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Dr.Fiona
Dr.Fiona, Cat Veterinarian
Category: Cat
Satisfied Customers: 6273
Experience:  16 years experience as a companion animal veterinarian in British Columbia, California and Ontario
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I have a question for Dr. Fiona, who helped us before.

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I have a question for Dr. Fiona, who helped us before.
Submitted: 3 years ago.
Category: Cat
Expert:  Dr.Fiona replied 3 years ago.
Hi Bill,

Sorry for the long wait! I am not here on Just Answer very much anymore, but for you, I am here!

How are things with you and Marie?

Fiona
Customer: replied 3 years ago.

My cat Marie passed away on May 9, 2011 when I had her put to sleep in our home
because of chronic renal failure (CRF). I am in a severe crisis right now because the loss is so great and because I feel utterly consumed by my own guilt. Both of my cats, who were sisters, were diagnosed with CRF at age 16. Marie died of CRF at 18 years, 11
months, and four days. Chantal died of cancer at 17 years, 5 months, and three weeks.

Marie "crashed" in early September, 2008. I left her at the hospital overnight
for IV treatment. At the time her numbers were very high (BUN:219, creatine:
8.4, and phospherous: 17.9). After her release, my vet advised me that her
numbers were "off the charts" and that she had no more than one month to live,
and he offered to stop by my house to put her to sleep the following week!

But she revived after I cared for her as tenderly and devotedly was it was
possible for any person to do, and she did so above all because she was a very
strong girl who had a such a strong love for her sister and father that she just
did not want to leave this world.

From early September, 2008 until this week Monday I changed my life to care for
Marie and Chantal: I ceased to travel out of town, except one time for a
necessary work appointment that kept me from home one day. I placed the hated
kidney-food all over the house and changed the litter box twice a day rather
than only once a day. I administerd sub-Q fluids to both cats, and gave them
the hated phosphate binder by liquid syringe. I also gave arthritis medicine to
Chantal. I stopped eating any fish or meat in the house so that they would not
smell it.

Chantal's CRF never advanced to a critical stage, and instead she died from
cancer in early, 2010. After she died I did not leave home on any account at all
for a month or so, as I did not want to leave Marie all alone for the first time
in her life when she was already 17!

I continued treating Marie for CRF, and she seemed to be stable if somewhat
frail. I live in San Diego and started seeing a woman in Tijuana, and at times I
would leave her alone for 4-5 hours and on a few occasions for up to 12 hours,
but whenever I left her alone I would have my assistant stop by to make sure
that she was ok. Marie seemed stable from January 2010 until February, 2011, when she started to assume the meatball position more and more.

In March, 2011 I took her to the vet for an examination, and the vet determined from a blood test that Marie had a hyper-thyroid condition, and he prescibed medication, which I purchased in liquid form and administered behind her ear. THIS MEDICATION LIKELY CAUSED HER KIDNEY FUNCTION TO DETERIORATE.

 

In mid-April, a few weeks after I began administering the thyroid medication, Marie suddenly went blind -- which I noticed when I saw her walking confusedly in the middle of the road in front of our house, completely lost! We have a cat door, and Marie continued to go outdoors every day, enjoying little excursions and coming back at will.

 

My vet saw her the next day, instructed me to stop giving her the thyroid medication, and put her on medication for hypertension. Her vision returned about 1 day later!!

During three days that Marie was blind, I gave her fresh fish again, mindful
that it was bad for her kidneys. She had lost weight and was down to only 4.5
lbs. (from 14 lbs when she at her most plump back in the salad days of her life), and I wanted to console her because now she was a blind, old cat afflicted with CRF, untreatable hyper-thyroids, and hypertension. Her sister had left the world. I thought that the fish would be a consolation.

After her vision returned she just about entirely refused to eat her old kidney
food, but I didn't try hard enough. I spoke with my vet about this matter and
his knowledgeable nurse, and his nurse said that with all of her problems and
after the kidney regimen she had followed for more than 2 and 1/2 years she
deserved to have fish! But his other two nurses said that the fish would be hard on her system, and so that I should give her only as little fish as necessary and mix it with the restricted food. I followed the advice that I wanted to hear, that of giving her all the fish that she wanted because of all that she had been through, so that she could enjoy feasting in fish in her last days.

 

And so I gave her as much tuna as she wanted. But did I want to do so becaue it allowed me to cook my favorite foods at home again after not doing so for 2 and 1/2 years?

Marie had been in the meatball position increasingly from February or so onward.
That is why I took her to see the vet in March, when we discovered the thyroid
condition. She was increasingly in this position by the time she went blind.

After I started feeding her fish she went downhill quickly, even though I
administered fluids more than ever. I administered 150 units daily rather than 100 daily or every other day. She actually gained weight, going up to 56 lbs or so, but after going
blind she stopped sleeping in my bedroom and stayed in the kitchen at night. Marie had always slept with me and had always followed me everywhere until this event (except that when she and Chantal were tiny kittens I gave them the run of the house at night, but closed my bedroom door so that I could get some sleep.


Even though Marie was not sleeping with me, she would join me at my worktable during the day when I was seated at it. I have worked at home since
1997, allowing me to be with both cats most of the time since then. She usually
was able to get comfortable, but more and more she would also sit in the
meatball position directly in front of me, wanting to be with me and seeking my
protection, but in obvious discomfort.

My vet came to our home on the last Saturday of her life, prepared if necessary
to put her to sleep. He said that she seemed to be doing better than he
expected, and that I was not yet ready for her to be put down.

 

Relieved, I fed her more fish, administered sub-Q fluids, and left home for 12 hours because I was having ongoing problems with my girlfriend and because I inexplicably wanted to get out. My assistant stopped by a few hours later, told me that she was comfortable and doing fine, gave her more fish, and sent me a photo of her. When I returned she was resting comfortably in her box in the kitchen.

 

The next day we spent the entire day together, and I told her all of the things that I ever wanted to say to her, all of the things that really mattered: How deeply and utterly I had
always, always loved her, and that if I had ever ler her down I was so sorry,
that it was my fault, never her own, and that by her love for me she had made my
life such much more fulfilling and healthy!! She slept contededly that evening
while I spoke with my mom by phone (it was mother's day) and later in the
evening she rested in her "comfortable" position directly before me in front of
the computer.

 

Later that night, however, she was in severe pain in the kitchen, and in
the middle of the night she awakened me by meowing in pain. I tried to sleep
next to her on the kitchen floor, but could not get comfortable. I thought of
taking her to an emergency hospital to have her put to sleep. But she settled
down and within an hour or so had fallen asleep in her box.

 

The next morning, Monday May 9, 2011, she ate tuna again, took her fluids, alternagel and hypertension medicine, and followed me to my worktable, where she stood before
me in the meatball position. She kept going to the litter box to urinate and then she would return to our table and sit before me in the meatball position. I was tender towards her, but acted similarly to how I had done on the last day of Chantal's death, working on a document while she was at my side.

 

I told her how much I loved her, but I was in a state of complete emotional shock. I called the vet, and we agreed that it was her time, that she had entered a period of suffering, and that all I could do now would be to prolong her suffering. He came at mid-day to put her down, but did not prepare me for it sufficiently: He gave her a sedative before he told me he would do so, and she became semi-conscious and prostrate. I told her that I
would love her for all eternity and that we would be reunited, but I was
distracted with my vet and his assistant, and then my vet administered the
lethal dose, and my Marie had left this world!

I have been crushed and devastated by her loss more than my words will ever be
able to say.

Above all, I went away from home too much in the last month of her life. Each
Friday I would spend the evening with my girlfriend (4-5 hours), and each
Saturday afternoon and then again on Saturday evening, but I would come home
just to spend 2-3 hours with her. On her final Saturday, I was gone for 12
hours, with only my assistant to stop for one and one-half hours about 3 hours after I had left, so that she was alone in our home for 3 hours, and then again for another 8 hours.

 

I wonder whether my these absences were stressful to her and whether this stress helped to induce the hypertension that caused her blindness, which in turn was the event that made me decide to feed her fish again rather than maintain a strictly enforced regimen of
protein-restricted foods?

Above all, was it wrong of me to continue feeding her fish after her vision
returned? Perhaps I just wanted to cook up fish for myself and it was easier to
give Marie what she obviously and desperately wanted? Perhaps I was burnt out
after years of this caring for her?

After giving her unrestricted helpings of fish for several dies, I really did try to get her to eat the kidney-diet foods, but she just would nibble at it and then clamor for fish. I think I had just thrown in the towel on trying to save her, and so I gave her all the fish she wanted, just as I had done for Chantal during the last week of her life (which was very hard because I had to separate the two of them in order to do so, and Marie could
obviously smell the fish). Did I tire of saving her from CRF and fail to save her when doing so seemed to difficult?


There were long, long stretches during the past two and one-half years when I
did not venture from home, except to go surfing nearby or to take a 40 minute
bike ride. Months and months at a time I lived this way with both of them and
then especially with Marie, since they no longer had one another. But during
the last month of Marie's life I had serious "issues" with my girlfriend and
spent too much time with her each weekend. Now Marie is gone, and I can never
make up this time with her. And I gave in too easily on the fish, knowing that
her system could not handle it.

At least she managed to enjoy all the fish she wanted during her last two weeks
(with an added 500 of sub-Q fluids per day), and on her final Sunday in this
world I showed her and told her how much I deeply and utterly loved her. But I
could have done this better, and I should not have allowed my own personal
problems to interfere with my love for her, but I did.

Now I am in a crisis and feel utterly crushed by what I did not take the time to
do, what I did not attempt to do, for my Marie.

I love them both, Chantal and Marie, and I really want nothing more in my
existence other than to be reunited with them for all eternity. I have never
had a love as deep, comfortable or true as this love that the three of us have
shared.

Bill

Customer: replied 3 years ago.

Fiona,

 

To the above I add only the following. I do not reproach our regular vet, who has always been very knowledgeable and practical. I have the following questions: Did I simply burn out and cease to do what I could to save and comfort Marie and thereby hasten her death? Did my absences on weekends cause her stress that in turn induced the hypertension that caused sudden blindness, which was the event that led to my feeding her fish? Should I have tried better to resume the enforced regimen of restricted food? Was it unconscionable of me to leave my dying Marie at home alone on weekend evenings and on Saturday afternoons during the last month of her life, including leaving her alone for three hours and then again for eight hours while I was gone for 12 hours on the final Saturday of her life? My consolation is that I made it up to her as best I could do on the final Sunday of her life and as much as I can remember on the final Monday morning as well, but I was in a state of emotional shock on Monday. I also know that Marie and I deeply loved one another her entire life, which lasted for 18 years, eleven months and four days! I just can't believe that I allowed my own personal problems to interfere with my love for her during her last month alive or that I gave in so easily on the fish diet, although perhaps this really is what was best for her (I partly thought that she should eat all of the fish that she wanted in her final days, and partly was glad that I could again eat my favorite foods at home after refraining from doing so since September, 2008, and I partly tried to get her to resume eating the restricted food. Also, Marie's weight went up to 5.6 pounds, not 56 pounds (that was a typo in my note above). She did eat the tuna and some halibut every day for the last two weeks or so of her life, and she had two helpings on her final Monday morning. She initially devoured the fish, but eventually would eat some of it, then return for more, and eventually eat most of it. From the time of her sudden blindness onward, and even after she recovered her vision, at night she stayed in the kitchen, sleeping in her box or crouched in pain, and by day she would stay by me at our worktable. I managed to spend the last Sunday of her life telling and showing her how deeply I loved her, while with Chantal, whom I never left at all, I was so burned out that I did not manage to do so before having her put to sleep, although I certainly showed her great care and compassion during the weeks that preceded her death. I will stop rambling and look forward to your counsel and HONEST ASSESSMENT OF HOW WELL I CARED FOR MY GIRLS. Thanks. XXXXX

Customer: replied 3 years ago.

Dr. Fiona,

 

I wonder whether you will be able to answer my questions? Thanks.

 

Bill

Expert:  Dr.Fiona replied 3 years ago.
Bill.....

I am so very sorry for your loss of Marie! My heart goes out to you - I know she was like a daughter to you, and I can only imagine the pain you feel....

I am working full time now, but I want to give your concerns the time and attention that they deserve. I have printed out your question and will read it over again tonight and address all of your concerns tomorrow when I have a few hours in the late morning.

((((BIG HUGS)))) I'm so sorry for your loss!

Fiona
Customer: replied 3 years ago.
Thank you, XXXXX XXXXX ask for your strict honesty in the matter. I really wonder whether I tired of saving her from the precipice and just threw in the towel prematurely, and I also wonder whether my time outside the home during the last weekends of her life were upsetting or stressful to her. I think I made things up with her, but I just don't want to think that after all of those years of sharing so much love with her I let her down in the end, but I do not want false praise, only your honest assessment. Thank you.
Customer: replied 3 years ago.
I think I just inadvertantly made my questions available to all experts, but I really seek my advice from Dr. Fiona, who has advised us before. Thank you.
Expert:  Dr.Fiona replied 3 years ago.
Bill,
I am working on your answer.... I have an appointment now, but will continue when I get back!

Fiona xx
Expert:  Dr.Fiona replied 3 years ago.

Bill,

 

Again, I am so sorry for your recent loss of beloved Marie. I know that you loved and treasured her and that she was truly a child to you.



Reading over your information about how she rallied after her crash in September of 2008, I am amazed by how much love and tender care can really do to treat disease. Marie clearly fought as hard for her health as you did. Despite being told she had only 1 month to live at that time, she went on to live another 2 ½ years! This was due to her strength and your love and care.



You mentioned that in March, 2011 your vet diagnosed hyperthyroidism, for which he prescribed medication. I am sure that medication was methimazole. I understand that you suspect that this medication caused her kidney function to deteriorate. Methimazole is a very effective drug for controlling hyperthyroidism. It is not toxic to the kidneys, but it can cause kidney values to increase....let me explain how.



First, here is more about hyperthyroidism:



http://www.peteducation.com/article.cfm?cls=1&cat=1340&articleid=218

http://www.peteducation.com/article.cfm?cls=0&cat=1303&articleid=1439

http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=516





Now, in terms of how CRI and hyperthyroid disease inter-act in a cat, it is important to know that the hyperthyroid disease causes an increased heart rate. A normal resting heart rate in a cat might be about 150 beats per minute (bpm). In a hyperthyroid cat, that rate might be 250 to 350 bpm!


The increased heart rate will increase the amount of blood going through the kidneys in a 1 minute period. The blood is flowing faster with this increased heart rate, so the glomerular filtration rate (GFR) is increased.



Let's imagine a cat with CRF - suppose her kidneys are only working at 50%. So, they only remove 50% of the toxins they are meant to. In one minute, suppose 100mls of blood goes through her kidneys and this 100mls had 100 units of toxins.


So, she removes 50 units of toxins in one minute.


Now, let's imagine this little cat has hyperthyroid disease as well. Her heart rate doubles. Thus, in that one minute period, 200 mls of blood goes through her kidneys. This has 200 units of toxins, and her kidneys remove 100 units of it.


So, she removes 100 units of toxins in one minute.



As you can see, when she has hyperthyroidism, her glomerular filtration rate is increased, and thus she can remove more toxins from her blood stream in a given period of time.


This does NOT mean her kidneys are actually working any better. However, it will mean that on blood tests, her BUN and creatinine will actually drop as her thyroid disease becomes more pronounced.


Similarly, when we take this same patient and LOWER her T4 levels by treating her hyperthyroidism, we will drop her heart rate and thus drop her GFR and thus her BUN and creatinine (the measures of kidney function) will increase. We are not actually harming her kidneys with the thyroid treatment, we are just lowering her heart rate and thus her kidneys can't remove as much toxin in a given period of time.



So, you must wonder why on earth we would even consider treating a cat's thyroid condition as it could be argued that it is beneficial to her if she also has CRF.


Well, the reason is that high levels of T4 can cause other problems (heart problems, weight loss, vomiting and diarrhea in some patients).

So, when we treat a hyperthyroid cat who also has CRF, we do expect her BUN and creatinine to increase as she is treated. That is NOT because the medications are toxic to her kidneys. It is simply because the treatment will lower her GFR.



As you can see, the thyroid medication would not have caused damage to Marie's kidneys, though it can decrease GFR. It's always tough to treat these 2 problems concurrently as we have to find a balance between treating the thyroid without lowering the GFR to the point that the kidney problem becomes worse. Sometimes, we simply cannot treat the 2, especially if the CRF is advanced.



You also mentioned that Marie went blind, and was then treated for hypertension. This suggests that her loss of vision was due to high blood pressure causing retinal detachment.


Marie's high blood pressure would have been due to her CRF, not by stress. One of the kidneys' functions is to control blood pressure. As CRF progresses, the kidneys lose their ability to monitor blood pressure and it then increases. It was definitely NOT your absences that caused her hypertension. It was her kidneys! So, stop worrying that this was in any way your fault. It wasn't!



Acute blindness is often the first thing that people notice when their pet is suffering from high blood pressure. The retina at the back of the eye is very delicate. High blood pressure can cause it to become unattached to the eye, and thus it is not able to transmit the message that light is striking it to the optic nerve and on to the brain.


If caught early, and if the high blood pressure is brought back down to normal, the retina can reattach and vision can return. Obviously, you caught it very quickly as her vision did return!



Here is a link to more information:

http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=1216




So, the fact that Marie's kidney disease had progressed to the point where her blood pressure went up and caused retinal detachment tells me that her kidney problems were advancing. This was before you fed her fish. You then offered her fish, and kept her on that as she so enjoyed it. You did not cause her kidneys to worsen. Your incredible care and love kept her alive for more than 2 years beyond what her veterinarian ever expected! When her kidneys finally progressed to a point where they were no longer able to even control her blood pressure, she also reached a point where she was no longer wanting to eat her kidney food. CRF leads to loss of appetite, for a variety of reasons. It is this loss of appetite that leads to the demise of most of my kidney patients. They lose the will to eat, and thus the will to live. You battled that by offering Marie the foods most tempting to her, to lure her into eating and fighting to live.



So, not only was it not wrong to keep feeding her the fish at this point, I really believe it was a delight to her, and the only thing that gave her the will to live for the final days! As you said, at least she managed to enjoy all the fish she wanted during her last two weeks!


I really don't think that this hastened her demise. I think it delayed her demise as it gave her a pleasure to live for.


You worry that you left her alone too much on her final weekend. As I type, I have 3 cats and a dog around me. You know what every one of them is doing? They are sleeping! All of them! I know that Marie must have slept a lot in her final months. Even young, healthy cats do, and she was neither of those things. I am sure she slept while you were out, not being aware of the passage of time. Have you ever been really sick? When you are sick, you sleep. Time passes in strange ways, and days slip by so quickly. Marie surely slept while you were out, and was unaware of how many minutes or hours passed. I have no doubt that she knew she was loved. She slept while you were gone, she did not feel lonely or worried. She was secure in her home, in the surroundings where she felt at peace and was able to sleep. Don't berate yourself!



Finally, Bill, you knew it was time when she woke you in the night, meowing in pain. I know you did not want her to suffer. I know you loved her so much that you would rather suffer than let her suffer... and that led you to do the thing which was the most painful for you, but the kindest for her. You let her go. Letting her go, with no pain, no fear, no suffering was gentle for her. It has cut you so deeply and hurt you so sharply... but that pain is the pain YOU take on in order to stop HER pain. It is your burden that you bear in order that she has no further burdens to bear.


I wish I could take away your pain as you took away hers. I wish I could help you to stop hurting... but I cannot. You loved her and she is gone. That hurts deeply. I'm so sorry! Your bond with Chantal and Marie is not broken by their deaths. It is strong and they are waiting at the Rainbow Bridge for you.


Rainbow Bridge

Just this side of heaven is a place called Rainbow Bridge.

When an animal dies that has been especially close to someone here, that pet goes to Rainbow Bridge.
There are meadows and hills for all of our special friends so they can run and play together.
There is plenty of food, water and sunshine, and our friends are warm and comfortable.

All the animals who had been ill and old are restored to health and vigor; those who were hurt or maimed are made whole and strong again, just as we remember them in our dreams of days and times gone by.
The animals are happy and content, except for one small thing; they each miss someone very special to them, who had to be left behind.

They all run and play together, but the day comes when one suddenly stops and looks into the distance. His bright eyes are intent; His eager body quivers. Suddenly he begins to run from the group, flying over the green grass, his legs carrying him faster and faster.

You have been spotted, and when you and your special friend finally meet, you cling together in joyous reunion, never to be parted again. The happy kisses rain upon your face; your hands again caress the beloved head, and you look once more into the trusting eyes of your pet, so long gone from your life but never absent from your heart.

Then you cross Rainbow Bridge together....

Author unknown...

(((BIG HUGS)))

Fiona

Customer: replied 3 years ago.

Fiona,

 

Again I cannot thank you enough for your insights and wise, moving advice and counsel. I ask only the following: Could the hyperthyroidism have caused the increase in blood pressure? Does it appear to you that Marie's CRF likely entered its final stage, and this is what caused her death? Above all, have you said your above comments to make me feel better or because you sincerely XXXXX XXXXX they are true? I was at home all week long during her last month, but out on weekend nights and Saturday afternoons, and then out for a very long time on her last Saturday. That final Saturday she was resting peaceably in her box when I returned home, but on at least two prior weekend evenings she came running to the door when I came home, but this is what she had always done her entire life. I hope that to the extent that I failed her she forgave me! I think so. These are my final comments and questions. I again thank you more than my words can say!

 

Bill

Expert:  Dr.Fiona replied 3 years ago.
Bill....

Although it is possible for hyperthyroidism to contribute to increased blood pressure, it is far more common for CRF to be the sole underlying cause. In 90% of cases of high blood pressure that I diagnose in cats, it is kidney disease that causes it. And since we know that Marie had advanced kidney disease 2 years before the hypertension, I am certain it was the CRF that caused it.

I have not said my comments to make you feel better, no. I have been a vet for 17yrs and I have treated hundreds or maybe thousands of cats with CRF. Of those, you are one of the top 3 care-givers I have ever had the honour to know. Your dedication and love is what pulled Marie through. Your vet did not expect her to live a month, let alone 2 1/2 yrs! She enjoyed her life for as long as she did because your care was exceptional..

I sincerely XXXXX XXXXX did not contribute to Marie's death, but instead prevented it for years. Also, when she was at the end, you fed her the fish she craved, keeping her going for another couple of weeks of enjoyable time with you. She loved you, you loved her...and you let her go when she needed to go.

To be loved and cared for like that - it is more than most of us humans can expect or hope for for ourselves!

Fiona xxx
Dr.Fiona, Cat Veterinarian
Category: Cat
Satisfied Customers: 6273
Experience: 16 years experience as a companion animal veterinarian in British Columbia, California and Ontario
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