The Darkest Day

Yesterday, after a very brief illness, we said goodbye to our sweet girl April. A week ago today, we had a nice normal day, went for a morning walk, and she was eating and behaving as she always has. As the next few days passed, her appetite began to wane until by Sunday, she had effectively stopped accepting food. Anyone who knew April would see this was completely out of character. I worked this last weekend, and as is usual, on those days I typically fed them their dinner. On Saturday night, she initially wouldn’t approach her food bowl. Only after I placed some of her food in my hand and held it out did she try eating it, probably mostly out of instinct. But, she wasn’t able to finish the bowl. We knew something was wrong. Aeyong later told me she had thrown up her breakfast. She became more lethargic and listless over the following days, and by Sunday we were already talking about taking her to the Vet. We decided to watch and nurse her overnight and then make a decision in the morning.

It was only a few days ago, but I can’t remember if she came into the kitchen when I woke up. Usually, April was the first to come out when the lights came on. I’m fairly sure she did on Sunday, but wouldn’t accept food and only drank some water. I can’t remember if she did on Monday, I think I may have had to find her. I went to my office and was looking at same day appointment options. There weren’t any I could find other than the emergency Vet. I was able to use the Vet Chat feature from Banfield, and after a brief exchange, their recommendation was getting her evaluated acutely, as labs and imaging would likely reveal the problem. This was my thinking beforehand, so we decided to take her to the Animal Emergency Hospital in Mansfield.

She was taken in and evaluated by Dr. Paules, and the first step was lab work. All of the steps were discussed up front in regards to cost and getting our approval before they were performed. It’s a necessary step, and honestly it was good to just get it settled and out of the way up front, knowing that we would hopefully get an answer. I had been looking at Yelp reviews of the facility, and most of them were positive. All the complaints I saw seemed to stem from the cost. As those online reviews go, the dissatisfied typically post reviews much more often than the satisfied. I can’t imagine there’s a price I would balk at to save one of my children’s lives. It’s hard to even have an opinion about the cost. It didn’t seem unreasonable and we almost certainly would have paid whatever was required to get an answer. We were told it would be about an hour, so we said we would drive home and wait for her answer, since we could come back within fifteen minutes.

We got a call about thirty minutes later, and the labs were mostly normal, only showing some anemia and slightly decreased renal function. Dr Paules related that her anemia would likely worsen with rehydration as they had to give her some IV fluids. We had been trying regularly to help her over to the water bowl and she would sometimes drink, but sometimes just stare as if she wasn’t sure what to do or just couldn’t stomach trying to swallow water. Aeyong was regularly giving her water by syringe and she had been trying extra hard to prepare some bland liquid food that April would accept and be able to keep down. It was a struggle for April, but she was able to swallow a bit of water and liquid food every few hours. Despite this, she was still not getting an adequate intake of fluids.

Dr Paules recommended imaging as the next step in evaluating her issue, and wanted to start with the abdomen. She predicted it would be about thirty minutes before she would call us with the results. It was around an hour later that she called and said April’s abdomen looked okay, but she had noticed something off about the fringe of her chest, which wasn’t completely imaged with the abdominal x-ray series. She ordered a chest series and it was there she discovered a tumor in April’s lung. Based on its size and shape, it was most likely cancer. She also had a noticeably enlarged heart with a pericardial effusion (liquid filling the sac that surrounds the heart), which was making her heart work much harder to beat and making it more difficult to get oxygen to her tissues.

As soon as I heard the word tumor, I knew that this was a terminal diagnosis for April. Dr Paules predicted that the definitive treatment would have to be a partial lobectomy, a highly invasive type of surgery. From what I know of this surgery in humans, they would have to crack her chest, separating her sternum and ribs to get access to her lungs. Even with this, the nature of lung cancer is that by the time it becomes symptomatic and is identified, it’s more than likely that the cancer has had time to metastasize given how highly vascularized the lungs are. Even if the lobectomy was “successful” and April survived, she would likely need chemotherapy and it would only be extending her lifespan temporarily, maybe only for a few months at best.

April was fourteen, so she was already in the predicted end of lifespan for cocker spaniels, which is typically 12-15 years. I didn’t clarify, but it’s possible Dr Paules noted that she had cardiomegaly/LVH that was present before she deteriorated, presumably in large part due to the lung cancer. From our observation, she hadn’t shown any significant changes in behavior up until her rapid decline. The more I think about it though, there was a walk last week, and I’m not sure if it was her last walk on Thursday or the day or two before that, that she was not quite as energetic as usual. April would always be in the lead and darting back and forth to follow her nose. This day she was hanging back more, and just looked slightly less interested. She wasn’t struggling to breathe that I noticed, she just didn’t seem as interested in the walk, which is something that we’ve seen in all of our pets occasionally, but it’s always been a temporary, fleeting behavior.

Maybe this change was the first real evidence that something was off, although Aeyong says she was noticing things even before then. Aeyong had mentioned that April looked like she was having a seizure earlier in the week, I’m not sure what day, maybe Sunday or Monday. This didn’t immediately concern me because all of our dogs have exhibited seizure like activity on one or two rare occasions for reasons unknown, but the seizures never persisted. With April, it had been several years since the last time as far as we could remember, probably at least five if not ten. I’m not even really sure I had witnessed a seizure in April, I can only remember Lucy having one and Bridget had a few right at the end.

Our decision to let April go was based on the realization that her time was fleeting. Sadly, her life as it had been for fourteen idyllic years, had already passed before our eyes. Once she declined, she wasn’t likely going to make it back to her old self, and the thought of putting her through such an invasive surgery followed by chemotherapy was untenable. We already know from experience how devastating chemotherapy can be, it’s the medical equivalent of an atomic bomb. If dogs could understand these choices and communicate their desires, I wouldn’t hesitate to accept their wishes. But, we can’t ask these questions and it’s hard to know if dogs truly understand death. Certainly, dogs understand when one of them is gone and I’m sure all of our dogs remember their sisters and miss them. I just don’t know that they have a real grasp of dying and how it’s a natural part of life.

All we can be relatively certain about April is that she knew she was suffering, and she probably didn’t understand why. She would stare into our eyes, and it seemed like there was just a question or plea for help in them. For our dogs, we have been everything to them (and they to us). They look to us for shelter, food, love, protection, companionship. April knew she was hurting and she probably didn’t understand why Mommy and Daddy just couldn’t make it better. It kills me to write that, but it’s probably all that her simple mind could form. That is why we had to make the decision to let her go. It’s the hardest decision we’ve ever had to make, by far. Nothing has compared to the pain of losing our daughters, nothing. I’m sure I’ve posted about it before. Losing my parents and grandmother was sad, and I missed them and regretted the time lost and mourned for what could have been. But, losing my dogs has been tearing a part of my soul out of me. It’s the same for Aeyong.

The decision mostly depends on when our dogs are suffering. When they reach a point in their lives where most of their time is spent hurting in some way, I try to understand what my frame of mind would be in their situation. Our dogs have always been happy, affectionate, playful, active, and just a source of energy and joy in our lives. Lucy, Bridget, and April all went through a change in personality, whether it was a slow change over months, or a rapid change over a few days like with April. When they are no longer their happy self, I can’t accept that they are in pain. It’s largely based on what I said before, we have no way to ask them what they want, but if the sum of their days are largely suffering, I want them to be without pain and so I know I must let them go. Keeping them around just prolongs their suffering and it’s likely only for our benefit and not theirs.

Aeyong has expressed regret and sorrow for how Lucy and Bridget passed on. Both of their lives had deteriorated and they were no longer themselves. With Lucy, she was declining for a few years, and it ultimately got to the point where it was obvious she was no longer herself. Lucy was always the sweetest, and most affectionate companion. Just like April was Momma’s shadow, Lucy was Daddy’s girl. Near the end, nothing seemed to make her happy. For most of her life, she would soak up attention. She would just stare into your eyes and snuggle with you as if she wanted nothing else in life. At the end, she didn’t respond to attention any more, and the only real activity she would show was when there was food, but even eating seemed like she was just going through the motions.

With Bridget, she declined over a matter of a few weeks. She had a mass on her abdomen that was starting to affect her breathing and energy levels. It then led to a change in her personality, where she would just stare and seem unresponsive. She then started to go into the backyard and just start digging at all hours of the night, and you couldn’t get her to stop or respond to you. She wouldn’t come when called and would struggle if you tried to stop her digging. At this point she ceased to be the Bridget we had known for fifteen years, just like her sister Lucy. Could more have been done? Maybe. My problem with pursuing more treatment is that I feel that their quality of life is never going to get back like we want. That’s a feeling and not objective fact. I can’t argue that it’s not possible something could have been done, but at the time I didn’t think we would have extended their quality of life for a reasonable amount of time considering what the treatment needed to be. I look at that decision as a mistake on my part. We could have possibly learned more about her and at least confirmed that her condition wasn’t treatable before going forward. I know Aeyong regrets this, but any of the blame lays on me and not her.

My wish will always be that my dogs don’t suffer. So, the decision with April was that because her condition was more than likely terminal, we could only prolong the inevitable. A small note about lung cancer - I’ve been the original provider for at least one case in the past that I remember, and it was during PA school. We had a middle aged male come into the ER for shortness of breath and chest pain, and plain chest x-rays revealed several lung masses. I had to break the news to him and his wife that although we couldn’t confirm it yet, it was likely lung cancer. As I recall, it was lung cancer and he died within a few months. There are some predictable features to lung cancer that can be seen on plain films, and I’m assuming that Dr Pauels is experienced enough that she was correct in her predicted diagnosis.

We discussed our options and we just wanted to know if it was possible we could have a little more time to say goodbye. Dr Pauels said it was hard to predict how she would respond, but a course of steroids and anti-emetics might help her to breathe a bit easier and regain enough appetite to get her to eat for a few days. She stressed it was only temporary and that she would succumb sooner rather than later. We accepted this plan and they gave her some more IV fluids as well as given her some subcutaneous rehydration that I assume was expected to resorb over a few days. She was given IV steroids and anti-emetics in the clinic and we took her home with oral prednisone and anti-emetic.

That was Monday morning, and we got her back home a bit before noon. We just spent the rest of that day/night and Tuesday right by her side. Other than showering and preparing meals, one of us was right by her side continuously until the end. I slept with her Monday and Tuesday night. We initially tried to get her to sleep between us in bed, but she started getting overheated fairly quickly, so I carried her down to the floor where it was cooler and let her crawl up on her favorite pillow. Periodically I would carry her over to the water bowl and she would sometimes drink, but would sometimes just stand and stare as if she was unsure what to do or didn’t have any energy. I carried her into the back yard and a few times she would pee, but she would often just stand and several times she would eventually turn around and try to come back inside.

As far as we could tell, she was still lucid. She would lift her head and look around if one of us wasn’t with her, or if there was a noise in the kitchen or our other girls were barking at something. On Tuesday morning she was laying on her favorite spot on the couch, and her head was facing outside. She suddenly raised her head and was looking at the back fence, and it was there I saw one of our neighborhood squirrels. She was still aware and her natural instinct as a sporting dog was still there. She just didn’t have the energy to run outside. We’re sure she knew we were there and that we loved her. We couldn’t fix her, but we never stopped loving her.

The medical interventions only seemed to be delaying the inevitable. Her breathing had become more labored on Monday and this remained an issue through Tuesday. At times it would be ever so slightly better, but she never stopped breathing rapidly and at times she was using all the muscles in her torso to draw breath, always seeming to be starving for oxygen. That’s why on Tuesday I made sure to discuss it with Aeyong that we really needed to accept her passing and let her leave this suffering. I called Tuesday to clarify that AEHM could perform the service and find out whether Dr Paules was available. She was working Wednesday but not Thursday, so we decided it would be Wednesday morning. We also decided to do it relatively early so that we could just have an hour or two after waking up but then could just let her go without prolonging it.

She laid on the couch in her favorite spot as a beautiful orange sunrise poked over the top of our back fence. It was a cloudy day, but there was sliver of clear sky to let the sunlight come through. I don’t know if she saw it, but she was facing the sunrise in her final hours. Aeyong had given her the nausea medication just to hopefully help her feel a bit better, and I was able to get her to drink some water from her bowl. I had to hold her up though, her legs were to weak to stand on the tile floor. I carried her outside and she was able to shakily remain standing and she eventually peed. She was so weak that she just sat down on the ground to go, she wasn’t able to hold her butt up off the ground. It’s hard to know what she was thinking, but she kept on fighting until the end, she just ran out of gas.

Aeyoung brought her favorite blanket and a shirt of Aeyong’s and mine so it would smell like home. Aeyong held her close as we drove to the clinic. April would normally get a bit of anxiety whenever we drove anywhere, because most of the time it was the Vet, and like most dogs, she was never a big fan. On this last drive, she didn’t appear to have the energy to get very upset, but she did hold her head up and look around at other cars and the people inside. Once we got to the clinic, they were able to bring her in within a few minutes. I had to pass her off to one of the Vet techs, but after filling out some paperwork and paying for the procedure, they brought us back to a room and a few minutes later April was brought back to us.

She had looked slightly distraught going inside, but she seemed to calm down once she was back with us in the room. They had placed an IV port with a syringe, presumably filled with saline. They made a point to tell us that there was no medication in the syringe yet, which I’m assuming may have been an issue with people in the past. I knew the Vet would have to make the injection based on our approval. They would have given us all the time we needed, but after spending several minutes with her we decided it was best just to let her go. No matter whether we were there or not, she wasn’t going to completely settle down given her condition and being in a strange place. Dr Paules came in shortly and let us know that she would get a sedative first, and that would be followed by what I presume was potassium chloride to stop her heart. The sedative put her to sleep and her breathing seemed to slow down slightly. The sedative was a clear liquid, but the medication was a pinkish color, and I seem to remember that was the case when we had to let Lucy and Bridget go, although my memory is a bit fuzzy.

A few seconds passed and then April’s chest stopped moving. Her spirit took flight and she was free of pain. We love her more than life itself and we’ll never let her leave our hearts. We love you our sweet baby April. You were the best girl we’ve ever had and we hope to see you again. Give a kiss to Lucy and Bridget and find a place to play. Chase those squirrels and rabbits until you’re tired and then rest. Get plenty to eat and sleep all you want. We’ll save up our kisses, hugs and scritches for you. Until we meet again.