Caring for Cats

Being a House Call Veterinarian – 1

The privilege is all mine. A home is a special place, and to be invited in, to handle the home’s innocent and intensely loved inhabitant, is an immense expression of trust.

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“Thank you so much for coming!” Beaming relief, Sandi ushers us out the door, “I feel so privileged!”

I glance back – Pebbles the cat is under the dining room chair, relaxed but watching us leave.

“That was the best veterinary visit ever! I just cannot get her in the box, and the trip to the vet is always so awful! She just poos on herself every time, and last time she peed herself on the vet’s table. It was so horrible! I could hear her screaming in the back. I felt so sad. I never want to go through that again. Thank you so much!”

The privilege is all mine. A home is a special place, and to be invited in, to handle the home’s innocent and intensely loved inhabitant, is an immense expression of trust.

My patients are wary, often downright terrified, and most of them are geriatric. They have a plethora of aches and pains, poor vision, diminishing hearing, and can feel quite insecure out of routine. It is a challenge to avoid causing them pain whilst we take blood pressures and lab samples. They have picked up on their owner’s anxiety, and the sense of relief when the visit is over, with all the unknowns having been dealt with, and knowing that there is no shaking, yowling, vomiting car ride back home, has an euphoric effect. I share that euphoric joy time and time again, because I can easily appreciate the vast difference between a clinic visit and a home visit for my patients.

Vancouver Feline Hospital, being so peaceful without the dogs and the tensions of a normal veterinary clinic, was already a reasonably cat friendly place.  However, after 13 years, the décor and workflow design was starting to show wear and tear. A revamp was overdue, but I had not the heart for it. Working ten and twelve hour days was taking a toll on us, and often I would be working several weeks without a break. A tired doctor is not a good doctor. In the last couple of years, our veterinary assistants had worked some magic, easing some of my workload. No associate veterinarian that applied for the job could afford to move to Vancouver. I was frustrated and exhausted with trying to find feline friendly staff. Feline only practices don’t sell easily, and I didn’t really want to sell so much as ease off.

I bought myself a wetsuit on a Christmas sale, and started cold water ocean swimming. English Bay of Vancouver has choppiness, strong currents and great mountain views. The climate is mild enough that if you buy the technical gear, you can comfortably do watersports or sailing year round. So it was that on a sunny day, early April 2015, whilst swimming, I thought of a way to make a change.

It was a great opportunity, to sell the commercial real estate in a hot Vancouver market, clear all debts, and take a more relaxed approach to being a veterinarian. We made the transition to housecall practice in summer 2015.

 

We were instantly busy. The first month was quite experimental, just figuring out logistics. So many asked us if we were going to have a special van. Cats are simple creatures, and my bulkiest item was the ultrasound, which fits into a suitcase. The rest of the stuff we need is in 2 rolling toolbags, 1 smaller toolbag and a backpack. We only take into the home what we need, and my assistant will return to the vehicle if necessary. Thomas did regularly drop the babyscale, and I am looking for a more rugged model! We work in a city, and relished having a tiny car that is easy to park. Maybe Vancouver is exceptional, but we found parking to be easier than expected, and much cheaper. In a year, we picked up only one parking fine. The rain didn’t bother us either!

Traffic could be tedious, and we learnt to deliberately schedule appointments to avoid the heavy traffic times. We also found it was best to limit the number of appointments in the day – we might visit four homes, but I would see 8 or more cats.

We revelled in the unexpected pleasures of housecall practice. I am absolutely hooked on housecall practice as being the most feline friendly way to be a veterinarian. It is sheer pleasure seeing my patients, whom I know so well in clinic, being (almost) themselves at home. Any cat owner, including myself, can tell you how terrified the cat is in clinic and how differently their cat will behave on the home couch.

Pebbles is a new patient. I have not met her before today. She is gentle beautiful calico, a little tubby as an indoor middle aged cat can be, and explores our bags without much nervousness. It doesn’t take her long to find the catnip treat at the bottom of the bag, and she drags this out to play with it whilst Sandi fills out some forms for us.

Cats share space with us, without the same degree of brain function (mass) loss as other domesticated creatures. They experience significant stress and anxiety when out of their safe zones, and adverse events such as veterinary visit can easily contribute to post traumatic stress disorders. They recognise individual human faces. Pain and fear is easily triggered by a movement, a smell, or even the sight of a stethescope. The converse is true too – they do remember the gentle touch, and can come to trust another veterinarian over time. Cats whom we have visited often treat us as family friends. They know what to expect, and know that we wont hurt them.

“So let’s go look at the litter box.” Pebbles has just turned 14. She has been pooping on the rug the last few weeks, with increasing frequency. Yesterday, she peed on the rug. I have watched her wander around her home, sit and lie down, how she gets herself comfortable. I can see her food and water dishes in the kitchen. She has a number of cat beds around the home. The small apartment is arranged around her needs. It is clearly her home. We sat on the living room floor, and I did my exam, talking about every little bit, nose to tail tip. We have checked her blood pressure, and taken a blood sample. Pebbles is resting on one of her cat beds. Her part in the consultation is over. She relaxes and watches us stare at her litter box.

“We want to make this easy for her” I say, pulling out my phone to show pictures. Together, we wander around the home, looking at my example photos, and discussing practical ways to accommodate Pebble’s ageing and medical needs within the constraints of the apartment space. This is the magic of doing this consult at home – we don’t misunderstand each other and can discuss our patient’s needs within the context of the home environment and the individual cat and owner abilities. This is so different from the lecture given to a stressed out cat owner over a wide-eyed trembling cat on the exam table.

Whilst I having been talking, my assistant has gathered Pebbles lab samples, packed up the bags, and prepared the invoice. That is my signal to conclude our discussion, which will continue a day or two later when the lab results come back.

“Pebbles bit the other vet” Sandi confides as she completes the transaction, “The other vet told us to never come back!” Sure, Pebbles was pushed to her limit, then, and I am relieved her emotional scars from that encounter did not trigger fear during my visit. There are some cats that will not allow easy handling even at home.

 

For me, I never have to close those cage doors on a sick cat and watch the feeling of abandonment (mixed with guilt, fear and worry) in the cats and owners.  Actually, I had stopped doing that many years ago. There was a reason why cats were so desperate to get out of those cages, pressing themselves against the bars and diving out as the doors open. No matter how big (we had 4’ and 8’ kennels for our patients, much more than any other veterinary clinic), how comfortable and homey we made that space with hidey boxes, endless washloads of towels and baby blankets, toys and accoutrements from home and the cat only cat friendly environment, most of the hospitalised patients were still fearful or worried. Cats heal better at home, if you can do the nursing. Several years ago, I realised I had not hospitalised a patient for more than a year! With good nursing backup, my patients were doing well with homecare. In the housecall situation, I can do so much more in guiding acute and chronic homecare. The difference is palpable, just because I can evaluate my patient and their dedicated nursing staff at home.

I don’t miss the clinic environment, and have no emotional regrets whenever I walk past the Vancouver Feline Hospital location. All its precious memories – those photographs and mementoes of my patients that kept us inspired, covering the walls of my office and reception, are now in the home office. The wall has been replaced with scrapbooks, and I still love to get those photos.

It has been a fantastic year being a housecall veterinarian. Unfortunately, my lung disease has got worse, and after several very bad adverse reactions to perfumes and cigarette smoke, I had to make the decision to limit my exposure to uncontrolled triggers. It may take several more ocean swims, but I guess, thinking of Pebbles and cats like her, that I will find a new way to take care of my patients.

 

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Taking care of the aged and terminally ill cats – 2- when is it the end?

We comfort each other.
We comfort each other.

Kiko (featured in a previous blog of the same theme) died a few weeks ago. Her last couple of weeks, the devastating infection she fought successfully, and the dying, were surrounded by the usual exhaustion and emotional trauma. Moments of sheer hope and denial were pierced by the very sharp pain of knowledge. This is how it goes. It is heartbreaking to see the little one struggle in the end of life. So gut-twistingly tough to watch her bravely get up, and gather the strength and sheer brutal determination required to get to the loo, get a drink, or swallow food. I spread towels over the bathroom floor, washed sheets endlessly, and just kept up with the care. Those last sleeps together, that sinking into mutual peace, waking to watch a deeply comfortable and content cat, surrounded by the only thing that mattered to her (love in a human beings arms), was the reward for the bone-wracking exhaustion.

We questioned our decisions every day for weeks. One morning we told the family this was it. But then we came home to find Kiko did not agree. Until the night she did. It was time.

So how do we know that moment? That is one of the most common questions I get asked. The conversation may be like this –

“Oh, well, you will know when the moment comes.”

“Yes, Doc, but what do I see? How will I know?”

“Well, she might stop eating. She might hide, become reclusive, reject social interaction….kind of, like, you know, a cat wanting to go outside and die under a bush.”

I have to continue talking at this point, because the face across from me wants to crumple. Once again, although I have seen that particular phenomenon happen all throughout my life, this may be the first time this person is facing such a thing. I just gave an inadequate description of what we really see and go through.

“We use this quality of life scale – we have to be sure we can meet these top three here. So if we feel we cannot control pain, if there is any difficulty breathing – because struggling for breath is rated highest on the human pain scale -, if we cannot keep her hydrated, and if we cannot control the misery of constant nausea; then we make that terminal decision. The rest of this scale is all about enjoying life, mobility, sociability, interaction, hygiene. I think those top three, and especially the first, controlling pain, is most important.”

Notice how this does not answer the question. We do not really have an answer to the question. What am I really looking for, that is not on that quality of life scale? How do I know when a cat is ready to die?

It has been my experience that our special cats rarely become reclusive at the end. Instead, they seek out our love and reassurance. Some people describe this as becoming “more needy”. The focus of the life may become that deep interaction, the quiet embrace of cat and human, although the ability to tolerate close contact (getting squashed in that embrace, as we do with a younger cat) is decreased. Cats, like people, draw intense comfort from the presence of loved ones at this time. We don’t need to do much, as simply being there can be enough, providing a lap or a warm body to lie against.

Appetite may persist, although food intake does decrease. There simply is not the strength left to eat, even when nausea is not present. We are doing our best to maintain hydration and prevent nausea and pain, and so not eating (a lack of appetite is a sign of pain, nausea or dehydration) is not really an indicator of imminent death for me anymore. Not eating is an indicator of pain or nausea.

I look for the will to live. Up to this point, we have been taking care of the necessities of life as much as possible. There should be no dehydration (we have been giving SQ fluids, and usually by this time, twice daily), nor debilitating extreme uncontrollable pain (we have become acutely aware of what pain looks like, and dose meds accordingly), and nausea is as controlled as we can manage with powerful drug combinations. We are able to maintain hygiene; we are aware of decreasing mobility and strength, and are adapting our care regime to manage this; and we are finding the time to provide that essential love.

All through this, we are asking the questions. Are we being cruel? Are we doing this for ourselves? How much longer? Do I need sleep? Have I gone crazy? Am I pushing this cat too much with the care? Can she tolerate the handling? Is the required care destroying the relationship? What am I not doing? Is it today? How much longer can I do this? Who can help me? Will I really know the time?

And then you know. The light drifts out the eyes. Head carriage changes. The body slumps in a different way. The beloved and essential routine is no longer. Only one thing is left, to sleep in your arms. There is a very deep sense of letting go and becoming adrift. This can happen from one moment to the next, or be slower, taking up to a day. It is like a flame went out, and now all that is left is the sinking into the final coma, allowing the body shutdown and the final process to happen.

What happens when we cannot do the care? For so many diverse reasons between cat and caregivers, we may not be able to prevent dehydration, pain and nausea; keep up with hygiene, feeding and basic needs; and successfully manage infections. Then we are making a decision based on suffering. If there is suffering, and we cannot alleviate the suffering, then, in animal medicine, we accept the right to take that life and alleviate that suffering. A decision based on suffering – the quality of life decision – may still leave us with regrets, of doing the wrong thing at the wrong time. It leaves us with less uncertainty than if we did not use the decision making tool of the quality of life scale, and helps guard us against convenience euthanasia. Discussed frankly with the veterinarian and any support group you have, it helps gives strength in moments of care-giver burnout and clarity when we cannot think clearly. It does not guard us against those cases when the suffering could have been alleviated to grant more life-time, because a severely ill but curable cat can score extremely low on the suffering scale until appropriate intervention occurs. Thus the use of the quality of life scale for a terminal decision may only be appropriate when we cannot do the care. Otherwise, it is useful in pointing out to us where we are falling short in care. It is subjective, and does not guard us against the opinions and beliefs of our peers, as each may have a different perception of what suffering is for a cat. A decision based on suffering can be the best decision under the circumstances at that time – which is the best anyone can do. Sometimes the answer is not euthanasia but help with the care-giving; there is no shame in needing help with care-giving, and accepting help when it is offered.

Finally, I look for a lack of doubt. In all our conversations that we may have, in facing the decision and feeling for the right time, if there is doubt or concern expressed from the one who knows the cat the best, then we need to reconsider the euthanasia moment. Sometimes in grief we may cling on and not recognise the suffering or the terminal process; our friends and veterinarians are there in that case to allay the doubt and prevent future regrets. More often, when you are expressing the doubt, and the cat is clearly not terminal, we have to accept this is not a euthanasia decision but a need to figure out how better to care for the cat till there is no doubt.

This is an individual decision making process – what is right for one cat and owner combination may not be appropriate for another.

Kiko chose her time. It coincided with a time when, if she was human, she would have become bed-ridden; reliant on caregivers to turn a painful, stiffening body for cleaning and bathing; ever increasing doses of morphine; and the slow drift towards death. Euthanasia spared her that. And really, I cannot tell you if Kiko chose or I chose; I feel it was right because there is no sense of wrong. There is no real way of knowing.

Taking care of the aged and terminally ill cats – 1

ancient sleep
Kiko

I was woken before dawn this morning by that distinctive cat vomiting sound. It was Kiko. She is 24, with lymphoma, and that means seriously old and frail. She will fall into her vomit. I have to leap up and hold her; grab desperately for the nearest towel to absorb the mess and prevent it getting all over us. As I cleaned her up, tucked her back in, comforted, medicated and dealt with the mess, I remembered I had started this blog post.

In veterinary medicine we have a gift, if you wish to call it that, of terminating life to prevent suffering and distress. That judgement call can be difficult. We use the quality of life scale together with our personal belief systems and deep attachment to our cats to help us make that decision. But until that point, many of us are first time caregivers of the seriously old or terminally ill cat. Veterinary literature is almost non-existent on this subject. The most I will plumb out of the new field of geriatric cat care is medically invasive – for example, place a feeding tube – and only superficially taking into account any of the special needs and considerations of the senior cat. It helps to draw on human experience in hospice care, coping with ageing and dying relatives, and all the other aspects of dealing with the ill and the dying. Contrary to what we expect, not all doctors are able to deal with this stuff – experience seems to be a requisite. In veterinary medicine, experience in terminal care is lacking – veterinarians and pet owners habitually request euthanasia well before the final comatose stage, and the support network required to help deal with caring for such patients is not there in vet medicine.

Each life as it approaches the end takes an individual way along a common path. There are some generalisations we can make. One of these is the lack of sleep you the caretaker will experience. And no-one within your social group may understand. Pacing. Howling. Appetite changes. Bad days. The uncertainty – is today the day of death? Whilst life becomes difficult, but still enjoyable, we the caretakers experience the emotional roller-coaster – emotions generated by inability to effectively communicate with our patients, thus relying on our interpretations and experience – is there pain, is there nausea, where does it ache, did this help, what more can I do….guilt at not doing enough, falling asleep, getting irritable…precious moments of quiet joy that the little one is sleeping so peacefully, soft peaceful moments of comfort together. These all wrap up into stress and we each have our ways of coping.

There are so many similarities in cat and human hospice care, that when I first saw a hospice booklet for human caregivers, I wanted to copy it for myself for the cats. Mostly, it was the relief that I was not just making it all up. I just wish I had been trained – rather than the learn-as-you-go experiences.

There are stages in the care –ill, but mobile, eating, reasonably well; progressing through increasing immobility, pain, and needing more personal hygiene care; to very weak; to immobile and the dying. The most important thing we offer in all stages is love – soft predictable comfort, even if we cannot purr, they know when we generate that emotion – love is the best pain medicine yet, dole it out wholeheartedly whilst you can.

The smallest things become the most precious. Life crystalizes to what is truly important. For the cat, that is you, food, water, warmth and toileting. You first. I cannot over emphasise that – just how much everything revolves around companionship, comfort and love. As pleasurable as that sunbeam may be, life is not about stuff, and the heat from the sun is weak without you there.

We do everything to maintain comfort and prevent pain. This involves different grooming tactics, changes to litter boxes, bedding and accessibility options. Treating infections effectively. Not causing extra pain in handling or veterinary procedures. We avoid oral medication, finding subcutaneous or transdermal drugs less stressful, less painful to give. Pain management is multifactorial, and managing pain takes a persistent experimental approach – what is required can change, and we have to observe responses to drugs. Pain is variable, never the same during the day or day by day. Recently, I have come to appreciate the value in pacing as part of pain management and pain awareness. There is also variation in the howling that the cats do that can help us clue in as to whether it is a pain-coping strategy or not.

For those who take care of the cat till the end, to and through the dying, it is important that we know that we can do the same care that we would give to a dying human relative. We need to know how to do it, and it helps to have the regular weekly or more often support visits. For me, as the busy veterinarian, I need a cohort of nurses trained in such support to help me – I know those 5 minutes I spend gabbling the long list of things to do is not enough – it takes constant care and re-evaluation. For you, it is private care, and that costs money, each visit.

Making the decision for euthanasia is the most heartbreaking difficult decision of anybody’s life. I have been through this way too many times with my cats. It never gets easier. In a way, I think that guilt we feel, that we pushed them too far, stems from a feeling that we were unable to care for them effectively at that point, and so the little one suffered. But then, terminating a life too soon – how fair is that and where is that line drawn between convenience and care? That is why we need that quality of life scale. It has been often the only way I could make that judgement call. But even then, and I will throw this doubt in here, that scale cannot differentiate between the very ill cat that will recover and the terminal cat. That scale can change from day to day. It is still not an objective scale. There are some cats that would have died, but are being cared for right now, with chronic illness that will be terminal one day, but absolutely enjoying life.

Kiko is enjoying her morning nap now, apparently blissful. I glue my eyes open with another pot of coffee.

There is a number to the title of this blogpost – that means the theme will be continued.

 

 

 

 

 

 

Edward (18) amputee

Edward is now 18. On Friday afternoon in September 2001, Edward was hit by a car on a West Vancouver side street. He was brought to a veterinary clinic in West Vancouver by a good samaritan. I was the veterinarian on duty, and it was just after 5pm, into the last hour of my shift. Stunned, in shock, and just overly handsome. Radiographs showed a very bad complex fracture of his right front leg. His owners did come in, and wanted to try save his leg, so he was transferred to the emergency clinic for ongoing care until a board-certified surgeon could be found to comment. He spent the weekend on heavy duty pain drugs. Monday a surgeon deemed his fracture unfixable, and amputation was recommended. The thought of managing a three-legged cat was hard to his owners, and they signed Edward over to me. With help and guidance of another veterinarian, I amputated Edward’s leg, including his shoulder blade. The next day, he came home – a new home, filled with cats, and feeling vulnerable and painful. Our pain management learning curve on amputees and what happens to them over a lifetime began.
On day three he was intensely grumpy but trying to jump. His back muscles were stiff and sore for the next few weeks, as he adapted his posture and walking to the single front leg. As a young cat (6), he healed and adapted rapidly. But he always snapped if I inadvertently touched his surgery site, and his back was often stiff and sore. Although he could do leaps up high, getting down was a problem, so we provided downward routes he could manage from his favorite spots.
Into his teens, he started experiencing severe back spasm and pain. His entire back eventually fused into one stiff inflexible system, and although the bouts of severe pain ended, there are still days when he really seems to ache.
I think his sensitvity to touching his amp site has lessened, and I no longer appreciate phantom pain in him. As a geriatric cat, now with no teeth, deaf, and having gone through radioiodine therapy for hyperthyroidism, and now dealing with progressive kidney disease, his absolute favourite thing is the memory foam bed.
Cats are more secure at about the height of a bed. Edward has steps that allow him access to different heights. He also has a secure padded downfilled grass basket in the closet, and he loves to sleep in boxes, again very well padded. He has heating pads, raised food dishes and several water bowls with the water level at just the right height. His litterboxes are open, low and big.
Many cats are amputees. They achieve a great quality of life, adapt to their disability with grace and aplomb, and age as any other cat. The difference is in the phantom pain, the sense of vulnerability some cats have to deal with (after all, if you were a street-fighter before, you stay a street-fighter), and the painful severity of the joint changes these cats experience early on in their ageing process.
Proactive and ongoing pain management makes a huge difference, from day of injury (before surgery) right through the entire lifetime. Simple lifestyle changes can make the most difference, especially in an older cat. As for drugs, be prepared to use acute pain management drugs as well as chronic pain management drugs. Each cat is different, and so there is no one recipe that fits all cats – I had to get to know the character, and then close observation with paying attention to details helps me decide when he is painful, and where. Edward has some mild cognitive dysfunction now, and we found one of the drugs made this worse. Since withdrawing that, he has been much more stable. Edward’s demonstration of pain or hunger is to get grumpy. I actively feed him through the night, on his memory foam bed. If I find him howling or stalking another cat, I will distract him with food.
He is well beyond the stage of metacam, and throughout the time I have known him, metacam was absolutely inadequate in providing pain relief. Opioids on demand have been his mainstay. I saw little response to amantidine or gabapentin (conversely, some of my patients cannot live without these); and understandably, since cartilage problems are not the cause of his joint pain, glucosamine did not appear to have effect. He still likes his glucosamine treats, but then he loves pill-pockets, Temptations and Greenies. Not a great one for stinky fish oil supplements, he will lap on the fluid in a can of salmon.
The dose of the drug varies according to the pain level – and chronic pain is never the same day to day and within the day itself. Being aware of the neuropathic effect of pain, and what will intensify it, and what seems to level it out, helps. Cats have imagination (so can anticipate pain), memory (so can remember and associate pain with space, time, smell, sight, sound, taste, touch and person), and emotion. Paying attention to the details, removing pain triggers, and redirecting emotions make a big difference.
Giving oral medication by opening the mouth and popping a tablet can cause pain in older cats. Explore other delivery options, and always be willing to adapt your technique to the cat. Forcing Edward’s head back, and his body into an unbalanced insecure position is not an option. He gets his meds as transdermal formulations (and yes, they DO work, in cats and humans!), hidden in treats, or given with his daily subcutaneous fluids.
Medicating him is on a routine, predictable and takes under five minutes. There is no fight. If he objects, is unwilling, we do not battle him down. We think and find a gentle, easy way. Some days are very different from others, and with cats like Edward, who are old, with limited mobility, and dealing with many concurrent conditions, no currently acceptable published veterinary standard and approach applies.
Providing quality of life to our older and disabled cats is possible. Caring for cats like Edward makes us think about it.

Vancouver Feline Hospital