“Ranjana, how long can Fifi live with liver cancer?”
An unexpected aspect of being an oncologist (for humans) is being approached for advice about pets (usually dogs) with cancer. Bruno, Marco, Maisie, Ziggy, Chloe, Tiger, Muppet, Jessie, Bella, Buddy, Johnny, Wilfred. Apart from my own Odie, the dogs of my friends form the backdrop of my life. Not all of them develop cancer but when there is a diagnosis, I know.
When I first qualified as an oncologist a neighbour told me about his cancer-afflicted dog, and the options for treatment being surgery or “let him die”. My first alarmed instinct was to beg that I knew precious little about human illness let alone canine oncology but, as he talked about his choices, I realised that I was merely a vessel for the anticipatory grief of losing his “top person”. This I was comfortable with.
There have been many conversations since: whether to do the biopsy, remove the kidney, resect the bowel, detach the leg, accept chemotherapy, when and where to palliate.
Now it’s Fifi’s turn. Fifi, who has lost her senses but navigates her surroundings with determination and behaves with unobtrusive gentleness, never one to bark at guests or nose her way into their laps. Fifi’s liver is heaving with cancer and the bloods are dire. Decisions weigh on her owners. To treat or palliate. How to gauge pain and define suffering. What is the right thing to do by a beloved pet?
I am running late to a work meeting and promise to call back.
Entering the room, I feel the gaze of hope and note with dismay the average age of the room. A young wife and kids. Youthful parents. And the patient? He is too weak to stand up. Uncannily, his liver is also full of cancer and the bloods are grim.
“What does your husband want?” I gently ask the wife.
“To go home to die.”
“And what do you want?”
“To take him home to die.”
In an era of (justly) seductive advances in cancer, it is hard to describe the heroism it takes for a patient to say enough. The decision to forgo treatment can vex oncologists who wonder if they could have done better. But my dying patient has made an informed choice and the tears that flow are tears of relief.
Leaving, I call my friend.
Fifi is lethargic and the vet has prescribed analgesia. I suspect she is actively dying.
After years of practice I now know that there are two kinds of conversations – one where I am expected to fix a problem and the second where I need only bear witness for the solution to reveal itself.
In place of “What does Fifi want?” I ask my friend, “What do you want for Fifi?”
This brings forward mature though heartbreaking insights, and a conversation with the thoughtful vet which culminates in the decision to spare Fifi further interventions. I exhale.
What gifts to take a dying dog?
Food and toys are futile, flowers weird. I write the owners a card, saluting their deep love for Fifi manifesting in the courage to let go. Fifi is a placid bundle of fluff in the corridor. My heart heavy, I whisper goodbye.
My friend asks how long. A couple of weeks, I estimate.
“How can you do this every day?” she exclaims, horrified by my clinical-ness.
In a landmark study, humans receiving chemotherapy and concomitant palliative care lived about three months longer than those who received chemotherapy alone. The survival benefit was attributed to early palliative care achieving a better quality of life and less depression.
I don’t know of a similar trial in dogs but, with chemotherapy replaced by abundant love and meticulous care, Fifi survives one week, two weeks and then three. She nibbles at food, responds to voices and seeks sunshine! The family is cautiously thrilled, and I stay humbled by a physician’s limited powers of prognostication in humans and animals.
Fifi lives a full two months after her diagnosis, comfortably and amicably. Then, one day, with everyone at work, she dies peacefully in the arms of the child who became an adult under her watch.
No preparation can ever be enough. The family is bereft, the intellectual matter of death no match for the avalanche of emotions.
People compare the loss of a pet to losing a limb, a child, a soulmate. My patients abscond from hospital to reunite with their pet. Their dementia spirals at the death of their pet. I am sure that if the hospital allowed easier access to pets, it would be a happier place.
How to console those who have lost a pet?
We call, text and talk favourite books but in the folds of our conversations lies grief. So much grief that I want to do more. Seeking their permission to write a column prompts surprised tears that the world could give a hoot about a deaf and blind dog whose time had come.
Fifi may have been all that but I know from the experience of others, and lately my own, that the love we have for our dogs is no ordinary love. Their unconditional loyalty and uncomplicated relationships are the stuff of human longing.
So, here’s to you, Fifi.
Thank you for the happiness you gave us. Thank you for your grace as you aged.
Most of all, thank you for teaching us a thing or two about life, love and how to care until the very end.
• Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called A Better Death
