Visiting Veterinarian : When pet owners face life-and-death decisions
It was Thursday. London, a petite middle-aged cat, was lethargic and hadn't eaten for four days. On physical exam the only abnormalities I found were fever and mild dehydration. "We call this a FUO," I explained to her owner. "That's Fever of Unknown Origin."
Fairly common in outdoor cats, FUOs are often transient bacterial or viral infections. Treated with supportive care, they may resolve without ever having a definitive diagnosis. London was feisty enough to foil our attempts to draw blood, so we opted to start with symptomatic treatment — subcutaneous fluids to hydrate, antibiotics and medication to lower her fever. She expressed her opinion about oral medications (vehemently opposed), but I sent her home with a tasty liquid antibiotic, hoping she would swallow it.
Paris arrived the same day. She was older, about 11. Her owner was away and Paris had recently disappeared for several days. On returning, her cat sitter noticed she was very thin, lethargic, and not eating. Like London, Paris was dehydrated and feverish. Palpating her belly, I felt several hard lumps in her bowel. "She's constipated," I informed her mom by phone, "but the dramatic weight loss and fever may indicate other problems."
We made a plan. Fluids, laxatives, enemas, blood work. Radiographs confirmed what my fingers felt — balls of dense material in her intestines. "She may have eaten something bony on walkabout," I ventured. The x-ray was odd. Maybe a foreign body, not feces? "If she doesn't defecate overnight, we'll anesthetize her tomorrow for a fecal extraction."
London's owners called again. The moment they got home, London had vomited repeatedly. " Might be an antibiotic reaction," I suggested. "Come back. I'll give her something for that."
This time London let us draw blood. I gave an anti-vomiting injection and advised temporarily stopping the antibiotic until we saw what the blood tests revealed. What they revealed wasn't good. London's liver values were extremely abnormal. Differential diagnosis included hepatitis, cholangiohepatitis (inflammation of the bile ducts and liver), cancer, or toxin. London might even have triaditis — a combination of cholangiohepatits, pancreatitis, and inflammatory bowel disease. Treatment could include antibiotics, corticosteroids, supplements for liver support, and medications to stimulate bile flow. Since London was so difficult to pill, I picked what I hoped were the two most useful medications and sent her home again. "If she improves, we can take it a day at a time. If not, I'd suggest consulting a specialist."
It was 5:30. I checked Paris. No poop. I administered her evening laxative and shut off the lights.
The next morning Paris was straining, but still no poop. We see constipated cats regularly and it is a common, albeit unpleasant, procedure to sedate them and extract the feces rectally. But something about Paris felt different. Her mom and I discussed the possibility she might need exploratory surgery. It was now Friday, a holiday weekend. Paris was older and debilitated. The optimum plan might be referral, but for many reasons that was not an option. "Do what you can for her there," her mom requested.
While we adjusted our schedule to make time for the fecal extraction and possible surgery, London returned. "She's not vomiting but still hasn't eaten," her mom reported, " and she's had some labored breathing and moaning." London had resisted all attempts to medicate her at home.
What to do? With Paris, I knew that under anesthesia I could remove feces rectally or locate a foreign body surgically. After that, recovery should hopefully be straightforward. With London, not so much.
Prognosis with liver disease depends on prompt, aggressive treatment and identifying and addressing underlying causes. Definitive diagnosis requires ultrasound and liver biopsy. Animals with compromised hepatic function also have high risk for bleeding disorders. London's needs exceeded my equipment and my capabilities. She needed ultrasound, blood bank, ICU. She needed specialists, a feeding tube, and staff to medicate and monitor her round the clock. London headed off-Island.
We anesthetized Paris. I fished out a large, firm wad of poop, but the next hunk wouldn't budge no matter what I did. It felt odd. Fleshy. Fixed.
Fifteen minutes later, Paris was prepped for surgery. I made my incision, then gently exteriorized the affected intestines. Ah. That fecal ball couldn't move because a tumor was growing around and into her bowel causing a blockage. I could remove the cancerous portion of intestine, but further examination revealed several other tumors. This was multicentric cancer. Probably lymphoma. No wonder she was so thin.
I telephoned her mom. Sadly, we agreed the most humane course was to let her go while still under anesthesia. Across the water, the specialists determined that London did, indeed, have clotting problems along with severe liver disease. Over the next two days, she continued to decline despite state-of-the art intervention. She received a blood transfusion but her condition still worsened. She seizured, then slipped into a coma. Ultimately the decision for euthanasia was made.
My father, who was chronically ill, opted for an elective procedure at the age of 64 that the doctors said would make him more comfortable. As I sat with him in the hospital beforehand, he said "This is easy for me. I either live or die. It's hard for you, who will be left behind." He was a wise man . . . and he died that day.
Could my father or his physician have predicted that? Should I have told him not to have the procedure? What about these kitties? Would it have been better if Paris had gone to the specialists? Or if London had not? My father also used to say, "Any decision you make is the right decision." When pressed to elaborate, he would explain. "All we mortals can do at any point in time is make the best decision we can with the information we have."
What initially appeared to be two fairly straightforward cases turned out to be far more serious illnesses leading to the loss of two beloved pets. My father was right. It's hard for those left behind.