Category Archives: death and dying

Maizie is Still Not Dead

October 30, 2011death and dying, Politics and Culture, true storycanine cushing geriatric, canine Cushings, canine cushings treatment, lysoderm, treating canine cushings, trilostane, vetorylMarion

(Originally posted: 10/30/2011 — See update at end)

Just wanted to follow up on the October 1 post, Whose Dog Life Is It Anyway, as I’m still getting occasional responses.

I’m writing the follow-up because dogs like humans are now living longer, but as with humans, extended life is not necessarily quality time, and may involve living with chronic debilitating conditions that require extensive and expensive treatment. More owners of geriatric pets are faced with a dilemma. Is it better to treat or to let nature take its course, and at what point is euthanasia the best option? So I’m going to review Maizie’s treatment, its outcome, and lessons learned, in case this is useful for other people with geriatric dogs diagnosed with Cushing’s, who come across this in their web travels.

Maize, a Jack Russell mix, is (probably) 15 years old. While she had abnormal liver enzymes indicative of Cushing’s disease, she was asymptomatic until July when she began to drink excessive amounts of water and urinate all over the house. She also could no longer hold her urine while sleeping or lying down and would wake up wet.

Testing revealed it was indeed Cushings. The two most effective treatments are either Lysoderm or Vetoryl. Lysoderm is the older treatment. The medication itself is less expensive than Vetoryl, but dosing can be tricky. Both drugs require frequent and very expensive monitoring in the form of invasive tests. The little research I did, led me to think Vetoryl would be a better choice. The vet started Maizie on 60 mg a day, based on the Dercha’s (the manufacturer’s) recommendation for her weight. Had I been paying more attention to the very helpful Canine Cushing’s forum,, I would have insisted they start her on less. As one of the more experienced consumers later told me, despite Dercha’s recommendations, there’s “no rhyme or reason” to how dogs react to Vetoryl. A big dog may do well on 10 mg a day, while a Chihuahua might need 30. Within ten days the polydypsia and polyuria had abated. Her first ACTH test showed that her cortisol level had come down. A more experienced vet, might have noticed it came down too much and too quickly. She didn’t and neither did we. The vet, at our insistence also started her on something for the incontinence that was still ongoing when she was sleeping. The medicine was called Pro-in. This was another one I wish I’d researched more on the net. Pro-in is the same formula as the old formula for Dexatrim, an OTC diet-pill for humans. The formula was banned for causing strokes in humans. Anecdotally, at least, the same problem is seen in dogs. Maizie seemed to lose her appetite almost immediately upon starting it. We lowered the dose and then stopped it within a couple of days. In retrospect, the reaction may have been a coincidence, though who knows? In any case, she was going downhill. Her cortisol had crashed, and she was in an Addisonian crisis. After prednisone, IV fluids, and an overnight at the vets, she came home, tapered off the pred and was once again symptomatic for Cushing’s. More tests and she was restarted at 30 mg a day of Vetoryl and DES for the incontinence. (Yes, that DES). She crashed again. The second time was so bad that we couldn’t get her to take the prednisone and she had entirely stopped eating. A two-day stay at the vets with more fluids, and more prednisone got her eating again. The bill was astronomical.

She came home. Again we had to taper her off the pred. The vet wanted us to bring her back for an expensive test to see if she was permanently Addisonian. We declined. Clearly she wasn’t. Her thirst, appetite and peeing were back. She still had the Cushings. Rather than start her on an even lower dose of Vetoryl, we made another decision. I bought Wee-Wee Pads. As we couldn’t live with the polyuria and were heading toward euthanasia, this was a kind of a “hail-Mary pass.” To our astonishment, she figured out what we wanted her to do with them within two days. All it took was putting the pads over the areas where she was most likely to urinate, praising her when she went on the pads, and scolding her when she didn’t. Suddenly, we weren’t slipping in urine puddles. We weren’t upset. She wasn’t nervous. She still signals when she has to move her bowels or just wants the opportunity to troll the buffet that is Amsterdam Avenue. We still walk her several times a day.

I wouldn’t have thought we could live with the pads, but here’s the thing — her urine is so dilute it doesn’t smell and the pads really do absorb ten times their weight in fluids. It’s easier than dealing with cat litter.

At this point the only medication she’s on is the DES, which is still working the way it’s supposed to and keeping her from wetting herself in her sleep. What she can’t do is hold out very long when she’s awake.

We are also giving her melatonin as a supplement, which may or may not be doing anything, but is touted by some as a natural alternative, and may slow down tumor growth. We’ve also started her on wet food only. This also may or may not make a difference, but she’s old and she likes it.

The take away for us is: If we had known that the Vetoryl would bring her so close to death, and how expensive treatment would wind up being — not only because of the required ACTH tests, but because of the iatrogenic Addison’s, then we would not have started to treat her. While Cushing’s is progressive, treatment probably does not extend life in geriatric dogs, and the high cortisol levels actually help alleviate symptoms of other age-related conditions like arthritis. If we’d known how easy it would be to train her to use the pads, that’s what we probably would have done in the first place.

Because every case is different, I’m hesitant to give advice, but if your geriatric dog is diagnosed with Cushing’s, here’s what I would recommend:

1. Read the forum. The people there are consumers not vets, but some of them may be more knowledgeable than your vet regarding treatments and side effects. While I had looked at the forum, I didn’t realize how helpful it could be. The people there will ask you to give them your lab results. Give them the information and take their advice. Ask them questions before making decisions.

2. Both Lysoderm and Vetoryl have some pretty severe side effects, including permanent Addison’s. You might be better off finding out which medication the vet has more experience with and going with that. Also if your vet does not have extensive experience with Cushings, find one who does.

3. If the vet is using Vetoryl, insist they start at a much lower dose than Dercha recommends. They started Maizie at 60 mg. If she’d weighed a couple of pounds less, it would have been half that. I wish they had started her at 10mg. Treatment protocols call for testing after 10 days, so if the low dose doesn’t work they can gradually raise it. That does mean you’ll be living with the symptoms longer, but the cost to you and your dog will be less.

4. Consider NOT treating. Most people begin treatment only when the polyuria becomes a problem. Treated or not, most dogs with Cushing’s are dead within two years. The Cushings may be masking other problem like arthritis, especially in geriatric dogs, and per the earlier information the medications can be pretty nasty. If your dog is NOT symptomatic and Cushings is only suspected because of tests, consider starting some safe alternative treatments like melotonin and/or flax seed oil. Melotonin may slow the growth of the tumors that causes the cortisol to rise, delaying your dog’s becoming symptomatic. If your dog is symptomatic, consider whether or not these are symptoms that you and/or the dog can live with. In Maizie’s case the main symptoms are excessive urination and excessive drinking. The drinking isn’t all that excessive. That is, she doesn’t seem to be dying of thirst, just drinking about two or three times as much as she used to. The urination was making us all nuts until she learned to use the pads. We are all happy now.

5. If you aren’t blessed with a house in the country that features a doggie door, buy Wee-Wee pads. Even without Cushings, as your dog ages, she or he may need more walks than you can reasonably supply. They are far superior to paper, and as stated earlier, training and clean up are simple.

——-

Update: 7/15/13 — Maizie crossed the rainbow bridge on Saturday, July 14, 2013. Euthanasia was a tough decision as there was no one “This is it” moment. She’d been having gastrointestinal issues for a while and losing weight. It finally reached the point where medication wasn’t helping to stimulate her appetite, and her sense of smell and taste were diminished to where she would reject anything that wasn’t loaded with sodium. Basically, her last week, she was eating only Chinese take-out duck, and chicken-shack rotisserie chicken, and even those reluctantly, with coaxing, and not enough. (Yes, we tried healthier alternatives including homemade foods.) At the same time, she seemed hungry, and we knew that must have been torturous.

She died of age-related conditions, that weren’t related to Cushings. Again, this is only our story, but I would urge anyone whose dog has been diagnosed to learn everything you can, find a vet you can trust (We changed vets after we decided to take her off Vetoryl) and consider both the age and temperament of your dog. In Maizie’s case, the stress level of frequent vet trips for the testing the medications require would have killed her even if the drugs themselves didn’t. We hope we gave her the best possible quality of life in the two years since her diagnosis, and are sure we made the right choice in taking her off the anti-Cushings meds.

Whose Dog Life Is It Anyway?

October 1, 2011death and dying, New York Stories, Politics and CultureMarion

Following my mother’s stroke, she sometimes knew she was in a hospital in Albany. Other times she thought she was in a library in Queens. However, when asked by the Bollywood-handsome resident whether or not she wanted the feeding tube, she replied quite coherently, “Not if it’s not going to make me better.”

She had a DNR, and her wishes were clear. Medication that might prevent more clotting in her brain would probably cause her heart to go, and the meds for her heart would have brought more clots to her brain (as would doing nothing). But even putting in the tube and waiting for nature to take its course, would have been prolonging her agony. As my sister said, “If she can’t eat ice-cream, what’s the point?”

With dogs it’s different.

Meet Maizie, a Jack Russell-mix-rescue. My better half took her in in 1999 when she was probably somewhere between two and four years old. Do the math. He was going to give her to a friend as a companion for her other dog, but when the two dogs met, Maizie attacked, and the friend got a nasty-Maizie bite while trying to break it up. After that, my future husband knew he had something “special” on his hands. When we began dating, and I brought up his possibly moving in, I had the feeling he was waiting for Maizie to die first, but oddly enough, she liked me, and there wasn’t a problem until that unfortunate incident in the elevator about which we never speak.

Maizie never had a 100% accident-in-the house-free record, but I was able to “un-paper train” her. She got the idea that the apartment was not for peeing and was pretty good about it. Then in July, that changed. Suddenly, there were puddles of clear looking pee all over the apartment. She was waking up unconcerned in her own urine, and drinking water by the bucketful.

So off to the vet, who had long suspected Cushings, quite common in older dogs and treatable. We were warned about the expense involved. Medication requires expensive monitoring and over-medication could cause the dog to slip into Addison’s disease and die. If the cortisol levels don’t go down enough, however, the symptoms will persist. So there’s a protocol that you have to commit to.

Some people choose not to treat older dogs, not only because of the monitoring, but because lowering the cortisol may bring out other conditions like arthritis which high cortisol actually alleviates.

We discussed our options, including putting her down. How long did she really have? The end was inevitable. Why wait till she was suffering? Why put her through all the vet visits? But were we being selfish? Reacting only to the cost of treatment and not really thinking about her best interest? We couldn’t live with the pee. Or could we? My husband probably could. He was at work all day, while I mostly work from home. Why do I hate her? It’s not like I’m a neat freak. Why draw the line at dog pee? Was he thinking I was being mean, wanting to kill his dog? She was his dog, before she was ours. Had I ever even liked Maizie? Hadn’t I just married him for the health insurance to begin with? Did we really even know each other? Could this marriage be saved?

Besides us, what about her? What the hell is the best interest of an animal? Does a dog contemplate her mortality? Would she be terrified of being put down because she knows what it is? Or would she be terrified because she’d read our anxiety and guilt, and because she knows that no good ever came from a vet visit?

We chose to treat. We didn’t really want to take that anniversary trip to Italy anyway. About three weeks in, her symptoms had mostly abated, but then she crashed. She could hardly move, wasn’t eating, had no sparkle in her eyes. We were ready to put her down, but the vet convinced us this was nothing more than a bump in the road, a medication management issue. With a little “pred” and a lower dose of the Cushings drug, she could go on for years.

Why was I suddenly remembering the last year of my 1973 Dodge Dart, and why was the vet suddenly reminding me of my old mechanic?

The clincher was Maizie herself. She rallied as soon as we got to the vets, a situation that probably caused her diminished cortisol to rise, and she really did seem to be saying, “Please don’t kill me.”

The second time she crashed, she was on the lower dose. She stopped eating. We couldn’t even give her the prednisone. By the time we brought her in, she needed IV fluids and critical care. Her electrolytes were messed up. After her first night, the vet asked us to visit to see if we could coax her to eat. We both left work, but we couldn’t get the normally voracious Maizie to try more than a few bites. She still had to stay over till the next evening, but finally her appetite returned and her electrolytes were good.

A few thousand dollars since her diagnosis and she’s home, tapering off the pred. They don’t want to withdraw it too quickly, lest she go into shock. She’s back to peeing clear streams and drinking constantly. Today, there was a minor victory when she finally figured out what the wee-wee pads were for. but it was probably just coincidence as she ignored them later.

Where do we go from here? Possibly she’ll be ok once we taper her, at least for while. The meds may have had the effect of screwing enough with the endocrine system to lower her cortisol for a while. However, given how rapidly her thirst and appetite have returned, we suspect that even without the pred she’ll continue to urinate in the house. I’m not talking about the occasional age-related accident by the way. I’m talking about walking her every two hours and still seeing about eight indoor accidents a day. I’m talking about the feeling of dread I now experience whenever I hear her lap up water. I’m talking about comically slipping on wet floors when we get up in the middle of the night. I’m talking about … an unsustainable situation.

Excuse me, but there she goes again.

The vet says if the symptoms remain once she’s off the pred, we could try an even smaller dose of the meds. The real experts, other dog owners who I’ve met on the forums, report that with this particular pill there’s no rhyme or reason. Sometimes big dogs do well on very little and tiny ones need a lot, and a more experienced vet might have started her on a really low dose, and worked up, which could have saved us thousands and not brought her to the brink of oblivion. I’m terrified of seeing her crash again, but beyond that, we’re going broke. The test they “need” before they can restart her will run upwards of $400 dollars. Then it’ll be around $100 for the new meds at the lower dose. After that, in another two weeks they’ll need to recheck her levels. The meds we have in the house are useless because they are capsules and not easy or safe to split. We can’t even try going rogue and splitting them because without a very expensive scale that measures milligrams we can’t measure the dose, and even if we could we’d need another refill if it worked.

My husband suggested, “You work in Washington Heights, surely you know someone with a pharmacy scale and a soft-spot for dogs.” He is considering bluntness telling the vet, “We don’t need more tests. Just give us the script or the dog dies.”

In the end, she dies anyway.

Hindsight is perfect. Surely, if we knew all this, we would have put her down weeks ago, maybe.

Update: Just adding a quick link to this video about our relationship with our animal companions via the late, great George Carlin. “Same shit, different species.”

Tempus fugit or in search of affective-time

May 5, 2011death and dying, Politics and Culture, true storyacceleration of time, affective time, passage of time, tempus fugit, time, time fliesMarion

I may be losing my mind. Or it may hormonal (I’ve been going through “the change” for about three years now). It could also just be a normal part of aging about which I didn’t receive adequate warning.

I’m talking about “time.” Time changes as you age. It moves faster. This is not a secret. Since time immemorial, the old have warned the young not to waste their youth. We are mortal, corporeal, and temporal. Tempus fugit. We’ve always known this, and yet…

Kitty Carlisle, who was old for a long time, famously said, “You know you’re getting older when every day seems like Monday.” We don’t think enough about the ramifications that many of us exist in different time zones, even as we work and live together.

I am not so much asking where did the time go, as I am amazed by its acceleration. In a normal day in my twenties or even thirties, I might get up, go running or do some other exercise, read a paper, have breakfast, all this and somehow be at work on time. Then after work there would be socializing. Sometimes even activities that extended into the next day. Still the rent got paid — by which I mean checks were sent, without even using the “time saving” Internet, but written and mailed. Other tasks were also taken care of. Yet now, I start on an assignment and the day is gone. It used to be that dull tasks felt like that they took forever. Now every time I look at a clock, hours have passed no matter what I was doing, and I wonder, “Where did the time go?”

It feels more and more wrong. Like I’m in an episode of Twilight Zone or on that island in Lost. People with certain psychiatric conditions talk of “losing time,” but I can account for my time. It’s not really lost, just gone. Maybe there’s always a generation gap because the old and the young are experiencing a completely different sense of time. Maybe it’s a miracle we can even see each other.

Is any of this making sense?

I noticed early on that things were getting faster. Even as a teenager it was clear to me that summers were much shorter than they used to be. At some point in my twenties, I recalled a party and realized it had happened, five years before, which was astonishing. But by the time I was thirty, there were people I hadn’t seen in ten years. Now it’s twenty, thirty? And they always show up in Facebook, and you either don’t remember them at all OR it’s like yesterday.

Time’s winged chariot is approaching quickly. The issue is not that I (probably) have fewer tomorrows than yesterdays, it’s that the remaining tomorrows will feel shorter and shorter. In the way that we experience time, childhood is not our first 12 years, it’s probably closer to half of how we feel time even if we live to be a hundred. I’m going to coin a phrase here, I think, “affective time.” Affective time is not time on the clock. It’s time as we experience it.

Affective time is why an infant panics when his mother is gone, but may attach to a babysitter within minutes. Affective time is why you may remember how you spent your childhood waiting till you would be a “teenager” like your cool big brother four years your senior, and it felt like you were never, ever going to reach that goal.

The implications are this: At twenty you may look ahead and imagine another sixty years of activity. You may think that if you are lucky, and the genes are good, life will be long. It won’t be. You’ll never have enough time. It’s almost irrelevant if you die at forty or eighty because after forty every time you blink, it’s your birthday.

So here’s my very unscientific imagining of an 80-year life span divided into affective time.

Age 0-3: 3 chronological years = Time moves so slowly we can’t even measure it. Everything feels like forever. The good part is, you won’t remember most of it. The bad part is whatever you experience will somehow stay with you and influence who you are for the rest of your life.

Age 3-13: 11 chronological years = 25 years in affective time

Age 14-24: 11 chronological years = 20 years in affective time

Age 25-35: 11 chronological years = 15 years in affective time

Age 36-46 11 chronological years = 10 years in affective time*

Age 47-57 11 chronological years = 5 years in affective time

Age 58-80 23 chronological years = 5 years in affective time.**

*Middle age is the point at which affective time begins to move more quickly than actual chronological time. Keep in mind that the above chart is an estimate. Affective time accelerates constantly, so between the chronological age of 36 – 40 affective time may still be slower than chronological time, but from 41- 46, it may begin to speed ahead of it.

**If you live past 80, it’ll be happening so fast, you’ll get motion sickness standing still.

Mortality is kind of a bitch.

Dora Stein, 1921-2011

March 27, 2011death and dying, true storyeulogies, how to write a eulogy, obituaries, tribute to a motherMarion

Dora Stein could be described in many ways — a devoted wife to Jack for almost sixty years. A mother of three. A proud grandmother. A “career woman.” A teacher. A volunteer. But mostly, and all of her life, my mother was a fighter.

It may sound silly to think of a tiny woman, who probably never had a physical altercation as a fighter, but she was.

When she was a little girl she almost died when her thyroid became overactive and she had to have a large chunk of it removed. It slowed her down enough to save her life, but not too much. She still managed to skip a grade or two and got into Hunter College of the City University of New York — the Vassar of CUNY. Her own mother didn’t see the point. Why did a girl need to go to college?

But my mother fought that attitude. And her whole life she was proud of being a “Hunter Girl.”

She majored in Math and it never to occured to her that “girls” weren’t supposed to be good in math.

When she met my father — no slouch in the intellect department either — she held her own. He proposed on the first date. She wisely neither said yes nor turned him down, but waited until she got to know him a little better. They married and she became, before it was a children’s show, Dora the explorer — following him as he was transferred in the army, working as an accountant at a time when “girls” weren’t supposed to be accountants — even going to one job as “D. Feldman”. When her ruse was discovered and she was told, “You’re not an accountant. You’re a girl.” My mother replied that she was a girl AND an accountant.

At a time when the movies and television offered the stereotypes of the perfect housewife or the lonely career woman, she chose to be a working mom, a phrase which didn’t even exist, settling eventually on teaching as a career. It didn’t occur to her to do otherwise. It was pragmatic — she wanted a good life for her family and she wanted to work. She didn’t need to wait until Betty Friedan wrote The Feminine Mystique to know there was more to life than ironing your husband’s shirts. You could get that done at the laundry.

It must hardly seem revolutionary to anyone under forty, to raise your daughters to believe that they could do anything and there were no limits imposed by gender — but at the time when she was raising her children — it was hardly a given. She raised her daughters to excel and always with the idea that they would someday go to college, and that having a career was as important for her girls as it was for her son.

Dora always fought for her family and for what she thought was right. In 1956, when a neighbor complained about my father’s having his business in their new house, Dora went to City Hall herself, to the office of Mayor Wagner, to get the certificate of occupancy changed, making it clear and legal that the home could be used for a business.

When the Vietnam War was raging, my fiercely patriotic mother joined in the protests, going with her teenaged daughter Anita to Washington and taking me — at age 10 to the Moratorium in New York City.

Dora never stopped fighting. She didn’t fight time in the way some do with plastic surgery or potions. She kept herself busy. My father complained that after she retired from teaching, she worked even longer hours as a volunteer for Hadassah, turning his old examination room into her office space, learning to use the computer to create newsletters and fliers.

She fought coronary artery disease for years.

She and Jack lost his fight with cancer, but even that didn’t defeat her. She wanted to be independent, but accepted she couldn’t stay alone in her home and moved into assisted living, where she kept active. She volunteered as a tutor with elementary school children. She met sister Hunter girls, and enjoyed Yiddish club and Boggle and discussions on current events.

The last few months were hard for her. She took a fall and fractured her pelvis, but she fought her way back in physical therapy even though it wasn’t easy for her. She was determined to remain independent. To stay out of a nursing home. Her only real fear was losing her mental agility, which she never did. She was still aware of the world around her, keeping up on current events. One of her hospital stays coincided with the President’s speech on health care, and we watched it together on the little set in her hospital room.

The last time I visited her in her apartment, she was showing Craig and me old photographs and the book about the Spatts — she was as proud to be a Spatt as she was to be a Feldman or a Stein, and still talked about working for her very successful uncle Sam Spatt what it meant to her that he believed in her brain.

Even, after her stroke — she was fighting. She made her wishes clear. Like Jack, her humor could be laced with irony. When Anita told her that it was ok to stop fighting, that the fight was over, Dora looked at her and asked, “Did I win?”

She came from a crowded railroad flat in depression-era Williamsburg and went to college, became an accountant, a teacher, a mother, a wife, a grandmother, and a volunteer. She traveled to Israel and Europe and even Alaska. She saw Paris and the Grand Canyon. She saw all of her children graduate college and go on to graduate degrees, one of her grandchildren become a lawyer and all of them get into good colleges. She sustained a marriage of almost sixty years. She had a good life and died with her family at her bedside. Yeah, Dora. I’d say you won.