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. 

COVID's prisoners. Dying in the age of a pandemic. My moms story.

Vacuuming ants off the table. It’s what I do now. Daily, let me add. They are there not because of the flowers I cut for her yesterday, (as she chooses to believe), but, because there is always food on the table, or, around the table, or, under the table, (found a half an orange there yesterday, desiccated and chewed clear of its pulp). Food lies in small unbitten nibbles everywhere around her make shift hospital bed. All have been placed there sporadically, sprinkled throughout the day. There for encouragement. Should the fancy strike her. Which these days it rarely does. The ants keep her honest at least.

The hyporexic is my mom. She has stage 4 metastatic breast cancer. She needs a lot of help these days. The whole COVID crap has made dying a much lonelier event than anticipated. I have become the nurse and the house cleaner. My dad and my husband are the only others on her visitation list. It’s a small tight group. We all know too much about each other. It leads to fighting most of the time.

Hence, I vacuum. Or bide my oversight time cleaning, often.

Like all things in these days nothing is easy. To get to the vacuum I had to beat back the dust around and within the broom closet. To get it to turn on it had to unbury it from the cobwebs that quarantined it. To get to that I had to uncover the post Katrina WHO deposit of stacked bottled water that could serve Flint for the remainder of the year. This is the broom closet of a husband who never had to do housework before his wife fell ill, and, the paranoid couple who refuse to drink tap water after moving from a farm with well water. Trying to convince them that there is at least some oversight on the town water supply versus the farm well that I once saw a dead ground hog floating in is like yelling at the tornado to stop at your doorstep’s threshold. There is a mole hills mountain of poetic justice and politically driven pardons sitting here at my feet these days. I too often have to find the comic relief in the utter aging madness I have fallen into.

Quarantined with a dying person inside their house is a never-ending loop of t.v., feedings, medications, questions about if its ‘time again?” for medications, and self-checking her vital signs. The t.v. is tuned to CNN non-stop. It is her way she will tell you, of “still being a part of the world.” To which I remind her that that’s going to shit too. Maybe don’t turn there for joining society and being a part of the whole we left soo many weeks ago.

At her house I clean, like a mad person. It's my ADD that I cannot apply to CNN and the myriad of measured pills in their clock driven doses. Providing some degree of order, civility and modicum of acceptance that the world will go on around me is placed in sanitizing swipes at cobwebs too distant for her to see never the less attempt to reach.

Food is a battle. Like all aspects of her life now. She’s is wasting away. She is so thin and weak she can no longer stand without metallic wrap around support and hand grips. Shuffling from across the room to the small bathroom she exists between. My mom wants endless hours of all-day small talk. The escape she yearns for outside of the destruction her body is catabolizing. I am not a chatterer. I never have been, and asking me to figure that out for the last inning of the last game is too hard to go back to parochial school for. There is no room for normalcy here. I cannot seem to embed it in the cleaning to provide relief to the endless news cycles. And yet I continue to clean. Keep moving. Try to be productive and helpful as I uncover artifacts from a once functional home. Small items cause major melt downs. A half-eaten pie sitting useless in the fridge is a day long discussion on appropriate resolution. Obsessing on triviality and the time consumption it fills the day with is the reality of four people in too close proximity for too long already and no end in sight.

My mom's painting of Lilly.

“I cannot always be just as you want me to be.” I know it is not what she wants to hear. She wants me to be like the rest of her cheering squad. Professing love, sending her peace and Gods warm embrace. Telling her ‘this too shall pass’ and reminding her of all the beauty that surrounds her. The blissful passivity to all things holy and predetermined. The baking squad sitting on the bench proud to be sitting this one out. Gleeful to let the uniformed players who actually showed up for practice and have a discipline to put the blood sweat and tears in. I am not one of them. I don’t even know if I could become one? A spectator in her last hurrah.

This is the horrible place I am right now. Standing at the intersection of letting go and surrendering the hope I felt I would never unclench. She has stopped trying. I am not sure if it is all exhaustion that caused her to surrender her hope, or, the pain that her fear gave up. But all are gone.

Today was the day I decided I had to come to terms with goodbye being only a few moments away. For as much as we are so similar, my mother and I, I am most assuredly the human of voicing and reasoning while she is the soul of submission and omission. She won’t ever tell you what is right at the tip of her tongue. She will never confess. She will never say she is dying. She won’t give that up. She will only remind you with her every single action that she checked out a long while ago. I can look back now and know exactly when that happened. We were all sitting around her hospital bed when the doctor came in to visit, one week into her hospitalization to manage pain trip, to break the bone scan findings to her. “It is bad…. (long,,,, long pause…..)…. Really bad. She has cancer everywhere.” Yes, these were his exact words. She swallowed the words slowly and lowered her pale worn face and gave up. She had her pass to never doing anything again that she didn’t want to and she has ridden that pony into where we are today.

Cait

That discussion and discovery was over two months ago. At that time it had been over two months since her biopsy came back as cancerous. We now knew she had advanced metastic cancer in all of her bones which no longer allowed her to be candidate for chemo or radiation. They gave up on her as being too late, and she gave up on them as offering too little. She left to go home to try to come to terms with the cards dealt.

Today we are at her monthly oncology check-up. She was wheeled in, after being carried from her home to my car. COVID screening threw a new twist onto today's visit. We were met at a distance by greeting staff to check our temperature with a forehead thermal scan and provided and required to don a mask and gloves and asked a series of questions to try to insure we were not infected, or around anyone who was. Even the hospital is afraid.

4/14/2020, UPMC oncology

Two floors up we were met by the oncology nurses. Check in includes the cursory checklist on the clip board. They took her blood pressure and temp again. We collectively lifted her on to the scale and waited. As a veterinarian the scale is one of the most important diagnostic tools I rely upon. It doesn’t lie and it reveals a wealth of clues if you have been diligent in recording it. When the digital screen came to its stand still even the nurse wouldn’t say the value aloud. It was another long pause in a diagnosis of too many already. She recorded it and moved on. The scale read 76. As in 76 pounds. She is 74 years old. We started this collision course in December of 2019. Five months ago at 106 pounds.

I saw the blue numbers flash, swallowed my silence and gave up. Today I have lost hope for her. That hope for her chance to ever function again in the capacity that I have known her has passed.

It has been months of days that were up for as many times as they were down. She is painful, almost uncontrollably painful. She is on higher doses of opioids than I ever thought were humanly possible, especially for the fact that she barely ever hit a hundred pounds in her whole lifetime. She is not, as her oncologist put it today, “opioid naïve.” I was almost proud of her. It might be the first time she has ever surprised me with a title she didn’t earn from years of perfecting a skill. She is an amazing artist. She has always been an incredibly talented artist. She can sketch, paint, imagine any beauty into a canvas. Her work is all around us. At the vet clinic. Every room of my house, but a hard-core opioid aficionado I never saw destined for her resume. Today she was classified as becoming immune to their affects. Her body was acclimating to them. Starting to blow them off as inferior, paltry, innocuous. Today we carried her out of the house. Wheel chaired her into the hospital. Pushed her in a wheel chair into every room, every exam, and every treatment. She is a skeleton you can push without effort and pick up without exertion. She is bones and an oxygen pump spewing little hiccup-coughs into her nose. Her lifeline to failing lungs. She will need more drugs, at higher doses to get the pain at bay this time. Higher doses, shorter time frequencies and more side effects because of them. They will take away her pain as the collaterally steal her gut function, cognition, and conscious time.

4/3/20

There is nothing left for her to give up. There is only one last designation left to be made. No one wants to call it, although everyone mentions it. Hospice is all that is left for her. We can discuss a 24/7 assisted living home. A place that can help her with the things she can no longer do by herself. Bathe, prepare food, get water, manage stairs to get to her kitchen, her shower, or her bathroom. She is here. She won’t face it. She needs more than her family can give her. Once she lies down and cannot get up, which is likely at 75 pounds, that is the only option next to hospice. We got here so fast I cannot masticate the bitterness and the toughness of it. But the care facilities are all COVID magnets now. Sending her there surely leaves her a defenseless victim to this? Which is worse? I don’t even know?

my moms Easter canvas circa 2015

My dad is seemingly un-phased by the whole thing. The unraveling and the diminished ambulatory, unhappy being she is now. He is short tempered, over-burdened, and oblivious. I don’t know if this is a self-protective measure of avoidance? He goes through the motions and yet he doesn’t see the changes within her. “Hey, have you seen that bump on her back?” he announced yesterday.

“It’s her shoulder blade.” She is misshapen, misaligned due to a lifetime of scoliosis and the aging of osteoporosis. Her spine is “S” shaped and her shoulder has always been left elevated and prominent. She now lacks the 30 pounds to hide it.

The vacuuming leads to laundry. The monotony of never-ending laundry. Put in the dirty, smelly old people funk, and, POOF! Out it comes anew. Refreshed.

“Mom, we have to figure this out?” I implore her. I don’t think she cares to entertain my burdened inquisitive agenda. I think I am just speaking out loud. I think I am being my own therapist. She already has her plan laid out. The analytical doctor used to non-speaking patients hiding their illnesses and masking their diseases is who I am at my best. She is another patient puzzle to solve. I can solve this. It’s a cancer patient like so many I have had before.

D.C.

And yet, we haven’t figured her shit out. Not her treatments, not her desires, not her abilities, Nothing. That’s the truth. She won’t even talk about end of life stuff and I can’t let go of that. Doesn’t everyone plan? The finality exists only for me. I cannot ask her to apply any sense of wishes to an end that looms in front of us both. Her agenda is maximizing time into flowery closing scene experiences.

Ambrose

I’m venting now. I would do it aloud to try to mitigate my cortisol level, but I have to do it silently and furtively. The walker lurks too nearby to allow a release in the open forum of the room we are both imprisoned within.

No, I didn’t dissolution myself to believe this would be easy. But dying under house arrest in a pandemic that seems extra cruel. There is no way out. I could try my dads’ approach, be so caustic the best recourse is silence, and then do whatever I wanted to anyway, but then she would be completely alone. And she’s still dying without any chance of a better tomorrow so I type in hard puncture wound passes.

Easter box painting 4/3/20

There are days that are bad. Days so painfully long and full of so much demanding angst that I want this to end. Days that are full of meaningless errands. Answering a barrage of demands for things I cannot find sense in. Like removing Christmas decorations in April. Always with the same preamble “can you just do me one more favor…?” The red bow on the mantle. It should have gone weeks ago. It drives her crazy, which then in turn, of course, drives me crazy too. I have a home I haven’t vacuumed, cleaned, done laundry in in weeks, and I’m at her house cleaning it.

There is a disconnect between her preferences and her immediate, vital needs. The clock is ticking.

Yesterday was a bad day. The second in as many. It was a day full of moaning, crying, and pleading for the only relief I can give her, short of drug advice, companionship. She is alone too much. The loneliness causes anxiety which manifests into sleepless nights and further exacerbates her fear of pain and loneliness.

She is afraid to fall asleep for fear of not waking up. We should all be so lucky to die so peacefully. Me, I don’t want to wake up in the morning. Find some quiet place to bury my head under the bedclothes, a mummy wrapped for the long voyage to the underworld. She cannot find peace while awake. Her pain refuses to relent, and yet she cannot find salvation in sleep. It is a never ending roller coaster of unfair and unyielding.

It took her 30 minutes to muster the courage to sit up. Shaking, eyes closed, willing herself into moving the tiny rigid structure that used to house her options of freedom and choosing. She is now a prisoner to a broken body breaking down without any reconstructive abilities.

She is melting into nothingness. Evaporating, decaying, just crumbling. She cannot stand up straight. Cannot sit in a chair and face her dinner plate without being bent over and buckled into her own lap.

Oxygen is a commodity she obsesses over. She is hooked into a clear tubing pushing her lungs to accept what they can no longer obtain independently. She has multiple redundant units and miles of spare tubing. She checks her own oxygen levels hourly, half-hourly, obsessively. It is a race she wants to beat herself at. I have decided asking, inquiring about her obsessions merely feeds the monster that dictates them. The questions are met with anxiety ridden hostility. She has no patience for reason any longer. I try to talk about what she does with the information she collects. The nurses regimen of monitoring her own stats? This is another battle with no end point suitable to perpetuate the understanding of her data.

“Is 99 degrees too high?” She wants to be ready to alert the front line should she fall victim to COVID. It's part of her vitals monitoring ritual.

“Do you know what a normal body temperature is?” I ask.

“No,”

“Then you’re fine. Don’t worry.

We spent months trying to identify the source of her pain while we also tried to get it under control. We are back at square one. She has returned to that place where everything is impossible. Moving is too painful to do. We are here this time with 5 medications, three of them opioids, and drugs to chase the side effects of the drugs. “It wasn’t any fun there the first time around. Was it?” She nodded with a dejection of reluctant silent admission. We can’t go back there. Back to that place without answers, suffering met but a struggle to plea for anyone listen, hoping without precedence that one person will stop their busy over burdened life and actually hold her hand and invest their talents, dare even themselves, into her cause. There is an impressive amount of competence and excellence in her doctors, but,, there isn’t much in the way of genuine heart break for her plight. Maybe they have seen too many before her? Made themselves into little fortresses of medical indifference? A short dismissive hello, here’s what we can offer, a keep in touch, and a farewell to another time. The only thing left is to increase the doses of everything. Add an anti-depressant to help her sleep. Make the fear of not waking up a thing forgotten. Sedate her. Medicate and sedate is all that is left. What will that cost her I wonder? It will cost her everything she has left. And she will willingly surrender it. Pain is unacceptable. Pain and fear is her deaths last demand. We gave in to it as I surrendered hope today for anything else.

I can tell you a few things about this journey. I didn’t expect it to be easy. I knew it would be grueling, but I had no idea how alone we would both feel within it. Helpless, well, I haven’t accepted that one yet. We both have some coming to terms with the cards life has dealt us.

For more on my moms journey see the previous blogs here;

Silver Linings Of COVID-19.

The Journey. Missed Pit Stops and The Pile Of Regret Souvenirs.

For more information on me, my vet clinic Jarrettsville Veterinary Center in Jarrettsville MD, or for our Facebook page, or, free pet care help please go to Pawbly.com.

Me and my girl Seraphina, COVID 19 PPE prepared.

Thank you to all of my dear friends and family for helping me through this. I sincerely appreciate everyone's support.

krista

What Is Life Worth Without The Trials and Tribulations? Murray's Story

"What is life worth without trials and tribulations which are the salt of life." M. Gandhi

Tragedies happen every day. Certainly in veterinary medicine they are never in short supply. Where there is life there is death and swirling in between these is the cosmic array of every imaginable scenario. Between the ends of this pendulum is marked as much by luck as it is by foresightedness and preparation. Where to go when destiny is undetermined and fate seems close at hand is where tragedy can land you into utter sheer dismay. It is the place that I fear veterinary medicine fails our patients most often.

This is Murray. He died last week. He was in hospice care with my sister for a year. His original family brought him to us a year ago to be euthanized. He had a bladder tumor that made it hard for him to urinate voluntarily; therefore, he needed a diaper and belly band 24/7. His family thought that his life, the quality of his life, was over. They also didn't want to manage a dog in a diaper. My sister saw in him a flicker of the dog she lost a few years ago. That dog Daisy, was her dearest friend and she knew helping Murray was a way to keep Daisy alive a little longer. They needed each other.

Some of the most disheartening tragedies I see happen when clients get overwhelmed, confused, lost and left without guidance about what to do for their companion who lacks a living will and end of life instructions. The AVMA (American Veterinary Medical Association) provides guidelines to help pet parents through the difficult waters of making end of life decisions. The old version, although intended to provide simple assistance in the most dire hours of indecision, reduced the verdict to pennies allocated to labeled "Good Day" versus "Bad Day" jars. In the most inane, coldhearted binary method clients were suggested to make the decision to say goodbye to their pet based on which jar had the most pennies. Reducing a life to a scale based on a spate of pennies is not befitting of decision of this magnitude. Our clients deserve more than a "good/yes" or a "bad/no." We have come a long way from the days when we didn't even admit pets could feel pain. We are now more broadly focused on providing care without discriminating and dismissing that our pets are sentient beings. Like all beings who can think, feel, and love we are providing less black and white suggestions to make the grey area of end of life more empathetic. It is long over due and we still, as a profession, look at euthanasia as a too often routine procedure that denies a pet their true measure of worth in our lives. The new 2016 AAHA/IAAHPC End-of-Life Care Guidelines is far better at assisting in understanding what end of life options there are and how critical an unbiased compassionate team effort is needed to provide all options with maintenance of patient care at the forefront even in the last moments of a waning story.

We too often promote euthanasia without providing options, assistance, and empathy. Why do we offer every single line item on the robust complete treatment estimate to provide optimal chance of recovery for a disease and not do the same for end of life care? How many veterinarians, specifically, house-call-euthanasia veterinarians, one time ER visits, and the GP who has never seen the pet before, are sought to provide hospice care instead of a last treatment option syringe, in whatever time frame and capacity the situation dictates? I don't know of one. Worse yet, I don't know of any of these euthanasia-on-demand-vets who calls for a referral of the patients record before they deliver that final act. Shouldn't this be common practice? If it isn't is it because we are more concerned about how our clients view our services than whether our services are placing patient care first?

There is adventure left to be discovered

I think we short change pets in almost every facet of their lives. It is getting better. We, the veterinary community, are openly admonishing and endorsing the benefits of companion animals to our overall well-being. Perhaps simply motivated by the robust spending pet parents never seem to hold back from? Perhaps because we are moving away from our utilitarian view of pet care? Or, perhaps because we are finally admitting to also snuggling with our pets in our beds and not denying that it isn't inappropriate. Too often death is simply another example. Great leaders and spokespersons of our profession write long diatribes about the merciful end we provide and the gratitude that we garner from not prolonging their suffering. The one sentiment that breaks my heart more than any other is the over played "I'm so glad I didn't wait any longer. I waited too long last time. This time my pet died with dignity." It strikes me to the core because we have options for this suffering beyond the sleep of that pink syringe. We sacrifice and surrender grace, beauty, and sympathy in being a part of dying. When we deny ourselves AND our pets those last few days we negate the ability to see the full circle of what life's meaning holds. Life is not about making it easier. It is about understanding, accepting and rejoicing in the spectrum. Mercy,, well mercy, is the surrendering of self when the force of power will yield its hand regardless.

I have learned this lesson time and time again. It has brought me both pain and chastising. It has also brought me closer to the belief that we all share the same path. We all want to live surrounded by those we love, with free choice, driven by basic survival until those most basic needs are met and we can open ourselves to affection and purpose for others.

We try to cheat what is inevitable because we fear pain and suffering. Perhaps we are simply denying an emotion so profound it mirrors love and lust in its most primitive and intoxicating moments? Perhaps we are too selfish to make time for the inconveniences that end of life bring us? Why do we so willingly provide pee pads and clean ups to the not-quite-housebroken puppies, but refuse to tolerate diapers on our geriatrics? Why when life is fresh and young do we tolerate the same inconveniences that the end of life brings?

Where do we think we safeguard the sympathy as we sacrifice the compassion?

The dealer holds all the cards

As the sands of time slow to a trickle of grains left in the hour glass it is too often over looked as "inconvenient" for us, and "prolonging suffering" for our pets. I just don't see it as either. If you can find the time to slow yourself, and your life down, to a place where the grains of sand are not within your realm of reality you can transcend to a place where the true beauty of life resides. There is grace and peace within the last few moments of a life drifting to its close. In this tiny wrinkle of the reality of bustling day-to-day life, the stress of work, the pressure to maintain a kept house, and the worthless rituals of self-promotion that lie in hair-dos, manicures, and frivolities of superficial status that bear no true meaning of the life we get too little of.

Multitasking JVC style

I have begun to let go of the grip of power that medicine embrues you with. There is too much we don't know and too much we presume to be able to bend, will, and yes, ultimately decide. Too much that we don't allow to see the beauty within even if age, disease, and life has tempered it.. Too much we think we need to manage, decide, control and cheat ourselves out of.

Pets With Santa 2016

As much as no vet wants to admit it, sometimes we are wrong, and often we don't have enough information to be spilling the forecasts we do. Murray's life is a testament to that. He lived a year past his presumed expiration date. A year of walks, hugs, car rides (his favorite thing to do in the whole world), kids activities, face rubs, sleepy-times, and love. He had a year of being loved.

If you can't make time for the last pieces of life's puzzle to fall into place, and find the time to care for those companions who served you for so long, how do you expect others to do the same for you when your time comes. There is not a difference in value, or position, or placement in society when the times are good, don’t make them in times of hardship.

Waiting for the bus

Murray may not be the example for every case. But, he is not the exception either. Within the small walls of my clinic there are numerous others. Pets who we invested ourselves in, championed their plights, and fought for their second chance. But, for the most part all we had to do was not be afraid to offer options, support, and a shoulder to lean on. All, and every, to any pet we thought might need a second chance. All things are possible and miracles happen every day. If you ask for them you will find they outnumber, outweigh and surpass those tragedies, and the pennies once destined for the "Bad Day" jar.

If you have a pet question that you would like to ask me please go to Pawbly.com. Pawbly is free to use and open to all pet lovers. If you want to visit me at the clinic we are open 7 days a week. You can learn more about us on our website JarrettsvilleVet.com. We publish our prices yearly, and always put our patients and compassion FIRST. Please also follow us on Facebook, my YouTube channel and on Twitter @FreePetAdvice.

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.

The Tiniest Steps and the Biggest Hurdles. Savannah's End Of Life Story

I have been talking about Savannah for a long time. She is my 18 year old beagle mix who has been struggling with the affects and burdens of aging for the last few years. I have chronicled her slow decline through a few blogs. For those of you who need a summary; She was a very active, stubborn, food driven, obsessive, loyal, and devoted girl since the day I adopted her from a college student who wasn't allowed to (for very good reasons) have a dog, 17 and three-quarters years ago..

I found her tied behind a small apartment on a make shift leash all by herself at 8 weeks old. The moment I saw her I knew she was ours. She was a very fuzzy beagle looking girl who never talked much but always had deep inquisitive thoughts. She loved being in the country, going on walks in the woods, sleeping on the furniture, and came everywhere with us.

About three years ago she had three strokes over about a 48 hour period. When they happened I was thinking the the writing was on the wall and our days with her were numbered. For about a week she couldn't stand or walk in a straight line. She also had a terrible bought of horizontal nystagmus. Nystagmus is when your eyes move in a rhythmic motion. For Savannah her eyes shuttled back and forth from left to right. It is very concerning to see and makes ambulating incredibly difficult.

After about a week all of the side effects of her strokes went away, except for the head tilt. She to this day keeps her head tilted to the left. So when she walks she circles to the left. It is much like steering a horse. If you pull the bridle to the left the horse turns left. Savannah thinks that she thinks she is walking straight ahead but from the birds eye view she spins like a top and always to the left. Because of her inability to walk in a determined direction she is not allowed anywhere near steps.

Over the past months she has gotten more and more tired. In part it is because she is losing muscle mass and in part because her once voracious appetite is waning. For a beagle (or my pig, I know that this implies the writing on the wall is getting bigger).

I keep her on a leash all the time. She has escorted bathroom breaks. When she wakes up its time to go out. If you don't get to her fast enough you will have to clean up. Her world has shrunk to a small contained easy to clean up area lined with pee pads, free from obstacles, areas to get stuck in, and the puppies to bother her. It is also lined with a baseboard heater so her area is the warmest in the house.

She wants to go outside and she tries to wait long enough for you to show up and carry her, but her ability to know its time to go out is about a minute before she has any ability to do anything about it.

I remind my clients that there is a very good reason they make adult diapers. Someday if you are lucky enough to live long enough to see the day you will be perusing the shopping center aisle finding your own diaper size. Savannah at 18 is about 100 for us. I know none of us want to think about it, but aging is the process of adapting to the things your body can't do any more.

Savannah has a hard time walking on almost all interior surfaces. To promote exercise, help her maintain her precious muscle mass and to keep her mentally stimulated I keep her outside as much as possible.

Feeding her has also gotten more difficult. She has to be on her bed, propped up and have her food right infront of her.

I spend every day offering a wide assortment of foods. These days it is about keeping her eating, moving, and stress free. This entails offering her anything, everything and hoping that I can offer something she will pick at. I rotate between hot dogs, hamburger, crackers, cat food, rice and veggies, dried chicken and/or  beef, pizza, and then whatever else I can think of. (I recommend to my clients any and all canned meats, baby food, whatever, and good luck).

The puppies wonder why she gets the good stuff, and they wait like vultures to clean up the food she spills.

When your time to leave this world grows near those little things we all take for granted everyday, like walking, daily activities, and our abilities shrink to a very small scale.

For Savannah the days are spent sleeping. She has beds everywhere. But where they used to be cushioned elevated dog beds they are now large opened sleeping bags. She can no longer get up into any sort of bed. Her shuffle has no ability to step up, or down.

I get up at least twice a night. It has been this way for months. I often have to get up to change her bed linens, run another load if laundry and give her a foot and butt bath. Its an hour long task most often at 2 am. I am tired. Like really really tired. And for as much as I look forward to that night that I can sleep for eight hours, I am bound to taking care of her at the time she needs me the most, and I am grateful for every last second of every last day (and night) that I have left.

Taking care of her at this stage in her life is a series of little tiny steps. Some of them are steps that we have lost. I will never see her run again. And I will never see her outwit me to sneak into the cats room to steal all of their food. As I look at her I am reminded of the girl she used to be, the companion I am slowly losing in tiny pieces and the inevitable turning of the tides.

But for today I am grateful that after the chicken, the rice, and the cat food that she turned away from, she sat and ate two hot dogs.

If you have any pet questions you can ask me, and a whole bunch of other pet lovers at Pawbly.com, or find me on Twitter @FreePetAdvice. 

More stories on Savannah;

Caring For Your Older Dog

Savannah's Story

Almost Hospice Care