a veterinarian’s perspective on end-of-life decisions

Posted by Dr. Alan Stewart on Jul 30 2013

She looked up at me with the most soulful beseeching eyes.

As if to say why?

And, no more.

And as always,

I love you.

She was my “godchild,” a rescue Chihuahua/terrier cross from our local SPCA, who was adopted by my best friend. Did I say she was only 4.5 pounds? But with a heart larger than an elephant?

It was love at first sight for everyone. Anyone who saw Dolce loved her and she simply loved everyone. The words “mean” and “nasty” were not in her vocabulary.

As a nearby specialty hospital, we had a relationship with our local SPCA to do pro bono work on some of their animals prior to adoption. Eight years ago Dolce had a cough. Such a deep cough that you wondered how such a husky sound could emanate out of this little being. As an internist, it was clear to me from her cough and her unremarkable radiographs that she needed bronchoscopy, a simple procedure. When under anesthesia, I am able to go into her airways with a (very) small endoscope and see everything. And seeing inside the airways is indeed worth a thousand words.

She even looked sweet inside! But her trachea had a grade IV collapse and where her trachea split into the left and right side there was complete collapse. The remainder of her airways that could be seen were also collapsing.

I called up my friend immediately.

"You have to adopt this dog. We can make her better,” I said.

My best friend adopted her and we started Dolce on a series of anti-cough and anti-inflammatory medications and a weight loss regime. Even to my surprise she did phenomenally well. After months we got her off all meds, kept her at an optimal body condition score (4.5 out of 9, thanks to a special prescription diet) and she rarely coughed. Dolce lived a charmed life and charmed everyone with whom she came in contact.

Six months ago she developed diabetes mellitus. As an internist, stabilizing a diabetic is fairly second nature, but I had never done one so small. To add to the matter, my best friend and I discovered the one thing Dolce did not like was SQ injections or having her blood glucose checked; this was not going to be easy. We tried multiple insulin types and concentrations. We even tried oral hypoglycemic agents, which are reported not to be effective in dogs (And weren’t).

After a few weeks we finally got her balanced and Mom developed a system of bribery that distracted Dolce enough so that she could get her life-saving insulin. It worked and she was fabulously stable. 90% of dogs with diabetes develop cataracts, but her lenses remained pristine. There was rarely a crinkle in her routine.

But then yesterday she was under the weather. Mom did all the usual things.

Check for ketones. Negative

Check her urine for glucose. Mild

Have a blood glucose done at the hospital. 259. Perfectly acceptable

No bribe would get her to eat. And this girl could eat. Aside from extolling love, Dolce’s other raison d'être was to eat. Over the phone, I said, “This is concerning. If she gets worse, bring her in.” When she began breathing hard at 5 a.m., Mom brought her into the emergency service at the hospital.

The emergency doctor began to treat Dolce for heart failure. She was placed in an oxygen cage and diuretics were administered, but she got worse. When I saw her after 8 a.m. rounds we could tell something very serious was going on. So could “The Dolce.”

This is when working in a multi-specialty hospital is a godsend; we repeated the diuretic and our cardiologist did an emergency echocardiogram. She was not in heart failure, but had mild pulmonary hypertension. This is a condition that could be a result of her chronic airway disease, but not quite enough to account for her severe state of respiratory distress. We began to immediately treat her with sidenafil (Viagra), a drug that has been very helpful for this condition (and its original use before Pfizer discovered the side effect that has made this the top selling drug for years). I was also concerned that her radiographs could indicate mild pneumonia so we added strong antibiotics.

During the next t two hours she seemed to be improving. But then for no obvious reason she suddenly began deteriorating. Rapidly. Her lungs sounded more moist, her color became more blue. We added other drugs to try to help. But nothing could help. I wondered if she could haven ARDS, acute respiratory distress syndrome, but she had gotten so bad so quickly that there was little testing we could safely do. And she was still only 4.5 pounds.

That is just about when she flopped over and looked at me with the imploring look.

Help, why, end this.

Within seconds the choice was clear. That, despite all the modalities and expertise at my disposal, euthanasia was the right thing.

Within moments we were cuddling her in our arms, giving her a comforting sedative. By then my eyes were too cloudy with tears so a very kind associate took over and administered the euthanasia solution, while we, her mom and I, both cuddled Dolce till she was no more.

Even at peace she looked like the cutest, sweetest being.

As an internist, I help clients make the decision to euthanize their beloved pets, almost daily. Dolce was my “godchild,” but even though my vision was hazy (literally), it was clear what was right for her. Not only did she make it evident (and I knew her Mother’s wishes), but I ran through the list of possibilities, long term repercussions and quality of life issues of continuing treatment for a dog that is 4.5 pounds and in her condition. The choice was obvious, just painful – like it always is. But more than anything, we never wanted Dolce to suffer or ever be uncomfortable. And we made sure she never was.