Posted on January 6, 2013
Not All Patients Read the Textbook
Fannie (in foreground) and Easy
My dear friend Juli is a seasoned veterinary technician. So when her own 16-year-old Cattle Dog named Easy developed bleeding into his belly because of a cancerous growth, Juli had a clear sense about the prognosis. Surgical removal of the tumor would likely buy some good quality time, three to six months on average before the cancer recurred. Post-surgical chemotherapy might expand that time frame just a little bit.
After some serious soul searching and “conversation” with her beloved dog, Juli opted for surgery without chemotherapy. Easy experienced a smooth, uncomplicated recovery. Within just a couple of weeks of surgery he was back to his normal routine of gentle walks, relaxing with Fannie (his little sister), good food, and enjoyment of an excellent quality of life. Every few months thereafter, Juli asked me to ultrasound Easy’s abdomen in order to detect recurrence of his cancer. Over and over again we were pleasantly surprised to nothing out of the ordinary. At the very generous age of 19, Easy succumbed to issues completely unrelated to the malignancy that had been diagnosed three years prior.
How is it possible that Easy’s cancer never recurred when statistics tell us that surgery should not have been curative? The answer is simple- not every patient reads the textbook! For every possible disease, there will always be “outliers”- those patients who fare far better (or far worse) than research statistics predict. Such “surprises” are part and parcel with the treatment of disease, whether treating dogs, cats, humans, or any other species.
Is there a way to predict who these outliers will be? Don’t I wish! With such a crystal ball I could alleviate so much angst for my clients as they wrestle to make good decisions for the animals they love so dearly. For a small percentage of my clients, medical decision making is relatively easy. They may be “numbers people” who base their decision solely on statistical predictions. They deem the outlier population to be too too small to be statistically significant. And then there are those clients whose decisions are made easier because they have absolute faith that their best buddy will be that outlier. No question, but they will opt to carry on.
Most of my clients struggle a great deal when there is uncertainty about the outcome. They know the prognosis is bleak, but not hopeless. Maybe their pet will be the one who defies the odds. When counseling these clients, in addition to engaging in some serious nose-to-nose “discussion” with their four-legged family member, I recommend that they play out all options to both their best and worst possible outcomes. I advise them to then consider which option provides the outcomes that will likely provide them with the greatest long term peace of mind. Juli did exactly this with Easy. She knew that attempting surgery, no matter the outcome, would provide her with the greatest peace of mind.
No one ever said this role of medical advocate was going to be easy!
Have you been in the position of making a difficult medical decision for your pet? Have you ever cared for a patient who didn’t read the textbook?
Best wishes,
Nancy Kay, DVM
Diplomate, American College of Veterinary Internal Medicine
Author of Speaking for Spot: Be the Advocate Your Dog Needs to Live a Happy, Healthy, Longer Life
Author of Your Dog’s Best Health: A Dozen Reasonable Things to Expect From Your Vet
Recipient, Leo K. Bustad Companion Animal Veterinarian of the Year Award
Recipient, American Animal Hospital Association Animal Welfare and Humane Ethics Award
Recipient, Dog Writers Association of America Award for Best Blog
Recipient, Eukanuba Canine Health Award
Recipient, AKC Club Publication Excellence Award
Become a Fan of Speaking for Spot on Facebook
Please visit http://www.speakingforspot.com to read excerpts from Speaking for Spot and Your Dog’s Best Health. There you will also find “Advocacy Aids”- helpful health forms you can download and use for your own dog, and a collection of published articles on advocating for your pet’s health. Speaking for Spot and Your Dog’s Best Health are available at www.speakingforspot.com, Amazon.com, local bookstores, and your favorite online book seller.
I had to make this terrible decision for my dog Tiki last June. He had collapsed in our back yard and I took him to pet emergency where he wasn’t diagnosed with anything. On Saturday we took him for a little boat ride around the marina with our other 2 dogs. Sunday we were back in emergency and he had blood in his stomach and the tissue around his heart was swollen. They drained the fluid, but it filled right back up again.
The vet didn’t have much advice, except that they could remove that tissue around his heart and that would buy him an indeterminate amount of time, during which fluid would continue to drain into his body and he could possibly have a repeat of being in acute pain. My husband was terribly upset so the decision was mine. Tiki went into a corner and just looked at me. I decided to have him euthanized which was a very painful decision for me, but I didn’t want him to face a painful death. He was 11 and the first dog I ever had. I learned so much from him. I hope I made the right decision. I’d like to believe that I did, as part of my responsibility to him.
I totally agree since I have had to make that decision for 5 beloved dogs and one almost human cat. There isn’t enough glue in the world to repair my broken heart. I cried when my mom passed but I felt I cried harder for my pets. My vet’s assistant said it was because I made the decision. That was exactly right. My friends and family tell me that when they pass they want to come back as my pet. I’ll take that as a compliment.
Yes! My rescued PolaBear was diagnosed with thyroid cancer. Online research said that 95% are malignant, and these metasticize quickly…BUT the prognosis is good if caught and removed early. I had no money, but found a vet who would allow me to make payments since time was of the essence. Of course, there were no guarantees that the cancer had not already spread, but I had to give her the best fighting chance possible. Her biopsy came back showing the tumor to be benign!!!
When my last dog, a rescued husky/cattle dog named Artic, became ill I spent thousands on tests, hospital care, everything suggested. Arctic told me she had to go; after she died, my vet apologized that I spent so much and we couldn’t save her. I was very clear: I gave Arctic every chance I could, knowing she was leaving. But if I hadn’t, I’d have died of guilt thinking I might have saved her.
Unless a dog was very young, I would not put them through chemo or radiation; it is just too brutal to buy a small amount of time. But surgery: yes.
Just like “Easy” some dogs write their own book..
Hi Dr. Kay
Have to say we see it with so many IVDD dogs every day. Its a good thing they don’t read the text book. i
You hit the nail right on the head (again), Dr. Kay – we try and predict, but in so doing we may be overly optimistic or pessimistic. We can quote averages based on populations, but the individual may have their own agenda. Getting this across to the pet owners is often a challenge.
I have had many dogs do better than I predicted, and, sadly, many who did not do as well as I predicted or the owners hoped.
We have a discussion on a similar theme – the difficulty in coming to a firm diagnosis – over at ANIMALicious:http://www.vin.com/animalicious/project/defaultadv1.aspx?pId=756&id=5156341
Thanks for yet another insightful post!
Fantastic story! Love it.
I have a client dog who was diagnosed with advanced lung cancer and given about 6 weeks to live almost a year ago. Traditional med was not able to help her due to various complicated issues.
Her “Mom” did tons of research and opted for Herbs, Cold Laser Therapy, Reiki & Oils (that is where I fit in).
The cancer is not gone but she is still here and living a wonderful life.
I think Jasmine read all the textbooks, just to defy them. All her vets agree on one thing – Jasmine’s body doesn’t follow any rules. Her primary vet often sits there, saying, “I know what I would normally do. Now I have to figure out what I’m going to do given it’s Jasmine.”
Saw many patients over the years at the VMTH who never read the textbooks! Have experienced the same thing with human family members and their medical challenges. There are exceptions to every rule.
Take my own 7 year old labrador with hemagiosarcoma (spleen). No prior history of health problems. Dog was playing fetch with me when all of sudden he stopped and gave me a strange look. Something was very wrong. I run over to him while stood there and stared at me. His gums were white as a sheet. Rushed him to the VMTH which took an hour to reach. By the time we arrive, Dog can’t stand and respirations are labored. Ultrasound of the abdomen shows it is full of fluid (blood) and his spleen has an irregular shape. Emergency surgery within 30 minutes of arriving at VMTH. Spleen appears to have a ruptured hemagiosarcoma. Average length of survival is 6 months. Dang! Removed spleen, transfusion and awaken Dog. Pathology faculty confirm hemangio. So we decide to spoil him rotten for the remaining months of his life. Guess what? He lived 8 more years with no problems! Faculty re-read his path slides around year 3 because they couldn’t believe he was still alive. Confirmed hemangio again. There are exceptions to every rule.
My current geriatric cocker, MacKenzie, has a large lymphoma in her abdomen that isn’t causing any problems other than pushing her intestines around and distending her abdomen. She’s 15 and her brother passed away in September from melanoma that went to his heart. In his case I was prepared to go the last mile, but even the regional expert in the procedure he needed didn’t think she could help him. For MacKenzie, I’m following the vet’s advice to give her prednisone and just keep her comfortable. If I had unlimited funds I might have considered having it removed despite her heart condition and age, but this seemed like a good middle course. She’s snoring at my feet right now, a very contented doggie.
A previous geriatric cocker of mine had presumed breast cancer metastasis in her spine. I just refused to believe it and at the time I had money for an MRI. It showed what seemed to be a massive fast growing cancer. I had her euthanized and sprung for a partial necropsy, which showed it was inflammation (probably from a cyst which was also in her spine). It wasn’t cancer! I wish I could have done more for her, but she would have had a very difficult recovery even if she’d been diagnosed accurately. She was also diabetic and that complicated everything. She had been rescued, blind and starving, in a cornfield, and she had 19 months of TLC (emphasis on the L) with me. She had a last meal of A/D and passed peacefuly in my lap.
I’m a softie for a needy geriatric so I’ve said goodbye to many. I think it comes to a gut-check question: “Would I be prolonging life or prolonging death?”