We all
want to give our cats every chance of life; yet at the same time we do
not want them to suffer, particularly if the end is near and inevitable.
Unfortunately, it can be very hard to know when a CKD cat is really
reaching his or her final hours. With CKD, many cats can be literally at
death's door, or to use the analogy from the first page of this site, at
the edge of the precipice; yet with treatment they may be pulled back to
safety and go on to enjoy many more days, weeks, months or years of
happy quality life.
This page discusses the signs you may see towards the end, the factors
to consider when deciding whether to euthanise and what to expect if you
do choose euthanasia.
End Stage Renal Disease (ESRD)
Eventually,
since CKD is terminal, your cat is going to move into End Stage
Renal Disease (ESRD), which ultimately leads to death. However, even in ESRD, death may not be imminent.
As discussed on the
How Bad Is It? page, there is no precise definition of what ESRD is, and
many cats can manage to live relatively long and happy lives even with
high bloodwork values and very little kidney function remaining — see Success
Stories for some examples.
Nevertheless,
once people learn their cat is in ESRD, they often start to wonder what to
expect as their cat's health deteriorates. This is perfectly
understandable, and if you can bear it, it can often help to think about
it in advance, before you are faced with this scenario at a time when you
cannot think straight, and when you will quite possibly not wish to accept
that your cat is dying.
This page is an attempt to make this horrible experience a little more
bearable.
Possible Signs That The End Might Be Near
The following
is a list of possible signs that the end might be approaching. If your cat
really is in the final stages of this disease, you will see more than one
of these symptoms, though you will not necessarily see all of them:
You will
notice that many of these symptoms are identical to those seen throughout
the course of the disease.
These symptoms in themselves do not mean the
end is near.
If you haven't
already tried treatment — if your cat has just been diagnosed and is on an
intravenous fluids drip at the vet's, for example — you should definitely consider trying the
various treatments available for a reasonable length of time before making
the irrevocable decision to euthanise your cat.
This applies
in particular if your cat has high BUN/urea and creatinine, but has only just been
diagnosed. In such a case, these values may be reflecting an acute situation
such as a kidney infection (commonly undetectable) or severe dehydration. In
many cases the
values will reduce dramatically with treatment.
I therefore usually recommend
treating a newly diagnosed cat for at least two weeks before making any
irrevocable decisions. Please check the
Index of
Symptoms and Treatments page to find more information on possible
treatable causes of the various symptoms.
The primary
differences between the symptoms of treatable CKD and symptoms of the
final hours are the severity of the symptoms and the fact that they no
longer seem to respond well or at all to treatment.
With those very
important provisos, here are the main signs that are commonly seen when a
cat is close to dying from CKD. Please, please do not take them as gospel,
as incontrovertible evidence that your cat's time has come. This is your
cat, you know him or her best, and if you are not sure if the time has
come for your cat to cross, and your vet is confident that your cat is not
in pain (CKD is not normally painful), then it is better to wait until you
feel more comfortable with your decision.
Of course, it
may be that you are deluding yourself because you simply cannot face the
thought of losing your cat, which is understandable. This is why your
vet's opinion can be helpful: ask your vet what he or she would do if this
was his or her own cat, and factor this response into your decision, but
do not base your decision wholly on your vet's opinion.
Generally
speaking, with a CKD cat, little or no harm is done through waiting a day or so before
deciding on euthanasia, and you will probably feel more at peace with
helping your cat to cross if you have time to say goodbye, and time to
come to terms with the fact that this is most probably inevitable.
Very High
BUN (Urea) and Creatinine Levels
These are not
in themselves a reason for euthanasia because many cats who are newly
diagnosed, or cats who
crash, have very high levels but pull through.
If the end is near, it is quite likely that creatinine
is over 7.0 mg/dl or 650 µmol/l and BUN over 150 mg/dl or 55 mmol/l
and — this is a key point — these levels do not fall after treatment. If your cat has just been diagnosed,
high levels such as this are by no means unusual and it is also not
unusual for them not to fall immediately (in fact, sometimes they get
worse, see
Intravenous Fluids).
Generally
speaking, urea and creatinine will continue to rise inexorably in ESRD. If
your cat suddenly experiences a hike in blood values, as opposed to a
gradual worsening, it may mean an infection of some kind is present, and
it would be worth trying treatment to see if this helps.
A sudden
increase or an increase for no apparent reason may also be a sign of
high
blood pressure, in which case I would get your cat's blood pressure
measured and try medication if appropriate before choosing euthanasia.
If your cat has been receiving sub-Qs but bloodwork is
worsening, you may wish to consider trying intravenous fluids (IV) for a few days, in case it
helps to reduce the values to a level manageable with sub-Qs once again.
If you have not yet tried treatments such as IV fluids or sub-Qs at all, as is
sometimes the case with cats who are only diagnosed when they crash, you
should give your cat a reasonable shot at these treatments.
When Thomas
was first diagnosed, his numbers were off the scale (his BUN level was
241 mg/dl) and he was on IV for
four solid days and nights, yet his numbers did not improve; but nevertheless, after
treating his anaemia and using sub-Qs for a few weeks, he improved
greatly. However, in humans giving IV to a truly end stage person can
be risky, because it may cause
pulmonary oedema, and the same may apply to
cats. And really high BUN levels can cause inflammation of the brain and
seizures (though this is not inevitable).
Thomas
recovered from his crashes and had six months of normal life before his
bloodwork climbed again. Even then, he enjoyed a few weeks of good quality
life (including eating well and going for walks) with his creatinine level
over 7 mg/dl, and he is by no means the only CKD cat to do this. Treat the
cat, not the numbers.
Just to confuse
matters, in end stage CKD, creatinine levels may fall (although this is
pretty rare). This occurs because creatinine is a by-product of muscle,
and towards the end CKD cats may lose a lot of muscle, and therefore
cannot produce as much creatinine. There is more information about this on
the
Diagnosis page.
High Phosphorus
Levels
High levels of
phosphorus may accelerate the progression of CKD and may also make the cat
feel poorly. It is usually relatively simple to control phosphorus levels, and
you should see a difference a week or two after taking steps to do so.
Towards the end though, you may find that, despite
feeding a low phosphorus food and giving large amounts of phosphorus
binder, your cat's phosphorus levels just keep on rising. Your cat will
probably become weaker as a result, and may have diarrhoea.
Please read up
on the importance of phosphorus control
here.
High Potassium
Levels
Although many
CKD cats have low levels of potassium, in advanced cases the potassium
levels often increase as the kidneys' ability to excrete potassium decreases.
If
potassium levels become really elevated, the cat can suffer seizures and
occasionally even a heart attack. You can read more about high potassium
levels here.
Reduced
Urination (Oliguria) and Inability to Urinate (Anuria)
Most CKD cats
urinate profusely. In ESRD, however, the cat may produce less and less
urine, and in the worst case may eventually be unable to urinate at all.
Although this is relatively uncommon, because apart from anything else
most people have their cats euthanised before this stage is reached, both
Tanya and Thomas became unable to urinate and this came on very quickly
indeed.
CKD cats are
prone to
kidney and urinary tract infections, which may result in the cat visiting the
litter tray and producing little or no urine.
Occasionally,
an inability to urinate may be caused by a blockage or
kidney stones. Therefore
do not assume the end is near simply because you see this symptom, have
your cat checked by the vet.
If the problems
with urination have no obvious cause, it is sometimes possible to "kick
start" the kidneys with
a diuretic such as
furosemide
(Lasix or Salix), but in both Tanya's and Thomas's cases we felt, based on
our vet's advice, that this was pointless. It was this inability to
urinate that made us decide for each of them that the time had come for
them to cross, since being unable to urinate is extremely uncomfortable,
and things were simply not going to get better. However, since this
is a relatively uncommon symptom, it is not
a common reason for people to choose euthanasia, based on
what I have seen over the years.
Pet Place has some information about
anuria in cats.
Incontinence
Just to confuse
matters, some ESRD cats develop the opposite problem and become completely
incontinent, urinating wherever they are lying. Often this happens in cats
who do not
have the strength to move so they end up lying in their own urine or faeces
or both, which can be very distressing to the cat, since cats are usually
very fastidious.
Do have your
vet check to exclude the possibility of a urinary tract, kidney or bowel
infection, which might respond to treatment.
Very Strong Bad
Breath
The distinctive
CKD bad breath smell may appear or worsen as your cat gradually
deteriorates. We got Thomas's breath under control after he first crashed, but over the last two weeks of his life his breath got
worse and worse, despite his sub-Qs and other treatments, as toxin levels increased in
his body.
Bad breath may
also be caused by
dental problems such as an abscessed tooth or gum disease, or by dehydration, so
be sure your vet checks for these.
Body
Odour
The same smell
as seen in the breath
may also seem to emanate from the cat's body; this is because the toxins
are no longer being excreted properly, so are building up in the body.
Body odour may
also be caused by dehydration, which is usually treatable.
Severe Oral
Ulcers
These may
develop when a cat first crashes, and can often be brought under control
once treatment is commenced.
With ESRD,
however, very severe ulcers, often covering the entire mouth and even the
throat, may develop, often quite suddenly, and be unresponsive to
slippery
elm bark powder, although
sucralfate
may bring some relief.
Uncontrollable
Vomiting
Most CKD cats
suffer from
vomiting
at least occasionally and it can usually be managed.
Towards the end, however, you may find
that the vomiting worsens to the point where you are unable to
control it well enough, and the cat's quality of life is severely
compromised as a result. In Thomas's case, this came on extremely
suddenly, he hardly ever vomited but the day before he died, he suddenly
began projectile vomiting, which simply did not respond to treatment.
Loss of
Appetite/Refusal to Eat or Drink
If a cat is
truly dying, the digestive process will cease to function and the cat will
not need food. Perhaps because of this, vets often seem
to tell people that if their cat will not eat, it is time to say goodbye.
Unfortunately,
almost all CKD cats will stop eating or drinking at some point, and it can
therefore be very hard to know when this symptom takes on a more sinister
meaning. If you haven't tried to treat this symptom, please do so before
fearing that the end is near —
food is an essential part of the treatment plan, and a cat can improve
dramatically after taking in some nourishment. This is particularly
true of cats who have been hospitalised, where they are often too stressed
to eat.
There are various
causes of inappetence in CKD cats, so you need to be sure you've looked
into any of those which are present and treated them as appropriate (see
Index of
Symptoms and Treatments, loss of appetite). Cats who don't drink are
often dehydrated, so look into correcting that too. Even when imbalances
are under control, cats may have got out of the habit of eating, so read
Persuading Your
Cat To Eat for more information on ways to get food into your
cat.
With Thomas,
a refusal to eat
was a very dramatic symptom since he ate almost the whole time during his
illness, even when his creatinine level was over 7 mg/dl, until the day before he died, when it was simply impossible for him
to eat — if we had forced him, he would have vomited it right up. This was
because his digestive system was shutting down.
However, our Indie had very little
appetite for several weeks after a dental, yet she made a full recovery.
So it is important not to look at this symptom in isolation.
Inability to
Walk and General Weakness
These symptoms are often caused by
low potassium levels,
high phosphorus levels,
anaemia or
metabolic acidosis,
all of which are treatable in principle; and, more rarely, by a blood clot
to the leg (arterial
thromboembolism), for which the prognosis is less favourable, though
some cats do pull through. If your cat has had a stroke, s/he might not be
able to walk.
If you haven't
already done so, do try some treatments, but in ESRD, these conditions may
simply no longer respond to treatment.
Meatloaf
Position
Symptoms has a full description of the meatloaf position. Many CKD cats sit
in this position when they are crashing, but may recover with treatment,
so this symptom alone is not reason to panic. However, if the cat assumes
this position despite treatment, or in conjunction with other signs
discussed here, it may be cause for concern.
If you are able to treat the condition causing the seizures successfully,
the seizures may not return. Most of the
cases I hear about are caused by high blood pressure, and virtually all of
them resolve once the hypertension is under control with daily medication.
If your cat does have seizures towards the end, it may comfort you to know
that people who have experienced seizures report that they often are not
aware at the time of the seizure.
Blindness
This is usually
caused by high blood pressure causing the retinas to detach. In about 50%
of
cases, treating the high blood pressure can mean the retinas successfully
re-attach, so try
treating it first.
Blindness alone is not a reason for euthanasia in my opinion: cats
navigate by smell rather than by sight, and are simply not as
psychologically affected by blindness as humans are. Blindness in
conjunction with some of the other symptoms described on this page,
however, may be grounds for saying goodbye.
Dull, Sunken
Eyes
Many people
take this as a sign from their cat that it is time to let him or her go.
This can certainly be a useful sign, particularly if you and your cat have
a very close bond, but be careful not to read too much into it, certainly
not without trying treatments first — dull, sunken eyes are often a
symptom of
dehydration.
I personally did feel that I could see in Tanya's eyes that she had had
enough; but then I saw the same look in Thomas's eyes when he first crashed,
and he pulled through, which has left me wondering what more aggressive
treatments might have achieved for Tanya.
If you get this sign after trying many treatments, it is obviously more
reliable than if you have tried none.
Hiding
Many CKD cats
prefer to be in a quiet place, such as in a closet or high up on a shelf,
so again, this alone is not always a reliable sign that the end is nigh.
Often as the cat improves, s/he will hide much less. In conjunction with other signs described here though, this may be
significant.
Restlessness
and Pacing
Some cats seem
to be unable to get comfortable, and keep moving from place to place,
never staying in one for long. Tanya exhibited this symptom on her last
day.
Restlessness
may also be a sign of pain, hyperthyroidism, hypertension, or a side
effect of certain medications. All of these are manageable. See
Index of
Symptoms and Treatments for more information.
Sudden, Severe
Weight and/or Muscle Loss
If your cat
seems to have lost weight, this may indicate dehydration or not eating
enough.
By his last
couple of days, it seemed like Thomas was losing weight and muscle tone virtually by
the hour, despite still eating several times a day. We did notice this ourselves
of course, but it was
really brought home to us by the vet. She had not seen him for a few days,
and when I took him in the day before he died because of his sudden
terrible vomiting, she was really shocked by how thin he had become. This
had happened despite the fact that Thomas always continued to eat fairly
well: he simply did not have any reserves left to draw on. By the time
Tanya died, she weighed three pounds (her healthy weight was six pounds),
and like Thomas, she lost a lot of the weight very suddenly.
Sudden Weight
Gain
Many people are
delighted when their CKD cat gains weight, but if this happens quickly it
may mean fluid is building up because the cat's body is no longer able to
regulate body fluids. In many cases, this can eventually lead to
congestive heart failure.
This may also
be a sign of
overhydration, which is usually treatable.
Difficult
to Rouse and Falling Temperature
The cat may
start to spend more and more time sleeping (which tends to be common in
older cats anyway) and may sometimes take time to respond and be difficult
to rouse.
The cat's temperature may fall as the cat's body shuts
down. Other possible causes for a low temperature are
high calcium
levels, anaemia and
heart disease,
which may be treatable.
Eventually in
some cases — if the end is near — the cat may slip into a coma.
Mental
Confusion
The cat may become confused and seem to not really "be there".
This can be a result of the toxins in the bloodstream, which may be
treatable, especially if the cat is dehydrated. It may also indicate
cognitive dysfunction.
Twitching
This may be
caused by toxins in the body or by
high potassium levels. Thomas began
to twitch on his last day.
Heart problems
are relatively common in CKD cats, as discussed on the
Heart Disease page. These can often be managed with medication,
but the treatment for the heart condition tends to put additional strain
on the kidneys, and vice versa. In the worst case,
the cat may develop
congestive heart failure
(CHF), whereby fluids in the
cat's body leak out of veins and build up in the lungs (pulmonary oedema),
around the lungs (pleural effusion) or in the abdomen (ascites).
It is possible
to remove this fluid, either through the use of diuretics or physically
("tapping"), but once congestive heart failure has developed, the outlook
can be relatively poor. Some people have managed to keep a cat with
congestive heart failure going for several months, but this is unusual and
for most cats the prognosis is usually only a few weeks. It partly depends
on how often the cat needs to have the fluid tapped: obviously a need for
tapping every two days is wholly different to a need for tapping every two
weeks or once every month. A cat in CHF is usually not able to absorb
sub-Q fluids well, if at all, which means the kidney values tend to
worsen; it is basically a vicious circle. In severe CHF, if the fluids are
not drained off, the cat effectively drowns from the fluid in the lungs,
so it is important to keep a close eye on the cat in case of distress.
Low
Blood Pressure
Blood pressure
tends to fall as death approaches, though you will probably not be able to
tell that this is happening.
Anaemia
Anaemia in CKD
cats is usually non-regenerative anaemia caused by the failing
kidneys not producing a hormone called erythropoietin. Generally speaking,
this does not kick in until the CKD is relatively advanced.
Mild anaemia is
unlikely to cause major problems, and even with severe anaemia caused by
the CKD, you may be
able to treat it very successfully with erythropoiesis stimulating agents
(ESAs) such as darbepoetin (Aranesp), epoetin alfa (Europe: Eprex; USA:
Epogen or Procrit) or epoetin beta (NeoRecormon). Blood transfusions may
also give you a breathing space, though in some cases treatment may be
started too late for it to help.
In general, there is no reason why a CKD cat should
die of CKD-related anaemia, but it is critical to keep an eye on PCV and
treat anaemia proactively if it appears.
There is more
information on the Anaemia
page and the ESAs page.
Sudden
Improvement Before a Crash (Rallying)
Some cats seem
to suddenly improve just because their final crash and act better than
they have in weeks. This phenomenon is also sometimes seen in humans. It
is also known as rallying.
Tanya kept
herself to herself the last couple of weeks, hardly ate anything and
generally looked very delicate. The, on the night before she died, she suddenly
appeared in the kitchen and ate a massive bowl of her favourite food of
her own accord, having refused to eat without a lot of encouragement for
weeks, and even then she had only nibbled. She then proceeded to spend the
evening with us for the first time in weeks.
Of course, when
she crashed the next day, this made it all the harder to accept because
she had been doing so well only the day before; but my vet reassured us
that this does sometimes happen.
At any rate,
once we were over the shock, we were at least left with a nice memory of
Tanya's final evening with the family.
Running Away
It is natural for cats to hide when they do not feel well: it is a
way to protect themselves from predators. Some cats near the end may take
this a step further, and may actually run away from home and hide if they
are allowed outdoors. Even an indoor cat who normally never has any
interest in going outside may take the opportunity to escape if one
presents itself. Unfortunately this may also mean that the cat's humans
cannot find him/her, so the cat dies a lonely and perhaps
uncomfortable death. For the cat who does survive and return home, the
lack of food and fluids during the absence can make an already sick cat
even sicker.
We experienced
this with Thomas: he normally went out alone, but on his last morning we
took him out on a lead to give him a last chance to smell his garden. He
tried to run away, and would have succeeded if he hadn't been on the lead.
Since it is
terribly distressing not knowing what has happened to your beloved cat, I
recommend not allowing your cat out alone if you suspect the end
is near. By all means take him/her outside on a lead, but please do not
make the mistake of thinking your cat is too weak to move, you could get a
very nasty surprise.
Accepting
the Time Has Come
Even if every
single one of the symptoms described above were present, you still might
not feel ready to let your cat go. That is perfectly understandable: it is
one of the hardest decisions you will ever have to make.
Also, if you
have been devoting much of your time to helping your cat, it can be very
hard to accept that you can no longer do anything to help him or her — the
feeling of helplessness is an awful one, so we cling to the hope that we
just need to find the one magic treatment that might help. I see this
sometimes when people join my support group (perhaps when their cat is
already in crisis) and see the success
stories and keep trying to be one themselves.
Unfortunately
not every cat can be a success story. Even for those who are, eventually
the day is going to come when there is nothing left to try.
Even when there is nothing left to try, we do not always know that is the
case.
Before the end: prepare highly attached clients to
face their-pet's death (2016)
Wooten SJ Veterinary Medicine says "As the pet's proxy, the owner
makes the decision for euthanasia based on uncertain anticipated events
rather than what is known. Uncertainty makes the decision more difficult."
If you think
you may decide to use euthanasia, please read
below for more
information on making the decision.
Home
Hospice
Your cat may be
near the end, but perhaps it is not quite time yet. You are probably familiar
with the concept of hospice care for terminally ill human patients nearing
the end of their lives, and hospice care for pets is also becoming more
popular.
This does not mean euthanasia is not an option; rather, the goal is to
ensure that your cat's last hours or days are comfortable, so you do not
have to act too soon.
2016 AAHA IAAHPC end-of-life care guidelines
(2016) Bishop G, Cooney K, Cox S, Downing R, Mitchener K, Shanan A,
Soares N, Stevens B & Wynn T Journal of the American Animal Hospital
Association52(6) pp341-356 explain more about this.
If you feel
your cat is towards the end but not quite there yet, your goal changes from prolonging
life to providing supportive care
focused on your cat's comfort and quality of life.
This would include the basics to keep
your cat comfortable, such as
sub-Qs to prevent dehydration, medications for nausea, treatment for mouth ulcers,
painkillers etc. However, other treatments such as vitamins or phosphorus
binders would probably not be given. You might want to give your cat
treats, this is normally acceptable but check with your vet if you are not
sure.
If the end is
truly nigh, the cat will probably not want to eat, so do not assist feed,
but keep food and water available. If there is a food your cat loves and
will still eat, such as tuna, by all means give it.
Undertaking
hospice can also help you come to terms with the harsh reality of your
situation.
2016 AAHA IAAHPC end-of-life care guidelines
(2016)
Bishop G, Cooney K, Cox S, Downing R, Mitchener K, Shanan A, Soares N,
Stevens B & Wynn T
Journal of the American Animal Hospital Association52(6)
pp341-356 explain more about hospice, and mention that care of the human
caregiver (i.e. you) is also an important part of the feline hospice
programme.
You need to
make some difficult decisions about your cat's death. i.e. whether you wish to let them die
naturally or whether you will use euthanasia when the time arrives.
We probably all wish our
cats would die naturally and peacefully in their sleep, but there is no guarantee that a
natural death will be peaceful (the same might be said for some
euthanasias, though fortunately not many).
A Natural
Death
Some
people decide to let their cat cross unaided for religious reasons. Other people feel they do not have the right to choose
death for their cat, or it may be that they simply cannot face
making the decision. Occasionally the decision is taken out of your
hands, e.g. there is a storm and you cannot seek veterinary help.
I used to be
terrified by the idea of a natural death. My opinion changed when my
kitten, Lily, began to die naturally at home (she had
FIP but not CKD). She fell
asleep on the sofa and her body temperature began to fall. She was so
deeply asleep and breathing so shallowly that for a moment I thought she had
already crossed. So what did idiot I do? I'd never lost a cat naturally
before, so I panicked and called the vet and asked her to meet me at her
premises (it was 9.30 at night). I was so distraught (I wasn't expecting
Lily to suddenly die) that I didn't even think to ask the vet to come to my
home, which she would have done.
Unfortunately
Lily woke up in the car en route to the vet's and was upset. I felt and
still feel terrible for taking her to the vet when she was so scared
there. I should have let her die peacefully at home on my lap.
Nevertheless, I
do still worry about the idea of a natural death for a CKD cat, because
sometimes a natural death can be unpleasant for such cats.
If you decide
to allow your cat to die a natural death, I would read the information
above about hospice.
If possible,
allow your cat to be in a comfortable place of his/her choosing. With CKD
cats who cross naturally, you may still see some of the signs outlined above,
such as strong body odour; reduction in body temperature and possibly
coma; hiding; incontinence; and twitching and possibly seizures.
Some cats will
simply gradually fall into a coma, become unresponsive, and die a gentle
death (as was happening with Lily above). However, other CKD cats may have
seizures and a heart attack. Dying may be swift and painless, or it may be
drawn-out and uncomfortable; it may even be painful, particularly if your
cat has congestive heart failure, when s/he will basically drown from the
fluids in the lungs.
Unfortunately,
it is impossible to predict which cats will die in which way. Therefore
please ensure that you are able to contact a vet at any time should your
cat appear to be in discomfort and you decide that you want medical
intervention after all. This should not be too difficult in the UK, where
vets are obliged to provide a 24/7 service, so you should be able to
contact a vet at any time, day or night. People in other countries may
have to find an emergency clinic if they need help out of office hours.
Below are two
experiences, one of a cat who crossed peacefully and one of a cat who did
not. If you have already
definitely decided on euthanasia, do yourself a favour and do not read the
unpleasant death story
.
Sometimes
people who allow their cats to die at home find that their cats
hang on while they are in the room, and only die when their caregiver
leaves the room.
If you allow
your cat to die a natural death, be careful about permitting outside
access, because some cats will run away to die (see
above).
Natural
Death (Unpleasant)
"My cat
died of CKD in my arms, without benefit of euthanasia. Not because I made a deliberate choice to have it that way but because the
vet didn't make it in time to ease his passing.
"My cat's last hours were not pretty to witness. His deterioration
was extremely rapid. He went from being weak but functional, to
being almost completely helpless, in a matter of hours. At one point
he managed to get himself up on a cat perch to sleep, but woke up later
needing to urinate. I had been in the room with him keeping an eye
on him, but sadly I wasn't in the room at that moment; I heard a crash and
ran back in to find that he'd tried to get off the perch to
make it to his litterbox but had been too weak, and he fell, hard, about
four feet to the floor. I found him lying there, stunned, leaking
urine and unable to get up. This was about two hours before he died. I left frantic messages for my vet, who was scheduled to come the next day
to euthanize him, but she didn't get the messages in time to be of any
help. I put my cat on my sofa and sat next to
him. He lay there for two hours, too weak to do anything but
breathe, until he was overtaken with convulsions. He kept convulsing
in my arms for nearly thirty minutes (while my neighbor was driving us to
an emergency vet) until he finally took his final breath and left me. I talked to him the entire time, telling him that I loved him and was
there with him, but I know he didn't hear me or even know that I was
there.
"There was nothing peaceful about his death, nothing to make me come away
feeling like we'd shared anything noble or beautiful. I would have
far, far rather been able to hold him in my arms while the vet helped him
to a truly peaceful passing, before matters deteriorated to the point they
did. I would have rather spared him what he had to endure on the
last day of his life."
Natural
Death (Pleasant)
"Roady slipped
peacefully away at 3:03 a.m. California time this morning.
"About 8:00 last
evening he came to me and wanted to be with me on the couch. My wife went
to bed about 11. She brought us a big fluffy towel and the
heating pad in case we got cold. I wrapped him loosely in the towel and
held
him in my arms. We stayed that way, until he passed. He gave a little
crackling meow, his bladder let loose and he was gone. There was no pain.
"Mine and Roady's final time together was the best and most private.
Something we would not have had, had I opted to take him somewhere to be
put to sleep.
"I knew Roady,
knew his wishes, knew in my heart that his crossing would be
without pain and it was."
Euthanasia
Euthanasia,
literally translated, means a good death (which is what we all want).
Unfortunately opting for euthanasia means the pain and uncertainty of making a decision to
use it.
If you feel
you would consider euthanasia when the time comes, it can be helpful to decide in advance, perhaps in conjunction with your
vet, the criteria which will lead you personally to seriously contemplate
euthanasia. This is not easy because different cats have different
tolerance levels (and so do their humans); and many of the symptoms of
CKD, which might lead some people who are unaware of the latest treatment
options to consider euthanasia, can in fact be
successfully controlled.
If you have
decided to have your cat put to sleep when the time arrives, this does not
necessarily mean you will know when to act. In fact, it can often be quite
difficult to know.
"You Will Just Know"
Some well-meaning people may tell you that that your cat will let you know
when it is time to leave, that you will look in his/her eyes and "just
know".
Although it is
comforting to think that your cat may effectively take the decision out of
your hands in this way, you have to accept that it is just as likely that
this will not happen. It might possibly be easier with a CKD cat to look
in his or her eyes and "know" that it is time, in that you are probably
giving your cat so much care and attention that you will know when
something is wrong; but that doesn't translate as always knowing when it
is time.
I looked into
Tanya's eyes and felt it was time; but then later on I saw that exact same
look in Thomas's eyes — and he pulled through. So I know from personal
experience that "looking into your cat's eyes" is an unreliable indicator.
I have also heard from people who have been told they will "just know" and
who are so worried about looking into their cat's eyes for "the signs"
that they neglect to enjoy their time with their cat.
So by all
means, hope for a sign; but do not count on receiving one.
How To Decide
There is sometimes a tipping point, where you realise things are not going
to improve. However, this does not always happen, and even if it does, you
still may not want to accept that death will follow.
We cannot know the best time exactly. I have heard
from many people over the years, and the consensus seems to be that they
would prefer to have acted a day too soon rather than to have left it a
moment too late. However, some people need to know they have tried
everything they can and that things are completely hopeless before they
act. I personally tend towards the latter approach, simply because I'm
very bad at giving up. Have a think about this, and consider whether you
would feel worse afterwards if you think you acted too late or too soon.
I would definitely talk to your vet about whether it is time. Vets
deal with death regularly, plus they have more emotional detachment
than you.
Coping With Your Loss has links to pet loss support helplines at
veterinary schools, and many of these are also happy to talk to you
before your loss, when you are trying to decide whether the time has
come.
At the same time, always remember that nobody knows your cat like you do: if you feel
pressurised into making the irrevocable decision, perhaps by your vet or family, this
may distress you afterwards; so again, try to decide in advance what are
the criteria you personally would use for making the decision.
Talk to your
cat. Your cat is an adult, and should be treated as such. Cats do not fear
death as we do, they live in the moment. On the day
before Ollie died, he was not eating much and seemed a little restless. In
the afternoon he sat on a chair opposite me. I gave him a cuddle and I
told him that we loved him very much, that we were so glad he had come to
live with us and we hoped to have much longer together, but we knew things
were tough for him and that we would understand if he had to leave us soon
and he mustn't fight on our account. Two hours later he collapsed and I
rushed him to the vet, where treatment overnight didn't work so we said
goodbye. I often wonder if our little chat gave him permission to go.
I would suggest an
approach something along the lines of:
if your cat
is in pain, or about to be in pain, which cannot be treated;
if your cat
has very little quality of life, however you personally define that.
Is your cat living or just existing? Has s/he lost dignity? Areas for
consideration might include whether your cat is incontinent; whether
your cat is able to rest comfortably; whether your cat still enjoys
interacting with your family. Obviously treatment might resolve some
of these issues, so what also matters is:
if there is
in your and your vet's opinion very little or no chance of curing or
improving the situation and regaining quality of life;
then consider
euthanasia.
Quality of life scale (2004) Canine and Feline Geriatric Oncology Honoring the Human-Animal
Bond, Villalobos A Blackwell Publishing, Table 10.1, released 2007 can be
helpful in determining whether it is time to say goodbye.
Quality of life scale for pets
Hilst K Journeys Home Pet Euthanasia has a quality of life
scale and an online calculator you can use to gauge your cat's situation.
Even after
reading the foregoing, you may feel unsure about what to do. If you are
not yet sure, in most cases waiting a few more hours or
occasionally days does not condemn a CKD cat to agony, but can at least help
you
to get used to the idea and to know that you have done all you could.
I brought
Thomas home to spend his last night with his family before he was put to
sleep the next day. He had become sick really fast, so this gave me time
to get over the shock and to be sure it was hopeless and to accept that
there was nothing to be gained for him from making him stick around. But having that
time together did help me, and I like to think he was not too
uncomfortable whilst we said our goodbyes.
However, if you
look at the list of symptoms you may see towards the end (see
above),
you will see that some of them are more tolerable than others. I would not recommend waiting too long if a cat is suffering
from congestive heart failure,
has problems
breathing, cases of
PKD in which
the cysts have ruptured (this is rare), or
seizures where you cannot
find and treat the cause. If your cat can no longer urinate, you should act
quickly. If you are at all unsure, call your vet. Saying goodbye a few
hours earlier than you planned may be easier for you to cope with
afterwards than worrying that your cat might have suffered even for a
moment.
You should consider visiting
the
Other
People's Losses page, which contains some personal histories
bravely provided by several people who describe
what happened during their cat's final hours, and in most cases why they
then decided to use euthanasia. These histories are very hard to read, but
offer a unique insight.
has a very sensitively written section about
euthanasia.
How I Make the Decision
When Tanya was
ill, I felt that I would never be able to bear having her put to sleep. I
had never had to make this decision before, and it absolutely terrified
me. I felt like I would be murdering her, and couldn't comprehend the idea
of killing somebody you love (well, I can't comprehend the idea of killing
anybody, but especially not somebody I love).
The only way I
was able to do it when the time came was when I finally accepted that
neither Tanya nor Thomas was ever going to get any better than they were
at that moment; that we had tried everything in our arsenal but our
weapons were no longer working; and that waiting any longer would
therefore ultimately be for my sake, not for theirs.
How much more
could I ask of them? Ultimately you cannot avoid death; but often it is
possible to avoid suffering. Once I began to look at it from the
perspective of what was right for them and what would spare them pain, it
was still by no means an easy decision, but I did at least feel it was
inevitable, because I simply could not stand by and watch them suffer when
it was within my power to prevent that.
By not
acting, I would not be prolonging their lives, I would be prolonging their
deaths.
I have put the
previous sentence in bold because many people tell me this single sentence
is the thing that has helped them most on this page.
A friend sent me a quotation shortly after Thomas died. It said that a
good death was not about when or how; it was about knowing love. This
comforted me greatly, because, for all my mistakes, my cats did know love.
Cats don't know how old they are, or wish to live longer, they live in the
moment. All that matters to them, however long they live, is that they are
loved and cherished.
Place of
Euthanasia
Most cats are
put to sleep at the vet's office, however, it is sometimes possible to
have euthanasia performed at home.
Euthanasia at the Vet's
If you have
to go to the vet's, let the receptionist know why you are coming. Many
vets make special arrangements in such cases, e.g. my vet uses one
particular room so you can leave without having to walk back through the
waiting room.
Aim to get the
last appointment of the session if possible so you do not feel rushed and
fewer people will be in the waiting room when you arrive and leave.
Try to arrange for somebody you trust to drive you
there and back. You will probably not be in a fit emotional state to
drive, and if somebody else drives, you can hold your cat during the
journey.
Euthanasia at Home
I think this is
the best option by far, especially in the time of
Covid-19. I recommend arranging in advance that your vet
will come to your home if possible when the time arrives, even though you
will not necessarily know when this will be. At home euthanasia is usually
much less stressful for your cat and usually for you, though some people
think they will be haunted by the experience if their cat crosses at home
and therefore prefer to go to the vet's office.
Most UK vets are
prepared to come to your home, usually with a vet nurse to assist, though
you may have to wait until they have finished their day's consultations,
and you will probably have to pay more.
Our UK vet kindly came to
our home at 9.30 p.m. on a Sunday evening to euthanise Tanya — it was a
terrible experience, but that act of kindness made it a little easier to
bear. Thomas was also put to sleep at home. This meant I could sob in
private, and also that I did not have to drive home; I really don't think
it would have been safe for me to drive in my state of grief.
I have heard that euthanasia at home is not permitted in France.
It can be much harder to find a vet who makes house calls in the USA.
My vet did not offer this service, but put me in touch with an ER vet who
came to our home.
Lap of Love
may be able to provide at home euthanasia, depending upon where you are
located within the USA. They also
offer hospice care and will let you know if they think the time has
come or whether you can wait a while. The reports I have had on Lap of Love
have been universally positive.
Try to decide
in advance whether you wish to be with your cat when s/he is put to
sleep. Again, this is a very personal decision. Some people feel they owe
it to their cat to be present; others simply cannot bear the idea. Both of
these approaches are perfectly valid.
Personally, I
have always felt I had to be there because I felt the presence of somebody
they knew and loved would comfort and reassure my cats.
What Happens
During Euthanasia
Many people are
very scared by the thought of euthanasia. Quite apart from the emotional
trauma associated with the procedure, there can also be a fear of the
unknown in terms of what to expect from a practical perspective: how is
euthanasia performed, what exactly happens to the cat etc.
The basic aim
of euthanasia is to stop the cat's heart in a painless way. In order to
achieve this, an overdose of an anaesthetic (pentobarbital sodium or pentobarbitone sodium) is given by injection. If you have ever had a
general anaesthetic, I would imagine that the sensation of dropping off to
sleep is similar for the cat, since an anaesthetic is used in both cases.
The injection
must be given directly into a vein, and most vets will inject into the
front leg. The vet usually has to shave or trim the cat's leg in order to
see the vein clearly.
Some vets
insert a catheter, a tube through which they will feed the anaesthetic but
other vets simply insert the fine needle with the anaesthetic directly,
which I preferred.
Some vets (particularly
in the USA)
give the cat a sedative
first, which is a single injection under the skin. If you have a cat who hates vet visits, you may wish
to ask your vet to do this. The sedative should relax the cat, and often the vet will then give you
some quiet time together, perhaps twenty minutes or so, to say goodbye to
your cat. Your cat may be relaxed but awake following a sedative, but some
cats may become very sleepy and not particularly responsive to you. My
British vet does not use sedatives because she says they can sting. I have
had euthanasia performed both with and without sedatives, and I do not think
the sedative bothered Harpsie, but nor do I think putting my other cats to
sleep without sedatives caused any problems.
Some cats
actually pass before the final injection is given, especially if you can
hear slightly gasping breaths (known as pre-agonal breathing) beforehand, but the
vet will always give the final injection, just to make sure.
Occasionally a
vet may inject the cat directly in the heart (intracardiac euthanasia),
which I personally would find very distressing. I would suggest that you
should not agree to this unless all other methods have failed; it should
certainly not be the method of first choice, but may on rare occasions be necessary if the cat
has very low blood pressure (which makes it virtually impossible to find a
vein to use). This type of euthanasia should never be performed on a conscious cat
(US law only permits it on animals who are heavily sedated, anaesthetized
or comatose).
Once the final injection has been given, usually the cat
will look as if s/he is falling asleep, and then s/he will
gradually breathe more and more lightly until eventually the breathing
stops completely: this only takes a few seconds.
Most cats cross
peacefully, though unfortunately some cats may struggle a little or cry
out, especially if they haven't been sedated first. However, this is
uncommon. I have now had seven cats
put to sleep in my presence and it has always been very gentle and gradual, and we didn't
find it scary.
The vet
checks the cat's eyes and heart and pronounces the cat dead. You may
notice a few little sighs even after your vet has pronounced your cat
dead; this is known as agonal breathing. This is just a physiological
effect of the muscles relaxing, not proper breathing, but it can be extremely upsetting if you are not expecting it.
Fortunately our vet had warned us about this possibility, which we saw
with both Tanya and Thomas. Very
occasionally your cat may suffer what appears to be a nosebleed — this is
also caused by agonal breathing, and simply means that some capillaries or
other larger blood vessels in the lungs have ruptured. This does not hurt
the cat because it happens after death. Tanya also
began pulling tongues, it was really just her tongue relaxing, and we
actually found it rather cute since she often pulled tongues when she was
alive.
We were
stroking both Tanya and Thomas the whole time as they crossed. You need to
be aware that, just as there can be involuntary breathing movements after
death caused by muscles relaxing, so other muscles may relax, including the bladder and the bowels. As a
result a cat may empty his/her bladder and/or bowels after death. For this
reason it is best to have a thick towel and/or incontinence pad on your
knee if your cat crosses while on your knee.
Unlike humans,
cats' eyes stay open after death. They look empty though, compared to the
depth in a cat's eyes before death.
It may help you
to spend some time with your cat after he or she has crossed. To be
honest, I found this essential in order to be absolutely sure that they
had definitely crossed. It had been
hard to groom Tanya for a while before her death because she was so thin,
but I promised her she would be beautifully groomed after she had crossed.
I kept that promise to her. If you have other animals, you may wish to let
them view the body, because it may help them understand what has happened.
You may have a
vet who cries along with you, or your vet may appear to remain detached.
My vet never cries during euthanasia, because she wants to focus on her
job of helping the cat to cross as peacefully as possible; but she told me
that all her team do find it distressing and often need some emotional
support from their colleagues afterwards. So if your vet doesn't cry, please don't assume he or
she doesn't care; and please do not let this stop you crying yourself if
that is what you want to do.
Ideally this is
something which you should think about in advance if you can. Although we
had previously decided to bury Tanya in our garden, we had not given any
thought to a suitable container so we were faced with a real problem when
she died. Also, she died in January, so the ground was very hard and
difficult to dig.
One thing that
I have found really helps me is to keep my cat's body at home for a while.
If my cat has been put to sleep at home, this is easy to do. I often keep
them overnight or for several hours during the day, then take them to the
vet for storage until they are ready to go to their final resting place. I
find it reassuring to be able to talk to them, look at them, hold them,
gaze at their beautiful faces, be sure they are dead and basically delay
the moment of truth. This way I am only dealing with the loss of life, but
I still have their physical presence for a little while longer.
Paw
Prints
Whichever
resting place you choose, you may wish to clip a lock of hair as a
memento. Some people
have a cast made of their cat's paw, which can be very comforting. In the
USA, vets often offer to do this, but you can do it yourself with moulding
dough, available from toy shops.
to have
your cat cremated and have the ashes returned to you
to have
your cat cremated and not have the ashes returned to you
to have
your cat freeze dried
Burial
If you wish to
bury your cat, you need a suitable place to do so, such as your garden.
If you do not have a suitable place to bury your cat, or if you do
not expect to stay in your current home forever, you may prefer to pay to
bury your cat in a pet cemetery.
If you are burying your cat privately, somebody needs to dig the grave.
You need to dig down at least a foot. We buried Tanya in our garden, but
digging her grave was a challenge since she died in January and the earth was
very hard.
Thomas was also
buried in the garden. Unfortunately, after we had buried him, I had a
dreadful urge to dig him up again just to make sure he was definitely
dead. I didn't, of course, but the urge was very strong, signalling my
unwillingness to accept that he really had gone.
Many people choose to mark the grave in some way. We planted a rose bush
on the graves of
each of our cats, and placed brass memorials on the wall nearby. See
below for suppliers.
Cremation
Some people
choose cremation because they prefer it to burial, while others choose
it because they know they will move in the future and do not want to
leave their cat behind when they do so, whereas ashes can travel with
you. Some people choose cremation because they do not like the idea of
their cat being outside in the cold ground.
If you
choose to have your cat cremated, your vet will normally arrange for your
cat to be collected from the vet's premises and taken to a special animal
crematorium. Often the vet's premises will only be visited once or twice a
week, so your cat may need to stay in your vet's freezer for a while,
which some people find upsetting.
You need to be
aware that quite often several cats will be cremated at once, so if you
ask for the ashes back, you will be receiving either mixed ashes, or
possibly none of your cat at all will be there.
If you wish, you can ask for an individual cremation instead (known as a
separate retort), which usually costs more. I always opt for a private
cremation. I not only do this, but I also always collect my cat's
body from the vet and take the cat to the crematorium myself, but I collect a few
hours in advance so we can spend a little more time together. Although the
cat is frozen, I find it very comforting knowing after the death that I
will see my cat again before the final goodbye.
Some places will allow you to attend private cremations if you wish.
I have attended two of them, one in the USA and one in the UK. See
below
for my experiences.
If you do not visit the crematorium yourself, it can be upsetting
receiving the call that your cat's ashes have been returned to the vet and
are ready for you to collect. However, many people actually find it
comforting to have their cat back home again, albeit in a different form.
If you choose to have your cat's ashes returned to you, they will usually be in a
sealed plastic bag within a plain, simple container. Many people choose to
buy a nicer urn or some other type of holder, either from the crematorium
or from another supplier. I have always used those offered by the
crematorium, for which I have usually paid a little extra.
Some people like to scatter the ashes, others like to keep them in their
home. It is possible to have some of your cat's ashes made into
jewellery
if you prefer. You might also like to ask for your cat's ashes to be mixed
with your own after you die, local laws permitting.
Cremation: Our Experiences
We have now had five of our cats cremated in two different countries.
The first time we used cremation was in the USA, the four later cats
were cremated in the UK.
We lost Harpsie in the USA, so since we lived in an apartment at the
time, we had no choice but to have him cremated.
I was dreading it. Many people had told me it
would probably give me a sense of peace and completion, which I thought
highly unlikely. I hated the thought of burning his lovely fur and beautiful
face in particular, even though all the humans in my family opt forcremation.
We chose to attend the cremation, which I gather is unusual. But we are
always present when we bury our cats, and we didn't want to do any less forHarpsie. Plus I wanted the reassurance of knowing they had got the
rightcat.
So we set off to the oldest pet cemetery in the USA,
Hartsdale Pet Crematory(founded 1895). It was in a
beautiful tree-filled setting, andthere was
torrential rain, which we didn't mind, it fitted our mood better.
Of course I sobbed my heart out but people were right, it was cathartic. We
were given plenty of time in a private room for a personal goodbye with
Harpsie. I'd been told that Harpsie might look a little
different, but I'm pleased to say he looked
exactly as he didwhen we took him up to the vet
the day after he crossed. They placed him ina
little casket for the viewing, with a little white satin pillow for hisadorable little head, and a little cat-sized white satin blanket. We
were able to hold and cuddle and stroke him, until we felt ready (after a
fashion) to part with his little furry body.
We placed two red roses in with him, and then watched as he was
carried respectfully to the crematorium. We watched the man (who was very
kind and considerate) place Harpsie in it, then we went inside the main
building to choose an urn.
We opted for a pale cream marble
chest with a few pinkish-red swirls — thebase colour is a similar colour to Harpsie. We felt this was very
fitting because when Harpsie was a kitten, he loved sleeping
with hishead resting on the marble hearth.
We then went for a walk and the heavens opened, so we got soaked to
the skin. We returned an hour later to collect Harpsie in his new form. It
was curiously moving.
We brought His Handsomeness home, and he now rests in his
marble chestsurrounded by the urns of our other deceased cats.
And whilst we of course still wish that cute little face, body
and personality were still with us, we do feel asense of completion that he is home at last.
Although I found Harpsie's cremation in the USA comforting, the one
I attended in the UK felt odd because it was more impersonal somehow
thanks to the infamous British obsession with health and safety. I
would return to Hartsdale in an instant, but for the last three cats
I have had cremated in the UK, I have taken my cats personally to
the crematorium, but have then visited a nearby garden centre during
the cremation and purchased a memento of some kind, such as a vase
or a rose bush.
In almost all cases I would suggest that burying your cat or having the
ashes returned to you can give you some small form of comfort, as if your
cat has come home to you.
Urns and Markers
Many people
find it comforting to select a pretty urn to hold the ashes, or mark the
grave in some way. The following
companies sell urns and caskets, although I do not know anything about them
unless stated
(they are listed in alphabetical order):
USA
Amazon sells a stone marker. Many
other styles are also available.
Casket Gallery sells wooden urns and
photo-urns, and granite headstones.
Life Cycle
Urns sell urns and charms,
including some suitable for Pandora bracelets. Their products are
available in the USA, Canada, UK, Australia, New Zealand and Singapore.
Paws 2 Heaven
sells a variety of pet remembrance items, with 10% of purchase price going
to a shelter or rescue group of your choice.
Perfect
Memorials sells a wide selection
of headstones and markers in the USA. I have had positive reports about
this company.
In the USA there
are now a number of businesses that offer freeze drying. This is not the
same thing as taxidermy (where the animal is stuffed). Instead, the cat is freeze dried
in a position of your choice.
The advantages are that your cat's physical presence can remain in your
home, and you can still hold your cat and stroke the soft fur.
Disadvantages include the fact that, if your cat has had any areas shaved
for previous treatments or for euthanasia, these will remain visible. In
addition, if your cat died of end stage CKD, s/he will not look as healthy
as in their prime, and may be rather thin.
From what I can see and have heard, freeze drying costs around US$800-1000
for a 10 lb cat.
I have heard from several people who were considering this option, but I
have not yet heard from anyone who has had it done.
Links on this page last checked: 01 September 2020
*****
TREATING YOUR CAT WITHOUT VETERINARY ADVICE CAN BE
EXTREMELY DANGEROUS.
I have
tried very hard to ensure that the information provided in this website is
accurate, but I am NOT a vet, just an ordinary person who has lived
through CKD with three cats. This website is for educational purposes
only, and is not intended to be used to diagnose or treat any cat. Before
trying any of the treatments described herein, you MUST consult a
qualified veterinarian and obtain professional advice on the correct
regimen for your cat and his or her particular requirements; and you
should only use any treatments described here with the full knowledge and
approval of your vet. No responsibility can be accepted.
If your cat
appears to be in pain or distress, do not waste time on the internet,
contact your vet immediately.
This site was
created using Microsoft software, and therefore it is best viewed in
Internet Explorer. I know it doesn't always display too well in other
browsers, but I'm not an IT expert so I'm afraid I don't know how to
change that. I would love it to display perfectly everywhere, but my focus
is on making the information available. When I get time, I'll try to
improve how it displays in other browsers.
This site is a labour of love, from which I do not make
a penny. Please do not steal from me by taking credit for my work.
If you wish to
link to this site, please feel free to do so. Please make it clear that
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