Chapter Seven
Illness, Aging, and Death
Our cats’ wild ancestors evolved with a talent for concealing illness, injury, and pain. To reveal weakness would be to invite attack. Despite having virtually no predators in their modern history to contend with, our cats have retained that talent. One might argue that it’s no longer useful, that in fact it is distinctly disadvantageous, since the reproductive capability of the species would surely be enhanced by the aid and comfort that modern medical care could provide if only the cats would let their compassionate human companions know when they were in need; but the era of human caring has been hardly a minute of evolutionary time. This is a perfect example of the survival of our cats’ wild ancestry inside the thin shell of what we like to think of as their domestication.
If Augusta showed any sign of her hip dysplasia in the summer of 2004, we missed it. We had rented a cabin on the East Fork of the Boulder for the second year in a row even though we didn’t like it, but it was all we could find. We ached with nostalgia for the shady old-growth cottonwood forest on the Main Boulder that Augusta loved so much, where she spent so much time every day we had come to call it her office. The East Boulder place was all sun and dust, and Lord, it was hot that August. Yet Augusta spent long days on the roof, in the sun—“frying her poor pea brain,” we laughed. Dumb kitty. Her black head, when she came down, seemed almost too hot to touch. She had good reason to perch up high: Once again, as in that bad summer on the lower West Boulder, there were rattlesnakes around, some of them big ones. There was one time, mid-month, when she didn’t come home in the late afternoon, and dread rose in my throat like a blade of ice. I looked everywhere. Dust, heat, sagebrush, all I could think of was rattlesnakes. Friends had asked us to dinner—forty miles north, typical Montana—but now of course we had to cancel. Darkness came on, and I continued with a flashlight, calling, calling into silence. Surely, no, she couldn’t have disappeared again, surely no.
At last, about to give up for the night, I shone the light into a corrugated steel culvert under a berm, no bigger than eight inches in diameter. There was the green-gold eyeshine of Augusta. She had drawn up into the smallest ball she could make of herself, equidistant from each end, and no, she was not coming out. She was terrified. I hypothesized that she had found refuge there from a coyote or a pack of them—the pipe was too small for a coyote, and cool, too—smart kitty! But please, kitty, come, it’s dark and I’m getting cold. And finally she did.
From then on, Augusta made no further excursions, but she continued to climb to the roof to fry her brains. There were plenty of perfectly safe places where she could have perched in the shade. Could the warmth have been relieving pain in her hip? It didn’t occur to me then, but now I wonder.
Cats seem to get old at different rates, and in general it seems that veterinary medicine is ready for whatever arrives—a relatively predictable bunch of problems, including not only Augusta’s apparent osteoarthritis but also kidney problems of various kinds and the usual deteriorations that we all face. Little attention has been paid until recently to successful aging, to those wondrous cats who stay sleek and athletic well into their teens, sometimes even their twenties. The one thing that has been identified as an almost guaranteed no-entry card is obesity. Now at last there has been a comprehensive report by a panel of scientists on the whole complex of physical factors that go into becoming a healthy old cat. More than 20 percent of American cats are now older than ten, so this information comes at a good time. The report is highly technical, intended for veterinarians, and let’s hope that it gets wide circulation among them. It lays out specific guidelines for assessing cognitive ability, medical conditions, musculosketal health, the state of the senses, dental and gum condition, gastrointestinal, respiratory, cardiac, renal, and endocrine systems; and a rich array of blood chemistry markers. It’s called “Evaluating Aging in Cats: How to Determine What Is Healthy and What Is Disease,” and I can’t recommend it as light reading, but it is a major contribution to the collective life and happiness of cats.1
By that December, in San Francisco, barely nine years old, Augusta no longer ran like a rabbit downstairs for her breakfast, but rather hobbled—we called it boodling. Going up, sometimes she would pour on the speed. At other times, she would limp upstairs, and I could almost feel the grinding of her hip joint myself. Pain? Undoubtedly. Courage? No, just being herself. Which meant no complaints, just do it. Her spirit never flagged.
We started her on a nonsteroidal anti-inflammatory medication called Metacam, which seemed to help. Within a few months, nonetheless, she couldn’t jump up on our high four-poster bed, so we found a rather handsome three-step mahogany library stair, which she took to with becoming dignity. It may well have been that being stuffed into her carrying case for a trip to the vet or the nightmarishly tiny box we had to squash her into for an in-cabin airplane trip to Montana caused Augusta agony, but she never once cried out.
They all hide their suffering. Step on Fluffy’s tail, and sure she’ll screech, but if cancer is consuming her bone marrow and it hurts all day and every night you will probably not know it until her legs begin to fail and it’s too late.
Still, it helps to pay attention. This book makes no claim to medical advice—there is plenty of that elsewhere—but it is worth remembering that cats are subject to a wide range of maladies that are difficult to detect and that can kill them with terrifying rapidity. The indications may be subtle. Hiding, loss of appetite, or loss of interest in playing or affection could be a sign of incipient illness. Recently an international panel of nineteen veterinarians with a wide variety of specialties identified twenty-five signs of pain—noting that all “were considered sufficient to indicate pain, but no single sign was considered necessary for it.” The researchers caution that “The severity or intensity of pain… is difficult to define or quantify.” The indicators, therefore, constitute only “a reasonable starting point.”2 They’re still worth keeping in mind. Paraphrased to eliminate technical jargon, they are:
• lameness
• difficulty jumping
• abnormal gait
• reluctance to move
• reaction to palpation (applying light pressure with the hands)
• withdrawal or hiding
• absence of grooming
• playing less
• appetite decrease
• overall activity decrease
• less rubbing on people
• general mood change
• temperament change
• shifting of weight
• licking a particular body region
• lower head posture
• squinting
• change in feeding behavior
• avoiding bright areas
• growling
• groaning
• eyes closed
• straining to urinate
• tail flicking
The veterinarian Jennifer Coates adds: “While this list is helpful, it only goes so far. For instance, a cat who has an abnormal gait might certainly be in pain, but other non-painful conditions (e.g., neurologic disorders) could also be involved. In cases where I have failed to find another reason for a cat’s change in behavior and I’m left with undiagnosed pain as the most likely cause, I often rely on a tried-and-true veterinary test: response to treatment. I’ll put my patient on a few days of buprenorphine—my favorite kitty pain reliever—and if his behavior returns to normal, we now know that pain is to blame.”3
Researchers are finding other, new ways to assess pain in cats. Based on facial expression scales developed for assessing pain in babies, models of cat faces have been developed that use measurements of almost imperceptible changes in nose and cheek flattening and ear and whisker movement to assign a numerical score to pain intensity. Another approach, the Composite Measure Pain Scale—Feline, assigns numerical scores to behavioral changes, including vocalization, posture, attention to a wound, response to touch, and response to people.4
Something we can all watch for at home: If a cat urinates or defecates outside the litter box, watch her the next time she approaches it and see if she’s having trouble getting over the side—that could mean pain in her limbs.5
Many problems, if caught early, can be quite effectively dealt with by a veterinarian. Taking your cat to the vet is not a hypochondriacal affectation. Even in the absence of medical symptoms, you should do it at least once a year. If you can find a veterinary practice that is cats-only, that’s all to the good. For one thing, when you take your cat there—who may be freaked out to start with—she won’t be surrounded by barking dogs in the waiting area. Perhaps more important, the cat doctor will have more experience than a generalist in diagnosing feline illnesses, injuries, and idiosyncrasies.
You also need to know where the nearest twenty-four-hour trauma center is. That will almost never be just a vet’s office but a full-on hospital. Here’s a quick list of things that call for immediate medical attention, from the newsletter of the Cummings School of Veterinary Medicine at Tufts University:
• repeated trips to the litter box
• labored breathing
• persistent vomiting
• seizures
• staggering or stumbling
• bleeding
• a symptom that persists or gets worse6
The international panel of veterinarians singled out three of their pain indicators that demand that you drop everything you’re doing and get your cat to the vet right away: panting, pupil dilation, and squinting.7
A team at Tufts is working with other veterinarians around the United States—all with board certification in emergency medicine—to establish a network of what they call Level I and Level II veterinary trauma centers, so that vets anywhere can know quickly where to send a case in urgent need of a particular type of attention. Online access will enable rural veterinarians—who are usually distant from highly skilled trauma care—to connect to immediate information. Over time, thus, the country vets will learn emergency practice for themselves. The group is also pooling data on treatment outcomes from around the world—“a five-to ten-year vision for learning what works,” says team member Kelly Hall of the University of Minnesota.8
The house we had found to rent in Sweet Grass County, Montana, in 2006 was Elysium for Augusta—far from the county road, with the swift Sweet Grass Creek running by to sniff along, a cottonwood forest full of downed and half-downed trees to prowl among for voles, rich green meadows crawling with mice. I was especially happy that the elevation was too high for rattlesnakes. There were coyotes out on the prairie, but as long as we made sure Augusta was well in before dusk and never out until full day, we were certain enough that she was safe from them: Their natural prey of rodents and rabbits was plentiful, and surely they knew through generations of life in ranch country that going near houses could be fatal. Coyotes are smart, and adaptable. A friend of mine in Sweet Grass County raises a band of a thousand sheep—with lambs—in the midst of whom a coyote family lives in peace, a détente with the big guard dogs having been reached long ago.
Within a couple of days of her arrival, Augusta’s fur gained a sleekness it never wore in the city. On the prowl she traveled low like a leopard, eyes scanning, ears up forward then swiveling toward the slightest noise of possible interest or threat. She could jump the full three feet to the top of the rail fence and dance along it with no slightest bobble or limp. She brought us gifts living, dead, and in between.
Sometimes Augusta came in from her hunting with leaf duff, straw, spider webs stuck in her whiskers and fur. All you had to do was show the brush and say, “Brushing?” and she would assume the position—sphinx, little front feet together, head high, facing away from you, ready. She loved to be brushed, especially when, as it still was that summer, her coat was shiny and smooth.
She moved more slowly than in her younger years, and slept more. In a way, she seemed to love her sleep more—she appeared to relax more fully, and when she rose and stretched, although her arthritis may have been creaking a little, what her body and face expressed was contentment. The veterinarian Kathy Blumenstock considers the age of seven to be the frontier of seniorhood; Augusta would turn eleven in August. “If any species can elegantly accept the arrival of golden years,” writes Blumenstock, “it’s cats.”9
When I was there alone, Augusta slept on Elizabeth’s side of the bed, but still always, respectfully, at the foot. When Elizabeth was there, especially on Montana’s chilly nights, she would stealthily find her way up to Elizabeth’s knees, which would part just enough to accommodate a small, stretched-out sleeping cat. When Elizabeth turned to sleep on her side, she did so slowly, so that Augusta could ride with the turn, and maintained the cat-width gap between her legs, all this without waking. Augusta never considered attempting even the first part of this maneuver with me.
She nipped Elizabeth’s bare ankles in the mornings, or, if she was wearing her backless slippers, her heels. She would follow Elizabeth in her robe with her tail straight up and her head cocked sideways and her mouth partway open. There was a particular look on her face. We called it bitey. Uh oh, she’s looking bitey. Sometimes Elizabeth would drop a newspaper on the floor in front of her, wham! And then, when the moment of startle had abated, Augusta would settle for biting the hem of her robe. Sometimes, when Elizabeth bent over her, Augusta would bite her hair. She knew not to try any of that crap with me.
Back in San Francisco, Augusta began not to like her food. We would find a new brand, which would work for a while. Cantaloupe, when aromatically ripe, was always a success. I’ve never known another cat who loved it so—and cantaloupe only, not honeydews, crenshaws, Persians, not even the fragrant Charentais. Sometimes I cooked her chicken livers. She liked the milk left when you had finished your cereal. Elizabeth would take it to Augusta’s feeding place in the kitchen repeating, “Milk?” in a tight little high-pitched voice, and she swore that Augusta’s answering Miew? was the same word. Sometimes Augusta, Machiavellissima, would sneak to Elizabeth’s cereal milk while it was still on the dining room table and get away with that. Her infirmities were buying her impunities.
Pets Unlimited is a big hospital, and sometimes, unless you want to wait forever, you see whichever vet is available. One veterinarian had prescribed Augusta’s Metacam for her joint pain, and then in 2005 another added Cosequin, which slows the degeneration of cartilage. Every time Augusta went in for a visit—several times a year at this point—she would see a different doctor. We felt very fortunate in the summer of 2006, when Dr. Randy Bowman came up in the rotation. He made sure we understood his explanations, and he handled Augusta with extraordinary tenderness. We decided that from then on, whenever possible, Randy was going to be Augusta’s doctor. Augusta’s weight was down from her customary ten pounds to 9.6—nothing to worry about, Randy said.
That December her weight was down again, to 9.1 pounds. Her agility was going downhill as well. When Randy manipulated Augusta’s back legs, she cried out in pain. He decided to step up her medication to the steroid prednisolone, which would reduce the inflammation and, thereby, the pain. It would probably increase her appetite a bit, which would be good, but we should watch and not let her get fat, he said. It was also an immune system suppressant, so we should be on the lookout for infections. Diarrhea could be an effect, but it would probably go away. If not, we should call him. There were a lot of other possible side effects on the information sheet Randy gave us, some of them harrowing. As it happened, Augusta suffered no ill effects whatever from the prednisolone. She improved quite a bit, in fact. You could tell her pain had been greatly relieved, and her spirit remained indomitable.
Yet there began to be mysterious midnight visitations of—we didn’t know what it was—some kind of terror? Augusta had begun to sleep sometimes in my office, in the high-walled circular bed behind my desk that we called the Bucket, instead of her customary place at the foot of the bed, and now sometimes, in the dead middle of the night, she would come out into the hallway, well down from the bedroom, and cry out loudly, the deep-pitched wail that she produced only when she was disoriented and lost in Montana. There, it meant, “Come find me,” or at least, “Tell me where I am,” and a good holler to orient her to the house or to oneself would usually be sufficient to bring her bounding home. But what was this? I would come to her and try to assure her that everything was all right. I would try to pick her up and bring her to bed, but usually she would not stay. She would go quietly back to the Bucket and not cry out again that night. But she might the next; you never knew. We joked, uncomfortably, about her “arias,” because she had begun trying out different sounds, many of which we had never heard before, all of them loud. She had never been loud.
If we had known then what the veterinarian Jessica Remitz has recently written about that phenomenon, we’d have been more upset—but, as is unhappily so often the case with aging cats, we wouldn’t have been able to do a thing about it: “Cats that may be experiencing cognitive issues (such as early Alzheimer’s or dementia) are very vocal during the evening and will meow as if they are lost.”10
Well, I could have said to Dr. Remitz, if Augusta was, in fact, suffering from dementia, she was doing so only in isolated episodes. Augusta and I spent a full two months of the summer of 2007 on the Sweet Grass, and for her that summer was heaven. Some days she hunted to the point of exhaustion, and would sleep in undeniable peace and comfort at the foot of the bed. Other days she was content to sit on her haunches on the porch and watch the comings and goings of our hundreds of birds. When she traveled into the cottonwoods, well out of sight of the house, she always knew the way home precisely, and could gallop there lickety-split if a deer barked at her or I called her to dinner. On the Sweet Grass she never cried out at night or showed any other sign of disorientation.
Midsummer for me was not so fine: Elizabeth and I and a group of friends went on a backcountry pack trip to celebrate my birthday, and my horse reared and then fell backwards almost on top of me. If he had landed true, I would be dead. In any case several ribs were broken and my sacroiliac wrenched, but I was alive.
True to form, as I lay in bed for the next couple of weeks, Augusta stayed with me. I believe she knew I was in pain. Did she know I knew that she was, too?
In December 2007, at what my calendar recorded as a “routine office visit” to Pets Unlimited—not with Randy Bowman this time—Augusta’s weight was down to 7.4 pounds. Neither we nor the veterinarian put together the fact—hideous in retrospect—that that was a loss of 1.7 pounds since the previous December, 18 percent of her weight. Worse by far, now that I was doing the arithmetic, I realized that over the course of the last two years she had lost 2.6 pounds, 26 percent of her customary weight. Why had none of us, why, especially, had none of the doctors at this top-flight hospital, taken adequate notice of such a drastic decline?
We really had all believed that we were doing the best we could for her. The best thing was that her pain had been much relieved. If she lost weight, was that so bad? It meant less strain on her joints, I tried to tell myself.
I spent June 2008 alone at the Sweet Grass place, and then Augusta and Elizabeth joined me for July. When you’re with your cat every day you may not notice change as it comes slowly on. When Augusta arrived in Montana after we’d been apart for a month, her appearance shocked me. Despite a five-milligram shot of prednisolone only a few days before, she looked disheveled and confused. She seemed not to have been grooming herself well at all, and her vertebrae made a line of sharp bumps from between her shoulder blades to the tip of her tail. Her whiskers had been white for a couple of years, but I had failed to notice the faint graying of her soft little muzzle.
Restored to her natural home, though, she brightened quickly, as she always did, and soon she was picking her way through the grass, which had grown tall that summer after a stormy spring. Augusta’s eyes shone happily. From time to time she would sproing into the air and describe the balletic arc of her youth, and a few of these ended in the actual capture of a mouse or shrew.
At the end of September 2008, Augusta returned to the vet for a “senior wellness profile”: a urine sample, blood tests, a thorough poking and prodding, a renewal of her vaccine against feline distemper and rabies. Augusta had been vomiting, rather often, and the vet suggested we elevate her bowl a couple of inches so her food would be easier to swallow. Also we should watch to see if fish-based food caused more vomiting—it was often a culprit, he said.
The test results showed that her red and white blood cells were fine, her liver was normal, her calcium normal, her electrolytes normal, her triglycerides low. The hyperthyroid test was negative. Best of all, her kidneys were normal—urological problems are the curse of the aging cat. The doctor pronounced her condition “very nice for thirteen.” But she weighed only 6.7 pounds, down 9 percent in nine months, a cumulative loss of 3.3 pounds. One-third of Augusta had wasted away.
If she continues to lose weight, said the doctor, the next thing to do is an ultrasound of her abdomen, to check for masses—tumors, abscesses, and such.
At her visit to Pets Unlimited in early April 2009, we saw Randy Bowman again. I told him that Augusta had been eating well for a while, but she had lost another half-pound—she was down to 6.2. She had soured on her usual Iams food, and I had been trying a bunch of highly touted, high-priced cat foods I had found online, without much success. I told him that recently Augusta was constantly asking me to “make her a drip”—that is, to set the kitchen sink faucet so that it barely dribbled, her favorite way to drink water. She was thirsty all the time. That could be a side effect of the prednisolone, Randy said. Palpating her pelvis and her rear legs, he told me that they had deteriorated significantly since the last time he had seen her. He noted that her coat was in poorer condition as well—oily and clumpy. He took her temperature, examined her eyes and teeth and mouth, checked her for swollen glands. He said that other than the weight loss, she looked pretty good—“really not geriatric.”
As for the weight loss, hyperthyroidism was a possibility even though her last test for it had come back negative. If that’s what it was, it was eminently treatable. Her blood sample was going to get a specialized thyroid test, and I could call for the results tomorrow. Inflammatory bowel disease was a possibility, also easily treatable; I was to bring in a stool sample. It could also be a lymphoma. We could treat that with chemo, he said, which is expensive, and unpleasant. In any case the disease is invariably fatal.
Her thyroid and IBD tests both came back negative. We managed, somehow, to avoid the unavoidable inference, that she had cancer. If we had recognized it, would we have asked for an ultrasound? And if a lymphoma had been diagnosed, what would we have done then? Knowing that it was terminal, I’m certain we’d have done nothing more than what we were already doing. As long as Augusta was enjoying her life—which she indubitably was—the best we could do was to keep it as enjoyable as possible.
At Randy Bowman’s suggestion, we tried a number of cheap mass-market cat foods, and Augusta seemed to like them, but only for a short time. Then we discovered Fancy Feast, which we just called “white food” because every flavor came drenched in some sort of creamy-looking white goop. A better name might have been Kitty Crack, because Augusta couldn’t get enough of it.
She began to gain weight, and her midnight arias waned. By May 2010 Augusta had made it back up to seven pounds. In July we took her to Pets Unlimited to ask if she was okay to fly to Montana. After an extensive exam, the vet gave Augusta a health certificate. Her weight was up again, a little, to 7.1 pounds. Elizabeth thought Augusta’s weight gain might have been due to the white food. I now think it was the growth of her tumor.
For the first time ever, Augusta did not do well in Montana. Her coat did not grow sleek nor her eyes bright. She did try a little hunting, but she seemed to grow disoriented, and would turn and head home. She threw up repeatedly. She did like sitting on the porch in the sun. Elizabeth and I decided that rather than cram her into the cramped confines of the air travel carrying case, we would drive home together.
At home in San Francisco, Augusta grew weaker by the day through the month of August. She turned fifteen years old.
Because veterinary medicine is so good these days, cats are living longer, and advancing age brings increased vulnerability to accidents, infection, cancer, parasites, and a host of afflictions that probably weren’t troublesome when your cat was younger. Many of them are eminently treatable now, but as a cat ages, illnesses that were previously less serious may threaten to be fatal, and damage or disease that will inevitably end in death becomes more likely. Advances in veterinary research and practice, however, have now made it possible that in some of those terminal cases, the end can be postponed.
The question of how far to take medical treatment of pets is a hot one in the veterinary world. In recent years there has been a dramatic increase in specialization and in the use of technologies previously reserved to human use. As among our own physicians, specialists are highly motivated to treat their specialties, and just as we have to look to our own real interests in the medical world, you cannot necessarily accept that every word from a veterinarian’s mouth is going to be appropriate to your and your cat’s situation. Veterinary oncologists, for instance, make their livings treating animals with cancer, and they now have at their disposal veterinary chemotherapy, radiation, and nearly all the other weapons developed for human oncology.
Picture yourself in this situation. You’re told that your cat has cancer, and that chemotherapy might extend his life by six months or a year. You’re aware that chemotherapy usually exacts its own high cost in misery. But you could have him with you for another year, alive, purring, loving you, and being loved. Sometimes you must look deep in your heart to find whether you want that extra year for the cat’s benefit or for your own.
Veterinary oncologists do make a strong case for their ability to ease suffering. Dr. Joanne Intile writes, “When aggressive surgery is not an option because an owner feels their pet is too old to withstand the operation, veterinary oncologists are able to offer less intensive chemotherapy therapies, most often designed to slow tumor growth and metastases while maintaining an excellent quality of life. Though we may compromise our chance for a cure, we are able to extend an animal’s expected lifespan and simultaneously ensure that their remaining time is spent as happy and healthy as possible.”11 Because cats’ happiness or absence of it can be so difficult to read, the value of such therapy can be difficult to judge.
There are always just enough rare cases of miraculous cures to keep countless flickers of hope alive. It’s extremely hard to think about statistics when you’re holding your beloved companion in your lap and she’s very ill. When you’re facing the prospect of many thousands of dollars in medical bills, there can be a curious psychological reversal. You wonder if, if you withdraw treatment now, will you be wracked with guilt for the rest of your life? You wonder, Will I be forever hearing a voice inside me whispering, I killed her to save money?
“Many people are enrolling their pets in insurance programs to help in the case of catastrophic illness,” writes veterinarian Jessica Vogelsang. “It’s the most likely way to save a life down the road.” But “It is not too uncommon to hear of bills over forty thousand dollars.”12
End-of-life decisions were easier not long ago. The adage was, She’ll tell you when it’s time. You’ll just know. When it’s clear that your cat no longer enjoys living, or that more of the things she has always loved to do are now beyond her capability than the few things left she still can do, you know. She stops grooming herself. She doesn’t seek out her favorite spot in the sun. She won’t eat. She stumbles. Even when she lies down you can tell she can’t relax—because she’s in pain. Then you know.
Or you used to know. Because now perhaps steroids, or chemo, or some other advanced life-lengthening treatment may be available, and you’re going to have to guess whether your cat’s lengthened life is likely to be worth living. Is there a realistic prospect of a cure? Could six months of chemo buy you three healthy years? It won’t be easy to decide how much confidence you have in a given doctor’s answer. With years of experience together and gut-level trust in your longtime vet, it may not be so hard, but you’re likely also to be dealing with a specialist whom you don’t know and who doesn’t make any money by recommending against treatment. In any situation in which the cat’s life is at risk, a second opinion would seem a worthwhile next step.
Asking your vet for a referral can be difficult. Vets are human beings. You may feel you’re somehow insulting them, questioning their judgment. Don’t. Referrals for second opinions are part of their lives. They’re trained to do it, and they can learn from it. And that second opinion could save your cat’s life.
A relatively new development for pets nearing the end of their lives is the animal hospice, which is quite similar to a human hospice. It is rarely if ever a place; it is a system of care that looks to all the needs of an animal near death, to an extent that may be beyond the capability of the pet’s owner—pain management, nutrition, hydration, hygiene, physical comfort. A veterinarian named Alice Villalobos has developed an evidence-based “quality of life scale” to help hospice workers in their decision making. It may be of help as well to some cat owners stymied by indecision, independent of any hospice. It’s still not easy, but by breaking down the decision about ending your cat’s life into meaningful components and giving them a numerical score, it may sharpen your thinking. Each category is to be scored from 0 to 10, with 10 being ideal:
0–10 HURT. Adequate pain control, including breathing ability, is the first and foremost consideration. Is the cat’s pain successfully managed? Is oxygen necessary?
0–10 HUNGER. Is the cat eating enough? Does hand feeding help? Does the patient require a feeding tube?
0–10 HYDRATION. Is the patient dehydrated? For cats not drinking or eating foods containing enough water, use subcutaneous fluids once or twice daily to supplement fluid intake.
0–10 HYGIENE. The patient should be kept brushed and cleaned. This is paramount for cats with oral cancer. Check the body for soiling after elimination. Avoid pressure sores and keep all wounds clean.
0–10 HAPPINESS. Does the cat express joy and interest? Is the cat responsive to things around him (family, toys, etc)? Does the cat purr when scratched or petted? Is the cat depressed, lonely, anxious, bored, afraid? Can the cat’s bed be near the kitchen and moved near family activities so as not to be isolated?
0–10 MOBILITY. Can the cat get up without help? Is the cat having seizures or stumbling? Some caregivers feel euthanasia is preferable to a definitive surgery, yet cats are resilient. Cats with limited mobility may still be alert and responsive and can have a good quality of life if the family is committed to providing quality care.
0–10 MORE GOOD DAYS THAN BAD. When bad days outnumber good days, quality of life for the dying cat might be too compromised. When a healthy human-animal bond is no longer possible, caregivers must be made aware that their duty is to protect their cat from pain by making the final call for euthanasia. The decision needs to be made if the cat has unresponsive suffering. If death comes peacefully and painlessly at home, that is okay.
TOTAL. A total score over thirty-five is acceptable quality of life for maintaining a good feline hospice.13
Hospice care can be a compassionate alternative for cat owners who simply aren’t ready to turn out the light, but whose cats are suffering and are never going to get better. There are now a number of organizations that can help you find a good hospice, among them the Animal Hospice End-of-Life and Palliative Care Project, the International Association of Animal Hospice and Palliative Care, and the American Association of Feline Practitioners. All can easily be found on the web.
The unbearable decisions pile on without mercy. Some people elect not to make the final decision, but to let nature take its course. Sometimes, when you haven’t yet decided how to decide, nature will sneak up behind you: You go to check on your cat and he’s already dead.
Most cat owners eventually accept the choice of euthanasia. The American Veterinary Medical Association has gone into the philosophy and practice of euthanasia in all its dimensions. The AVMA guidelines, in 102 compassionately considered pages, range from definitions of “consciousness and unconsciousness,” “pain and its perception,” and “stress and distress” to “a good death as a matter of humane disposition” and “a good death as a matter of humane technique” to rules for acceptable and unacceptable methods of euthanasia and “behavior in presence of owners.”14
A generation ago, veterinarians were much less sensitive than most are today. It cannot be easy to kill innocent, uncomprehending animals day after day and to bring compassion to their sorrow-sickened companions. To seal out their own emotions, no doubt often both strong and mixed, and to wall themselves off from their clients’ grief—as so many practitioners of human medicine do—would be perhaps a less draining course, at least in the short term. The decency and the concern that we see in our veterinarians are worth remembering to be thankful for. Bringing the mind to rest on gratitude to someone else is not easy in a time of such entire focus on one’s own emotional state.
That some vets now will even come to your home to end your cat’s life seems to me beyond remarkable. Imagine being that veterinarian, driving or on the train, black bag in hand, on that errand of unspeakable mercy. What, if any, music can they play? What, if any, thoughts can they allow, and to which must they deny entry? Now that there are a few places where human euthanasia is permitted, the same but perhaps even more heart-choking agony must occupy those needle-bearers’ rides. Yet maybe no: For the human will have chosen to die and will be facing death in some degree of courage and understanding. We call it “assisted suicide,” aptly. The physician’s burden is, morally and philosophically, that of an assistant, albeit a brave and admirable one. The veterinarian’s burden is entire, private, and unimaginable. Until the very last, the cat in almost every instance looks into your eyes in unknowing innocence. The hand that pushes the plunger down the hypodermic shaft belongs to a person who has chosen to undergo an extraordinary suffering to render an extraordinary kindness.
You will have some moments to recognize as your last time together. You may choose to be present at your cat’s death, or not to be. Hard as it is, it seems better for most people to be there at the end. You can hold him if you wish. There will be an injection of a sedative, and he will drift softly into unconsciousness. Then, after a second injection, into a vein, he will take a deep breath, perhaps another, and fade away.
If you have a burial place, you may take the body away. If you have chosen cremation, the body will be taken now.
It will tear a hole in your life. Her love was unconditional. When you stayed away too long, she didn’t sulk when you came home, she welcomed you with gladness. She was so innocent. So naïve. No human being ever loved you with the purity of her love.
Did you tell her things you never told anyone else? Did she purr just because you were there—because you existed?
His stuff is going to be all over your house. What are you going to do with his bed? His toys? You’re going to listen and listen for the bup-bup-bup of his paws on the floor as he comes trotting to greet you, and you won’t hear it. You’re not going to be able to sleep. You’re going to eat too much, or not enough.
You’re going to wonder if there’s something wrong with you. A lot of people stay home just so they won’t have to hear somebody say, “Come on, it was only a cat.”
Somebody’s going to tell you to get a kitten, and you’re going to think, No! No kitten could possibly replace her. You’re right—don’t get a kitten until you want one. You’d only be making invidious comparisons. One study, in Scotland—with dogs, so we can’t be certain whether it would apply to cat households—showed that getting a puppy when your old dog was still alive but dying could ease the pain, especially if there are kids in the house.15
The children are going to be hysterical with grief in any case, and then, after a couple of days, maybe one of them isn’t going to care at all. Younger children seem to be more resilient, but if your cat’s life ended in euthanasia, chances are that children of any age will blame you.
You may be blaming yourself as well.16 You may be secretly comparing the intensity of the grief you’re feeling now with the grief you’ve felt in the past for some person very close to you and realizing that the loss of your cat hurts more. You may blame yourself for that too. You may find comfort in the knowledge that serious studies have shown that grief for the death of a pet and grief for the death of a person are psychologically indistinguishable.17 No comfort? There may be no comfort to be found now, and there may not be any comfort for a while.
Your other pets, if you have any, will grieve, often deeply. A surviving cat will probably search for his lost companion, returning and returning to the places they shared, sniffing for now-absent scent. He may produce sounds you’ve never heard before, yowls from deep in his throat, calling his friend to come home. He may stare blankly out the window. Like you, he may not be able to sleep or eat. He may cling to you for comfort, or try to soothe himself by overgrooming. His grief, like yours, may not diminish quickly. Some people believe that letting him see the body just after his companion’s death may ease the pain; others consider that absurd—there has been no research on the question. What can you do? Attention, kindness, love may help to fill the emptiness, and comforting the grieving animal may comfort you too.
And what if another person in the household isn’t grieving, doesn’t care? Horrible. Divorce rates as high as 23 percent have been reported for bereaved pet owners.18
Take a deep breath. Not ready? Don’t worry. You know you’re going to have to take yourself in hand sooner or later. You’ve known it all along. All these things, you can do them through tears.
First, memories. In honoring your memories of your cat, you are honoring him. Try to remember everything. The order isn’t important.
You felt his warmth and his breathing, and sometimes you would slide your hand beneath his chest to feel the amazing flutter of his heart. When you touched his fur, it was alive, it rose to your touch, and then as it relaxed you could feel the silent sigh. Remember how he turned his ears toward the front door before you knew someone was coming. There will be no end to these memories, and let there be no end. Write them down, or speak them into a recorder. Keep them alive.
Dabbing in the sink with her paw for a leaf. Waiting till you had established the fine and regular drip—bip bip bip bip bip—then swatting at it till she was ready to turn her head sideways and lap from the thread-thin stream. The wind ruffling her fur from behind revealing patterns you had never seen—dark brown and darker brown tabby stripes. Our little black cat wasn’t black! The twitching of her legs and lips and the squinching of her eyes in a dream—of what? How she would push, push with her back feet against your hand, the cool rabbit-soft fur of her heels, the lizard-skin one-way roughness of her hot toe pads. The little pocket on the side of her ear, lined with ineffably soft fur. Was that little spot perhaps a refinement of her hearing apparatus? What matters now is that it was a place which in perfect trust she loved your finger to caress from within. With the same trust, how she loved you to press your finger to the inner point of her closed eyes and run it softly outward across the lid, perhaps picking up along the way a bit of oozy gradu. Her pink tongue when she gave herself a bath. How she always knew the sound of you coming up the front steps, and always would come trotting to greet you with tail held high.
I remembered. Augusta sniffing my extended index finger first thing in the morning with great interest, almost as if it was new. Augusta plunging into laundry warm from the dryer. Augusta jumping up on the dining table and biting the flowers, preferably tulips. She liked for us to watch her when she used her litter box. She liked when we threw out the old sand, washed the box, and filled it deep with new, unscented litter. She would wait, transfixed, excited, and before the dust had settled she would have jumped in, dug like a fiend, and christened it with a big fresh poop, eyes shut tight in pleasure.
All the times when she walked away in indifference. Times when I called, Augusta, Augusta! and she would not come, even when I tracked her to her hiding place and I insisted, Augusta, come down! but all she would do was tiptoe back and forth on the branch or in the attic corner or wherever the hell she’d gotten to, in some impenetrable trance, mewing pitifully, not even looking at me yet pleading Please help me! still refusing the slightest recognition of my exhausted repetitions of Augusta, come! till at last all I could do from the teetering ladder top was seize her by the scruff of her skinny little neck, and even as I rescued her she would bite me and scratch me till I clasped her to my chest not lovingly but like a firefighter pulling a crazed child through flames. These and a hundred other memories I wrote and wrote. I made a list of her names, Bdingle, Bdomble, Busta, Doodoo Head, Dummy, Little One, Panterina, Piece of Shit, Schbdingle, Schkblodgit, Stoopie, You Idiot, Beauty Kitty. I kept remembering more. Augusta? Augusta!
Grieving. Helpless.
In September of the year 2010 Augusta began to eat less and less. She acted hungry, but then would take only a few bites. Her affect was foggy, absent. She moved very slowly. She had lost another 20 percent of her weight in six weeks. The veterinarian she had always loved, Randy Bowman, found a hard mass in her lower abdomen. An X-ray confirmed that it was a large tumor, probably a lymphoma. She was going to die.
Randy gave us pain medication to spread on her gums, and an appetite stimulant, but she could not hold the medicine down. She began to hide in Elizabeth’s closet. When I looked in, she looked back and me and cried in a way I had never heard before, a low moan. When she came downstairs, we tried to think she was better. We tried all her favorite foods. She sniffed almost eagerly at the cantaloupe, but she would not eat it. I put out a few of her favorite crunchy treats, but she seemed unable to find them on the plate. She went back to the back of Elizabeth’s closet. Elizabeth spent that night in a sleeping bag just outside the closet, to be with Augusta.
In the morning, Augusta roused herself and went downstairs. She ate a few bites of white food, used her litter box, and lay down in the sun on the kitchen rug. She brightened, ran upstairs, not ready, after all, to die that day. We decided that if she was better again tomorrow, we would wait and see if she might start eating and feeling a little better; that if she was worse, we would go ahead and have her put to sleep; and that if she was the same, we would have to decide then.
I spent most of that night in the sleeping bag next to Augusta. She left the closet at least once, when I was asleep, to eat some of the raw hamburger that we had left out near the closet and also to use the litter box in the bathroom across the hall. In the morning she was wide awake but showed no inclination to come out. She did not sleep at all. Her eyes were open, her face a blank, an absence. She was purring constantly. I had read somewhere that a constant purr means that the cat both knows she is dying and is comfortable.
Elizabeth and I agreed that today was the day. Augusta would face only further weight loss, and further decline. It would not be long before some vital organ would fail. In recent days she had seemed no longer to experience pleasure beyond a few seconds of petting or brushing—and even that soon became bothersome and she moved away from it.
We called Pets Unlimited and made the appointment with Randy Bowman. Augusta lay curled up well back in the closet, in the dark, purring. Occasionally she changed position very slowly and, I thought, painfully. Occasionally I stroked her head, and I thought she liked it. She began to lick a front paw, as though she was going to wash her face, but then she laid her chin on the paw. From time to time she looked at me. From time to time she closed her eyes. Mostly she just stared at nothing.
At 12:40 we were shown into a cold examining room at Pets Unlimited, and Randy came in behind us. We put Augusta on her own blankie underlain by a pad on a cold metal table. She was calm. Randy explained that he would first give her an intramuscular injection that would act over the course of five to ten minutes to sedate her into unconsciousness. He administered that at 12:45, and it hurt—Augusta squirmed and turned as though to try to bite him. She made brief eye contact with Elizabeth, and then she relaxed quickly, staring straight ahead, very still. I watch her flanks moving as she breathed, and as her breath slowed very slightly. As imperceptibly as the hour hand on a clock, it seemed, she lowered her head to the towel. We continued to stroke her gently as she relaxed, relaxed.
By 12:50 her nose was on the towel. I lifted her chin so she could breathe more easily. Randy checked her blink response, which was still there. Two minutes later it was not. He took an amazingly noisy electric shaver to the front of her right front leg, making the vein there easily visible. She did not react at all to the noise, which under ordinary circumstances would have scared her. Her eyes were open, but she was unconscious.
Elizabeth and I both continued to stroke and hold Augusta. Elizabeth asked Randy to show her where to put her hand so she could feel Augusta’s heart beating. At 12:55 he injected a large syringeful of barbiturates into the vein in Augusta’s shaven foreleg. Her heart stopped instantly. Randy told us that her brain had died equally instantly.
We had read to expect several possibilities: a series of deep, searing last breaths; shuddering; urination; a release of her bowels. None of these came to pass. She was simply utterly still.
We stayed with her a few minutes. She looked exactly like herself alive. I tried unsuccessfully to close her eyes. I put my fingers between her toes, something she didn’t like much when she was alive but something I always loved the feeling of. As we left, Randy was wrapping Augusta in a towel, to take her to a freezer.
She was never afraid of us. Inevitably sometimes we would step on her tail or trip over her, but that left no memory: She was never afraid we would hurt her.
Soon her places were empty, the litter boxes gone, her food bowls, the Bucket. The pantry shelves where we kept her food were bare. The library steps we had gotten so she could climb up onto our bed were in the basement, awaiting the Salvation Army.
Up until her last morning, she would come when I called, even up or down the stairs, “Augusta, come!” In my mind I couldn’t stop calling her name.
I collected her toys, her blankie, her ribbons. Beside the back stoop I dug and dug until the hole was three feet deep. We took a last look at the little pine box that her ashes had come in from the crematorium. I reached down and placed it softly on the bottom of the hole. We covered that with her stuff, the Anchovy Mouse, the Spider Ball, the strip of cloth with AUGUSTA cut from the Bucket, the lists and the memories, then dirt. We planted a tall, thin Coprosma that we would see every time we went in or out of the door that Augusta went in and out of so many times.