Blue, Diane Harris’s adopted stray cat, is on the list for a kidney transplant at the North Carolina State University Veterinary Teaching Hospital in Raleigh. The 11-year-old has undergone numerous stays in an intensive care unit after his kidneys began to fail; he’s endured intravenous fluids, subcutaneous fluids, blood transfusions, blood draws, echocardiograms, injections of Epogen® (a recombinant version of a human protein used in the treatment of chronic renal failure), a feeding tube to help him regain enough weight to undergo the transplant and an orange Lycra® vest to hold his feeding tube in place. After having dropped to five pounds, Blue is up to 12 and stable. Should his kidney values begin to rise, Blue will start anti-rejection medications and two weeks later undergo transplant surgery.
“I chose a transplant because I was determined that we have more quality time together,” says Harris, who thoroughly researched options for her cat.
Like Harris, many pet lovers are taking advantage of cutting-edge veterinary medical techniques to give their companion animals a chance for longer, better-quality lives. These include kidney transplants, hip replacements, chemotherapy, radiation therapy, laser surgery, dialysis, ventilators, pacemaker implants, intensive care units and gene therapy to create “smart bomb” treatments that target cancers. What were once weapons in the arsenal of human medicine are now available to our pets.
Price Is No Object
Going to what many might call extraordinary lengths to provide medical care to our companion animals reflects the place that pets now hold in our lives. “More than 84 percent of modern pet caretakers consider their pets to be children,” says Amy Shojai, author of Pet Care in the New Century: Cutting-edge Medicine for Dogs and Cats (New American Library, 2001). “The pet generation wants the same level of care for their cats and dogs as [for] their human family members.”
Mike and Dorothy Miller spent $15,000 on their eight-year-old golden retriever, Brittany, to combat a cancerous chest tumor. The fee included X rays, blood transfusions, trips to the University of Pennsylvania Veterinary Hospital, surgery, more than one stay in the intensive care unit and chemo and radiation therapy to buy her from one to two additional years of life. “I have a son,” says Mike Miller, “and Brittany’s like my daughter.”
Leigh and Tara Stivers spent $8,300 to obtain a new kidney for their cat, Hobbes, at the Veterinary Medical Teaching Hospital of the University of California/Davis. “Our pets are real members of our family,” says Leigh Stivers. “What parents wouldn’t do everything possible to save their own children?”
Barbara Nienaltowski has never counted the time, money or effort she’s invested in Dina, the abused kitten she rescued in Mexico in 1994, whose fractured spine has resulted in lifelong urinary incontinence. Expressing Dina’s bladder several times a day has been “no big deal” for Nienaltowski, but this past year the cat was hospitalized twice with acute kidney infections. In May 2002, Dina’s doctor estimated her life expectancy to be just a few months. “Her will to live is so very strong – it’s her defining characteristic,” says Nienaltowski. “How could I not give her every chance?” Now Dina’s daily care includes fluid therapy, antibiotics, anti-nausea medication, vitamins, potassium gel and a stool softener – plus having her bladder emptied. “You know that saying?” she asks. “That when you save a life, you’re responsible for that life forever? Well, I believe that.”
Marian O’Connor, a former director of the Bergh Memorial Animal Hospital in New York City, spent $3,000 to treat her cat, Henry Bergh, for hyperthyroidism and cardiomyopathy. “I would have spent $10,000 if I could have made him well,” says O’Connor. “I’d do anything for my cats.” Apparently O’Connor speaks for many. In its 2002 Pet Owner Survey, the American Animal Hospital Association asked pet owners how much money they would spend to save their pet in a life-threatening situation. “Any amount,” said nearly half.
This response, however, may be naive, especially if the caretaker has never experienced a protracted, terminal illness in a pet. Today’s unprecedented medical advances may provide an opportunity to extend a pet’s life span and quality of life when serious illness strikes, but they also present a dilemma for many pet parents as they struggle to decide where to draw the line.
The reasons for this are complex and frequently have little to do with the cost of care. “Many caretakers don’t want the feeling that life and death are in their hands,” says Stephanie LaFarge, Ph.D, a psychologist at the ASPCA. Deciding how far to take treatments for what is an uncertain future for the animal is not easy.
Some caretakers, however, have no ambivalence at all.
“People who take heroic measures to save their pets may share some personality traits, but no profile describes them all,” says Lila Miller, DVM, the “A’s” veterinary advisor. “I’ve seen men completely fall apart,” she says, “or elderly persons who associate their own mortality with their pet. It’s a very subjective thing.”
Other characteristics may include a high degree of attachment or extreme commitment to the animal, or relying on the animal for primary emotional support. “A pet owner may have a symbolic connection to an animal,” says Carolyn Butler, MS, coordinator of Bond-Centered Education for the Argus Institute at the Colorado State College of Veterinary Medicine and Biomedical Science in Fort Collins. “Maybe the pet belonged to a spouse who died, or the pet represents a difficult time in the family’s life.”
Many pet parents, however, do not have a ready answer to the question, “How much is too much?” Increasingly, psychologists, counselors and veterinarians are called upon to help pet parents make these difficult decisions. They advise anyone who is facing extended treatment for a sick animal to begin by gathering as much information as possible about the potential outcome. “You have to push the veterinarian for how long the pet may live and what her estimated quality of life will be after treatment,” says LaFarge.
The veterinarian will perform tests to evaluate an animal’s response to a particular treatment and ultimately what the prospects may be. “We do a lot of investigations to know what the prognosis is so we can educate the client,” says Philip Bergman, DVM, Ph.D. and head of the Donaldson-Atwood Cancer Clinic at the Bobst Hospital of the Animal Medical Center in New York City. “For example, a 12-year-old dog with a tumor may be easier to cure than a five-year-old dog with poor kidneys.”
At the University of Pennsylvania Veterinary Hospital in Philadelphia, Lilian Aaronson, VMD, head of the kidney transplant program, explains that before recommending specific treatments, the referring veterinarian undertakes numerous pre-surgical workups and evaluations. “By the time clients get to us,” she states, “they have learned about [kidney transplant] and are very serious. We’re very strict about who is a candidate and who is not. Underlying disease can cause problems later.”
Of course, even with the most reliable diagnostic procedures, there are no guarantees. The Stivers lost Hobbes five weeks after surgery when his body rejected the new kidney. “The transplant was a gamble that gave Hobbes his only fighting chance,” says Stivers. Harris, meanwhile, is putting no limits on her expectations for Blue after surgery. “One year or five years or a few months – every day is a blessing for which I am eternally grateful,” she says.
No Easy Answers
Veterinarians differ on how far to go when treating sick or injured animals. Although a veterinarian may feel that euthanasia is the kindest thing a client can do for a pet, he or she is obligated to follow the owner’s wishes. Under the law, pets are considered personal property. “That causes two problems for veterinarians,” says Bernard E. Rollin, Ph.D., a distinguished professor of philosophy, biomedical and animal studies at Colorado State University and the author of Veterinary Medical Ethics: Theory and Cases (Iowa State University Press, 1999). “One [problem] is when people want healthy animals killed. The other is when the veterinarian believes that the animal is suffering, yet the client wishes to pursue treatment.”
Professionals disagree on the best course of action. To resolve differences of opinion among staff at the University of Pennsylvania Veterinary Hospital, an ethics committee headed by James Serpell, Ph.D., professor of Humane Ethics and Animal Welfare and the director of the Center for the Interaction of Animals and Society, deals with issues in patient care on a case-by-case basis, because “people come with specific problems.”
Preventing suffering is of primary concern to pet caretakers and veterinarians alike. Yet how is suffering measured? “Experiencing pain is only one way that an animal suffers,” says LaFarge. Becoming unable to groom or to reach favorite perches, disorientation, dementia, confusion, struggling to breathe and incontinence are others. “An animal may not look like he’s bothered, but I believe these failures can be a source of significant distress for him.”
Conversely, pet lovers may project how they would feel if they had to experience what the pet is experiencing. “Some people think a dog will be horribly unable to enjoy life if he loses a limb to osteosarcoma,” says Rollin, “but that’s not the case.” Chemotherapy is a treatment that often strikes fear into the heart of a person. “We may have vivid memories of a relative dying of cancer who went through radiation and chemo,” says Bergman, “but pets handle chemo better than humans do.”
How much time a procedure buys for an animal is secondary to other considerations. “I don’t think there’s any procedure about which you can automatically say that the person has gone too far,” says LaFarge. “Maybe a kidney transplant to save a cat for a month is a good decision. The quality, not quantity of life after surgery is more important.”
Most veterinary teaching hospitals have staff who help clients work through these tough decisions. “We encourage clients to think about what the animal wants,” says Butler. “That differs for everyone.” LaFarge urges caretakers to define what a quality life is for their pet long before the pet becomes ill and life-or-death decisions must be made.
Sometimes caretakers just need a little time to come to grips with their animal’s condition, especially if the onset is sudden. “Often it takes just 24 hours to get used to the decision to euthanize,” says Lesley King, MVB, head of the intensive care unit at the University of Pennsylvania Veterinary Hospital. “Our job is to help them make the decision and make the animal as comfortable as possible.”
In the past, euthanasia was the only way to alleviate suffering. “Now we have stronger and better pain relief,” says Miller. Today pet hospice care allows the caregiver to treat the animal at home under the guidance of a veterinarian who prescribes medication and instructs the owner in its use. This allows the pet to die at home, pain free. It’s ideal for pets with terminal illnesses, such as cancer. “The veterinary community is picking up on home hospice care,” says Serpell. “An animal is probably happier at home.”
It’s a fact of life, however, that many pet owners cannot afford the new technologies. Because many of them are labor- and equipment-intensive, they are costly. “We develop all these expensive new technologies,” notes Miller, “but there’s no mechanism in place to make them affordable.”
Harris, who has several cats who require expensive medical treatments, has taken out a home equity loan to pay for Blue’s transplant if and when it occurs. “I won’t hesitate to do what is needed for any of my kids,” she says.
When the pet lover cannot afford additional treatment, veterinarians and counselors try to help him or her uncouple love for the pet with the ability to pay. “It’s not about love or care,” says Butler. “It’s about the realities of life.”
Pet insurance in the United States currently provides only minimal help. Most insurance policies either don’t cover the more advanced techniques or require a special rider to the basic policy.
The Veterinarian’s Role
Despite the ethical dilemma a veterinarian sometimes finds herself facing, the practitioner nevertheless plays a major role in determining the direction in which the caregiver goes. “Veterinarians have to be skilled at helping their clients arrive at a decision that is right for them,” says Butler. “Everybody is at a different place.”
How far to go may depend as much on the bond the person has with the pet as it does with the pet’s medical condition or the costs involved. “Veterinarians need to be trained in the human/animal bond and approach the subject with sensitivity,” says Alice Villalobos, DVM, consultant and veterinarian with the Veterinary Centers of America Coast Animal Hospital and Cancer Center in Hermosa Beach, California. “Our duty is to treat the bond like we treat the animal – each pet and person needs to be evaluated individually.”
Preparing veterinary teams to meet the emotional needs of families is the role of the Argus Institute, which seeks the widespread implementation of veterinary practice models that make the emotional support of people as much a priority as the medical care of pets. “We have to help veterinarians understand that all sorts of issues are at play in people’s lives when they decide to terminate treatment,” says Butler.
The veterinary teaching college at Colorado State requires 100 hours of study in client/staff relations to better equip veterinarians to understand the emotional needs of the client, and Butler has given presentations on the topic at conferences. “You have to raise awareness and be able to regulate your own emotions so you preserve the self-esteem of the client,” says Butler. “That’s not being sappy. It’s just knowing how to communicate with people in emotionally trying situations.”
Very rarely does a veterinarian want to stop treatment when the client wants to continue. “A veterinarian can always tell a client that he doesn’t wish to go on treating an animal,” says Serpell. “He can provide names of other veterinarians, but very few vets do that for fear that the client will switch to another veterinarian or the owner will treat the animal at home.”
Villalobos, one vet who has treated animals when other veterinarians have recommended euthanasia, operated on a 26-year-old cat with cancer on his ear and forehead who had seen five other veterinarians. “We performed radical surgery on the ear and grafted skin from the neck to the forehead.” The cat lived another year and a half before succumbing to kidney failure.
When an animal is diagnosed with advanced disease, there are many opportunities to treat symptoms rather than immediately jumping to the ultimate fix – euthanasia. “We need to solve each problem,” says Villalobos. “The veterinarian should let the client know her options and guide her. If the pet has mouth cancer and won’t eat, we can give the animal an appetite stimulant or put in a feeding tube. If pain is an issue, we need to put a pain patch on that animal. There is a lot of space between diagnosis of advanced illness and death.” In Queens, New York, small-animal practitioner Louis Alvarez, DVM, puts it this way: “First, you have to be an advocate for the animal’s quality of life. But then you offer everything you can think of. You can’t put a price on another man’s pleasure.”
The Heart of the Matter
Making use of all available veterinary procedures to save an animal companion bears testimony to how slowly hope fades from the human heart. Audrey Pavia borrowed $15,000 to treat a plethora of conditions that her appaloosa, Rosie, developed in their three years together. All of the illnesses except Rosie’s eye disease were cured or managed. It was only after Rosie lost both eyes to corneal ulcers that Pavia drew the line – not on the basis of cost, but on the basis of the mare’s future quality of life as a prey species without vision. In spite of the fact that Rosie ultimately lost her battle, Pavia has no regrets. “I would do it all again,” she says. “I needed to know that I had done everything possible to make Rosie well.”
Not all pet lovers consider heroic attempts to save a pet’s life the way to go. Pat Crumb opted to euthanize her nine-year-old retired greyhound, Dobbit, after initial treatment for osteosarcoma in his shoulder failed to give appreciable results. “By giving him a prescribed pain killer, I was able to take him for walks, but the walks got shorter and shorter.” Then one night, Dobbit woke up at 2:30 a.m., crying. Crumb lay on the floor with her dog the remainder of the night, but called the veterinarian the next morning to arrange for euthanasia. “I would rather sacrifice a few months with him and let him go gracefully,” says Crumb, ‘than put him through the amputation operation and possibly lose him anyway.’
Ann and Greg Kulp, whose shar pei, Bubba, was diagnosed with kidney failure, opted for euthanasia even though the dog did not yet show outward signs that he was succumbing to the disease. Diet had helped slow the course of disease for a year, but Kulp didn’t pursue fluid therapy to buy Bubba more time. “It seemed that administering fluids would have been more for us than for him,” says Kulp, whose previous two shar peis also died from renal disease. “If he had cancer or something operable, we would have looked into our options.”
Although spayed, Boots, one of Judy and Steve Ostraha’s three cats, developed mammary cancer. After a second surgery to remove the tumors, the cancer returned. Their veterinarian suggested chemotherapy, but they decided on euthanasia. “The chemo might have helped for a while, but it wasn’t going to cure her,” says Judy Ostraha. “My only regret is that I put her through the second surgery.”
Harris has adopted an accepting attitude about Blue’s condition as well. “If at any time it doesn’t look favorable for Blue to have a successful transplant, I’ll abandon the idea,” she says. “I won’t put him through this if the odds aren’t in his favor.” Nienaltow-ski, too, keeps a sharp eye on Dina’s quality of life; she believes she knows her spunky friend well enough to know when to stop fighting.
Regardless of the decision, a pet parent knows the pet better than anyone, and it’s the pet’s health and the owner’s peace of mind that are at stake. “People should never be made to feel guilty about the choices they make for their pets,” says Shojai. “There are no right or wrong choices.”
Stivers concurs. “For me, no material item could come close to the pleasure and happiness of having such a special companion,” she says. “Total cost to treat Hobbes: $8,329.00. Chance to have Hobbes feel healthy again: Priceless.”
Karen Commings, a writer based in Harrisburg, Pennsylvania, specializes in pets. She is the author of The Dog Lover’s and The Cat Lover’s Survival Guides (Barron’s, 2001).
© 2003 ASPCA
ASPCA Animal Watch – Spring 2003