Tough choices in pet cancer care... for everyone
This post is neither about money nor pet safety…whew! We all needed a little respite after three serious posts on that subject. It does concern euthanasia, though, so those of you needing to close your eyes, plug your ears and sing “la la la la…” to shut out the impending doom of another potentially depressing post can come back to it after a respectable period of time.
This post is about Misty, a thirteen year-old shepherd mix. She’s been my patient for the last eight years or so (nearly all of her sweet, submissive life).
Misty has suffered from arthritis for the past five or so years. She’s had two hip surgeries (the last more successful than the first) and she might also have been the poster-child for canine knee replacement…had the technology been adequate to the task.
About two years ago, Misty cracked a nail. It wouldn’t heal right so I took a sample from her nail bed (a biopsy). The pathologist said it looked like a melanoma so I amputated her toe immediately. (Melanomas are notoriously aggressive skin cancers that have a way of spreading quickly to other parts of the body, so they deserve aggressive treatment.)
After the procedure I sent Misty to an oncologist, thinking he’d have the best tools to prevent further spread of the tumor (had it already begun to do so before I’d had a chance to lop it off her toe). This specialist wasn’t big on the new melanoma vaccine I’d heard of and was loath to recommend any further treatment. (Chemotherapy, radiation and the new vaccine weren’t such a big draw at the time for one localized, well-managed tumor.)
But when Misty started breathing funny about two weeks ago, I had that bad feeling you get when you know something’s deadly amiss. After my initial house call, I sent her to the specialists for an immediate workup of her condition.
She had fluid in her chest, which was limiting the expansion of her lungs, hence the rough respiration. The ultrasound confirmed the presence of three chest masses corresponding to her lymph nodes. It seemed obvious that her melanoma had metastasized to these lymph nodes, which were now secreting a dangerous fluid.
What to do now? This was one of those classically gut-wrenching decisions:
Was it advisable to remove the tumors surgically, administer chemotherapy and hope for a few more months? Or were we in a position where we’d likely do more harm than good, given the pain of surgery, the difficulty of recovery, the potential side-effects of chemotherapy, and the stress [of all of the above] on a geriatric dog already suffering from advanced osteoarthritis?
Misty’s owners were torn…they were of two different minds. One wanted to do everything possible because they owed it to her, the other felt like doing so might be cruel in light of her circumstances.
Interestingly, the specialists were similarly torn. The internists wanted to do everything possible because of compelling statistics in the recent veterinary literature (supporting a full twelve-month remission). The surgeons didn’t feel they’d be able to get everything out of her chest—and they didn’t believe her deteriorated orthopedic condition recommended a major, open-chest surgery. (On the latter point they were silent in front of the owner, believing it best to be directly asked before rendering that kind of an opinion.)
It’s a daily dance we all do when making tough decisions about our patients’ care. We consult, we gather info, we opine openly to our colleagues…then we let the dust settle with the owners and their ultimate decisions. Everyone wants to do the best thing. And getting there’s the hard part—more so for family, of course, but undeniably for vets as well.
I felt like a fly on the wall, listening in on the stats versus the mechanical realities discussion. I was grateful the owners couldn’t hear all the back-room discussions but was that really fair? Sometimes it helps to hear how frustrating, stressful and downright impossible your pet’s case is. That’s what really makes the difference when it comes to making a decision.
Ultimately, Misty made up her mind for us. She lost the battle with her melanoma 24 hours after the decision was made to pass on the surgery, attempt some oral chemo, and simply see what happens. Sometimes it’s not up to us, much as we’d like to delude ourselves that it is.