When is it the end?

We comfort each other.
We comfort each other in those last days.

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.