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The Anvil of Indecision


 

Lying in bed, I’m jarred by what can only be an anvil dropping heavily upon my chest. Wakefulness reveals a more canine, cranium-like object. Staring deep into cataract-smudged eyes, I ponder the question that has occupied my mind for nearly two weeks: What would Hogan want?

My Dog Has Cancer

More accurately, he has a tumor—or, I guess, what appears to be a tumor on his chest X-ray. It was discovered, incidentally, on a liver ultrasound that was being done for abnormal liver function test results. That study revealed nothing wrong with his liver, but led to a follow-up radiograph showing a 4.9-cm, right-lower-lobe lung mass. Also uncovered in this process was a tangle of complex emotions, turmoil, and uncertainty surrounding my first personal foray into end-of-life decision-making.

Hogan, my now-presumed-cancer-ridden, 10-year-old Weimaraner, came into my life permanently when he was all of 8 weeks old. I first met him during a visit to the breeder when his litter was only three days old. Over the successive weeks, I visited him often, anxious for the day I’d be able to take my new companion home.

So, on the advent of his 10th birthday, we are asked to decide how many resources, how much physical distress, how much intervention we afford to an older, sleep-most-of-the-day arthritic dog.

I picked up Hogan on Fourth of July weekend during my chief year of residency—sort of a gift for completing my grueling training. He was the first dog I raised, trained, and cared for by myself. And while we had our share of eaten walls, destroyed comforters, and chewed bits of Jeep Cherokee, this was no “Marley & Me” relationship. We were more like roommates, best friends. We hiked, camped, and went everywhere together—either an idyllic boy-and-his-dog relationship or a sad, pitifully lonely, soul-in-need-of-a-girlfriend existence, depending on your point of view, I suppose.

In the end, the two viewpoints melded as Hogan eventually brought my wife and I together, a story that shall not be printed in these pages.

Through the years, Hogan bore witness to many personal and family milestones. My chief residency, my first grand rounds (his constant audience during my preparation brought him unparalleled expertise in canine zoonoses), my first house, our marriage, a horribly flailing attempt to recapture the magic of my first dog through a second Weim named Grady (definitely “Marley & Me” mixed with a healthy dose of “Dumb & Dumber”), and the birth of our first child.

It was during this time that Hogan began a long journey toward today. He became a little long in the tooth, droopy in the belly, and slow on the trail. His limitless energy and boundless passion for chasing tennis balls gave way to such leisurely pursuits as park pooping and command disobedience. His fluid, sinew-laced limbs became arthritic shells of their former selves, betraying the youthful grace that still echoed inside of him. I distinctly recall the first time Grady beat him to a tennis ball, a moment that clearly represented a passing of the baton—a crestfallen 6-year-old canine eclipsed by the 2-year-old whippersnapper. The youngster sprinted back, bursting with a mouthful of tennis ball and pride. The elder took a decidedly more tortuous and tortured route back—a carriage of nonchalance that failed in its attempt to convey the message that “chasing tennis balls is stupid.”

Hogan hiking the Rockies.

Hogan hiking the Rockies.

On the advice of our veterinarian, we stopped throwing Frisbees at Hogan at age 8, out of concern that an awkward jump might result in a paralytic shift in his progressively stenosing spine. While Hogan is otherwise healthy, his hips and forepaws are riddled with osteoarthritis, his eyes carry the cottony haze of cataracts, and his abdomen and skin are home to lumpy lipomas. So, on the advent of his 10th birthday, we are asked to decide how many resources, how much physical distress, how much intervention we afford to an older, sleep-most-of-the-day arthritic dog.

This scenario is complicated by the idiosyncrasies and mores of veterinary medicine. Unlike human medicine, which is replete with tomes of data steeped in decades of experience, our veterinarian counterparts often are left with gaping treatment holes and inadequately studied interventions. This is not a knock against the profession. In fact, I have had nothing short of fantastic experiences with the veterinary professionals with whom I’ve interacted. Rather, there just aren’t prospective, randomized, controlled trials to inform whether intervention will enhance Hogan’s quantity and quality of life.

Then there are the economic realities of the situation. As one who has rarely been ill and always been insured, I was staggered by the cost of medicine for the uninsured. Two-hundred-dollar antibiotics, $500 ultrasounds, $1,500 CT scans, and up to $10,000 operative and surgical ICU stays would have invoked, “you’re joking, right?” exclamations from me prior to this experience. Now they are just another variable that complicates this already emotionally complex discussion—the variable that makes you feel hollow inside for considering it, foolhardy for not.

Questions Abound

What price would I pay to have another few years with my best friend? What if it’s only a year, six months? Would the money be better spent funding my child’s 529 account? What if this is a benign process and intervention is for naught? What if this tumor is metastatic and intervention is futile? Should we spend the extra money on an upfront staging CT scan that has much lower sensitivity than those we routinely utilize?

If we intervene, should we attempt a costly, CT-guided biopsy to rule in malignant disease, or go straight to lobectomy? What if the surgery negatively alters his quality of life? What if he dies on the table? What do I know about the surgical outcomes of the two centers I’m considering? Should we attempt an open or laparoscopic approach to this tumor?

Can we achieve a cure? If we do, what does that mean for a dog in the twilight years of his life? Should we just let the disease progress to its natural endpoint?

What Would Hogan Want?

These are the questions that haunt me. As I stare into Hogan’s eyes, a portal to my companion’s soul, I am tormented by the cauldron of emotions, the indecision bred by incomplete information and the guilt that comes from knowing that Hogan unconditionally trusts that I will do what is right for him.

Will I? My eyes continue to ask Hogan what he would want until finally the answer becomes obvious.

Hogan wants his breakfast. TH

Dr. Glasheen is associate professor of medicine and director of the hospital medicine group and hospitalist training program at the University of Colorado at Denver.

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