Spencer is an 11 year old black and white boy who has been battling small cell gastric lymphoma for 2 + years. He's just over the past few days stopped eating and is very low profile. He's been on Cerenia every day or two to control nausea and vomiting, medical cannabis in coconut oil (the kind without the THC, it's hemp terpenes), just started a couple of weeks ago on prednisolone, has had mirtazapine every few days (doesn't work anymore). He's dropped over the months from 15 pounds to 9.2 pounds. He gets 120 ml sub Q fluids twice a week when a retired vet tech comes over to help with it. He used to be diabetic but it's in full remission since he's lost so much weight. I think it hurts him to eat. There is no blockage and he does have normal bowel movements when he's eating. When he had an endoscopy (prior to chemo) the vet said his stomach was quite diseased. But then he had chemo and went into remission. Eventually the chemo stopped working.

Do you think a feeding tube would help Spencer or should he just be euthanized at this point.

It's heart breaking.

ANSWER:

We want to live our lives to the fullest. Wring it out to the last drop.

Lets say for the sake of argument that you have done everything you could.

So that there are no more drops to give.

By these decisions, you have become an expert at survival. You are good, no, great at it!

But none of us are experts at death.

We feel stunned and unprepared for it mostly.  

When we acknowledge that the body of our companion must and will pass, it does not mean you are giving up.

It means you are giving in.

You see that there is in fact one more drop to give: dignity despite the disease.   

This could mean you provide him a feeding tube. This could mean that you don’t.

We don’t abandon each other when we let go.

We instead we realize our human potential for growth within the pain.

It’s the only way you can carry their memory, and let it change you in a way that they would want.

Dr. Kris

I am wondering if zach was able to get through the ataxia. I saw the video but it was open-ended.

I have a female cat who has similar symptoms.

Answer:

Zack was able to get through the Ataxia, and lived for years afterward!

I can’t say without having my hands directly on your cat that a neurological issue like ataxia is not part of the issue here.

But what I can say is that your kitty does not look Ataxic to me.

I see bilateral hind end lameness, worse on the left, with epaxial muscle atrophy, perhaps a plantigrade gait occasionally on one of the videos, and altered posture while urinating on another video.

She has conscious control of her limbs, but is purposefully reluctant to use them because she is likely painful.

Just like your girl is showing here, pain often happens without a peep, while they are doing other things normally in their lives. Like, playing, being cute, eating, and all the other normal stuff they do. At any age, no crying, yowling or distress calls.   

Assuming everything else was ok with her health, DJD (degenerative joint disease) of her back, hips or knees is what I would be checking her out for at your vet. She looks arthritically flared up, but she's probably been subtle or hiding it for a while.

Good luck at the vets, and if they agree, know there are many great things you can do to improve how she feels. We’ll be talking about arthritic cats a lot this year!

 Also, pebbles person asked this:

Hello Dr. Our cat is now 22 her name is Pebbles and I think she has developed Ataxia. Her back leg wobble has gotten worse and quickly. We have been to a vet and he gave us meloxicam please help!

So I hope you saw “Zack Vs Ataxia”:

They need some time (about a week) to know if they will turn around or not.

Pick and choose what’s in the video according to what you and your vet feel is applicable for Pebbles.  

Will be thinking of you;

Dr. Kris

 Hi Dr Kris, Re Metacam, I have a 15yr old kitty named Griffin who has advanced DJD in both front legs (wrists & elbows), confirmed by xrays. I'm going to start Cold Laser Therapy & he's already on Cosequin but he needs some sort of pain medication as well. I know NSAIDs are great for arthritis but like everyone else they scare me.

I've watched Zack's video & read this blog & am leaning towards using Metacam for my boy but I am still reluctant. Griffin has stage 1 CKD, his SDMA is about 19 & his BUN & CREA are normal altho at the high end of norm. Those values have been that way for the past yr & his SDMA has actually gone down a few points in his last two blood tests. So I guess that means his kidneys are stable?? Griffin weighs 6.5 kg, he's robust boy, he also has HyperT controlled by Methimazole & he also has a grade 5 heart murmur (no concurrent heart disease).

In Zack's video you said you only give Metacam to well hydrated cats so does that mean you always give SQ fluids when giving Metacam? You also mentioned using the weaning dose of Metacam but I can't seem to find info about what the weaning dose actually is. Griffin just had a dental by Dr Thatcher at AVAH & I did give him Metacam for 3 days at a smaller does than was rx'd (3kg dose instead of 6kg dose) & I didn't notice any outward signs that it bothered him. What are your thoughts on giving Griffin Metacam daily for his DJD? I really appreciate your input!

Thank you! Luanne

Answer:

Thank you for your question Luanne.

I went to school with Dr. Thatcher who did Griffin’s teeth! He’s a cool dude.

So, lots of stuff to unpack in your question there.

A lot of folks have all-cap opinions on things. As in THIS IS MY OPINION AND YOU SHOULD LISTEN TO ME.

But cats need us to be more nuanced than that. They are complicated. They don’t exist in the black n’ white, all-cap world of opinion.

It’s perfectly normal to be reluctant to use an NSAID. Or any drug for that matter.

Why?

Look through these pictures.

Which one stuck with you? Which one made you inhale a bit deeper? Sit up straighter? Eyes widen?

Which one had the most impact?

Most people react to the last one. The unpleasant one. The foreboding one.

The one that speaks to our insecurities and doubt.

And that one wasn't even real. It’s a painting from someone’s imagination. And yet we still emotionally react to it as if it were.  

I can show you pleasant memories of water most of the time, but you only need to see something negative once to affect your thinking.

We humans have a negative bias. We are supposed to - it helps us survive!

When you are figuring out what to give your cat, you have to live with that feeling.

For some, that’s enough to say no thanks. And you can’t blame anyone for feeling that way.

For myself and others, we dig upwards through those feelings, and know that the first 3 images is where our mind needs to go. Because I can guarantee you that when we don’t, sometimes the best choices for our cats fall through the cracks. And some of those cats don’t come back from that.

So, with the understanding that you will never fully get rid of the uncertainties and those feelings, lets unpack some more of your question:

Griffin has stage 1 CKD, his SDMA is about 19 & his BUN & CREA are normal altho at the high end of norm. Those values have been that way for the past yr & his SDMA has actually gone down a few points in his last two blood tests. So I guess that means his kidneys are stable?? Griffin weighs 6.5 kg, he's robust boy.

For my patients, cats with Griffin’s profile are candidates for NSAIDs if it fits the goals we have for that patient. Stable. Robust enough. No radical progression in kidney disease occurring.

In Zack's video you said you only give Metacam to well hydrated cats so does that mean you always give SQ fluids when giving Metacam?

It’s mandatory if they are getting an injection of it. For the oral liquid you give at home, I often do but not necessarily. It’s just that many arthritic cats, or cats who only eat dry food, or cats with some concurrent illness affecting their appetite, their hydration status might not be the best. And that’s when you start to run into problems with NSAIDS. And If I can’t tell, I give them the benefit of the doubt.  And many people can’t tell at home. And that’s the thing with CKD…if they are having advanced symptoms, then they are gonna be sub clinically dehydrated. So for me, the fluids are a safety factor.
 
You also mentioned using the weaning dose of Metacam but I can't seem to find info about what the weaning dose actually is. Griffin just had a dental by Dr Thatcher at AVAH & I did give him Metacam for 3 days at a smaller dose & I didn't notice any outward signs that it bothered him.

You gotta use everything you know about a patient to create success with a dose. So that means I'm never at the box recommendation.

I’m off label.

I don’t know what’s up with the labelling in the United States - it seems to be higher than what is written for Canada.

And even then, my doses are typically 50 to 75 % lower than what’s on the box.

And then, my dose scheduling is rarely every day. It can be. But it also can be a monday, wednesday friday with weekends off. Or less. It’s all about the individual’s response to it.

What are your thoughts on giving Griffin Metacam daily for his DJD?

First, we make a goal. We define the purpose for using it. What we want to achieve by using that. Beyond pain control. And once we have that goal, we plan from there.  We know when we are going to use it, and when we might not use it, and when we substitute something else for it.

P.S. - so many of you have written in, wanting solutions for your arthritic, DJD cats. I do have something in the works that will help…

Dr. Kris

First, thank you, thank you, for the Give SQ Fluids Lilke a Pro (and Save Your Cat) video. Watching that gave me the confidence to help my cat Russell feel better. He's an old guy, a rescue so I dont' know how old, and now he's got CKD, so we give him fluids twice a week.

I'd really like to give the shebang method a shot, so I'm writing to ask for more details on the equipment needed. The syringes were easy to find, 60cc with luer lock tips. The IV extension set is a little harder to figure out. Standard bore? Mini-bore? Length?

So, I'd really appreciate it if you could give some recommendations for the iv extension set, like the length, the bore (?), connector type, etc.

Finally, the needles. In the video, you mentioned 18g needles. Do you use a different type of needle to draw the fluid out of the bag (and would a blunt tip be ok for that?) And if you do use the same type of needle to draw the fluid from the bag and give fluids to the cat, should you use different needles for drawing out the fluid and poking the cat?

Thank you so much for sharing our knowledge and compassion. Really, it helped calm me down so much when we needed to start the SQs.

Answer:

Thank you for treating Russell, your older cat.

You would not believe how many people give up on their older pets...just because they got old.  And because we don't want to "put him through something".   As their bodies weaken, so does the will to carry them through their problems it seems.

But life is about "being put through something", isn't it?

And as our bodies weaken, how we deal with it gives us perspective. Gives us meaning. And it gives us hope.  

It's easy to see how the thought of poking him with a needle is "putting him through something".

But for those of us who share ours space and time on this earth with these companions, we know that the bad times are just as important as the good.

That the cycle of life happens, and all we get to control is how we handled ourselves as we go along for the ride.  

So I'm glad you’re pushing further. Learning more.  Seeing what possibilities there could be for Russell. Doing the things you need to do to be good with your choices for him.

Now when you are on this path, most people come to realize that their cats need choices.

As you expand those choices, we tend to get better results.

Some of us have marshmallow cats that let you do anything the first time you try.

Some of us have cats that will react and reject anything.  

But if you make the right choices, look at what can happen.

Look at all the ways that these cats chose to happily accept their SQ fluids:

Some cats will only perceive the experience of receiving SQ fluids as a positive thing in their life if you keep the proceedings fairly short. So a large 18G or 20G needle allows them to have all the fluids they need in less time. Anyone that tells you it's bad to use an 18G needle because it's larger is utterly missing the point that cats are individuals and their one size fits all opinions will fail.  
 
Some cats can be made to feel that a larger needle feels like no needle!

Some cats have a preference for a small needle, so then the syringe technique shines.

So really, any choice of needle and tubing can work.

It's more about the choices your cat wants you to make.

I have a second video that goes into detail about how to do that here:

I always use an 18G needle to draw up the fluids from the bag, then a fresh needle (which ever Gauge my cat tells me to use)

So, Russell’s people person.

You said my video helped to calm you down when you needed to start the SQ fluids.

When I hear about you and Russell, I get to calm down too. You remind me about why I do this in the first place.

So thank you.

Dr. Kris

My poor 17 yr cat has kidney, IBD, and I'd now anemic , too many UTI . Meds destroyed her appetite and it is too hard to get her to eat. Wish someone had done a feeding tube months ago . Took her to emergency and the vet felt that a blood transfusion wouldn't help her for more than 4 days. I don't know...so many opions, high costs and getting no where. She was on budesinide, now I switched her to predsiolone and convenia shot.

ANSWER:

She has so many things going on.

So many battles that are being fought.

So many opinions you are going to get that will make you feel conflicted.

So many hopes that a medication could work...only to watch her appetite get worse.

So many things that could have been tried it always seems.

So many trips in the car, back and forth, to the vet, the emergency, then back to the vets.
And then it seems that bit by bit, things are falling apart.

But there is one thing that it's never too late for.

You look her in the eyes, and you see unhappiness.

And it's fair that we are all going to be unhappy at some point in our lives. For people who live with chronic pain or mental illness, it can be every day, every week. But we keep on going. We can see some sort of future that is joyful. Even if it's just watching the world go by, sitting on the balcony sipping a cup of tea.

So yes, by all means try. Flip opinions on their head. If there was any advice we were first dismissive of, sometimes we come back to it and get curious about it to create new options.  

But if your companion is without respite. If the joy is fleeting or not coming back.  

Then it's ok to relieve them of that.

It's not because you didn't try.

It's not because they’re old.

It's because it's never too late to look them in the eyes, tell them you did the best you could. Tell them that you will love them forever. You'll never forget them.

And you'll never let any harm come to them.

Which is why it's ok to let them go.

Dr. Kris