How far do we go?
That question came up this week in caring for Zelda, a kitty in the prime of life at age 7½, who presented with the primary complaint of loss of appetite.
Our first indication that something was terribly wrong came when we weighed Zelda and compared her weight to her last visit just six months before. She had dropped over three pounds. Zelda had not eaten a bite in three days, terribly abnormal for a kitty who usually had a voracious appetite.
Our physical examination findings were unremarkable. No lumps, no bumps, no fever, no heart murmur, just a skinny kitty.
We took blood samples for a complete blood count (CBC), chemistry profile, Feline Leukemia Virus test, Feline Immunodeficiency Virus test and thyroid hormone level. We wanted a urine sample for chemical and microscopic urinalysis (U/A), but Zelda’s bladder was empty, so we scheduled that for the next day.
When we got the blood test results back the results were surprising in that almost everything was normal and the parameters that were abnormal were barely so.
The urinalysis was still pending, but having a slightly elevated white blood cell count we decided to order a urine bacterial culture and sensitivity simultaneously so that we wouldn’t lose additional time should a urinary tract infection (UTI) be part of Zelda’s trouble.
Soon we had the U/A results and the urine culture informed us of an E. coli bacterial infection in the urinary tract. Still, it was unlikely that alone was causing a total lack of appetite.
One abnormality on the blood panel that agreed with the urinalysis results indicated bile was not flowing from the liver as it should. Rather than proceed to something invasive like a liver biopsy or abdominal exploratory surgery we elected to order a test on the urine sample already at the lab. It is called urine bile acids/creatinine ratio and it gives us an indication of liver functionality. It was abnormal, but only moderately so.
Forty-eight hours have now passed since Zelda first came to see us. She still has not eaten and we still don’t have a diagnosis. We are at our first crossroad.
“Dr. Randolph we’re going to have a family conference about Zelda tonight. We need to talk about just how far we want to go with her diagnostics and therapy.”
“I understand,” I told Zelda’s mom. “You have been generous in spending on the tests she has needed. At this point we still don’t have a diagnosis, and it is difficult for us to give a prognosis without a diagnosis. When you have your conference tonight discuss whether you want to proceed to a couple of X-rays of Zelda’s chest and abdomen. After that, if we still haven’t identified her problem the next step would be to send her to a specialty group who can perform ultrasound and possibly ultrasound-guided biopsy. They are only an hour and a half away.”
“How much would that cost, Dr. Randolph?”
A valid question. “I would plan to be able to spend at least $500.00, but you could quickly get to $1000.00 or $2000.00.”
“What would you do?”
That was an easy question for me. I tend to be approach illness and injury aggressively in my own pets as well as for patients in our practice.
The family decided to proceed to radiographs and then have another conference if those were not diagnostic.
Unfortunately, no next step was needed. Masses were present in the chest as well as one in the abdomen, tucked up in the liver where it could not be palpated. The obvious question came next.
“Do we proceed to the specialist to see if it’s a kind of cancer that can be treated?” Zelda’s mom inquired.
“You recall that on our last talk I said that I always approach patient care aggressively. In this situation, if she were my kitty, I would not proceed beyond this point. The masses we see in the chest are large and having masses in two body cavities likely represents spread. The chances of buying Zelda a meaningful amount of time are small.”
So, we sent Zelda home with medication to treat her UTI, and to wait. We, and the family, are waiting to see whether she will pass on peacefully or need our assistance to end her suffering.
So, what is the answer to the question, “How far do we go?”
There is no one answer. Every illness and every family is different.
As illustrated above, finances can be a factor.
Level of attachment to a pet can be a factor. Unthinkable as it is to some of us, not everyone thinks of their pets as family. Some are hunting dogs or working dogs with little more than an economic value, like livestock. These are difficult cases for veterinarians to handle.
Many other personal factors can come into play in these decisions. It is important to recognize that there is no right or wrong.
Your pet’s doctor will advise and guide you to help you make the decision that is best for your individual situation.