Daniel found his dog Shadow at a rescue centre 11 years ago. Shadow and Daniel have had a great life together – spending much of their time travelling across the country together – by car train and plane.
At the age of 13, Shadow developed a urinary problem and the vet diagnosed a bladder tumour using ultra sound. The cancer specialist oncologist that Daniel found suggested finding out if the cancer was malignant by an operation which would visualize and biopsy the lump. Daniel’s own vet urged caution as a general anaesthetic has a high risk.
“[even without the investigation]…the doctors were still pretty certain that this was bladder cancer, known as transitional cell carcinoma (TCC). On average, dogs live only six months following this diagnosis.”
” My wife and I…felt utterly helpless. We didn’t know if he was in pain, and if so, how much more he was facing, either from the treatment or from the disease. His care was entirely in our hands.”
Daniel is logical and rational by profession and he recognised any decision can’t just be emotionally based.
” You can think critically even when the decision is emotional. Even when it’s your dog.”
“This is a typical medical scenario for people or pets: two doctors, two different opinions, many questions. What are the risks of surgery? What are the risks of the biopsy? How long is Shadow likely to live if we give him the operation and how long is he likely to live if we don’t?”
Daniel recognised that pathology (the reading of biopsy samples – amongst other things) is not a precise science. Like most of medicine, there can be different opinions and even mistakes made. There can be no certainties.
“Patients and pet owners almost never ask about the risk of biopsy. For humans, these statistics are well known, but they are less well tracked in veterinary medicine”
Daniel’s own Vet suggested an alternative to the Oncologist’s approach would be to do a FNA – which uses a small needle through the body wall. His vet suggested the risks of this procedure as 5% chance of infection and 10% chance of the needle spreading the tumour into other tissues. There is also a small risk of scarring making follow up surgery less successful.
Daniel now had 6 options:
This is the finding out what it is stage. But Daniel, being careful and thoughtful, then asked,
“Once we have found out what it is, what are the next steps?”
Too often, patients focus on the immediate, upcoming procedure without regard for what the next steps might be.
His vet told him they could only talk in generalities as they don’t know until they confirm the diagnosis – but the chances were that as most bladder tumours ultimately block the tubes into or out of the bladder, then Shadow would suffer acute kidney failure at some point. So not very useful for Daniel’s decision making.
Daniel went back to his 6 options. He knew he had to use rational decision making or otherwise the huge amount of information would just make him freeze. He ruled out putting Shadow to sleep and doing nothing (Numbers 5 and 6).
Number 4) – The oncologist, being a specialist, was pushing for major surgery which is the gold-standard for such cases. There was a 20 percent chance that the surgery would end badly, killing Shadow right away. So Daniel ruled out the major surgery because they weren’t even sure yet if the mass was malignant yet.
The Vet profession doesn’t keep statistics for risks and survival times for most procedures, so Daniel was unable to use these to help his decision between the final 3 options: Numbers 1, 2 and 3.
Daniel recognised that many owners put their dog to sleep early on in the process of their bladder disease based on concerns about their dog’s and their own quality of life. (Incontinence, extreme pain, blood, etc are all developments of the cancer).
He discovered that even with treatment, the chances were Shadows life would last:-
“three months if we do nothing, three months if we give him chemo, three months if we give him surgery.”
Sounds like nothing helps, but in fact these results are skewed because many owners were typically ending their dogs’ lives before the cancer did, and this makes the statistics unreliable.
Daniel went to Dr Google and he found out that there was a 30 percent chance Shadow could improve simply by taking a drug called Piroxicam. This is an anti-inflammatory drug. It can have significant side effects if not used properly. Daniel’s vet agreed to try it.
“From the Purdue University website we were able to obtain the following survival statistics: Median survival with major surgery = 109 days. Median survival with chemotherapy = 130 days. Median survival with Piroxicam = 195 days”
“The range of survival times in all of these studies, however, varied tremendously from dog to dog. Some dogs died after only a few days, while others lived more than two years”.
Daniel recognised that Shadow was not a statistic, and that although 195 days sounds better than 130, Shadow could get very ill at any time.
Daniel and his wife decided to go with Pirixicam and also to have the cystoscopy (a camera examination of the inside of the bladder – Number 3) on his original list.
Two weeks later, Shadow had the procedure and they found the cancer was inoperable. The oncologist was not able to collect a biopsy either. So Daniel still didn’t know if it was malignant or not!
He decided to continue with Piroxicam and he hoped Shadow was one of the 30% who improved on it.
“We wouldn’t have to subject him to the discomforts of surgery or chemo, and we could just enjoy our time together at home.”
“There are many instances, with both pets and humans, that a treatment doesn’t statistically improve your life expectancy. Taking a statin if you are not in a high-risk group or surgically removing the prostate for cancer if you do not have malignant prostate cancer are both treatments with negligible impact on life expectancy. It sounds counterintuitive, but it’s true: Not all treatments actually help.”
Daniel assembled all his information and opinion
“It’s clear that Shadow would be better off without the surgery (so that we could avoid the 20 percent chance it would kill him) and the chemo wouldn’t buy him any time [either], statistically.”
Shadow luckily did well on the Piroxicam. He looked and behaved a lot better within a few days.
And then, after 4-5 months, his kidneys began to fail. He had lots of tests and had treatments for kidney failure. None of the vets or specialists seemed to know what was happening to Shadow.
[It seems to me that here Daniel lost his rationality somewhat. It seems that he forgot (or ignored) the bladder cancer, and assumed the kidney failure was an unrelated disease – where as in fact it had been mentioned back when the cancer was first diagnosed. Also Piroxicam can cause kidney failure, but Daniel seemed to ignore this information too. Not sure why – perhaps he is more emotional than he gives himself credit for and just wanted to increase the number of days Shadow lived at whatever cost.]
Poor old Shadow stopped eating and he was hospitalized away from home with IV fluids and pain-relief for a week or so.
Daniel was pleased that Shadow had done so well and managed to avoid hospitals and hospitalisation for most of his illness. Daniel and his wife decided to put Shadow to sleep.
“He was in pain, and we felt that we had perhaps waited one or two days too long.
“It was awful to see that large personality suddenly drift away and disappear.
“We found comfort knowing that we had considered every stage of his care and that he had as good a life as we were able to give him for as long as possible.
“Perhaps the most difficult emotion that people experience after a disease ends a life is regret over the choices made. We were able to say good-bye to Shadow with no regrets over our decisions. We let our critical thinking guide us.”
I have built this article from Daniels’ very readable book on Logic and Critical Thinking. Rather shamelessly I have cut large portions from his book because they are so good. It is because I am currently attending a course in Nottingham on Philosophy, Thinking and Truth, that I came across this revealing case study the other day. These are the questions and quandaries I hear every day as I visit homes in my role as Quietus Vet – Caring Pet Euthanasia. I know some people going through a similar process with their pets will benefit from knowing that you can be logical, rational and emotional at the same time. In fact we can use our emotions to force us to be rational and logical. At the end of the day, we love our pets and want what is best for them. Blaming our emotions for not fulfilling that promise will only come back to bite us afterwards.
Thank you WEA (East Midlands) and thanks to Daniel and his obviously much-loved dog Shadow.
Daniel J. Levitin. Weaponized Lies: How to Think Critically in the Post-Truth Era 2016 Penguin Publishing Group. Kindle Edition.