A snack for the journey

The Room

     It’s after closing time. I don’t remember when I last left before closing time. I'm halfway through 18 months of clinical rotations in my fourth year of veterinary school, and I’ve been learning by doing. I’m enjoying the warmth of a cozy former exam room on a cold mid-October evening in upstate New York. Its institutionalism has been softened by the addition of comfortable but clashing chairs, generically benign art, and the yellow glow of an honest-to-goodness table lamp (in a hospital!). Beige blinds have been added to the exam room door window for privacy.

     When possible, this room is where we prefer to bring clients of the Cornell University Hospital for Animals (CUHA) when it’s time to let go of their beloved pets. The effort to transform the exam room into a truly comfortable euthanasia room falls a little short, but is endearing enough to be forgiven.

The Patient

     I’m seated on the floor, in part to give my supervising cardiology resident and the husband and wife clients first crack at the chairs. I've also found that sitting on the floor is a good way to build rapport with patients and clients; it's a habit I'll continue throughout my career. As it turns out, I’m joined by the husband. He sits with his left leg extended, his right leg bent. Red, his companion, perches his big, blocky Golden Retriever head on the bent knee. The man wears a knit stocking cap and flannel jacket. Folks often leave outerwear on during euthanasia visits; the experience is engrossing enough that some conventions are forgotten.

Illustration by Kiva Bay, all rights reserved

     The client absently strokes Red’s muzzle with the thousand-yard stare common to some clients in the euthanasia room. This moment -  between making the decision and carrying out the act - often looks this way. From the outside, I can see the memories flitting across the internal movie screen. It hurts, but it’s necessary. It’s a moment of introspection juxtaposed with the openness that fills the room. In these moments, all of the barriers we humans erect between one another, invisible but opaque, dissolve. In these moments, facing death, we open up and genuinely connect.

Case History

     Red presented to the cardiology service after his primary care doctor detected fluid accumulation around his heart, lungs, and abdominal organs, in addition to heart and liver tumors. Red’s tri-cavity effusion, as we call it, was preventing expansion of his lungs and heart, making breathing and exercising difficult. When Red first arrived at the CUHA, the fluid had been removed and only small amounts remained. Like flipping a switch, fluid removal had immediately improved Red’s breathing and heart function, but there was no way to predict how quickly the fluid would re-accumulate.

                                  Illustration by Kiva Bay, all rights reserved

     In Red’s case, it took about a week. His family elected for a surgery called a pericardiectomy to be performed, where a hole is cut into the sac that contains the heart. This allows drainage of fluid into the chest, in hopes that fluid would be reabsorbed faster than it was being produced.

     Unfortunately, this was less likely in Red’s case, because his tumors turned out to be a type of cancer called mesothelioma. Though humans also get this type of cancer, its causes and characteristics are somewhat different in dogs. Red had hundreds of small tumors on the lining of his chest, lungs, and heart, each constantly producing fluid. Removing that many tumors was impossible, so they were left to do their insidious work. Red recovered well from the surgery itself, but re-accumulated fluid rapidly. After five weeks of frequent fluid-removals, he collapsed on a walk and his family decided it was time.  

                                                                                           Illustration by Kiva Bay, all rights reserved

A Human Moment

     The man’s wife does most of the talking. She is a hospice nurse, and gamely takes on the journey she usually guides. I pay close attention to her, hoping to glean what I can so I can better lead clients through this experience in the future. Also, I’ve grown close to Red. He is charming and intelligent, a patient patient, loving to strangers even through pain. My heart hurts and I work to maintain composure. 

     We discuss Red's progress, and why tonight is the night. His mom has watched me bond with Red over the past five weeks and she picks up on my sadness now. She tells me that I've been helpful to Red and his family, and reaches out, confident I'll welcome her hug. I do. Her expertly nurturing response buoys me. It’s one of the most generous acts I’ve ever experienced. I silently wish to run into a professional with as much fortitude and compassion in my final days.

Decisions

     The cardiology resident explains the process: first, a sedative injection to make sure Red experiences little to no distress during handling. This also cuts down on some of the more dramatic vocalizations and spasms that can occur during and after death. Next will come the euthanasia solution injection, which is essentially an overdose of anesthesia. This means that no matter what, Red will not experience any pain or suffering while dying.

     There is some variation between doctors and patients regarding exactly how these steps are carried out. Some patients, for example, don’t require a sedative due to illness or personality. Some practitioners prefer to place an IV catheter to minimize the risk of damaging veins during injections. Some clients find it difficult to let go of their pet while the catheter is placed. Therefore, some practitioners will place the catheter while the client watches or inject the medications without a catheter, sometimes needing to poke in multiple places.

     The amount of time each step takes and their precise order vary and depend on client preference, doctor preference, and local laws and regulations. In all cases, the goal is to balance the wishes of the client with our ethical responsibility to provide the patient as painless a death as possible.

     The cardiology resident discusses these and other options with the clients: Would the clients like to be present for the euthanasia? Would they like to spend time alone with Red before or after? Would they like a paw print or lock of hair? Would they prefer Red’s remains to be returned for home burial, cremated and scattered with other pets, or cremated and returned in an urn?

     Throughout this process, the wife answers while her husband remains silent in his reverie. The last question, however, gives her pause. Would Red’s family like to pick up his remains at the CUHA (a three-hour drive for them), or have them sent to their home?

     “Honey?” She gently prods.

     “Huh?” Her husband's attention snaps back into the room.

     She reformulates the dilemma, “Would we like to drive back down here when his ashes are ready, or do we want them mailed to us?”

     His face twists into an expression that says her question is painful and absurd. “He’s never been mailed before!”

     We all laugh, the tension falls away like shaken-off snow.

Red Leaves

     The four of us now turn as a team to the task at hand, bonded uniquely through death. Red refuses a treat, leaving his head resting weakly on his dad’s knee. He remains stoic through the sedative injection, fading into a stupor without announcement. Then the second injection of the euthanasia solution does its work and Red passes peacefully into death in seconds. Movies are unreliable teachers - his eyes remain open.

     The cardiology resident listens with his stethoscope and confirms heart death. (He will tell me later, “Always confirm, and don’t ever lie. Wait until there’s not even a flutter. Only do this procedure once per pet.”).

     We ask Red’s family if they would like to take his collar; it has to be removed for cremation. As we discuss the final details, the husband asks, “Can the treat get cremated with him?”  The resident and I look at each other, having never encountered this question before. We both shrug, "That sounds lovely." He squats down, places the treat two inches from Red’s nose, and says quietly, “A snack for the journey.”

                                                      Illustration by Kiva Bay, all rights reserved

Dealing in Death

     Performing euthanasia is a sacred privilege. This job brings me into people’s lives at their most vulnerable, and provides the opportunity to assure the animal they care for a peaceful, painless death. I appreciate that death is an extension of my role as healer and health professional, a final kindness I can offer when the alternatives are too ugly. Of course, there are instances where the ethical water is murky, no clear answer exists, and every choice feels crummy. 

     But I want to be the one in that room with the client, struggling through the dilemma, weighing the factors, trying to come out the other side with the kindest choice for my patient. For most people, the death of a loved one is rare; the responsibility to choose its timing and method rarer still. I want to be the one guiding the experience, taking the sting out of the unfamiliar responsibility, smoothing death’s rough edges. Hundreds of euthanasias after Red, my goal remains the same: I want to be generously compassionate, as a grieving client was to me in her most personal moment.