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Enjoying Companionship, as Long as It Lasts

2018; Elsevier BV; Volume: 19; Issue: 12 Linguagem: Inglês

10.1016/j.carage.2018.12.003

2377-066X

Karl Steinberg,

Human-Animal Interaction Studies

I’m dedicating this column to my frail geriatric canine, Tessa. I’ve taken dogs on nursing home rounds with me now for almost 25 years, and it never gets old. The joy they bring to my residents is palpable and undeniable, and it brightens up my day, too. Yes, it slows me down some because there are lots of informal visits and the unplanned detours between patients when someone shouts, “Oh, a dog!” from their room. Luckily, I am usually not in a rush, and I figure I am collecting some sort of karmic currency for sharing the pooches with others who really appreciate them. Making rounds with the dogs doesn’t get old, but the pooches themselves do — just like our patients, really just like everyone and everything. It’s entropy. Our pets’ compressed life spans are much too short, and it’s not unusual for older people (or even not-so-old ones) to come to a point when they say, “I just cannot go through that again” and decide never to get another pet. That’s understandable, because it rips a chunk out of our hearts when a beloved pet dies. The fact that they are so dependent on us, and so trusting, makes it all the more difficult — and many of us have used modern veterinary technology to keep our pets alive a lot longer than we probably should. But they are so worth it, when all is said and done. So let’s talk about my 13-year-old blonde cockapoo, Tessa, who is beautiful inside and out. Tessa was the product of two 20-pound cockapoos, and we were expecting the same, but she just kept growing until she landed at 40 pounds! She started rounding with me back in 2005 at the age of 6 months or so, along with our then-5-year-old black standard poodle, Sophie. Tessa was, of course, an immediate hit as a puppy. She quickly grew into a beautiful, fluffy, very photogenic youngster with the longest eyelashes I’ve ever seen, the envy of many an old lady. She passed the therapy dog requirements, and Tessa was obedient and docile in the nursing home, doling out oodles of unconditional love, well, unconditionally. Because she hung out with a poodle, she often was assumed to be one herself, and in truth she is pretty poodley looking. It quickly became clear that young Tessa could be trusted not to get in trouble if she wandered around from room to room and through the hallways, accepting caresses and the occasional unauthorized people-food treat. (In her later years, she “forgot” the rule about waiting to jump in bed with people until she was invited. She assumed that she was welcome in anyone’s bed — making it more important for me to stay vigilant.) I would estimate that over her career Tessa has made well over 1,000 days of nursing home visits to at least 20 different homes in San Diego County, and she has brightened those days for countless homebound palliative care patients, assisted living community dwellers, nursing home residents, staff members, visitors, and others. Her tricks included the usual sit, down, roll over — and the slightly more esoteric bow, stretch, and whisper — to the delight of many. By anyone’s accounting, Tessa has accrued quite a legacy over those years. Should I show up to a facility without her, people ask where she is and are clearly disappointed. I won’t go on about Tessa’s many adorable quirks and idiosyncrasies because the majority of our readers, being pet lovers, already know the kinds of things I’d be recounting, and the minority who endorse the “it’s just a dog” philosophy wouldn’t care about them anyway. They probably stopped reading this column after the first paragraph. But I’ll fast forward to the part of her story that’s relevant to Caring and the work our readers do. In August 2017, Tessa suddenly collapsed in our bathroom, with all four legs splaying out. Before that she had periodically been a little sore and stiff, especially after overdoing her squeak-toy chasing or a five-mile hike just like any 12-year-old dog, but this was sudden and dramatic. We rushed her to our vet’s office, and she took one look at Tessa’s gums and said, “She is profoundly anemic.” A hematocrit was quickly run and found to be 18, compared with the 52 of about four months earlier. Dr. Herman advised us to rush Tessa to the specialty veterinary hospital for a transfusion and further workup, which we did. (Yes, they transfuse dogs with donor dog blood.) There she was diagnosed with autoimmune hemolytic anemia. Unbelievably, a few hours later just before the transfusion, her hematocrit at the hospital was down to 11, with platelets also low, around 30,000. Her white blood cells were literally destroying her red cells at a pace that would have been deadly within another few hours. They ran some tests, which included an ultrasound of the abdomen that was suggestive of a malignant process in Tessa’s liver and spleen as well as some sludge in the gallbladder. They recommended a needle biopsy of the liver, which I shut down immediately: “I’m not going to have my dog exsanguinate for a procedure that will give us information, but will not change our management.” They kept Tessa overnight, and the next morning her post-transfusion hematocrit was up to about 25. She was sent home on cyclosporine, prednisone, ondansetron, and omeprazole. Tessa did poorly for several days after the transfusion, eating and drinking very little. She was listless and seemed pretty miserable. The vet tech told us that Tessa had cried the whole night she was in the hospital — she’d never spent a night away from home before, other than traveling with us. We had already decided there would be no more transfusions. So we thought she was fading before our very eyes, probably hemolyzing again, and probably with a malignancy at the root of it. We were contemplating asking the vet to come out to the house and put her down. I’ve always felt it’s a disservice to take a beloved pet to the place they hate the most to spend their last few moments, and home visits for euthanasia have become much more widely available in recent years. We had a follow-up vet appointment, and they found that her hematocrit had climbed slightly. The specialty vet recommended putting the cyclosporine in the freezer to reduce nausea and suggested trying 15 mg of mirtazapine to help her appetite. Tessa’s weight had dropped down to 34 pounds, and she clearly was not going to survive if she didn’t eat. Well, perhaps coincidentally but definitely happily, after the very first dose of mirtazapine Tessa was ravenous! Like you’d expect a dog on prednisone to be. Over the ensuing days and weeks, Tessa regained her playful spirit, joie de vivre, and several pounds. In the meantime, though, she had developed dyspnea, tachypnea, and very harsh lung sounds. She was provisionally diagnosed with pulmonary emboli and started on enoxaparin injections twice daily, plus clopidogrel. Not long after that, she was also diagnosed with more significant and probably symptomatic cholelithiasis, with ongoing concerns about a slowly progressive malignancy in her liver and spleen. So ursodiol was added to the regimen, bringing her total med count up to eight — a level of veterinary polypharmacy that mortified me as a geriatrician but seemed to be doing the trick. Over time, we were able to get Tessa off the mirtazapine and enoxaparin, and we got her prednisone down to 2.5 mg daily. This column is not an obituary because unbelievably, Tessa is still with us more than a year after what appeared to be a terminal event. I’m not sure I’ll be up to writing one after she dies. Every day, I cannot believe how blessed I am to have our sweet girl still with us — perky and wanting to play every morning, always excited to go out on rounds. She can still hike a mile or so, and — importantly — she is continent, ambulatory, and can go up and downstairs usually unassisted. (As our readers know, these are important functional parameters for anyone!) She’s still on five different medications, but she seems to tolerate them well. There’s no question in my mind that we’ve done the right thing by giving Tessa fairly aggressive care, even though her days are clearly numbered from what is probably an incurable but thankfully indolent malignancy. From here on in, it’s all palliative care — no laboratory tests, no hospitals. In the last year, Tessa has become a little deaf (or maybe it’s just selective hearing?), a little blind (though she’s still pretty reliable at catching a piece of meat if you toss it to her gently), and maybe just a bit slow cognitively. She is too weak to jump up in a resident’s bed, so she’s allowed to wander in the nursing homes again. Unquestionably, Tessa’s quality of life is good by any reasonable person’s standards, and I am thrilled that she is getting this “bonus time” that has surpassed all of our wildest expectations. It does not escape me that the ability to pay for veterinary bills is another blessing I’m most fortunate to have. I cannot imagine how agonizing it would be to try to decide what to do when a true financial hardship is created by an ailing pet. And that’s just a veterinary bill. Imagine what it would be like to have to choose between accessing the health care system for ourselves or our (human) family members and paying our rent/mortgage, buying groceries, or other necessities. Most of us have cared for patients and have known friends who have either lost everything (including their homes) because of medical expenditures, or who have suffered severe and preventable (or at least treatable earlier) health crises because of fear of incurring insurmountable medical bills. There is something categorically wrong with a country as wealthy as ours not providing some automatic, “just minimum” (as my late great bioethicist colleague and mentor Dr. Larry Schneiderman called it) level of catastrophic health care coverage for all people. In today’s political climate, I fear such coverage is a long way off. In the meantime, we can help as individuals by providing care to the indigent, by supporting charitable organizations, and by promoting legislative and regulatory initiatives to expand coverage. We need to remain grateful for our own health and our health insurance, whatever our relative levels of functional independence are. Working in nursing homes is a constant reminder of how fortunate we are. For me, I’m especially thankful to be enjoying the extra, unexpected quality time with my sweet furry angel, Tessa, for as long as it lasts. Dr. Steinberg is chief medical officer for Mariner Health Central in California, and a longtime nursing home and hospice medical director. He is editor in chief of Caring and chairs the Public Policy Committee for the Society. The views he expresses are his own and not necessarily those of the Society or any other entity. He may be reached at [email protected] and he can be followed on Twitter @karlsteinberg.