What ELSE can we do?

When I was a kid there was a TV show called "Let's Make a Deal".  There were lots of appeals to greed in the program and many ways to make a fool of oneself.  The BIG deal of the day always involved three doors (evoking that great short story "The Lady or the Tiger", by Frank R. Stockton).  Behind one of the doors would be a terrific prize like a brand-new car!  Behind another would be a pretty okay prize like a new home entertainment center (which would be a console stereo, or maybe even "hi-fi" in those days. If you were thinking home theater with surround sound, you are the age of my children).  The remaining door would have something pretty useless, like a pile of popcorn or a stuffed moose-head (although, personally, I like a stuffed moose-head...maybe not as much as a new car, but better than a "hi-fi").  This was known as the "zonk".  Part of the enjoyment of the show was seeing some poor devil pass up the car and choose the door with the zonk.  What could be funnier than the misfortunes of others?

In real life (as opposed to game shows) the zonk is not funny.  It is especially not funny when there is a zonk behind all three doors.  No brand-new cars, just moose-heads.  Not cool moose-heads, either -- old ratty, moth-eaten moose-heads with no ears.

What, you may well ask, am I talking about?  I'm talking about medical problems where I cannot offer an attractive solution: problems that are either insoluble, or where the solutions are not within the client's reach, or where the client doesn't consider the risk acceptable (in view of the expected benefit). 

For instance, today my client brings in his ancient Labrador retriever, once black and now gray (literally).  "His breath is really bad. What can we do about it?"  In this case, the bad breath is not from some terrible illness; in fact, his bloodwork is good. It's just a case of teeth that are totally encrusted with tartar (which we know to be half bacteria by weight: "the germs that cause bad breath").  The only way to make the bad breath go away is to clean the dog's teeth.  Owner hates the bad breath, but fears anesthesia for the dog.  In this case, I think the risk is low, but there IS always a risk.  If anesthetics were good for you, you wouldn't lose consciousness.  Two choices: accept the risk and clean the teeth, or accept the bad breath (and the health hazards associated with a nasty mouth).  "What ELSE can we do?"   

The little (and I do mean little) girl Boston Terrier was bred on her first heat.  She's only about 3/4 grown herself, a little young to be having babies (like a thirteen-year old girl: she can have a baby, but all concerned would probably be better off if she grew up herself before  becoming a mommy).  We could do a hysterectomy (Nope, they do want puppies later), hope for luck (she might not get pregnant on the first date), abort the pregnancy (yuck!), or see her through the pregnancy (and likely Caesarean section to deliver).   That looks like plenty of choices, but they don't like any of them.  "What ELSE can we do?"

These may seem trivial, but how about this one (and these were all today, mind you)?  Abby is a 12-years old, too fat, but very sweet Labrador Retriever.  She's had a series of episodes where she just gets weak and feels crummy, rebounding fairly quickly.  After doing some pretty nifty diagnostic work, we've determined that her problem is most likely to be a bleeding tumor in her abdomen.  We know that something in her abdomen bleeds until she's about a quart low, then stops. This is when she's weak and feeling crummy.  She reabsorbs the blood into circulation and feels okay again.  It's probably a tumor, but it's too small to see clearly with the ultrasound (not like some big whacking tumor on the spleen, for instance).  Here are Abby's doors, and there is no car:   

Door Number One:  Keep letting her have internal bleeding episodes until one kills her.

Door Number Two: Send her to the specialists for $300 to $1,000 in additional testing to see if surgery can either be avoided or more closely targeted.  If they do surgery, they estimate a cost of $2,500 to $3,000.

Door Number Three: Open her up here (still several hundred dollars, but probably about $2,000 cheaper than the specialists).  The incision will have to be "stem to stern" (or xyphoid to pubis, as we say in the profession, or "crown to groin" as they say in the Conan books), as you could have more than one spot bleeding, and it (or they) could be the size of a pin-head.  Even if you find it (them), it could be something malignant (or inoperable) and you've gone to all that trouble for something that's not going to get fixed.

I can explain it all really well, but I don't have an attractive choice for my client.

"What ELSE can we do?" Zonks are not funny in real life.

Comments

[Cara deBeer]

Hi Dr. Mobley. I love the blog. Thank you for posting it, it's very insightful.

I didn't really know where to put this question so I went with the communications tag. Really, though, it's about euthanasia.

My husband and I have a cat, Zoe, who is 15. She is diabetic, which is fine (we have another diabetic senior cat too, diabetes is not in itself a big problem.) But even when her diabetes is stabilized, she's so skinny! She has gone from a big 12 pound Maine Coon to a weeny 5 pound Maine Coon. She looks and feel bony. We know she has some arthritis (she gets chondroitin); the vet thinks she may have a tumor of some sort, possibly even/as well as a brain tumor. She definitely has dental problems.

My husband and I have made the decision that at her advanced age, we aren't interested in aggressively treating the tumor or even the dental problems (we have four other cats - most with chronic health problems - in addition to this one, which is a bit of a financial strain. Zoe's insulin and prescription food alone run about $150/month.) Zoe's quality of life seems to me to be poor - she will accept petting but is not the affectionate lapcat she used to be; she has always lived in a multicat household but now HATES the other cats; and she's occasionally incontinent. Mealtimes get her excited but that's it; the rest of the time she spends asleep.

How do we know when it's time? We keep taking her back to the vet every 3 months for an assessment to see if she's in much pain and they never seem to think she is. I don't want to euthanize her just because she is no longer a charming little kitten or because she has health problems - she has definitely earned her retirement, but I also don't want her to suffer through a terrible existence because we haven't got the guts to make a decision.

Do you have any advice? And by the way, if you think the dental issues are worth treating, we would reconsider, if it would improve her quality of life.

Thanks again.

[Doc]

Hello, Cara,

Well... no pressure, huh?

The decision to provide euthanasia is often a difficult one. In fact, it is almost always a difficult decision, even when the situation is pretty clear-cut (as in the dog caught in a combine harvester header who had all four of his legs cut off: the owner wanted me to "fix him". Holy cow!)

"Quality of life" and "quality of life issues" are the buzz-words. They are more than just buzz-words, though. If one is sure that a patient is in constant pain which is NOT going to get better, then the decision is pretty clear. But what about the patient who just never feels GOOD?

You don't really see obvious signs of pain (screaming, moaning, writhing, restlessness, etc.), but you never see what you consider the normal activities. No playing, no exploring, no interaction with other pets or people. She still eats and is interested in food, but just sleeps the rest of the time.

With this pet, we know she won't have any energy -- she's wasting away, burning up her body fat and muscle tissue just to stay alive. This means that she isn't getting much good out of her food. Just breathing is taking all she's got.

Is she in pain? This is a very hard question to answer, particularly with cats, as they are very stoic and famous for concealing signs of illness. Even when you know your pet better than anyone else, this can be a hard call. One of the few ways that I know to assess this is to give a trial therapy of pain medication, such as buprenorphine, and see if there is improvement.

Another criterion that I use is to think to myself, "If this were me, would I be in pain?" This is less useful here, as I've never been 100 years old and wasting away (at least not this lifetime). My great-aunt Clara lived to be 101. She retained her mental faculties to the end. She was rather feeble physically in the last ten years. You could tell pretty quickly how interesting your conversation was. If you were boring her, she'd just go to sleep. If not the conversation would be lively for as long as you could stay with it.

Aunt Clara didn't feel bad, but she had trouble getting up and walking, even around the house. She slept a lot. When asked how it felt to be 100, she would reply, "I'm just surprised every day when I wake up."

Contrast this with an experience I had with a relative dying with cancer in a hospice environment. She begged me to smother her with a pillow.

Which brings me back to my opening statement: No pressure, huh?

Whenever a client uses the "S" word ("Do you think he's suffering?"), I know it's over. In 31 years, nobody has ever used this word unless they were looking for the way out.

In your case, you are concerned about whether you are condemning the cat to slow death. Ironically, you are afraid someone might think you were considering a "convenience euthanasia". Since most cats don't live to be 15 in the first place, and many owners will not go to the trouble to treat diabetics (and it IS some trouble, I know), you could hardly be thought to have cut any corners in the cat's care.

Here's what the numbers say:
Your cat has lived to an above average lifespan of 15 years.
Your cat has lost sixty percent of its body weight.
Your cat never plays, explores, or interacts with others.
Your cat never "feels good".

Your question: is the cat in pain? Answer: I don't know.
Your question: is it "time"? Answer: Only you can decide.

I wish I could make it easy for you, but it never is.

Best wishes.

[Joey]

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