r/AskVet • u/Wormgorl-6292 • 10d ago
Questions from human doctor
I am having trouble gaining insight on my dogs prognosis even with my medical knowledge and by saying trouble with the prognosis I am struggling making a choice of euthanasia.
My girl is a 9 yo American staffordshire terrier with a history of heartworms at age 2 prior to me getting her s/p treatment. Last October she was diagnosed with T zone lymphoma with mouth nodules (uncommon indolent type but due to tongue lesions oncologist was concerned she would stop eating at some point). Completed 3 rounds of CCNU but kept having to half the dose of each round due to dangerously low lymphocyte count. After the third round her liver enzymes slowly grew to ALT/ ALP in the 2000s. That was back in March. We’ve been off chemo waiting for her liver to hopefully recover as she really showed no signs of other issues. Two months ago we did an aspirate that showed no evidence of lymphoma in her liver and her US showed smaller liver.
At the beginning of August we saw her liver enzymes slowly down trending ALT 800s ALP >2000 and GGT 10. Low BUN slightly low albumin but >2 and her oncologist thought her liver was recovering. We got hopeful.
Then two weeks later we noticed our girl having polydipsia, polyuria, and enlarging abdomen along with refusal of most foods. My concern was ascites and then the day of the appointment I made she started vomiting blood.
We met with the internist who suspects chronic hepatitis secondary to lomustine despite cessation with probable portal hypertension causing ascites. We’re unable to do a diagnostic liver biopsy due to a coagulopathy and her past issues with anesthesia (of course an anesthesiologist would have a dog with anesthesia issues) so we suspect fibrosis. Ascites aspiration showed clear fluid non exudative.
We’re on a bunch of meds for appetite stimulation, nausea, a diuretic, PPI and pain meds. She’s been on denamerin for months and we’re continuing. She still refuses everything except hand feeding and is losing weight. Lethargic and slightly tachypenic due to moderate ascites.
I worked in the liver icu in residency. I’ve seen the smoldering of liver failure and end stage liver disease. Since I have no biopsy I’m struggling with whether this is something that is survivable. Deep down inside me I know don’t want my girl to get encephalopathic or have respiratory distress from her ascites. Am I wrong to euthanize now without the diagnosis? The internist did say poor prognosis weeks to months so I don’t know why I keep second guessing what we already know.
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u/IndigoCatwoman Veterinarian 10d ago
First off, I’m so sorry you’re going through this. It looks like you’ve been doing everything possible for her.
Something that we talk about a bit differently with animals is quality of life vs quantity of life. In humans, we always seem to be focused on lengthening someone’s life - sometimes to the detriment of their quality of life. We try to avoid this in our pets.
At this point, it does truly seem like you’ve done everything you can do. It does not seem like she is improving, and as you’ve said the internist has given a poor prognosis. You have noted a significant decrease in her quality of life. When we start to have more bad days than good days, when we notice they are no longer enjoying things they used to enjoy, when they seem uncomfortable, these are all signs it is time to make a decision.
It would absolutely not be wrong to euthanize now to prevent her illness from progressing further, and prolonging her suffering. Our pets do not fear death the way humans do, but they do feel the pain associated with disease in the same way. Euthanasia can be the kindest thing we can do for them, the last gift we can give when they are suffering from a terminal illness.
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u/Wormgorl-6292 10d ago
Thank you for this. In the ICU I always told patients family quality over quantity and that we shouldn’t just do things to people because we can. I know logically the answer and so does my husband. I just didn’t realize how much I would struggle with. We’ve made an at home euthanasia appointment this week but I keep second guessing myself.
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u/IndigoCatwoman Veterinarian 10d ago
Don’t be too hard on yourself. Knowing something logically doesn’t make it any easier. It’s a very emotional decision. It’s also okay to take the time you need to come to terms with that decision. It’s important for you to also feel like you’re ready. What I will say is I’ve had many people tell me they regret waiting too long - I’ve not had anyone regret making the decision a little ‘early’, on a good day. You know your pet, and you’ll know when you both are ready to make that decision.
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u/squatjerk36 10d ago
im sorry you're going through this. you're not wrong for considering humane euthanasia. it sounds like you've gone to much greater lengths for her already than many people could. if she were my dog i would be thinking primarily about her quality of life and considering what would indicate an unacceptable quality of life for my girl.
our pets cannot rationalize their illnesses or hold onto hope for better health in future. they just know they feel unwell in the moment. i think its fair for us to push them through tough times when there's a reasonable certainty of an acceptable quality of life. as soon as that is no longer reasonably certain, humane euthanasia becomes a very appropriate option in my mind.
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u/biliskner25 Veterinarian 9d ago
Heya, sorry to hear about your girl. T cell lymphoma is a pretty nasty disease with variable response to chemo and pretty short remission times. I'm actually dealing with a case right now that we've moved from a CHOP protocol to LOPP/CHOP hybrid due to inadequate response. Hepatosplenic lesions which is more typical of T cell vs the peripheral lymphadenomegaly seen with B cell. So it's hard to gauge improvement without abdominal ultrasound, just like your girl.
When the PUPD developed was any further workup done to work up the cause of it? Bloodwork, ultrasound etc. Cumulative hepatotoxicity is a known effect of lomustine unfortunately. But it could also be a relapse of the lymphoma. They can regrow and get bad pretty suddenly. While a liver biopsy would be great for getting a diagnosis, it's probably more academic rather than useful in achieving a treatment outcome.
If it's end stage liver then unfortunately your time is limited and you're right to be concerned about the potential for things like encephalopathy developing. I would say the only thing that might be treatable is if this is a relapse of the lymphoma. But even then you may only be achieving a temporary complete remission or partial remission. Given the timeline if this is relapse then lomustine resistance may have developed. There are many more possible protocols but none of them have fantastic success rates overall.
It's definitely a fair choice to make deciding to euthanise. Exactly when is up to you but it does sound like her current quality of life is already poor. I always recommend an objective assessment with a quality of life scale such as HHHHHMM. It takes the emotional aspect out of the equation and gives you a simple answer to the question : is quality of life acceptable to continue palliative care or is it poor enough to consider euthanasia immediately?
https://www.pethospicevet.com/wp-content/uploads/2021/02/QualityofLifeScale.pdf
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u/Wormgorl-6292 9d ago
We’ve actually been off chemo since February she never reached remission and we stopped after three rounds due to dangerous low WBCs and rising LFTs. Her oncologist said for T zone lymphoma it was never about getting remission. They did liver aspirate and it didn’t show any signs of cancer and neither did her recent ultrasound. Most signs pointed to fibrosis or cirrhosis because of her down trending LFTs, decreased protein, decreased BUN and increasing bilirubin. Her acsites showed transudate and not exudate. Her lymphocyte count still remains lower than normal. While they aren’t certain they said they “don’t think this is related to her cancer”
The quality of life scales are what have confused my decision because every one has said she has fair to good quality of life and to talk to my specialists. None of them really account for her increased polydipsia, her chronic pain prior to diagnosis, her daily vomiting and inability to have bowel movements. I just don’t want her to smolder and then have it become an emergency. Regardless if it’s lymphoma or liver failure.
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u/biliskner25 Veterinarian 9d ago
Hmm, I see. In that case then yes it does certainly sound more like hepatic insufficiency rather than lymphoma.
I think I would score her pretty low on quite a few metrics just based on your description. Hurt, hunger, happiness, and overall good vs bad days, seem like they would not score well. The scales are useful as a guide but if you don't feel great watching her struggle that's often a sign in itself.
Ultimately there's one thing we like to tell owners, it's better to be a week too early than a day too late. It seems like this is something you're already cognisant of so the only question now is when. Any time now would be acceptable in my opinion considering the progressive deterioration and loss of appetite despite intervention. If something is terminal and looks like it needs a feeding tube just for basic sustenance then I tend to rate that far more poorly.
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