ancient sleep
Kiko, old and ill, but comfortable.

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.

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