Sunday, April 29, 2018

a dog's life


Cooper, New York City, 2007

1.

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Thursday morning, I woke up, got my kids ready and took them to school. I came home, tidied up the rest of the dishes, and gave my dog Cooper an indulgent breakfast: a full can of her favorite soft dog food—not just a quarter of a can mixed in with her dry food like usual, but the whole thing, every last bit, all to herself. After she finished, I carried her to my car. We drove to the vet, where a kind receptionist showed me into an exam room, past a potted ficus plant and a cheerful wooden sign reading, “Think PAWS-ITIVELY!” I sat down on a bench. Cooper stuck her head behind my knees.

And then we killed my dog.

2.

Cooper was a really old dog. She lived to be fifteen and a half, which in human years would make her (let’s see, multiply by seven, carry the three…) a million. Our dog was a million years old. Approximately.

We’d adopted Cooper from the animal shelter back when she was a nine week old puppy small enough to tuck into the crook of my elbow. She was a black lab mix (mixed with what, we never quite determined) who came to us with a shaved belly and a crooked spaying scar inelegantly perforated with royal blue vicryl suture. As fourth year medical students, we fussed over this scar, criticized the surgical knots with a superiority born of inexperience, and treated Cooper like a dress rehearsal stand-in for a baby, which in most ways she was.

Cooper lived with us in six different homes, through medical school and residency and fellowship and our first “real” jobs. We have three children who have never known a life without Cooper in the background. She grudgingly tolerated the insult of our second dog, Spot, who we adopted three years ago not explicitly as a spare, but certainly with an unspoken shared awareness that our first dog had could not live forever. When we adopted Cooper, I was 24 years old. This summer, I turn 40. My entire adult life, she’s been there.

And now, she’s not anymore.

3.

She’d had arthritis for many years, though it had gotten much worse in the last year or two. Her hips were stiff, and she had progressive trouble walking, or even standing up at times. I noticed increasing muscle atrophy in her back legs, which would sometimes lose footing on our hardwood floors. Sometimes she would fall and not be able to get up again without assistance. Sometimes she wouldn’t even try to get up anymore, and we’d only find her there on the floor hours later, uncomfortable but oddly still, just staring at us.

Joe and I are doctors, so with a performative sense of brio learned on the job, we moved her dog bed to the middle of the living room rug, where the textured floor could help her back legs gain purchase. We built her a ramp with a rubberized surface leading down to the backyard so she would no longer have to negotiate the steps. I joked about buying a Hoyer lift, a hydraulic sling we use at the hospital to move patients too weak to move themselves. There’s a certain grim absurdist humor one develops after years working in a hospital, and the visual of the Hoyer lift plays right into that—patients invariably ended up looking like perverse babies, dangling there as though carried in the beak of some giant mechanical stork.

We got her prescription anti-inflammatories to help her discomfort, and when, after a month, it was clear these measures were not enough, we added on tramadol, an opioid pain medication. Each solution helped a little bit, and for a time, but nothing ever really helped that much. At some point, I realized I couldn’t remember the last time I saw her tail wagging.

Her appetite, which had always been appallingly bottomless, started to fail. She had increasing trouble keeping food down. We started getting her special soft food and mixed in with her dry kibble to tempt her—this, too, helped a little bit, but only for a while. Her ribs and pelvic bones started to show. Her fur became dull. She started to look like she was shrinking inside herself, a smaller dog wearing a too-large fur coat, pulled out of mothballs from the back of the closet for one last night out on the town.

4.

But this is not meant to be a maudlin reflection piece about my old dead dog.

I have a healthy respect for the blessing of a good death, a mortal welcome not overstayed. Having taken care of many terminally ill patients over the last decade and a half, I realize that the greater injustice is often not the death itself, but the way that we—as doctors, as families—sometimes just can’t let people die quickly. No one just dies anymore, they die long, protracted deaths, perforated by painful procedures in cold harshly lit rooms; sleepless nights spent in uncomfortable beds in the middle of squalling wards where the lights never fully turn off; tolerating needle sticks and tubes and medications and plastic, which only seem to multiply exponentially even as their own bodies are withering away. Joe and I have talked about not wanting to subject ourselves or anyone we loved to this type of death. When it’s my time, we’ve said, just let me go. A death by lightning strike, not slow asphyxiation.

And yet, even knowing this, there was that moment of hesitation when it came to choosing the death for our dog. Our dog. Not a human, not a parent, not a patient, but a dog, one who had already lived and improbably long life and appeared to have no personal opinions on the matter.

We thought: But she’s still doing fine, right?

We thought: Maybe there’s something else we could try.

We thought: How will we know when it’s time?

We thought: Are we doing this for her, or are we doing this for ourselves?

She became more unsteady. We started having to carry her in and out of the house because she could no longer walk down the stairs. The pain medications didn’t seem to be working anymore. She appeared more confused, getting lost in her own house. She started losing interest in people.

We’d made one appointment at the vet a month earlier, and in a spasm of doubt, cancelled the night before. A week ago we made another appointment. This one, we kept.

5.

Sometimes having a little clinical distance helps. Though I hate leading with this (generally I find very little good comes from telling people you are a doctor), I made sure to mention that I was an anesthesiologist so I would not be spared any technical details of the process. I wanted the reassurance of understanding the pharmacology, the protocol, to grab on to the quotidian comforts of considering administration routes and uptake and circulation time instead of thinking too hard what was going to happen next.

The tech moved the exam table over to the side and put a plush bath mat on the ground, which she then covered with a thick white towel. Cooper could do whatever made her most comfortable, she explained, but this would be warm and soft if she wanted to lie down later on.

The veterinarian entered holding a 10 mL syringe filled with a radioactive-looking bright yellow solution. This, she had explained earlier, was the first phase, a sedative cocktail which would be administered intramuscularly to make Cooper “very sleepy and very comfortable.” It consisted of midazolam (a benzodiazepine), ketamine (a dissociative anesthetic), and a drug called acepromazine, which in humans had originally been used as an antipsychotic, but is now almost exclusively used in veterinary medicine as a potent sedative. Cooper’s only protest was the handling of her sore back leg for the injection, but she did not react to the needle stick at all.

This phase took about fifteen minutes. At first I let Cooper pace around the room. She was still exploring the corners, sniffing the floor. She was panting—Cooper didn’t like the vet’s office, the smell of it made her anxious. I patted her on the neck and watched.

Over the next few minutes, the panting slowed down, then stopped. She started to look more unsteady on her feet. Her atrophied back legs started to cross and slide on the linoleum, just like they sometimes did at home before she fell. Gently, I lifted her one last time and positioned her on the soft towel, her front paws on either side of her face, her back legs curled behind her. She looked around, breathing slowly. I looked back at her and stroked her head.





The vet came back in, this time with a 5 mL syringe filled with a hot pink solution. All the syringes at the vet’s office look like they came out the props department of a science show, I thought to myself. At the hospital, almost all the medications we drew into syringes were clear and colorless. This cheerful-looking syringe held the lethal dose of pentobarbital.

It all happened very fast after that. The vet wiped down Cooper’s back leg with an alcohol wipe (Why? I wondered, surely antisepsis surely is no longer a concern—but maybe wetting down the fur made palpating a vein easier) and injected a 22-gauge butterfly needle. I saw the flash of blood tracing back into the tubing and knew she had gotten in on the first pass. Nice work! I thought reflexively, though it seemed like a weird thing to say out loud in the moment, so I didn’t.

Slowly, she injected the pentobarbital, and flushed it through the short tubing with a small amount of saline. She talked to Cooper throughout. “You’re a beautiful girl. Yes, such a good dog. You’re OK. What a good, long life you’ve had. Yes, sweet girl.” It only took about a minute. Cooper’s eyes were still open, but I could see that she was no longer breathing. The vet touched one finger to Cooper’s eye and noted that she had lost her corneal reflex. She took out her stethoscope and listened to Cooper’s chest. There was silence for a few seconds. Then she nodded. “She’s gone.”

I said, “That’s it?”

6.

In the time after Cooper had gotten her first shot but before the pentobarbital, I mentioned to the vet that I was working on a piece about end-of-life care in human patients. I told her I appreciated the fact that euthanasia was an available option. After all, our dog didn’t have cancer or anything. She wasn’t actively dying. I don’t even know that she was suffering in any overt way that she could communicate to us. But we just wanted to afford her the dignity of a gentle death while she was still capable of having good days. “With human patients,” I said, “it’s different. It feels like this is not a choice. With human patients, we always want to ramp up, do more. It’s always about trying the next thing, and the next, and the next. It’s about exhausting all options rather than choosing the most humane one. With human patients…” I paused, thought a bit. “With human patients, sometimes it feels like we just…can’t…ever…stop.”

The vet nodded—she’d heard this before. Conversationally, she noted, “The suicide rate among veterinarians is very high.” I glanced up, concerned. She continued, “Not because of the stresses of the job, though I’m sure there’s some of that too. But the rate is high because we get to see this.” She gestured to Cooper, at both of our feet, breathing deeply. I thought about how Cooper used to dream. She’d be lying there asleep, making little half-barks, her legs twitching, her breath catching in her chest as though she were running full-out, chasing after some ball or squirrel only she could see. I wondered if she was dreaming right now.

“You get to see this?” I asked. I didn’t quite understand. Was she saying that having to euthanize pets day after day was a psychological strain?

She redirected me. “We get to see this. We’re familiar with it. How easy it is. How peaceful. How merciful. You’re right, it’s not like this for human patients at all. It’s something we’re allowed to do for the animals we love, but not for the people.” Cooper’s breathing was slowing down. I hadn’t seen her this comfortable in years. Every muscle in her body was relaxed. For the first time in a long while, it was clear she was in absolutely no pain. “So for many veterinarians, when their time comes, they look at their options and think, ‘Well, screw this.’ And we know how to do it.”

I considered this for a moment. The vet injected the pentobarbital. After it was over, she left us alone, and told me that the room was mine and that I should take all the time that I needed. 

7.

So now I got to see it too.

Every doctor has witnessed the opposite scenario. Patients ill and in pain, suffering the tail end of a dwindling life yet not actively dying, unable to do anything but agree to the next indignity, and the next, and the next. We see these patients again and again because they keep getting sent back to us for more. They do not have the choice to opt out while their good days still outnumber the bad. And pretty soon they are all bad days, just so many of them, one blending into the next, on and on until it’s unclear what precisely we’re trying to gain. Is it even for the patient anymore? Or is it for ourselves, the doctors, because more is all we’re trained to do?
Every doctor has seen this play out many times over, and every doctor has felt party to the crime. Major surgeries on critically ill patients that will not extend their lives, but only extend the amount of time they spend suffering in them. Medications that beget more medications, treatments that only invite further interventions. Procedures to insert feeding tubes, tracheostomies and indwelling IV lines on patients who might have died peacefully months ago, except that we just wouldn’t let them. “What exactly are we doing here?” we’ve all thought on countless occasions. “Why is this happening? Someone needs to say ‘no.’ This is crazy. It needs to stop.” But there’s a big divide between letting a patient die and helping a patient to die peacefully and with dignity, and that is a line that, as physicians, we have yet to negotiate.
The American College of Physician’s position is that physician-assisted suicide is “problematic given the nature of the patient–physician relationship, affects trust in the relationship and in the profession, and fundamentally alters the medical profession's role in society.” The American Medical Association agrees, opining that “permitting physicians to engage in assisted suicide would ultimately cause more harm than good,” and that “[p]hysician-assisted suicide is fundamentally incompatible with the physician’s role as healer”.
I agree the issue is not straightforward, and I have only limited insight into the full scope of ethical scenarios to which physician-assisted suicide might give rise. But I do object to the language the AMA uses, that “[p]hysician-assisted suicide is fundamentally incompatible with the physician’s role as healer”. I think this too narrowly defines the role of the physician, and the responsibilities to our patients. Yes, as physicians, healing is a large part of our job, but sometimes people can no longer be healed. What, then, does our role become? When the treatment goals turn from cure to care, are we offering all we could humanely provide?
Mahatma Gandhi once said, “The greatness of a nation can be judged by the way its animals are treated.” In some cases, however, the options we give our animals are kinder than those we offer our people. Few argue with the logic of offering compassionate euthanasia to companion animals who have reached the end of life or who are suffering unduly. It’s hard, then, not to wonder why it is so unthinkable to offer the same comfort to our human patients should they ask.

Physicians wield an incredible power over our patients’ lives, and that power must ultimately be tempered with humanity and mercy. This becomes all the more important closer to the end of life as our options dwindle, because no longer being able to cure the patient does not mean we lose all ability to take care of them. We can still do more even in the absence of doing more—the simple mercy of being able to say, as our veterinarian did, “It’s OK to have reached this point. And it’s OK if you’ve decided to stop. I’m here. I can help.”


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10 comments:

  1. Anonymous10:32 AM

    Michelle,

    I'm so sorry for the loss of your Cooper. We'll probably soon be approaching this decision for our big dumb black dog, and it will break all of our hearts.

    I'm a small animal veterinarian who's been reading your blog for years, through my veterinary training and beyond. Thank you for sharing your experience - it sounds like it truly was a euthanasia ("good/easy death") for Cooper. Thank you for recognizing that there comes a point when we're doing things TO our pets, rather than FOR our pets.

    (Interesting aside, most of OUR medications are YOUR medications - clear and colorless. We purposely make euthanasia solution a color that NO other medication is - bright blue or pink - to make sure it's never given inadvertently.)

    If you only want support and sympathy over the loss of your dear friend, stop reading here. For musings on the touchier subject of euhanasia across the species, read below.

    The subject of assisted suicide in humans is so very fraught. As a Catholic I am 100% opposed to euthanasia or assisted suicide in humans, but as a veterinarian I see how wonderfully peaceful it can be.

    We have so far to go in accepting death, and embracing hospice and palliative end of life care. I see my own grandmother withering away in a nursing home, on multiple diuretics, antihypertensives, ionotropes, confused and lonely even when her family is there. Yes, the valve replacement she had a few years ago gave her a few more years. But a few more years of what? This is not what I want for myself. But I don't want to die of fulminant congestive heart failure, either. There are no perfect answers, I'm afraid.


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  2. Thank you for posting this. We are still (hopefully) a few years away from having to go through this with our dog, but your post gives me hope that I will be able to handle it. Thank you.

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  3. I am so sorry for the loss of your sweet Cooper. I find, as I get older and see people around me fall victim to what advanced age and disease can do to us humans, I too think about how kind we are able to be to our pets. I am a veterinarian and fervently hope that when I am old and in need of compassion and help to leave a life I wouldn't have let my pet suffer through the help will be there. We shall see.

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  4. Really touching story :(

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  5. I'm sorry for the loss of Cooper. We went through this with our cat last May, it was the first time we've ever euthanized a pet and I was the same way - "that's it??" It was so peaceful and comfortable. I used to be a nurse in CCU but switched to hospice. I definitely have much less professional angst. The things we'd do to keep people alive when they were so far gone.... anyway, good post, thanks.

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  6. Anonymous11:14 PM

    Dogspeed, Cooper.

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  7. Thank you for the piece. I'm always thrilled to see your feed update, though I'll admit this isn't the lighthearted vacation piece I'd read the last go-around.

    It's very thought-provoking, isn't it, the niceties and the courtesies we can afford to bestow on our pets and make decisions for them when the same decisions are so difficult for our own loved ones.

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  8. Thanks so much for this. I am also a P&S grad (a few years behind) and have been following your blog since I was in school. I remember reading about when you got Cooper. We have two labs approaching 10 years of age and one is really starting to show arthritis in the hips. My husband also enjoys your blog and forwarded me this entry after you wrote it. Thanks as always for your perspective, both as a physician but also as a dog owner.

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  9. Calalily9:57 AM

    Really sad to hear of the death of your companion Cooper. It is hard. Very hard. There will be the feeling of an empty space for a long while before the sadness fades. The happy memories will return to the fore in their own time.

    It is difficult to broach this subject following the death of a much loved pet - the following words are said gently and with respect.

    For context, I'm a doctor in the UK. I agree with you about the problems with the medical approach towards the end of life, but I disagree with your conclusion.

    The focus in modern day medicine seems to be on *doing* something, rather than being. Doing interventions, to extend life, without thought to quality, or even sometimes to what the patient would want themselves. The continuation of the interventionist approach is *do* something to end life - killing with consent effectively.

    An alternative could be to focus less on doing, and instead on being. Be ready to acknowledge the difficulty of the situation at hand, to have those difficult conversations gently and honestly, to be honest about the options and potential outcomes and the not knowing of how things could be or turn out, to listen deeply to patients, and give them the space to think about things and come back to talk again. To spend time.

    In the present system, it takes a very strong minded patient with a very supportive family to say 'stop, enough, let me be'. It would take a mature and gracious doctor to listen to them, to facilitate the practical support a person needs at the end of life. It would take a sensible wider clinical team to the doctor to help support the patient switch from 'active treatment' to 'active caring and support'.

    The end of life is messy, and difficult, whatever shape it takes. It needs practical support. People to feel able to take time away from work to care (and for the job to still be there when they are ready to return, for financial support during the period of caring for their dying relative), for the wider family to able and willing to come in to support the core family with practical tasks (food shopping, cooking, cleaning, to provide space etc), for nursing support towards the end.

    But these are all expensive. In time. In money. They go against the grain of the structure of the modern medical system. To an extent, it might go against the grain of the modern consumerist culture we have grown up in.

    There is more than one way to die. There are no easy answers. Many questions. The answers, whatever they may be for each individual when the time comes, isn't binary.

    I had found this article an interesting read a few years ago on the subject - https://www.wsj.com/articles/the-ultimate-endoflife-plan-1378504239?tesla=y

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  10. Anonymous3:17 AM

    Thank you for your article. I'm so sorry for the pain of losing Cooper!

    I am a small animal emergency doctor. Euthanasia is something I perform perhaps 9-10 times per week. I have had shifts where I have performed a dozen in one shift - usually around a holiday.

    I desperately hope that euthanasia might be an option for me some day when it becomes appropriate - I have no desire to string out a decent life and end it with days or weeks or months of suffering. I joke with my MD sister that perhaps she could slip some pentobarbital into my IV line when I'm too infirm to do it myself. Except, I'm not sure I'm joking. God knows I'm in no hurry to get there any time soon, but when it's time - it's time.

    I found it interesting that the ACP's statement brought 'trust' into the picture with regards to the ethics of physician-assisted suicide. I know that if my physician had euthanasia in their toolkit it would engender MORE trust - it would help give me the sense that if they are recommending further diagnostics/therapy it's because there is a point to it. And if they aren't, it's because there is no better choice. As things stand now, I maintain a high level of skepticism for the recommendations from MDs because I know that the system is designed to keep pushing for more diagnostics and more therapy, regardless of whether it's truly in my best interests. So, my response to the ACP would be that find an ethical path forward to allow euthanasia would increase trust. At least, for me.

    Do MD ethicists view euthanasia as a failure of medicine? Is that part of the problem?

    I wonder how the dynamic of the discussion might change if the word 'euthanasia' was used instead of 'physician-assisted suicide'.

    In any case, I'm sorry you are without Cooper. It leaves a hole, and at least for me, that hole never entirely goes away. Thank you for giving him such a wonderful, family-filled life. Thank you for writing about your experience.

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