As a veterinarian, I’ve seen lots of cancers: lymphoma. Melanoma. Osteosarcoma. Hemangiosarcoma. Mast cell tumors. Wait, those are just my own dogs I’m talking about. When I factor in my clients, I think I’ve seen it all.
Dogs get cancer, at very high rates: about 50% of senior dogs die of it, if the statistics are to be believed. Why? Well, if you read overly simplified, graphics-intensive websites by people who really don’t know what they’re talking about, they will tell you that they know why cancer happens: GMOs. Preservatives. Kibble. Microwaves.
I wish it were that simple. It’s not. And the reason that line of thought drives me nuts is that it has sent so many lovely people into spirals of depression when their dog dies and someone on the internet convinced them it was their fault because they, the owner, did something terrible like feed their dog kibble or use a plastic bowl. People end up in therapy because of things like this.
Cancer is not a singular diagnosis; the type and breath of neoplastic disease means there’s often little resemblance from case to case; a transmissible venereal tumor bears very little resemblance to a splenic hemangiosarcoma. If we could pinpoint cancer to one cause, we’d all be rich. And yet, with all this secret knowledge, overall cancer rates aren’t budging.
Because I love a breed known for having one of the highest rates of cancer (is it the fact that Golden Retriever owners feed worse food overall? Or is it genetics?) I watch Brody pretty closely. Knowing that 60% of Goldens get cancer in their lifetime, I spend a lot of time inspecting him for lumps. As we speak, the largest observational study of its kind is currently underway to help us better understand what’s going on. In the meantime, you do the best you can but truthfully, there’s not a whole lot of ability to predict and prevent cancer. Even for the people who home cook organic food (sorry. Do it because you want to, not because it will make your dog live forever.)
You can save money (and life expectancy) by doing some simple things:
Knowing he is an at-risk breed, I do what I can to try and keep Brody healthy. When he gained too much weight on his food, I got the weight off. Obesity is thought to be a risk factor for cancer. Just as importantly, I get his bumps evaluated and when I find one, I don’t mess around.
The dog eats like a king; I give him the good stuff because I care about quality ingredients, though not enough to condemn people who can’t afford it. But even with his high end diets, at age 6, he’s on his second cancer. The first one, a melanoma, was excised two years ago and has yet to recur- because we caught it early. And now we have this: a little teeny ear lump.
I thought it was no big deal, but I got it evaluated anyway. See? We vets do it too. A lump is a lump is a lump. Until you get it microscopically evaluated, you just don’t know. I just got the call last week: it’s a mast cell tumor.
I’m thrilled we got this diagnosis
Am I thrilled Brody has a mast cell tumor? Of course not. They stink. Despite the fact that the visible mass is only half a centimeter, this type of tumor has tons of microscopic disease and is notorious for requiring huge surgical margins for a complete excision. For that little tiny tic-tac mass on his ear, he is very likely going to need to lose his entire pinna. (I’m getting a surgical consult this week.)
However, losing an ear is minor compared to where these things end up when people wait. You can lose an ear, but you can’t lose an entire head, for example. This is small beans compared to what lots of pets need to go through later in the game when masses grow. If we get a complete excision, this should be a closed case. And guess what? It’s so much cheaper than tons of radiation and chemo and massive surgeries. Win-win for the dog and your wallet. I’m not happy he has it, but I’m happy I know now, early.
Why wait? Aspirate that shizz!!
What one thing can you do to guarantee your pet won’t get cancer? There isn’t one.
What you can do is maximize their chances of survival and recovery: Don’t mess around. Dr. Sue Ettinger, veterinary oncologist and all-around brilliant person, has an initiative called Why Wait Aspirate that is as simple as can be: when a vet tells you that a lump is ok to “just watch”, what does that mean? When do you do more than watch it? Here’s Dr. Sue’s guidelines*:
ASPIRATE OR BIOPSY IT!
Easy peasy, no pun intended. Of all the things you can do to help your pet live long and live healthy, none matters more than early detection.
*Photo Credits: Calendar by Michael Hyde, Flickr Creative Commons license; Peas by Isabel Eyre, Flickr Creative Commons License
I am becoming increasingly convinced the communication gap between veterinarians and clients is the number one problem we’ve failed to solve. We’re just not on the same page a lot of the time, it seems, and it makes me sad. I can’t read a single article online without coming across “veterinarians are money grubbing pigs that suck” (true blog title) and someone else saying “if you can’t afford x/y/z/q you shouldn’t have gotten a pet, jerk.” I feel as though this is perhaps a bit extreme, but it’s what happens when we don’t work together to identify our goals.
Common Fallacies of Bad Client Interactions
(In just as many cases, the vet on the left is an associate up to his or her ears in student debt and just trying to make it through the day without getting yelled at one more time, and the client on the right is a stressed out single parent who just spent a grand fixing her car.)
Much of this angst comes from the pervasive assumption that in all cases we will do everything we can medically, no matter what, which was fine a while back when “everything” meant “antibiotics” but as veterinary medicine has advanced, has come to mean “MRI, spinal tap, radiation.”
This assumption, of course, carries over from human medicine: if you’ve got the insurance, you’re getting the treatment. Everyone’s happy, right? Right?
Not so much. Satisfaction with a medical course of action relies on multiple factors.
Sometimes getting to “Everyone Happy” (Square B) is impossible. D’s not so bad either, but A and C are no-fly zones.
Human Medicine Satisfaction
I would argue that satisfaction with outcomes is directly correlated to the balance between the amount of treatment pursued, and its benefit.
So really, the goal here isn’t to push everyone towards the far extremes of treatment; it’s about getting to that center line of balance. In human medicine this change is slowly creaking along with things like hospice care, which moves people from C to D in low treatment benefit situations, and increased access to insurance coverage, which moves you from A to B in high benefit situations. With Mom, we were squarely in the D category, and while we’re not HAPPY, it’s a hell of a lot better than if we had treated her to death.
So how does this apply to veterinary medicine? It’s similar, except we tend to find ourselves walking a line most strongly related to finances.
Now, since we have no ability to magically divine which people are up for specialty treatment and which people are not, we always offer all the options to clients- as we should. There are people who spend thousands, lose their pet, and are still ok with the outcome- but they were also very clear on the risks and made an informed decision. Many clients, it seems, feel as if they are not.
So what do we do to improve outcomes? In my experience, the best way to move the dial from A to B is pet insurance, at least for emergency situations. There are few situations more likely to prompt a Facebook mob than a pet who died a preventable death because the owner couldn’t afford treatment and the ER vet wouldn’t do the treatment for free- nor should they. Owners need to shoulder some of the responsibility here of financial preparation, and if they refuse to take even basic steps to be prepared, maybe they really are a crappy client.
And conversely, moving the dial from C to D involves good veterinary communication, and a willingness to understand that lots of factors go into the decision about whether or not to seek treatment. If a veterinarian talks a senior on a fixed income into a kidney transplant for a 15 year old cat in renal failure, after she expressed concern about paying her rent for the month and her own upcoming surgery- maybe they really are a money grubbing vet.
But I like to give everyone the benefit of the doubt. Clients and vets both have work to do here. And I believe with all of my heart that the better we get about empowering clients to make informed decisions, the more that will carry over into human medicine- which is a wonderful thing.
I realize this is a vastly oversimplified explanation of some really complicated issues, but hey, we have to start somewhere. Whatever it is we’re doing now sure doesn’t seem to be working too well.
A few weeks ago, while my publicist was asking online dog lovers if they might be interested in reviewing my book, he came back with a question:
“Do you recommend Science Diet or raw?” he asked.
“It’s really not an either/or thing,” I said. “The book doesn’t talk about nutrition at all.”
“Well, one of the people we approached said they only write about things from a raw food perspective,” he said.
“Oh, then they don’t want my book,” I said. “It’s just from a dog lover’s perspective.” And that was that. Because here’s the truth, which is going to probably cause a few people’s heads to explode: when it comes to my belief about the omnipotent power of food, I’m an agnawstic.
This belief started, as many things do, with my own experiences with food evangelism: Atkins, paleo, etc, wash, repeat. For one brief, terrifying month my husband dropped down the rabbit hole known as “extreme diets.” Now, I can’t blame him for trying- I’ve tried them too over the years, but he’s never been on board. After years of ignoring my attempts at zoodles, banana “ice cream” and other current food trends on the paleo circuit, he announced one day he was “going keto.”
“What does that mean?” I asked.
“Less that 20 net grams of carbs a day,” he said. “I heard it’s great for detoxing.”
“Did you find this on reddit?” I asked. He didn’t answer.
For the next 30 days, I learned what it is like for someone to be discovering enlightenment. He would follow the kids around the house asking them if they had any idea how much sugar was in their ketchup, pouring verboten salad dressings down the drain, and meaningfully wait until we were all in the room at the same time before turning on “Food Inc” on Netflix.
He preached fire and sugarstone, swallowing almonds with one hand while tossing pretzels in the trash with the other. He was flush with the light, or maybe just a little zany from ketotic acidosis, who knows. He says he felt great. He was online talking to people who gave up dairy, sugar, alcohol, gluten, fruit, potatoes, and on life in general and were now convinced their nuts were causing inflammation when he finally broke and had a fudgesicle. Now we are living a life of moderation together, and it is wonderful.
Now, don’t get me wrong. I think the idea of knowing what you are eating, and preparing it yourself, is a mighty fine thing. I try to avoid bread and pasta and sugar in favor of veggies, water instead of soda, but the last two months it was ALL CHOCOLATE AND CHEESE AND WINE and I didn’t feel bad about it at all. I have permission to meander in my choices. Good nutrition matters, but it isn’t the only thing that matters.
Life is balance, right? I eat well mostly and exercise a lot and don’t smoke and try to get enough sleep. Know who else did that? My mom. All my grandparents lived to 90 and she got brain cancer when she was 67 and she did everything right. It doesn’t mean I’m going to start lighting up. The CFO of Rady Children’s Hospital was killed a mile from my house during my mother’s memorial service while he was out riding his bicycle, being healthy. Sometimes shizz happens, and while diet matters, it’s no more a guard against bad luck than any of those other multitude of things in your life like genetics and a careless woman in a Range Rover.
Which brings me to what I refer to as “blog chum,” the words I always hesitate to type lest it attract a group of angry club wielding acolytes the way blood draws a Great White: Dog Food. I don’t care what you do with it. There. I said it.
You can feed a crappy kibble and your dog might live to 20 or he might look like he got run through a wood chopper.
You can feed a high quality kibble and your dog might live to 20 or he might get cancer when he’s 2.
You can feed raw poorly done and your dog might live to 20 or he might look like Casper when he’s 4 months old because he got nutritional hyperparathyroidism.
You can feed raw that someone balanced for you and your dog might live to 20 or he might get kidney failure when he’s 7.
That’s the way it works. Food is one piece of a really complicated puzzle, and anyone who tells you otherwise is selling something. (Probably dog food, magazines, or coconut oil.)
Now clearly, my education (paid for without the aid of Big Pet Food, by the by) and my experience lead me to recommend that with which I am familiar- that would be commercial dog food- but if you want to feed your dog raw and you swear it’s the most amazeballs choice ever and your dog is the healthiest dog who ever walked the face of the earth, go forth and be happy, because I really don’t have the energy to fight over any of the following:
who taught me
who bought me
who sends me places
how much I make off selling food
If you want my opinion, I’ll give it, and I think it’s an educated one. I’ll listen to what you have to say, though I may not agree. If you have decided that my views on that one topic mean my years of experience and knowledge about all things animal health related are bunk, well, we might as well enjoy a lively discussion about the upcoming primaries while we’re at it because might as well go out with a bang.
And then I will go make a healthy chicken salad and wash it down with a glass of wine, because that’s what agnawstics do.
When people ask me what my book is about, I feel silly saying, “Dogs,” so I’ve been trying to refine it. I got a little further: “3 Dogs,” and then, “3 dogs who were really important to me and also it’s about my friend Kevin and a funny play on words,” and then I took a break.
It didn’t really hit me until my mom got sick: This is a book about the purpose dogs have in our lives, about how they are here for a discrete space and time and change us for the better in very specific ways. And the beauty of it is, you don’t even know what that is until after the fact. I always assumed Brody would be my kids’ dog…but that was Kekoa.
Brody was my mom and dad’s dog. What he did for them, and for us, during the worst two months of our lives was nothing short of transcendental. I didn’t know he had it in him.
If you enjoyed that and would like to preorder, don’t forget to zip over to my Preorder Incentive Page and help yourself to my massive array of treats! I’ll be featuring all those goodies over the next week but the quantities are limited!
I wrote my mother’s eulogy the day of the service, this Sunday. I was stuck. I wanted to share all the profound things we had said to one another over the years, but we just didn’t have that kind of relationship defined by meaningful, deep philosophical conversations. As I sat with Brody’s head in my lap, it occurred to me that we also did not share in deep conversations, but it never lessened our bond. As soon as I thought about that, it all started to come.
My mother was not one for profound conversations. Don’t get me wrong- she was a profound thinker, absolutely, but I think she found the idea of sitting around talking about philosophy either pretentious, or simply a distraction from the things that really mattered, like dessert. This was a hard thing for me to accept.
I spent my whole life waiting for us to have those deep, intense, heart to heart talks where we would bond over politics, being a woman, or a mother, or a wife. It was really important to me that my mother and I share that kind of moment, and I’ve been working at getting her to engage in one with me for as long as I can remember.
I started when I was eight, by attempting to start a Mom and Me Book Club discussion. I said, “Mom, what does the word ‘conceive’ mean?” I often asked her about words I didn’t quite understand.
She said, “What’s the context?”
So I opened up my Judy Bloom book from the library and read, “I was conceived under the Million Dollar Pier.”
She pursed her lips, pointed to the Encyclopedia Britannica and told me to look it up. That was the end of Mom and Me Book Club, though to her credit, she never once banned me from reading Judy Blume- or anything else, really.
When I was in high school, my subversive reading habits led me to writing all sorts of editorials for the school newspaper about the availability of birth control for teens, the failures of the Oceanside Unified School District, Administrative Team, abortion. I spent a lot of time in the principal’s office. No one could figure out how I grew up to be such a diehard feminist. They all thought my sweet little mom would be mortified to know what I was saying. She knew. She’s the one who planted the seeds in my head in the first place.
Still, I was bound and determined for us to get our deep moment of profound conversation. I kept giving her chance after chance. When I went away to college, I was down for every holiday, and many weekends. She was there for every milestone event in my life. She was at the birth of both my children, the doctor’s appointments when I was worried about something scary, the triumphs and the defeats and the myriad tiny moments in between.
When the kids got older, we’d meet for lunch every week. Brian hated those lunch meetings, because ‘lunch’ was always followed by ‘shopping.’ She’d always convince me that I needed a new pair of boots, a necklace, a pair of earrings. She did not believe in practical gifts. Gifts should be beautiful and shiny and able to be physically opened and lord help you if you used one of those little gift bags instead of wrapping it with actual paper and ten pounds of curling ribbon.
Christmas, 1980-something ish.
Our interactions were a lot like those presents: plentiful, beautiful, and fun.
When she got sick, I panicked, because I was thinking, you know, all this time together, hours and hours and hours, and we still haven’t had those profound conversations that mothers and daughters are supposed to have.
I tried, once, to talk to her about what was going on, and she said, “That’s depressing. Pshaw. Turn on Harry Potter.”
I asked her if she could have anything, what would it be. Anything, Mom. And she said, “I want to go and watch the balloons in your backyard.” That was our life these last two months, Harry Potter and balloons and just being together.
I sat with her every day, Dad and I and the kids, making sure that when she was ready to impart her wisdom, I was not going to miss it. So when Dad was taking the kids to swim class, and I was sitting next to her on the bed, she held my hand, looked at me, and said in as earnest a tone as I have ever heard, ‘Can I ask you about something?’
I was thrilled. This was it. This was the moment I had been waiting for my whole life.
“Of course, mom.”
She took a deep breath, fixed me with her gaze, and said, “Do you know what Spotted Dick is?’
“It’s a spotted pudding, right? What made you think of that?”
“I don’t know. It sounds gross.”
“OK, Mom. I won’t make you eat one.” She giggled.
As the weeks wound down to days, I knew I had to figure this out if I was going to be able to move forward without regrets about wisdom left unshared. So I thought about what Mom would tell me to do- and I looked it up.
I found a book about dying, and it laid out the things that you’re supposed to say in order for someone you love to be able to die peacefully: I forgive you. I love you. We’re going to be ok.
I put the book down and shook my head. That’s all they had to say?
Forgive? There’s nothing to forgive. There were no unresolved hurts.
I love you? That’s nothing new. We said that every day.
We’re going to be ok? She knew that. We were always trusted to figure things out for ourselves, and though she was there for me if I needed her, I rarely did.
And that’s when I finally figured it out. There is no need to have profound conversations when you live a profound life. She truly did lead by example, with grace, kindness, toughness. For all those friends and family who are so upset that they didn’t get a chance to tell her something, don’t fret. She knew. And you knew her.
I will never have to wonder what advice she would give me in the long days ahead, where she would have stood on an issue. She has built a place in my heart minute by minute and day by day for decades now, and now that she’s disappeared inside its confines, I will never worry about whether or not she is there.
Patricia Anne Marzec, the greatest woman I’ve known.
Has it already been a week since my mother died? I feel like I’ve been in a haze, dropped in the middle of the ocean and swimming only because I have to, not because I actually know where I’m going. I’ve found a new appreciation for Dory, a different nuance in Finding Nemo.
I don’t know why life insists on dumping everything on us all at once instead of pacing things one month at a time, but it seems to be a rather consistent theme. What I’d like to be doing right now is sitting in bed with the sheet over my head, but there’s just too much to do.
When a death ends, the work just begins. Closets to go through and memorials to plan and family dynamics to breathe through. In this case, all these tasks are intermingled with the other responsibilities of being a mother as well as a daughter. I pick my mother’s casket, and on the way home pick out a birthday cake for my son. That sort of thing.
My daughter graduated fifth grade this week. I was not really aware fifth grade graduation was a big deal. I thought we might hear a song, clap politely, and get on with it. I was sorely mistaken. What we were in for was a two hour event with five speeches, two processions, music, slideshows, choreography. It was longer than my high school and college graduation combined.
The line for the auditorium starts an hour and a half early. I walk into the auditorium with the grandparents behind me, mentally counting off the number of seats I needed: 2, 2, 2….oh. 2, 2, and 1. It’s the little moments like this that catch you unaware. Mom would never have missed a graduation.
When the ceremony finally ended and the kids file into the lobby, I pull out the flower bouquet my father picked up for us on his way over. I hand it to my daughter, who stands surrounded by children wearing leis made of dollar bills. Mom would have brought a lei. She always did stuff like that. My daughter smiles politely, seeming vaguely disappointed, but she always seems vaguely disappointed. I am told this is part of being a tween. I am too tired to care.
I was supposed to volunteer at the promotion picnic today, but I leave early because I have to get Brody to the groomer in advance of the family arriving this weekend for the memorial. That, and order programs, write a eulogy, bring an end of the year gift to the teacher, bring a blanket to the funeral home, clean the house, find something to wear, pick up the kids from school, celebrate something, I guess. People offer to help, but these are all tasks I need to do myself.
I am exhausted, in a bone wearying way I didn’t know could exist.
Brody comes back from the groomer, and sits next to me on the couch. He is never disappointed with his lot in life. He just is. I put my head on his back and inhale, feeling the rising waves of grief intruding on my to-do list. He smells like one of those old Strawberry Shortcake dolls. When I cry, he doesn’t say anything or search for unhelpful platitudes or edge away uncertainly. He is surprisingly absorbent.
He is here, breathing with me. It is enough. For now, he is enough.
Did you know tomorrow is National Donut Day? Donuts have always held a special place in my family’s heart. Mystical, you might even say.
I grew up in New England, where Dunkin Donuts are as ubiquitous as Starbucks and McDonalds. Driving through for a box of Munchkins was our way of celebrating, commiserating, or simply getting a sugar fix.
For my grandfather, the Dunk was also a neighborhood gathering place where he went to shoot the breeze, down a jelly donut with a coffee regular (it’s a Massachusetts thing), and read the newspaper. Always a neatly folded newspaper. At his memorial service, there was actually an entire Dunkin Donuts contingent who came to pay their respects, which made me feel better about sneaking a bag of Munchkins into his hand at the wake. It’s what he would have wanted.
When my parents moved to California in the mid-80s, we lost that donut connection, because Californians aren’t really that into donuts. They became a special occasion sort of thing, and with that excuse my mother made sure that when we got them, they weren’t just regular old donuts but those big chocolate slathered cream puff monstrosities. It was our homage to the past, comfort food for the sweets obsessed.
When Emmett was diagnosed with lymphoma, I bought him a doggie donut because, well, what else are you supposed to do. Enjoy your donuts while you can and party on. I took what to be a bit of an iconic photo that sort of defines this blog:
When life gives you lemons, throw them away and eat a donut because making lemonade is way too much work.
My son turned 9 yesterday, and as I was planning what treat he wanted to bring into school for his classmates, I asked him: “Cupcakes or popsicles?”
“Donuts,” he promptly replied. “OK,” I said, “you shall have birthday donuts.”
At 5 am on his birthday, he crawled into bed with me. “I couldn’t sleep,” he said. “I’m just so excited about my birthday.”
At 5:30 on his birthday, my mother died.
And so we sat, dumbstruck, for a bit and attended to the things one must attend to, and then my dad and I sat on the bed side by side and said, “Now what are we supposed to do?”
So we went and got some !@#$!#@!#@!# donuts.
You can be sad and happy at the same time. That is the joy and pain of being human.
So when I say I’m happy tomorrow is National Donut Day, I mean it. It is a day to not only eat a literal donut, which I hope you do, but to put aside the petty crap of who bought the best end of the school year gift and whether or not your net carbs are coming in under 30 grams, but to say,
“I AM EATING A DONUT BECAUSE I CAN AND I AM GOING TO ENJOY IT, DAMMIT.” Because one day, you might wish you had.
And if you want to make me smile, I would love if you- or your dog, or you and your dog*- have a donut in Pat’s honor tomorrow (or today, who cares) and share a photo of you enjoying it with me. We would both love that. And for every photo here, on Twitter, or Instagram with the #brainfood I will donate a dollar up to, I don’t know, $500, to the National Brain Tumor Society because Mom still had a lot of donuts left in her to enjoy, dammit, and two months was not nearly enough time to let her know that.
Mother’s Day, 2015 at the beach. Each day is a gift and a chance to eat a donut.
*And by donut for your dog, I mean dog treats shaped like donuts, or other your-dog-appropriate ring shaped goods
So here we are. I wake up every morning and do what I have to do, because that is what you do, and write articles about broken toenails and plan for the book release, and then when I pause in my activities I remember: oh yes. That. It wasn’t a bad dream.
I have done what I am supposed to do. We held hands and stood in the face of a futile fight, and laid down our weapons. You may come, death. We do not fear you. And yet now that we have welcomed him, he hesitates, the rotten bastard.
We spent Mother’s Day at the beach, and afternoons watching the balloons drift by overhead. We enjoyed what moments we had, knowing they were to be short. And they are short, even shorter than we all had realized. The last full conversation we had was about a currant pudding, and then she moved into that chill fog of wandering from this plane into the next.
One of the last things I heard her say clearly, besides “I love you,” was “My bags are packed.” It doesn’t get much clearer than that. Our slates are clean, our consciences clear, and all we can do now is wait for the capricious whims of a malignancy that creeps this way and that in the motherboard of the brain, until at last, millimeter by millimeter, it overwhelms.
When you talk to the dying and ask them what they fear most, it is not being dead, something which is when all is said and done, rather dull by all accounts. It is the journey that worries them, the brambly path and the hands that pull them back or the quicksand of ineffectual treatments that, despite our best attempts, cannot make us immortal. They worry that they will suffer, and they are right to do so, because we do much to prolong it.
“Cherish every moment,” they say, and I did. There was a time, days or weeks ago, when there were still moments to cherish. But despite what some people will tell you, there is a line that some cross, a time where those moments are gone, where 22 hours of agitated sleep are interrupted by an hour or two of fretful wakefulness and perhaps a nod, and when they tell you the suffering is worth those small remaining moments, they are wrong. “Cherish these last days” does not bring me comfort, because she is gone in all but the literal physical sense.
Perhaps for you, the one by the bedside drinking those drops of life like a parched man in the desert, these last hours are worth it, but I do not believe they are for the one in the bed. I understand not everyone agrees, but I do believe we have the right to decide for ourselves when that line has been crossed. I’ve always felt that way- after all, I do this for a living for pets. The vast majority of people, in that situation, recognize the line way before the body reaches it on its own, and we can conjure death to our sides when he’s dragging his feet.
When the line is crossed with people, all that remains is an agonized twiddling of the thumbs, a bedside vigil that stretches ahead, vast and unrelenting. Those at peace have been waiting for it, and welcome it with open arms and relief and often not a small bit of impatience.
My mother is not suffering too much I suppose, though more than I would like because to me she shouldn’t suffer at all. We are managing her with a large and extensive brew of medications, consulting with the hospice team, feeling her feet for signs of cold and moving her this way and that so she doesn’t develop sores. What dignity she strove to live with her whole life is reduced to the fact that what we must do, is done by family and not strangers.
I am sad, because I know she is dying, and there is so little control of the situation.The pain of her being gone from my life is nothing compared to the feeling of helplessness while we try to ease her discomfort. We are doing all we can, and in my conversations with the hospice staff I know what we are doing as a family is more than most are able to, and that makes me both grateful and sad for others.
I believe she can still hear me, so for now I can whisper in her ear and hold her hand, choking down tears I don’t have time for- I can do that later. It will have to be enough. But do not tell me to be grateful for these last hours. There are many blessings in this journey, but this is not one of them.
Maybe someday I can look back at the ghosts of this experience and make something of it, but for now, all I can do is be frustrated at a world that views compassion so very differently for a person than they do a dog.
Today marks five weeks since my mother’s diagnosis with aggressive Grade IV glioblastoma, five weeks since my family’s lackadaisical spring was hit by a grenade that launched us into the surreal world of watching someone next to you on the beach suddenly snatched away by a rogue wave and pulled, slowly but inexorably, off by a receding tide.
I thought I would be much more angry than I am, angry at the unfairness of a universe that takes her in such a cruel manner while it leaves behind the thieves and liars, the selfish and the cruel, but I learned a long time ago that as much as we think we’re all playing the same boardgame, we’re only playing against ourselves. So all I can do is look at the situation in front of me and ask myself, what do I want to do with this? And every moment I spend being angry is one moment of quiet and comfort I will miss, the small scraps of lucid time I can gather up more valuable than gold.
I will, I decided, be unguardedly, relentlessly, grateful. It is a conscious decision, and not without effort, but it’s getting easier every day. It is a mantra I wrap around myself like a shawl, holding onto it until the shivers stop and the chill leaves my bones:
Instead of being angry that my beloved mother has a brutal disease, I am grateful she decided to forego treatment she didn’t want. Grateful I can be here for her.
Instead of being angry when hospice is slow to return my call or suggest solutions, I am grateful I have the benefit of knowledge so I can be proactive and figure them out myself.
Instead of being angry that I can do more for a sick dog than I can for my mother if she winds up in terrible pain, I am grateful that for now, at least, she is not.
Instead of being angry at the people who would make things more difficult, I am grateful they number so few.
Instead of being angry that I need to read through books to counsel me on what amends we should be making and forgivenesses to seek, I am grateful that upon reflection, we have no need. We have always been at peace with each other.
It gets easier with practice. For now, we are at peace with what is happening, and content with the thought that when we look back, we can say with certainty that we have no regrets about how we handled it, and that is perhaps the best one can hope for.
As you can imagine I have been hanging around my mom quite a bit these days, filling the air with talk of the day and the children. She has made it clear she prefers the conversation light. However, when and if she has a moment where she decides she has something important to impart, I want to make sure I don’t miss it because I still feel like there is still so much more left to say.
This afternoon, when the visiting family departed and my dad headed off to the store, she took a deep breath and turned to me, her bright cornflower blue eyes swiveling into focus as they peered into mine.
“Can I ask you something?”
“Of course, Mom.”
“I don’t know if you know what this is, or even if you know how to get it…” she paused.
I took a deep breath, as this is a moment I have been simultaneously anticipating and dreading.
“What is it, Mom?” I took her hand.
“Do you know….what spotted dick is?”
Of all the things I had pictured her asking me about, that was about last on the list, somewhere between “Sam Kinison’s used socks” and “an 8 track of the Bay City Rollers.” I paused, letting that rattle around in my brain: spotteddickspotteddickspotteddick, then I started laughing.
“Yes Mom, I think it’s a gross British dessert. Where the heck did that come from?”
“I don’t know,” she sighed, running her hands through her hair. “I was just thinking about desserts, and that sounded disgusting.”
I took her hands. “I will never,” I said, “Make you eat a spotted dick.”
She looked at me, Miss Proper Victorian Lady, and burst into laughter. Me and my mom, reduced to 10 year olds by a canned pudding. Then I brought her a cookie. Chocolate chip, because raisins are gross.
Desserts have always been very important to this family.
I know you were all hoping I would have more wisdom to impart about these momentous last days, but so far this is all I got. And I wouldn’t have it any other way, really.
I know I’ve been remiss in posting, and I wish very much I could say it’s because I’ve been so busy creating amazing and exciting book campaigns and creating a plan to hit the NY Times Bestseller List in July. I still want to, don’t get me wrong, and I still plan to at least give it ago. But that’s not why I’ve been quiet.
I guess you could say I’ve been doing nothing. Nothing. Let me explain.
I’ve said to many people when I started working with Paws into Grace two years ago it was like my career and work finally made sense. I liked working in a clinic, I liked the day-to-day stuff, but only two jobs in life ever touched my soul and felt as close as one could come to a calling: writing, and veterinary hospice. Stepping into hospice work was like buying a new pair of leather shoes and finding them already perfectly worn in.
If you recall, I took it a step further when I began speaking on the topic at various Ignite talks, the first one being in January this year at NAVC:
Then later, in San Diego in February:
Putting those two talks together forced me to really dig into why I thought this work was so important- first, I realized, we can do a lot to help people understand the process of grieving a pet.
Then, I realized losing a pet is in itself a really important lesson in how to lose a person, or more importantly, how to help them gracefully experience the end-of-life process. I really, really wanted to share that message.
I remember a lot of things about that night at Ignite San Diego, namely about how I said that all people should hire me so their kids wouldn’t stick them in a nursing home later in life because they were too scared to deal with them. I pointed at my parents and said, “See? Aren’t you glad I made this promise to you guys in front of like, 200 people?” And they laughed, because we knew that was all a long time away.
It all happened very suddenly: the fall, the seizure, the diagnosis of an inoperable brain tumor. One day, my life was filled with the usual concerns, getting annoyed with pseudoscience on the net, figuring out Teacher Appreciation Week. The next day, I forgot everything except this: My mom, still young, beautiful, and full of life, looking at the same diagnosis that made Brittany Maynard a household name last November. It is perhaps one of my worst fears, this particular beast, and now it has invaded someone I love more than words can adequately express. The person who, in other circumstances, would be the one I called for support.
Now she was looking to me, and then it all made sense, this need to understand the importance of hospice and advocacy and learning to let go gracefully. I wasn’t meant to help other people understand the difference between living poorly and dying well. I was doing all of this preparation, whether I knew it or not at the time, for my own mother.
In the space of two weeks, I moved my parents into my house, earned frequent parking points at the hospital, and had to dig deep into everything I ever stood up for and ask myself if I really meant it when I said I thought people should change how they dealt with illness and end of life in their families:
Would I help someone honor their own wishes to say no when everyone in an authority position was pushing for treatment? It seems like oftentimes it is easier to do all the treatment than to say no and risk upsetting loved ones who want you to try it.
Would I be honest with my children in an age-appropriate way or just kind of try to avoid it for a while? Use the old la-la-la-everything’s-fine approach our family has relied on for generations?
Could I bring this whole experience into my house, ask my husband and my children to take on this really intense experience, when it would be a lot easier on them- in the short term at least- to keep my parents at arm’s distance, in their own home, in skilled care?
The two weeks during the diagnosis phase was an unending slog up and down the linoelum floors of the hospital, trudging from one cramped waiting area to another: CT. Neurooncology. Neuroradiology. Neurosurgery. Each appointment took an emotional toll that far compounded the physical one, leaving mom too pooped by the end of the day to do more than go to sleep. Waiting rooms filled with other seriously ill people nervously picking at the fraying vinyl upholstery, doctors too aware of the gravity of the diagnosis to be able to offer a smile.
My mother was so upset at the prospect of poorly effective radiotherapy she didn’t want that she could barely speak after the appointment with the radiologist. He had recommended six weeks of daily radiation and chemo, tied to those halls and the stale air. Glioblastoma, a poorly researched and dreaded cancer- even in the world of oncology, it’s a bad one- has had few treatment advancements in 25 years. Treatment doesn’t cure the disease, just kind of kicks it down the line a little.
“And if we choose not to do the radiation?” I asked.
“You could do nothing,” he said, “But I don’t recommend it.” No one did, but nonetheless that was exactly what Mom wanted.
So we did it anyway, leaving through the doors of the hospital one last time into the cool evening breeze of the evening marine layer rolling over, before calling in the ‘Nothing’ that is hospice. So far, Nothing has included the following:
Watching hot air balloons fly by in their sunset flights
Getting through all the Harry Potter movies
A comprehensive plan for managing every symptom, every discomfort
Greeting the children every morning and tucking them in every night
Trying every flavor of macaron at the local French bakery (lemon = best)
Getting our nails done
Going through old photo albums
Driving to the beach
Brody, exhibiting that strange instinct most dogs seem to possess, hasn’t left my parents’ side. He’s been so protective, in fact, that he came barreling out of their room last night to bark at me when I got up at 2 am for some water.
My mother has chosen to die well instead of living poorly. But really, I can’t call what she’s doing right now dying. The walls of the hospital, filled with fear and extended wait times and the ever-looming spectre of illness, feels more about dying. She is living. Each moment, each breath of spring air, each hug, is imbued with a gratitude and a joy it wouldn’t have had in a different situation.
I don’t believe one person’s tragedy is any greater or less than anyone else’s, no story more worthy of being told. But I do hope that in sharing this one I might reach someone who is struggling with a similar situation or just looking to understand why a loved one may have made the same choice.
We’re terrified, but we’re ok. We’re devastated, but happy. I have an incredibly high tolerance for stress right now but Rubio’s running out of pico de gallo leaves me in tears. We are doing what we can and continuing what routines we are able to do. We are together, and that matters most.
We are doing nothing but living, and that is enough. It is, in fact, everything. And this Mother’s Day, we’re having a hell of a celebration.
I always assumed my experience as a veterinarian would serve me at some point when I needed to navigate the human healthcare system. The similarities between veterinary training and medical training, after all, lend themselves to a good number of similarities: how to read scientific articles critically. How to read an MRI. When to call the office and say, this prescription doesn’t seem quite right, is this what you wanted?
The similarities are all well and good, but I never understood, in the marrow of my bones, until recently that what would serve me best was our differences.
We MDs and DVMs are both given an ethical mandate to ‘do no harm’, which we as communities hold dear. Our duties to our patients are guided by this overarching principle; we look to it for direction in complicated cases, fall back on it when we feel conflicted about a request, and hold it like a flashlight when we shine a light into the cave of an uncertain future, looking for direction.
But oh, do those lights shine in very different spectrums.
As a veterinarian, I agree. We veterinarians occupy a strange place in the medical field in that most of us view it as not only an option but often a moral imperative to ease the pain of a traumatic death process through pharmacologic means. We are precise in our process, with the goal of minimizing stress and pain. We view it not as causing death, but as easing an uncurable pain. In this, we view our fulfillment to do no harm.
But in the human medical field, the prevailing attitude is by and large that hastening death is, indeed, harm, and anything we do to prolong a life is conversely fulfilling their requirement to do no harm, no matter what it does to a person or family in the process.
Even if it is multiple craniotomies.
Months of chemotherapy.
Daily radiation therapy with a bevy of ill effects. And you have to get screwed down to the table wearing one of these while they shoot brain shrivelling radiation beams at your head:
Not to cure a disease, but to make a patient breathe one more day, for better or for worse. It is the second most common utterance to me in my hospice work: we do better with our pets than we do our people when it comes to end-of-life decisions, and truly, friends, we really do.
I was recently-by invitation- listening to a doctor outline just such a series of events and possibilities to a patient who didn’t want to partake in them, who has been looking- without success- for someone to say, it’s ok to say no to months of hospital visits and yes to fewer days filled with this:
Plenty of people do want everything we have to throw at disease, and more power to them all. Thank God for modern medicine. But when did it become not only an unthinkable mistake, but an outright affront to the medical community to say, “thanks but no thanks”?
Searching for information on hospice and palliative care has been as challenging as getting bootleg rum during prohibition, furtive conversations in hallways and whispered hints at such necessary things as family support and respite care, secondary concerns far down the to-do list after scheduling yet another CT. I never knew how much of an afterthought the emotional wellbeing of the patient truly is in many medical decision making processes.
“So what if they don’t want to do this?” I asked.
“Well, this is the standard of care,” the resident responded.
“And if they choose not to do this?” I asked again.
“Why wouldn’t you?” he said, dumbfounded. He never did give me an answer.
This month’s JAVMA features confirmation of what those of us in the profession for more than a year or two already suspected: veterinarians are a sad bunch, compared to the general population. Consider these stats from the CDC’s first-ever survey of the veterinary population:
1 in 6 have considered suicide;
25% of men and 37% of women in the profession report depressive episodes;
1.1% of men and 1.4% of women have attempted suicide;
That last stat is the only one where vets figure in below the national mean, but before you cheer consider this: it’s because more veterinarians successfully complete suicide.
This preliminary data doesn’t delve into the causes or the proposed solutions, though those are currently hotly debated. Nonetheless, it’s good to see on paper what so many who are struggling have needed to hear: You’re not alone.
After watching my Ignite talk on being a Death Fairy, a veterinarian asked me how I avoided compassion fatigue in my work. I told her I would answer that, but first I have to admit this:
For a long time, I didn’t avoid it at all. I didn’t just float out of vet school and find an amazing job and love every second and plan to be a hospice vet because I knew that was the right thing for me to be. I wish I could tell you I was that organized and thoughtful, but the truth be told I did what most people I know in this field do when they’re stressed: power through bad situations until they became untenable, taking on more responsibility every other second.
So no, I didn’t avoid compassion fatigue. In fact, I burned out and quit. But then I reincarnated, I guess you could say, with a lot more perspective and a healthy understanding of what I’m really supposed to be doing here. But not until after I got really sick, like going to specialists and talking about scary tests sick, did I decide to get my priorities in order. Once that got sorted out, life got really good!
How to be a zen vet in a Prozac profession
1. Don’t underestimate the importance of your co-workers
I think there is no greater indicator of how happy you will be at work than how well your team works together. They will prop you up when you’re down, have your back when things get nuts, and inspire you to do better every day. Unfortunately, the converse is also true. The saying “turd in the punchbowl” exists for a reason.
2. Don’t settle for a toxic environment.
Temporary Like Sadness by Dominic Alves on Flickr
Sometimes you think you’re starting in at the best place on the earth, but something happens. The office manager is stealing. Your mentor turns out to be Voldemort. You get pregnant and can’t work overnights anymore. So many people stick it out in a bad situation because 1) we’re taught not to whine and 2) we’re scared there’s nothing better out there.
There’s always something better out there, but you won’t find it if you don’t look. If you are in an office that is causing you physical symptoms of anxiety, it’s time to start looking for a new job. Living in modern day American comes with certain advantages, like the whole “no indentured servitude” thing.
3. Don’t be afraid to explore.
I had no intention of being a veterinary writer. Blogs didn’t exist when I started vet school, nor did hospice veterinarians. Sometimes you just have to strike out in a direction that looks good and see what’s out there. Because guess what? I don’t care what anyone else has told you, you’re allowed to come back and be a vet if you leave. Taking time off to explore another career, take care of family, get another degree, none of it is a one way valve- unless you want it to be.
4. Set boundaries. Mean it.
Out of every rule I laid out, this is seriously the number one important one. With the exception of the rare shining star who really does want this to be their life, most of us want a life of which veterinary medicine is only a part. This is a profession where it is very easy for it to take over your life, because there will always be more asked of you than you are able to give. Always. It is not a failing to recognize that.
Set boundaries with your clients, your co-workers, and yourself. Take vacations. Exercise. Enjoy your family. Do not let work intrude on this or else you will begin to resent it, and that is the seed of burnout. You can (and should) work your butt off, then go home and play your butt off.
Set those boundaries, and enforce them like your life depends on it.
It was an ironic realization to figure out that point of diminishing returns in terms of giving of yourself. You cannot truly understand compassion unless you’re willing to extend it to everyone, including yourself.