The Vigil

People always say, “You’ll know when it is time.”  Sometimes that is true.  But sometimes it’s hard to tell.  This has been one of those times.  Having lived through the horrendous experience of our old deerhound Magic fracturing his leg due to a previously undiagnosed osteosarcoma, I want very badly to spare Queen that awful demise.  But when is it time, actually?

With a horse, I think it’s easier.  Those that are spared the usual disasters which befall horses—the broken leg due to a fall, the perforated intestine due to colic—they simply get old.  When their arthritis can no longer be managed, when the tendons finally give way and the hooves can no longer bear the weight of their bodies, they lie down and cannot rise.  Or they stop eating and stand quietly in a corner of a green pasture.  And then you know its time.

Dogs are different.  They want to be with you.  They are willing to put up with pain and suffering beyond what a human thinks is possible, as long as you will lie down with them, pat their heads, give them a special treat while looking into their eyes on a sunny day.   Leaving must seem to them, after a life of protecting you, a betrayal.  They want to stay for as long as they can.

The vigil started this morning.  The dogs are smarter than I am.  I let the puppies in the house while the lawn was being mowed—the mower frightens them.  When Pibb was ten weeks old, he made the mistake of stepping on Queen who was asleep at the time.  She made sure that never again will he forget the maxim to “let sleeping dogs lie”.  When the kerfuffle ended, I was shocked to see that not a hair on his head had been harmed.

When Pibb came in today, he immediately lay down with Queen, head to head.  An hour later, I noticed her position had shifted.  Her front leg was touching his, paw to paw.  I think she was reassuring him.  This afternoon, she felt well enough to go out and bask in the sunshine.  Yoda, my little mixed breed rescue, has always been an empathetic little dog.  He cries when the girls have their nails trimmed.  Today he plopped down right beside her face.  And there he stayed, his little body shielding her eyes from the sun.

Saying goodbye has never been easy for me.  But I know that it’s time.  And if there is a heaven for dogs, Magic and Izzy and little Jack will be waiting for her.  We will be okay down here, knowing she is no longer in pain.

Rest in peace, GCh. Jaraluv Queen.  Forever our Queen of Hearts.

Another Dog, Same Breed, As Soon as Possible

“Hark to Beaumont. Softly, Beaumont, mon amy. Oyez à Beaumont the valiant. Swef, le douce Beaumont, swef, swef.” Beaumont licked his hand but could not wag his tail.”  T.H. White, “The Once and Future King”.
               For the past couple of years, my life has been pretty easy.  I spent last summer putting in a vegetable garden, and making improvements in the landscaping around my home.  In September I went back to work after a somewhat abbreviated bout of retirement, but just part time covering other radiation oncologists’ practices.  My two Scottish Deerhound sisters, Queen and Quicksilver were then approaching 7 years old, and were long past the destructive behavior so characteristic of the giant breeds in their youth. My little mixed breed rescue Yoda had never been a problem.
             On December 19, 2015 I upended my quiet comfortable life by getting a new puppy, a ten week old borzoi named Pibb.  Two weeks later, I compounded the chaos by acquiring a “brother” for him to play with, an eighteen week old Scottish deerhound puppy named Cole.  Despite a few misgivings and knowing full well what I was getting myself into, I went ahead with what I knew deep in my heart was a preemptive strike. Queen had been limping off and on, and despite my denial I knew that the proverbial “other shoe” had dropped.  Her chronic lameness worsened suddenly a few weeks ago and like her dam before her, she was diagnosed with osteosarcoma, a bone cancer common in her breed.
                  As a radiation oncologist for adults with cancer, my day to day ethical challenges are few. I do my very best to be sure that my patients understand their diseases, and the side effects, risks and benefits of treatment. As a devastated dog owner, the decision making process is not so simple. The tell tale X-rays resulted in a consultation with a board certified veterinary oncologist, where my husband and I sat and listened to our options. Amputation and chemotherapy, the standard of care, would give Queen a median survival of 9 months.  Untreated the disease progresses rapidly, often times resulting in a pathologic fracture. Pain control is also a problem, and pain can often be ameliorated by radiation therapy–my own specialty. Except in the rarest of cases, the disease is incurable because metastases are present, whether they can be detected or not.  All treatment is palliative.
               As we sat with the veterinary oncologist two weeks ago, contemplating our options, I remembered my friend and vet oncologist Dr. Greg Ogilvie saying, “The dog doesn’t look in the mirror and say, ‘Oh, I only have three legs.’ The dog only knows that the pain is gone.”  And we were told that dogs tolerate chemotherapy exceptionally well, much better than human beings.  So we sat and nodded and thought that perhaps our initial instinct, which was to provide comfort care only, might be wrong.  Who knows better than a cancer doctor how important it is to provide and maintain hope?  And so we wavered.
                 In her incomparable essay “Oyez a Beaumont”, Vicki Hearne describes what it was like to lose her Airedale Gunner when he fractured his pelvis from prostate cancer.  As a dog trainer, her advice to clients has never wavered:  ”Another dog, same breed, as soon as possible.”  And then she admits to us, that it was ten years between the death of Gunner and the purchase of a new Airedale pup.  She says, with feigned indifference as our hearts break, “That was as soon as I could get to it,what with one thing or another.”  I got to it a little sooner.
               Deerhounds are homebodies, and our Queen particularly so.  Carsick since puppyhood, trips are stressful for her, and the risk of fracture even getting such a large dog in and out of the car is significant. Outside the veterinary specialty hospital, in the cold light of day, we lifted her into the car and she fell immediately into a sound sleep because she knew she was going home-home to her sister, her humans, and even those pesky puppies. We knew then that home is where she will be for what remains of her life.  We love her and this, more than anything, is what we owe her.

The Things His Father Taught Him

If you had asked me before today, I would have told you that I was beyond being inspired by cancer stories.  There are so many of them, and I have tried to share the ones that have been most meaningful to me with you. But today was different.  Today, Teddy Kennedy Jr. gave the keynote address at ASTRO. For those of you who don’t remember, Teddy Kennedy Jr was twelve years old in 1973, when he was diagnosed with osteosarcoma—bone cancer that was widely considered fatal at the time.  Teddy is now Edward, and he is an all grown up cancer survivor who has dedicated his life to health care law. He told  endearingly funny jokes and family vignettes as an introduction—he said that in turn of the last century Boston, his grandmother used to go to his great grandfather’s political speeches because back then Irish Catholics couldn’t become doctors or lawyers so they went into politics, and seeing how they were quite “prolific in their ability to multiply” (his words), they succeeded in getting elected.  His grandmother was quite adamant that the children and grandchildren not waste their hard earned political clout—they had to DO something with their lives.

Edward Kennedy Jr told us all what it was like to have his father tell him that the doctors were going to remove “part” of his leg.  When he asked what part, assuming that it would be the raised red lump on his calf, his father told him that it would be “all of it”—the lower leg beneath the knee.  And that when the surgery was over, he would be getting an experimental chemotherapy regimen of high dose methotrexate at the Jimmy Fund, the part of the Dana Farber Cancer Institute in Boston where they treat children.  As he put it, this was at an age where having a pimple was a disaster, and having a bald head was unthinkable.  He talked about how, as a Kennedy only a few years after the assassination of both his uncle John and his uncle Bobby, he was expected to keep up a façade of being brave.  He spoke of what it was like to have people tell him that they “felt sorry for him”.  And about how, after the operation, the doctors would come in with their entourages of medical students and residents, and look at his stump, but not at him.  And he talked about how his father, Edward Kennedy Sr told him that the biggest obstacles he would face would be the ones he created for himself.  His leg was amputated in November.  He was skiing again by March.  His father died in 2009 of a malignant brain tumor.  By then, he was called “the Lion” of the United States Senate.

The last part of Edward Juniors talk was about survivorship.  He reminded us that it is okay to be sad and to feel loss when diagnosed with cancer, and of the importance of aftercare for psychosocial and emotional issues.   He talked about the fact that when a person with cancer leaves my care, and the care of the surgeon and the medical oncologist, that person becomes a person with a pre-existing illness.   He spoke about Obamacare, and what this legislation has done for people with cancer.  He called it a godsend.  Insurance companies can NO LONGER deny a cancer patient coverage because of their pre-existing condition.  They cannot drop that person, or charge outrageous sums.  They cannot deny that person access to potentially life saving clinical trials.  He spoke of the birth of his daughter eighteen years ago, and how that event was the culmination of everything he thought would never happen to him and how grateful he feels, to this day, to the physicians who treated him.

One in four of us will get cancer.  And many of us will die from it.  Do we want to be cancer victims?  Or cancer survivors?  Do we want to help those less medically fortunate than ourselves, or not?  It is time to decide.

I am a Dog Person

If it’s true that in this world there are cat people and dog people, I am most definitely a dog person.  I cannot remember a time when I have had fewer than four dogs.  Most of my like-minded friends think that this is normal.  My chosen breed is the Scottish Deerhound.  This is a very old breed, used in Scotland to hunt the red deer even before the advent of firearms.  These powerful hounds were able to keep pace with the fleetest of foot, and are pictured in old etchings going for the neck and throat, or for the hamstrings of the unfortunate deer. It has been said that the deerhound is the “Royal Dog of Scotland”, that no one ranked lower than an earl could own them, and that a “leash” of deerhounds was the price whereby a convicted murderer could buy back his life.  My friend Richard, historian of the breed, says that these stories are likely apocryphal, but they please me nonetheless.  Lately, my husband has taken to calling himself “The Laird”, while three or four of them lounge about his feet as he watches Monday night football on the giant screen tv.  Sir Walter Scott’s monument sits in the heart of Edinburgh, his deerhound Maida at his side, whom he called “the most perfect creature of heaven.”  I couldn’t agree more.

And so it was only natural, that when the veterinary specialty clinic in our area was looking to partner with human radiation oncologists for the purpose of delivering stereotactic radiosurgery to dogs with brain tumors, I was chosen to forge ahead with the alliance.  As part of the bonding process, I was invited to tour the veterinary cancer center with my staff.  The facility was clean, bright and airy, the staff cheerful and obviously skilled, and the linear accelerator used to treat the animals was state of the art. Stationed outside the linac was a white board schedule with the names and treatment times of the dogs under treatment. I was surprised to see that the schedule was full, morning to evening. Both the medical oncologist and the radiation oncologist greeted us, and we discussed ways in which we could collaborate to improve the lives of both dogs and humans affected by cancer.   As we were leaving, a sad eyed basset hound, held tightly in the arms of a vet tech, gave a low whimper as his IV was started for his chemotherapy.  To my amazement, my office manager, who has seen EVERYTHING in the human spectrum of suffering over a 15 year career working in cancer centers, burst into tears and exclaimed, “It’s just so SAD!”.  And she is not a dog person.

What is it that drives human beings to spend thousands of dollars treating their pets for cancer?  People who swear that they would never under ANY circumstances themselves undergo chemotherapy or radiation change their minds abruptly when it comes to their beloved pet.  People who become apoplectic when faced with 20% co-pays on their own insurance will cheerfully re-mortage their homes to give their 11 year old dog a chance of cure.  What is it about the human-animal bond that compels us to never give up, to fight the good fight for our cat with lymphoma?  Especially since that animal cannot tell us that yes, they want that amputation and they want that chemotherapy and radiation.  Scottish deerhounds are particularly susceptible to osteosarcoma, a nearly always fatal bone cancer very common in large to giant breed dogs.  I asked the veterinary oncologist, who has since become a good friend, “Why do people amputate the leg of a giant running hound, and give intense chemotherapy, when on average the dog lives only a year?”  I tried not to sound judgmental but he knew what I meant.  He said, “Miranda, you must stop thinking of the dog as a human being.  The dog doesn’t look in the mirror and say, where did my leg go?  Look at how deformed I am!  The dog says, I am so grateful that the horrible pain is gone.”

I have been very fortunate.  I have never had to make the decision to amputate the leg of a dog who lives to run.  But I have corresponded for years with a British couple, Marc and Bev Doyle, who made that decision for their deerhound Darcy, who lived happily as a “tripod” for four more years before dying of other causes.  Marc and Bev have used Darcy’s example to raise a huge amount of money for osteosarcoma research and have likely benefited countless other Darcys in the process.  Marc is a photographer, and one of my favorite images of his was taken out on the moors, when Darcy ventured out for a walk for the very first time after her amputation.  It is a purposely grainy black and white photograph, taken from behind as the day is waning.  Darcy has become tired on her walk and pauses for a few minutes to lean on her deerhound brother Duffy, who stands very still to support her while she rests.  There is a gentle breeze reflected in the dogs coats. They are both looking ahead to the horizon.  I call this picture “Lean on Me”.   Marc calls it simply, “Hero.”

The odds are that one day, perhaps soon, my luck will run out and I too will face the decision of whether to pursue aggressive cancer care for one of my dogs. When that time comes, I don’t know what I will do.   Do you?