Is it time to let her go?
August 13, 2010 12:15 PM   Subscribe

Is it time to let her go: diabetic cat edition.

Four years ago Maggie, my 13 y.o. cat, started vomiting, lost a lot of weight and started avoiding the litterbox. After taking her to the vet, and then a specialist, an ultrasound found a mass that seemed to be on her pancreas. The vet said that it was either cancer, an abscess or pancreatitis. We decided to treat the symptoms as best we can since further diagnosis would require risky surgery.

We gave her stimulants to bring back her appetite, and gave her a new diet that would be gentle on her digestive system. She returned to her peppy self. A year later we rechecked the ultrasound and found that the mass had shrunk and migrated to the kidneys. Her kidneys were in very mild distress, so we switched her to the renal LP diet to try and slow down any kidney failure from being a 14 y.o. cat.

Fast forward to three months ago. Her weight dropped dramatically while eating everything in sight. She was drinking about 30 ounces of water a day, and leaving all of it on my bathroom floor. I bought some doggie diapers to leave on the floor and took her to the vet.

The vet determined that the underlying issue (whether the kidneys or pancreas) have affected the production of insulin and found that her glucose levels were very elevated. We started her on subcutaneous fluids to keep her hydrated and 1 unit of insulin twice a day. Over the last two months her weight is stable and she seems more alert. But she still drinks quite a bit and has escalated her peeing. In the last month she has started using any stray clothes or my bed as a litterbox alternative.

She has been on elavil for the last three weeks and we've increased her insulin twice. The day after we increase the insulin, she uses the litterbox, and then stops until we increase the dosage. The vet hasn't come up with a solution except to wait every two to three weeks to increase her insulin until we find a level that works.

I feel unsure of whether or not it's worth it to keep moving forward. She is more alert, but she is still frail and sleeps most of the day. She shows little interest in keeping herself clean. When she pees in her own bed, she'll just curl back in to go to sleep. Because she's peeing on non-litterbox surfaces her back paws are always covered in urine unless I clean them. She avoids the litterbox as noted, which I know is typically because a cat is in pain. And we're going three months without being able to mitigate that pain, regardless of how proactive we've been.

Her appetite is up and she is still social. She sleeps in her same cocoon bed most of the time (aka not hiding). Because of this, my vet continues to argue that my cat still has a quality of life that most would consider acceptable. In her mind, these are the prime indicators that I should be focused on.

Obviously this is a grey area. I want to hold on to this cat for as long as possible, I've had her since sixth grade. But when she was diagnosed four years ago I decided that I wasn't going to focus on prolonging her life. I was going to make sure the time she had left was positive. My vet seems convinced that I'm considering this decision because I'm constantly schlepping through cat urine, and I admit that this aspect is trying. So I'm turning to all the cat-lovers on the green for advice.

(obligatory pics here)
posted by politikitty to Pets & Animals (29 answers total) 1 user marked this as a favorite
This sounds like when my (now-)wife's cat Flower was nearing her end. She wasn't enjoying life, frankly. I'm sorry. At this point you have to decide to do what's best for Maggie and let her go.
posted by notsnot at 12:22 PM on August 13, 2010

It doesn't sound like time yet. I am so sorry about this situation, and that the end of her life is so difficult for you. You are going to feel better about what is always a painful decision if you wait for the time when her quality of life is not there to put her to sleep, though.
posted by bearwife at 12:25 PM on August 13, 2010 [1 favorite]

I'd maintain that you having to constantly schlep through cat urine should definitely come into play. As you say, cats avoid the litterbox because they are in pain. And you cannot mitigate that pain. Allowing an animal to live in pain is not promoting a very high quality of life. I'm not sure what your vet is thinking, frankly.

We recently had our dog put-down after 14 years. At the end, she was emaciated, feeble and unable to make it through the night without crapping on the floor. I still flog myself for allowing her to go on like that for months.

It's a very hard decision to make. And only you can make it. I'd certainly confront the vet over what seems to me a huge guilt-trip they are trying to lay on you. An animal in the condition you describe certainly sounds to me to be in the end stages.

I'm sorry.
posted by Thorzdad at 12:26 PM on August 13, 2010 [1 favorite]

This is such a personal decision, but my first question for something like this is always, how diminished is this cat's life? Is this cat living the life she deserves?

Is this the cat you know and love and remember. It sounds like you and your vet are not of the same mind about this.

It also sounds like you have already seen an internist. Is the internist the one recommending these options, or is it your rdvm? I would also recommend going back to see the internist one last time to see if there is anything else that can be done- and there is always something else that can be done.
posted by TheBones at 12:27 PM on August 13, 2010 [1 favorite]

Can the vet do a glucose curve on the cat? That's what they did for mine. Cat has to stay at the vet for a day, but they got the insulin dose right the first time.

My cat was given a 10% chance of making it through a diabetic crisis about four years ago. He is doing really well, after a few months and an adjusted diet, he no longer needed the insulin.

Good health to you & your kitty!
posted by kellyblah at 12:28 PM on August 13, 2010

She's drinking all the time because she's thirsty. Can you imagine having endless thirst and not being able to quench it with water? Can you imagine constantly peeing yourself because you can't help it and it hurts and you've given up on caring about it? She sounds like a cat who's suffering and you're not able to make her comfortable. To me it sounds like it's time.
posted by amethysts at 12:38 PM on August 13, 2010 [5 favorites]

My vet seems convinced that I'm considering this decision because I'm constantly schlepping through cat urine

I'm pretty disgusted at the idea of a vet acting judgy at a time like this, when the physical illness is so obviously extreme. It's easy to look down on someone when it's not YOUR home that's being turned into a pee-swamp.

The four years you've given her since her diagnosis is a really long time, almost a quarter of her life. Go see another vet if you need to, but I think you should take care of this the way you've always planned to.
posted by hermitosis at 12:40 PM on August 13, 2010 [5 favorites]

I'm so sorry for you and your cat. When I was struggling with the same decision for my beloved dog this summer, one piece of advice that helped immensely is this: you know it's time to make this decision when you can't stop focusing on whether or not it's time. When it's hard to focus on day-to-day activities because part of you is constantly agonizing over whether or not you should be making this decision right now. That's your heart telling you what you already know but don't want to know.

And of course that doesn't make it easier. After I let Bandit go I tortured myself over whether or not I could have done anything more - whether or not I could have found one more drug to try, taken her to one more vet appointment, done anything to give her one more nice day ... but would the hope of that one more day have really been worth putting her through any more? As much as I wished other wise, of course it wouldn't. And as my wonderful partner so rightly pointed out, she had an entire lifetime of love, of wonderful days, of everything I could give her ... She already had an infinity of love, and I'm sure your cat does, too. No matter when you decide to let her go it will feel too soon to you, but please know that you won't be short-changing her on anything.
posted by DingoMutt at 12:44 PM on August 13, 2010 [6 favorites]

I can't make the choice for you. I can only say that I waited too long with one my cats. I'll spare you the details, except to say seven years later I still painfully regret that decision.

Set aside, for a moment, the issue of schlepping through urine. If Maggie was having the same set of issues but still using her litter box, would you still feel like it was time to let her go?
posted by theBigRedKittyPurrs at 12:47 PM on August 13, 2010

I understand wanting to keep your cat as long as possible, and I also understand the guilt that goes along with having to make this decision. In the past two years I've had to euthanize the two best cats I've ever had in my life, and even though both were clearly terminal and had no hope of recovery, I still felt guilt about it. It's a hard decision, ending the life of something you love, but I always said that I wouldn't prolong an animal's life unnecessarily if they were very sick - not only for their benefit, but also, I admit, for mine. I think your vet is being unreasonable here. Your cat may be clinging to life, but as far as I'm concerned, sleeping in one's own urine doesn't equal a good life, and it's making your life unpleasant on top of the emotional stress that goes along with seeing your little friend suffer.

If you're asking for permission to put her down - well, I'd do it if I were in your shoes. And I agree with Thorzdad about speaking with your vet, or maybe even finding a new one. My vets have always been very good about presenting the facts and leaving me to my own decision, and I have always appreciated it very much.
posted by something something at 12:48 PM on August 13, 2010 [2 favorites]

Yes I think its time.

Better a month too soon than a day too late. Your vet should know that.
posted by fshgrl at 12:49 PM on August 13, 2010 [1 favorite]

I hate to sound like an ass, but the truth is, your vet gets money the longer your cat's alive, with more frequent visits and testing. Maybe your vet's completely altruistic, but I've run into end of life issues where the vet will say "well, we can try X, Y, Z..." and not mention putting the animal down might be the best for the animal. We made a mistake by letting our dog stay alive too long and it's something I regret - her last days were painful. A cat who is so miserable she pees in her bed and doesn't move from the bed- that sounds like it's time. But it's not up to me, you know?
posted by kpht at 12:57 PM on August 13, 2010 [1 favorite]

I think DingoMutt has a good point about /you know it's time to make this decision when you can't stop focusing on whether or not it's time./

I made the decision for my beloved cat of 18.5 years, Matthew, last summer, and I instantly regretted it. Frankly, I still have many days where I just look up at the sky and tell the Universe that I WANT MY CAT BACK ALREADY -- I WANT MY FRIEND BACK ALREADY. But honestly, it *was* time. After he'd passed and I was holding him, I realized it had been a long since he'd really relaxed in my arms, and I realized that he'd been in more pain than I'd known. At 10 he was diagnosed hyperthryroid, and from years 10 - 18 he'd had a number of incidents where I thought it might be the end, but I gave it a week and he would go back to himself. Last summer, he was wandering about and would be unsteady and then sit, like his back legs were weak . . . and it didn't go away.

I'm so sorry you and your sweet cat are going through this. I hope it's a fluke thing and she's more herself next week.
posted by MeiraV at 12:59 PM on August 13, 2010

IANYV. I'm so sorry for what you and Maggie are going through. My baseline is always that the owners know when its time. Sometimes a good owner can feel overwhelmed, so breaking the situation into manageable parts can be helpful and saves lives. Finding the right balance between letting the client know you're there to help and making the client feel like you're pressuring them to take the case further than is in their comfort range is sometimes really difficult. It gets more complicated when the client has social difficulties, because what they are saying doesn't match their behavior. (Disclosure: I am guilty of pressuring clients to pursue treatment a few times... but never in a chronic situation like you're dealing with. It sucks, but sometimes a little nudge saves lives, and I've had most of those clients come back years later to thank me for laying out all their options.)

You say that she is happy and alert with a good appetite, these are all good signs. We don't know how much cats care about sitting in their pee. There are some incredibly fastidious felines who are clearly horrified, but it sounds like Maggie isn't one of them. It can be hard to tell with cats when they are suffering from dementia, all this would be far easier if we could.

I think the question you need to ask yourself is how important is it to you that you have exhausted all your options. For some people, not perusing every reasonable option to extend quality of life is haunting. For some people, seeing a beloved pet decline and dealing with the nitty gritty of what that means as an owner is painful enough to overshadow the desire to seek further palliative care.

If you're interested, there are ways to check her blood glucose at home so that you can be more responsive with insulin.

When you know it is time, it is time. Thank you for being a good owner, Maggie is lucky to have you.
posted by Nickel Pickle at 1:00 PM on August 13, 2010

Better a month too soon than a day too late. Your vet should know that.

I can't believe there was ever a time when I might have disagreed with that. Part of me worries that I may have waited that one day too long for my dog ... I'll always regret that.

Another thing I wanted to add: shortly after my dog died, I visited relatives whose 12-year old Maltese was also doing very poorly. The day I'd visited, though, they had just brought him back from the vet, who had done blood tests and found he had a thyroid problem. The pills the vet had given him seemed to perk him up immensely, almost instantly - and left me going through yet another round of agonizing over whether or not I'd let Bandit go too soon (why didn't I have her thyroid checked???). Sadly, however, the pills only helped for a few days, and my relatives' Maltese had to be put to sleep within the week.

My point is that even if there are things that you could still try, there's always a limit to how much it can help. Sure, you might be able to prolong her life for a period of time, but you never know whether that period will be another year or another week. Please don't beat yourself up over whether or not there are still things to be done. You know your cat better than your vet does, you know if she's suffering, or if her quality of life is at a level she'd want ... No matter what you choose, no matter what the other options may or may not have provided, your decision will be the right one if you're making it in good faith, as someone who loves and wants what's best for your cat.
posted by DingoMutt at 1:05 PM on August 13, 2010 [2 favorites]

nickel pickle is right on the money. There are always more options for treatments, if that is what you want to do. At this juncture though it sounds like you have exhausted everything your rdvm can provide you with, so it would be up to a referral to a specialist to help you out further, if that is what you want to pursue.

But, again (and I agree wholeheartedly) "the question you need to ask yourself is how important it is to you that you have exhausted all your options."
posted by TheBones at 1:06 PM on August 13, 2010

I had to put my 15 year old cat down 2 years ago. Her quality of life was greatly affected, she also was avoiding the litter box, sleeping all day. It was a hard decision, made after a year of trying all sorts of things to make her a happier cat. My vet kept pushing for me to try more and more things to make a difference, but ultimately, I felt that her quality of life wasn't what it should be. I miss her all the time, but do not regret making that decision.
posted by Zophi at 1:11 PM on August 13, 2010 [1 favorite]

Have you considered getting a second opinion? Another vet's perspective on your cat's symptoms might give you a better sense how to proceed or they might know of a course of treatment your current vet doesn't (though I admit re-paying for a bunch of exams would be expensive - believe me, I understand how that money hole works too).

Either way, a lot of us understand the difficult situation you're in -- it's impossible to know for sure that you have made the right decision about when "enough is enough" with a chronically-ill pet. I've had to have several elderly, chronically-ill pets euthanized over the years, and it's been torment and second-guessing no matter what, even when I was as certain as I could be that it was the right choice. You have my sympathies, and best wishes that this or another vet can find a treatment that will give your pet some additional non-suffering time with you.
posted by aught at 1:39 PM on August 13, 2010

"the question you need to ask yourself is how important it is to you that you have exhausted all your options."

No. The question is "what is the right thing to do for this animal despite my personal feelings on the matter?"

I've had dozens of animals put down over the years, often for clients and the only time its been hard is when someone has insisted in keeping an animal alive long past anything remotely humane because they can't "deal with it". All too often vets encourage this, I have no idea why.
posted by fshgrl at 1:52 PM on August 13, 2010 [2 favorites]

I'm so sorry - i've been there, and there's no getting around it - it sucks. I waited a couple days too many with my 20 year old cat, and I still feel bad about it.

I had a great vet once who's criteria was simply "have they stopped doing what they used to enjoy, stopped the things that made them who they are? Will we be able to get that back for them any time soon?". For every cat, that's a different set of criteria. If your cat used to love playing and now doesn't... then maybe its time. If your cat normally loves food and they're life revolves around meal times, and then they can't eat... maybe it's their time. It involves knowing your cat, which you do - and your vet simply cannot.

I have the "best cat in the universe II" at home right now, but she's sick, and I'm constantly asking myself this question. For her, when it gets to the point where she no longer comes and cuddles, I know it's really time to start thinking the hard thoughts.
posted by cgg at 1:58 PM on August 13, 2010 [2 favorites]

This is the worst part of being a pet owner, and everyone who has been in your position understands your pain. I am a long-time cat owner, and I have, I'm sad to say, waited too long twice in the past. Both times, as soon as it was over, I thought to myself, "My poor cat. I should have been braver about letting you go."

The second time was very similar to yours -- cat not able/willing to use the litter box, having to go through dreaded repeated visits to the vets, sleeping almost all the time. To me, that sounds like it's time. I'm so sorry.
posted by BlahLaLa at 2:33 PM on August 13, 2010 [1 favorite]

I posted a question about my own cat's health problems lately. The vet said something very important to us during our cat's most recent health crisis: it's not only about what's best for your cat, but also what's best for you.

Think about why you got your cat, and what good it does to either you or your cat to keep her life going on in this condition. She is in constant distress, and it doesn't seem like anyone really has hope of her condition substantially improving. I think of cats as proud animals, and they have dignity - they carefully keep themselves clean, and they have a strict internal code to only pee and poop in certain places. When they don't do these things, something is seriously wrong, as you know. Your cat has lost an essential part of her catness with what she's going through, even if she is alert and eating.

Your vet certainly sounds like she lacks empathy. I would recommend seeing if there is another vet in the area to get another opinion, and take it from there. But know that there is no reason to feel guilty if you decide not to pursue further treatment.
posted by wondermouse at 2:38 PM on August 13, 2010 [3 favorites]

WAIT!! She may not be avoiding the litter box because she's in pain. She may instead not be making it to the litter box in time due to the condition of her kidneys. Has the vet examined Maggie's kidneys and done that blood work yet? If her kidneys are starting to give out (not unusual for elderly cats; my beloved cat Butch had kidney failure), that may account for the accidents.

Have you tried adding more litter boxes (yeah, I know) so that she doesn't have as far to schlep when the urge strikes? Kidney failure can often be managed for a while, though you would want to put Maggie to sleep before the very end stages.

I know things seem grim and I know how hard it is to make end of life decisions for your cherished pets. I'm sorry you and Maggie are going through this.
posted by Maisie at 3:52 PM on August 13, 2010

I'm going through something similar with an old cat, though he's responding quite well to the insulin shots. I can't answer if its worth keeping going or not, but diabetes is a treatable disease in cats, in some way more so than humans. If she's not responding well, its possible you need a second opinion, as some vets are better than others for treating diabetes. But I'm sure that the reason your vet wants you to keep going is that diabetes in cats shouldn't be a death sentence once its treated.

A couple of thoughts -
- For the peeing, we discovered that human pee pads in a low sided pan were enough to attract our cat and keep him from peeing on everything else. Those are available by the adult diapers in places like target and walmart.

- Make sure you're feeding the wet version of the food. Carbohydrates are high in dry food and they will aggravate diabetes. I think the big thing we did that started getting my cat's diabetes under control was switching him from the dry Hills KD to the wet. It takes more work to entice him to eat, but a small amount of fancy feast and warming the food up seems to have worked like a charm.

- Make sure you're using the right insulin. Some vets use insulin that isn't very effective on cats. My kitty get Lantus (glargine) which cats are supposed to respond very well to and have a high likelihood of remission from diabetes after using it.

I suspect you're feeling frustrated because you're not seeing the results you'd like, and that's understandable. But in this case, it really sounds like the diabetes isn't well controlled yet and that's what you need to work towards.
posted by [insert clever name here] at 3:56 PM on August 13, 2010

I'm so sorry for your situation. I just had to take my very beloved cat to the vet last week to have him euthanized. Its an awful, terrible, sad, guilt-ridden thing to do and an agonizing choice. He had kidney failure (and possible IBS or cancer too). He spent most of his day hiding, and would pee and poop where he was sleeping. The last couple of days I had to keep him locked in the bathroom while I was at work (easy clean up) and he took to sleeping in the litter tray. I decided at that point, that really his quality of life was totally gone. He seemed happy whenever I went to him for cuddles, but never came to me for cuddles. To me, this communicated that he did not have the energy to move unless he absolutely had to. He also was eating just a few mouthfuls of food a day (previously his life centered around food).

Our vet was wonderful and reassuring, and listened to our concerns and explanation. They outlined other possible options for treatment, but also said that now would be a perfectly reasonable time, as his quality of life seemed to be gone. I strongly suggest you take your cat to another vet for a second opinion. I find the fact that she does not clean herself, fairly compelling indicator that she no longer cares about herself, which is a sign it might be the end. Yes, even though she does not hide. By contrast my guy hid 24/7 but still groomed. It's never simple, I really don't believe "you will know when it is time" is true, because its complicated. There is no clear cut sign that this is it, 100% when the illness is a slow decline. Ask yourself "does she enjoy any part of her day, or is she just surviving?". Its amazing what a big difference there is between the theory (I will euthanize my pet when his quality of life is gone) and the reality of euthanizing a family member you love so much.

I'm so sorry. My best wishes and sympathies. Someone recently told me something that helped me immensely, "when you choose to euthanize a sick pet you take their pain and suffer it yourself instead".
posted by Joh at 4:16 PM on August 13, 2010 [3 favorites]

On re-read, I do not mean my last post to sound so much like I am suggesting it is your cat's time. My recent experience is on my mind and I needed to share. The short version of what I was trying to say is - get a second opinion, since you seem to be uncomfortable with your vet's recommendations, and if you do decide that it is time, it's OK.
posted by Joh at 4:20 PM on August 13, 2010

My boy was diabetic for the last year of his life. He also suffered from diabetic neuropathy, which made it hard for him to climb in his pan (and walk, and jump...) You might want to come up with a pan with as low a barrier to entry as possible, perhaps multiple ones as others have suggested. If the urine is the main factor driving your decision, see if more/lower pans helps.

When a cat is chronically ill, I think that's a decision for an owner to make based on their long knowledge of their cat, and how the humans in the house are affected as well. Your vet knows animals, and may know your animal's health, but they can't judge "is it time?" like you can. I will say that my husband and I just woke up one morning, observed our cat, and knew that was it. He wasn't playful, his bathroom issues were worse, he couldn't move well - we fed him a last meal of treats and cheese, and brought him to the vet. Despite his issues, we hadn't expected the end to come when it did - we'd bought a case of food a day or two before. There was just something about him that particular morning. Our vet's office was kind and reassuring, explained the options, and took care of everything. At no time did they question our decision or make us feel guilty in any way. We left in mourning, but feeling like we'd done the right thing at the right time.

I agree with the people who say better too soon than too late. Remember your cat as healthy as possible. Remember them positively, and not a long and bitter end.
posted by booksherpa at 8:20 PM on August 13, 2010

A few points I would think that are totally sucky to think about:

1) your cat is 17 years old, and though we always want more time with our pets, even without the problems she's having now she is an elderly cat. I think it's especially hard with older pets because we tell ourselves "well, they're just tired or less energetic because they're older". But, this also means it's harder for them to deal with health issues they could have dealt with when younger, and the medications are harder on them. Even if her treatments continue to work somewhat, she's not going to live forever, nor will the rest of her life have the quality of life she had as a young cat.

2) Animals think in the moment. As humans, I think we torment ourselves thinking that our pets would want to live longer or hold out for the hope that they'll feel better in the future, the way humans feel about being sick. But I really don't think pets have that cognizance of the future. They think about being healthy and happy and 'normal' TODAY. If they're not those things - if you can't remember the last time they were those things - then I think it's right to let them go.

Had to let go of my cat at 14. It sucks. :(
posted by nakedmolerats at 12:35 PM on August 14, 2010

What a sweet girl she is! A what a great friend you've been to her. About 5 years ago, I lost the best pet I ever had. Eric was a sweet black and white boy who chose us. My mother in law called him the ugliest cat she ever saw! But he had a heart of gold.

After about 2 years with us, he became symptomatic with feline HIV. He would just sit in the same spot in the garage, rarely moving, wetting himself and then going back to sleep. This all happened in the space of about a week. We thought he just had the flu, or something like that.

We took him to the vet. I still get misty eyed when I think about it. We held him, and petted him, and he purred and purred and purred. Then, he fell asleep. It was a peaceful end for a loving companion.

No one can tell you when it is time. It was easy for us - he was obviously no longer the playful little guy he once was. From what you've said, I would say it was time. But I'm not you - only you know your cat.
posted by humpy at 6:25 PM on August 14, 2010

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