One of the most painful experiences in life is losing a close friend or relative. I have lost many relatives, friends, and co-workers through the years. It’s hard to think about them soon after they pass, but you always cherish your memories of those precious times you had together. And the memories of all the dumb, selfish things you wish you could take back stay with you, too.
Those of us who have pets understand just how deeply attached we can become to animals. And, of course, they say that dogs are man’s closest and oldest friends from the animal kingdom. The most recent research suggests that humans and dogs have lived together for 27,000 to 40,000 years. That is far longer than any known human culture has existed. Human civilization only began about 10,000 years ago, maybe 12,000 at the most.
As my last article about our dog Yoshi reveals, I know just how deeply the loss of a pet can affect you. Within days of his death I had reached out to Doctor Marie Haynes, who runs the Ask a Vet a Question Website, and asked her to answer questions my wife and I wish we had known to ask before we lost Yoshi. She was very compassionate and took the time to respond quickly. Unfortunately, writing this article was too painful for me at first; and, of course, I had to get back to work and only recently decided I needed to finish this project.
Chances are that you have a good relationship with your veterinarian and feel confident that he or she is giving you the best available advice. But we felt that way and yet were unprepared for how quickly Yoshi’s end came. We had to make a hard decision under the most difficult of circumstances. The emergency vet we took Yoshi to warned us that it is normal to second-guess yourself, to feel guilty, and to doubt the choice you made after the fact. He had put down a couple of his own pets in the past, so he knew exactly what we were going through.
Although there seem to be a lot of Websites out there that attempt to answer these questions, I found none were satisfying enough for me. I wanted to hear answers that, as you will see from Dr. Marie’s responses below, are not easily forthcoming. For families of small dogs, which breeds are prone to suffer exactly the kind of heart condition that took Yoshi, the vet community has not been able to offer much hope. But below the interview questions I will share what I have learned about recent research and developments in small dog health care.
I have not had a chance to discuss this research with Dr. Marie or other vets. If she has any follow up comments I will either publish them here or write a new article. Any other vets who see this article and want to comment are welcome to contact me. I may not publish any follow ups for a while but I will publish them eventually.
These questions are exactly as I sent them to Dr. Marie and I have not edited her replies. These are her own words.
We have read that congestive heart failure often begins with a heart murmur. How common are heart murmurs that lead to non-terminal conditions? When should families be concerned about heart murmurs?
It is very common for a dog to have a heart murmur. I don’t know the actual statistics, but I would estimate that perhaps 5% of all of the dogs that I see for healthy visits have a heart murmur. How many of those go on to get a serious heart disease? That’s a tough call. I would say that most of these dogs do not die of a heart problem. The vast majority of heart murmurs are nothing to worry about.
Unfortunately, it’s really difficult to know whether a heart murmur is a sign of something serious or not. In many cases, a heart ultrasound can tell us what the cause of the murmur is, but not always. Given that this type of test is expensive and that it can often be inconclusive, especially in a small dog, it doesn’t usually make sense to do an ultrasound just because we’ve heard a murmur.
When I hear a murmur, I will usually mention it, note it on the records and then monitor it at each visit. Where I start to get a bit worried is if the murmur gets significantly louder or if the dog starts to show signs of heart disease. We only treat heart disease when there are significant symptoms, so there is no point in doing extensive diagnostics for most dogs with a heart murmur.
When a small dog is first diagnosed with a murmur, is there anything the family can do as preventive medicine to watch for the development of CHF?
No. You will read of all sorts of herbal or natural supplements that can be used, but there is no evidence that I am aware of of anything that can be given to prevent congestive heart failure. In a human, we would likely advise a low salt diet and a healthy lifestyle if we were concerned about heart disease. I suppose the same could hold true for dogs. Low salt dog foods exist, but they don’t taste good and most dogs won’t eat them. Still, keeping unhealthy treats to a minimum is a good idea. It’s also a good idea to try to keep the dog’s weight at a healthy level.
When a vet sees a slight bulge on the heart, is that always a sign of CHF? And if not, does it always indicate a terminal illness?
X-Rays are hard to interpret. X-Rays of small dogs are even harder. Sometimes I will look at a heart and say, “I see a bulge here.” or “This heart looks enlarged” and one of my colleagues will disagree with me. But sometimes it is quite obvious that something is not right. A bulge, depending on where it is on the heart usually means that there is enlargement of some part of the heart. That is often a sign that something is not right. But, I have seen many dogs that appear to have an enlarged heart and don’t go on to get heart disease. I think that if I saw this on a patient, I would recommend regular checkups and perhaps a repeat X-Ray from time to time.
The problem though is that nothing really changes if I do see that the heart is getting bigger. So, let’s say I see this same dog back again and the bulge looks bigger. What do I do? We really don’t treat heart disease until there are symptoms that are causing the dog to feel uncomfortable.
We have read that CHF can be caused by a bacterial infection that damages the valve. Could his periodontal or kennel cough problems have contributed to this? If so, what could we have done to detect a potential problem?
It is possible for a murmur to be present because of bacterial endocarditis. Some dogs with severe dental disease can have a build up of bacteria on a heart valve that can cause a murmur. I think it would be rare for this to lead to heart failure though. I have never heard of kennel cough contributing to bacterial endocarditis. If this was the problem with your dog, and I don’t think that it was, there really would not be any way to know this. With that said, I suppose that if there was a serious enough bacterial infection it could be detected on blood tests. But again, I am doubtful that this was the problem.
Given that predicting the future is impossible, at what point should a family begin to think about their dog’s end of life situation? In addition to setting aside money for euthanasia and maybe a memorial (if services are available), what kind of budget (in terms of number of visits and diagnostics) do you think a family might want to make for that last year of life?
That’s tough to answer. Just like humans…no one knows when a pet’s life is going to come to an end. I think that it is wise to have money put aside for any time of veterinary emergency, whether it is for medical needs near the end of your pet’s life or perhaps for an emergency. I tell my clients that the minimum amount to put aside is $500. But, $500 will not go very far unfortunately in most emergency situations. I am actually a fan of pet insurance for emergency situations. If you’re interested, I wrote a thorough non-biased article describing common questions that are asked about pet insurance. (http://www.askavetquestion.com/pet-insurance.php)
I see many clients that don’t realize that end of life decisions are rarely black and white. Many will say, “If he gets really sick we’ll put him down.” But, we don’t know how sick he is until we’ve done tests. And often those tests can be inconclusive. And sometimes there are hard decisions to be made about tests. For example, let’s say that I’m suspecting some type of cancer. I can do an X-Ray and that might give me the answer or it might just make me more suspicious. So then I offer an ultrasound. The ultrasound might pick up a mass, but it doesn’t tell me that it’s cancer. So then I might offer a biopsy which is going to cost more money. By the time we’re finished with all of this the bill could easily be a couple of thousand. And that’s just for diagnostics. We haven’t even treated the disease yet.
This is one of the things that I really dislike about veterinary medicine. Everything is very expensive and nothing is black and white.
We were totally unprepared for this. We hoped he would have at least another year. Our vets did not make any promises, but we don’t feel like they fully shared their opinions with us. As a vet, do you try to NOT be alarmist about a pet’s end-of-life?
I suppose that every vet is different in their philosophy here. I don’t think “being alarmist” is ever a good idea unless there is an urgency. For example, if an animal has been in a bad accident and is in pain and needs to be euthanized immediately, yet the owners want time to decide, I will be a little pushy in advising euthanasia.
The other thing to know is that we just don’t know what is going to happen. When I hear a heart murmur and I start seeing signs of heart disease I will mention something to let the owners know that things could get worse quickly. But, I am not a fan of giving numbers. What I mean by this is that owners often want to hear things like, “He should live another year”, or “90% of dogs live 6 months with this condition”. Those numbers are usually wrong. No one knows what the future holds.
In reading up on how vets handle these end-of-life emergencies it’s clear to me that a lot of people ask for the impossible (e.g., heart transplants) and in online reviews I have found some people are very angry about the post-euthanasia bills they receive when vets attempt to prolong the lives of beloved pets. What can the family do to prepare for these hard decisions in advance? Do professional veterinarian organizations offer guidance we can share with people? How much can a veterinarian volunteer in opinion and planning advice before running into ethical or legal issues?
This is a tough question to give specific answers to because every case is so different. I think that most vets do a good job of supplying different options. But again, it is difficult because we can never guarantee the outcome. I have had clients go as far as a $25K kidney transplant to save their pet (and that animal lived for many years). I have had others that have spent tens of thousands in surgeries only to have their pet die a month later from complications. Were they wrong to do the surgery? It would seem so considering the pet died, but what if he lived?
The other difficult factor here is that people often have to make a decision under duress. I used to do a lot of emergency work. So, let’s say that I see a dog that was hit by a car and I am suspicious that his back is broken. I could offer euthanasia on the spot but these owners are usually not in an emotional state to make that decision quickly. So, instead, we decide to X-Ray. Because the dog is in shock, I’ll need to get IV fluids in place and some type of sedation as well as pain medications. By the time I’ve done all of this and taken X-Rays we could easily have a bill of $2,000. If the X-Rays show that the injuries are too serious and that euthanasia is the best option then that is a lot of money that was spent considering that the dog did not survive.
I hate those situations and I understand the feelings of someone who felt that they were pushed into spending more money before they euthanized. I think that it is rare that a vet will offer tests and treatments just to make more money. I know that many will disagree with that statement. But I think that every vet I know wishes that we could practice and not have to bill people.
Again, if you’re interested, I wrote another article about why veterinary bills are so expensive: http://www.askavetquestion.com/why-are-vets-so-expensive.php
We asked that Yoshi first be sedated, thinking he would fall into a normal sleep. But instead he simply became very relaxed and struggled to breathe again. Would his breathing have been easier if we left him on oxygen?
Should we have bypassed the initial sedative?
I think most people expect a pet to lapse into sleep as if they have been anesthetized. Is anesthesia ever used in euthanasia? Is it more humane?
The doctor administered the second injection while I was trying to comfort Yoshi as he gasped for air.
Euthanasia is difficult. Euthanasia on an animal that is unhealthy and struggling is extremely difficult. Every vet has a procedure that they follow when they perform a euthanasia. This procedure is born out of trial and error. Some will sedate an animal first, but some won’t. In some cases when an animal is sedated it works really well…They get a little sleepy and relaxed and they hardly notice that the intravenous injection of euthanasia solution goes in. In other cases though, the sedation causes the dog to get too sedated and owners complain that the dog looks dead already. And in some cases, there can be reactions to the sedation. In sick animals the sedation can possibly cause other reactions. It’s impossible to predict. In each case, we try to do what we can to make the scenario as peaceful as possible.
I have performed hundreds if not thousands of euthanasias. Most have gone well and have been quite peaceful. But, even with years of experience, I have had some that have been horrible. I have had animals bite me in the process. I have had owners freak out and yell, “WHY CAN’T YOU HIT THAT VEIN? HE IS SUFFERING!!!!”, while I am doing my best to find a vein the size of a thread in a thrashing animal. I have had some cases where the animal did not die and needed more medicine injected. I’ve had other cases where the death was peaceful but 30 seconds later, the body produced a muscle contraction that made it look like the dog was gasping for air.
Euthanasia is so difficult. Even the most experienced vets will have cases that don’t go as well as hoped. Sometimes in hindsight we can say, “I wish I had sedated”, or “I wish we hadn’t given that kind of sedation”, or “I wish we had tried to give oxygen”, or “I wish we hadn’t tried to give oxygen and stressed the dog out.”
I wanted to be with him in his last moments. I didn’t want him to be alone. That was selfish of me, but did it make much difference?
In my opinion, whether or not the owner stays with the pet is really what feels best for you. Most of my clients stay when their pets are euthanized. When my pets are euthanized, I used to do it myself. Now, I have a colleague do it and I leave the room because it is too hard on me emotionally. I think that either option is successful.
The ER doctor did tell us that people experience all sorts of emotions after euthanasia (he had had to put one of his own dogs to sleep at some time in the past). I felt he was very sympathetic and understanding but he just moved so quickly. He tried to explain the difference between giving him one shot and two, but we really didn’t understand what would happen. I guess what I want to know is if we rushed things and should have asked better questions? Knowing each vet may have different procedures and tools, how much in advance can or should the family discuss those last moments?
I have had cases that sound almost exactly the same as yours. I am thinking right now of a chihuahua patient whom I had seen for years. He developed a cough and congestive heart failure and we treated with medications. He would improve and then decline and we would adjust his medications. Then one day his owners rushed him in and he was in heart failure and struggling to breathe. Although we had discussed euthanasia before, the owners were still not prepared. They wanted to have a long discussion about the pros and cons and the procedure. But all that I could see was that the dog was suffering. So, I explained what I could as quickly as possible and we signed paperwork and sedated the dog. Within 15 minutes of coming in our door, he was put to sleep.
I am sure that those owners felt rushed. But I was doing what was best for the dog. I could have spent another 30 minutes discussing options and explaining what could happen, but my first priority was making sure that this dog did not suffer.
In the last day or two Yoshi stopped coming over to me when I called him. He struggled to get water right before we took him to the emergency room. I didn’t realize he was so weak. I guess I’d like to know (because we have another Chihuahua) if we were mistaking the Xanax incident from the day before for a failing heart, or could the Xanax still have been affecting him (about 32 hours after he was dosed)?
This mixup with the Xanax is very unfortunate. Thank you for being so understanding about this. Accidents do happen in veterinary medicine and many people would be unforgiving about this. From what you have described, it sounds like the mixup did not have anything to do with Yoshi’s death. I can’t see this causing him to go into heart failure so quickly. I think that the lethargy you were seeing was because he was dying and not because of sedation.
Over the past few weeks when Yoshi seemed to cough too much I would gently massage his back and shoulders. I would also gently rub his throat. He would calm down and stop coughing. But was this really helping him? I began massaging him last year because our regular vet said that he also had a tinge of arthritis in his front shoulders.
I don’t know that anyone could answer this question definitively. The massaging certainly would not have caused harm and probably felt good.
Is there a way to determine that coughing is caused by tracheal collapse rather than CHF, or are the two very similar or very closely linked together? What should a family look for?
Kennel cough is quite common. Usually the symptoms are different from heart disease though. We can usually tell that the cough originates in the trachea rather than from the chest. However, in some cases of heart enlargement, the enlargement can press on the trachea and it can make diagnosis difficult. A chest X-Ray *might* help determine the difference between the two. However, if the only symptom is a cough, it may not make sense to X-Ray. If I did $150+ of X-Rays on every dog on which I suspected kennel cough that would mean I’m doing a lot of unnecessary X-Rays. Also, if we did see signs of heart enlargement on the X-Ray my treatment would still likely be to treat for kennel cough and see what happens. If things improved in a few days then that would be good. If there was no improvement, we’d do further tests.
I would encourage people who have lost a pet to look for a grief support group either online or in person in their area. In my area, we have ottawapetloss.com. Many people feel silly for feeling so much grief over the loss of a pet, but in some cases it is actually more difficult to lose a pet than a close relative. It is normal to feel grief.
Michael, it is up to you whether you want to include this in your article, but I would like to mention that I am not practicing veterinary medicine any more. I started my first job cleaning kennels in 1987. I have worked in vet clinics all of my life. 14 of those years were spent working full time as a small animal veterinarian. While there were many things that I loved about being a vet, there were so many things that I did not enjoy. The biggest of these was the financial aspect. When counselling owners who were making hard decisions it would kill me when owners could not afford the options that I gave, or even worse would get upset at me because I wanted to charge them so much money.
I have always had an interest in understanding how Google works. My hobby for many years has been creating websites and learning how to make something thrive on the internet. I had a dream that perhaps one day I could retire from being a practicing veterinarian and work at creating websites for vets and promoting their online presence.
In 2012, I was pregnant with our second child and on bed rest. When Google released their “Penguin” algorithm that was designed to demote websites that were trying to cheat their way to the top of Google, I was fascinated with it. I learned everything I could about the algorithm. I asked people in SEO forums if I could look at their websites. Eventually someone asked me if they could pay me to look at their website. I didn’t charge money until I felt that I had enough knowledge to give out. But bit by bit I felt comfortable consulting with business owners on SEO matters. Today I work almost exclusively with websites that have been affected by a Google algorithm or manual penalty. I have seen many sites make fantastic recoveries and I speak at SEO conferences such as Pubcon and SMX on Penguin and Penalties.
Today I have a thriving online business doing SEO consulting. I am still licensed as a veterinarian, but more and more it looks like I will not practice again. There are some things I really miss about my veterinary life, but I am thoroughly enjoying what I am doing today.
I want to thank Dr. Marie for taking the time to write so much in response to our questions. She did not have to do that. And as someone who provides SEO consulting services, I know how time-consuming the work can be when business owners are losing Web traffic and need help right away. You will see that Dr. Marie is included in the small directory of SEO Consultants I maintain on the SEO Theory Website. You cannot buy a listing in that directory. You cannot ask for it. Those are all legitimate recommendations.
But now let me turn to the research I mentioned. What is most troubling for me is that our pet health care system is not as advanced as the health care system we have for ourselves. Maybe that is the way it should be, but when you take an animal into your home you are responsible for that animal’s well-being. So I was raised to believe. I just want them to have as good a life as is humanly possible to give them, because they bring us joy, they help us in our needs, and they provide emotional sustenance for many people who would otherwise be lonely and isolated.
What was hardest for me to learn was that once a small dog develops congestive heart failure the veterinary community begins talking to families about the pet’s “end of life” cycle. It’s a very hard discussion to have, and you don’t want to hear that “there is no cure for this” or “there is no way to do heart surgery for a small dog”.
In all practical terms that is correct. You would be hard-pressed to find a vet who is equipped to perform such procedures. But I kept asking, “Who does the research that advances veterinary science?” I had a friend in college who went on to become a vet. You don’t just hang up a shingle and start practicing. You go to veterinary school, and some of those schools do active research.
So I’ll just cut to the chase: Yes, there IS a form of surgery that can extend the life of small dogs with congestive heart failure. But had I known that 1-2 years ago, it might have made no difference for Yoshi. The surgery is expensive and experimental and so far I only know of one university where this kind of surgery is even contemplated. But it was highly successful across dozens of operations, extending the lives of small dogs by years, in a case study to which I link below (I don’t know where those surgeries were performed as I can only show you the article summary).
It is my sincere hope that by the time our surviving Chihuahua faces this problem (if she must) that more practicing veterinarians will have been trained in this surgery. And the best news is that they don’t have to find living dog donors to do it. They can use valves from pigs just like in human surgery (I don’t know how or where the valves are harvested). I have a friend who has had that kind of surgery and it has extended her life by years.
Going forward, more families will face these hard choices. But after you read this article, you can talk to your vet about what it will take to get this surgery into the field. I think that knowing there is a procedure is the first step. The second step will be to organize sufficient public demand for it to stimulate whatever financial activity is necessary to start training and equipping regional veterinary specialists with the skills and tools they need. But if these doctors are already in the field then they need to contact people like me and Dr. Marie so we can help them get the word out.
Here are the links I have found to help you help our pets live longer.
Project CARE at Colorado State University
CSU is a veterinary teaching hospital and they do ongoing research into improving health care for pets, including small dogs.
Case Report: Mitral Valve Replacement with a Mechanical Valve for Severe Mitral Regurgitation in a Small Dog
The pet lived another 2 years with this surgery.
Researchers Study Causes and Treatment for Degenerative Mitral Valve Disease
This article describes an experimental method for early detection of mitral valve disease, and a new diuretic that may be more effective at treating the disease.
From 2011: Mitral Valve Displacement – Treatment
This article explains the four stages of the disease. Although it does not provide much information about the surgery, it mentions oxygen therapy. Yoshi might have lived longer had we understood that oxygen therapy was available. But I don’t know what it costs or how it works, so I cannot say that our emergency vet made a bad recommendation.
Mitral valve repair under cardiopulmonary bypass in small-breed dogs: 48 cases (2006-2009)
Here it is 2015 and three vets told us that there was no surgery available for small dogs. And yet this surgery has been done and the successful results have been published. Had any of those vets been able to offer the surgery to us, we would have looked our budget to see if we could afford it.
My impression is that the surgery is not widely available. If it is more available than these research articles suggest, we need to tell people that. But surgery is not cheap. We have heard about people who spent thousands of dollars trying to save their pets’ lives only to lose their beloved companions anyway. And those people were often bitter and angry with their vets over the expenses and failure to keep the animals alive.
There is no miracle cure for this terrible disease but I can assure you that there are more options available than just giving your dog some pills. Discuss this research with your vet and ask if they can refer you to a dog cardiologist. We were offered such a referral but we were told it might cost $1000, and that was money we did not have at the time.
Knowing what I know today, I think I could have dug deeper at the time. That doesn’t mean we would have been referred to a specialist who can perform the surgery. But I would have wanted to ask if it was available in our area. Heck, I work from home. I would have made a cross-country trip to get the surgery for my dog, if I thought he would have benefited from it.
All I can do now is hope that this article will extend the lives of some good animals. They deserve better than what we can give them today.
UPDATE: Dr. Marie shared the following comments with me.
I spent some time researching mitral valve replacement surgery on VIN (Veterinary Information Network) which is a huge forum where vets talk about the latest treatments available. I found a discussion from 2012 saying that a couple of universities offer it but the success rate is extremely low. I found a more recent discussion saying that there is one doctor in Japan who will do it.
The reality is that this surgery is not widely available at all and has definitely not been perfected. Most likely the cost of having the surgery done would be tens of thousands of dollars. I have had a few clients go for similar surgeries such as kidney transplants and the cost was about $30,000.
So I don’t want to raise false hope for anyone. There may be better treatments in the future as the veterinary research hospitals look more closely at the early warning signs of this disease. And maybe one day the costs of those surgeries will come down, and the success rates improve.
Until then, we shall love our friends as we always have and always shall, and enjoy the time we have with them.