Veterinary hospice care in practice: one case of bladder cancer
Altogether too often, the diagnosis of cancer in pets comes complete with death sentence attached: The vet makes the case, presents the histopathology report or the X-rays, then exits stage left. Or the client exit stage right. Either way, the pet (unless immediately euthanized) is left standing in the middle with no hope of anything except the possibility of eventual euthanasia—at some future point coincident with the owner’s conscience and personal schedule.
This may not be the way you’d do things (nor I) but, like it or not, that’s how the vast majority of US pets’ terminal disease treatment goes. The concept of pet hospice turns this model on its head. Once the diagnosis is made the real work begins.
Yesterday’s patient had spent the first year after his diagnosis receiving practically no care (save a rabies shot so the county wouldn’t fine the owner). The owner had eventually tired of her dog’s chronic symptoms, her vet’s complacency in the matter and her guilt at seeing her family’s pet suffer (and knowing, deep down, that something could be done for him).
Whenever I see “second opinion” writ large on the schedule posted on the wall, I know I’m in for it. Usually it’s an hour-long appointment with a client who should have gone to see a specialist instead of me. In this case, it was a ninety-minute deal, which I finally determined appropriate for the level of care this pet needed. No surgical or oncology referral was going to help this patient.
Bobo is a cute old, thirteen year-old mutt his owner calls her family’s “National Geographic” dog. That’s because when you open the magazine and see a photo of a dog crossing some muddy street in a third world nation, it inevitably looks like Bobo: medium-sized, black and skinny with slightly raised, terrier-ish ears. Makes sense.
Bobo was diagnosed with bladder cancer about a year ago. His owner doesn’t quite know how the final diagnosis came about or what kind of bladder cancer he’s got but Bobo’s got all the symptoms, all right: bloody urine, straining, leaking, etc. Since then, Bobo’s been on one medication: Piroxicam (Feldene), which has been found to reduce inflammation in these masses.
But Bobo’s gotten worse, much worse, just as her previous vet had predicted. She was wondering when it might be time to put him to sleep. “He’s not in pain now,” she asserted. “He never whines or anything.”
If you’ve read any of my posts on pain you’ll be familiar with my take on this line: Pets do not show their pain the way we do. They hide their pain as best they can. This trait is an important survival skill for most animals. We humans tend to forget this and assume that no vocalization means no pain.
Needless to say, Bobo was in significant discomfort (read: true pain). And because he’d gone a year without a workup, we decided to repeat his X-rays and bloodwork. In so doing, we passed a catheter up his urethra to instill air into the bladder (so I could perhaps see the outline of a mass within the bladder’s wall).
Once I did this, I could feel the fibrous resistance of irregular tissue right at the neck of the bladder. Not good. I tried gently to feed the catheter past. Nothing doing. I tried to get air in—not possible. And when I extracted the catheter, out came little bunches of bloody tissue. So that’s how her vet diagnosed the cancer.
X-rays of the bladder were unrevealing—except for the obvious presence of large bladder stones. Again—not good. This would add significantly to the discomfort—and to the nastiness of the obvious infection Bobo had raging inside this terminally ravaged organ. I made sure to get a culture from the pieces of junk I collected so my antibiotic choice could be matched to the bacteria’s sensitivity.
Now it was time to see if there was anything else I could do to give the owner an idea of how much sand Bobo had in his hourglass. Usually, this takes a crystal ball. But chest X-rays are a nice help when we’re dealing with cancers. Because many cancers tend to metastasize to the lymph nodes and lungs, chest X-rays are indispensable for these patients.
And Bobo’s were not the happy pics we’d hoped for. Sure, I might be able to make his bladder feel better with antibiotics, but a tangerine-sized mass in his chest was not likely to improve his chances any. And it didn’t even look like a metastatic lesion. It looked like another cancer altogether. Great.
So now we have a patient with two probable cancers (I have no hard evidence yet—just hearsay and inference) and one raging infection. Add some osteoarthritis to the mix and you have a dog that needs attention but for whom nothing can be done beyond maintaining a modicum of comfort. Enter the concept of hospice:
Bobo is the perfect example of a hospice case. They come into the hospital looking like a train wreck and exit with enough pills and scripts to improve life just a little—or maybe a lot, depending on the case.
I hope Bobo will fall into the latter category (there’s a lot there to work on) but surgery is out of the question given the bladder mass’s location. Add a chest mass into the mix and you’ve got a case fraught with clinical uncertainties. A thirteen year-old dog of his breed mix is not likely to take well to any of these aggressive approaches: best let him go with the most dignity and comfort the owner can manage to provide—with the vet’s help, of course. ;-)
Hospice home care is one of my favorite areas in vet medicine. It’s about optimization and comfort—and respect for the animal. While it can be emotionally stressful and technically challenging, to my mind its rewards are worth all the stress. At the end, when I euthanize Bobo, hopefully in his home, I’ll expect that familiar feeling of seeing something difficult through to the very end—and of having made a difference