Tuesday, May 12, 2009

End of Life Care

Today I euthanized a favorite patient. "P" was a little Schipperke who I've been treating for years with lymphosarcoma. Lymphosarcoma is one of the tumors in dogs that responds very well to chemotherapy. The chemo is not too harsh (no vomiting, and no baldness), and usually we can get an additional year of life out of them.

These owners had a dog who'd previously died from chemotherapy, so they were referred to a veterinary oncologist. However, they did NOT get along with the oncologist and decided to continue the therapy at our clinic, and that's how I inherited them.

I got along very well with these owners, and grew to know them intimately from caring for their dog every few weeks for three and a half years. "P" was famous at our clinic for how long he survived after diagnosis. He came out of remission a few times, but we always managed to pull him back. He was amazing and an inspiration to us all.

Chemotherapy is not cheap. Fortunately these owners had the financial means to thoroughly work up and treat every problem. I even cleaned his teeth twice in between treatments. And although no treatment or test was too costly, his owners always made it clear to me that they did not want him to suffer. They did not want to extend his life artificially just for their own sake. In this regard, we saw eye-to-eye.

Lately, "P" had not been quite as vigorous at his rechecks, although he still chased the tennis ball every night and was eating well. Today, they told me he had suddenly gone downhill: no eating or ball playing for 2 days. Physically, he looked pale and quiet, but his lymph nodes had not gotten larger. I ran some labwork. His kidneys, always before compromised but stable, had dramatically failed.

I talked to my clients about their options. We could hospitalize, put him on fluids and try to get him out of this crisis, but I wasn't sure if he would be better in 2 days or if he'd be the same as today. And I didn't know how long he had anyway with the cancer.

The owners were a wreck. Although they'd prepared for this day for over 3 years, it hit them hard. "We can't do that to him," they decided. "It's time to let him go." I placed an IV catheter and sent them home. A few hours later, on their beautiful back porch, I injected the pentothal into the catheter, and he literally passed away peacefully in their arms.

It was so sad to say goodbye to "P," but it was the right thing to do for him. It made me so glad for my profession. I'd had a conversation with my Uncle Tom recently (he's an ICU nurse) and he said, "You vets are much more compassionate to your patients at the end of their lives than we are." He described how many invasive, extensive, and costly procedures are done in the last few days of their lives, even when they are moribund. Shortly after that discussion, I heard Robert Martensen on Fresh Air. He talked about the same issue, and how he handled it with his elderly mother. He talked about how physicians will ask family members to decide whether to continue "life support," (how they describe pacemakers and heart valve replacements) and how these people, with have no medical training, feel pressured to continue. Both Tom and Dr Martensen mentioned how the cost of these procedures on patients with multiple health issues and limited life spans is draining the whole system.

If "P" had gone to a human hospital, he would have been admitted for days, put on dialysis, had ultrasounds and cultures. Eventually he would have died in a hospital bed, perhaps with his family, perhaps not.

Of course we can't decide to euthanize people, for multiple ethical reasons. And, I am so glad when pet owners decide to authorize expensive, heroic treatments for the animal companions that share their lives and their homes. But I am equally glad when they recognize it is time to stop fighting death, and to welcome it for its ending of suffering. As much as it was a privilege to care for "P" during his life, and help him fight cancer, it was an honor to be with him and his family at his death.


get2eric said...

The best. If poss I want you there when I go. Tom too.
But more than either of you two caring people I want Beverly.

I really don't know how you live this deeply moving stuff weekly. But I'm glad you do. You are a blessing.

Paige Morrison said...

I found your blog, obviously.
I knew you were a great Dr to this kiddo without even reading the story.

Also, as a side note, kinda, It is my understanding that "euthinisasia" is legal in the state of Oregan? We just had a client yesterday who PTS their dog who had lymphoma and as we were doing it he cried that he wished he had the same option for his life when the end was obviously near. I think it is the ones who have yet to experience and feel compassion for the dying that would be against this process for humans. Well, that and the religious aspects that stand in the way of it. But, my mom was a church going christian till the day she died and 2 days before she died as she laid miserable in the hospital she lifted her weak hand, took off her oxygen mask and said "i wish they would just let me die". She was ready to go, we had "prepared" for that time but she had to wait...
Euthiniasia is a blessing. Im glad this was such a peaceful one and they got to be at home, together.
I know I speak for MANY when I say this...thanks for being so compassionate Dr. Martin, may you be blessed 100 times more.

Nanc said...

As a LVT (for 30 years), I can attest to the fact that this is the hardest part of the job. It is impossible not to feel the pain and grief of the owners when you have worked so closely with their beloved friends. I always tell them that this is the last loving gesture they can share with their pets. What a blessing to be able to help them out of their suffering in such a peaceful manner.

Emily said...

Great post, Jenn. It reminded me of sweet Terlingua's passing in your home, in yours and Anthony's arms. I feel so grateful I was there, as she was so special to me, too, but it still brings tears to my eyes remembering her passing, even though I think it was a good thing to let her go that way.

I remember Tom and Jill discussing end of life issues when I was there last. It certainly is an issue of concern as we as a nation grapple with rising healthcare costs and trying to provide everyone with health coverage. I read an incredible story about an elderly mother who chose to end her life. Thought you might find it interesting:
when my mother killed herself

Laura said...

It seems like almost every time I visit my vet's clinic, which is far more often that I'd like (no offense) there are clients there who are heart broken and in tears over the choice they're making to end their pet's suffering with compassionate care. It makes me feel better knowing that thoughtful veterinarians, who go through this far more often than any individual pet owner, are still moved by the difficulty of those situations and decisions. I'm glad to know you haven't grown callous - not that I thought YOU would!

mainlyclearskies said...

The end of a life is always sad, but the suffering is so much worse. This was a great post (even tho I cried)!