Fifteen years ago I had a patient named Bianca — an exceptionally nice Portuguese water dog with an exceptionally dedicated owner. I was at that point in my career where I was confident of my diagnostic skills (maybe a bit too confident), but not yet old enough to readily admit I didn’t know everything. Bianca’s owner had concerns. Bianca was having episodes of lip-licking, repeated swallowing, marked borborygmus (the fancy name for stomach gurgles), and malaise. But every time I examined Bianca, she seemed completely fine to me. Good body weight, alert, active. Basic bloodwork was normal. She bounced around, eating treats eagerly. I more or less dismissed the owner’s worries as being, well, worries, not real problems. I was wrong.
As many of you know, I have been traveling to Connecticut frequently for the past 2½ years to care for my mother, who is almost 100 years old. She had already been gradually declining, but when she fell and broke her hip in 2022, her condition worsened dramatically, including senile dementia, which has hampered her ability to think and communicate clearly. Four months ago, her physician advised bringing in hospice. What does this have to do with a Portuguese water dog named Bianca? Bear with me.
Navigating human hospice care can be confusing for veterinarians. We have a very different relationship with death and dying with our patients. So it took me time to wrap my head around how this was all going to work. Our hospice nurse explained there would be no “life-extending” treatments. Only palliative care. I read a helpful book that defined hospice goals as keeping patients “safe, clean, and comfortable.” OK, that made sense. We sometimes make the same choice for animals. But there are gray areas, in my opinion, in both human and veterinary medicine. For example, say my mother had an acute bout of food poisoning. Something curable with a day or two of treatment, but potentially fatal to a tiny, bed-bound nonagenarian. If we wanted her to get intravenous fluids, we would have to “take her out of hospice” first.
We could make those decisions on a day-by-day basis. Next they suggested stopping all the medications my mother had been on for decades, saying they were no longer necessary. I resisted at first, but finally acquiesced. Less than a month after stopping medications, my mother got much worse. She stopped eating. She just lay in bed, staring into space, barely able to speak. She would look at me silently, shaking her head, and clenching her upper abdomen. “Does something hurt?” I kept asking, but she was too weak and confused to communicate. We summoned my brother from California. I kept asking the hospice nurse (who came for an hour twice a week), “Why is she having abdominal pain?” The nurse shrugged and suggested turning her onto her side and giving antinausea medication. We did all those things. They didn’t help. They suggested morphine (which my mother adamantly opposed, even through her dementia). I could see the nurse was frustrated with me. Why couldn’t I just accept that my mother was at the end of her life?
With Bianca, I had been like the hospice nurse. I wasn’t listening well enough. I was seeing the case through my own lens. I was too confident about my own experience, and not giving the owner’s observations enough attention. Bianca’s owner thought the dog had indigestion. I agreed, figuring there was no harm in trying antacids, but eventually I referred them to a specialist, who agreed the dog was experiencing gastric or esophageal discomfort. They prescribed hypoallergenic food, tried several different acid reducers, and suggested state-of-the-art scoping to rule out esophageal motility disorders.
Back to the present. I spent three days sitting at my mother’s bedside feeling helpless. Then suddenly an idea struck me, like a bolt of lightning. What if, like Bianca, my mother had gastroesophageal reflux, also known as GERD? For decades she had taken Protonix, a prescription drug similar to Prilosec or Pepcid, that reduced the acid in her stomach, but hospice had discontinued that medication, along with all her others. If you have ever had acid reflux, you know how painful it can be. Heartburn is bad enough. GERD is awful. What if, without her acid-blocking medication, her GERD had become so bad she couldn’t eat at all and things spiraled downward from there?
The nurse was skeptical. My mother wouldn’t be able to swallow the big Protonix pill, she said. My mother’s system wouldn’t be able to absorb the medication anyway. I persisted. I suggested using Prilosec instead. “It comes in capsules we could open and sprinkle on a spoonful of applesauce,” I said. “I’m sure I can get my mother to take it.” The nurse shrugged and acquiesced, just like I had with Bianca.
Twenty-four hours after starting the acid blocker, my mother started eating. Within a week she was eating two or three times a day, no longer in pain, and awake for longer hours. Even her dementia seemed less. We knew we were on track the night she finished dinner, then asked for cake and coffee!
Something as simple as acid reflux. Something dogs can’t explain. Something so small, but with potentially deadly repercussions in a person as old and frail as my mother. I appreciate her nurses, but wonder if maybe every hospice team should have a veterinarian on board. We are trained to listen to our patients even though they can’t speak in words. Conversely, it’s a vivid reminder to me that when I am on the other side of the equation, I have to listen to the people who come with the animals. To remember that owners (like daughters) may observe important things about their loved ones that veterinarians (and hospice nurses) miss. To be the best veterinarians we can be, we need to listen carefully, not just to the pets, but to whatever the human owners have to contribute. Thank you, Bianca.
