello Tina and Chandi,

      Thank you for leaving such a beautiful note,.

      Savannah has had a really good last week. She is on a new bunch of meds and they seem to have given her a second wind. She is sleeping through the night, calmer, clearer headed and really happy. I am so grateful it is beyond words.

      She may not have years left, but I am thinking that she has months! And she is happy..it is all I could have ever asked or hoped for.

      Many thanks again.

      Sincerely
      Krista

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  8. Hi Krista, I can't tell you how much comfort reading your blog has been to me. So many things I am going through both mentally, emotionally, and physically, you talk about. I have a 15 1/2 year old miniature dachshund with cognitive dysfunction. She has been on Selegiline for almost 2 years. She is currently on 4mg every 12 hours. We recently upped her dosage from 6MG once a day to 4MG twice a day to see if that would help the morning pacing in which she would run into walls, etc and help with the night restlessness. Splitting the dosage of Selegiline did help some both during the day and night. Did you give SAM-e in addition to giving Selegiline at the same time? Was there a problem with serontonin syndrome? I am giving Melatonin (1MG) at night and it works for about 4 or 5 hours. Did you also give Tramadol along with Selegiline and SAM-e? She is still eating well (never misses any of the 4 meals during the day or the one in the middle of the night I feed her), knows what time all snacks should be, wags her tail, will come step on my foot to tell me she needs to go out to potty, can find her way back into the house if she follows me and wants me to hold her close at night when she is ready to go to bed and will give kisses. She will still bark at passing cars, whatever my other dachshund barks at including deer. My little girl IS still in there and I want to continue to do the best I can to help her while keeping some semblance of sanity myself by getting enough sleep for us both. Meds she is on: Selegiline 4MG BID Amantadine 20MG QD Rimadyl 12.5mg BID . Melatonin: 1MG QD at night. Would you recommend adding in SAM-e 100MG? Would you recommend adding in Tramadol at night? Increasing the dosage of Melatonin? She weighs 12lbs. Thank you so very much for your blog on your journey with Savannah! It has been truly like finding an oasis in the middle of the desert. Thank you so much for any recommendations you may to help me help my sweet little girl. Warmest regards, Sharon

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    1. Hello Sharon,
      I empathize with your dilemma. It was a long and challenging road! In the end I was happy we had soo much time together and I was left with a feeling of gratitude that I could see her through to the end regardless of how confusing and difficult seeing her decline was. There was great beauty in seeing her pass into a world I couldn't penetrate. It might sound odd but through all of her life I learned to accept her and her challenges bravely and unwaiveringly, and I am grateful for the oppurtunity. As much as it was hard and painful I stayed true to my committment to her and I loved her more than ever as I had to say goodbye to more and more of her. We needed each other and I was proud to be her caregiver. I wouldnt have wished it be easy or peaceful. It wasn't, but such is life. We fight for those we love..
      I abandoned the SAM-e rather quickly. I just didnt see any evidence of it working.
      I did use tramadol intermittently and rarely on the nights she was so delirious I couldn't get her to calm down. At a fraction of the dose recommended it put her into a drug induced coma for about 24 hours. It hit her hard, but honestly it was one of the few peaceful sleeps she had, I was desperate, and I knew there might be (and were) consequences but she was manic,, I have no regrets.
      If you play with doses try to avoid the drugs that arent compatible. After that trying do whatever you can to keep her happy. There is no magic recipe, every pet is different, and in the end we all want our pets to be pain free and at peace. It is often hard to know what will, or will not work.
      I wish you both the best
      Krista

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