Putting the Pieces Together

Yesterday, we had to put our dog, Red, down due to illness and severe hip dysplasia.  For the first time in almost 11 years, he isn’t here.  For the first time in almost 20 years, we don’t have a dog.  I know he was a dog, he wasn’t a human.  But I think there are a lot of parallels that I could post here that just might help someone as they notice their loved ones decline.

 

When I work with hospice patients and families, I’ll do what I call “Putting the Pieces Together”.  It’s a time of reflection, a summarization really, of when the patient started to decline, started to feel poorly, started to think maybe something was wrong.  One of my favorite tools to do this is called “Preparing for the Death of a Loved One” (Romayne Gallagher, MD CCFP).

Many hospice patients can pinpoint when they started feeling badly.  But more often, it’s generalized.  You know, they started feeling more tired.  Their appetite wasn’t what it used to be (which happens during normal aging, right?), they were losing weight without trying, they didn’t feel like going anywhere or having anyone over; slowly narrowing their circle of family and friends in order to preserve their energy for the ones they really want to spend time with.  Sometimes getting out to see the doctor is all they can  muster the energy to do.  Sometimes it’s too much to even take a shower or bath.

Any or all of these things can cause someone to begin having illness related anxiety. I remember about four or five months before my mom died, she could actually verbalize that she was afraid to take a shower, that she felt something bad was going to happen (despite my sister being there every time to help her and assure her).  It’s an old saying that cardiac patients will have a feeling of impending doom prior to a cardiac event, alot of them do.  Maybe there is something to just a generalized anxiety when we start to decline.

We noticed Red begin to have anxiety in the summer of 2016.  For nine years, the only anxiety he had was when there was thunder and lightning.  In 2016, it became more generalized.  He started actually chewing through the wood on our front gate, and escaped several times.  Only to then pace back and forth trying to get back in.  After a trip to the vet just to make sure he was ok physically, we started him on Xanax on an as needed basis (once or twice a month at that time).

He then started to eat less every day.  You could see he was gradually losing weight.  He didn’t run around the yard as much as he used to, and taking him on walks would really take it out of him.  He was moving more slowly, but didn’t seem to be in any discomfort so we chalked it up to him getting older.

Then, about a year later he developed a small lump in his chest.  It didn’t bother him for me to feel it.  Dogs sometimes get fatty tumors that are benign.  He started skipping his food for a day or two.  He’d had more weight loss (his collar and harness were loose), was even more tired, was sleeping a lot more and subdued overall.  After another vet appointment with noticeable muscle atrophy and the fact that he didn’t seem to be in pain, we decided to just watch him.  As a hospice nurse, I let the vet know that if he did have lymphoma or something like that, we weren’t going to treat it with aggressive measures.  We just wanted him comfortable.

From the fall of 2016 to January of 2017, he had developed multiple lumps and sometimes they did bother him.  His back end seemed tighter and stiffer. He was drinking water only every other day.  Since he seemed to be in pain, we headed to the vet.  We decided on blood tests and xrays (his blood tests from two years prior were “the best I’ve seen in a dog that old” per his vet).  Now, it looked like there was some type of inflammatory process in his liver and the xrays revealed severe hip dysplasia (we were expecting arthritis).   We’ve had a dog with severe hip dysplasia and Red didn’t exhibit any of the classic signs which told me this old dog had a very high pain tolerance to start with.  Sometimes I wonder if the diagnostic tests we run tell us more than what we really want to know.

The vet wanted to do a fine needle aspiration of his liver to either confirm or rule out a hyperplasia tumor syndrome, which I declined.  She seemed to have forgotten that our goal for him was comfort measures, not invasive or aggressive treatments.  Red didn’t like to be poked and prodded already, so making this decision was a piece of cake.

Coming out of the sedation from the xrays was the worst part for him.  He moaned and groaned and cried all the way home.  He had a hard time supporting his back end and couldn’t swallow until the next day.  I’ve had many patients tell me that they feel they started to feel poorly after “that first surgery, I think it was the anesthetic” and “It gets worse after every surgery.”

Being sent home without pain meds for him over the weekend made it really easy for us  to switch to a mobile vet whose website seemed like they would be on board for comfort measures only, providing palliative/hospice care to Red in our home.  No longer would he have to go out to the vet (although he missed the car ride), but the anxiety it was producing in him just wasn’t worth it.  And we weren’t going to do any more blood draws either, so an in home vet is just what we needed.

We started palliative care for Red on February 8th.  He was receiving 100 mg Benadryl daily (this vet seemed to think his lumps were mast cell tumors, a type of canine cancer), 100 mg Tramadol daily and 25 mg Carprofen daily for pain.  This seemed to work well for two to three weeks, but then the nausea started.  We added 0.5 mg Xanax daily for nausea and that helped.  Driving out to our vet in a dark rural area to pick up the Xanax, my daughter said “I feel like we’re out making a drug deal in the middle of the night.”  Well, that’s exactly what we were doing!  I so appreciated the ability to get meds on a late Friday night and it gives me a whole new appreciation for 24 hour pharmacies.

March 12th, in an hour’s time, Red did something to his right front leg and could barely walk on it much less support his body (along with his bad hips) for any length of time.  He seemed to be sleeping 20 out of 24 hours a day now.  By simple mathematics, when you’re sleeping 20 hours a day, it doesn’t leave much time for eating or drinking…even for humans.  Then all of a sudden, his belly started to look distended.  When he pooped in the morning, we’d be watching to see what color it was (usually an orange or clay) which likely indicated liver involvement.

Fortunately, our daughter had been able to come home to say her goodbyes (I know she was concerned that I might be “rushing things” since I’m a hospice nurse.  Even though she knew better, I assured her I was not that kind of hospice nurse).  Our son made a couple trips home to say goodbye to his buddy, and my husband was just home for a few days prior to yesterday.

Red had a good last day.  He died in the comfort of his own home, sprawled out in the middle of the family room floor.  Peacefully, quietly, and in his home where he loved to be. He was such a good dog, I can’t imagine him leaving us any other way.

 

 

 

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