I know that my decision to stay with Zoe and to be so intimately involved in her care will strike some people as beyond ridiculous. My decision not to even really try to force myself to take basic care of my body with food and sleep was admittedly psychologically unhealthy. I realize that because I was so intimately involved in Zoe's care, I saw a lot that perhaps an owner shouldn't see. What I saw was undeniably traumatizing. This was a self-inflicted wound. I don't feel the need to justify it, but I have reflected a lot over these last several days about why I've done it.
As pet-owners, we are responsible for our pets' health and well-being. I believe we have a duty to give them the best life we can give them, even when this requires great sacrifice. I also believe we have a duty, when the time comes, to give them a good death. To me, this means they don't die alone or only in the company of strangers, they don't die in fear, and they die quickly (typically through euthanasia) when the remainder of their natural life promises nothing but suffering. If my dog has to die, and it is at all physically possible for me make that death a good one, I will of course do so.
In my opinion, Millie and Ruby did not have good deaths. Millie died alone while I slept peacefully, expecting her to come home the next day. I'll never know if she died quickly or if she suffered for minutes or even hours before death brought her relief. I did my best to give Ruby a good death. I knew that the experience of going to the vet's office to euthanize her would be terrifying, so the vet gave me a hefty dose of tranquilizer to give her before bringing her in. The amount of tranquilizer I gave her should have taken her down completely, but it had no significant effect, which reveals something about how intense her body's fight-or-flight response was, and how much adrenaline was circulating in her body even on what was a perfectly ordinary day from her perspective. But because the tranquilizer didn't work, she did not die in peace. We sat in a courtyard outside the vet's office, since going inside would be much more stressful for her. She had to wear her muzzle, and I had to restrain her while the vet quickly administered a drug that would paralyze her, followed not soon enough by the drug that would stop her heart. I held her head in my lap waiting for the paralytic drug to take effect, for what seemed like forever. She was physically healthy and strong. She did not want to die. She struggled to get up again and again. I knew that everything in her body was telling her to get up and run. I stroked her head and spoke calmly to her, but I know she was beyond any comfort anyone could provide. I know she was very afraid in the moments before she died.
So in four years, I had already lost two dogs, and I had been unable to give either of them a good death. When it became clear how gravely ill Zoe was, I was afraid that she would die, and I was even more afraid that I would once again be unable to give my dog a good death. So I wasn't psychologically capable of doing anything other than what I did. If the vet hospital had not allowed me to stay with Zoe, I would have sat in their waiting room all day and all night asking to visit as often as I could. If they kicked me out, I would have waited in my car in the parking lot.
I did manage to give Zoe a good death. The gratitude I feel toward the vet hospital staff for allowing me to do what I needed to do is almost as strong as the grief itself. Because of their decisions, I was able to shoulder some of Zoe's burden. Yes, I was exhausted and uncomfortable (I even have bruises from lying on my side on a not-very-soft mat for so long). But by enduring my own discomfort I was able to make Zoe more comfortable than she would have been otherwise. No vet hospital can keep a constant eye on a single patient, certainly not for three days. For most of the time that she was sick, what seemed to make her most uncomfortable was when she would urinate, defecate, or bleed, and she was unable to get herself out of the mess. This happened about every 30 to 60 minutes. As I wrote in my previous post, during roughly the last 36 hours she was able to move herself around, but she couldn't clean herself up. Because the vet and nurses, especially at night, have so many critically ill patients to monitor, I know that Zoe would have had to lay in these messes for a lot longer, even in a facility that I believe gives its patients the best possible care, based on what I saw during the many hours I spent sitting with Zoe in the ICU before they set us up in an exam room. By being there, I could often tell from her breathing that she was about to make a mess, and I could always tell within a minute or so if she already had. (She had to be covered by a blanket to make sure she stayed warm enough, so these messes weren't automatically visible.) So because I was there and able to monitor her constantly, I made it possible for her to get comfortable again in less than a couple of minutes, and I also prevented her from developing the kinds of skin irritation that result from laying in such a mess. I was also able to make sure she was getting enough pain medication, since I could immediately detect the fluctuations in her comfort level and report them to the vet or nurses. There is no doubt that my sacrifice kept her more comfortable and in better condition than she otherwise would have been. That undeniable fact made it obvious (to me at least) that I was doing the right thing.
I also had purely selfish reasons. I could not focus on anything else but Zoe. When I was away from her, I couldn't stop worrying about her, wondering what was happening at that very moment, wondering if she would die, wondering if she already had died, and so on. When I was with her, I could focus on the immediate task of keeping her comfortable and monitoring her. It was meditative and very calming. By focusing on whether or not her immediate, basic needs were being met, I was able to avoid worrying excessively about the bigger question of whether or not she would survive.
So I am grateful for the way things went. This is a crushing loss, made worse by the fact that this is the third dog I've lost in four years. But at least it was not the third time I was unable to fulfill what I think is one of the most basic obligations we have to our pets. It's a small comfort, knowing that I gave Zoe a good death, but a comfort nonetheless.
Tuesday, May 13, 2014
Zoe's last days
Initially, I thought that whether Zoe recovered or not, I would want to forget everything about these last days. But as soon as I reflected on it I realized I want to remember it all. I began writing some of this while I sat by her side.
I guess I first need to just write down the sequence of events, the answer to the question I've been asked many times: what happened?
First, I must make a disclaimer. I've left out the names of the vet hospitals we went to because the second one made the most compassionate exceptions to their policies to allow me to spend so much time with Zoe and to be so involved in her care. There is no way to express my gratitude to this hospital, and I would love to give them rave reviews, but no one should ever expect to be given the gift I was lucky enough to receive. Indeed, it would have been irresponsible for them to give this gift until I had proven while just visiting Zoe, following the rules, that I would not interfere with their work. I will share my recommendation with friends privately if anyone in the area asks, but it would be a betrayal to advertise this in a semi-public way.
Zoe vomited early (about 4:30am) on Thursday, May 8th. She seemed to be okay though, so we went back to sleep. When I woke up later in the morning it was clear that she was feeling pretty lousy, and luckily our normal vet had an appointment available later that morning. Zoe stayed there Thursday until about 4:30pm, when they had me transfer her to one of the 24-hour vet hospitals in town. She spent Thursday night there, and I managed to get a little bit of sleep at home, since she did not appear to be deathly ill. On Friday morning the vets at that hospital decided she needed an ultrasound. We believed she had eaten something bad and had developed pancreatitis, but before treating her for that we needed to rule out the possibility of an intestinal blockage. I had to take Zoe to another emergency vet hospital to get the ultrasound.
I was called back to that hospital early that afternoon, and they explained to me that Zoe must have eaten something toxic. We still don't know for sure what it was, but we suspect it was a poisonous plant at the Douglas Family Preserve, where we take off-leash walks almost every day. She was experiencing acute liver failure. Things looked very bleak, but under the vet's guidance we decided to proceed with treatment for several reasons: (1) she was so young, not even two years old yet; (2) depending on the type of toxin she ingested, dogs can recover from this kind of liver failure, even dogs in much worse shape than Zoe; (3) there were clear signs that her body was fighting and she was not ready to give up; (4) they had been able to get her pain under control, so the vet estimated that her level of discomfort was most likely 1 on a scale of 1-5 where 5 is the worst, and we would likely be able to keep her at that level or better most of the time with treatment; (5) after Millie's lifetime of expensive medical disasters, I bought veterinary insurance for Zoe quite a while ago, making even prolonged, intensive treatment financially possible; and (6) have you met Zoe? She is not the kind of dog you just give up on unless it is clearly in her best interest and experts advise you to do so.
So Friday afternoon they gave her a plasma transfusion to give her blood-clotting factors. I was very fortunate that the people at this vet hospital allowed me to stand by her cage and cradle her in my arms while she got the first transfusion, followed by more IV fluids and then a variety of tests to determine the transfusion's efficacy. She was awake and clearly comforted by my presence. Ultimately she responded well to the transfusion, so they immediately gave her a second one. I never left her side. I helped during most of the procedures, just giving the staff an extra set of hands. By the end of the day Friday, the hospital staff recognized that Zoe and I simply needed to be together and that my presence would not interfere with their ability to care for Zoe and their other critically ill patients. Indeed, they thanked me for being so helpful, so they made a very special exception to the rules and set Zoe up on a bed in an exam room, where I could sleep (theoretically) on a pad beside her. This brought me tremendous comfort, because we all knew there was a definitely possibility that she would die that night, and after losing Millie the way I did, I felt so strongly that I needed to be with Zoe if and when she died. Her heart rate was in the 40s (a normal heart rate for her would be three times that), and she was not able to maintain her body temperature. So I curled up next to her and spent the night with a hand on her back, monitoring her breathing, her body temperature, and her heart rate. I learned quickly that a particular change in her breathing indicated that she was about to urinate (she had little or no bladder control), so I could immediately clean her up and change the pad she was on.
We were all a little surprised and encouraged when she survived the night. I went home and slept for about two or three hours. Then the vet called and told me that Zoe's condition had been steadily declining since I left, and I should return immediately. When I got there Zoe was "stuporous," meaning that mentally she was basically gone. There was no life in her eyes, and she was hardly breathing at all. I sat with her, expecting to see her simply die right then and there, and trying to decide if it was time to euthanize her if she didn't die naturally then. The vet told me that there was still hope, so we started another plasma transfusion. Again, I was allowed to hold her for another two hours or so while they did the transfusion. During that time the life came back into her eyes, just a bit. After the transfusion was over, while we waited for the post-transfusion test results, Jackson came and took me to dinner, which was very helpful even though my anxiety began to climb any time I left Zoe's side. When I got back, she was very much mentally present and was doing much better. I sat with her for another hour or so before the vet came to tell me that they had decided to allow me to stay with Zoe overnight again. They got us set up on the floor in the exam room again, just in time for my mom to arrive (she had flown in from Colorado). When my mom walked in the room, the look on Zoe's face was priceless. She looked like a child who had stopped believing in Santa, only to have Santa walk through the door. With Mom there, I felt comfortable enough to run home and grab my tooth brush and a change of clothes, and then I rushed back to the vet to spend another night on floor with Zoe.
On Sunday morning the vet decided that Zoe and I could stay in the exam room both day and night, again disregarding so many hospital policies. Zoe showed some of the strongest signs of improvement that day. Her heart rate was holding steady in the 80s, she was able to maintain normal body temperature on her own, and she was able to maintain her blood glucose level with half the supplementation she had previously been getting. She was very present mentally. She slept most of the time, but she looked and acted very much like her normal self when she was awake. She was able to change her position when she got uncomfortable, and she even stood all the way up at one point. She seemed to be comfortable most of the time as long as I was able to get her cleaned up right away any time she urinated or defecated, and she seemed to be mostly just annoyed to be hooked up to so many tubes and wanted to be close to me. At some point during the day on Sunday I managed to run home and take a shower while my mom stayed with her, but I could not stand to leave her any longer than that and I rushed back to the vet ready to spend my third night there. Even though she was showing signs of improvement in some ways, she was still not producing her own clotting-factors, and she was bleeding in her digestive tract, meaning that she was relying entirely on the plasma transfusions. Another problem was the buildup of toxic substances in her colon, like ammonia. To try to counteract that, she had to receive medicated enemas on a regular basis.
Around 12:30am on Monday I assisted the vet in administering another enema. Basically the vet put in the medication, and then I monitored Zoe closely for 20 minutes before it was removed. Something changed drastically during this time. After maybe five minutes she became extremely distraught and uncomfortable, and she urinated and released a lot of digested blood. I stepped out the door to call for help, and in that moment Zoe actually pushed out the enema and began crawling toward the door. The nurse came running and we began to clean Zoe up. She began to vomit, so I held her with her face tilted down so that the vomit would come out of her mouth instead of going down her trachea and choking her. With my hand on her chest I felt her heart begin to race. The nurse unhooked her from all of the machines, scooped her up, and told me to stay put for a minute while she took her to the ICU where they would have access to anything they might need. As I waited, I was convinced that this was the end. But the vet came in a few minutes later and told me--shockingly--that she was very encouraged by all of this. She explained that while it was very alarming to see such a sudden change in Zoe's condition, and to see Zoe in such distress, this was the first time that Zoe was responding to her situation the way that a normal dog would. When I felt her heart rate shoot up, it shot up to about 160, which is normal for a stressed and upset dog, and then it slowed and hung out between 120 and 130, which is exactly where it should be. She was also even more mentally present than ever. That meant she was in a lot more pain, and the vet explained that this, too, was a good sign. For most of the previous maybe 36 hours she had been on an incredibly low dose of pain medication. She hadn't needed more than that because her nervous system was hardly processing pain. So all of the sudden, in terms of her heart and her brain, Zoe was a normal dog. And since she had been on so little pain medication, there was plenty of room to safely increase the dose. Within ten minutes they had boosted her pain medication and gotten her comfortable again.
Even though it ultimately was a sign of Zoe's increasing strength, what happened at 12:30 that morning terrified me. I didn't need the vet to tell me that she was in more pain than she had ever been before, and I was shocked and horrified to see her in such a terrible state. This made it clear to me that she needed to be in the ICU with the vet and the nurse, and I needed to sleep. It took a couple hours for the adrenaline from that moment to wear off, and then I crashed in the exam room where Zoe and I had been staying, and I slept for about three hours. During that time, Zoe apparently slept peacefully and comfortably, doped up on plenty of pain medication. The nurse even took a photo of her looking so peaceful and sweet.
At about 5:30am (Monday, 5/12) the nurse woke me up. Zoe had just taken a hard turn for the worse. When I got to her I could tell she was bleeding much more than she had at any other time, and she was very uncomfortable. I needed to authorize another transfusion. I hesitated. Fortunately my mom was there to help me process the information the vet was giving us and to help me make decisions. The vet said that it would not be unreasonable to let Zoe go at that point, but that there was also still a chance (perhaps 10-20%) that she would make a full recovery if we continued. So we increased her pain medication further and went forward with the transfusion. I held her in my arms through the transfusion once again, but we were not able to keep her comfortable. She seemed to be able to rest comfortably for 3-4 minutes, but then she would begin to cry and more blood would come out. By the time the transfusion was over it was evident that it was not helping at all. For the first time, her body stopped responding to treatment. If pumping clotting factors directly into her body didn't stop the bleeding and make her more comfortable, nothing would. We spoke with the vet and we all agreed that there was nothing to do but deliver mercy. We immediately euthanized her. She did not fight it, as some animals do. She was ready to go, and she died in my arms in less than a minute.
I'm deeply grateful that I was able to see her through this process to the very end. I'm glad it was so clear when she was ready to stop fighting and that we allowed her to fight as long as she wanted to. I'm glad that the last thing she saw was my face and the last thing she heard was my voice telling her I love her and that it was time to let go.
I guess I first need to just write down the sequence of events, the answer to the question I've been asked many times: what happened?
First, I must make a disclaimer. I've left out the names of the vet hospitals we went to because the second one made the most compassionate exceptions to their policies to allow me to spend so much time with Zoe and to be so involved in her care. There is no way to express my gratitude to this hospital, and I would love to give them rave reviews, but no one should ever expect to be given the gift I was lucky enough to receive. Indeed, it would have been irresponsible for them to give this gift until I had proven while just visiting Zoe, following the rules, that I would not interfere with their work. I will share my recommendation with friends privately if anyone in the area asks, but it would be a betrayal to advertise this in a semi-public way.
Zoe vomited early (about 4:30am) on Thursday, May 8th. She seemed to be okay though, so we went back to sleep. When I woke up later in the morning it was clear that she was feeling pretty lousy, and luckily our normal vet had an appointment available later that morning. Zoe stayed there Thursday until about 4:30pm, when they had me transfer her to one of the 24-hour vet hospitals in town. She spent Thursday night there, and I managed to get a little bit of sleep at home, since she did not appear to be deathly ill. On Friday morning the vets at that hospital decided she needed an ultrasound. We believed she had eaten something bad and had developed pancreatitis, but before treating her for that we needed to rule out the possibility of an intestinal blockage. I had to take Zoe to another emergency vet hospital to get the ultrasound.
I was called back to that hospital early that afternoon, and they explained to me that Zoe must have eaten something toxic. We still don't know for sure what it was, but we suspect it was a poisonous plant at the Douglas Family Preserve, where we take off-leash walks almost every day. She was experiencing acute liver failure. Things looked very bleak, but under the vet's guidance we decided to proceed with treatment for several reasons: (1) she was so young, not even two years old yet; (2) depending on the type of toxin she ingested, dogs can recover from this kind of liver failure, even dogs in much worse shape than Zoe; (3) there were clear signs that her body was fighting and she was not ready to give up; (4) they had been able to get her pain under control, so the vet estimated that her level of discomfort was most likely 1 on a scale of 1-5 where 5 is the worst, and we would likely be able to keep her at that level or better most of the time with treatment; (5) after Millie's lifetime of expensive medical disasters, I bought veterinary insurance for Zoe quite a while ago, making even prolonged, intensive treatment financially possible; and (6) have you met Zoe? She is not the kind of dog you just give up on unless it is clearly in her best interest and experts advise you to do so.
So Friday afternoon they gave her a plasma transfusion to give her blood-clotting factors. I was very fortunate that the people at this vet hospital allowed me to stand by her cage and cradle her in my arms while she got the first transfusion, followed by more IV fluids and then a variety of tests to determine the transfusion's efficacy. She was awake and clearly comforted by my presence. Ultimately she responded well to the transfusion, so they immediately gave her a second one. I never left her side. I helped during most of the procedures, just giving the staff an extra set of hands. By the end of the day Friday, the hospital staff recognized that Zoe and I simply needed to be together and that my presence would not interfere with their ability to care for Zoe and their other critically ill patients. Indeed, they thanked me for being so helpful, so they made a very special exception to the rules and set Zoe up on a bed in an exam room, where I could sleep (theoretically) on a pad beside her. This brought me tremendous comfort, because we all knew there was a definitely possibility that she would die that night, and after losing Millie the way I did, I felt so strongly that I needed to be with Zoe if and when she died. Her heart rate was in the 40s (a normal heart rate for her would be three times that), and she was not able to maintain her body temperature. So I curled up next to her and spent the night with a hand on her back, monitoring her breathing, her body temperature, and her heart rate. I learned quickly that a particular change in her breathing indicated that she was about to urinate (she had little or no bladder control), so I could immediately clean her up and change the pad she was on.
We were all a little surprised and encouraged when she survived the night. I went home and slept for about two or three hours. Then the vet called and told me that Zoe's condition had been steadily declining since I left, and I should return immediately. When I got there Zoe was "stuporous," meaning that mentally she was basically gone. There was no life in her eyes, and she was hardly breathing at all. I sat with her, expecting to see her simply die right then and there, and trying to decide if it was time to euthanize her if she didn't die naturally then. The vet told me that there was still hope, so we started another plasma transfusion. Again, I was allowed to hold her for another two hours or so while they did the transfusion. During that time the life came back into her eyes, just a bit. After the transfusion was over, while we waited for the post-transfusion test results, Jackson came and took me to dinner, which was very helpful even though my anxiety began to climb any time I left Zoe's side. When I got back, she was very much mentally present and was doing much better. I sat with her for another hour or so before the vet came to tell me that they had decided to allow me to stay with Zoe overnight again. They got us set up on the floor in the exam room again, just in time for my mom to arrive (she had flown in from Colorado). When my mom walked in the room, the look on Zoe's face was priceless. She looked like a child who had stopped believing in Santa, only to have Santa walk through the door. With Mom there, I felt comfortable enough to run home and grab my tooth brush and a change of clothes, and then I rushed back to the vet to spend another night on floor with Zoe.
On Sunday morning the vet decided that Zoe and I could stay in the exam room both day and night, again disregarding so many hospital policies. Zoe showed some of the strongest signs of improvement that day. Her heart rate was holding steady in the 80s, she was able to maintain normal body temperature on her own, and she was able to maintain her blood glucose level with half the supplementation she had previously been getting. She was very present mentally. She slept most of the time, but she looked and acted very much like her normal self when she was awake. She was able to change her position when she got uncomfortable, and she even stood all the way up at one point. She seemed to be comfortable most of the time as long as I was able to get her cleaned up right away any time she urinated or defecated, and she seemed to be mostly just annoyed to be hooked up to so many tubes and wanted to be close to me. At some point during the day on Sunday I managed to run home and take a shower while my mom stayed with her, but I could not stand to leave her any longer than that and I rushed back to the vet ready to spend my third night there. Even though she was showing signs of improvement in some ways, she was still not producing her own clotting-factors, and she was bleeding in her digestive tract, meaning that she was relying entirely on the plasma transfusions. Another problem was the buildup of toxic substances in her colon, like ammonia. To try to counteract that, she had to receive medicated enemas on a regular basis.
Around 12:30am on Monday I assisted the vet in administering another enema. Basically the vet put in the medication, and then I monitored Zoe closely for 20 minutes before it was removed. Something changed drastically during this time. After maybe five minutes she became extremely distraught and uncomfortable, and she urinated and released a lot of digested blood. I stepped out the door to call for help, and in that moment Zoe actually pushed out the enema and began crawling toward the door. The nurse came running and we began to clean Zoe up. She began to vomit, so I held her with her face tilted down so that the vomit would come out of her mouth instead of going down her trachea and choking her. With my hand on her chest I felt her heart begin to race. The nurse unhooked her from all of the machines, scooped her up, and told me to stay put for a minute while she took her to the ICU where they would have access to anything they might need. As I waited, I was convinced that this was the end. But the vet came in a few minutes later and told me--shockingly--that she was very encouraged by all of this. She explained that while it was very alarming to see such a sudden change in Zoe's condition, and to see Zoe in such distress, this was the first time that Zoe was responding to her situation the way that a normal dog would. When I felt her heart rate shoot up, it shot up to about 160, which is normal for a stressed and upset dog, and then it slowed and hung out between 120 and 130, which is exactly where it should be. She was also even more mentally present than ever. That meant she was in a lot more pain, and the vet explained that this, too, was a good sign. For most of the previous maybe 36 hours she had been on an incredibly low dose of pain medication. She hadn't needed more than that because her nervous system was hardly processing pain. So all of the sudden, in terms of her heart and her brain, Zoe was a normal dog. And since she had been on so little pain medication, there was plenty of room to safely increase the dose. Within ten minutes they had boosted her pain medication and gotten her comfortable again.
Even though it ultimately was a sign of Zoe's increasing strength, what happened at 12:30 that morning terrified me. I didn't need the vet to tell me that she was in more pain than she had ever been before, and I was shocked and horrified to see her in such a terrible state. This made it clear to me that she needed to be in the ICU with the vet and the nurse, and I needed to sleep. It took a couple hours for the adrenaline from that moment to wear off, and then I crashed in the exam room where Zoe and I had been staying, and I slept for about three hours. During that time, Zoe apparently slept peacefully and comfortably, doped up on plenty of pain medication. The nurse even took a photo of her looking so peaceful and sweet.
At about 5:30am (Monday, 5/12) the nurse woke me up. Zoe had just taken a hard turn for the worse. When I got to her I could tell she was bleeding much more than she had at any other time, and she was very uncomfortable. I needed to authorize another transfusion. I hesitated. Fortunately my mom was there to help me process the information the vet was giving us and to help me make decisions. The vet said that it would not be unreasonable to let Zoe go at that point, but that there was also still a chance (perhaps 10-20%) that she would make a full recovery if we continued. So we increased her pain medication further and went forward with the transfusion. I held her in my arms through the transfusion once again, but we were not able to keep her comfortable. She seemed to be able to rest comfortably for 3-4 minutes, but then she would begin to cry and more blood would come out. By the time the transfusion was over it was evident that it was not helping at all. For the first time, her body stopped responding to treatment. If pumping clotting factors directly into her body didn't stop the bleeding and make her more comfortable, nothing would. We spoke with the vet and we all agreed that there was nothing to do but deliver mercy. We immediately euthanized her. She did not fight it, as some animals do. She was ready to go, and she died in my arms in less than a minute.
I'm deeply grateful that I was able to see her through this process to the very end. I'm glad it was so clear when she was ready to stop fighting and that we allowed her to fight as long as she wanted to. I'm glad that the last thing she saw was my face and the last thing she heard was my voice telling her I love her and that it was time to let go.
Subscribe to:
Posts (Atom)