pain management

I have been meaning to write an update for days now, but I think on some level I was waiting to see how things were going before I dared.

carver went to see a pain management specialist at Angell Memorial hospital in Jamaica Plain. it took me awhile to decide to make the appointment. e and I have had some not so great experiences at angell over the years (one including a test-crazy intern, a $500 bill, and our finding out in the end that all we needed was an extra litter box for our elderly cat [which a non-Angell vet had to tell us]). a few months after the amputation surgery I had made a silent pact with carver-no more vet visits, no more invasive tests. but the home visit vets (maija and emily) had recommended her, and carver was obviously not doing well, not wanting to walk at all. about a year ago I had set aside money for the end of carver's life. i have guarded that money with a tight fist, but finally realized that if I did not spend some of it, the end could be coming sooner rather than later. so, appointment made, and off we went.

our awesome neighbor friend ryan drove me, e & c up the street to the hospital (it is literally up the street, about a 5 minute walk, if carver could still walk). we met with dr. M last friday. she is a wonderful person, really present. the appointment started with loads of questions, about his diagnosis, surgery, recovery, treatment, and current decline. she did a physical exam and then asked us if we wanted to do x-rays, which we did, just 1 view of his lower spine. we wanted to rule out the possibility of the cancer having spread to his spine and to eliminate the possibility of there being a mass in or around his spine. the x rays showed no cancer returning, but what she suspected, which is lumbar spinal stenosis. basically some of his lower vertebrae have shifted their angle, and are pressing on the nerves of his spine.

the big surprise of the appointment was that she also diagnosed carver with canine cognitive dysfunction, or ccd, or doggie Alzheimer's, if you will. this explained the staring at the walls and barking. more on this in a moment.

we discussed doing an mri to confirm the diagnosis of stenosis, and the option of surgery (both of which i declined)
we talked about quality of life, and she did help me by giving me the most basic of things to look for and consider-can he walk, go to the bathroom without assistance, I can't remember the other things, but it grounded me in a way that the number system that m & em gave me could not. it gave me some bench markers to pay attention to.

then we discussed meds. she started us on a program that has room to grow, lower doses of med that can be slowly raised. (i will write the protocol at the end of this post.) we discussed prednisone, which I had brought up to m & em, but the side effects of the drug sound like a horror show, including the need to first ween him off of the deramaxx, a process which he would have to take narcotics in order to stand. We have taken the prednisone option off the table for now. I left with the promise to check in with her early this week, and we will begin the process of tweaking the medication.

I walked out of the hospital feeling totally drained, and not a little confused emotionally. it seems like all the good news was mixed in with bad. it was great to see that the x-rays did not show any cancer, but the stenosis is a terrible thing. and in a way if we had seen the cancer returning, we would have a more clear view of what to do. I think a part of me wanted to know something concrete-something that would make our decision making more clear cut. the stenosis is degenerative, so we know things are going to get worse. and then there is the CCD. I was relieved that carver's crying in the evening was not due to built up pain. but still, it is heart breaking to hear him cry no matter what the reason, and the thought of him feeling afraid or confused makes me feel awful. I grew up with my grandmother, and took care of her for a time when she was succumbing to Alzheimer's. I was 14 at the time, and she would have had days where she was terrified, when she didn;t know where she was and wanted to go home, when she would speak only in Gaelic. I can only hope for a dog that it is a less terrifying, painful experience. I spoke with a friend in the bonecancerdogs yahoo group who shared with me that her dog with CCD got to the point where he did not recognize any of the family members.

So, onto a little good news. Carver has shown steady, subtle improvement over the past 5 days. he slept all day saturday, i think partially traumatized by the appointment. we began to put olive oil & some raw pumpkin into his food to help his digestion -he had been constipated since he began the gabapentin a week or soon ago. By sunday his digestion returned to normal. By monday we noticed carver was having an easier time getting up and rolling over. he showed interest in a neighborhood dog who came by to visit. carver even met me at the door when I returned home from work! I worked a double on tuesday, but ryan (who came by to take c out & give him meds-thank goodness for ryan!) & e both reported that he was doing well. carver even walked to the door of where e was sleeping to let her know he needed to go out in the morning. these all sound like simple things, but they are things carver has not done in a while. it is strange how quietly things change, what becomes normal when you are not looking, or when you do not want to look. if anything, seeing him improve gives me an idea of how bad things had gotten, and gives me a view of what "bad" looks like, for the future, when I will have to access how he is doing, in a big picture kind of way. I have begun to do daily assessments, trying to look objectively at how he is doing day to day, both physically and mentally. I find this process incredibly helpful, a way to check in with myself about him, separate from the moment to moment taking care of his needs.

I think the main thing I took away from the appointment was the fact that the odds are much greater at this point that we will have to make the decision to euthanize carver at one point in the future. I really was still praying pretty hard that it would not come down to this, that he would be able to live out his life and die a natural death. but I am know realizing that we are going to come to a point before that where we can no longer manage his pain, or that he will no longer mentally be with us, and we will have to step in. dr.m admitted that our situation is the hardest, where we most likely will not see him failing in the traditional sense, where he will stop eating, get weak etc-all the signals you would look for to know when "it is time". we will have to rely more on our knowledge of carver, and our ability to judge his pain.

to close this update I really want to emphasis how much I like Dr. Lisa Moses, and to recommend her to anyone in the Boston area. She was great with carver and even better with us. she is knowledgeable and compassionate, and has dedicated herself to relieving animals of pain. here is a link to her practice:

dr. lisa moses @ the mspca

oh, and a very important detail-she told us about the pharmacy at costco. we used their online pharmacy, and reduced carver's monthly medication bill from $250 to $50. you do not have to be a member to use the online pharmacy & shipping is free if you plan ahead and place your order early. this has been a huge relief. thank goodness for costco!

carver's new med regime

tramadol, 50 mg, 2 tablets, 3x daily
deramaxx 75 mg, 1x daily
gabapentin, 300 mg, 2x daily
Amitriptyline, 10mg, 1.5 tablets, 1x daily
melatonin, 3mg, 1x daily, to help sleep