hard decisions

one of my closest friends from vet school is currently faced with a very big dilemma. it's a quandary that will face us for the rest of our lives - because we are veterinarians. to euthanize or to push on with treatment in the face of grave illness?

about 6 months ago, she went to NYC to do her externship at the animal medical center in downtown manhattan. shortly after she left, her catsitter found sam - her 8 year old cat - dragging his rear legs and vomiting. he was admitted to our school and found to be in acute renal failure. after several diagnostics, it became apparent that he had a ureterolith (stone in his ureter). this obstructed flow from that kidney to the bladder - in essence forcing the kidney to balloon up with urine backflow and become dysfunctional. cats can usually handle this. it's not uncommon to xray a cat for some other reason and see what we call "big kidney/little kidney syndrome" - in which one kidney has shut down for whatever reason. this problem is typically asymptomatic for a long time, because the other kidney can compensate (god gave us 2 for a reason). should the other kidney ever begin to fail - then the cat is in trouble. in sam's case, one kidney was obstructed. his other kidney should have compensated. but it was failing too - for what reason we weren't (and currently aren't sure). further, the ureter that had the stone was torturous and enlarged, evidence that there had been previous injury (likely other stones). sam's prognosis was poor. he was placed in ICU, where he remained for 2 long weeks. he was very ill - uremic even.

uremic is a description of what happens when the kidneys can no longer function as they should and filter blood. toxins like BUN and ammonia build up in the blood, circulating to other organs of the body. clinical signs are wide and nasty - as one would expect as a result of circulating toxins. vomiting due to the action of uremic toxins on the brain, gastric ulceration due to the lack of the kidneys filtering out gastrin (a substance produced by the body for the stomach/food degradation), ulceration of the tongue and lips due to the toxins, and a whole host of other terrible side effects. kidney failure is an awful way to die.

sam hung on and actually pulled through his acute renal failure (ARF). his bill was $2000, but he seemed to be recovering well - despite picking up a nosocomial herpes infection from another cat while in ICU (like people picking up staph infections in the hospital after surgery). he'd done well up until the past few days.

the problem with cat kidneys is that once they fail - they will fail again inevitably. many cats that have acute renal failure can recover from this with aggressive renal support- massive doses of IV fluids, pain medications, appetite stimulants, and the like. unfortunately, even if they pull through the ARF, they will likely suffer chronic renal failure. cats in particular are prone to kidney problems. no one knows why - although there are theories floating around out there. some maintain that cats should be fed moist diets (canned) because they do not voluntarily drink enough water to keep the kidneys well-perfused. but the theories abound and no one really knows for sure.

at any rate, sam became a chronic renal failure kitty. as dire as this sounds, cat can often do quite well with CRF for some time. i've seen cats last 2-3 years with CRF. sometimes they go into acute renal failure again - where the kidney values shoot through the roof and the uremic syndrome returns. this is called acute-on-chronic renal failure. and sadly - that has happened to sam.

and now my friend is faced with a heart-wrenching decision. she just graduated from vet school with a significant loan burden. her credit is in not so hot shape. her credit cards are maxed out, and she's about to move to NYC for an internship (which pays a paltry $23,000/year). she already paid $2000 for sam's first ICU visit. that bought him a mere 6 months. so she turns to me and asks - should she press on? should she stop and euthanize sam?

i firmly believe there is no right or wrong answer here. and that is what makes being a vet so hard. how do you tell owners - when they look to you as the doctor and ask - that this is so? that letting go is okay but that not letting go and fighting is okay too? and what about when you're wrong? what about when you keep treating, and the animal does worse and worse? or what about the times you'll never know about - when you could have fought through it and brought the animal back to health? that's the thing about medicine. we're doctors - not fortune-tellers. we have to base our answer to this question on experience with certain diseases, with probabilities, with papers and research - but in the end - we're feeling our way too. added to the burden of making the right decision for both the owners and the animal is the burden of financial concerns. it makes many people feel terrible to consider finances when discussing the life of a beloved pet. many will throw away thousands treating a condition that will - in the end - claim the life of the pet. others will not. either way - it makes everyone in the situation (including the vets) feel terrible to base the decision of life or death on financial concerns. at the moment, there is no way around this fact.

sam will always be a renal failure kitty. his kidneys were badly damaged in the first bout of acute renal failure, and they will have been by this second go round as well. does that mean that he can't be treated and managed through this acute episode and have a few more good years? no, it doesn't. there's just no way to know.

sam is being euthanized in the morning.