September 28, 2013

Treatment Options for Ailing Animals: Can We Ever Speak for Spot?

As I listen to an interview of Dr. Nancy Kay with Terri Gross, NPR Fresh Air A Veterinarian Advises How to Speak for Spot, I am reminded of a line from the movie, Jerry McGuire: "First class used to mean a better meal. Now it means a better life."

Does first class means a better life for your dog too?

Advances in veterinary medicine offer a host of diagnostic procedures and treatment options that are amazing. Stem cell therapy regenerative medicine for dogs with arthritis. Chemotherapy for cats with cancer. Radiography. Biopsy. CT scans. MRI  Just about any diagnostic procedure, treatment and drug that is available to the human animal is also available to dogs and cats. Their costs are equally astonishing.

Not everyone can afford them.

When it comes to making medical decisions you and your dog can live with, this adds another stage to grief: guilt. And it's all about money and the means to choose what's best for our pets.

I've labored on this post for weeks striving for objectivity. What would diagnostic tests have looked like for Matisse? What treatment options were available? What was the prognosis? Did I miss an opportunity to improve his quality of life? Did I make a mistake? Did I let him suffer out of my own inability to let go?

In the last three or four years of his life, he was plagued with symptoms of chronic disease - chronic bronchitis, laryngeal paralysis and otitis media, middle ear infection. Diagnosing and treating them started with anesthesia and ended with antibiotics, antacid, corticosteroidal drugs. Even with the best veterinary care available, the prognosis was uncertain.

Once permanent damage occurs in the airways, chronic bronchitis is incurable.

A surgical solution for laryngeal paralysis may have made breathing easier; it would not have stopped the progressive degeneration of nerves caused by Geriatric Onset Laryngeal Paralysis Polyneuropathy (GOLPP.) He would still have experienced hind-end weakness and generalized muscle wasting over several years. It is not painful and affected dogs are still bright, alert and happy. And it would have left him more vulnerable to bacterial pneumonia are common.

We'd been there. 

The middle ear problem was a constant reminder of how utterly unknowable and uncontrollable the side effects of antibiotics. It began subsequent to a six-week course of antibiotics for bacterial pneumonia. We cured the pneumonia and left him with an ear oozing a river of pus. The protocol to diagnose it involves a general flush under anesthesia.

Let me stop you at anesthesia.

After Matisse was diagnosed with chronic bronchitis, I simply would not take the risk of having him slip away without me at his side.

If that's being a Bad Mommy, so be it.

So why am I still belaboring this?

For many people, costs are a consideration. It hurts to own that. We may feel guilty that the decision comes down to cash. We may feel ashamed of our poverty or our selfishness. But financial resources are a fact.

How do we strike a balance between what we want for our companion animals and our own best interests?  

Dr. Nancy suggests pretending you have all the money in the world. What would you do?

Once you are clear on this, you can figure out how to pay for the treatment plan. Finance it. Get a second job. Take out a second mortgage. Liquidate assets. Take on more debt. When all is said and done, you can tell yourself that you did everything in your power to relieve your dog or cat of its pain.

Certainly these are ways. Even if they are workable, are they wise? Are they even necessary?

First, throwing a lot of money at a problem may not be the best recourse for your dog or cat.

As Dr. Nancy points out in her interview, a cat that hates car travel may not be a good candidate for chemotherapy. Moreover, the benefit of investing upwards of $10,000 in surgery, radiation and chemotherapy may not out-weigh the risk. Feline vaccine-associated sarcoma (VAS) is incurable. If you knew that you were only buying a year of life, much of it recovering from surgery, would you still put your cat through this?

I know people who have done this. They are not rich people, but wage earners who financed the treatment over five years. They lost their beloved cat before they paid off the bills. Without exception, they feel ill-advised by the veterinarians. Bitter. 

Second, there’s often more than one right answer. This is the advantage of having a veterinarian partner on your health care team with a consultative approach rather than blindly following the advice of one who tells you what to do.

Should you give your dog antibiotics when there's no evidence of a bacterial infection? Perform a diagnostic test when it's not clear how the results might change what happens next? Vaccinate for "the works" without knowing which diseases he might be exposed to?

Asked this way, these questions almost seem silly, but I must tell you that, as an internist who receives referrals and provides second opinions, I encounter situations where testing was performed or treatment administered that truly didn't make sense in the case at hand. If your veterinarian is prescribing care that, in your mind, doesn't "jive" with your dog's problem, I encourage you to question, investigate, poke, and prod, until things "click."

 Dr. Nancy offers a laundry list of objective criteria to help you make your decision.

1. What are the facts? As Dr. Nancy points out, there is extensive information available about medical conditions, diagnostic testing and treatment plans. Merck Veterinary Manual, the same "bible" veterinarians access is available online for anyone to use. Information on drug benefits, risks and side effects is also available online. Research on canine and feline disease and treatments published in medical journals online. Ask Dr. Google. Then confer with your veterinarian. Yes, it's a foreign language. You can learn.

2. Does the medical plan make sense? Every shot, blood draw, drug or test has a risk and a benefit. Is it wise to vaccinate a dog or cat that is sick or stressed? Is it prudent to vaccinate a puppy while maternal immunity is still protecting its system? Is every diagnostic test under the sun necessary to formulate a treatment plan? Sometimes going to extremes is simply not necessary.

3. What does your dog or cat think about it? No one knows better the likes and dislikes of your companion animal than you. Dr. Kay advises to consider your pet's emotional response to veterinary care. My cat hated riding in the car. My dog loved it. Getting into that mindset, I suspect that my cat would have said, "Leave me alone. When I need something, I'll ask." and my dog? "Ain't no big thang, Mom." That's the difference between dogs and cats.

Dr. Kay raises more good questions to ask in order to support your decision-making. But in the end, it all boils down to what serves your peace of mind?

Every medical procedure and medicine has a risk as well as a benefit. Can you accept the outcome if it brings a worse case or the worst of all cases - death?

As the caretaker of family pets, our job is to give them what they need to thrive. Not just shelter, but habitat. Not just food, but nourishment. Not just exercise, but play. Included in this is medicine or medical intervention that helps without causing undue distress or long-lasting harm.  To our animals and to ourselves.

It is neither germane nor fair to ask: what would your dog or cat say about this?

Dogs and cats live in the moment. Given they have no concept of past and no anticipation of future, they are living testimony of acceptance: "it is what it is."

When the possibility of laryngeal paralysis made its debut in 2009, we went from never hearing Matisse in the back seat on our car rides to only hearing him. Heavy panting. Roar (breathing like a freight train). Stridor (high-pitched squealing on exhale.) I was concerned. He was just happy to be riding in the car.

When his back legs no longer obeyed his will, meaning he could no longer jump onto the sofa to sit by me, I grew sad. He just adapted, putting his front legs up to signal that he'd have a boost now, Mom.

Throughout his final months, he may have felt punk; he never felt sorry for himself.

By domesticating them, we have made dogs and cats our responsibility. But just because they've adapted to co-exist with humans doesn't mean that they think or feel like humans.

Given their way, independent cats are perfectly content to hunt and scavenge as solitary creatures. They only hook up when nature calls. Social dogs find buddies and roam, hunt, mate and play as packs.

Everything we do for our companion animals' best interests is for us. 

After we let Matisse go, I regretted that I had not pursued more information and said so to Dr. Bouloy:

"I should have done the tests."

He put me at ease:

"It would not have changed the outcome."  

And therein lies the value of Dr. Kay's book.

As pet parents, we need the willingness to do our homework before agreeing to any course of action. We need the courage to question, challenge and say "no," if it feels wrong or too risky. Unless it's an emergency, there's always room for a second opinion. And we need the commitment to find a veterinarian we trust and respect, who trusts and respects us, and who's willing to work with us and whatever resources we have available.

And when they go, as they inevitably must, we need to make peace with our decisions. We did the best we could with the information and resources that were available to us at the time. But did we truly speak our companion animal's mind?

Somehow I don't think so. 


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