TANYA'S

COMPREHENSIVE GUIDE TO

FELINE CHRONIC KIDNEY DISEASE

 

 

THE FINAL HOURS

 

"Oh! I have slipped the surly bonds of earth and danced the skies on laughter-silvered wings..."

John Gillespie Magee

 

ON THIS PAGE:


Signs That the End Might Be Near


Accepting the Inevitable


Euthanasia or a

Natural Death


Resting Places


If you need help as you grieve, join

Tanya's Feline Loss Group

 

HOME


Site Overview


What You Need to Know First


Alphabetical Index


Glossary


Research Participation Opportunities


Search This Site


 

WHAT IS CKD?


What Happens in CKD


Causes of CKD


How Bad is It?


Is There Any Hope?


Acute Kidney Injury


 

KEY ISSUES


Nausea, Vomiting, Appetite Loss and Excess Stomach Acid


Maintaining Hydration


The Importance of Phosphorus Control


All About Hypertension


All About Anaemia


All About Constipation


Potassium Imbalances


Metabolic Acidosis


Kidney Stones


 

SUPPORT


Coping with CKD


Tanya's Support Group


Success Stories


 

SYMPTOMS


Alphabetical List of Symptoms and Treatments


Fluid and Urinary  Imbalances (Dehydration, Overhydration and Urinary Issues)


Waste Product Regulation Imbalances (Vomiting, Appetite Loss, Excess Stomach Acid, Gastro-intestinal Problems, Mouth Ulcers Etc.)


Phosphorus and Calcium Imbalances


Miscellaneous Symptoms (Pain, Hiding Etc.)


 

DIAGNOSIS: WHAT DO ALL THE TEST RESULTS MEAN?


Blood Chemistry: Kidney Function, Potassium, Other Tests (ALT, Amylase, (Cholesterol, Etc.)


Calcium, Phosphorus, Parathyroid Hormone (PTH) and Secondary Hyperparathyroidism


Complete Blood Count (CBC): Red and White Blood Cells: Anaemia and Infection


Urinalysis (Urine Tests)


Other Tests: Ultrasound, Biopsy, X-rays etc.


Renomegaly (Enlarged Kidneys)


Which Tests to Have and Frequency of Testing


Factors that Affect Test Results


Normal Ranges


International and US Measuring Systems


 

TREATMENTS


Which Treatments are Essential


Fluid and Urinary Issues (Fluid Retention, Infections, Incontinence, Proteinuria)


Waste Product Regulation (Mouth Ulcers, GI Bleeding, Antioxidants, Adsorbents, Azodyl, Astro's CRF Oil)


Phosphorus, Calcium and Secondary Hyperparathyroidism (Calcitriol)


Miscellaneous Treatments: Stem Cell Transplants, ACE Inhibitors - Fortekor, Steroids, Kidney Transplants)


Antibiotics and Painkillers


Holistic Treatments (Including Slippery Elm Bark)


ESAs (Aranesp, Epogen etc.) for Severe Anaemia


General Health Issues in a CKD Cat: Fleas, Arthritis, Dementia, Vaccinations


Tips on Medicating Your Cat


Obtaining Supplies Cheaply in the UK, USA and Canada


Working with Your Vet and Recordkeeping


 

DIET & NUTRITION


Nutritional Requirements of CKD Cats


The B Vitamins (Including Methylcobalamin)


What to Feed (and What to Avoid)


Persuading Your Cat to Eat


Food Data Tables


USA Canned Food Data


USA Dry Food Data


USA Cat Food Manufacturers


UK Canned Food Data


UK Dry Food Data


UK Cat Food Manufacturers


2007 Food Recall USA


 

FLUID THERAPY


Intravenous Fluids


Subcutaneous Fluids


Tips on Giving Subcutaneous Fluids


How to Give Subcutaneous Fluids with a Giving Set


How to Give Subcutaneous Fluids with a Syringe


Subcutaneous Fluids - Winning Your Vet's Support


Dialysis


 

RELATED DISEASES


Heart Problems


Hyperthyroidism


Diabetes


Polycystic Kidney Disease (PKD)


Pancreatitis


Dental Problems


Anaesthesia


 

OBTAINING SUPPLIES CHEAPLY


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Canada


 

SAYING GOODBYE


The Final Hours


Other People's Losses


Coping with Your Loss


 

MISCELLANEOUS


Early Detection


Prevention


Research


Canine Kidney Disease


Other Illnesses (Cancer, Liver) and Behavioural Problems


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SITEOWNER (HELEN)


My Three CKD Cats: Tanya, Thomas and Ollie


My Multi Ailment Cat, Harpsie


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Home > Saying Goodbye > The Final Hours

 


Overview


  • We all want to give our cats every chance of life; yet at the same time we do not want them to suffer, particularly if the end is near and inevitable.

  • Unfortunately, it can be very hard to know when a CKD cat is really reaching his or her final hours. With CKD, many cats can be literally at death's door, or to use the analogy from the first page of this site, at the edge of the precipice; yet with treatment they may be pulled back to safety and go on to enjoy many more days, weeks, months or years of happy quality life. 

  • This page discusses the signs you may see towards the end, the factors to consider when deciding whether to euthanise and what to expect if you do choose euthanasia.


End Stage Renal Disease (ESRD)                                                                           Back to Page Index


 

Eventually, since CKD is terminal, your cat is going to move into End Stage Renal Disease (ESRD), which ultimately leads to death. However, even in ESRD, death may not be imminent; as discussed on the How Bad Is It? page, there is no precise definition of what ESRD is, and many cats can manage to live relatively long and happy lives even with high bloodwork values and very little kidney function remaining - see Success Stories for some examples. 

 

Nevertheless, once people learn their cat is in ESRD, they often start to wonder what to expect as their cat's health deteriorates. This is perfectly understandable, and if you can bear it, it can often help to think about it in advance, before you are faced with this scenario at a time when you cannot think straight, and when you will quite possibly not wish to accept that your cat is dying. This page is an attempt to make this horrible experience a little easier.

 


Signs That the End Might be Near                                                                                       Back to Page Index


 

If your cat really is in the final stages of this disease, you will see more than one of these symptoms, though you will not necessarily see all of them:

 

 

You will notice that many of these symptoms are identical to those seen throughout the course of the disease: this is what makes it hard to tell when your cat is approaching the end of his or her life. The primary differences between the symptoms of treatable CKD and the final hours are the severity of the symptoms and the fact that they no longer seem to respond well or at all to treatment.

 

If you haven't already tried treatment - if your cat has just been diagnosed and is on a IV drip at the vet's, for example - you should definitely consider trying the various treatments available for a reasonable length of time before making the irrevocable decision to euthanise your cat. This particularly applies if your cat has high BUN/urea and creatinine, but has only just been diagnosed. In such a case, these values may be reflecting an acute situation such as a kidney infection (commonly undetectable) or severe dehydration. In many cases the values will reduce dramatically with treatment. I therefore usually recommend treating a newly diagnosed cat for at least two weeks before making any irrevocable decisions. Please check the Index of Symptoms and Treatments page to find more information on possible treatable causes of the various symptoms.

 

With those very important provisos, here are the main signs that are commonly seen when a cat is close to dying from CKD. Please, please do not take them as gospel, as incontrovertible evidence that your cat's time has come. This is your cat, you know him or her best, and if you are not sure if the time has come for your cat to cross, and your vet is confident that your cat is not in pain (CKD is not normally painful), then it is better to wait until you feel more comfortable with your decision. Of course, it may be that you are deluding yourself because you simply cannot face the thought of losing your cat, which is understandable. This is why your vet's opinion can be helpful: ask your vet what he or she would do if this was his or her own cat, and factor this response into your decision, but do not base your decision wholly on your vet's opinion. Generally speaking, little or no harm is done through waiting a day or so before deciding on euthanasia, and you will probably feel more at peace with helping your cat to cross if you have time to say goodbye, and time to come to terms with the fact that this is most probably inevitable.  

 


Possible Signs of the Final Hours                                                                       Back to Page Index


 

Very High Urea (BUN) and Creatinine Levels


These are not in themselves a reason for euthanasia because many cats who are newly diagnosed, or cats who crash, have very high levels but pull through.

 

If your cat was diagnosed some time ago, you may well decide not to put your cat through the stress of additional bloodwork. If your cat has just been diagnosed, I would ask for bloodwork to be run so you can see how things look.

 

If the end is near, it is quite likely that urea will be over 55 (US: 150) and creatinine over 650 (US: 7.0), and - this is a key point - do not fall after treatment. If your cat has just been diagnosed, high levels such as this are by no means unusual and may not fall immediately.

 

Generally speaking, urea and creatinine will continue to rise inexorably in ESRD. If your cat suddenly experiences a hike in blood values, as opposed to a gradual worsening, it may mean an infection of some kind is present, and it would be worth trying treatment to see if this helps. Similarly, a sudden increase or an increase for no apparent reason may be a sign of high blood pressure, in which case you might wish to get blood pressure measured and try medication before choosing euthanasia.

 

If your cat has been receiving sub-Qs but bloodwork is worsening, you may wish to consider trying IV for a few days, in case it helps to reduce the values to a level manageable with sub-Qs once again. If you have not yet tried treatments such as IV or sub-Qs at all, as is sometimes the case with cats who are only diagnosed when they crash, you should give your cat a reasonable shot at these treatments. When Thomas was first diagnosed, his numbers were off the scale and he was on IV for four solid days and nights, yet his numbers did not improve; but nevertheless, after treating his anaemia and using sub-Qs for a few weeks, he improved greatly. However, in humans giving IV to a truly end stage person can be risky, because it may cause pulmonary oedema, and the same may apply to cats.

 

Really high levels can cause inflammation of the brain and seizures. Having said that, Thomas did enjoy a few weeks of good quality life (including eating well and going for walks) with values close to or above these numbers, and he is by no means the only CKD cat to do this. Treat the cat, not the numbers.

 

Just to confuse matters, in end stage CKD, creatinine levels may fall (although this is pretty rare). This occurs because creatinine is a by-product of muscle, and towards the end CKD cats may lose a lot of muscle, and therefore cannot produce as much creatinine. University of Georgia College of Veterinary Medicine explains more about changes in creatinine (scroll down to Variations in Creatinine Concentration).

 

High Phosphorus Levels


High levels of phosphorus may accelerate the progression of CKD and may also make the cat feel poorly. It is usually pretty easy to control phosphorus levels, and you should see a difference a week or two after taking steps to do so. Towards the end though, you may find that, despite feeding a low phosphorus food and giving large amounts of phosphorus binder, your cat's phosphorus levels just keep on rising. Your cat will probably become weaker as a result, and may have diarrhoea.

 

Please read up on the importance of phosphorus control here.

 

High Potassium Levels


Although most CKD cats have low levels of potassium, in advanced cases the potassium levels often increase as the kidneys' ability to excrete potassium decreases. If potassium levels become really elevated, the cat can suffer seizures and occasionally even a heart attack. You can read more about potassium here.

 

Reduced Urination (Oliguria) and Inability to Urinate (Anuria)


Most CKD cats urinate profusely. In ESRD, however, the cat may produce less and less urine, and in the worst case may eventually be unable to urinate at all. Although this is relatively uncommon, because apart from anything else most people have their cats euthanised before this stage is reached, both Tanya and Thomas became unable to urinate and this came on very quickly indeed.

 

It is sometimes possible to "kick start" the kidneys with a diuretic such as frusemide (Lasix or Salix), but in both Tanya's and Thomas's cases we felt, based on our vet's advice, that this was pointless. It was this inability to urinate that made us decide for each of them that the time had come for them to cross, since being unable to urinate is extremely uncomfortable, and things were simply not going to get better. 

 

CKD cats are prone to urinary tract infections, which may result in the cat visiting the litter tray and producing little or no urine. So do not assume the end is near simply because you see this symptom, have your cat checked by the vet.

 

Occasionally, an inability to urinate may be caused by a blockage or a kidney stone, so you may wish to ask your vet if this is a possibility in your cat's case. See Kidney Stones for more information.

 

Pet Place has some information about anuria in cats.

 

Incontinence


Just to confuse matters, some ESRD cats develop the opposite problem and become completely incontinent, urinating wherever they are lying. Often these cats do not have the strength to move, and end up lying in their own urine or faeces or both, which can be very distressing to the cat, since cats are usually very fastidious. Do have your vet check to exclude the possibility of a urinary tract or bowel infection, which might respond to treatment. 

 

Very Strong Bad Breath


The distinctive CKD bad breath smell may appear or worsen as your cat gradually deteriorates. We got Thomas's breath under control after he first crashed, but over the last two weeks of his life his breath got worse and worse, despite his sub-Qs and other treatments. This tends to be a sign that the toxin levels are increasing in the cat's body, although occasionally bad breath may be caused by an abscessed tooth or gum disease. 

 

Body Odour


The bad breath smell may seem to emanate from the cat's body; this is because the toxins are no longer being excreted properly, so are building up in the body. 

 

Severe Oral Ulcers


These may develop when a cat first crashes, and can often be brought under control once treatment is commenced. With ESRD, however, very severe ulcers, often covering the entire mouth and even the throat, may develop, often quite suddenly, and be unresponsive to slippery elm bark powder, although sucralfate (Antepsin or Carafate, see Treatments) may bring some relief.

 

Uncontrollable Vomiting


Most CKD cats suffer from vomiting at least occasionally and it can usually be managed. You may find that the vomiting just worsens to the point where you are unable to control it well enough, and the cat's quality of life is severely compromised as a result. In Thomas's case, this came on extremely suddenly, he hardly ever vomited but the day before he died, he suddenly began projectile vomiting, which simply did not respond to treatment. 

 

Loss of Appetite/Refusal to Eat or Drink


If a cat is truly dying, the digestive process will cease to function and the cat will not need food. Perhaps because of this, vets often seem to tell people that if their cat will not eat, it is time to say goodbye.

 

Unfortunately, almost all CKD cats will stop eating or drinking at some point, and it can therefore be very hard to know when this symptom takes on a more sinister meaning. If you haven't tried to treat this symptom, please do so before fearing that the end is near - food is an essential part of the treatment plan, and a cat can improve dramatically after taking in some nourishment. This is particularly true of cats who have been having treatment at the vet's, where they may be stressed and not eat.

 

There are various causes of inappetance in CKD cats, so you need to be sure you've looked into any of these which are present and treated them as appropriate. Cats who don't drink are often dehydrated, so look into correcting that too. Even when imbalances are under control, cats may have got out of the habit of eating, so read the Persuading Your Cat To Eat page for more information on ways to get food into your cat.

 

With Thomas, this was a very dramatic symptom since he ate almost the whole time during his illness, even when his creatinine level was over 7, until the day before he died, when it was simply impossible for him to eat - if we had forced him, he would have vomited it right up. This was because his digestive system was shutting down.

 

However, our Indie had very little appetite for several weeks after a dental, yet she made a full recovery. So it is important not to look at this symptom in isolation. 

 

Inability to Walk and General Weakness


These symptoms are often caused by either low potassium, high phosphorus, anaemia or metabolic acidosis, all of which are treatable in principle; and, more rarely, by a blood clot to the leg, for which the prognosis is less favourable. If you haven't already done so, do try some treatments, but in ESRD, these conditions may simply no longer respond to treatment. 

 

Meatloaf Position


The Symptoms section has a full description of the meatloaf position. Many CKD cats sit in this position when they are crashing, but may recover with treatment, so this symptom alone is not reason to panic. However, if the cat assumes this position despite treatment, or in conjunction with other signs discussed here, it may be cause for concern.  

 

Seizures


These can be caused by very high levels of urea/creatinine, by high levels of potassium, by high blood pressure, by calcium imbalances or by anaemia. If you are able to treat the condition causing the seizures successfully, the seizures may not return. 

 

Blindness


This is usually caused by high blood pressure causing the retinas to detach; in some cases, treating the high blood pressure can mean the retinas successfully re-attach, so try treating it first. Blindness alone is not a reason for euthanasia in my opinion, cats navigate by smell rather than by sight, and are simply not as psychologically affected by blindness as humans are (see Hypertension). Blindness in conjunction with some of the other symptoms described in this section, however, may be grounds for saying goodbye.

 

Dull, Sunken Eyes


Many people take this as a sign from their cat that it is time to let him or her go. This can certainly be a useful sign, particularly if you and your cat have a very close bond, but be careful not to read too much into it, certainly not without trying treatments first - dull, sunken eyes are often a symptom of dehydration.

 

I personally did feel that I could see in Tanya's eyes that she had had enough; but then I saw the same look in Thomas's eyes when he first crashed, and he pulled through, which has left me wondering what more aggressive treatments might have achieved for Tanya. If you get this sign after trying many treatments, it is obviously more reliable than if you have tried none. 

 

Hiding


Many CKD cats prefer to be in a quiet place, such as in a closet or high up on a shelf, so again, this alone is not always a reliable sign that the end is nigh. In conjunction with other signs described here though, this may be significant.

 

Restlessness


Some cats seem to be unable to get comfortable, and keep moving from place to place, never staying in one for long. Tanya exhibited this symptom on her last day.

 

Sudden, Severe Weight and/or Muscle Loss


By his last couple of days, it seemed like Thomas was losing weight and muscle tone virtually by the hour, despite still eating several times a day. We did notice this ourselves of course, but it was really brought home to us by the vet. She had not seen him for a few days, and when I took him in the day before he died because of his sudden terrible vomiting, she was really shocked by how thin he had become. This had happened despite the fact that Thomas always continued to eat fairly well: he simply did not have any reserves left to draw on. By the time Tanya died, she weighed three pounds.  

 

Sudden Weight Gain


Many people are delighted when their CKD cat gains weight, but if this happens quickly it may mean fluid is building up because the cat's body is no longer able to regulate body fluids. In many cases, this can eventually lead to congestive heart failure

 

Difficult to Rouse


The cat may start to spend more and more time sleeping (which tends to be common in older cats anyway) and may sometimes take time to respond and be difficult to rouse; the cat's temperature may be falling as the cat's body shuts down (other possible causes for a low temperature are high calcium, anaemia and heart disease, which may be treatable ). Eventually in some cases - if the end is near - the cat may slip into a coma.

 

Mental Confusion


The cat may become confused and seem not to really "be there". This can be a result of the toxins in the bloodstream, although there may also be an element of senility involved.

 

Twitching


This may be caused by the toxins in the body or by high potassium levels. Thomas began to twitch on his last day. Of course, you should first try to treat any possible causes of twitching as outlined in the Index of Symptoms and Treatments.

 

Congestive Heart Failure (CHF)


Heart problems are relatively common in CKD cats, as discussed on the Heart Disease page. These can often be managed with medication, but the treatment for the heart condition tends to put additional strain on the kidneys, and vice versa. In the worst case, the cat may develop congestive heart failure (CHF), whereby fluids in the cat's body leak out of veins and build up in the lungs (pulmonary oedema), around the lungs (pleural effusion) or in the abdomen (ascites).

 

It is possible to remove this fluid, either through the use of diuretics or physically ("tapping"), but once congestive heart failure has developed, the outlook is relatively poor. Although some people have managed to keep a cat with congestive heart failure going for several months, this is unusual, and for most cats the prognosis is usually only a few weeks. It partly depends on how often the cat needs to have the fluid tapped: obviously a need for tapping every two days is wholly different to a need for tapping every two weeks or once every month. A cat in CHF is usually not able to absorb sub-Q fluids well, if at all, which means the kidney values tend to worsen; it is basically a vicious circle. In severe CHF, if the fluids are not drained off, the cat effectively drowns from the fluid in the lungs, so it is important to keep a close eye on the cat in case of distress.

 

Low Blood Pressure


Blood pressure tends to fall as death approaches, though you will probably not be able to tell that this is happening.

 

Anaemia


Anaemia in CKD cats is usually non-regenerative anaemia caused by the  fact that the kidneys are failing, and generally speaking it does not kick in until the CKD is relatively advanced. Mild anaemia is unlikely to cause major problems, and even with severe anaemia you may be able to treat it very successfully with rhEpo (Europe: Eprex; USA: Epogen or Procrit), or blood transfusions to give you a breathing space; but in some cases treatment may be started too late for it to help.

 

In general, however, unless your cat is already in an advanced stage of renal failure at diagnosis (when there may not be sufficient time to start treatment before it becomes critical), or develops problems with rhEpo or blood transfusions, there is no reason why a CKD cat should die of CKD-related anaemia - but it is critical to keep an eye on PCV and treat anaemia pro-actively if it appears. There is more information on anaemia on the Anaemia page.

 

Sudden Improvement Before a Crash


Some people have experienced this phenomenon, myself included. Tanya kept herself to herself the last couple of weeks, hardly ate anything and generally looked very delicate. The night before she died, she suddenly appeared in the kitchen and ate a massive bowl of her favourite food of her own accord, having refused to eat without a lot of encouragement for weeks, and even then she had only nibbled. She then proceeded to spend the evening with us for the first time in weeks.

 

Of course, when she crashed the next day, this made it all the harder to accept because she had been doing so well only the day before; but my vet reassured us that this does sometimes happen. At any rate, once we were over the shock, we were at least left with a nice memory of Tanya's final evening with the family. 

 

Running Away


It is natural for cats to hide when they do not feel well: it is a way to protect themselves from predators. Some cats near the end may take this a step further, and may actually run away from home and hide if they are allowed outdoors. Even an indoor cat who normally never has any interest in going outside may take the opportunity to escape if one presents itself. Again, this is instinct, the cat is trying to find a place away from predators, but unfortunately it may also mean that his or her humans cannot find him/her, and that the cat dies a lonely and perhaps uncomfortable death. For the cat who does survive and return home, the lack of food and fluids during the absence can make an already sick cat even sicker.

 

We experienced this with Thomas: he normally went out alone, but on his last morning we took him out on a lead to give him a last chance to smell his garden. He tried to run away, and would have succeeded if he hadn't been on the lead.

 

Since it is terribly distressing not knowing what has happened to your beloved cat, I recommend not allowing your cat out alone if you suspect the end is near. By all means take him/her outside on a lead, but please do not make the mistake of thinking your cat is too weak to move, you could get a very nasty surprise.

 


Accepting the Inevitable                                                                                        Back to Page Index


 

Even if every single one of the symptoms described above were present, you still might not feel ready to let your cat go. That is perfectly understandable: it is one of the hardest decisions you will ever have to make. Plus, if you have been devoting much of your time to helping your cat, it can be very hard to accept that you can no longer do anything to help him or her - the feeling of helplessness is an awful one, so we cling to the hope that we just need to find the one magic treatment that might help. But the day is going to come when there is nothing left to try.

 

When Tanya was ill, I felt that I would never be able to bear having her put to sleep. The only way I was able to do it when the time came was when I finally accepted that neither Tanya nor Thomas was ever going to get any better than they were at that moment; that we had tried everything in our arsenal but our weapons were no longer working; and that waiting any longer would therefore ultimately be for my sake, not for theirs. How much more could I ask of them? Ultimately you cannot avoid death; but often it is possible to avoid suffering. Once I began to look at it from the perspective of what was right for them and what would spare them pain, it was still by no means an easy decision, but I did at least feel it was inevitable, because I simply could not stand by and watch them suffer when it was within my power to prevent that. By not acting, I would not be prolonging their lives, I would be prolonging their deaths. Ask yourself, how much more can I ask of him or her?

 

A friend sent me a quotation shortly after Thomas died. It said that a good death was not about when or how; it was about knowing love. This comforted me greatly, because, for all my mistakes, my cats did know love.

 

When Is It Time?


If you do decide to euthanise, the decision as to timing is often no easier. Some well-meaning people may tell you that that your cat will let you know when it is time to leave, that you will look in his/her eyes and "just know".

 

Although it is comforting to think that your cat may effectively take the decision out of your hands in this way, you have to accept that it is just as likely that this will not happen. It might possibly be easier with a CKD cat to look in his or her eyes and "know" that it is time, in that you are probably giving your cat so much care and attention that you will know when something is wrong; but that doesn't translate as always knowing when it is time. I looked into Tanya's eyes and felt it was time; but then later on I saw that exact same look in Thomas's eyes - and he pulled through. So I know from personal experience that "looking into your cat's eyes" is an unreliable indicator. I have also heard from people who have been told they will "just know" and who are so worried about looking into their cat's eyes for "the signs", that they neglect to enjoy their time with their cat. So by all means, hope for a sign; but do not count on receiving one.  

 

At the same time, always remember that nobody knows your cat like you do: if you feel pressurised into making the irrevocable decision, perhaps by your vet or family, this may distress you afterwards; so again, try to decide in advance what are the criteria you personally would use for making the decision.

 

I have heard from many people over the years, and the consensus seems to be that they would prefer to have acted a day too soon rather than to have left it a moment too late.

 

Talk to your cat. Your cat is an adult, and should be treated as such. Cats do not fear death as we do, they live in the moment. On the day before Ollie died, he was not eating much and seemed a little restless. In the afternoon he sat on a chair opposite me. I gave him a cuddle and I told him that we loved him very much, that we were so glad he had come to live with us and we hoped to have much longer together, but we knew things were tough for him and that we would understand if he had to leave us soon and he mustn't fight on our account. Two hours later he collapsed and I rushed him to the vet, where treatment overnight didn't work so we said goodbye. I often wonder if our little chat gave him permission to go.

 

Home Hospice


If you feel your cat is towards the end but not quite there yet, or if it is a holiday weekend and you cannot reach your vet, your goal changes from prolonging life to providing supportive care focused on your cat's comfort and quality of life. This would include the basics to keep your cat comfortable, such as sub-Qs or treatment for mouth ulcers, but don't bother with other treatments such as vitamins or phosphorus binders. If the end is truly nigh, the cat will probably not want to eat, so do not assist feed, but keep food and water available.

 

The American Association of Feline Practitioners has a brochure about hospice care, with information on criteria to consider in relation to quality of life issues, and where to find pet hospice services in the USA.

 

The International Association for Animal Hospice and Palliative Care offers information and support.

 


Euthanasia Versus a Natural Death                                                                      Back to Page Index


Deciding Whether To Choose Euthanasia


The first thing you need to think about is whether you agree with the concept of euthanasia. Some people think it is fundamentally wrong, and would not contemplate it in any circumstances; while others view it as the last act of kindness you can perform for a beloved friend. If you do not yet belong to either category, you need to give this subject some thought. 

 

If you do feel you would consider euthanasia when the time comes, it can be helpful to decide in advance, perhaps in conjunction with your vet, the criteria which will lead you personally to seriously contemplate euthanasia. This is not easy because different cats have different tolerance levels (and so do their humans); and many of the symptoms of CKD, which might lead some people who are unaware of the latest treatment options to consider euthanasia, can in fact be successfully controlled. 

 

You may hope that your cat will cross unaided, or you may choose to let your cat die naturally. My personal view is that helping your cat to cross is the final act of love and kindness which you can do for them; but some people simply cannot find it in themselves to do it, or believe it is wrong for moral reasons. If you fall into one of these categories, that is your prerogative and your wishes should be respected.

 

Some CKD cats do cross peacefully, in their sleep, and yours may perhaps be one of them; but this is not guaranteed. Therefore, if you are planning to let your cat die unaided, please ensure that you are able to contact a vet at any time should you change your mind if your cat appears to be in discomfort and decide that you want your vet to intervene after all. This should not be too difficult in the UK, where vets are obliged to provide a 24/7 service, so you should be able to contact a vet at any time, day or night. People in other countries may have to find an emergency clinic if they need help out of office hours.

 

If you do decide you want to utilise euthanasia when the time comes, I would suggest an approach something along the lines of:

  • if your cat is in pain, or about to be in pain; 

  • if your cat has very little quality of life, however you personally define that. Areas for consideration might include whether your cat is incontinent; whether your cat is able to rest comfortably; whether your cat still enjoys interacting with your family. Obviously treatment might resolve some of these issues, so what also matters is: 

  • if there is in your and your vet's opinion very little or no chance of curing or controlling this pain or discomfort and regaining quality of life;

then consider euthanasia. Dr Alice Villalobos has developed a Quality of Life Scale (2004) Canine and Feline Geriatric Oncology Honoring the Human-Animal Bond, Blackwell Publishing, Table 10.1, released 2006, which can be helpful in determining whether it is time to say goodbye.

 

Even after reading the foregoing, you may feel unsure about what to do. If you are not yet sure, in most cases waiting a few more hours or occasionally days does not condemn a CKD cat to agony, but can at least help you to get used to the idea and to know that you have done all you could.

 

I brought Thomas home to spend his last night with his family before he was put to sleep the next day. He had become sick really fast, so this gave me time to get over the shock and to be sure it was hopeless and to accept that there was nothing to be gained for him from making him stick around (as I mention above, if I had made him stay with us for a longer period, I would have been prolonging his death, not prolonging his life). But having that time together did help me, and I like to think he was not too uncomfortable whilst we said our goodbyes.

 

However, if you look at the list of symptoms you may see towards the end (see above),  you will see that some of them are more tolerable than others. I would not recommend waiting too long if a cat is suffering from congestive heart failure, problems breathing, cases of PKD in which the cysts have ruptured (this is rare), or seizures where you cannot find and treat the cause. If your cat can no longer urinate, you should act promptly. If you are at all unsure, call your vet. Saying goodbye a few hours earlier than you planned may be easier for you to cope with afterwards than worrying that your cat might have suffered even for a moment.

 

You should consider visiting the Other People's Losses page, which contains some personal histories bravely provided by several people who describe what happened during their cat's final hours, and in most cases why they then decided to use euthanasia. These histories are very hard to read, but offer a unique insight.

 

The Pet Center has a very sensitively written section about euthanasia.

International Cat Care has a leaflet on euthanasia.

Clarkston Animal Medical Center has information on making the decision and what happens during euthanasia.

 

Place of Euthanasia


If you do opt for euthanasia, I recommend arranging in advance that your vet will come to your home if possible when the time has come - this is often less traumatic for both you and your cat, though some people think they will be haunted by the experience if their cat crosses at home, which is a valid point.

 

Most UK vets are prepared to come to your home, usually with a vet nurse to assist, though you may have to wait until they have finished their day's consultations, and you will probably have to pay more. It can be much harder to find a vet who makes house calls in the USA but The American Association of Housecall and Mobile Veterinarians will help you search for one. Westoba Canadian Business Directory has details of house call vets in Alberta, Canada. If you live in Florida, Georgia, North Carolina, Illinois, Texas, Massachusetts, Pennsylvania, St. Louis, Conneticut, Maryland/DC or Tennessee, Lap of Love may be able to provide at home euthanasia. The In Home Pet Euthanasia Directory may also be able to help you find a vet who can assist.

 

Our vet kindly came to our home at 9.30 p.m. on a Sunday evening to euthanise Tanya - it was a terrible experience, but that act of kindness made it a little easier to bear. Thomas was also put to sleep at home. This meant I could sob in private, and also that I did not have to drive home; I really don't think it would have been safe for me to drive in my state of grief.

 

If you do have to go to the vet's, try to arrange for somebody you trust to drive you, and aim to get the last appointment of the session if possible so you do not feel rushed and fewer people will be in the waiting room.

 

It is also worth deciding in advance whether you wish to be with your cat when he/she is put to sleep. Again, this is a very personal decision. Some people feel they owe it to their cat to be present; others simply cannot bear the idea. Both of these approaches are perfectly valid. Personally, I felt I had to be there because I felt the presence of somebody they knew and loved would comfort and reassure my cats.  

 

What Happens During Euthanasia


Many people are very scared by the thought of euthanasia. Quite apart from the emotional trauma associated with the procedure, there can also be a fear of the unknown in terms of what to expect from a practical perspective: how is euthanasia done, what exactly happens to the cat etc. 

 

The basic aim of euthanasia is to stop the cat's heart in a painless way. In order to achieve this, an overdose of an anaesthetic, pentobarbital sodium or pentobarbitone sodium, is given by injection. If you have ever had a general anaesthetic, I would imagine that the sensation of dropping off to sleep is similar for the cat, since an anaesthetic is used in both cases.

 

The injection must be given directly into a vein, and most vets will inject into the front leg. The vet has to shave or trim the cat's leg in order to see the vein clearly. Some vets insert a catheter, a tube through which they will feed the anaesthetic but my vet's method is to just insert the fine needle with the anaesthetic directly, which I preferred. Sometimes with CKD cats it is hard to find a vein because the cat is dehydrated or the veins have largely collapsed.

 

Unfortunately some cats may fight the process, so if the vet expects this, a sedative may be given first. If you have a cat who hates vet visits, you may wish to ask your vet to do this. In the USA it is quite common for the vet to give the cat a sedative anyway before they give the euthanasia injection. This is intended to relax the cat, and often the vet will then give you some quiet time together, perhaps twenty minutes or so, to say goodbye to your cat. Your cat may be relaxed but awake following a sedative, but some cats may become very sleepy and not particularly responsive to you. My British vet does not use sedatives because she says they can sting. I have had euthanasia performed both with and without sedatives, and do not think the sedative bothered Harpsie, but nor do I think putting my other cats to sleep without sedatives caused any problems. 

 

When it comes to the euthanasia injection, some vets choose to give a small amount of anaesthetic in order to send the cat to sleep, then they add a bit more in order to stop the heart. My vet just gave one amount. It usually takes effect very quickly.

 

Occasionally a vet may inject the cat directly in the heart, which I personally would find very distressing. I would suggest that you should not agree to this unless all other methods have failed; it should certainly not be the method of first choice but may on rare occasions be necessary if the cat has very low blood pressure. If you do agree to this, insist that a sedative is given first.

 

Usually the cat will look as if he or she is falling asleep, and then he or she will gradually breathe more and more lightly until eventually the breathing stops completely: this only takes a few seconds. Most cats cross peacefully. Unfortunately there is no guarantee. It was very gentle and gradual with both Tanya and Thomas, and we didn't find it scary.

 

The vet checks the cat's eyes and heart and pronounces the cat dead. You may notice a few little sighs even after your vet has pronounced your cat dead; this can be extremely upsetting if you are not expecting it, but fortunately our vet had warned us about this possibility, which is known as agonal breathing. Tanya and Thomas did indeed give one or two little sighs; this was just a physiological effect of the muscles relaxing, not proper breathing. Very occasionally your cat may suffer what appears to be a nosebleed - this is also caused by agonal breathing, and simply means that some capillaries or other larger blood vessels in the lungs have ruptured. This does not hurt the cat because it happens after death. Tanya also began pulling tongues, it was really just her tongue relaxing, and we actually found it rather cute since she often pulled tongues when she was alive. 

 

We were stroking both Tanya and Thomas the whole time as they crossed. You need to be aware that, just as there can be involuntary breathing movements after death, so other muscles relax, including the bladder and the bowels. As a result a cat may empty his/her bladder and/or bowels after death. For this reason it is best to have a thick towel and/or incontinence pad on your knee if your cat crosses while on your knee.  

 

Unlike humans, cats' eyes stay open after death. They look empty though, compared to the depth in a cat's eyes before death.

 

It may help you to spend some time with your cat after he or she has crossed. To be honest, I found this necessary in order to be absolutely sure that they had definitely crossed. It had been hard to groom Tanya for a while before her death because she was so thin, but I promised her she would be beautifully groomed after she had crossed. I kept that promise to her. You may find it comforting to clip a lock of hair as a memento, or to take a paw print. If you have other animals, you may wish to let them view the body, because it may help them understand what has happened.

 

You may have a vet who cries along with you, or your vet may appear to remain detached. My vet never cries during euthanasia, because she wants to focus on her job of helping the cat to cross as peacefully as possible; but she told me that all her team do find it distressing and often need some emotional support from their colleagues afterwards. So if your vet doesn't cry, please don't assume he or she doesn't care; and please do not let this stop you crying yourself if that is what you want to do.

 

What Happens During a Natural Death


Sometimes people decide to let their cat cross unaided, This may be for religious or similar reasons, where people feel they do not have the right to choose death for their cat, or it may be simply because they cannot face making the decision. 

 

If you decide to do this, if possible allow your cat to be in a comfortable place of his/her choosing. With cats who cross naturally, you will still see some of the signs outlined above, such as strong body odour; reduction in body temperature and possibly coma; hiding; incontinence; and twitching and possibly seizures. Some cats will simply gradually fall into a coma, become unresponsive, and die a gentle death. However, other CKD cats may have seizures and a heart attack. Dying may be swift and painless, or it may be drawn-out and uncomfortable; it may even be painful, particularly if your cat is in congestive heart failure as well, when s/he will basically drown from the fluids in the lungs. Unfortunately, it is impossible to predict which cats will die in which way. 

 

Ultimately, as your cat's caretaker, it is your responsibility to decide what you want to do. I do respect the fact that individuals have the right to make choices for their own cats; but before you make up your mind, I think it is important that you appreciate how unpleasant crossing naturally can sometimes be. Below is the story of a CKD caregiver who would prefer to remain anonymous. If you've already definitely decided on euthanasia, do yourself a favour and skip this. In the interests of balance, there is also the story of a CKD cat, Roady, who crossed unaided in a peaceful manner.

 

Natural Death (Unpleasant)


"My cat died of CKD in my arms, without benefit of euthanasia, on January 4, 2002.  Not because I made a deliberate choice to have it that way but because the vet didn't make it in time to ease his passing.

 

"My cat's last hours were not pretty to witness.  His deterioration was extremely rapid.  He went from being weak but functional, to being almost completely helpless, in a matter of hours.  At one point he managed to get himself up on a cat perch to sleep, but woke up later needing to urinate.  I had been in the room with him keeping an eye on him, but sadly I wasn't in the room at that moment; I heard a crash and ran back in to find that he'd tried to get off the perch to make it to his litterbox but had been too weak, and he fell, hard, about four feet to the floor.  I found him laying there, stunned, leaking urine and unable to get up.  This was about two hours before he died.  I left frantic messages for my vet, who was scheduled to come the next day to euthanize him, but she didn't get the messages in time to be of any help.  I put my cat on my sofa and sat next to him.  He lay there for two hours, too weak to do anything but breathe, until he was overtaken with convulsions.  He kept convulsing in my arms for nearly thirty minutes (while my neighbor was driving us to an emergency vet) until he finally took his final breath and left me.  I talked to him the entire time, telling him that I loved him and was there with him, but I know he didn't hear me or even know that I was there. 

 

"There was nothing peaceful about his death, nothing to make me come away feeling like we'd shared anything noble or beautiful.  I would have far, far rather been able to hold him in my arms while the vet helped him to a truly peaceful passing, before matters deteriorated to the point they did.  I would have rather spared him what he had to endure on the last day of his life." 

 

Natural Death (Pleasant)


"Roady slipped peacefully away at 3:03 a.m. California time this morning.       

 

"About 8:00 last evening he came to me and wanted to be with me on the couch. My wife went to bed about 11. She brought us a big fluffy towel and the heating pad in case we got cold. I wrapped him loosely in the towel and held him in my arms. We stayed that way, until he passed. He gave a little crackling meow, his bladder let loose and he was gone. There was no pain.

 

"Mine and Roady's final time together was the best and most private. Something we would not have had, had I opted to take him somewhere to be put to sleep.

 

"I knew Roady, knew his wishes, knew in my heart that his crossing would be without pain and it was."

 


Resting Places                                                                                                         Back to Page Index


This again is unfortunately something which you really need to think about in advance if you can. Although we had previously decided to bury Tanya in our garden, we had not given any thought to a suitable container so we were faced with a real problem when she died. 

 

Resting Place Options


The options are:

  • to bury your cat in your garden;

  • to bury your cat in a pet cemetery;

  • to have your cat cremated and the ashes returned to you;

  • to have your cat cremated and not have the ashes returned to you.

Thomas was also buried in the garden. Unfortunately, after we had buried him, I had a dreadful urge to dig him up again just to make sure he was definitely dead. I didn't, of course, but the urge was very strong, signalling my unwillingness to accept that he really had gone.

 

If you choose to have your cat cremated, your vet will normally arrange for your cat to be collected from the vet's premises and taken to a special animal crematorium. You need to be aware that quite often several cats will be cremated at once, so if you ask for the ashes back, you will be receiving either mixed ashes, or possibly none of your cat at all will be there.

 

If you wish, you can ask for an individual cremation (known as a separate retort), which usually costs more. Some places will allow you to attend this if you wish.

 

If you choose to have the ashes returned to you, they will usually be in a sealed plastic bag within a plain, simple container. Many people choose to buy a nicer urn or some other type of holder.

 

Our Experiences with Cremation


We lost Harpsie in the USA, so since we lived in an apartment at the time, we had no choice but to have him cremated. I was dreading it. Many people had told me it would probably give me a sense of peace and completion, which I thought highly unlikely. I hated the thought of burning his lovely fur and beautiful face in particular, even though all the humans in my family opt for cremation.

 

We chose to attend the cremation, which I gather is unusual. But we are always present when we bury our cats, and we didn't want to do any less for Harpsie. Plus I wanted the reassurance of knowing they had got the right cat.

 

So we set off to the oldest pet cemetery in the USA, Hartsdale Pet Crematory (founded 1895). It was in a beautiful tree-filled setting, and there was torrential rain, which we didn't mind, it fitted our mood better.

 

Of course I sobbed my heart out but people were right, it was cathartic. We were given plenty of time in a private room for a personal goodbye with Harpsie. I'd been told that Harpsie might look a little different, but I'm pleased to say he looked exactly as he did when we took him up to the vet the day after he crossed. They placed him in a little casket for the viewing, with a little white satin pillow for his adorable little head, and a little cat-sized white satin blanket. We were able to hold and cuddle and stroke him, until we felt ready (after a fashion) to part with his little furry body. We placed two red roses in with him, and then watched as he was carried respectfully to the crematorium. We watched the man (who was very kind and considerate) place Harpsie in it, then we went inside the main building to choose an urn. We opted for a pale cream marble chest with a few pinkish-red swirls - the base colour is a similar colour to Harpsie. We felt this was very fitting because when Harpsie was a kitten he loved sleeping with his head resting on the marble hearth.

 

We then went for a walk and the heavens opened, so we got soaked to the skin. We returned an hour later to collect Harpsie in his new form. It was curiously moving. We brought His Handsomeness home, and he now rests in his chest under his portrait. And whilst we of course still wish that cute little face, body and personality were still with us, we do feel a sense of completion that he is home at last.

 

In almost all cases I would suggest that burying your cat or having the ashes returned to you can give you some small form of comfort, as if your cat has come home to you. You may choose a pretty urn to hold the ashes, or mark the grave in some way: we have planted a rose on the graves of each of our cats, and placed a brass memorial notice on the wall nearby.

 

Urns and Caskets


The following companies sell urns and caskets, although I do not know anything about them (they are listed in alphabetical order):

 

USA


Amazon sells a stone marker for under US$15.

 

Angel Ashes sells a variety of urns.

 

At Peace sells a number of urns and memorials.

 

Casket Gallery sells wooden urns and photo-urns, and granite headstones.

 

Eturnity Urns makes handmade glass urns.

 

Forever Pets sells burial markers and cremation urns.

 

MHP Pet Urns and Caskets sell wooden urns and caskets.

 

Paws 2 Heaven sells a variety of pet remembrance items, with 10% of purchase price going to a shelter or rescue group of your choice.

 

Rays of Joy sells stained glass urns.

 

Starlight Memorials sell a variety of urns, markers and statues.

 

UK


Pets in Paradise offers a variety of urns and markers in the UK.

 

Pets Remembered offers urns, crosses and headstones in the UK.

 

***************

 

"They that love beyond the world cannot be separated from it.

Death cannot kill what never dies.

Nor can spirits ever be divided, that love and live in the same divine principle, the root and record of their friendship.

If absence be not death, neither is theirs.

Death is but crossing the world, as friends do the seas;

They live in one another still."

 

William Penn, More Fruits of Solitude

 

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This page last updated: 24 January 2012

Links on this page last checked: 27 April 2012