Ultimatums On End of Life Care Make This Vet Lose Sleep
Friday. What a sorry end-of-the-week experience I`ve just had. Fridays, as usual, never fail to disappoint. After waiting nearly 45 minutes (after-hours) for my emergency patient, he arrives. Covered in blood and saliva, Huey makes a spectacular entrance.
Huey is a long-haired housecat of seventeen years. He’s lived a long, indoor life of endless naps, frequent pettings and delicious treats. His adoring parents have known for some weeks, from his emaciated frame and poor appetite, that Huey is not long for this world.
When they first brought him in two weeks ago Huey's family was primarily concerned about his declining appetite and subsequent weight loss. Visual inspection of his oral cavity, however, revealed a nasty infection on one side of his mouth. Examining the edges of the wound and noting exposure of the roots of several teeth, I assumed the worst: squamous cell carcinoma. Almost nothing attacks mucous membranes so violently as this cancer.
Squamous cell tumors are horribly aggressive and usually disfiguring. They affect cats most commonly on their ears, nose and mouth. I see a fair number in dogs as well, though most of these are either oral or nail bed tumors. While they tend not to spread (metastasize) like other tumors, their fierceness and rapid pace are legendary.
The worst part of squamous cell cancers? The inevitable pain, especially in oral forms of the disease. As the tumor rapidly invades the bone of the jaw, the pain becomes intense. Then, because the oral cavity is so bacteria-ridden, tremendous infection ensues. Try to administer oral antibiotics and pain relievers to a cat with severe mouth pain and you’ll know why these tumors are the bane of my existence. It’s excruciating to watch them decline.
Some of these cancers, caught early enough, can be treated with aggressive surgery and/or radiation. Although Huey's case looked far too advanced for definitive treatment, I checked with my local surgeon and internist. As expected, Huey was not a candidate for either approaches mentioned above. The mass was too widespread.
If alleviating the patient’s suffering is the goal, as owners typically profess, then these cats are best euthanized quickly on the heels of this tumor’s discovery. Yet because afflicted cats remain so alert, their owners are typically loath to euthanize them without a fight. In their eyes, the problem is largely one of hygiene. Sticky blood mixed with saliva coats their muzzle, lips, paws, chest, and anywhere else they choose to lick. In advanced stages, they smell like rotting flesh. It’s my job to alert them to the severe pain their cats are concealing and offer euthanasia early on as an alternative to the inevitable suffering.
On this Friday, as always, Huey is a love. He lets me clean him up and examine his mouth again. He purrs and head-butts me as I wipe his mouth. I can understand why his family believes he is not in pain.
Two weeks after his initial [presumptive] diagnosis, Huey`s entire upper and lower jaws are enveloped by eroding, tumorous tissue. His owners had seen the writing on the wall two weeks back and had chosen not to subject him to a surgical biopsy and debridement (removal of dead tissue at a wound site). They had elected daily liquid antibiotics (Clavamox, AKA augmentin) and NSAIDs (Metacam, AKA meloxicam). Obviously, this approach is woefully inadequate for Huey`s advanced disease.
Today the choice is clear: euthanasia is best. Second best? Control the infection by debriding the area (get rid of all those rotting teeth, for starters) and apply fentanyl patches (opiate drug releasing skin patches) every two to three days—in addition to the antibiotics and NSAIDs.
Because Huey`s mother was heading out for a weekend trip to her son’s college, she wanted to wait on the procedure and was iffy about the pain patches. The stress, the need for Dad to come on Monday and every few days thereafter for a patch change, the inevitability of his demise, his apparently high level of comfort, and her unwillingness to cope with his imminent death all contributed to this seemingly unfeeling attitude one might not expect from a loving parent.
Why did you bring him in? I queried softly. Well, because he was bleeding, of course. Obviously, pain was not yet on her emotional radar screen.
Trying hard to maintain control of my emotions, I put it to her like this: You have only two choices at this point. Euthanize him now or let me treat the pain I can assure you he’s feeling. We can deal with his infection later, if you choose, but I can’t—no, I won’t—offer you anything else. You have to understand that he’s in serious pain before we can move on.
Faced with such a strong reaction to her pet’s situation, she might have grabbed her cat and left. But I was lucky. She got it.
I can’t exactly tell an owner she’s being pig-headed and I’d never underestimate the delicacy of her emotional state, but I will do everything in my power to advocate for my patient. I have to break through the denial in some way.
I hate offering ultimatums. It seems so awful to act like I know their cat better than they do. But, in a sense, I do. I know from experience that, properly treated, Huey will continue to live much more comfortably. If he must carry on for their sake, let it require as little suffering as possible.
Some vets might refuse to treat Huey altogether. Go elsewhere, I can’t watch your cat suffer. Others would follow the client’s wishes to the letter. I can’t do either, because sometimes I find myself treating not just the patient, but also the sacred relationship between the patient and his loving (if understandably misguided) family. That means I have to involve myself uncomfortably in the psychology of their experience.
I didn’t get much sleep Friday night. Huey filled my thoughts. I hated being in such a horrible position. End of life care is so sticky and rife with moral ambiguity. Sometimes I wish someone would just hand me a manual—throw me a bone, somebody! What is it I need to do here?
Huey feels better today (Saturday). His fentanyl patch has kicked in and he’s eating well again. His parents are impressed by how much better he looks—they hadn’t realized he’d declined so far. But how long will this last? A week? A few days? Who knows? Maybe he’ll last a month. All I know is that I’ll keep applying that patch and I’ll keep holding their hands as I steer them towards the inevitable.