My cat has hepatic lipidosis. I need urgent help decision-making :(
May 24, 2020 7:02 PM   Subscribe

2 weeks after my primary vet told me our 8 tear old cat had elevated liver enzyme/ALT levels and sent me home with dry food (for metabolism...) and told me to call him in a month, I took my cat to the ER yesterday (Saturday) and I was told he has hepatic lipidosis and would need immediate hospitalization and a feeding tube to fully reverse his condition and get him back to health. The cost is incredibly high. Please help me chart a course given my current understanding and options.

See previous post here for more initial information after my first vet appointment, two weeks ago:

5 days after the primary vet visit where I was sent home with a bag of some prescription metabolism food I called again and let them know George was continuing to lose 2oz a day and was barely eating the new food. They prescribed an appetite stimulant, which I apply transdermaly once a day and began trying a whole variety of wet cat food (and some human food). The first day or two he'd eat some but he then reverted to eating nothing. 

Yesterday we noticed he was yellow and assumed he must have jaundice. We immediately took him to the ER (not our primary vet, who was closed on the weekend) and after explaining the events of the last two weeks, and examining George, the vet told us he clearly had hepatic lipidosis. She ran blood tests and confirmed that his levels were very high (though not "extreme") and that to reverse the state he was in would require up to 3 days of hospitalization to get fluids and calories in him, additional diagnostics so that we could rule out cancer or other ailments as the underlying cause for the original lack of eating, and finally the insertion of a feeding tube via surgery, so that we could feed him medicine and calories at home until he would eat on his own again. The low end of the bill would be $5,000, the high end $7,000.

The vet was kind and thorough in explaining what was going on. I also asked her to answer a difficult question, which was, did my primary vet make a serious mistake in initially not diagnosing him with hepatic lipidosis, as it appears as if it was glaringly obvious (significant weight loss, lack of appetite/eating at all, elevated liver enzymes...). She said she wouldn't want to throw the other vet under the bus, but...she knew almost immediately what his diagnosis was, and treatment needed to be swift.

We cannot afford a $7000 vet bill right now. We have our first baby, a 4 month old, and we are overwhelmed to begin with. We love George beyond words, and having to make the choice between a curable sickness that costs that much money and making the decision to let him go is heartbreaking. I told the ER vet we would take him home and bring him to our primary vet Tuesday morning (Monday is a holiday) and demand to speak with our vet about what had occurred, treatment options, etc. She said he was purring and quite alert, and because his levels weren't yet "extreme" we could wait until Tuesday. He's still behaving mostly normally, being extremely friendly, sleeping snuggled against me, sits on our laps, etc. In the meantime, we've tried syringe feeding, spoons, etc. but George is incredibly difficult when it comes to being manipulated and fights us hard as hell. We've bought multiple soft treats, tried giving him cream cheese, tuna, etc. Many things that were recommended to us in my previous post above.

My questions:
1. Does this cost seem way too high? Should we be calling every vet in the area asking for how much their treatment options in this scenario cost?
2. Are there any alternative treatments for hepatic lipidosis you are aware of?
3. How can I approach my primary vet in the proper way to express that it seems like he made a very serious mistake in misdiagnosing George, and that we've lost 2 weeks in what is a really precarious situation? Do you think it would be appropriate to ask that he treat George at a significant cost reduction? I can't help but feel anger and frustration that what is apparently a straightforward diagnosis, and a serious situation with an animal refusing to eat and having lost 5 lbs, that he really screwed up.
4. Is there anything else you can offer in the way of advice or guidance?

Thank you so much!
posted by indyjones to Pets & Animals (22 answers total)
I am so sorry you're going through this! I hope someone else will comment soon. The main thing I have to offer is a tiny suggestion of a food to try: fresh crab. My kitty couldn't resist it even toward the very unpleasant end, and I think even the smell of cooking it (boiled in some water on the stove) increased his appetite. Plus you the cooking/opening process can yield some juice to pour over other food and/or you might mix it in.

I would try explaining the situation to your vet and asking if he can offer you any hope for the costs. Of course the vet did the best he could, and he loves animals or he wouldn't be a vet -- he'll probably feel bad so, while you may be completely justified in feeling entitled to some recompense, maybe don't try to make the vet feel _worse_.

I would also definitely call around and ask questions. Can you quantify how much more expensive your options are now, because of the delay?

*** Is George drinking water? If not, can you give him fluids? The emergency vet could have set you up with a kit; if not, call them back and ask about it. It's not hard to do even though it involves inserting a needle under the skin, if your cat can be persuaded to stay mostly still/in your lap/near your lap for petting for a while. It generally doesn't hurt the cat to put the needle in, and it can help the cat a _lot_. There were a few good YouTube videos showing how last time I checked, but if you can get someone from a cat fostering org, or a friend with experience, to help walk you through it the first time, so much the better.
posted by amtho at 8:00 PM on May 24 [1 favorite]

My gut says that the Emergency Vet cost for _anything_ is going to be HUGE compared to a regular vet practice.

Also, if you're talking about Monday's holiday being Memorial Day, I wonder if some vets might be open on Monday. Or even your own vet, if you call early and let them know what's happening.
posted by amtho at 8:02 PM on May 24 [2 favorites]

I'm so sorry.

My story wasn't a great one with this issue.

We went through this with a relatively young cat (4.5 years), our first. We didn't know how urgent it was when a cat stops eating and so he had progressed to jaundice as well. We went ahead with the feeding tube, at a cost of $4k (in 1996.) It was not successful and he passed away. The feeding part was so awful and he hated it so much. In his case, I feel that it was not a good end for him.

There were some differences in his story...we were his second owners and although we had a lovely year and half with him, I think he was always missing his first cat mum, who had gone into a long term care facility. We later found out he stopped eating the week she died, which is odd. I don't think he ever fully trusted us and so with the tube feedings it just wasn't a great scene. They need a lot of patience from both cat and human. It sounds like he had gotten sicker than your cat currently is.

I personally wouldn't do it again, but I wasn't sorry I had either. These questions are really hard. I would ask a lot of questions about prognosis and about determining what stopped the eating in the first place. I think it would be fine to talk to your vet about costs given that the initial treatment wasn't clear (come back in a month does not seem quite right.)

Again, I'm really sorry your cat is so sick and I hope for a better outcome for you!
posted by warriorqueen at 8:18 PM on May 24

Vets are ethically required to offer you the highest standard of care. Did you tell the emergency vet that you couldn't afford it and ask about other options? I'm concerned that it sounds like the vet's plan is to spend $7K to save George but then you potentially still have a cat who isn't eating. I'd want to know more about the diagnostic pathways they're looking at - are there outcomes where George lives a happy life for years afterward, or are all the options likely to require extensive additional treatment and a loss of quality of life? Are there less expensive tests that would help narrow down which it is?

I wouldn't necessarily blame your primary vet based on your description - it sounds like George developed additional symptoms over a week after the vet saw him last? It sounds like your vet was trying first-line treatments given George's condition at the time, but unfortunately George didn't respond to them.
posted by momus_window at 8:31 PM on May 24

I went through hepatic lipidosis with one of mine in 2015, very similar... prolonged period of not eating, lost a lot of weight, then hospitalization, feeding tube and everything.

To try to answer questions directly:

1. I was quoted $3500-$5500 at the emergency vet in Brooklyn, NY. So your quote seems maybe a bit high, but that was 5 years ago. We ended up coming in at the lower end of the estimate.
2. I'm not aware of any other treatment if they won't eat.
3. I would be inclined to just ditch the previous vet, if you have a better option. It probably isn't going to be best to have him treated in what would become a hostile environment. Not good for you or the cat.
4. Temptations treats (dairy flavor especially) were great for getting the appetite going.

To be honest, hand feeding via the tube at home was pretty dreadful. It's messy, time consuming, and a cat will be understandably upset about that kind of situation. But my girl DID make a full recovery and has enjoyed relatively good health since then, now at 17 years old.

I feel your pain, it's a hell of a tough situation. Best of luck to you.
posted by Ultra Laser at 8:42 PM on May 24 [2 favorites]

I'm so sorry you're dealing with this, this sounds like an awful, stressful situation.

Regarding other options, for comparison the Cornell College of Veterinary Medicine has a page describing hepatic lipidosis, and the treatment plan they describe seems to match what your emergency vet recommends. Based on this I suspect this really is the best standard of care, and there probably aren't very good alternative treatments.

Regarding cost, my experience is that emergency vets are significantly more expensive than other vets. However, a treatment that involves the vet keeping your cat overnight for several days is like to be pretty expensive regardless of who does it. That said I think it is reasonable to call other vets in the area and ask them about their costs for this type of treatment. They may or may not be willing to give you an estimate without having seen George but it doesn't hurt to at least call and ask. But, again, you may not be able to bring the cost down by more than a relatively small percentage of the total.

Regarding your regular vet's diagnosis or failure thereof, I certainly can't comment if this is something he should have been able to catch. However it's worth noting that two weeks passed between your primary vet seeing George and the emergency vet seeing him, and what was very obvious to your emergency vet may not have been at all obvious two weeks earlier. Also from the Cornell Vet website there's no discussion of alternative treatment strategies available if the condition is caught early, so it's possible that this expensive treatment plan would have been required regardless. Which isn't to say that it wouldn't have been better had your primary vet caught this early, that's basically always true.

Regarding other advice, if you decide you want to move forward with treatment for George but the only obstacle is cost, perhaps you can ask your vet (whichever one you have do the procedure) if they will be willing to set up a payment plan. Vets have to make a living and keep their techs paid, but in my experience they also hate seeing an animal fail to get necessary medical care only because of reasons of cost. I've had vets work with me on costs for expensive things when I explain that I want the best standard of care for my cats and am willing but not able to pay for it. They may or may not be able to bring the actual cost down for you, but they may be willing to set up a payment plan or find other ways to make it easier for you to afford right now. This conversation also usually helps clarify what costs might be reduced by not performing certain procedures that are part of the best standard of care but may be acceptable to dispense with, such as some diagnostic procedures. Personally I would suggest trying this with your usual vet first -- he and his practice will want to keep you as a customer if possible, in addition to bringing George back to health. Your primary vet will also probably appreciate the opportunity to do right by George after failing to properly diagnose him the first time, whether or not he actually did anything wrong in missing it, and he's likely to get more attention as a result.

Best of luck to you and George, and please let us know how it turns out.
posted by biogeo at 8:52 PM on May 24 [4 favorites]

I can only offer some thoughts:
1. It's possible the cat did not have hepatic lipidosis two weeks ago and that the continuing anorexia precipitated it in the meantime. And be aware that without further diagnostics the vet could not have been 100% sure this is what he has or that it's all he has. I feel like they should have told you that.
2. I wouldn't do any surgery until a vet I knew and trusted had determined the likely cause of the appetite loss. Some additional testing like ultrasound or aspirate seems like a much cheaper and more sensible place to start.
3. I would be very hesitant to do a feeding tube with a cat that reacts this badly to syringe feeding or handling. I've been in this position before with a sick pet that I dearly loved and who was extremely stressed by any treatment and I know how tough it is, I'm sorry.
4. The emergency vet will 100% be the most expensive option and you'll lack continuity of care as the staff rotate in and out so if I were you I'd have the cat treated at a normal clinic if you decide to.
posted by fshgrl at 8:57 PM on May 24 [3 favorites]

I’m so sorry you’re dealing with this.

I think the suggestion to go back to your regular vet on Tuesday is a good one. They’ll probably be cheaper and they know your cat better.

You might consider approaching it from the question “Could we have known this was what it was earlier?” That doesn’t sound as angry (though it makes sense that you’re angry!) and gives the vet a chance to explain why he or she missed it or wasn’t considering it a few weeks ago. If the vet brushes you off or you don’t like the response, you’re still free to go elsewhere, but you’ve started from a more neutral place in the conversation.

I think asking for a payment plan makes total sense. I also think if you’ve been going there for awhile and you’re friendly with any of the techs, you might be able to pay them to take George home for the first week or two to get him feeling better and used to the feeding tube. I realize that’s even more money and may not be feasible at all, but they may not charge you a lot and it sounds like the help might be worth it.

I also want to say that dealing with this, in addition to a four month old, not to mention a pandemic, is really really hard. It completely stinks and you’re a rockstar for not completely losing it already. Hugs from this internet stranger if you want them.
posted by bananacabana at 9:09 PM on May 24 [2 favorites]

I'm sorry you and George are going through this. That vet bill sounds accurate to me because of the two separate issues of sustaining him as well as getting to the bottom of the primary inappetance. Some cities have cheaper options, like the ASPCA clinic in NYC, for those that qualify.

Hepatic lipidosis is typically the result of weight loss not the cause, and it is likely much more pronounced after a further two weeks of not eating. I'd be more concerned about the first vet not telling you that more of a diagnostic work-up was necessary after the bloodwork came back to figure out what was causing the loss of appetite. 5 lbs in the few weeks before your first appointment is highly concerning.

Has he ever had dental issues? Does he pick food up and then cringe and drop it? If not, I'd ask the second vet to take the diagnostics step-by-step. As in, do a full-body radiograph, and then re-assess. If that didn't point to anything, then the next step may be an abdominal ultrasound. The underlying issue may be relatively simple or it may not, but I think it's crucial to figure this out before you'll know how to proceed.

If hospitalization is definitely not an option for you, I'd also ask the vet for help sustaining him on an outpatient basis. They may be able to give subcutaneous fluids and syringe feed him once a day at a cheaper rate than it would be to keep him there full-time or to insert a feeding tube. They may also be able to work with you on a payment plan instead of expecting an upfront deposit.

Is he on any nausea medication? Cats easily develop food aversions where they associate their nausea with what they've eaten, even if it wasn't the cause, and then they avoid those foods going forward. It makes it harder and harder to get a sick cat to eat anything. Pills and injections are more effective, but if he won't tolerate those, you could ask about getting a nausea medication compounded into a transdermal med for you. Then half an hour after that's onboard, you'd offer him a food he hasn't had before, preferably a stinky new kind of wet food. Best of luck to you and George.
posted by crone islander at 9:59 PM on May 24 [4 favorites]

If you post your location, someone might have a specific vet or clinic recommendation for you to at least call first.
posted by amtho at 11:09 PM on May 24

Call around for prices. Don't be afraid to ask.

I was in your shoes once, and used a feeding syringe at home many years ago. It was messy and awful and I had bloody arms. I have a vivid memory of being covered with cat food. The vet was helping me as much as he could with kitty astronaut food and an iv drip for fluids. Another option was putting in a feeding tube and feeding her at home, but I was able to get enough down her with the syringe.

The thing with the syringe feeding at home is that it must be done mercilessly and frequently. I grew up working on a farm that did its own vet care, so I'm reasonably good at immobilising a cat in a towel but this is what it will take.

FWIW besides scratches and feeling like I smelled of cat food all the time, it worked and she lived out the rest of her life as a grumpy healthy cat.
posted by frumiousb at 2:10 AM on May 25

Anecdata: my cat had to have a feeding tube put in her neck to treat hepatic lipidosis, and while feeding her through the tube was initially very stressful and made me feel like a monster, she made a full recovery and lived for many years afterwards until cancer did her in.

My understanding is that recovery is possible even in relatively advanced and dangerous stages of the disease, and also that non-tube options like forcefeeding through the mouth with a syringe carry the risk of the cat developing a permanent aversion to the food, which is why the tube is preferred -- but I am not a vet.

I can't make a direct price comparison because I live in a completely different country with completely different medical care prices. I would shop around, if that is an option.
posted by confluency at 3:17 AM on May 25

Also: as others have pointed out, an emergency vet is likely to be much more expensive than a normal vet. This has also been my experience here.
posted by confluency at 3:20 AM on May 25 [2 favorites]

Thank you all for the anecdotes, advice, opinions and well wishes. Just following up to post that I’m located in Atlanta, if anyone knows of a great vet to try down here.
posted by indyjones at 4:39 AM on May 25

We went through a very similar situation a few years ago, but with one big difference in communication from our vet. Our vet specifically told us that our cat Flip was in the early stages of hepatic lipidosis, but that the diagnostic problem was figuring out what was causing him not to eat. The way it was explained to us, hepatic lipidosis is almost never the primary problem. It always happens when the cat stops eating for some other reason, and the challenge is figuring out the primary cause before the symptoms of the secondary problem (i.e. hepatic lipidosis) become life threatening. I would think it's less likely your vet missed the diagnosis, and more likely your vet didn't communicate as well as ours did about how treatment and diagnostics work when the only visible symptoms are coming from a secondary condition.

In our case, the vet also didn't find any obvious primary problems (like a blockage or a bad tooth) and sent us home with an appetite stimulant and some prescription food, but the vet also told us some things we needed to be looking out for as signs that we needed to take more immediate action. We called on a subsequent Saturday and said we were concerned that things weren't improving, and even though they were open on Saturdays they just referred us directly to the emergency animal hospital. They (correctly) thought he was going to need overnight care, and they said they'd just end up referring us there anyway if he needed to be hospitalized even if we brought him to them for diagnostics. Off we went.

At that point, the vet at the animal hospital ran through an even more detailed version of the first conversation we'd had with our regular vet: visible symptoms were all of hepatic lipidosis, hepatic lipidosis almost always happens because of some other problem that happened first, and if symptoms aren't improving with an appetite stimulant then the primary cause may be something serious like a tumor or blockage, and here are the next steps to diagnostics and treatment. This sounds a lot like your "additional diagnostics so that we could rule out cancer or other ailments as the underlying cause for the original lack of eating" but without any back and forth about whether our regular vet had missed anything. Honestly, I think I may have asked a question like that, but the emergency vet backed up the diagnosis and initial treatment and said "with cats, sometimes you never know what causes them to stop eating."

This is where I got into differential diagnosis, though. I asked the ER vet what each one of the diagnostic steps she was proposing was, what additional information it would give us compared to the last one, and what both the procedure and any additional information would mean for Flip's recovery. I think we had already paid for an ultrasound, but they were proposing exploratory surgery to look for a blockage in his digestive tract that hadn't been found with an exam or ultrasound. I asked how it would change the treatment and recovery. The vet said that if they did the surgery he'd have to be held for a day or two just to heal from the incision and that there was always a possibility of complications from surgery, but there was also a possibility they wouldn't find anything new anyway. So then I asked how he'd be treated differently based on the outcome of the exploratory surgery, and the vet said aside from Flip's recovery from the surgery itself, the treatment for hepatic lipidosis would remain the same, with a tube in his neck and regular syringe feeding to get his weight back up, his liver recovering, and get him on the road to having an appetite of his own again.

At that point I kind of went back and forth with the vet trying to ask versions of "so why do I need to pay for this, again" and "what happens if we stop looking for a primary cause and treat just the symptoms we can see" and "will his condition get worse in an irrecoverable way if we don't do that now" until it became clear that the additional diagnostics were a high expense for a pretty small chance of changing the course of treatment. So we did not choose to do the exploratory surgery. They put a tube in him, and they fed and monitored him for a few days until they thought he was OK to go home.

After we brought him home we kept in regular contact with both our regular vet and the staff at the animal hospital. We had to tube feed him for a few weeks (six? I want to say six) but we eventually started offering him a little wet food to eat on his own, and when it was clear he'd eat we could get the tube and collar removed.

I'm sorry you're going through this, but I can say that with treatment Flip recovered completely. It's been six years. I'm looking at him now. He's fine.
posted by fedward at 6:04 AM on May 25 [2 favorites]

I'm so sorry. I haven't read through the other answers yet but yes, unfortunately, that amount is very much in line with what Madison emergency vets were quoting us. The university's clinic was somewhat cheaper (our regular vet didn't have the capacity for it), but their high end still overlapped that range. Eventually the money versus quality of life versus expected outcomes equation became too much.

About your vet, I of course hesitate to say too much as Not A Vet, but... HL was my immediate thought, just based on my experiences with managing one diabetic cat and caring for the one who actually had HL. I never got the impression that it's a weird/exotic problem for cats to have. Getting regular food into cats is crucial, and big weight losses are highly problematic, and I did wonder why your vet seemed to be so relatively sanguine about George being on the wrong side of both of those with liver enzymes creeping up. Your vet might just be a relatively chill, low-intervention kind of person, though, and often enough that attitude is exactly what people are looking for in a provider. I've deliberately picked vets like that at times (me: "hi, I want this exact type of insulin, and I'll do the glucose curves at home, thanks"), but I've also had much more intensely-involved vets (vet: "here's my personal cell, call me any time"), and sometimes one is a better fit for a certain pet/situation than the other. I don't know. I am really sorry his treatment plan wasn't correct for George in the moment. If you choose to continue to try working with him, his reaction to the changed situation will give you more information about whether he guessed wrong on something that could have gone either way, or if he's just somehow not getting it. Just fyi, I don't know if it's the same everywhere, but when I took my cat to the emergency vet, they always notified our regular vet and she would call to follow up, so you might near from him.

One thing I realized in helping my cat with HL was that the emergency/high-intervention-type vets will really tailor their responses to your apparent wishes. When we were saying gung-ho things like "yes, a feeding tube is fine, yes, let's go ahead and try the ultrasound, oh hmm an MRI sounds really expensive, so let's exhaust our other diagnostic tools first," instead of "wow this cat is unhappy about that tube, and hates having been shaved, and frankly an MRI just isn't going to happen unless it's magically 70% off," we went down very different conversational paths. I was upset at first because it seemed like nobody would just commit to telling us what was right, like how if there's a human medical emergency you can check in to the hospital and the doctors generally jump in and take over, but the truth of it was that there were multiple correct approaches, and we had to choose. The general assumption that's present with humans that, "up until the very obvious end, of course we're going to keep trying" doesn't necessarily apply with pets, and the vets were very willing to shift to that conversation whenever we were, even if things weren't that desperate yet. On the other hand, if we wanted to keep going, they were up for it almost indefinitely. It was a weird space to navigate, particularly because we were talking to a bunch of different people and each had their own subtly different approach and varying levels of knowledge about the situation besides. I don't know if it'll get to the point where any of this paragraph applies to George, but I wanted to let you know in case it starts feeling like there's no solid ground. There might not be, but if so, it may well be because you're in a giant support net and any decision you make will be enacted with love and care.
posted by teremala at 6:57 AM on May 25 [4 favorites]

This probably doesn't apply to you, but you mentioned that you have a 4-month-old, which might be taking away from cat time, so:

I have seen a lot of cats who were basically lonely become interested in food only when they were actively being petted and/or talked to. I know that you are probably giving George a lot of attention, but just in case there hasn't been time -- maybe try playing with him (not strenuously, obviously), talking to him, and especially touching and petting him a lot more (if he's into that), just in case that stimulates his appetite.
posted by amtho at 12:13 PM on May 25

The cost you were quoted is in line with what we recently paid in Chicago to hospitalize our elderly cat who had stopped eating, and who was eventually diagnosed with advanced kidney failure, and ultimately had to be euthanized. I think that you could definitely ask your vet for the reason behind their original treatment decision, but I would prepare myself to hear that they did have a good reason for doing what they did (e.g., choosing to begin with less invasive treatment before moving to more aggressive options). It sounds like each time you followed up, they gave you a more aggressive option to get him eating, and it just really, really sucks that that it didn't work and now you are at the point that hospitalization is an option.

I also want to offer a counterpoint to some of the experiences above, which I hope can help with your decision.

We are lucky enough that we could afford to pursue hospitalization and aggressively treat our cat's kidney failure. We ended up spending roughly double what you were quoted, and the treatment was not successful. This was worth it to us because (A) the treatments did resolve his original discomfort and gave him a relatively pain-free final week at home; and (B) were not invasive enough to impede his normal lifestyle once he was discharged. In your shoes, I would ask myself whether you would be comfortable spending $7,000 to ultimately have to say goodbye to your cat, knowing that he will spend at least some of that time away from you at the hospital, possibly in additional discomfort due to treatment.

Our primary vet was kind enough to lay it out like that for us at the very beginning so we were able to make an informed decision going into treatment and were also able to make the decision to stop pursuing treatment without guilt. Our ER vets were the same. I would hope any vet would do the same for you, but if they don't, you have this internet stranger's approval to decline aggressive treatment for your kitty; it is a kind and reasonable option, regardless of whether you can afford it. That said, I am so sorry you are going through this right now, it is a truly, truly heartbreaking thing to experience.
posted by ailouros08 at 9:54 AM on May 26 [2 favorites]

Update on George: I took George to my vet Tuesday morning when they opened and they took him in right away. I was told they'd get fluids into him along with anti-nausea meds and they'd try to feed him, even if that involved force feeding. The vet called later in the day and told me George had eaten the canned wet food they gave him, which was obviously good. He also called me again before he left for the evening and told me he was continuing to eat the food offered. I was called again this morning and told he'd eaten the food he was left with overnight.

Onto the various questions and answers:
1. The vet said that because the levels weren't extreme and he didn't see jaundice, he hadn't treated George aggressively the first time he was brought in. The appetite stimulant was prescribed but didn't work, at which point I'd gone to the ER next because it was a weekend and my vet was closed. He also explained, when I asked, that the metabolism food he had given me the first time was an attempt to see if he wasn't eating as a result of psychology/finickiness, as is often seen in cats, and knew it was a better tasting food than some of the other alternatives.
2. I told him what the ER treatment plan was: diagnostics for an underlying cause, hospitalization for fluids/meds/force feeding/feeding tube. I told him that course of treatment was far more than we could afford. He then asked me how much I had been quoted for that treatment, and when I said "5 on the low end, 7 on the high end" he asked, "Five...thousand??" He seemed a bit taken aback but then said that of course an ER is going to be a lot more money than a regular doctor. He said he'd like to keep George for 2-3 days/nights, to get the fluids, meds, etc. to try and flush out the bilirubin or whatever else is involved with the liver damage, and to try to get him eating on his own and the jaundice cleared up. He said the cost would be $600 for 3 days of that treatment, which I was completely comfortable with. It's now been 2 days and one night and I've been told he's eating on his own, so I guess that's some good news.

Tomorrow when I speak to the vet I have the following questions: what is the prognosis here? If he's eating on his own, does that mean we're for sure on the road to recovery? Why have we been told over and over that the feeding tube was going to be the requirement for recovery? How many calories a day/how much food does he need to eat on his own to continue that recovery? What happens if he comes home and stops eating? Does that imply that it's his recently disrupted/changed environment (new baby at home, my wife and I home all the time because of the pandemic)? How do we handle that scenario?

Lastly, the ultimate question is, why is his approach to this condition seemingly so much more measured and less urgent-seeming than so many things I've read and been told? Is it possible he's had experience iwth this and it's been successful? Is he more sensitive to high cost treatments and tries the middle road rather than all or nothing approach? I admit it's confusing to me but the doctor just doesn't seem to be all that worried and on the phone sounds confident and steady when describing the current treatment.
posted by indyjones at 6:08 PM on May 27 [2 favorites]

Thanks for updating us. Overall it sounds like the current progress is good, and I'm really glad to hear George seems to be doing okay so far and you can get treatment for him without breaking the bank.

The responses from your vet sound very reasonable to me. It sounds like he prefers a cautious wait-and-see approach to this sort of thing, which explains his overall treatment strategy so far. If George is actually back to eating on his own without needing to be force-fed with a feeding tube then it may in fact be that that approach has paid off, but it's probably too early to say yet.

I think your follow-up questions are very good, and I would suggest adding one more. Most resources that I and other answers linked did seem to suggest that anorexia resulting in hepatic lipidosis is often a sign of an underlying condition that caused the cat to stop eating in the first place. It sounds like your emergency vet wanted to do some expensive tests to rule those out, and if George turns out to be fine after all this then perhaps that isn't necessary at all, but if I were you I would ask your vet to help you understand the relative merits of doing further diagnostic tests to rule out some serious underlying condition that started all this in the first place, versus just treating the hepatic lipidosis and monitoring George to make sure he keeps eating on his own. Keep in mind that these diagnostics could be somewhat costly, but if your vet can help you understand the full picture of the options and why he thinks a particular strategy is better, it will help you make a more informed decision and also help put your mind at ease.

As for your final question, some of this I suspect is bedside manner. I understand that vets sometimes talk about pet owners being patients just as much as the animals themselves are, and a good vet tries to be calm and confident while also honestly conveying how serious a situation is. And indeed, I think you're right that some of this may be experience: according to the sources linked in this thread, hepatic lipidosis isn't terribly uncommon in cats, so if he's been practicing for more than a few years there's a good chance he's seen enough cases to have an intuition for when to wait and see and when to act quickly. And finally, it may just be that he's of a school of thought that it's often better to wait and see with less invasive treatments, until the situation clearly calls for something more direct. I've worked with several vets in the past who tend to take this approach, and I have a lot of respect for it: it not only avoids unnecessary procedures that can be hard on the animal but reduces the opportunities for side-effects and complications. On the other hand, maybe a more aggressive vet like the one you saw at the emergency clinic would have moved to the current treatment strategy more quickly. I'm not sure there's a definitive right answer as to which approach is better overall.

At any rate, I think when you talk to your vet tomorrow your main goals should probably be 1) make sure you understand what George's recovery plan in the immediate term looks like, and 2) make sure you understand whether there is a likely or possible underlying condition that could cause other problems, or cause this one to reoccur.

Good luck, and if you can keep us updated I'll be really glad to hear how George is doing.
posted by biogeo at 11:18 PM on May 27 [3 favorites]

Here with a fairly large update. I'm currently incredibly emotionally conflicted and trying to process things, fyi.

After having kept George since Tuesday, the vet had gotten him to eat a bit on his own but then he stopped eating again. They then began force feeding him but after a day of this it was clear George was experiencing too much anxiety over it and wasn't having it anymore. So I just got a call from the doctor, explaining this and then telling me that he'd gone ahead and done the esophageal tube procedure...which was a shock to me, to say the least. I immediately told him there were two issues: we weren't prepared to pay for this procedure and we're going to be out of town for two weeks, two weeks from now, and that would present a problem as far as getting George fed via the tube multiple times a day as needed.

The doctor explained that 1. understanding our financial concerns, 2. knowing we had to take him to the ER, and 3. it having been some time since he's done the procedure, he did it at no cost. He said he wanted to make sure George was taken care of and that he was going to do what was needed for us. Several weird feelings about all of this, naturally.

ok, so the original wish we had, for this guy to take responsibility and fix this for us and George for free, has happened! Yay! Except he didn't let me know he was going to help us in this way before doing the surgery. And that feels really odd to me. Maybe it was guilt? I don't know but it just seems so strange and sort of wrong.

While we are of course so grateful that George will continue to live (assuming he can eventually eat on his own), we didn't really sign up for the burden of dealing with the feeding tube right now. We have a 4 month old, my wife and I are both working full-time with no daycare, and we have that trip to my family scheduled. We had essentially come to the decision, my wife and I, that because we couldn't even afford the feeding tube, and even if we could it might be too overwhelming for us right now, we may have to make the upsetting decision to let him go (assuming the stay with the vet/force feeding didn't result in him eating on his own). Now the vet made that decision for us. We're hoping that the tube feeding goes well once George is back with us but we wont know until he's back on Monday. The vet wanted to keep him until then.

Additionally, we'll now have to board him for two weeks, so there's that additional unknown cost. I'm going to have to ask the vet to give us a break on that cost, as well. He also mentioned the levels of the bad things in his system had come down and his jaundice was clearing up. So he did additional diagnostics, for better or worse.

My wife and I are both just very shocked, confused, conflicted, overwhelmed, etc. right now. Anything you guys might have to help us better process and stay positive and sane would help. And any insight into the ethics of how the vet handled this would also be nice.
posted by indyjones at 3:24 PM on May 29 [1 favorite]

Yeah, it's weird that the vet put the tube in without even notifying you, much less asking your permission. It does seem that he maybe feels responsible for a treatment plan that was less aggressive at the start than now seems called for (but also, hindsight is 20/20). To some extent he seems willing to do a little more to try to get your trust back, but people don't go into veterinary medicine without having a personal interest in the welfare of each animal they treat. I'd give him some benefit of the doubt that he's now personally vested in George's recovery.

Here's what I'll tell you about tube feeding, though: it's not hard. There's an adjustment period for you and the cat, and it feels overwhelming at the start. Flip had medicines we had to mix into his food. Some were liquids, but there were also pills we had to crush in a mortar and pestle. The medicines weren't all on the same schedule, so we had a spreadsheet we'd mark off with every medicine that went into a particular feeding. Everything went into a big syringe along with the right amount of water to make a slurry of food and medicine that would go through the tube. Our vet gave us specific guidelines (no more than X food at once, taking Y amount of time), and I ended up doing the math down to the second. I'd open the stopwatch on my phone, hold Flip on my lap so that he was both comfortable enough not to get too stressed out, but also secure enough that he couldn't bolt, and carefully plunge every (specific) few seconds. It was fine. We both got used to it. He started to seem really happy a couple weeks in, maybe when he started to associate feeling better with having been fed. I assume. I can't read a cat's mind.

He did manage to bolt exactly twice over the six weeks. Once the syringe was still screwed on, so he couldn't get far fast. Once though, he twitched and ran just after the syringe was unscrewed. Thurber defined humor as "chaos remembered in tranquility," and a panicking cat running all over the house spraying food slurry from an open tube in his neck is definitely that.

Anyway: your vet seems like a good guy overall, trying to do the best thing for George in a trying situation. See how George is doing on Monday and how the vet talks to you about what he will or won't charge you, and go from there.
posted by fedward at 4:50 PM on May 29 [2 favorites]

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