The Cost of Loving an Animal Part 3: When Everything Possible Is Too Much (#730)
There is a phrase veterinarians hear frequently at moments of crisis.
I want you to do everything possible.
I understand it.
Behind those words is love. Fear. Hope. And sometimes guilt.
The person standing beside the examination table is terrified of losing an animal that may have shared their life for 10 or 15 years.
Do everything possible sounds like the ultimate expression of devotion.
But after a lifetime in veterinary medicine, I have come to think that those words deserve much more careful consideration.
Because modern veterinary medicine has made an extraordinary amount possible.
The more important question is whether everything possible is necessarily everything we should do.
A Very Different Veterinary Medicine
When I graduated in 1975, the limits of veterinary medicine often made decisions for us.
There were diseases we could not diagnose accurately. There were operations we could not perform. There were cancers we could not treat. There were critically ill animals we simply could not keep alive.
Those limitations were frustrating, but they also created boundaries.
Many of those boundaries have disappeared.
Today we have MRI and CT. Advanced neurosurgery. Chemotherapy. Radiation therapy. Dialysis. Mechanical ventilation. Interventional procedures. Intensive-care medicine. Sophisticated anesthesia. Feeding tubes. Blood products. Specialist hospitals staffed around the clock.
An animal that would once have died can sometimes be kept alive for days, weeks, months or years.
That is one of the great achievements of modern veterinary medicine.
It is also one of its great ethical challenges.
Because keeping an animal alive and giving an animal a life worth living are not necessarily the same thing.
The Question Changes
When medicine had little to offer, the question was relatively straightforward:
Can we do anything?
Increasingly, the question has become:
How much should we do?
And eventually:
When should we stop?
Those are much harder questions.
Technology can tell us whether another procedure is technically feasible.
It cannot tell us whether that procedure is right for this animal.
An MRI can show us what is happening inside a brain. A laboratory test can measure kidney function. A CT scan can identify metastatic cancer. An intensive-care monitor can display blood pressure, oxygen saturation and heart rate.
But none of those machines can answer:
Is this animal still enjoying being alive?
That remains a human judgment.
The Seduction of One More Thing
Serious illness often develops its own momentum.
Let's repeat the blood tests. Let's obtain another scan. Let's try another medication. Let's keep her hospitalized for another night. Let's see what happens tomorrow.
Each decision may be perfectly reasonable in isolation.
But medicine can become a sequence of one more things.
Eventually we need to stop asking whether there is something else we can do and ask whether doing it is likely to produce an outcome that matters to the animal.
That distinction is fundamental.
What Is the Goal?
Every treatment plan should begin with a deceptively simple question:
What are we trying to accomplish?
Cure? Long-term survival? A few additional months of comfortable life? Relief of pain? Restoration of mobility? Enough improvement for the animal to go home? Or simply enough time for the family to say goodbye?
Those are all legitimate goals.
But they are not the same goal.
Problems arise when treatment continues without anyone clearly defining what success would actually look like.
Keeping an animal alive for another week may be an extraordinary success if that week is comfortable and meaningful.
Keeping an animal alive for another week in pain, frightened, unable to eat and separated from the people it loves may represent something very different.
Duration of life is not the same as quality of life.
Whose Benefit Are We Considering?
This is perhaps the most uncomfortable question of all.
Sometimes continued treatment benefits the animal.
Sometimes it primarily benefits us.
We are not ready. We want another day. We want one more weekend. We want the children to come home. We want to believe the next treatment might work.
There is nothing shameful about those feelings.
They are profoundly human.
But our animals cannot understand why they are being hospitalized again. They do not understand that the chemotherapy might give them another three months. They cannot understand why they must endure another procedure because we desperately need them to remain with us.
They know something much simpler.
Am I comfortable? Am I frightened? Can I eat? Can I walk? Can I sleep? Can I breathe comfortably? Are my people with me? Does anything I used to enjoy still give me pleasure?
Those questions may matter more than another laboratory value.
The $10,000 Decision
And then money enters the room.
Suppose another treatment is available. It will cost $10,000.
There is perhaps a reasonable chance it will provide additional useful life.
What should the owner do?
There is no universal answer.
The wealthy owner who spends $10,000 is not necessarily more loving.
The owner who declines it is not necessarily less loving.
Nor should veterinarians create that implication.
Money matters.
It matters to families. It matters to marriages. It matters to retirement. It matters to children's education. It matters to people living from paycheck to paycheck.
Financial circumstances are part of medical decision-making whether we are comfortable acknowledging them or not.
An owner should be able to say:
I cannot afford that.
Or even:
I could afford it, but I am not prepared to spend that amount.
Those are not declarations of indifference.
They are statements about personal circumstances and priorities.
The veterinarian's responsibility is to help that owner understand what those choices mean for the animal - not to judge them.
More Expensive Does Not Mean More Compassionate
We need to be particularly careful about equating increasingly aggressive treatment with increasingly compassionate treatment.
Sometimes the opposite is true.
A peaceful day at home may be kinder than another day in intensive care. Pain relief may be kinder than another diagnostic procedure. Palliative care may be kinder than another round of treatment. And sometimes euthanasia may be kinder than another attempt to postpone death.
That is one of the peculiar responsibilities veterinary medicine carries.
We are able to end suffering deliberately and peacefully.
It is an enormous responsibility.
It can also be an extraordinary gift.
But What If?
The hardest part of deciding to stop is uncertainty.
What if another day would have made the difference? What if the next treatment had worked? What if we had tried one more thing?
Medicine rarely gives us perfect certainty.
That is why these decisions can haunt people.
But there is another what if worth considering.
What if we wait too long?
Anyone who has practiced veterinary medicine for long enough has seen both possibilities.
Families who later wonder whether they stopped too soon.
And families who know, painfully, that they waited too long.
Perhaps the goal should not be to identify the perfect moment.
There may not be one.
The goal is to make a thoughtful decision based on the animal's condition, prognosis, suffering and remaining capacity to enjoy life.
A Timely Death Is Part of Good Medicine
Veterinary medicine spends enormous amounts of time teaching people how to prevent death.
Perhaps we should spend more time talking about how to approach it.
Death is not always a medical failure.
For an old animal at the end of a long life, death is inevitable.
The medical question becomes not whether death can be prevented indefinitely, but how the animal will experience the time that remains.
Comfort matters. Familiar surroundings matter. The presence of people the animal trusts matters. Freedom from fear and pain matters.
And when those things can no longer be maintained, allowing a peaceful death can be entirely consistent with excellent veterinary care.
Perhaps one of the most important things a veterinarian can say is:
You have done enough.
Not because there is literally nothing else medicine could attempt.
But because nothing more needs to be attempted to prove that this animal was loved.
The Courage to Stop
There is tremendous emotional pressure in the words do everything.
Doing everything sounds courageous.
Stopping can sound like surrender.
But sometimes stopping requires more courage.
It means accepting that medicine has limits. Accepting that life has limits. Accepting that our desire to keep an animal beside us cannot be the only consideration. And accepting something particularly difficult:
The fact that we can postpone death does not always mean that we should.
The Cost of Loving an Animal
Across these three essays, I have been writing about cost.
But perhaps money was never the whole subject.
Part 1 was about the commitment we make when we bring an animal home.
Part 2 was about the increasingly sophisticated - and increasingly expensive - medical system we have created to care for those animals.
And Part 3 brings us to the final cost.
Letting go.
For most of us, that is ultimately the highest price of loving an animal.
We bring home a puppy knowing, somewhere in the background, that the puppy will become an old dog. We adopt the kitten knowing that, if all goes well, one day we will sit beside an elderly cat. We spend years protecting them from illness, injury, pain and death.
And then comes a moment when protecting them may mean something entirely different.
It may mean allowing death rather than prolonging dying.
That is not abandoning the promise we made when we brought them home.
It may be the final fulfillment of it.
Because perhaps the promise was never:
I will keep you alive for as long as medicine possibly can.
Perhaps it was much simpler.
I will care for you.
I will protect you from suffering when I can.
And when I can no longer make you well, I will not make you suffer simply because I cannot bear to lose you.
That, too, is the cost of loving an animal.
And sometimes, it is the greatest act of love we can offer.
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