The Gift of Time
When we first received JJ’s lymphoma diagnosis, the realist in me knew she probably only had a few months to live, even with the chemotherapy. However, we were graced with not just four, or even six months, but a full year before the cancer reared its ugly head to the point of saying “enough”. I often tell the family members of our dying hospice patients how a brief window of lucid time can be such a gift.
I knew from the moment of her diagnosis I would be facing the biggest challenge in my hospice career. There were many people to prepare along the way. I made a commitment to be honest and open along the way about all JJ would be going through. I had spent much of my time talking about death and dying over the years using her as a conduit for difficult topics and conversations. Even when close to home, I knew there would be many opportunities for both teaching and supporting through sharing JJ’s illness.
One of the secrets of being a long-time hospice nurse is the ability to maintain strict boundaries. After twenty-four years, I knew I could share publicly while doing my own anticipatory grieving privately. I became excellent at scanning through comments and messages, taking in the sentiment, while not taking on the burden of others’ angst. It’s not much different than being able to be a caring, compassionate, and empathetic nurse, while not taking on the emotional baggage of someone else along the way. It was a skill set that came in very handy over the course of the year.
JJ had a good response immediately to the chemotherapy. I knew there was time shortly after treatment started and as each month progressed, to gently touch on what was happening without throwing the reality of JJ’s life limiting illness like a pot of boiling water in someone’s face. We knew we were buying time and that canine lymphoma is not curable in the sense some cancers are. I was upfront about this, but in the manner I would be with a hospice patient who has some time left. The conversations evolve over time from “What has your doctor told you?” to “What would you like to know? I’ll answer any question you will have along the way to the best of my ability” to “Tell me your stories”, eventually arriving to “What are you most concerned about now, as you are getting close to death? What can I help with as your nurse?” During this time, I shared articles regarding end of life regarding our pets, including quality of life assessment tools. It wasn’t just to be helpful in the bigger sense of people needing this information for their own pets, but also was a way to gently nudge people in the direction I knew we were going with JJ.
When JJ was doing well, it was easy to keep the focus on day to day activities, while reminding people to enjoy the moment and live in the spirit of Barke Diem. I was transparent throughout, and it was when she was having an off day that her cancer diagnosis was foremost in my mind. These days always had me thinking “What if this is the progression of the cancer?” While I didn’t post these thoughts out loud, I would reply to questions about it with “Time will tell, and we take it day by day.” No one has a crystal ball in human or veterinary medicine, and people often dread not knowing. I personally am not in that category, so it was easier for me to take most days in stride, waiting to see what the next day would bring. My mom and I often would say, “It is what is” when she was diagnosed with ALS, and I have said it countless times since then. This saying would run through my head, keeping me centered, when so many expressed how unfair it was to have such a loving dog diagnosed with cancer. It was usually during the off days when I got the most comments of either treatment options I should be doing, because “XYZ” cured Spot the Dog of a random cancer, or “How dare I put that dog through torture? Euthanize now.” Those were the times I did light skimming and relied on others to keep the outrageous in check.
One of JJ’s greatest joys in life was being a nanny to puppies born here. Since she was four months old, she was fascinated with them, and quickly decided that each puppy belonged to her. It didn’t occur nearly as often as she would like, and she vibrated with joy when the magical puppy basket started filling up. She assisted with clean-up duty and was their playmate as they grew older, but she drew the line when any of them dared to assume she was the milk bar. It’s strange how timing works out. Before we ever knew about the cancer, I decided at some point I would need an understudy to carry on the work when JJ was no longer here. I had kept one of her nieces, Bria, for this purpose. When Bria was only ten weeks old, JJ was diagnosed with her lymphoma and everything changed. I chose to focus on JJ, not knowing how much time we would have together. Luckily, Bria loved the retrieving game and she quickly became my husband’s dog, joining many others in field training. JJ got to spend time with “her” puppy, wrestling and playing, while I didn’t have the added stress of trying to focus on puppy training. It was a win-win for both of us.
As the year progressed, I knew eventually I would need to consider finding a new potential partner. We are in a unique position of sharing our lives with a lot of dogs, and we had planned on having a Golden litter at the end of the year. JJ’s niece Shylah was pregnant, and I had decided to keep one of the puppies. It was something to look forward to, and it was easy to become hopeful that JJ would be able to do some training and mentoring of her great-niece for a while. At our Hospice House, when family visits with multi-generations, it reminds everyone of the Circle of Life. It was the same sentiment having a new group of puppies while knowing at some point JJ’s disease would progress.
With canine lymphoma, very often one of the first things owners notice is an enlarged lymph node. When JJ’s nanny Callie was diagnosed seven years earlier, she had a huge lump on her neck from one of the lymph nodes in that region. Since JJ’s original diagnosis came from noting a very high calcium level on her bloodwork, her lymph nodes remained on the small side throughout her treatment. Eleven months into JJ’s original diagnosis, I experienced a Deja-vu moment when I could suddenly palpate a large node in her neck. At the time, she was otherwise asymptomatic, so the oncology team said they would recheck her during her normal every three week visit. As we got close to that appointment, several of us at work again noticed a slight change in her breathing. I was not at all surprised on December 19, 2017 to find out her lymphoma was no longer responding to treatment and she again had a recurrence of the fluid in the lining of her lungs. The malignant pleural effusion had returned, although not to the level it had in July. While there were more desperate, hail-Mary options to be had, it was time to stop and enjoy the days we had left. The decision was easy on my part, as I knew eventually we would reach this point.
Very often in oncology, whether human or animal, when a cancer no longer responds to the treatments that are available, it is worded in the terms “There is nothing more we can do.” This is unfortunate, because there is a way to re-frame how to look at the end of life, whether for a loved one or a beloved pet. Since none of us get out of dying, if treatment options are no longer working, there is so much that can be done while facing death. We went home and made the most of each day. For JJ, this came in the form of mooching, pretending to retrieve, hunting her hay bales every day and drinking in the wonderful aromas, snuggling with her therapy person, and joy of all joys, spending time with the glorious creatures that filled the magical puppy basket just eight days earlier.
JJ was feeling good enough that she continued to accompany on my work days to the Hospice House. As always, she could sleep, play, and visit to her heart’s content at what had become her second home over the years. We worked on Christmas Eve, but as the morning progressed, she just seemed tired and was going through too much effort with the simple things. I called my husband and asked him to take her home, knowing her work as an extraordinary hospice dog was ending. When the Hospice House opened, JJ taught herself to walk next to the gurney of our deceased patients on the way to the funeral van. Her presence during these walk outs often made us all a bit more emotional. As she often made these unique at our Hospice House over the years, JJ had a walk out like no other. She got to walk herself out the front door with the toy of her choice, Lambchop. It was a poignant moment for all of us that day, knowing how our work would be so different without JJ helping to comfort everyone.
JJ always had special relationships with different people who got to see her over the years. I remember taking Callie into our hospice office for those who wanted to say their goodbyes. When I looked back, I was struck by Callie’s ability to comfort those saying goodbye to her. In the same vein, it was important for those who wanted to be able to say goodbye to JJ. She was spending more time sleeping, but still enjoyed playing outside and snuggling. Three days after Christmas Eve, I was back at work. At lunch time for two consecutive days, my husband brought JJ for short visits. While these goodbyes were hard, JJ channeled her nanny Callie and found a way to comfort and make everyone laugh through their tears.
JJ spent her remaining days gopher hunting and snuggling with puppies. It was obvious she didn't have the energy she once did, but she was able to spend time doing what she loved. I often tell my hospice families that when a cancer patient finally declines, it can be like cliff diving, as it goes so fast. It is the same with our pets. I am fortunate to have been a hospice nurse for four score and twenty years (some days it feels like that), because it is in our bones to be constantly assessing for the subtle signs that things are changing and to be prepared. I shared these goodbyes as a way to prepare people, although most were surprised by how quickly she declined.
It was obvious she was changing daily, and I had made an appointment a few days for euthanasia if she continued at the rate she was declining. If anything, people often have regrets for making their pets live longer than they should because it was too difficult to make the call. I continued to keep a very close eye on her, but she primarily just slept a lot, like so many of our hospice patients do as they are slowing down. We spent the evenings in the whelping box with the puppies, including the same night of her final Hospice House goodbyes. In the middle of the night, my nurse ears were wakened to the sound of JJ having some breathing difficulties. It was bad enough that I gave her a medication we often use for our patients when they have these symptoms, something I had left over from my own surgery months earlier. It was 3 am, and we had the choice to go to the emergency clinic if needed. I stayed next to her and was relieved to have her settle comfortably once her medication took effect.
There was no question about the phone call I made a few hours later. It was time. I was supposed to work, but I had been put on call, knowing this quick decline might happen. I am fortunate to have colleagues who understand, and they quickly found coverage for me. While it is never an easy part of veterinary medicine, euthanasia is essential in the health continuum for our pets. We were extremely thankful for the care of all the staff at our vet clinic, who knew JJ so very well. There were several people in the room as she took her last breath. Later in the day, I received a text with the photo of JJ’s mosaic at work in our chapel, with a candle lit in her honor. One of the traditions at the Hospice House is to light a candle for 24 hours in remembrance of those who have died and now it was JJ’s turn. I was so touched by this unexpected gesture.
For me, the last week of JJ’s life was hard, but it was also easy because of my experience. Along the way, JJ got to do the things she enjoyed. What more could anyone ask for? Personally, I would love this ending for myself, although I might think of something other than sticking my nose in a gopher hole. Indeed, a life well lived to the very end. There will never be another JJ, but oh, what a legacy she has left.