Dying With The Absence Of Intentions

"Two options," I usually start with telling clients that they have two options for their pets care when they come to see me. The operative word here is usually. I should have started this blog by saying "used" to. I used to say that there were two options when at the clinic. And here's why I now need to stop assuming there are only two options,,,

My pups play in the last rays of Summer sunshine and humming fields of daisies.

On Sunday I saw a client with a dog who looked like she had already passed away. A lifeless mass of fur laying without any sign of life. Her name was Lily, she was emaciated, laying on a blanket on the floor and not responding to anything happening around her. She appeared as a dirty, dusty, weathered coat of dull black poorly draped over a boney protruding skeleton of what a dog used to be. She could barely lift her head. She was so weak, sad, and weary looking that I assumed if she wasn't already gone she was surely here to be put to sleep. Where I had not previously realized that there are more than two options when at the vet clinic, I have learned that you shouldn't ever assume a pet parent sees their pet with the same veterinary trained scrutiny and collective experience to guide your prognostic indicator as I possess. So many people are so deeply emotionally embedded in their pets lives that they can't see their pets suffering, death, or the looming vultures of either at the cost of breaking their own hearts to say goodbye. There are times where I have to explain this in painstaking, emotionally devastating detail. On this particular Sunday I had two dogs who had arrived at the exact same time, and looked to be in the same predicament. Both were old big black dogs who couldn't stand, react, or show much of any signs of existence. They were dying, and they had been here in this pitiful state for quite some time. I also had about 20 other patients waiting to be seen. It was a Sunday. We are open for walk-in appointments for 2 hours, 1-3 pm. It was a bright idea (or so I had thought) about 15 years ago, or, as we all measure time now, before COVID changed vetmed into a war zone. Since COVID my Sundays have become the "open-to-all-neighborhood-ER." It's insane. Every single Sunday. It has gotten to the point where almost all of the people I see are non-clients, and all of the say the same thing; "I've been waiting for the ER to call me back to say my turn is up in another 12-24 plus hours." If these dogs have looked like this for over a day (and let's be honest I know they have) then the face of vetmed is no longer wearing a compassionate white coat. 

Our clinic vagabond, Saffie. Mostly trouble, occasionally demanding attention,
and almost always sleeping on the job,

The two women who sat behind Lily as she was slipping into her coma were sisters. Lily had been diagnosed as a diabetic over a year ago. The medical record was a list of missed appointments, phone calls left without follow throughs, and proposed diagnostics that hadn't been done to manage her disease adequately. Diabetes is a disease that leaches persistently. It can be managed with a huge amount of effort on both the clients and vets parts, but, it is a slippery, encumbering beast. Even people do a miserable job of managing their own diabetes and they have endless easy wearable tools to help monitor and guide them. Dogs get diabetes from eating crappy food and being too sedentary. It is incredibly difficult to convince a diabetic junk food addict couch potato to eat better and exercise. Old dogs/new tricks, the analogy is applicable. The two sisters loved Lily, it was obvious from the beginning. They never looked away from her as I spoke to the tops of the backs of their heads as they bowed over her stroking the dry brittle coat. (To this day I am not sure what their faces look like?). I could hear them sobbing. The assumption that Lily was here to die was so pervasive that the front staff had immediately placed the party of three in our comfort room, (our less veterinary medicine looking room that has real furniture in it). It also has its own entry and exit and a long bench for multiple family members to congregate.  There are two crystal light fixtures and multiple boxes of tissues. 

Hamilton

Lily didn't move as we carried her from the comfort room into the treatment area. She had lost over 20 pounds since her last visit which was many months ago.  Her breath smelled like nail polish, her eyes were not registering our movements, the foreignness of this place, or the sounds that made it so obviously worrisome to the other patients. She just lay on the stainless steel exam table absently.  I stroked her head and whispered into her ear that she would be "ok." While she is my patient and I have work to do on her, samples to collect and observations to assess her condition, she is also a heartbreaking site to see and a dying girl to protect. In this moment, in the place where patients are away from their families, on a stainless steel table, weak, and dying she is all I am here for. All I have ever strived to be, become, and exist as. At this moment she is one and all. The singular soul that mine is devoted to. It is at these times that I wish our hospital was like those old episodes of ER. The scenes where a caring, kind nurse stands over the patient clasping their hands and telling them calmly that they "will be alright." Why can't I have someone who tells my dying patients that? Someone to just be the angel and not the judge, jury and executioner too? 

In the treatment area we quickly discover what I had already presumed; Lily is massively dehydrated and her brain and body are being intoxicated with polluted ketones, which will slip her into a complete coma and kill her imminently. She needs immediate and aggressive help. She needs a highly trained veterinary emergency facility that can treat her for a minimum of 3-4 days, and even with that her prognosis is abysmal. She is too far gone and too sick. I tell her moms this. I do what I very rarely ever do, I tell them they should alleviate her suffering and say goodbye. They tell me that they have no money to do anything past $500. Lilly needs about $10,000 of care. I try to ease their grief and pain by saying that even with this it is vey unlikely she can survive this with much quality of life. They tell me that a transfer to the ER is impossible because of the cost. I leave the room so they can spend some time with Lilly and process what I have said. I move on to the other 19 cases waiting for me.

The war room,, aka treatment area.

I came back some time later to a very quiet room. 

Lily's moms weren't able, or ready, to say goodbye. So we did what we could for her. We gave Lilly all of the quick patch band-aids that I could. I dumped a massive amount of fluids under her skin, gave her an antibiotic, anti-emetic, and an injection for pain. I essentially given her all of the options I had without being able to hospitalize her. I had given them instructions to continue her insulin and they had agreed to bring her back first thing the next morning for more care. 

Lily, her moms and the mass of 19 other cases came, and went, (both black dogs went home). Although I leave the clinic for the evenings at home, it never leaves me. I carry it, the weight of every patient, their plight, and the families who love them with me. I dream about them. I wake up with surges of adrenaline coursing through me. I head to work each day ready to slay a dragon that medicine is and fate wins at. I prepare for battle everyday knowing I buy time, never destiny.

Vela. Our latest rescue effort. 
Her story to follow soon.

Lilly did not show up the next morning so I called to check on her. I had expected that they would tell me that she had passed away over night. Instead they told me that she was up, eating and walking, and therefore they wanted her to stay at home. I was so relieved to hear this, and yet, worried for what today, tonight and tomorrow would bring. I begged them to bring her back to us to run some blood work, give her another round of the medications we had done the day before. I reminded them that these had helped, and without them she would be back where she was 18 hours prior. They said that they wanted her to pass at home. They didn't want anymore medical interventions. It seemed that they were very upset that I had helped her the day before and that they no longer wanted interference. 

So here I am at option number three; People show up for care at your vet clinic, but, they don't want your help. Since when was this an option? Why did they drive over to the hospital, check in at reception, wait in a room, wait for me to explain her condition, agree to all of the treatments we gave her, and then get angry about it all 24 hours later?

I was dumbfounded on the phone. I could hear the anger in their voices, the betrayal that they felt I had provided them all. I paused. That long pregnant, my brain can't quite process this, pause. I offered them financial assistance to get Lilly some much needed medical care. I got back more anger. We were both doubling down and Lily was going to lose another round.

While I understand passing at home, hospice care, and the deep swath of divide we all feel about the act of dying, I also feel compelled to speak on behalf of the patients I have who cannot. In some cases I have to remind myself that I am bound to picking sides. I have to chose humans over my patients if there is a viable fear that the patient might impact the humans life.. (think rabies, aggression, etc). Then there are the cases I can't discern neglect and cruelty within. Do I honestly feel that Lilly is suffering? Yes, 100%. Do I feel her moms can care for her? No, even though they love her so much. Does the degree of love supersede the obligation to put our pets well-being above our own? Can passing at home without any kind of pain management ever be peaceful? Fair? kind? I don't know? I didn't know for Lilly. I told her moms that. 

I do think that a key part of my job, and everyday,
is kissing every dog and cat I come across.

They hung up on me. And then they went public and called me some really hurtful names. 

Maybe its me who needs that nurse holding my hand?

P.S. I have changed names and details.,, I feel that I have to, this is a diary on display.