Do we “replace” our pets when they pass?

Many owners look to purchase or adopt a new pet following the loss of a prior companion. I’m frequently consulted as to my opinion the best time to consider bringing another dog or cat into the household. Should they do so prior to the death of their beloved friend, or wait until after they have passed? My answers are a bit feeble, as I’m not the authority for making educated guesses about what works best for the dynamics of their particular family situation.

 

Many owners will send pictures or updates on their new additions- I’m always thrilled to be included, especially when we’re talking fuzzy puppies and squishy kittens. It’s an honor to be a part of meeting new family members and a nice way to close the circle of loss. However, I’m always a bit startled when owners quickly get another pet following the loss of a longtime companion.

 

I know there’s no statue to place on mourning, and I’d never suggest they are truly replacing their lost pet with another animal. But there are many instances where the time between death of one pet and the addition of a new friend is often a few short days or weeks. It has me considering the fragile and fluid nature of the bonds we form as humans.

 

I stand before you guilty as charged – I’ve had the unfortunate experience of losing my first cat at only 4 years of age. I never was a cat person until meeting this my Cosmo, an outgoing and confident 6-week old stray kitten who happened upon a family member’s back porch. Though I’d worked in the veterinary field for some time, and had cats as pets growing up, I never considered them particularly compassionate creatures.

 

Cosmo was more dog-like in nature, and it was his gregarious personality and quirky antics that sold my soul to the crazy cat-lady side of life. Whether it was how he played fetch with his toys, or raced to greet me at the door when I returned, I learned cats could be equally (if not more so) faithful and loving as a dog.

 

When Cosmo passed from feline leukemia, I was devastated by his death, and exceptionally lonely without his ever cheerful presence. I wasn’t looking for another pet, but the absence of his companionship and silly behaviors weighed heavily on my heart. When a stray kitten quite literally fell into my hands a mere 6 weeks after his death, I took him in with barely a second thought.

 

Bailey was a scrawny and fluffy long haired tabby cat who grew into the most handsome feline I’d ever seen. I’m not just bragging or being “that” pet parent – he actually won “Best Looking Cat” at the Feline Follies during vet school. Bailey’s most impressive feature was his sheer size, tipping the scale 23 pounds in adulthood.

 

Bailey was affectionate and outgoing, similar to Cosmo, but different in many ways. He was guaranteed to offer a “Meow” for every time I sneezed and would travel contentedly in my car sans carrier, sleeping quietly in his own car seat.

 

Unfortunately, his great size predisposed him to a myriad of health issues, including cardiac problems. Bailey died suddenly, also at 4 years of age, during the most stressful time of my internship.

 

Once again I was pushed into the shallow depths of sadness and loneliness that comes from the loss of a pet. I hadn’t planned on getting another cat as I was set to move back to upstate New York in 2 months’ time to start my residency in medical oncology.

 

A stranger dropped two pet carriers off at the clinic one evening, packed full of cats of varying ages, genders, and colors. In the midst was a teeny gray tabby kitten who purred when he was held and ate like it was his job. The decision was made to bring all the cats to a local shelter as our hospital was not equipped to handle strays. I took the kitten in under the guise of helping out an animal in need, when actually I was filling the void created by my cat’s death.

 

Nadir was visually essentially short haired version of Bailey, but once past the coat color, there was nothing similar about the two. Nadir was the coolest cat. Ever. Nothing bothered that guy and he had no enemies. Well, maybe the vacuum.

 

Following his tenuous start on life in a cramped carrier, Nadir settled into my apartment as first a “foster” kitten, who stuck around forever. He moved with me from Long Island to Ithaca to Rochester, NY to Rockville, MD. He took it all in stride. As long as there was a full food bowl and a sun patch to sleep in, he didn’t care about geography.

 

Ironically, Nadir also succumbed to a heart problem at the tender age of 9. The difference between this devastating loss and the prior ones was this time was I had adopted another kitten a year after Nadir came into my life. I’d also gotten married and adopted my husband’s cat into our household. When Nadir passed, I wasn’t alone. The crushing sadness was somewhat mitigated by my other pets.

 

I’ve half-jokingly told my husband how sure I was he would replace me within 6 months should I experience an untimely death. He laughs and tells me I’m crazy, but am I really so off base to think loneliness and depression are not the major accelerants for such actions? Does our action to replace animals mirror what would happen in life with our loved ones?

 

The void created by the passing of a pet is obviously different from that created by the loss of a person. Different doesn’t imply an attempt to quantify pain – I’m not here to comment on whether there’s more or less grief under the different circumstances. But there is grief for sure, and the loss can be mitigated with the addition of another pet.

 

It’s human nature to seek to comfort when grieving. And interesting to see the roles pets play in keeping us soothed. Even when their loss is the impetus for our sadness, we are able to find sanctuary in the companionship these future animals so freely and unquestionably provide.

When cancer hurts, but only part of the time…

People readily associate a diagnosis of cancer with severe adverse clinical signs. I’m not speaking of the effects of chemotherapy or radiation; rather I’m referring to the decline in a patient’s quality of life occurring secondary to progression of disease.

Regardless of whether the patient is a human or an animal, we’re equally capable of visualizing a person or pet experiencing vomiting, diarrhea, inappetance or lethargy directly because of a diagnosis of cancer.

As a veterinary oncologist, my responsibility is to guide owners in deciding whether to pursue treatment versus palliative (comfort) care versus euthanasia following a diagnosis of cancer. Those conversations are difficult, but can be a bit more straightforward in cases where pets are obviously sick from disease, versus when they are diagnosed incidentally or with minimal signs.

When an animal’s quality of life is poor and is manifested by major symptoms such as weight loss, lethargy, or breathing difficulties, it’s not difficult to explain to an owner that their options are limited and heroic measures are not in their pet’s best interests. With rare exception, such poor quality of life is considered an absolute “endpoint” for pet owners.

However, pets with locally advanced forms of cancer, rather than systemic disease, are more likely to only sporadically show dramatic adverse signs from their condition, rather than constantly behave sick or painful. For those patients, the line in the sand of “good versus bad” health is blurred. It’s challenging to discuss the profound impact a temporary, but consistent, deterioration in behavior has for a pet.

The best examples of such tumors are those affecting the urinary bladder and perianal/rectal regions. The most common tumors of the urinary tract include transitional cell carcinoma, leiomyosarcoma, lymphoma, and squamous cell carcinoma. The most common tumors of the perianal/rectal region include anal sac adenocarcinoma, perianal gland adenomas and adenocarcinomas, rectal carcinoma, and lymphoma.

Cancers arising from these specific anatomical areas do not cause the typical, systemic signs of illness mentioned above, at least in their early stages. However, tumors of the urinary bladder can obstruct the flow of urine out of the bladder. Likewise, tumors of the perianal region are significant because they can inhibit the pet’s ability to pass fecal waste.

Tumor growth within the urinary bladder or perirectal/perianal region causes signs such as straining to urinate or pain and difficulty while passing stool. When tumors are small, signs are usually subtle and occur only a few times per week. Over time (weeks to months), signs progress to include more extreme discomfort when attempting to eliminate urine or feces on a regular basis.

During the specific time period the pet is attempting to void, I know their quality of life is exceptionally poor. The pain associated with elimination, though intermittent, drastically impacts their lives. However, at other times, affected animals will eat, drink, sleep, play, beg for treats, and wag their tails in the same way they would prior to their diagnosis of cancer. They don’t look sick, but are they truly healthy?

Owners struggle with assessing quality of life in those situations. The temporary, but intensely negative impact makes answering the question of “How will I know when it’s time?” so much more fluid. The conversations are complex. The answer lies in the gray area between the extremes of health and illness.

We never consider cancer a “good” diagnosis to face. We associate the word “cancer” with swiftly growing tumors that spread rapidly throughout the body, leading to a patient’s hasty demise.

Unfortunately, tumors located in a place where their presence interrupts vital processes necessary for survival may never need to travel farther than their anatomical site of inception to cause equally devastating effects.

Pet owners and veterinarians bear tremendous responsibility in ensuring that the needs of animals affected by any type of cancer are met. Even if symptoms occur intermittently, we must remember that quality of life is measured both quantitatively and qualitatively. Are we truly keeping an animal’s quality of life at the forefront of our decision making if we allow suffering to occur?

Have you always wanted to be a veterinarian, but couldn’t because of this one thing???

When someone I’ve met for the first time discovers I’m a veterinarian, reactions vary from detached amusement to wild-eyed enthusiasm. The latter is far more common as there appears to be unexplainable mystique and awe surrounding veterinary medicine as a career choice.

About one in five people I meet will exclaim, upon hearing what I do for a living, “I wanted to be a vet myself!” while simultaneously flashing the broadest, most pride-filled, fervent smile possible. It’s easy to share in their instant passion for my work, and I’ll often respond with a resounding, “That’s amazing!” or “What a coincidence!”

However, our connection is typically sustained for only a few fleeting seconds. Almost as rapidly as the explosion of cheer erupts from their mouth, a peculiar gravity overtakes their expression, and a cloud envelops our joy, masking it with sadness.

Invariably, my new VTBBFF (veterinarian-to-be-best-friend-forever) will solemnly whisper something along the lines of, “But I could never deal with putting animals to sleep.”

I’m never certain how to proceed from that moment. If their concern for becoming a veterinarian had to do with the expectations associated with the many rigorous years of study, or passing board exams, or even anxiety at the sight of blood or an animal in pain, I would feel better equipped to respond. When the principal association of my chosen career path is causing the death of my patients, I’m at a loss.

Euthanasia is an integral part of my job. Though certainly not a top activity to participate in, I respect the tremendous privilege associated with my ability to relieve suffering and allow animals to die with dignity. The word euthanasia translates to “good death,” and this is the most fitting description of the service I provide.

But euthanasia represents only a small fraction of the many complex aspects of veterinary medicine. And it’s certainly not the primary attraction of the profession for those of us who choose this path. Our training, motivation, and desire lie in curing disease and healing sick pets. We are scientists who look to use our intelligence and compassion to help animals feel better. Death is a part of our position, but it is not something that sustains our motivation.

Mentioning euthanasia as a reason to never pursue a career as a vet is akin to deciding against becoming a singer because of a fear of being rejected by a record producer. Or not wanting to pursue teaching because you’re afraid of the challenging students you might face. It’s focusing on the damage rather than celebrating the positive.

There are burdensome aspects to every profession, but they should not outweigh the remarkable potential of the more rewarding qualities of the job. Singers, teachers, and veterinarians toil diligently at their respective crafts because they truly believe in their endeavors. The negative aspects are neither pervading nor permanent, and in the right environment can be capitalized to increase satisfaction and to strive to be better at what you do.

I understand some individuals view the inability to euthanize animals as a deal breaker for choosing veterinary medicine as a career path. I wholeheartedly agree, if your primary association of veterinary medicine were with euthanasia, you would be unable to sustain yourself in this emotionally complicated profession.

But if the association is centered on euthanasia, and this occurs at the expense of considering the many other wonderful and rewarding aspects of the profession, I would urge you to consider spending some time working in a clinic alongside the doctors entrusted with this precious gift.

Allow yourself the chance to better understand the breadth of responsibilities veterinarians hold. Even better, allow yourself the opportunity to explore your own capability to endure something you’re convinced would prevent you from pursuing your ideal career path.
And if your principal association to hearing me say I’m a veterinarian is immediately thinking about how difficult it is to put an animal to sleep, please take a second to pause and consider the impact those sentiments could have on someone who is dedicated to preserving the health and wellness of their patients.

Their death isn’t my primary focus.

And I don’t want it to be yours either.

Survival time isn’t the end…

Most owners of pets with cancer are fixated on the familiar phrase “survival time.” The words describe the approximate length of time a pet is expected to live following its diagnosis.

Survival time is a meaningful endpoint to measure for humans with cancer, where death occurs as a natural part of disease progression. In veterinary medicine, survival time is a complicated marker of outcome because of the bias introduced by euthanasia.

I struggle with answering owners when they ask me to predict their pet’s survival time. Despite being an expert in veterinary oncology, trying to anticipate how long a patient will live is nearly impossible.

Experience affords me the ability to describe the signs their pet will show as the disease progresses. I can forecast whether there will be issues related to appetite or pain, respiratory or gastrointestinal distress. I can usually pinpoint how long a decline will last on the order of days to weeks to months. But I cannot tell an owner how long their pet will live because that decision, in the vast majority of cases I see, is up to them. I’ve written about this topic before in an article describing Euthanasia Bias.

Consider the hypothetical scenario of two different sets of owners of dogs with an identical diagnosis of lymphoma. Lymphoma is a common blood borne cancer in dogs and cats.

Dog #1, a 5-year-old mixed breed, was diagnosed after his primary veterinarian palpated enlarged lymph nodes during its physical exam performed prior to routine vaccinations. Lymphoma is frequently diagnosed incidentally, as was seen in this dog that showed no adverse signs related to its cancer.

Dog #2, a 14-year-old shepherd, was determined to have lymphoma after his primary veterinarian performed a thorough diagnostic work up for a several week history of lethargy, vomiting, poor appetite, and weight loss.

Both dogs were diagnosed with the same cancer. Both owners underwent the same consultation with me and I made the exact same diagnostic and treatment recommendations in each case.

The statistics and data I memorized in order to become a board certified medical oncologist tells me that without treatment, dogs diagnosed with lymphoma live an average of one month. With treatment, survival time is about 12 months. This information was relayed to both owners, including expected quality of life, both with and without treatment.

Dog #1’s owners elected to pursue treatment. They felt their pet was young, otherwise healthy, and they possessed the emotional and financial reserves to move forward with all of my recommendations. Their pet underwent six months of treatment, attaining remission for a total of 14 months, and was euthanized when the cancer resurfaced and clinical signs caused a decline in quality of life unacceptable to their standards.

Dog #2’s owners elected to euthanize their dog the day after meeting with me. They knew their pet was geriatric and approaching the end of his normal expected lifespan. Their dog was also sick at the time of diagnosis, further reducing their interest in pursuing aggressive treatment.

In each instance above, despite the identical diagnosis, the survival times are vastly different—1 day versus 20 months.

These examples demonstrate several key points:

Despite what research studies suggest, neither dog lived to their expected survival. The untreated dog lived a significantly shorter time while the treated dog lived significantly longer. My predictions for survival time were incorrect in both cases

In both cases, the owners decided their pets’ survival time. Neither dog passed “naturally,” so we will never know an accurate numerical time frame for how long they would have survived.

Variables such as age, overall health status, finances, etc. always play a role in how long pets with cancer will survive. These are unpredictable influences that change outcome equally as often as the more controllable variables do.

I understand why survival time is a major consideration point for owners of pets with cancer. But I also understand my limitations in anticipating survival for the majority of animals I meet.

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Owners are often frustrated when I’m vague in my description of how long I believe their pet will live. Many are disappointed the information cannot be measured in more absolute terms.

The best I can do is honestly and openly guide owners through their journey with a pet with cancer and guide them toward the endpoints I consider essential in making decisions about life, death, treatment, palliative care, and quality of life.

Even if the journey is only a few hours long, my job is to ensure that time truly is the most sacred part of the phrase “survival time.”

Quality of life over life at all costs

Humans with terminal cancers or with widespread metastases are offered treatment with the hope of an extended lifespan, despite a grim prognosis. People are routinely administered second, third, fourth, and beyond treatment plans when they fail to respond to the frontline therapies. This is done with little to no evidence-based information that would suggest such interventions will actually result in a positive outcome.

The benefit of aggressive therapy in patients with terminal cancers is poorly described. The American Society of Clinical Oncology (ASCO) identified chemotherapy use among patients for whom there was no clinical value as “the most widespread, wasteful, and unnecessary practice in oncology.”

When I read those words as a veterinary oncologist, I had only one thought.

Ouch.

The majority of patients I treat with cancer will ultimately succumb to their disease. Pets are typically diagnosed at an advanced stage of disease, and a cure is nearly impossible. We also accept much lower rates of toxicity with our chemotherapy protocols than our human counterparts; therefore, with good reason, we can’t treat animals’ cancers to the “fullest potential.”

I would estimate that the premise of treatment for greater than 90% of cases I see is rooted in palliation (i.e., relief from pain) rather than a true belief of cure.

Yet, veterinary oncology is fundamentally based on principles of human oncology. So if the data for human oncology tells us that the treatment of terminally ill cancer patients is not only poorly beneficial but also wasteful (in terms of not only finances but resources), how can I justify the recommendations I make each day?

The answer is simple: Veterinary oncology is premised on the idea of treatment making our patients feel better, not worse. Rarely are animals diagnosed with cancer incidentally. Most show some sort of clinical signs prior to their diagnosis of cancer. Treatment, therefore, is aimed at relieving such signs and returning their quality of life to their baseline level.

A study recently published in the Oncology edition of the Journal of the American Medical Association examined the evaluation of the use of chemotherapy and quality of life for people with end-stage cancer. Specifically, researchers were interested in knowing whether chemotherapy had a positive or detrimental effect during the last week of life for human patients with cancer, and if the effect was dependent on the patient’s overall health status prior to treatment.

In people, performance status is used to evaluate a patient’s quality of life. There are several different scoring systems, with the Eastern Cooperative Oncology Group (ECOG) being widely accepted and outlined as follows:

143-ecog performance status

In the aforementioned study, a patient’s quality of life near death (QOD) was measured using a validated caregiver’s rating of their mental and physical distress during their final week of life.

Results from the study raise several interesting points:

There was no improvement in QOD scores for people with performance scores of 2 or 3 who underwent chemotherapy, compared to those who did not undergo chemotherapy.

People with performance scores of 1 showed a significantly worse score for quality of life near death with treatment.

Though difficult to compare side by side, how can the results of this study be translated to veterinary medicine?

We do have a modified performance scale we use in screening the overall health of dogs and cats, which scores pets’ activity level and ability to eat, drink, and eliminate as either normal (0), restricted (1), compromised (2), disabled (3), or dead (4).

We are able to have owners evaluate how their pets behave at home following treatment and their assessment of their quality of life in a subjective manner.

We have several veterinary studies examining an owner’s perception of their pet’s health status prior to, during, and after treatment. Results consistently showed owners were happy with their decision to treat their pets, most felt their pets’ quality of life increased, and they would pursue treatment again in the future if faced with a similar decision.

Despite the shared foundation of human and veterinary oncology, there is an enormous disparity between the end goals of each discipline.

Human oncology is based on the concept of treating patients with the mantra of “life at all costs,” while veterinary oncology accepts our limitations, choosing to “maintain or improve quality of life” over cure.

This is the message I attempt to relay during each new consultation I see.

This is the information I am passionate about dispersing with my written and spoken dialogue each day.

This is why I work so hard to help animals and their owners at every possible junction I am afforded.

The battle to dispel the misconceptions about cancer care in animals is never-ending but worth enduring, knowing I can make a difference if even for just a few.

Especially if the few are those who feel the “ouch” factor mentioned above just a bit deeper than all the others.

How much is too much?

I regularly face owners who decide not to pursue therapy for pets that have what are considered treatable cancers. The reasons for this choice can stem from concerns for too many vet visits, too much strain for the pet to go through, projection of their own feelings about cancer treatments on their pets, or financial limitations.

Over the course of my career, it hasn’t become any easier to be on the receiving end of those appointments. I want to help all pets with cancer and I want all animals to be afforded the opportunity to undergo the ideal plan to afford them the best chance of survival. Logically, I know this isn’t a realistic expectation. But it’s an accepted part of my job, and it forces me to remain open-minded about my professional goals.

Consider the opposite scenario. Those owners who want to do everything for pets that have been diagnosed with a form of cancer that has no known beneficial therapeutic option, or where we’ve run out of choices with any realistic expectation of helping them fight their disease. Those cases create a different sense of anxiety for my soul.

Practically, this translates into a scenario where the “frontline” therapy fails to keep a patient cancer-free, yet they remain relatively asymptomatic for their condition. I need to be prepared with a back up plan. In those cases, most owners want to know what else can be done to help maintain their pets’ quality of life.

My goal as a veterinarian is to make all decisions about my patient’s care using evidence-based information. I want to be sure the recommendations I present are medically sound and proven to be of a benefit.

Unfortunately, evidence based information is severely lacking in veterinary oncology and a startling amount of choices are made using simple inferences, experience, and logic.

The good news is that the more common cancers (e.g., lymphoma, osteosarcoma, mast cell tumors) do actually have fairly specific preliminary treatment algorithms. Different oncologists will offer subtle variations on the same theme, but for the most part we agree on the same initial plan of attack.

What many owners find confusing is that once we’ve moved past the primary recommendation, there are usually no universally agreed upon “next best” options amongst our oncology community. Just because I possess solid research-based information about how to treat one disease at the onset does not mean there’s enough evidence to support what the next best plan of action could be. The same is true for those cancers with no accepted initial standard of care. For those cases, we just face the confusion a bit earlier on in the plan.

Using an example of a dog with lymphoma, oncologists typically endorse a multi-drug injectable chemotherapy protocol that lasts about 6 months in duration. This plan offers the average patient about 1 – 2 years of survival. Many owners are willing to pursue this plan because of the low chance of side effects and the ability to maintain an excellent quality of life well beyond the treatment period.

However, despite being considered our most valuable and effective protocol, 95% percent of dogs with lymphoma are not cured with this plan. Therefore, more often than not, I need to be prepared to offer owners “something else” to help their pet when the cancer resurfaces.

There are numerous “rescue” protocols for such cases. In actuality, few owners are willing to try such second and third line protocols for their dogs with cancer. Many times they perceive the disease relapse as the real indicator that their pet truly has a fatal disease. Other times, a myriad of emotional, physical, financial, and ethical considerations factor in to the decision-making process.

The most difficult scenario occurs when pets are asymptomatic for their disease and I have no suitable options to help them battle their disease. It may seem counterintuitive to feel frustrated at not being able to make an animal that already feels good any different, but it’s a core part of my work.

I want to be able to keep trying to help pets with cancer, not only for their owner’s sake, but also for their own happiness and well-being. Even when a diagnosis of a cancer known to be 100% fatal is on the table, if the animal feels good, and the owners are happy with it’s quality of life, then I am always willing to try to come up with an alternative plan.

Sometimes it’s because I want to be able to give owners some form of hope. Other times it’s because I want to try a new therapy or idea and see if it can help. Mostly it’s because I want to be able to kick a patient’s cancer down as much as possible.

I can appreciate how owners might read my honesty as lack of experience, or “hedging” on telling them how we should proceed. Most people I meet prefer the simpler approach to treating their pets’ cancer. They want me to make a recommendation they can agree, or not agree, to follow.

The most important point I can make in any of these scenarios is that “just because we can, doesn’t mean we should.” This is the phrase I tell all owners when making such difficult choices about their pet’s cancer care.

It’s how I remind everyone involved in the process to keep the right perspective and to make sure we truly first do no harm.

What do you think about grief?

Lately, I’ve been thinking a lot about grief. I’m not sure if it’s associated with the particularly gloomy run of cases I’ve seen at the clinic or the personal stress and sadness I’ve recently faced, but something is pulling my emotional barometer towards focusing on the different ways people inwardly, and outwardly, express grief.

I’ve witnessed grief in many different forms. Grief is an emotion shared by all humans, and, if you’re a believer, animals as well. Setting aside observations incurred in my daily activities with friends, family members, and even strangers, and considering only what I see working as a veterinary oncologist, I feel qualified to contemplate this complex topic with a fair share of authority.

Death, illness, disappointment, heartache these are not unfamiliar terms or experiences for me professionally. I recognize this makes me far from unique.

What is particularly distinctive to my perspective as a veterinary oncologist is that I am entrusted to deliver news that will bring grief to other human beings.

The stereotypes of doctors being perceived as compassionate and caring are often equally juxtaposed against those suggesting we are inanimate, cold, and sterile in our delivery of information, especially when it is anything negative or complicated.

The words “bedside manner” are used to describe our ability, or inability as it may be, to perform this exact task. I’m hard-pressed to think of a time when I’ve heard the words used to describe the way we discuss the positives or present favorable news.

I received only very rudimentary grief training during vet school. I possess no formal education in counseling or psychology. I’m not someone considered overly outwardly emotional myself. Like many of my colleagues, I entered the field of veterinary medicine because I relate better to animals than people.

Despite the shortcomings of both my professional training and my personal mental outlook as it relates to grief, my job requires me to be capable of gauging human emotional responses, and to thoughtfully discuss complex topics such as death, palliative care, and hospice. For better or for worse, my education with grief has pretty much solely come from on the job experience.

To this end, I’ve been a quiet observer, watching colleagues speak with owners about issues related to illness, death, and suffering. In this capacity I’ve witnessed ineffective speech, disheartened wording, and dispassionate phrasing.

I’ve also seen colleagues show remarkable empathy, patience, and kindheartedness — even in the face of an owner who literally is taking their grief out on the individuals associated with their pet’s care.

I’ve watched pet owners comfortable with outward manifestations of their sorrow, shedding copious tears, their sadness obvious not only in their facial expressions, but also by their physical actions. Equally as often, I’ve seen those owners who are quiet, preferring to restrict communication to silent glances, nods, or short-worded answers.

When confronted with grief, some owners will ask a tremendous amount of questions, probing for details and explanations of why the terrible event is happening and what can be done to change it. Others are much more accepting, seemingly unconcerned with specifics, focusing more on the moment at hand and how to move on.

What I find the most shocking are those who express their grief through anger. When an angry owner, looking to impart blame as a means to deal with their pain, confronts me in a hostile manner, my faith in all the good aspects of my profession is completely rattled. Of all the emotions I encounter in a given day or week, it’s anger that causes me the most personal anxiety and strain.

It would be wonderful if I always knew the right words to say or the best way to console someone, or if even half the time I felt as though I did an “okay” job calming down an aggressive owner. The truth is, I simply don’t always know the right response. When anger and grief mix, I’m not the person you want playing on your team.

Though I’m a tougher person than I was when I first started working, I’ll never possess thick enough skin to let such events roll off without consideration. When I write about such cases from vet school, or about my early days as an oncology resident, my husband will ask me, “How do you remember these pets?” I answer honestly, “These are the things I can never forget.”

Despite knowing I’d certainly rest a bit better if I could dislodge those memories of angry pet owners from my brain, I’m certain I wouldn’t want to forget them. The fact that I still consider the words and actions of a few select owners this far along in my career keeps me grounded.

Even though I’m far from perfect in my ability to handle aggressive situations when they arise, I’m still capable of feeling something other than resentment towards those who are angered at the news I bring. This is, at least in part, because I can remember those who do the opposite; sharing their sorrow with me because they trust my response.

Those are the one percent we doctors do it for. Their quiet voices are heard as much as the raging ones. Their grief affects me as deeply as those who resort to anger.

My bedside manner indelibly influenced their pain and grief.

Do Veterinarians Owe Owners Anything After A Pet’s Death?

Several years ago, an owner scheduled an appointment with me about a week after I’d euthanized their pet. It was an unusual request, seeing as though their pet was no longer alive and in need of my services. I urged the owner to call me or email me with any outstanding questions or concerns. It was explained that if they were to schedule a specific time to see me, not only would it take a spot away from another pet in need of treatment, but that I was required to charge them for the appointment spot, while it would not cost anything to talk on the phone or via email.

 

The owner elected to keep the appointment. We met and talked about their pet and its disease and how it had progressed over time. We didn’t spend a great deal of time together, but it was a significant moment for both of us. As per the policy of the hospital, and our prior discussion, an appointment fee was generated.

 

Several days later, I received a letter from the owner criticizing the fee on the grounds it was unethical for me to charge a visit after all they’d been through. An additional suggestion was made that I should provide follow-up appointments, free of charge, to owners who’d recently euthanized their pets as a means for them to obtain closure and to provide a forum where they could process their feelings and/or frustrations.

 

As I read the letter, a complex mixture of emotions rose within my mind. Empathy, sadness, resentment, and confusion – I felt it all. But my overriding sentiments regarding the words were, “Why had I not accurately prepared this owner for their pet’s death, leading to their compulsive need to talk with me afterwards?” and “Why should I be obligated to give my time for free when a human physician would never face this expectation?” I didn’t feel particularly good about my thoughts, but I’m being honest in my description.

 

Discussing end of life care is something I’m entrusted with nearly every time I enter a new appointment. Invariably owners want to know what to look for to indicate their pet has reached the end stage of their disease. It’s never easy to consider concepts such as death and dying, planning for end of life care, advanced directives, or euthanasia. But experience tells me it’s much better to talk about these topics before we’re in the midst of an emotionally charged situation.

 

In human medicine, dialogue centered on end of life care is frequently entrusted to social workers or hospice providers. Though well-trained in these difficult topics, it’s a patient’s doctor who is best equipped to do so. They possess the medical knowledge about the specifics of what actually occurs physiologically within the body during measures such as cardiopulmonary resuscitation, or in response to treatment of disease, and how to prepare owners for what lies ahead.

 

The results of a pilot study presented this year at the annual Quality of Care and Outcomes Research Scientific Sessions showed physicians were reluctant to discuss end of life issues with their patients because they perceived their patients or their families were not ready to discuss it, they were uncomfortable discussing it, they were afraid of destroying their patient’s sense of hope, or they didn’t have the time to engage in those conversations. The latter example tells us, if a doctor isn’t going to be paid for the time it takes to have an end of life discussion, it’s not going to happen. Period.

 

The good news is more and more private insurance companies now offer reimbursement to doctors for conversations related to advanced care planning. The American Medical Association (AMA), the country’s largest association of physicians and medical students, recently urged Medicare to follow suit, indicating doctors are not only committed to the cause, but recognize they are the ones best equipped for the job.

 

Unfortunately, insurance companies offer lower reimbursement rates to doctors for the time spent talking to people compared to performing medical procedures. If we’re simply sitting around talking, we can’t be ordering tests or administering drugs or performing surgeries, and, ultimately, we’re not making any money. Even when doctors try to do the right thing, it seems we manage to be penalized.

 

It is incredibly sad that innocent animals develop debilitating diseases.   I recognize how fortunate I am to work with owners who have the time and resources to treat their pets. And I understand the loss of a pet is an intensely painful process. None of this changes the fact that being a veterinary oncologist is my job and my source of income. I too, must earn a living, pay bills and loans, and support myself.

 

Was if wrong of me to charge for an end of life/closure discussion? Did this represent detraction from my reservoir of compassion? Worse yet, did it make me a bad doctor? My answer to each of those questions is a resounding, “No!”

 

Years later, I still think about that owner and their letter, and something deeper than being labeled good or bad, compassionate or unethical, or right or wrong continues to weigh on my mind. By gaining a sense of closure and peace for themselves, this owner ironically created a sense of uneasiness in my soul.

 

Sometimes the toughest cases for veterinarians have nothing at all to do with actual animals we are treating. Sometimes the price we pay for the stress can’t be quantitated in dollars or cents.

 

And sometimes this is why we so often work for free, even when we know we shouldn’t, because we hope it will somehow save us from the unyielding pressure of charging adequately for doing our jobs.

 

Quality of death in real time

Mornings are when I catch up on current events and scan social media for trending topics.  While the news streams live on my TV in the background, I give cursory review to the headlines along my Twitter and Facebook feeds and The Huffington Post.  I’m aware of the dubious nature of those sources with regard to authenticity and content, but nine times out of ten, by the time my husband and I sit down to watch Nightly News, I’m surprisingly well versed in the journalistic “hot topics” of the day.

This morning, before I’d even made it through half of my first cup of coffee, I came across an article that stirred my consciousness and pushed my emotional barometer towards its most uncomfortable point.  The headline read “Terminally Ill 29-Year-Old Woman: Why I’m Choosing to Die on My Own Terms.”  The bait worked well, and I eagerly clicked on the link.

The story unfolded about  a young woman named Brittany Maynard, a newlywed diagnosed with a terminal form of brain cancer this past Spring.  Her initial treatment was aggressive, but her cancer rapidly progressed.  Her prognosis is now considered grave and the side effects from her disease are exceedingly painful and debilitating.  Her death, predicted by her doctors to occur within a few short weeks, will be “a terrible, terrible way to die.”

Though incredibly sad, it’s not Brittany’s back story prompting this post.  Rather, it’s her current status that is resonating so deeply with my emotions.  You see, once she was deemed terminal, Brittany researched her further options for treatment, and ultimately made the decision to actively end her own life in just a few short weeks.  Brittany and her family moved to Oregon, one of five states in the US where assisted death with dignity is legal.  Her plan is to obtain a prescription from her doctor for a lethal dose of medication, which she will take at home, and she will die surrounded by her family and loved ones.

Brittany is using her remaining time to be an advocate for death with dignity in her home state of California (where the process is currently not legal), as well as for Compassion and Choices, a nonprofit organization committed to providing a quality of death to patients facing end of life choices.  She will launch an online video campaign starting on Monday designed to fight to expand death with dignity laws nationwide.

I read the article with a quiet sense of awe and a mixture of compassion, sadness, inspiration, and empathy.  Here, was a real life and real-time example of the question I’ve asked numerous times: “How can we maintain a dignified death for cancer patients?”

As a veterinary oncologist, I deal with death on a regular basis.  I’ve written numerous articles on the difficulties I face in talking about death with pet owners and my concerns about how to best provide a quality of death for my patients.  I in no way wish to discredit Brittany’s struggle by comparing my profession to her situation.  Though I am a veterinarian, I will always hold human life in a higher regard than animals.  However, I am compelled to capitalize on the opportunity raised by Brittany’s story to further the understanding of the complex topic of death with dignity as it relates to cancer.  Whether we speak of animals or people, the strains faced by those dealing with a diagnosis of cancer are so similar.

We dedicate the month of October to raising awareness for breast cancer, and by honoring and commemorating stories of survivors who bravely battled this horrific disease, individuals currently fighting against it, and those who succumbed to its aggression.  This is an invaluable endeavor, especially when we consider not too long ago that a woman diagnosed with breast cancer was stigmatized with shame.  It’s remarkable what an open dialogue has done to demystify and to humanize patients with this terrible disease.

As such, I issue a challenge people to step outside of their comfort level, and recognize it’s equally as important to celebrate the difficult topic of death as it relates to cancer, as it is to honor the more obvious success story.  Death is not an easy thing to talk about, but if we work on it together, we can, at minimum, ensure individuals like Brittany, die with dignity, respect, and with the merit they deserve.

More about the Brittany Maynard Fund and the story inspiring this post: The Brittany Fund

Why I don’t worry about quality of life sometimes…

When faced with a diagnosis of cancer, invariably the most consistent concern owners have is being assured of maintaining their pet’s quality of life. Though they may have trouble with articulation, and stumble over word choice, I know they wish to select a treatment plan that refrains from inflicting pain or adverse side effects while simultaneously providing a prolonged lifespan over what would be expected without any additional intervention.

 

I fiercely agree quality of life for animals undergoing anti-cancer treatment is important, but I’ve also come to appreciate the attention that must also be focused on the opposing side of the spectrum: We must give credit and recognize the importance of the quality of their death.

 

What defines dying with quality? What exactly are we are hoping to provide or maintain during this time? How can veterinarians and owners ensure pets are able to die with dignity and respect, worthy of the unwavering companionship they provide during their lives?

 

To me, a quality death means an animal dies without pain, distress, or discomfort. They die while they are still self-sufficient and ambulatory. And they die without fear and without suffering. If death is a likely consequence of their disease, every effort must be taken to maintain an animal’s dignity and preserve their pride.

 

To fully understand quality of death, I think we need to clarify the definition of what we mean by palliative and hospice care as these terms relate to animals. Many people use the terms interchangeably, when in truth, the meanings of these terms are quite different.

 

Palliative care refers to care designed to maintain an animal in a state of self-sufficiency, where we infer (based on both quantitative and qualitative factors) animals are enjoying the things we would define as indicators of a good quality of life. Palliative treatment, by definition, is not designed to prolong life. However, as cures are rare in veterinary oncology, when we successfully palliate adverse signs associated with cancer, we afford pets the ability to live out their remaining time with their disease as more of a “chronic condition”, which often translates into potentially longer survival. Palliative care is active, ongoing, and a huge focus of my career as a veterinary oncologist.

 

Hospice care occurs when death is pending. There are no further heroic gestures, treatment is ceased, and the focus is on relieving pain and suffering related to disease. Hospice care allows for the patient and their family to be supported through the process of dying. Hospice care is also active and ongoing, but instead of maintaining quality of life, we are now compelled to provide a quality of death.

 

In veterinary medicine, and specifically within the specialty of veterinary oncology, there is a remarkably narrow and blurry gap between what constitutes palliative care and hospice care, further confounding our ability to understand the concept of quality of death.

 

As an example, consider a dog diagnosed with an inoperable oral melanoma tumor. Without treatment, their expected lifespan would be anywhere from a few weeks to maybe a month or so before they would become so debilitated from their disease that we would recommend humane euthanasia. Without euthanasia, the dog would quite literally waste away and, eventually, they would likely die from dehydration and malnutrition.

 

Most dogs presenting in such condition will already be experiencing difficulty ingesting food or water so they may not satisfy my criteria of being self-sufficient. They are likely to be in pain from either the physical presence of the mass, or invasion of the tumor into surrounding bone or muscle. Again, failing one of my main standards for having a quality of death.

 

In some cases, the lifespan of a dog with inoperable oral melanoma can be extended with additional treatments such as radiation therapy and/or immunotherapy.  These actions would not be expected to result in a cure, but would rather be expected to provide temporary palliation of signs, with death being a near inevitable consequence at some point in the future.

 

Let’s say the chance of success of the treatment is 30%, and the chance of some impacting side effect is 25%, and the chance of eventual death is near 100%. Considering an owner’s (and their oncologist’s) priority is to make sure their pets do not undergo adverse consequences from the options we have for attacking their cancer, how do we decide whether to focus on palliation or hospice care? Do such figures allow us to be comfortable with providing further options, or should we focus truly on the quality of death that is imparted by excellent hospice care?

 

For some owners, simply hearing me say, “There is nothing more I can do” will be enough for them to draw the line and end their pet’s life. Others will need to know they’ve exhausted every option before “giving up” on their beloved companion, trying second, third, and even fourth line protocols, with the hope that something could be successful.

 

People never hesitate to tell me they think my job has to be hard or that it must be sad, but likely they underestimate that the absolute hardest and the hands-down saddest part of my profession is discussing with owners when I feel that we are at the crossroads between palliation and hospice care for a particular patient. The second most stressful part is feeling confident that I am the one best equipped to make that decision for the pet.

 

Our concern for the quality of life for animals with cancer prevails, sometimes surprisingly even to the detriment of achieving our goal of helping them live a longer life. I argue an equally important effort needs to be made to maintain their quality of their death. And attention should be paid to both ends to make sure we’re maintaining our responsibility to the legacy they leave us during this most difficult of times.

 

More information on the American Veterinary Medical Association’s stance of hospice care:

https://www.avma.org/KB/Policies/Pages/Guidelines-for-Veterinary-Hospice-Care.aspx

 

 

What does Obama have to do with Euthanasia?

Your travels through social media may have brought you to a photojournalistic webpage of a dog named Duke’s final day of life (see: http://www.robynarouty.com/i-died-today/) If you not seen it before, I’ll issue a fair warning to be sure you have a handful of tissues nearby before opening the link. The images and words are guaranteed to cause the most stoic of souls to tear up, if even just a little.

I don’t remember how or when I first came across the story, but as I stared at the photographs and read and re-read the words on the site, I found myself thinking, “Even though I do not know this dog, I know this story.”

In my mind, Duke was previously diagnosed with a terminal cancer and his owner had recently made the most difficult of choices that it was time to end his pain. The pictures clearly illustrate though Duke’s disease was advanced enough to affect certain portions of his life, he still was able to face death with dignity and peace, enjoying his favorite things and people during his last day on Earth.

A factor particularly significant to me was Duke’s euthanasia was performed not within the sterile and clinical confines of a veterinary hospital, but rather was done outdoors, in a tranquil and comfortable setting. Duke spent his final hours doing what he enjoyed most, surrounded by the people who cared for him the greatest, in a completely natural setting. The images tell us he passed serenely and calmly, outdoors, on a beautiful summer day.

On a related note, you may have heard some of the buzz surrounding the “Veterinary Mobility Act.” This piece of legislation makes it legal for veterinarians to transport and use controlled substances beyond their primary places of registration and across state lines to treat patients. Much to the relief of veterinary professionals who have lobbied for this legislation since 2009, President Obama very recently signed the act into law.

Controlled substances include pain medications, anesthetics, and drugs used for euthanasia. For veterinarians who provide house call services, travel to farms or backyard barns, or work with wildlife and in the field of research, these are indispensible treatment options. Prior to the passing of this law, it would be illegal for those doctors to carry and use medications necessary for even the most rudimentary of treatments.

The American Veterinary Medical Association’s (www.avma.org) press release regarding the law states: “By passing and signing this legislation, the president and our legislators recognize the critical role veterinarians play in treating sick animals and relieving their pain and suffering. The health and welfare of our nation’s wildlife, food animals, and even our companion animals depend on veterinarians being allowed to do their jobs wherever the need arises.”

The importance of Veterinary Mobility Act is obvious when we consider veterinarians practicing in rural areas, or for those who run mobile or ambulatory services. These doctors need to be able to transport and administer controlled substances in order to perform their jobs. They also need to be able to do so without fear of breaking a law or losing their license.

What may not be obvious is why a veterinary oncologist would care about whether or not it would be legal to transport pain medication or euthanasia solution from their base hospital to another location or state?

I’ve written before about the “specifics” of the euthanasia process (http://www.petmd.com/blogs/thedailyvet/drjintile/2014/july/heartbreak-losing-pet-can-be-cushioned-planning-31864), with the details centering on the actual event occurring within the veterinary hospital.

Though we make every effort to ensure pets are comfortable during this time, for some animals the simple act of traveling to the vet can be so stressful and anxiety provoking. For many owners, there can be a “trickle-down” effect of increased strain and worry.

Some pets with end-stage cancer can be painful or so debilitated from their disease that they are unable or unwilling to walk out of their homes. Some owners may not be able to carry their pets or lift them into their cars. I’ve even had some owners tell me their pets bit them out of fear or pain during attempts to transport them. Therefore, in certain cases, it truly is in the pet’s best interests to not spend their last moments in a veterinary hospital.

Owners have asked me if I could perform an at-home euthanasia and I know I’ve disappointed them with my answer. I’ve had to tell them that legally, I cannot do it. It’s typically a somewhat awkward conversation, where I think both the owner and myself feel unsatisfied.

This isn’t to say I possess a strong desire to euthanize pets at home and certainly it would not be practical to make such practice a routine part of my daily schedule. I’ll leave that up to those veterinarians who make this part of their professional services. But being able to provide this option for owners in particular cases would be invaluable.

Many pets with cancer will die from their disease. Veterinary oncologists are integral to the successful treatment of such cases. We are able to afford animals with longer and happier lives and manage their diagnosis as a chronic disease. Unfortunately, cures are uncommon and in most cases owners must consider euthanasia at some point. It is a part of our job and a part of our responsibility to always put our patients needs first.

Duke’s story is just one of many – but I think it brilliantly outlines why the Veterinary Mobility Act is so important and provides owners and pets with additional options not previously established.

It’s wonderful to know the President, an obvious animal lover, feels the same way.

No one wants to talk about it, but it’s something we all must face: All about euthanasia

One of the most difficult aspects of pet ownership is considering their mortality.

 

Yes, this is a heavy way to start an article. But reality tempers the excitement of picking out a new puppy or kitten, or adopting an older dog or cat, with the knowledge that animal’s expected lifespan will, in all likelihood, be far shorter than your own.   A major consideration for pet ownership is what can be done to ensure that a good quality of life is provided during all stages of their existence.

 

The loss of a pet can be unbearable for owners whose attachment far supersedes what would be considered a “typical” healthy human-animal bond. Those cases require professional help when it comes to the complications surrounding euthanasia and death. Fortunately, there are health care providers specifically trained in dealing with supporting exceptional cases of grief related to pet loss.

 

What I encounter far more frequently are owners who, despite a rational understanding that their pets are not immortal, become overcome with fear and anxiety once faced with the diagnosis of a terminal disease.

 

Even though owners may be able to comprehend their pet has a fatal disease, the tension surrounding the details of the actual “process” off loss can be overwhelming. A more frightening concept for most people is the actual act of euthanasia itself.

 

The word “Euthanasia” literally translates to “The good death.” It is simultaneously the most humbling and powerful aspect of my job.

 

The perception of what transpires during euthanasia of a pet can be clouded by experiences with the deaths of relatives or friends or even from sensational images put forth by the media. I cringe each time a television show depicts death as some remarkably dramatic flat lining of an EKG or theatrical intake of a last breath. In reality, the passing is marked with much less spectacle.

 

As difficult as it is to discuss the subject, I thought it would be helpful to provide factual information for pet owners to think about prior to the difficult choice of euthanasia and allow some opportunity for learning and discussion about an otherwise unmentionable topic.

 

The first step for most owners is deciding where to have the euthanasia take place. For some, the decision may unfortunately need to be made on a more urgent basis, but for many other situations we are able to somewhat “plan” the process.

 

Most euthanasia occurs in a veterinary hospital, however some veterinarians will travel to an owner’s home in order to provide an additional layer of comfort during this difficult time.   This can be a very helpful service for very sick or frail animals or for owners who are incapable of transporting their pets to the vet and would otherwise be limited in their abilities.

 

Owners must then decide whether they will be present or not during the euthanasia. This is often a difficult choice for many pet owners and I urge owners to think about this particular aspect of “the plan” ahead of time. From personal experience, I know that the answer to this question can be different for each individual pet, and is dependent on many different unique emotional aspects.  Take this time to consider the right choice not only for yourself, but also for your pet.

 

Although the specifics of euthanasia can vary with facility and from doctor preference, in most cases a small intravenous catheter is placed into a vein located on the lower part of one of the limbs. The catheter will be taped in place temporarily. This is to facilitate the administration of the euthanasia solution, a drug called sodium pentobarbital.

 

This drug is a barbiturate medication that at “routine” doses, can be used as an anesthetic/sedative, but at the high doses used for euthanasia, will be fatal. The drug will cause unconsciousness within the first 5-10 seconds of administration. During this time period, there is also a drop in blood pressure, along with cessation of breathing, and cardiac arrest. This occurs within 10-30 seconds of administration. There is a surprisingly brief amount of time from the initiation of injection to the passing of the patient.

 

Many times we also administer a sedative prior to injecting the actual euthanasia solution. This is to make sure the pets are calm and quiet, and able to relax in their owner’s arms or near them on the floor in a comfortable and kind environment.

 

Once the euthanasia solution is injected, I will take my stethoscope and listen for a heartbeat. Once I’ve confirmed the heartbeat has stopped, I will let my owners know their pet has passed.

 

Some owners will elect to take their pet’s home for burial. Most owners elect for private cremation of their pet, with their ashes being returned to them.

 

Veterinary hospitals typically have a contract with a local pet cemetery that provides this service. The cemetery may also offer special options for owners including viewings, witnessing the cremation, and burials with plots similar to those available for humans. Owners are encouraged to contact their veterinarian for further details, or even to search on their own for a cemetery better suited to their personal needs.

 

In most situations, owners will need to return to the veterinary hospital to pick up their pet’s ashes once they return. This can often be a very difficult thing for owners to face as they are returning to the place they will associate with the loss of their beloved companion. If needed, ask a friend or family member to accompany you, or act in your place at this time.

 

Educating yourself on what to expect at the end of life might just be the first step in coming to terms with a terminal diagnosis for your pet. Doing so doesn’t make you heartless or uncaring. On the contrary, I find it represents a commitment to one of the major responsibilities of pet ownership.

 

The process is certainly emotionally taxing and painful, but with a small amount of exploration in advance, can also be demystified, allowing for a calm and peaceful closure for owners dedicated to their pet’s care.

 

It’s the final gift we can give to our companions who never ask for anything in return.

 

What would you do if your dog suddenly collapsed and it could be from cancer?

Imagine taking your dog for it’s usual morning walk. Nothing seems out of the ordinary; your companion’s energy level and demeanor is perfectly normal, as it’s been for as long as you can remember. Imagine leaving for work, or to run errands for a few hours, and returning home to find your pet completely lethargic and unable to rise, breathing shallow rapid breaths, with a distended abdomen, pale gums, and an exceedingly rapid heart rate.

 

Imaging rushing to the nearest open veterinary hospital, and within moments of arriving, hearing the devastating news your pet is suffering from internal bleeding from a mass associated with its spleen, and will require emergency surgery in order to have any chance of survival.

 

Now imagine hearing the mass very likely represents a deadly form of cancer called hemangiosarcoma. And that with emergency surgery, this disease is typically fatal within 2-3 months, and even with aggressive chemotherapy after surgery, survival is extended to only about 4-6 months. While trying to wrap your head around this information, imagine hearing there is a smaller chance the bleeding results from a completely benign tumor that will be cured with surgery alone. And there is no way to know whether your dog has a cancerous or benign tumor before making the decision to go to surgery. What do you do when all you can think is “My dog was completely normal this morning when we went for a walk”?

 

Hemangiosarcoma is a fairly common cancer diagnosed in dogs. It arises when mutations occur in the endothelial cells lining blood vessels. The most common primary sites of tumor development include the spleen, the right atrium of the heart, and the skin. The liver is also a common site for a tumor to form, and also a frequent site for metastases from other locations. Hemangiosarcoma occurs more commonly in older dogs, especially larger breeds such as Golden retrievers, German shepherds, pointers, Boxers, and Labrador retrievers.

 

As hemangiosarcoma tumors grow, rapidly dividing endothelial cells try to form blood vessels and vascular channels, but their growth is erratic and abnormal, and tumors are fragile and prone to bleeding. If bleeding occurs while a tumor is small, or the cancerous vessels can be repaired, dogs will usually be asymptomatic. Once a tumor reaches a critical size, bleeding will typically be more severe and dogs will show signs related to massive internal blood loss. In most cases, owners have no way of knowing their pet is afflicted with this type of cancer until it is very advanced and they are literally faced with a life or death decision about how to proceed.

 

The statistics surrounding a diagnosis of hemangiosarcoma are fairly abysmal. It is estimated over 80% of affected pets have microscopic metastases at the time of diagnosis, therefore even though the surgery to remove the immediate source of bleeding is life-saving, it is generally not curative. Chemotherapy can prolong survival, but typically only for a short duration.  Even when dogs are diagnosed with hemangiosarcoma “incidentally”, meaning tumors are discovered before dogs show signs of bleeding, the average survival time with surgery alone is about 6-8 months.   The unluckiest dogs have visible metastases in multiple organs at the time of their diagnosis. Survival times for those dogs may only be on the order of a few short weeks.

 

What I find most problematic is there is little information to help determine whether a splenic mass is cancerous or not before a tissue biopsy is obtained, so owners are forced to make a decision about pursuing emergency surgery without having all the information they might need to feel completely educated about their choice. Although most splenic tumors are ultimately diagnosed as hemangiosarcoma, other types of cancers can occur within this organ, many of which carry a more favorable prognosis than the odds I’ve listed above. I’ve also seen dogs “diagnosed” with hemangiosarcoma within their spleen, with spread to their liver, based on images obtained with an ultrasound, yet biopsy showed the masses in both organs were completely benign.   Hemangiosarcoma is uniquely challenging for this exact reason: owners are forced to make major decisions with limited evidence-based data to feel comfortable they are truly making the “right” choice for their dog.

 

I’ve treated many dogs with hemangiosarcoma, and happily continue to monitor a small number of patients who are alive a year or more after their diagnosis. I’ve talked with their owners about the spectrum of emotions they experienced when deciding whether or not to proceed with the initial emergency surgery. The most common answer I hear is they just knew they had to give their dog a chance.  They felt should something happen during or after surgery, they would be content knowing they made their decision with their pet’s best interests in mind.   And they knew even though the odds for long-term survival were not in their favor, the odds for a chance to have a few more usual morning walks were great enough to warrant the risk of a diagnosis of cancer. Of course, there was always the hope the tumor would be benign, but even when hemangiosarcoma was confirmed, they were comfortable knowing it wasn’t the duration of time that mattered for them, but the time itself.

 

Whether dealing with cancer, or with any other of life’s infinitely challenges, I think we could all stand to benefit from approaching things from a “quality over quantity” standpoint. And really figure out what it means to enjoy the moment while it lasts.