On loss, grief, and letting go.

In human medicine, we can generally talk with our patients and ask them: what’s wrong, where does it hurt, what do you need, what can I do for you? It’s infinitely harder when there’s a communication barrier – when they can’t tell you where it hurts, when you can’t tell them why you’re doing all of these things. Cats, and animals in general, won’t understand why you prick their ears four, five, six times a day; why you insist on syringing them when they’ve made it clear they don’t want water because their abdomen hurts so much; why you’re taking them away from their comfortable home when all they want to do is lie in the bathtub next to you because that’s where you are; why you make the terrible, compassionate decision to end their life because even though you want nothing more than to keep them with you they might not get better and you can’t imagine making that call after they’ve been hospitalized in pain and a place anything or anyone familiar for two days, or else condemning them to a life that progressively worsens and results in much more cumulative pain.

In school we’re studying geriatric care, which has included talks on the importance of discussing end-of-life care and desires with patients while they’re capable, and then reassessing frequently to make sure their desires are known and up-to-date. I also recently read « Being Mortal » by Atul Gawande, in which he discusses the importance of these very things, so end of life care and the concept of « dying well » has been on my mind lately. Aria’s passing was as sudden as it was unexpected – what was a chronic condition that I felt I could manage with some careful organisation of my schedule and a bit of support became very complicated very quickly. Pancreatitis is commonly seen in diabetic cats and can be treated (although it is chronic and does tend to recur frequently), but her failing kidneys were a complete mystery, difficult to explain and heavily predictive of future decompensation.

I’m heartbroken. I feel like I’ve been amputated. During our short time together, Aria saw me through some tough transitions and has been an immeasurable source of comfort and companionship to me. I’ve never met a cat who loved having her entire face pet as much as she did, or who chewed on fingers as an expression of affection (subsequently scaring off many who would have given her pets). She was an integral part of my little family, and I hope she felt as loved as she was. In spite of her health problems, she certainly seemed happy, even as recently as three days ago.

In many ways, I also feel that I lost my first patient. I was her care coordinator, her nurse, her ally; I was the one who pricked her marginal vein to test her blood glucose and injected her with insulin twice, thrice daily and brought her in for veterinary care when things went wrong. The veterinarian team asked me for my input once in a while, and took my care suggestions seriously – we truly worked as a unit. I was the one who was constantly re-evaluating her diet, who agonized about how to pay for the dental surgery she’d need sometime in the future, who wanted her happiness and well-being above all, who got frustrated with her when she’d bite me after I’d pricked her one time too many and tried again anyways, who syringed water and a slurry into her mouth when she got sick and wouldn’t eat or drink. I was also her family, as much as she was mine, and that always complicates matters when you’re ultimately faced with the task of deciding if we should try to prolong life or end it today. That subjectivity and emotionality can be as biasing as it is necessary in making compassionate decisions. We have the capacity to think beyond our own feelings and look at the bigger picture, and to use that to decide if the quality-of-life tradeoffs are worth it for a loved one, particularly if they made their desires known. If they haven’t, then substitute decision makers are tasked to make that decision for the individual as though they were them – we trust that they know their loved one well enough and will do as they would have wanted.

I couldn’t ask my cat what trade-offs she was willing to accept; what made her life worth living. The vet told two things: firstly, that when cats and dogs are in pain, they don’t know that they might get better, and secondly, that they have no concept of no longer being alive – sadness about death comes from us. What I do know is this: Aria probably would not have gotten better, at least not for any meaningful length of time (we can’t put cats on dialysis, unfortunately), she no longer wanted to drink or eat (and eating was her one true love, I’m convinced), and she wasn’t responding very much to pets or affection. She got lots of the latter in any case, and closed her eyes contentedly when I rubbed her face yesterday morning, at the end.

Capture d_écran 2018-04-10 à 15.37.26

Our house and my heart feels emptier. She was loved for her many idiosyncrasies and her social personality and her wonderful way of being, and we all feel her absence acutely. We all did what we could to give her a good life, and in the end a good death. That’s what we all deserve, I think – acts of love, of kindness, of compassion. Good night, sweet kitty – my life has been better for knowing and caring for you. I love you very much.

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