Three days ago, I made the decision to have my incredibly sweet, gentle, playful cat of 16 years put to sleep at home. As much as I loved her, it was not a hard decision. She was at the time lying stretched out, ramrod straight, panting unevenly, and unresponsive to my touch or voice. I had found her lying on the floor and, thinking to make her more comfortable, had moved her to a nearby chair, one of her favorite resting places. She screamed in pain at being moved, which she had never done before. Seconds later, despite having eaten almost nothing in the past two days, she passed what appeared to be bloody stool (tarry black slime covering the otherwise normal-looking stool; I apologize for the graphic description, but I am looking for answers to what killed Xena, and so am being as detailed as possible in my descriptions).
What I am trying to learn is how Xena got to that point.
In November 2019, Xena was diagnosed with hyperthyroidism, which was controlled with Methimazole at a dose that was increased steadily from an initial 5 mg per day, peaking at 12.5 mg per day in 2021 - 2022, reduced to 10 mg per day in October 2022, and finally lowered to 7.5 mg per day in October 2023. She had a flare-up of hyperthyroidism in June 2022 when, for a few weeks, I lowered her Methimazole dose to 5 mg per day, suspecting hypothyroidism for various reasons. Her brother, Casper, was on that dose and his hyperthyroidism was well controlled. This very bad idea resulted in an emergency vet visit for Xena and I never took that sort of unilateral action again. There were reasons that made it appear urgent to reduce her Methimazole dose, which I will not get into here because I do not think they are relevant to her final months of life, and it turned out that I was right about her being over-medicated at 12.5 mg per day. However, cutting her dose so drastically was probably the single worst decision I ever made with regard to Xena's care.
In October 2022, Xena was diagnosed with stage 2 CKD. Even though she refused to eat a kidney diet, her CKD remained stable through the end of her life, with no progression in her Creatinine or BUN levels, and both hovering just above the normal range. She drank a lot of water, but otherwise showed no symptoms that I could specifically link to CKD.
In late May 2023, Xena gradually began to lose her appetite, and became less active. She was still very affectionate, but did not go outside as much despite the nice weather. I did not notice more than the occasional vomiting that she had exhibited for most of her life, and saw no evidence of problems with defecation (either diarrhea or constipation). It is possible that I simply missed those signs, as she preferred to do her business outdoors, but I think that I would have noticed increased vomiting. She also did not show signs of itchy skin (minimal scratching and no visible skin problems). She had not been grooming as much for some time, but I am not sure exactly when that began. Her fur (black and white; short hair) was a bit dull and slightly oily to the touch.
I took Xena to the vet in late June 2023. The reason for the delay was that her symptoms did not seem to require urgent intervention, and the particular vet I wanted her to see had very limited availability. However, this vet is also by far the best that any of my cats have ever seen, and I felt that it was worth the wait to get an appointment with her. At this appointment, Xena's weight was 6.8 pounds and she was visibly thin. Her weight had been 8 pounds at her last appointment in January 2023, so this was a significant loss. The vet did fairly extensive blood work, which was mostly unremarkable. Xena's T4 (thyroid hormone) level was on the low side of the normal range. She had a very mild anemia, slightly elevated calcium, somewhat low lymphocytes, and significantly elevated neutrophils/eosinophils (the latter was a longstanding finding in Xena's blood work spanning many years; these levels were stable but somewhat above the normal range).
Xena's brother, Casper, had recently had similar behavioral symptoms that were entirely remedied with a 1.25 mg per day reduction in his Methimazole dose. Hypothyroidism (from over medication with Methimazole) can cause lethargy and inappetence, so I tried a similar approach with Xena in consultation with her vet, dropping her Methimazole dose from 10 to 8.75 mg per day. On the advice of Xena's vet, I also began B12 supplementation with a chewable called Cobalequin at the recommended dose of one tablet per day.
Xena's next appointment with her vet was in early August. In the interim, her appetite and activity level continued to fall. I became increasingly reliant on Mirtazapine to motivate Xena to eat, which I had on hand because it had been prescribed for Casper before his inappetence was resolved with a reduction in his Methimazole dose.
At her August appointment, Xena's weight was 6.7 pounds, .1 pounds lower than in June. She had vomited a lot a few days prior to the appointment, which was very unusual, but not since then. Oddly, she had a runny nose and drooled throughout the appointment. Those two symptoms, never seen before, never occurred again.
More blood tests were done. The results were consistent with those in June, except that the anemia had disappeared, neutrophils and eosinophils were within normal ranges, she had elevated ALT (liver enzyme), and her T4 was above the normal range. An additional test for ionized calcium (ordered because of Xena's elevated calcium level in June) came back just above the normal range. Her vet said this could be an indication of a cancerous process, but the elevation was slight (1.52 vs 1.4 at the high end of normal).
An ultrasound was also done, on an emergency basis, as Xena's vet felt something that she thought might be a growth of some kind (it turned out to be stool). This had not been planned, so Xena had not fasted, and food in her digestive tract complicated the findings. Her kidneys were noted to be unusually small and irregular, consistent with CKD. She had mildly dilated bile and hepatic ducts and thickening of the duodenum, including a presumably benign possible leiomyoma. There was also a "mild-to-moderate variation in the mucosal lining of the small bowels" (quoting from the ultrasound report). There was no firm diagnosis, but a suggestion of cholecystitis/cholangitis and an "inflammatory process" in her small intestine.
In response to her elevated T4, I raised Xena's Methimazole dose back to 10 mg per day. Her vet tentatively diagnosed with with IBD and offered some treatment options. Xena was generally a picky eater and dependent on pill pockets for her Methimazole, so I did not try a restricted diet. This may have been a mistake. I will note that she did not exhibit the vomiting, diarrhea, and itchy skin that are common signs of food allergies.
Another option discussed was Chlorambucil, but this would have been prescribed following a biopsy (if it confirmed lymphoma), which was described to me as a significant surgical procedure requiring anesthesia. I was concerned about complications from surgery as well as side effects of chemotherapy. A pill that had to be handled with gloves seemed like something that would likely have many side effects, and I had never known someone who successfully treated an animal for cancer. My own experience in that regard had been with a pet rat who had an abdominal tumor surgically removed, only to have it recur and kill her shortly thereafter. That said, I am open to the possibility that I may have been wrong to decline the biopsy.
The option that I decided to pursue was Prednisolone at a dose of 5 mg per day. This produced an immediate improvement in Xena's appetite, but her activity level continued to decline.
At her next appointment, in late September 2023, Xena weighed 7.7 pounds (a full pound gained from August), but she was notably anemic and her neutrophils were again above normal. Her T4 was at the very low end of the normal range.
I discussed options with Xena's vet and decided to reduce her Methimazole in 1.25 mg per day increments, down from 10 to 7.5 mg per day. Her vet had consulted with an internist who believed that the Prednisolone was increasing the absorption of Methimazole, leading to her hypothyroidism at her previous dose. I brought up the idea of lowering Xena's Prednisolone dose as well, and her vet was agreeable, but ultimately I did not do this, as I was concerned about Xena losing her appetite again and a lower Prednisolone dose resulting in worse absorption of Methimazole (with consequent hyperthyroidism resulting from the reduction in Xena's Methimazole dose).
Xena's next appointment was on November 30, 2023. In the interim, her activity level fell even further. She increasingly did very little except eat and sleep, though she was still affectionate if approached (what I mean by this is that she no longer came to me; I had to come to her). Her appetite remained good until late October, when she began asking for food less and started to resist eating the pill pockets containing her medications. She did not show any signs of digestive issues or other health problems except for her noticeably limp, slightly oily fur, and a new decision to sometimes urinate on and around a potted tree rather than in the litter box.
At her November appointment, Xena's weight was slightly over 8 pounds. I was surprised to see that she had actually gained weight since September, since she had not seemed to be eating as much. The day before her appointment, she threw up a lot of food, which was very unusual and something I mentioned to her vet. During the physical exam, Xena growled when the vet felt her abdomen, which Xena had never done before. The vet noted that Xena's bladder was full.
More blood tests were done, which were largely the same as Xena's September test results. Her T4 was basically perfect at 2.5 (range 0.8 - 4.0), her anemia had improved very slightly, and her kidney values were a little better as well (Creatinine was now at the very high end of the normal range instead of above normal). Her neutrophils were still elevated, but less so than in September, and her eosinophils were within the normal range.
Xena's health collapsed two days after her November appointment. After vomiting up her last few meals, she refused food altogether. I made an emergency appointment for her on December 3. The vet (not Xena's usual vet) diagnosed her with extreme constipation and recommended hospitalization for IV fluids and enemas. I agreed. The next day, following three enemas in the hospital, Xena passed the stool and was discharged. Her appetite was much improved that evening (December 4), but she refused to eat pill pockets and I had to manually put those down her throat in order to give her medications.
December 5 was much the same; Xena ate a modest amount of food, but most pill pockets had to be given manually. On December 6, Xena ate breakfast, but then began vomiting, which at least once included a string of partially clotted blood. I contacted her regular vet that evening and asked for advice. I did not want to hospitalize Xena again, given that the previous hospitalization had produced no lasting improvement (indeed, vomiting blood seemed like a more serious symptom than constipation). In the evening of December 6, Xena improved a bit, and ultimately ate and drank enough that I was concerned about her vomiting from overeating. However, she held down the food and water, and I was optimistic when I went to sleep that night.
On December 7, Xena refused breakfast altogether and it became increasingly difficult to even manually give her pill pockets. That evening, I administered subcutaneous fluids for the first time. I had misread the discharge instructions, calling for subq fluids 3 times per week, as instead saying every 3 days, so I should have done this the previous day. However, Xena was very tolerant of the process. She struggled near the end and the needle slipped out, so I ended up giving her more like 70 cc rather than the prescribed 100 cc (I did not want to poke her again that night to give the remainder). A couple hours later, Xena seemed much better, talking (meowing) for the first time since coming home from the hospital. She even ate a few tablespoons of dry food. I did not try again to force her to eat the pill pockets.
Something clearly changed much for the worse sometime between the evening of December 7 and the morning of December 8. Xena would eat nothing. She lay down, but shifted position frequently, at times choosing to lie on the floor rather than in her usual spots. I consulted with her vet on the phone that afternoon and made a list of interventions to try at home, but as soon as I got off the phone, I found Xena as I described at the beginning of this story. She was clearly in agony, breathing through her mouth heavily and irregularly, and passing what appeared to be bloody stool. I could not see the point in prolonging what appeared to be inevitable, and Xena was put to sleep by her vet that evening.
What I am trying to understand is how what appeared to be a gradual decline in Xena's health took such an abrupt turn for the worse, a few days after an appointment at which her physical exam and blood test results were not especially concerning. One of the items retested on November 30 was Xena's ionized calcium level, which at 1.39 was within the normal range (meaning that it was not necessarily indicative of cancer).
I am of course second guessing all my decisions of the past six months. I have some ideas about what I could have done differently, but I do not want to prejudice any replies by sharing those thoughts just yet. For the sake of Xena's brother Casper, still a spry outdoorsman at 16 years, I hope to learn what I can do better to keep him healthy. Any ideas, advice, and even criticism of my decisions would be much appreciated.
What I am trying to learn is how Xena got to that point.
In November 2019, Xena was diagnosed with hyperthyroidism, which was controlled with Methimazole at a dose that was increased steadily from an initial 5 mg per day, peaking at 12.5 mg per day in 2021 - 2022, reduced to 10 mg per day in October 2022, and finally lowered to 7.5 mg per day in October 2023. She had a flare-up of hyperthyroidism in June 2022 when, for a few weeks, I lowered her Methimazole dose to 5 mg per day, suspecting hypothyroidism for various reasons. Her brother, Casper, was on that dose and his hyperthyroidism was well controlled. This very bad idea resulted in an emergency vet visit for Xena and I never took that sort of unilateral action again. There were reasons that made it appear urgent to reduce her Methimazole dose, which I will not get into here because I do not think they are relevant to her final months of life, and it turned out that I was right about her being over-medicated at 12.5 mg per day. However, cutting her dose so drastically was probably the single worst decision I ever made with regard to Xena's care.
In October 2022, Xena was diagnosed with stage 2 CKD. Even though she refused to eat a kidney diet, her CKD remained stable through the end of her life, with no progression in her Creatinine or BUN levels, and both hovering just above the normal range. She drank a lot of water, but otherwise showed no symptoms that I could specifically link to CKD.
In late May 2023, Xena gradually began to lose her appetite, and became less active. She was still very affectionate, but did not go outside as much despite the nice weather. I did not notice more than the occasional vomiting that she had exhibited for most of her life, and saw no evidence of problems with defecation (either diarrhea or constipation). It is possible that I simply missed those signs, as she preferred to do her business outdoors, but I think that I would have noticed increased vomiting. She also did not show signs of itchy skin (minimal scratching and no visible skin problems). She had not been grooming as much for some time, but I am not sure exactly when that began. Her fur (black and white; short hair) was a bit dull and slightly oily to the touch.
I took Xena to the vet in late June 2023. The reason for the delay was that her symptoms did not seem to require urgent intervention, and the particular vet I wanted her to see had very limited availability. However, this vet is also by far the best that any of my cats have ever seen, and I felt that it was worth the wait to get an appointment with her. At this appointment, Xena's weight was 6.8 pounds and she was visibly thin. Her weight had been 8 pounds at her last appointment in January 2023, so this was a significant loss. The vet did fairly extensive blood work, which was mostly unremarkable. Xena's T4 (thyroid hormone) level was on the low side of the normal range. She had a very mild anemia, slightly elevated calcium, somewhat low lymphocytes, and significantly elevated neutrophils/eosinophils (the latter was a longstanding finding in Xena's blood work spanning many years; these levels were stable but somewhat above the normal range).
Xena's brother, Casper, had recently had similar behavioral symptoms that were entirely remedied with a 1.25 mg per day reduction in his Methimazole dose. Hypothyroidism (from over medication with Methimazole) can cause lethargy and inappetence, so I tried a similar approach with Xena in consultation with her vet, dropping her Methimazole dose from 10 to 8.75 mg per day. On the advice of Xena's vet, I also began B12 supplementation with a chewable called Cobalequin at the recommended dose of one tablet per day.
Xena's next appointment with her vet was in early August. In the interim, her appetite and activity level continued to fall. I became increasingly reliant on Mirtazapine to motivate Xena to eat, which I had on hand because it had been prescribed for Casper before his inappetence was resolved with a reduction in his Methimazole dose.
At her August appointment, Xena's weight was 6.7 pounds, .1 pounds lower than in June. She had vomited a lot a few days prior to the appointment, which was very unusual, but not since then. Oddly, she had a runny nose and drooled throughout the appointment. Those two symptoms, never seen before, never occurred again.
More blood tests were done. The results were consistent with those in June, except that the anemia had disappeared, neutrophils and eosinophils were within normal ranges, she had elevated ALT (liver enzyme), and her T4 was above the normal range. An additional test for ionized calcium (ordered because of Xena's elevated calcium level in June) came back just above the normal range. Her vet said this could be an indication of a cancerous process, but the elevation was slight (1.52 vs 1.4 at the high end of normal).
An ultrasound was also done, on an emergency basis, as Xena's vet felt something that she thought might be a growth of some kind (it turned out to be stool). This had not been planned, so Xena had not fasted, and food in her digestive tract complicated the findings. Her kidneys were noted to be unusually small and irregular, consistent with CKD. She had mildly dilated bile and hepatic ducts and thickening of the duodenum, including a presumably benign possible leiomyoma. There was also a "mild-to-moderate variation in the mucosal lining of the small bowels" (quoting from the ultrasound report). There was no firm diagnosis, but a suggestion of cholecystitis/cholangitis and an "inflammatory process" in her small intestine.
In response to her elevated T4, I raised Xena's Methimazole dose back to 10 mg per day. Her vet tentatively diagnosed with with IBD and offered some treatment options. Xena was generally a picky eater and dependent on pill pockets for her Methimazole, so I did not try a restricted diet. This may have been a mistake. I will note that she did not exhibit the vomiting, diarrhea, and itchy skin that are common signs of food allergies.
Another option discussed was Chlorambucil, but this would have been prescribed following a biopsy (if it confirmed lymphoma), which was described to me as a significant surgical procedure requiring anesthesia. I was concerned about complications from surgery as well as side effects of chemotherapy. A pill that had to be handled with gloves seemed like something that would likely have many side effects, and I had never known someone who successfully treated an animal for cancer. My own experience in that regard had been with a pet rat who had an abdominal tumor surgically removed, only to have it recur and kill her shortly thereafter. That said, I am open to the possibility that I may have been wrong to decline the biopsy.
The option that I decided to pursue was Prednisolone at a dose of 5 mg per day. This produced an immediate improvement in Xena's appetite, but her activity level continued to decline.
At her next appointment, in late September 2023, Xena weighed 7.7 pounds (a full pound gained from August), but she was notably anemic and her neutrophils were again above normal. Her T4 was at the very low end of the normal range.
I discussed options with Xena's vet and decided to reduce her Methimazole in 1.25 mg per day increments, down from 10 to 7.5 mg per day. Her vet had consulted with an internist who believed that the Prednisolone was increasing the absorption of Methimazole, leading to her hypothyroidism at her previous dose. I brought up the idea of lowering Xena's Prednisolone dose as well, and her vet was agreeable, but ultimately I did not do this, as I was concerned about Xena losing her appetite again and a lower Prednisolone dose resulting in worse absorption of Methimazole (with consequent hyperthyroidism resulting from the reduction in Xena's Methimazole dose).
Xena's next appointment was on November 30, 2023. In the interim, her activity level fell even further. She increasingly did very little except eat and sleep, though she was still affectionate if approached (what I mean by this is that she no longer came to me; I had to come to her). Her appetite remained good until late October, when she began asking for food less and started to resist eating the pill pockets containing her medications. She did not show any signs of digestive issues or other health problems except for her noticeably limp, slightly oily fur, and a new decision to sometimes urinate on and around a potted tree rather than in the litter box.
At her November appointment, Xena's weight was slightly over 8 pounds. I was surprised to see that she had actually gained weight since September, since she had not seemed to be eating as much. The day before her appointment, she threw up a lot of food, which was very unusual and something I mentioned to her vet. During the physical exam, Xena growled when the vet felt her abdomen, which Xena had never done before. The vet noted that Xena's bladder was full.
More blood tests were done, which were largely the same as Xena's September test results. Her T4 was basically perfect at 2.5 (range 0.8 - 4.0), her anemia had improved very slightly, and her kidney values were a little better as well (Creatinine was now at the very high end of the normal range instead of above normal). Her neutrophils were still elevated, but less so than in September, and her eosinophils were within the normal range.
Xena's health collapsed two days after her November appointment. After vomiting up her last few meals, she refused food altogether. I made an emergency appointment for her on December 3. The vet (not Xena's usual vet) diagnosed her with extreme constipation and recommended hospitalization for IV fluids and enemas. I agreed. The next day, following three enemas in the hospital, Xena passed the stool and was discharged. Her appetite was much improved that evening (December 4), but she refused to eat pill pockets and I had to manually put those down her throat in order to give her medications.
December 5 was much the same; Xena ate a modest amount of food, but most pill pockets had to be given manually. On December 6, Xena ate breakfast, but then began vomiting, which at least once included a string of partially clotted blood. I contacted her regular vet that evening and asked for advice. I did not want to hospitalize Xena again, given that the previous hospitalization had produced no lasting improvement (indeed, vomiting blood seemed like a more serious symptom than constipation). In the evening of December 6, Xena improved a bit, and ultimately ate and drank enough that I was concerned about her vomiting from overeating. However, she held down the food and water, and I was optimistic when I went to sleep that night.
On December 7, Xena refused breakfast altogether and it became increasingly difficult to even manually give her pill pockets. That evening, I administered subcutaneous fluids for the first time. I had misread the discharge instructions, calling for subq fluids 3 times per week, as instead saying every 3 days, so I should have done this the previous day. However, Xena was very tolerant of the process. She struggled near the end and the needle slipped out, so I ended up giving her more like 70 cc rather than the prescribed 100 cc (I did not want to poke her again that night to give the remainder). A couple hours later, Xena seemed much better, talking (meowing) for the first time since coming home from the hospital. She even ate a few tablespoons of dry food. I did not try again to force her to eat the pill pockets.
Something clearly changed much for the worse sometime between the evening of December 7 and the morning of December 8. Xena would eat nothing. She lay down, but shifted position frequently, at times choosing to lie on the floor rather than in her usual spots. I consulted with her vet on the phone that afternoon and made a list of interventions to try at home, but as soon as I got off the phone, I found Xena as I described at the beginning of this story. She was clearly in agony, breathing through her mouth heavily and irregularly, and passing what appeared to be bloody stool. I could not see the point in prolonging what appeared to be inevitable, and Xena was put to sleep by her vet that evening.
What I am trying to understand is how what appeared to be a gradual decline in Xena's health took such an abrupt turn for the worse, a few days after an appointment at which her physical exam and blood test results were not especially concerning. One of the items retested on November 30 was Xena's ionized calcium level, which at 1.39 was within the normal range (meaning that it was not necessarily indicative of cancer).
I am of course second guessing all my decisions of the past six months. I have some ideas about what I could have done differently, but I do not want to prejudice any replies by sharing those thoughts just yet. For the sake of Xena's brother Casper, still a spry outdoorsman at 16 years, I hope to learn what I can do better to keep him healthy. Any ideas, advice, and even criticism of my decisions would be much appreciated.
