Measuring quality of life: a delicate balance


Landon has never been a dog who hides his feelings. Adopted from an off-Island shelter six years ago, no one knew for sure how old this sweet beagle was nor much about his medical history, but when anything hurt, Landon let us know loud and clear with a classic hound dog howl. He suffered periodic neck and back pain, yelping in anticipation if his mom went to lift him. As he got older, he developed a heart murmur, a cough, a benign growth inside his eye called an iridociliary cyst, and a case of separation anxiety. He made himself sick eating chicken bones from the trash and chocolate chips off the counter, but his mom adored him, nursing him tenderly through one thing after another.

As his veterinarian, it was often hard to know when something was really wrong, since Landon would scream any time I touched him. Did his leg hurt, or was he just anxious? What about that tooth? It looked fine, but he shrieked whenever I tried to examine his mouth. I was just thankful his owner knew I was not, in fact, torturing her beloved pet when he carried on this way in the exam room. But when he arrived on emergency late one night there was no doubt Landon’s distress was real. Earlier that evening he had been restless and breathing hard. She had called me, but knowing Landon’s propensity for drama, I hadn’t been overly concerned. “Let’s see if he settles down overnight,” I said, suggesting a little Benadryl to calm him, but several hours later his owner decided he truly needed urgent care.

She was right. Landon walked in my door, his breathing rapid and labored, his stomach heaving in and out as he tried to move air. He held his neck stretched forward in his efforts to breathe and had been coughing badly at home. Putting my stethoscope to his chest, I immediately heard loud crackles. “Sounds like fluid in his lungs,” I said. “And that heart murmur is much louder.”

Landon looked like a classic case of acute congestive heart failure (CHF), a cardiac illness that is usually characterized in dogs by sudden onset of fluid in the lungs. The underlying heart problem may vary. Elderly small dogs often have heart valve disease. Certain large breeds such as Doberman pinschers are prone to a genetic condition affecting the heart muscle called cardiomyopathy. Regardless of the initiating cause, the result is often pulmonary edema — fluid in the lungs. Symptoms may include coughing, rapid, labored respiration, and an elevated heart rate. Landon fit the picture and we made a presumptive diagnosis of CHF.

“I’m giving him a diuretic to draw the fluid out of his lungs, and other medications to support his heart,” I said, then explained how to monitor his sleeping respiratory rate (SRR) at home, i.e., the number of breaths per minute when he was fast asleep. “We’ll repeat doses of the diuretic until his SRR is less than 40. Tomorrow we’ll take radiographs. Maybe consult a cardiologist.”

The next day Landon’s SRR was down to 36 and he was feeling fine, but I still wanted X-rays of his heart and lungs. The films surprised me. There was a little fluid in his lungs, but his heart looked pretty normal. His liver and spleen, however, were enlarged.

“Let’s run a few blood tests,” I suggested, beginning to question my late-night diagnosis. A chemistry profile revealed a few abnormalities including elevated liver enzymes. Moving on to a complete blood count (CBC), my in-house machine kept refusing to register a white blood cell count, lights flashing and error messages telling me to make and examine blood smears under the microscope. That’s what we did, and in no time flat realized that something was desperately wrong. There were way too many of the white blood cells called lymphocytes. Way way too many. A sample sent to the pathology lab the next day confirmed our fears. At more than 10 times normal, Landon’s lymphocyte count was consistent with a diagnosis of lymphoid leukemia.

Lymphoid leukemia is cancer of the bone marrow resulting in a huge proliferation of one specific type of white blood cell, the lymphocyte. It is classified as acute or chronic.

Chronic lymphoid leukemia (CLL) often has an insidious onset with virtually no clinical signs initially. It progresses slowly, leading to weight loss and lethargy. Treatment can be delayed until the dog is feeling poorly. Survival times with chemotherapy range one to three years.

Acute lymphoid leukemia (ALL) has a more dire prognosis with less than half responding to chemotherapy and an average survival time of two to four months. It is more common in younger animals, around four to five years old, but older dogs may be affected. Signs may include lethargy, weight loss, poor appetite, nose bleeds, bruising, increased respiratory rate, labored breathing, lameness, and/or enlarged liver and spleen. Sometimes a pathologist can differentiate ALL from CLL on the CBC, but in Landon’s case we would need additional tests — flow cytometry, ultrasound, possibly liver, spleen, and/or bone marrow aspirates.

Landon’s mom was faced with tough choices. The prognosis for ALL was very poor, no matter what we did. CLL might be treatable, but the medications are extremely expensive. While we were still considering the options, Landon suddenly developed another problem, one more consistent with ALL. He went blind in one eye, the eyeball bulging and red. Despite having been surprisingly stoic so far, he now was obviously in pain and his owner was increasingly concerned about his quality of life.

We started oral corticosteroids in hopes of making him feel better, maybe even getting temporary remission, also eyedrops to lower intraocular pressure, and analgesics for pain. Once again, Landon rallied.

We know his time is short, but we’re taking it one day at a time. Landon is not a dog who hides his feelings, and we trust he will tell us when it’s time to say good-bye.