Do Dogs Know They are Dying?

Labor Day, 2006, is a day I will never forget.  It was a gorgeous day here in San Diego—bright, sunny and nearly 90 degrees.  I decided it was a perfect day to give the dogs an outdoor bath.  At the time, we had Valentine, the matriarch at nearly twelve years old, Izzy who was four, and the two young  ones Magic and Angelina who were two years old.  We started with Valentine—at her age she’d had a little problem with urinary incontinence, and she needed her bath the most.  We knew that the coiled up hose sitting in the sun on that hot afternoon had enough warm water to bathe her in, so my daughter and I mixed shampoo in a bucket of hot water from the kitchen sink, and just outside the garage, we soaped her up.  She seemed to be enjoying herself, a nice soapy massage on a beautiful day, and then a quick rinse.  As I turned to get the towel to dry her, I heard my daughter say loudly and in a panic, “VAL, DON’T FALL DOWN!”  I turned back around and she was gone, down on the wet pavement, eyes blank.  She never felt a thing.   I spent the rest of the afternoon sitting on the driveway with my dead dog, brushing her hair until it dried and the crematorium people came to take her away.  Needless to say, no one else got a bath that day.

I once read an essay by an oncologist who said that she hoped that she would die of cancer.   I was baffled by this, because my personal preference would be to go suddenly, of a heart attack or a massive stroke, preferably while doing something I enjoy.  But her reasoning was quite clear:  she said that with cancer, when you know that your days on earth are numbered, you still have time—time to do the things you always wanted to do, time to say good bye, time to make amends.  This has actually been true for most of my patients—when they know that they are diagnosed with a life threatening illness, their priorities change.  If they have the means, they live the lives they always wanted to live, for as long as they are able.  They remember, they forgive and they forget.  The trivialities of daily life become unimportant, except insofar as they struggle to get through them.   Many become the person they always wanted to be, and I hope that if this is my fate, I have the grace to do the same.

Today we took old Magic to the veterinary cardiologist.  Magic is my eldest deerhound—a big male at 120 pounds, and nearly ten years old.  The last two weeks have been hard for him—we’ve had thunderstorms and he has always been afraid of thunder.  In desperation over his anxiety last week I called his vet for a prescription for a tranquilizer.  It worked temporarily, but on Tuesday we had strangers in the house and he was panting, salivating, and his heart was beating far too rapidly.  I laid a hand on his chest and I knew instantly that his big old heart was failing.  Today the diagnostic echocardiogram confirmed what I already knew—that my big guy has dilated cardiomyopathy, and that he is in congestive heart failure.  We started medication immediately, and I am hoping for a few more weeks, or a few more months with this grand old man who is, as my husband says, “the dog who never did anything wrong.”

Do dogs, like humans, know when they are dying?  I don’t think so.  And in fact, for their sake, I hope not.  Unlike us, they have nothing to apologize for, and perhaps their next meal, or a walk in the park, or in a dream a wild chase after a highland stag, followed by a soft bed and the touch of a human hand is all that they hope for and dream about.  As Magic slowly made his way out of the van today onto solid ground, he was greeted warmly by Queen, Quicksilver and little Yoda.  I can no longer promise him a life beyond his years, but I promised him today that every day from now on will be the best day I can give him—lots of treats, a comfortable place to rest, and with all certainty, no more baths.

Two Hundred and Nine Short Essays Later

 

Here I am in Boston, on the eve of my very first writer’s conference, feeling a bit like an imposter.  After all, the extent of my writing so far has been this blog, apart from thousands of histories, physical exams and treatment plans over the last thirty-nine years since starting medical school.  It occurred to me that someone might actually want to know what it is that I write about.  And then it occurred to me that I had never actually thought about it.  So I did, and this is what I came up with.

 

WHAT I WRITE ABOUT:

Cancer                                                                                                                           Radiation Therapy                                                                                                                 Dogs                                                                                                                                   Cats                                                                                                                                     Horses                                                                                                                                   Being a mother                                                                                                                         My kids                                                                                                                                 Travel                                                                                                                                    My father                                                                                                                               My mother                                                                                                                             Being a doctor                                                                                                                         Life

WHAT I AM TRYING TO SAY ABOUT LIFE

Cancer patients inspire me and motivate me                                                                       I’d like to explain a few things about cancer                                                                         I’d like to explain a few things about radiation therapy                                                     Cancer is evil and is not selective and makes me sad                                                 Cancer patients can be funny and they also make me laugh                                   Sometimes people do really stupid things when it comes to cancer treatment         Sometimes simple people can be heroes                                                                         Dogs are good therapy for me, my cancer patients, and my kids                                     Ditto on cats                                                                                                                       Horses are beautiful, liberating, dangerous and always expensive                                     You can be a mother AND a doctor and it’s going to be very hard                                     Your kids will forgive your shortcomings                                                                            Your kids will make fun of you                                                                                           Your kids will be successful if you EXPECT them to be and don’t harass them              Travel is enlightening and sometimes difficult and sometimes funny                                    My surgeon father is both an inspiration and a source of extreme annoyance                       My mother had a hard life and a hard death, despite appearances                               There’s always someone worse off than you                                                                   There’s always something to hope for

 

WHAT I AM TRYING TO SAY ABOUT BEING A DOCTOR AND ABOUT MEDICINE

Examine your patients—it’s important                                                                               Think for yourself and follow your gut instinct                                                                Beware of templates.  They tempt us to cheat                                                                     The Rules of the House of God still apply                                                                      Doctors make mistakes.                                                                                                       Be very selective about who you hire and set a good example for them                             Be the captain of the ship                                                                                                     Try not to whine, even if you fail                                                                             Communicate with your referring doctors and with your patients                                     Take the time and make the time                                                                                         Learn to speak slowly and clearly in layman’s terms                                                           Try not to say no, and never say “never”                                                                             DO NOT DROP THE BALL when dealing with cancer patients                                           And finally, answer your goddamned phone calls

Did I leave anything out?

Cancer and AIDS, AIDS and Cancer

For Dr. Abraham Verghese, who inspires me.

This evening on the way home from Boston I finished a book that I had started more than a month ago, on my way back from Albuquerque.  Well, that is not entirely truthful.  I stopped reading on page 408, because if I had kept going everyone on the plane would have seen me cry.  I finished it at home a few hours later.  The book is called “My Own Country—a Doctor’s Story” by Abraham Verghese.  I had read his novel, “Cutting for Stone” last year and wanted to read more.  This book, “My Own Country” is autobiographical, detailing the author’s early years after residency and a fellowship in infectious disease in Boston, as doctor caring for the first HIV positive and AIDS patients in rural Tennessee in the early 1980’s, when there was no treatment for the infection, and doctors watched helplessly as each and every patient they cared for died.

I am old enough to be all too familiar with this scenario—in 1982 I was a resident in radiation oncology married to an attending in pulmonology and infectious diseases and we were both seeing the ravages of this disease for which there was yet no blood test, only a constellation of symptoms and opportunistic infections that had heretofore been seen only in the most immunosuppressed cancer patients. It would be a few years before the medical profession figured out the exact mode of transmission, and discovered the retrovirus that caused the illness—and a few more years before the first treatment, the drug AZT was approved.  In the meantime, we watched the patients die, and it was not pretty.  In lighter moments, I would joke that we were the “fun” couple at the cocktail party—cancer and AIDS, AIDS and cancer.  In private, I realized that if I had to choose between one or the other, I would choose cancer.  At least most of my patients had a fighting chance.  My husband’s, at the time, did not.

Verghese left Tennessee, and a job he loved but which had clearly taken its toll on him personally, in 1989.  My husband left his post as the Chief of Pulmonary Medicine at the New England Deaconess Hospital in 1992.   If you ask him, he will say it was the lure of the biotech boom, and the promise of stock options and an early retirement.  But I think there was another side to it, the side that is difficult for doctors to talk about, that part of the job where each time a patient dies, a little part of the soul of the doctor dies with him.  In Boston, the pediatric oncologists at the Jimmy Fund were my heroes—to me, watching children die would be the hardest job of all.  The AIDS doctors, before the development of the drug combinations which have turned HIV infection into a chronic disease, had the second hardest job.

I’ve moved around quite a bit in my career—five years here, five years there, Houston, Boston, San Diego.  Every five years or so, I start to get a bit restless, and I look for something new, something different.  I like to say I need a new challenge.  Tonight, finishing Verghese’s book, I realized that he was able to put into words that nagging need for transformation, relocation, and change so I will quote him:  “It all happened so suddenly.  I left my own country, my beloved Tennessee.  Perhaps my perennial migrations, almost hereditary, are a way to avoid loss.  With deep roots come great comforts.  Yet deep attachments are the hardest to lose.  Maybe that is why drifters avoid them.”

For most of us doctors, leaving is easier said than done, for medicine is our own country.

Perspective

When I was young and foolish, or very smart depending on your perspective, I married a man who is five and a half years older than me. When my husband was my age (and never trust a woman who will tell you her age, but between you and me I am 58), he started to say something quite often whenever he would get annoyed.  He would say, “I’m too old for this!”  This would irritate me no end because I thought that I would never be too old for ANYTHING, and if I was I would never admit it so freely.  I would reply, “If I ever start saying that, just take me out behind the barn and shoot me!”   Now that I am exactly the age that he was when he started to say it, I find myself saying it too.  Luckily for me, he hasn’t gunned me down yet!  Our tolerance for little annoyances seems to lessen as we age.  In other words, we become a lot more like our least favorite parent.

There is another curious phenomenon I have noticed. I had to put one of my all-time favorite dogs to sleep in July.  He was old, for a deerhound male and he had lived a wonderful life as the “patriarch”, the alpha dog and the undisputed best puppy raiser ever in our household.  As it turned out, we had to do the deed on our thirty second wedding anniversary, July 13.  This year, fittingly, that day was a Friday and I didn’t much feel like celebrating after that.  I am always sad when we have to put a dog or a horse down—it’s natural to feel that way.  But I am finding that the older I get, the harder I am taking each loss.  I’ve thought about it and I think the reason why is that I am staring my own mortality in the face when I watch another beloved pet die. When you’re a kid, you just don’t see how these things could be applicable to you.  When you’re older, you think you should get used to it, but the funny thing is, you just never do.

When I started in radiation oncology, most of my patients were older than me, in fact, a lot older.  Now each day I realize that many of them are younger than I am and that is a sobering thought.  In college, one of my favorite quotes was from Andrew Marvell’s “To His Coy Mistress” –“But at my back I always hear Time’s winged chariot hurrying near.”  I know what it means now.  It’s why I stay up late; it’s why I am writing.  The company No Fear updated Marvell’s sentiment on a T shirt that I wore until it wore out after too many washings.  On the front it said, “It’s not the pace of life that concerns me.  It’s the sudden stop at the end.”

Nothing like taking care of cancer patients to give you a little perspective.

Why Won’t They Stop Talking to Me About Sex?

I have recently checked the website of the American Board of Sexology, and I can absolutely confirm that I am NOT a sexologist.  So why is it that my patients ALWAYS want to talk about sex?  Old, young, male, female, gay, lesbian and transgendered—it doesn’t matter.  This is a topic on everyone’s mind, apparently all of the time. In spite of, or perhaps because of their cancer diagnosis, sex, whether for recreation or procreation is the “hot topic” in many of my consultations.

Secretly, I wonder if they are trying to make me blush.  This is not hard to do, for I am fair complected and extremely gullible.  If I am not having a hot flash, I am scarlet with embarrassment over some of these exam table confessionals.  Like the guy, now in his late sixties, who regaled me with the tales of conception of each and every one of his 14 children.  You read that right—FOURTEEN!   He was concerned that his prostate cancer treatment might slow him down a bit and that his wife might not be satisfied.  (Pause here to glance at the Mrs, seated close by, who is rolling her eyes while trying to reassure him that indeed, honey, she could use a break!)  Or the man who needed to tell me about every little sensation which has occurred in his nether regions now that he is ten days into an eight week course of treatment.  He omits nothing—soup to the proverbial nuts. My nurse and I glance at one another.  It is going to be a very long eight weeks.

These conversationalists are not only men—my female patients get right into the act.  A seventy year old breast cancer patient sees me once a week for her “on treatment visit”.  I want to talk about her side effects of the radiation therapy, her skin reaction, her fatigue.  She wants to talk about her new boyfriend, and the best possible vaginal lubricants.  When I find myself deep in conversation regarding the benefits of Astroglide versus the traditional KY jelly, I know for certain that I am out of my element.  I am not a sex therapist, nor ever meant to be one.  It was so much simpler back in my ER days during my internal medicine residency.  There the task was simple:  seek out and FIND the lost sex toy in the bodily orifice where it was last seen. Send the grateful patient home with appropriate admonishments regarding the use of such objects.  Next Saturday night, repeat.  Easy.

I have concluded that they think I must know something.  Or have a very exciting life outside the clinic.  Little do they know that my late night entertainment is to browse eBay and Etsy, looking for bargains unique and unusual.  I have discovered a little shop on Etsy, called Lumme Designs, where the proprietor, Tiina, describes herself as working deep in the woods in Finland.  I imagine her blonde head bent over her sewing in those never ending winters, where the days are dark and blend into the nights.  Each item she sews is unique and handmade to order, but one in particular caught my eye—a purple linen and black leather corset, fitted with many buckles and straps and laces and cinches.  Tiina describes this creation as Handmade Harlot Fashion.  In an alternate universe, I picture myself in this corset. Perhaps my patients are on to something after all!