An ending

[simrob]

Kallisti, Chris's dear cat and mine as well by way of marriage and adoption, died at 2:15am on Monday morning.

Background

In late September of 2017, it was clear something was up with 11-year-old Kallisti, as she was seemingly healthy but, on about a daily basis, giving a yowl and throwing up bile (almost never food) exactly twice.

Her regular vet recommended a GI biopsy and kidney stone removal. The day after her kidney stone removal when we brought her home she was miserable, weak, in an inflatable collar that made her uncomfortable, constantly needing to pee, and in apparent pain. It was probably one of the two worst days of her life.

On November 27, 2017, we learned that the GI biopsy had unexpected results. In addition to small-cell lymphoma in her intestines (which I think the vet would have been unsurprised to find given her symptoms), she had a much more aggressive large-cell lymphoma in her stomach.

Given that she was in very good health - most cats don't show weakness and so are very sick when they get diagnosed with this kind of aggressive cancer - we opted for a fairly aggressive treatment (the CHOP protocol). This involved weekly or every-other-weekly appointments over a period of 6 months, and basically would have not been possible if I had a full time job or if I didn't have an effectively part-time job that more or less approximately paid for Kallisti's treatment. She was a happy and healthy cat throughout this entire six-month period, though she gradually lost weight from about 11 pounds to about 7.5, stopped wanting treats of any kind, and became progressively less excited about food.

On June 12, Kallisti "graduated" from the CHOP protocol, but it was evident both because of her symptoms and because of an ultrasound that she had not gone into full remission, which is the goal of the CHOP protocol. It's likely that she was in partial remission for part of the time the treatment was going on, on account of her still being alive more than six months after diagnosis. On the other hand, we caught the cancer very early, so maybe it did nothing. There's very little way to tell.

Kallisti then went on a "rescue protocol," which was a similar process but oral-only, which was easier for her (and the oncology nurses...). The drug was known to reduce white blood cell counts, so she seemed to only be able to tolerate it once every five weeks, instead of the every-other-week that might have been ideal, cancer-fighting wise. She received the second dose of this drug on July 18, the day before we went to Hawaii for 10 days. Her usual pet sitters weren't comfortable with a cat that was ill enough to quite possibly die during the long pet sitting period, but we were able to find another professional pet-sitting organization that was willing to help.

At this point, the omniscient narrator points out that some time between here and June 30, Kallisti got fleas, which she's never had before to our knowledge. Maybe from the vet, maybe from the pet sitter, maybe from one of her trips outside to the back yard. We have some resentment towards the pet sitter for not picking up on the signs of fleas (particularly flea dirt), and we have some guilt for being in semi-denial about what the problem was when we came home.

We noticed that Kallisti had some bumps and skin issues when we got home, but we chalked it up to us-being-gone stress. She was grooming more than usual, but not outrageously so. On August 6 we decided we should contact a vet. On August 8 I did so, and she had a regular vet appointment scheduled for today, August 14, to see what was up with her skin. She was clearly declining and losing appetite rapidly; with each meal it was harder to find something she would eat, and for many meals she did not touch her food. We assumed this was part of a decline from the cancer. I was hopeful that the next dose of chemotherapy would give her a boost, as the previous ones had, but I was already anticipating that she wouldn't make it 5 more weeks to the subsequent dose.

Omniscient narrator: during this time Kallisti was becoming extremely anemic. Probably in part because her blood was literally being sucked by fleas. Probably in part because her cancer was progressing to the point where she was bleeding into her intestines. Even possibly some of it was because of the chemotherapy itself: while writing this, I realize that tomorrow would have been 4 weeks since her previous chemo, and not 5 as I had thought. Her blood counts were very low 4 weeks after the first round of chemo, and recovered enough for a second round at 5 weeks. I'd thought she was due for treatment tomorrow, but it was in fact much further away. This anemia was the cause of the loss of appetite and other symptoms, including spending most of the day and night inactive in increasingly unusual dark corners of the house.

Sunday

Sunday, August 12 was the other one of the two worst days in Kallisti's life. We finally came to the realization that yes, she definitely had some bugs on her, and Chris convinced me that yes, it was definitely fleas. We bought a flea comb and flea shampoo and got some fleas out with the flea comb. Then we gave her the first bath of her entire life and realized she had a LOT LOT of fleas. We bathed her a second time to make sure we got her infested belly well, and as we were drying her off realized she still had more fleas on her face. We also realized she was having trouble walking, which made me panic that we'd hurt her badly while bathing and grooming her aggressively.

Her snuggles with us after her bath were the last time I am absolutely sure we had our cat Kallisti with us.

We called the animal hospital where she got chemo for advice, and they suggested we bring her in. The hospital discovered how anemic she was - anemic enough that if she hadn't reached the state she was in gradually, she would have gone into shock and died. The very kind doctor said that our options were really a blood transfusion or euthanasia. This was really hard. If her condition was primarily due to fleas sucking her blood, she would have likely recovered significantly (but still had terminal cancer), and if she was anemic largely because of intestinal bleeding, she would have felt better after the blood transfusion, but for at most a day or two. And for the transfusion, she'd spend the night in the hospital, which I really didn't like the idea of. If I had gotten her to the vet last Wednesday or Thursday, she would almost certainly be an alive dying cat today, and we'll never know how dying she would have been at this point if that had happened.

The vet said she was "right on the edge," and wasn't sure she'd make it 24 hours. We knew we wanted to take her home: we'd planned for an in-home euthanasia group when the time came - we'd contacted them before to be ready in case Kallisti declined while we were in Hawaii. At 4:30 Sunday, calling from the vet, they didn't have any appointments for Sunday or Monday. We called their first recommended alternative and she said she could be home at 6. I hung up and panicked: that felt too fast, too soon. Over text she said she couldn't come after 7, and could come before 9am the next morning, "I'm just concerned with her being comfortable overnight." I replied "The doctors said she was not uncomfortable or in pain, just very weak, so I think we're willing to take the risk that she passes overnight."

We also insisted that the ER vets give her a lasts-just-24-hours-and-kills-all-the-fleas-during-that-time pill. Unnecessary as it was, we wanted, as much as possible, for her to not die with fleas. Viscous cat-stealing motherfuckers.

Kallisti was clearly weak and not entirely herself at home, but would eagerly drink the water from a tuna can with bits of tuna in it, her last most favorite food. We set her on a pillow between us and went to bed around 10. Kallisti didn't die on either of the worst two days of her life.

Death

At 2am Monday I think I heard a loud long meow and Chris calling to me. As I came to awareness, Kallisti was seizing, her mouth was relaxed slightly and her eyes were wide open. There was enough time for Chris to say something like "this is bad" and for me try to reply with something reassuring. I described what was happening as a death rattle, but it was actually almost certainly agonal respiration as she entered cardiac arrest and her brain stopped receiving oxygen.

She relaxed, I tried to close her eyes but they were clearly not closing, and then she meowed loudly again, seized with wide eyes and gasped, and then went limp. She was gone. We looked at a paper the next day on the ethics around agonal respiration in humans, because of course we did [link, the interesting bit is "Agonal Respiration and Suffering"]. Agonal respiration is physiologically interesting: it's kind of like the drowning response in that it is a basically involuntary response, and it won't actually save your life. (This seems important to the ethics of stopping the gasping response in humans, especially when it goes on for an extended period of time. It was only about a 60 second process for Kallisti.) Also similar is that if you want to resuscitate a mammal, this response is a good sign: it means the brain is still able to do involuntary core-brain things. If you're not intending to resuscitate, though, it's awful. "Many parents report that watching their children gasp at the end of life is among the worst experiences of their children's illness," says the article. Chris is among those (cat-)parents.

The article we read I think gives both of us a clear-eyed picture of what may have been going on. Kallisti was, according to the preponderance of evidence, not conscious while she was seizing. Even when humans have experienced this and been brought back to life, they haven't remembered it, so it's even more likely that any consciousness was "sealed off" in the way anesthesia seals off the pain of a root canal in an apparently conscious human, a socially acceptable horror, though one I've personally always found really disturbing. However, if we're going to posit that there was any meaningful consciousness, she would have had the opportunity to perceive hands holding her. In that way I feel squicked about trying to close her eyes, as that was a sign of "giving up" a minute early, almost a tiny form of being buried alive. But then again, closing the eyes of the dead is a culturally imbued gesture that a cat wouldn't interpret that way, and at this point we have hypothetical on hypothetical.

I feel like having a doctor come to euthanize Kallisti at 7pm Sunday night would have felt rushed. Because the doctor planned to come in the morning, we were able to do things like sit with Kallisti in the yard, and I could do some laundry and go get dinner (we hadn't eaten since breakfast) that I wouldn't have felt good about doing between 5 and 7 if I'd been focused on it being the last two hours we had our cat.

On top of this, I feel like that death is, well, it's no fun. And we all have bodies - here in 2018 at least - and those bodies die and part of that is weird and strange and horrible, but it's also part of being creatures that live in bodies. It's natural, and so is smallpox and so is being rendered blind because of nearsightendness and we fixed those things and the natural shouldn't be worshiped or elevated too much, but it also is real and present. I've always been troubled by how different our ethics are around pet death and human death, and how quick we are to euthanize and accept euthanasia for sick pets. Fundamentally, Kallisti's death was not so different from how I'd imagine a good death for myself to be, and I don't think she was in great distress, and the combination of those things brings me comfort.

If she'd made it until the morning, I certainly think that would have been better, especially given how awful it was for Chris that she watched Kallisti die in seizure without sedation. But if she hadn't died in the night, I don't think she would have suffered unnecessarily waiting for the doctor at 9am, and on balance I think she suffered less in her passing than in having a weird new doctor poking at her before she was sedated to die in apparent peace. I wouldn't have wanted to wait a minute longer than her scheduled euthanasia. But, we've noticed that it's a common refrain in people's stories that pet owners feel like they euthanized too late. I think it's important to say that I really don't feel that way, and Chris really does, and it's about the same situation.

Another thing I am glad about is that the in-home euthanasia person would have taken Kallisti's body for cremation right away, just because that's by default a thing they offer to do. Instead, we got to spend the morning with her, and that was really special to me, and not something I had any idea I wanted. (Maybe this part was also way too distressing for Chris, I'm not sure.) In any case, I wish I'd know ahead of time that I wanted to keep Kallisti's body and take it to the vet for cremation myself, rather than having the in-home euthanasia person take care of it herself.

The body

After we were confident Kallisti had passed, we put her limp body in her cat bed, so that she was in the room with us but not the bed with us. I got a Laboradorite stone that Chris had bought in Asheville and put it in her paws to absorb the last warmth of her body. (I have never been a, uh, "crystal woo" person, but it felt like good symbolism and felt right. And I may end up a crystal woo person, there are worse fates.)

In the morning, Chris and I were able to go on a long walk out of the house to get breakfast, buy some candles, and have some rituals of saying goodbye that drew from both of our religious traditions and experiences, as well as our shared religious experience as members of the Unitarian Universalist congregation in Raleigh. This was really, really hard and tearful, and it was probably harder to have Kallisti's body there with us, but I think it was also more healing to have Kallisti there.

In the early afternoon, I drove Kallisti's body to her vet, having called ahead to hand her off for cremation. We'll get an urn and a little paw print in about a week.

Based on this experience, I would strongly suggest to anyone that can afford it to go with in-home euthanasia, but to then make separate arrangements for the body. Part of this experience is definitely influenced by the fact that I've been watching Caitlin Doughty's videos for years and years, something that I feel is... maybe a little bit out of character for definitively not-goth me? But the encouragement to give respect to a body in the home is definitely a possibility that I've picked up from Doughty.