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Thursday, November 17, 2016

Abbey's Last Days

In a recent post celebrating the twelfth anniversary of Abbey's adoption, I wrote,
The vet, when he did Abbey's most recent exam, said, as he's had in the past, that she's in great shape for her age and he never would have guessed at a glance that she's fourteen. He made me extremely happy by saying that as long as we kept on top of her care, it is quite possible that she could live to be as old as seventeen or eighteen. Having cared for a number of geriatric dogs in recent years, I can attest that she is doing well. I know cancers can arise at any time and act swiftly, but despite UTIs and a couple of little rotten teeth and medication-induced seizures that have had to be dealt with this year, she's still my vibrant Abbey, always at my side, eyes alight.
 Little did I know that the ending had already begun.

Abbey passed away at 4:30 in the afternoon on October 21, 2016, little more than a week after her adoption anniversary on October 12th.

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The following is a detailed account of Abbey's final illness. It is written as much for me as it is for anyone else, as I want to preserve these facts without necessarily having to keep them in my mind. For those who do not want to know all the details of the six days that passed between when she first got seriously sick and when she exhaled her final breath, I've written a second post about my remarkable emotional journey since Abbey's passing that can be found here.

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Abbey may have thrown up before dawn, but she seemed perfectly fine later!

Abbey had woken me at 5:00 a.m. on the 12th by vomiting up some of her partially digested dinner from the night before. This was not wholly unusual--Abbey's always had a sensitive tummy and sometimes she vomits in the night after excitement or stress the day before. We had gone to the vet on the 11th for a followup to her dental work and while the vet had been very impressed by how great everything looked, Abbey was rather less pleased to be back at the vet's and it was plausible that it had triggered her upset stomach. The only thing that was at all out of the ordinary was that she hadn't eaten all of her dinner at once the night before, though she'd licked her bowl clean by bedtime. I gave her rice for dinner Tuesday night just to be sure and everything was fine. Wednesday she didn't eat all of her dinner at once again, so I picked it up, not wanting to repeat the whole 5:00 a.m. upchuck thing if possible. Not much later, she had another partial seizure that temporarily disabled one of her back legs and then she vomited after it was over. I was bummed, since it meant that the seizures in August had probably not been caused by the flea meds and made a note of this to tell the vet. Thursday and Friday, she didn't eat all of her dinner at dinnertime, so I put her bowl up and fed her the leftovers for breakfast. She devoured it all hungrily and without any negative consequences. I was watching all this closely, wondering why her appetite was shifting, and planned on making an appointment to see the vet on Monday. Saturday, after putting her half-eaten bowl of dinner up on the counter, she made such a convincing display of being hungry again a short time later that I put it back down and she ate it right up. She dry-heaved that night, though didn't bring anything up. I didn't sleep very well, listening for any sounds of imminent vomiting. I gave her rice for breakfast, which she consumed hungrily. I then gave her rice again for dinner.

Her appetite was off, but in all other ways, Abbey seems like her regular self.

That was on October 16th, 6:00 p.m. She ate her dinner eagerly enough, but immediately afterward urgently requested to go outside, where she had some diarrhea. She didn't want to go back inside right away and tried a couple more times to have a bowel movement, though nothing happened. Then she started vomiting. She vomited up all of her dinner and continued to vomit after was nothing to bring up. Finally, she wanted to go back inside, and while her tail was up in an alarming way that suggested that diarrhea might still be on the immediate horizon, I let her back into the house, keeping her on the kitchen floor, though, and put down a towel and spread newspaper behind her just in case. She was hunched and miserable and not wanting to move. Then she started having waves of intestinal cramping so massive that I could actually see them squeezing her sides and belly as they rolled through. Eventually, she decided to lay down. The cramps continued, wracking her whole body. She was in terrible pain. By 7:00, we knew that she needed to be taken to the emergency vet.

As we waited for her to be admitted, Abbey tried pacing and hiding behind the furniture and laying down to get away from her pain, but there was no escaping the horrible spasms, each one causing her to extend her neck and hind legs in agony as they gripped her gut. As someone who has had plenty of experience with GI pain, I could understand all too well the misery she was in! I'm thankful that the torrential bloody diarrhea didn't start until after they'd taken Abbey back to X-ray her abdomen. It had been hard enough to watch her suffer the pain; witnessing blood being wrung out of her intestines would have been unbearable.

Abbey was admitted, of course. The X-ray ruled out bloat or blockages, but a brief glance at her insides with the ultrasound wand had revealed fluid in her abdomen, the cause unknown. More tests would be run overnight to figure out what was causing her severe GI distress and the fluid accumulation. She'd also be receiving pain meds and medication to stop the nausea and diarrhea. When we went to say goodnight to her, Abbey's hindquarters had already been bathed free of the bloody diarrhea. It was some comfort to know that she was in good hands. It was late when we returned home. I went to bed, trying not to let my fears get too far ahead of me.

We were relieved to learn that she had stabilized in the night and that medications were controlling her pain, vomiting, and diarrhea. A more rigorous ultrasound had revealed an intestinal tract so inflamed that it was impossible for the doctors to make out any details and the rest of her abdomen and the organs therein were also experiencing some inflammation. The fluid in her abdomen was clear, which was a good sign, but the most worrisome thing was the low blood protein level revealed in her blood work. In short, it meant that she had not been absorbing sufficient nutrition through her intestines and this resulted in imbalances that were was causing fluid to seep out of her blood vessel and into her body, which was where the fluid in her abdomen was coming from. At that point, the internal medicine veterinarian said it was too soon to rule out an acute issue, like eating something that violently disagreed with her (unlikely) or a reaction to the antibiotic she'd just finished to clear out dental infections (plausible), or something chronic, like inflammatory bowel disease. The only way to know for sure, the vet said, was to have her anesthetized to do an endoscopic bowel biopsy. The vet had difficultly justifying why we should do this, since the treatment approach would be the same as what we were already doing. We were highly reluctant to pay $1,800 to risk sedating our sick dog just so we could learn exactly what dose of steroids would be most effective. Start the steroids, we said, and give it a few days and see if Abbey would start to improve.

A very out-of-it but pain-free Abbey.

When I visited her on Monday evening, Abbey was so out of it from the fentanyl they were giving her for pain that I honestly don't think she knew who I was. When she looked at me, there was no change in her focus, no sign of recognition. She briefly rested her chin on my knee, but she spent far more time staring blankly at the sides of her pen. It was hard to see her so woozy, but it was preferable to the horrendous pain she'd been in the night before!

Once removed from the fentanyl, Abbey again recognized me and can be seen wrapping her paw around my shoe as I sit with her in her hospital pen, tempting snacks at the ready.

The next thing the doctors wanted was for Abbey to eat. I was glad to hear that they'd stopped the fentanyl, since there was no way Abbey was going to eat while that out of it. We'd delivered some of Abbey's kibble and a few of her favorite Rice Chex and oyster crackers in hopes of tempting her appetite, but on Tuesday during the day she wouldn't eat for the hospital staff. I was not surprised, but convinced I could do better. Abbey was much more alert and happy to see me because she wasn't drugged to the gills and while she didn't eat a lot, I got her to eat some Rice Chex, oyster crackers, and special bland baby-food-like dog food. What she REALLY wanted were the peanut butter pretzels I'd brought for myself. I let her have some of those, too, but not too many, since I didn't think peanut butter was likely ideal for a dog with a horribly inflamed GI tract.

Abbey at the veterinary hospital.

Since Abbey had eaten better for me and could control her bladder and bowels and wasn't having bloody diarrhea and was no longer in terrible pain, we requested that Abbey be discharged into our care, figuring she'd be better off at home in her own bed and own environment with her own girl taking care of her. The vet was willing to try it, since she was stable (though her blood protein level was still very low and had in fact dropped slightly lower during the time when she was in the hospital), making us promise to bring her back if she still wasn't eating after a few days. We were very ready to have her home, enthusiastic about taking over her care--after all, I'd spent weeks hand-feeding her and giving her water through a syringe last summer when her mouth and tongue were too weak for her to properly eat or drink because of her disastrous response to being given acepromazine after getting her ears cleaned. Also, seeing as it was costing $1,000 per day to have her treated at the hospital, we didn't want to keep her there any longer than was absolutely necessary. So we stocked up on chicken baby food and cream of rice cereal, one of the techs taught me how to give Abbey her steroid injections, and we brought her home on Wednesday evening.

Once she was at home and not confined to her hospital pen with her IV, Abbey looked much sicker. Her back legs were so weak she could hardly support herself and she swayed and wobbled terribly when she walked. She drank water and ate a bit of the proffered mix of chicken baby food with rice cereal, but she didn't want to eat a marshmallow. Abbey will ordinarily do ANYTHING for a marshmallow and it's how we give her pills--you stick 'em in, toss the marshmallow to her, and down it all goes. I quickly found that trying to get a dog who doesn't want to swallow any sort of food to take pills is really awful, especially if there are seven different medications and some of them are so big that they have to be broken down into multiple pieces. I finally managed by coating the pills in a bit of peanut butter, sticking them as far down Abbey's throat as possible, clamping her jaws shut, and then squirting water into her mouth with a puppy-feeding syringe, forcing her to swallow. By the time she'd taken all of her medications, both Abbey and I were exhausted!

Abbey at home.

I'd arranged for Abbey to see her regular vet the next morning. I trust him completely. The animal hospital provided excellent care, but they never met a test or procedure they didn't want to undertake--and then bill you for. The internal medicine vet had been so vague about the necessity of the various things she had suggested and everything she said was said with rising inflection, making it hard to get a read on what was actually necessary and what was her trying placate us for some reason and what was being suggested to in order to pad the bill, etc. Also, he has roughly twenty more years of practical experience. I knew the regular vet would give me straight talk. And he did. He looked at Abbey's test results and said, "You only see these values in a dog with a chronic condition and there are really only two possible diagnoses for this set of numbers: cancer or inflammatory bowel disease." The reason to get the endoscopic bowel biopsy (which he recommended as the next step), he explained, was so we knew which we were dealing with. Inflammatory bowel disease could be managed with the medications she was already on, but if she had cancer, there was nothing more for her that could be done except make her comfortable. (The hospital vet had said, "I don't think she has cancer?" and didn't mention it again, though it hadn't been ruled out by any of the tests or scans.) In ten minutes, he managed to explain everything more clearly than the internal medicine vet had over the course of three days. He also cut the medications for Abbey to be taking by half, eliminating redundancies, gave her an anti-nausea injection that would take up any of the rest of the slack from the eliminated medication, gave me some cans of special intestinal protection food for once she started eating again, and a bunch of different size syringes to help feed her. (He also mentioned he'd had a lot of communication issues with the internal medicine vet and said to feel free to consult with him if Abbey had to be hospitalized again and we were confused about our options.) Abbey, who'd spent the last few days being handled by a wide variety of strangers, was the most at ease with the vet she's ever been, sniffing him all over and asking for petting as he and I sat on the floor discussing her care. I left feeling much encouraged, despite the fact that he'd just told me my dog might have terminal cancer.

Abbey ate and drank a bit when she got home, and after I'd taken care of a few tasks, the two of us settled in on my bed, where she took a long, hard nap snuggled up against me. I was glad to have her home, seeing her sleeping there in her usual place, and felt good about what we were doing. A couple hours of hours later, I noticed she was shivering in her sleep. Then she got up and changed her position multiple times before finally coming over and pressed her head against me, making me wonder if she needed to go out. And she did. She held it until she got to her regular bathroom area, but once there, she had diarrhea. I'd been expecting dribbles. This was like the spray jet from a hose. It was pure liquid. Whether or not there was blood in it, I couldn't tell, but it was shocking enough as it was and definitely not the product of a well dog. She settled in okay once she was back inside, but she only ate just a little bit of peanut butter. Whatever you offered, she'd politely turn her head away. She stopped drinking her water, too. She'd approach her bowl, put her muzzle down to drink, then decide against it. I didn't realize how worried I was until my mother called in the late afternoon to see how Abbey was doing and I burst into tears. That's when I knew what my subconscious had been slowly piecing together: Abbey was dying.

So I cried on the phone and so did my mom and then she got home and we both cried some more and we decided if Abbey still wasn't eating by the end of the weekend, we would know that it was time. At this point, she was refusing all food and water and it didn't look good. I couldn't believe my dog, my dearly beloved Abbey, was dying, and yet I could believe it. And just weeks after the vet had said that she might make it another three or four years! It was a punch in the gut. It was a stab in the heart. I'd always thought I'd have more warning. I wanted more warning, more time to get used to the idea. I felt dazed, bereft, agonized. I tried to collect myself, though. My sister was coming over for her birthday dinner in a couple of hours. Abbey and I went upstairs to my study, where we spent so many of our days together, while I tried to distract and collect myself. Abbey, I noticed, didn't settle on her pillow like she normally did. Instead, she stood in a place where she could see out of the study door, her weak back end listed to the side. It eventually dawned on me what she wanted, so I moved her pillow to that spot and she immediately lay down where she could watch family members going up and down the stairs, though it wasn't long before she fell asleep.

It was right around the time that my sister and her husband arrived that Abbey woke up and started vomiting. When she wasn't vomiting, she was retching and coughing and sometimes dry-heaving. When dinner was ready, I brought Abbey's pillow down next to my chair, but the first thing she did was throw up without any warning. Before long, she decided that she wanted to be upstairs and she threw up on the stairs themselves. I spent the rest of the evening sitting on the floor next to her bed, reading and holding a bucket under her muzzle. In the past, when Abbey was going to throw up, it would be preceded by a certain amount of noisy heaving, but this time when she vomited it just burped out of her without warning. As I sat with her, I came to understand that she needed to go back to the hospital. There was no way I was going to be able to give her her evening medications and it looked like that without IV medical intervention, she might vomit and gag all night. She was sick beyond my capacity to care for her. This was likely to be her last night on earth.

We took her back to the hospital and she threw up twice more as we waited for her to be admitted and had an accident for good measure. We explained to the hospital that we just wanted her stabilized and made comfortable, that we didn't want more tests, that we weren't looking for her to be cured. She wagged her tail when we said goodbye to her. It was late when we got home. It was later yet before I felt settled enough to go to bed and before I did, I kneeled before her open crate door and said all the things I was terrified I might not get to say to her if she died in the night. The thought of her dying in the night, at the hospital, with me not by her side, was agonizing. I was awake a long time in the early hours, too, and I tried to read to keep being overwhelmed by my grief. I was still reading when the hospital called to give the first morning report: she had made it through the night and rested comfortably. I slept then, finally.

I woke up at 12:30 to face some hard decisions. While I'd slept that morning, my mother had done the hard work of calling our vet to see if they recommended an at-home euthanasia service. That service had an appointment available at 3:30, just three hours away. I did not feel ready to put down my dog in three hours. Would it be better to wait one more day? What if that was too late? I knew it should be done that day, but so soon? While I felt so exhausted? We spoke to the hospital again and while Abbey was still resting comfortably, they said that her protein level remained so low that fluid was going to start filling her lungs. There was absolutely no doubt that her body was failing and fast. That helped me make my decision. I had a list of things I wanted to accomplish to prepare for the final goodbye and two and a half hours (it was now 1:00) still seemed awfully tight. My mom called the home euthanasia service if they could do something just a little later and we got confirmation that they could come at 4:00. We called for my dad to come home and let my sister know the time and I got to work.

First and foremost, if we were going to having Abbey put down in our home that day, I needed to have all signs of our hopes for her recovery removed. That meant all of her medicine and the papers from the hospital and the jars of baby food and every bit of paraphernalia that went with our brief effort to help heal her at home. There was to be no healing. I needed those things out of sight. Even now, the thought of those vain hopes makes my throat tight.

Secondly, I'd decided that Abbey should pass in my bedroom, where she'd spent so many hours sleeping blissfully on my bed, and I wanted it took look nice. I cleaned it, moving haphazard piles of books to another room, and cleared miscellaneous items from the top of my dresser and stowed them in my closet. I dusted all the surfaces. I remade my bed so that it was tight and crisp and smooth. I was sweaty from my exertions, so I took a shower. During the shower, I cried one last time, a few sobs and a silent, gagging, agonizing scream that bent me double with its grief. Once showered, I selected my outfit with care. I wanted to look nicer than my average sweatpants and sweatshirt, but not TOO dressed up, because then Abbey would be wondering if I was going somewhere or if company was coming over. Like every dog, she was alert to all the nuances of everything I did and their potential meanings. I wanted her to feel like I was my normal self.

Abbey was so happy to see everyone and be surrounded by her family!

By then it was two. My dad and I went to the hospital to pick Abbey up. It took forever, both of us waiting tensely. It was almost three when finally the nurse brought Abbey out. My dad had been prepared to carry her to the car, but Abbey was alert and seemed comfortable on her feet. I rode in the backseat with her and Abbey couldn't stop licking my face and my hands. She seemed truly happy. We arrived home just as my sister pulled up. Abbey was utterly delighted to see her--the whole family was together! With light in her eyes and pep in her step, Abbey even cruised the kitchen to see if any crumbs had fallen. I wanted a few last photos of and with Abbey. Abbey was overjoyed to have me down on the floor and a great deal more enthusiastic licking ensued. She even nibbled my nose, which was my very favorite of her affectionate gestures. My sister got down on the floor to be in photos, too, and Abbey could barely contain her delight. That task taken care of, my dad carried Abbey upstairs and put her on my bed.

Me and my dog. She's gazing into my eyes as she gives me a kiss.

Abbey and I had some time alone for a few minutes, so I petted her and sang some of the songs I'd made up for her over the years. My mom joined me and petted her, too. Soon my sister was on my bed as well. Abbey was loving it. In the days prior, I hadn't been sure Abbey had really enjoyed being petted because she wasn't feeling well, but she was clearly enjoying this epic rubdown session.

After about half an hour, she got tired. Abbey had been laying between my legs, facing the door, but she got up, gave me another lick on the nose, and then settled herself against my right side, her head facing toward the pillow, one leg draped over my legs, as was so often her habit. She snuggled her belly up against me and fell asleep, using one of my arms as a pillow. As she napped, the four of us started telling stories about Abbey and all of the things we loved that she did. It was a joyful half an hour, one spent in smiles and laughter, not tears.

Abbey positioned herself for a nap beside me, a leg slung over mine. It was one of her ways of being connected to me.

At the appointed hour, the vet and her assistant arrived. They were wonderful, bringing calm, gentle energy with them, though they themselves remarked on the lovely atmosphere we'd built around Abbey during that final hour. We could tell just from how they moved and spoke that they were the right people for the job. Abbey, catching their scent, woke up briefly, but after being handled by so many people in scrubs in recent days, the presence of two more vets in my bedroom didn't seem to surprise her any. She settled back into a doze as they explained the process and asked a few necessary questions. And then it was time. Everyone else was crying, but I was not. I didn't need to. I was where I was supposed to be. They gave Abbey the sedative in a quick injection in the loose skin at the back of her neck. I wiggled down so that Abbey's nose was just inches from my own and sang her my favorite lullaby as her eyes closed and she sank into a deep sleep. I whispered a few more words of love. The vets carefully rolled Abbey over so they had access her legs. They had some difficulty getting a vein in her hind leg ("Is her blood protein low?" they asked), but Abbey had no awareness of any of this. I had my arms wrapped around her, one hand over her heart. It was her breath that stopped first--her exhalations ceased to puff against my cheek. I felt her heart slow, and then go quiet.

It was 4:30 p.m., October 21, 2016.

She was gone. My Abbey was gone.

She looked so serene, so sweet, so utterly at rest. My dear dog, my brindle baby. I held her for a while longer as the vets put their things away and carried their equipment out. At length, I sat up and gave my family members a chance to say goodbye. The vets pressed one of Abbey's front paws into a bit of modeling clay for a paw print to remember her by. Then, the head vet came in with a carrier. Calmly, gently, she moved Abbey on to it. She admired Abbey's soft brindle fur and speculated that Abbey might have had a bit of border collie in her. (According to the DNA test we did, Abbey was 25% border collie!) Every move she made was done with quietness, competence, and reverence. It made it easier to let Abbey go, seeing her handled in such a way. We all walked down the stairs together. In the open doorway, I had to stop the vet so I could give Abbey one last kiss on her velvety forehead. And then she was borne away, half-wrapped in the green carrier, her dear little face resting on the crook of the vet's arm, my last view of my beloved dog in her corporeal form.

Abbey's paw print.

My father closed the door and I drew one deep, shuddering breath, exhaling sharply. My whole family wrapped their arms around me and one another.

We all sat together for some time afterward, talking about the beauty of the thing that we'd just seen, how much we loved Abbey, how glad we were that she had passed in such a peaceful way. I was feeling slightly stunned, but okay. My primary feelings were of gratitude, amazement, but most of all, peace. And thus, one journey with Abbey ended and a new one began.

Bed is too small for my tiredness
Give me a hill topped with trees
Tuck a cloud up under my chin
Lord, blow that moon out, please

Rock me to sleep in a cradle of dreams
Sing me a lullaby of leaves
Tuck a cloud up under my chin
Lord, blow that moon out, please

For Abbey, dog of my heart

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