Preparing for the Worst, Hoping for the Best…Making Tough Decisions in Patient Care

I heard the cries and screaming vocalization in the background with my own mother’s voice on the phone saying

“Abby’s in real pain. I can’t even touch her without her biting. What should I do?”

There is always a desperation in the call for help but when it is your own mother you can hear the unspoken words, the anguish in seeing her beloved little dog so painful she would bite in opposition to handling.

Abby is a senior Dachshund and had fallen from the couch earlier that week and had been a bit sore. I recommended some pain meds and rest. With a Dachshund it is always their back until proven otherwise. I had years before stood on the other side of the exam table with their other Dachshund, Harley, when he had back pain secondary to intervertebral disc disease, and progressive paralysis.  There comes a point in this disease when it progresses fast enough or far enough that surgery or a humane goodbye become the two options.

I saw the bottle of euthanasia out of the corner of my eye while we discussed the options. My father hadn’t handled it well and was reliving goodbyes from years ago and was essentially distant from any reasonable discussion and my mother held the weight of the decision on her shoulders. While Harley’s body was failing him his brain was very much intact and aware of his distraught owners. They had elected to drive all night for imaging and surgery. Harley walked again but now how has neurologic deficits and was never 100% normal again. Now it was Abby, their other Dachshund. They had been down this heartbreaking and difficult road before.

“I knew the discussion would come…wait and see, referral for imaging and surgery…or euthanasia.”

It was decided that we could try what we could here but the option of referral and surgery just wouldn’t be available. Abby had been on a variety of pain medications including a Fentanyl patch but nothing was touching her pain. She was even sedated for radiographs and bit me as I was trying to touch her. The happy little dog at your feet just waiting for a crumb to drop had transformed into a screaming painful feral creature.

“Her radiographs showed intervertebral disc disease.”

We breed these lovable little dogs for their long backs but with that comes the risk of instability of the discs between the vertebrae. They can bulge and burst, pushing on the spine or nerves, causing unbearable pain or even complete paralysis.

I started a morphine/lidocaine/ketamine continuous rate infusion and intermittently just sedated her to facilitate her pain. I brought her home and kept her by my bed in a tote. The Kiddo peeked into the tote and with concerned eyes asked if she would need to go to puppy heaven. My heart ached.

It had been two days and I couldn’t touch her without the screaming and biting and she had progressed with motor loss on her left hind. The bulging vertebral disc was pushing on spinal nerves and her spinal cord, causing pain and loss of function. First it is conscious proprioception…knowing where your feet are…then paralysis…then superficial pain…and then at the end there is no pain sensation left at all.

We made the decision to pick up the  “supplies” that would be needed to end it all…the strong sedation and thick blue syrup that would stop all her earthly pain, but open up a pain for those that knew and loved her.

“With our animal companions, I have seen the struggle to know “when”. Do we allow a day’s worth of suffering so they may enjoy a lifetime without? Do we allow no suffering at all?”

It is emotionally tasking to watch pain in an animal knowing they can’t communicate if it is all too much or they are willing to keep going. I had stopped her MLK drip, continuing her other pain meds,  with the decision that if she couldn’t maintain comfort without it, it was unfair to continue.

I continued her therapy exercises, hoping and praying those little neural pathways would be stimulated, that the unstable disc would stop its pathway to paralysis. I stimulated her toes, did bicycle motions, stretches, massages, even took a electric toothbrush to her toes to stimulate her nervous system.

 

With clients there are lots of words and discussion, the knowing when, the hows, the questions. With my own family I found it harder to find the words. When someone has know you your entire life, they can read your face, your ticks, your eyes, and hear the words unsaid. So much of the discussion wasn’t a discussion at all but a knowing. I wanted to make the right decision for Abby.

The bag of “supplies” lie on my vehicle’s floor board and as we drove home my mind spun, dreading the moment, trying to push the details out of my mind. I felt frustrated that it had come to this. Should I have ended the pain sooner? Should I hold on for a miracle?

I peeked into the tote and Abby was bright, alert, more upbeat than I had seen her. The test would be could I pick her up without the screaming. I could and she even wanted to eat something. Could 5 hours have brought a miracle, a turning point? I knew the drugs would affect her and cause her to be dysphoric but I hadn’t expected her pain to be controlled without them.

I texted an update and said let’s give her more time. Thru the weekend she was able to start moving, placing her left hind leg that previously was worthless. I did her sessions at least 3 times a day…stretching, massaging, stimulating, hoping. A new day came and her appetite improved, her attitude improved, her function improved. Had the suffering she endured been worth it to get to this point?

We added acupuncture and continued laser treatments and she went home with my parents yesterday. Is she out of the clear…I don’t know. Will she ever be 100% normal…I don’t know. She has chronic changes that will probably always be a risk…and lead to a relapse. But at least we have hope, though prepared for what may be.

“How do we define the end? We all share so much earthly emotional and physical suffering that we want none of it for our animal companions.”

Was her suffering selfish? Maybe. Was her suffering worth it if she can recover to enjoy another day? I look back and say yes now.

This isn’t the first time I was disheartened, preparing for the worst, wondering if we humans were selfishly keeping a patient alive for our own purposes, only to be amazed at the recovery that can be made. I have literally had the euthanasia solution in hand walking to the exam room when the owner cried out the door “He tried to walk!!!” The paralyzed HBC (hit by car) dog had pulled himself to his unsteady feet after no improvement while hospitalized and there were simply no more financial resources to continue the effort. He made that first step and didn’t look back making a near full recovery. As a new vet it was a powerful lesson about making that decision for our pets which we do from a place of love and concern for their suffering, but sometimes they decide it just isn’t time and want to keep fighting. I am forever amazed at the healing and recovery possible.

“As a veterinarian, the struggle comes with trying to predict that recovery, only having the info available at that moment, with no magic ball to guide decisions.”

*Update on Abby. She had some regressions with her rehab and became a somewhat difficult patient. She has since been staying with me to continue her exercises and monitor her recovery. She is still periodically weak in the back end and mis-steps occasional. While she may never be 100%, we are hopefully she will recover to enjoy more quality time, with her pain controlled. Her spirit is definitely back.