Maia's Challenge
After a bright start to the new year, things took a quick, harsh turn. Maia became very sick.
It's been a hell of a ride these past four weeks, and it's not over, but things are definitely much better now. The future is bright again. I've learned a lot.
This is a long post. Hang with me. There's lots to share. Ultimately I hope the lessons I've learned can help others avoid finding themselves in similar situations.
Maia's problems actually started in late December, but the symptoms were subtle. See how her elbows are splayed in the photo above? I thought she was just giving her elbows a break. Several times in her life she developed small growths on her elbows where most dogs get calluses, growths that eventually were surgically removed. So I simply wrote off this new way of laying on the ground as a result of her elbow history and aging joints.
But Maia had also grown increasingly clingy since Christmas, seeking my attention, demanding it. I'd massage her all over, seeing if she reacted to being touched in any particular spot, but no, she seemed to just want a good massage and lots of love.
Just before New Years I noticed her voice becaming a little raspy, like you or I getting laryngitis. Her quiet woof! to come inside took on a hoarse quality. She also seemed to pant more, breathing loudly without having exerted herself. She was often restless. I noted all of this as odd, and started to become concerned in a vague way, but didn't have anything concrete to go on. Her appetite, thirst, energy, and peeing/pooping were all normal. On New Year's Day I gave all the dogs a marrow bone as a treat, and Maia enjoyed hers as much as ever.
The nights of January 1st and 2nd were especially restless for Maia, and so for me as well. I could hear her pacing during the night, both outside on the deck and downstairs in the living room; she couldn't seem to get comfortable. Rather than lay on her side to sleep, as usual, she mostly remained on her chest, head up, breathing loudly. Eventually she'd put her chin on the ground as if to sleep, but within minutes, raise her head and start the panting again. A couple of times in the wee hours she let out a small whimper. I could not figure out what was bothering her. I did my best to provide comfort and tried to not wig out.
The morning of Thursday, January 3rd, Maia didn't want to eat her breakfast. Skipping breakfast isn't that unusual for her, or malamutes in general. Usually, with Maia, it means an upset stomach, and the cure is to walk a block down the street to where that type of grass all dogs like to eat when their stomachs ache grows. I grabbed the leash and took both Maia and Meadow down to that spot. Rather than practically dragging me in desperation to get to the grass as she usually did, Maia's pace was very slow, lagging behind me. When we got to the grassy spot, Maia didn't eat a blade. That got my attention. Still, I couldn't see anything obviously wrong, but now I was on high alert and watching her closely.
Later that day, she accepted some treats. By dinnertime (around 4:00 pm) she was eager to eat. But I noticed she was eating more slowly than usual, chewing differently, carefully. I wondered if, when gnawing on that bone New Years Day, she broke a tooth. I kneeled in front of her, wanting to inspect her teeth.
That's when I saw it: her throat was swollen, at the back of and underneath her lower jaw. Dramatically swollen, now that I looked closely. Malamutes have very thick fur, so to be noticeable underneath her fur, the swelling had to be serious.
I immediately put Maia's old dog harness on so that I could help her get in the car. I drove her to Seattle Veterinary Specialists, a 24/7 vet ER. They're just five minutes away. Maia had been there once before, when she got a piece of rawhide stuck in her throat. They're awesome for urgent care.
The vet who came in to see Maia remembered her from the earlier visit, over a year ago. That was nice. After the exam, she said Maia's lymph nodes in her neck were very swollen, which constricted her throat and explained the discomfort, raspy voice, and awkwardness eating. That also explained her laying on her chest, elbows out - it's the best way for a dog to keep its airway open. The vet found no broken teeth, no other obvious explanation. Notably, none of Maia's other lymph nodes were swollen.
The vet explained that Maia could either be fighting an infection, or - more likely in old dogs - had lymphoma, cancer of the lymphatic system. Hearing that was a shock; I hadn't even dreamed it could be something like cancer. The vet said I could try a course of antibiotics and see if that cleared things up. I could also have them do an aspiration of the nodes to test for cancer. I could do both, or start the antibiotics and come back for the biopsies if the swelling didn't go down. Or I could do nothing. I opted to start antibiotics - if it was an infection, best to attack it right away - and do the needle aspiration while she was there, since it's an ordeal getting Maia into the car now that her hind end is so weak. Besides, now that the possibility of cancer had been put on the table, I wanted an answer, yea or nay. I also asked that they do a blood panel, as long as were they going to treat Maia like a pin cushion anyway. The more information about her overall health, the better, I figured. After a 30 minute wait for the aspirations and blood draw to be done, Maia came back out to me, looking none the worse for wear but happy to leave. I was given a five day supply of Clavamox, a broad spectrum antibiotic. Lab work would be back by the end of the next day, Friday. I started the Clavamox Thursday night.
Friday morning, January 4th, Maia tucked into her breakfast like usual. Already her neck looked better. She got her second dose of Clavamox with her breakfast. Maia seemed a bit tired, though, so I didn't take her for a walk that afternoon. Meadow, however, needed some exercise, so we went out into very cold and clear weather that afternoon. I brought my phone. About a mile into the walk, the phone rang. The vet said the lab results confirmed lymphoma.
Shit.
Given Maia's quick response to the antibiotic, I had convinced myself it wasn't cancer. I told the vet about her response to the antibiotic. She said that did seem to indicate some sort of infection, but beyond that, couldn't comment.
Shit, shit, shit.
The vet then informed me that the SVS oncologist visits every third weekend from Wisconsin where he teaches at a vet school. He happened to be in town that weekend; did I want to schedule an appointment? I did. Maia and I would see him the next day, January 5th, Saturday afternoon.
In the meantime, I worked my connections. My friend Joan, a nurse, whose own malamute Nisqually had sadly succumbed to a different sort of cancer in recent months, shared lots of great information, including a book titled The Dog Cancer Survival Guide, by Demian Dressler, DVM. (I highly recommend it if you find yourself in similarly challenging circumstances with your own dog.) I did some research online. I called my friend and vet Stacy Steele. I learned that because lymphoma involves the immune system, which includes all lymph nodes and thus basically the entire body, surgery isn't an option. Oddly, that was comforting. At 13 years and 10 months of age, I did not want to have to decide whether to put Maia through surgery. The other thing I learned is that while there's no cure for lymphoma, it has one of the highest remission rates when treated with chemotherapy. And dogs handle chemo much better than people (mostly because the doses are much lower for dogs).
The Dog Cancer Survival Guide does a fabulous job of laying out the three primary treatment options for lymphoma, with the expected remission rates and durations for each.
The options:
1. A multi-drug chemo protocol called COPLA. This requires hospital visits once per week, three out of every four weeks, over a total of 19-24 weeks. Prognosis: survival of 6-10 months, with an absence of symptoms for 6 months. (The author notes that this protocol was developed by the oncologist Maia will be seeing. I take this as a good omen; Maia's specialist studies lymphoma. He should know his stuff, right?)
2. A single drug chemo protocol. Hospital visit for chemo once every three weeks, with follow-up blood work one week after each of five chemo doses. Four of five dogs respond, kicking the cancer into remission that can last as long as 9 months, with many dogs making it a year. The author noted that this treatment is gaining popularity.
3. Prednisone only, to reduce inflammation. Dogs on this protocol, or without any treatment, typically live 4-8 weeks after diagnosis.
Except for this unexpected diagnosis of lymphoma, Maia is incredibly healthy. Still, she's two months shy of her 14th birthday. My first malamute, Opus, died in 1999 at the age of 14 years and one month. I've always said that if I get Maia, and Meadow, to age fourteen, then every day, week and month thereafter is a bonus and a gift.Torn ligaments in Maia's left knee are her only general issue; with the support of massages and Novox (generic Rimadyl) for the past two-plus years, Maia has continued her activities - including daily walks of 1-2 miles in recent months, down from 2-4 miles in 2011 and most of 2012 - since her knee gave out in September 2011. Her quality of life is high.
[A slight aside that's relevant to this story: I understand that many people think Rimadyl - and by extension, its generic, Novox - are poison. Horrible; should be taken off the market. Google it; you'll see what I mean. But I know Novox to be a very beneficial drug that has helped Maia enjoy her life and stay active. She's the equivalent of a 90 year old woman, yet a very spry oldster. I'm convinced Novox has helped her immensely along the way.
As I tell people who get a little hysterical about these things, We're all an experiment of one. This applies to our pets as well. What works for one may not work for another; what's poison to one is an elixir of health to another. Do your due diligence, make an educated decision, and proceed with caution, willing to change course if the signs warrant.]
Saturday, January 5th, Maia and I set out to visit the oncologist. I've pretty much made my decision - the single drug protocol - based on my earlier research, but I'm willing to listen and be swayed in another direction. My decision is based on these factors:
1. Maia has responded so significantly to the Clavamox/antibiotic, by Saturday afternoon her lymph nodes are back to normal, after just 3 doses. This tells me she has been fighting some underlying infection (cancer wouldn't respond to antibiotics). The fact that lymphoma was discovered was a by-product of the infection causing her neck lymph nodes to swell so much and the vet saying that in old dogs, that's often because of lymphoma. This sequence of events made sense to me - if cancer is lurking, even in low levels, in the lymphatic system, the lymph nodes probably have to work even harder to fend off an infection. That caused the extreme swelling, which led to doing the biopsies.
2. Maia's age and expected life span without cancer. She has already exceeded the average for her breed, by a long shot. Her heart and lungs are strong, so she's got several months of happy life ahead of her, but...how many? If she responds to the single drug protocol, then the months of remission the treatment buys her will likely get her to the end of her best case scenario lifespan. If the cancer progresses without treatment, it could shorten her life significantly, and cause discomfort and pain.
3. Her appetite and thirst and bodily functions all remain normal, despite the apparent infection. She's happy and healthy and getting over the infection.
As my father used to joke in his later years, If you live long enough, something will eventually kill you.
The oncologist didn't offer any information or options that I hadn't already read or heard and spent a sleepless night considering. He seemed to be biased toward the multi-drug protocol, but then, he's one of the researchers that created it, so that didn't surprise me. He was nice enough, but...brisk. He spent 10 minutes with me and gave Maia just a cursory exam. I said I wanted to try the single drug protocol. He accepted that, and noted I could start that day. He then said that because Maia had been on Novox, I would have to stop that drug for 48 hours before I could start giving her prednisone, which went along with the chemo but would also address her arthritis and knee issues. He added that when the one month course of prednisone was done, I could put her back on Novox. I knew only that prednisone acted as an anti-inflammatory. The oncologist explained that Novox is a non-steroidal anti-inflammatory, while prednisone is a steroidal one, and the two don't mix. He didn't say, and I didn't ask, why the anti-inflammatory had to be prednisone. He never indicated I had the choice of leaving her on Novox.
I regret not asking.
Maia received her first dose of chemo (doxorubicin) the afternoon of January 5th. She was discharged with a five day supply of an anti-nausea medication. I was also told to finish the course of antibiotics. I asked the oncology vet tech what to do about pain, now that Maia wasn't going to get her Novox. The tech gave me some Tramadol for pain management. When I got home, I read the clinic notes from the oncologist: lymphoma, stage III-a. My friend Joan had warned me to ignore any stage designation - it's just a guess - but this was my first red flag that the oncologist didn't seem to grasp that Maia was already responding to the antibiotic, before any chemo; by the time the oncologist saw her, her lymph nodes were virtually normal, so his declaration of stage could only be based on the description of swelling from the initial vet visit on Thursday, when Maia presented with huge lymph nodes.
Maia eagerly ate her dinner after that first dose of chemo, a good sign. She seemed to prefer laying on the deck outside, despite the very cold temperatures. She still kept her elbows out, but the previous night, she was finally willing to sleep on her side again. Her breathing was back to normal, as was her voice. Huge improvement in just 48 hours - all of them before she got her first dose of chemo - so clearly (to me, at least) a result of the antibiotic.
Believe me, Maia wasn't the only one resting easier.
Maia's last dose of Novox was on Saturday morning January 5th, before that afternoon consultation with the oncologist. On January 7th, she felt good enough to go for a one mile walk, although she was slow. On Tuesday morning, January 8th, I started the prednisone. We skipped a walk that day because of rain. January 9th, Maia walked another mile, but very slowly and she didn't seem interested in smelling anything, unusual for her. Her demeanor was just flat.
Prednisone's protocol is a full dose for a week, then ever decreasing doses over the next three weeks until finally stopping. Joan and Stacy both told me that the prednisone usually makes a dog feel wonderful, like a puppy, giving them a huge boost especially if they have any pain from arthritis or anything else. It improves their appetite and makes them drink a lot. Since Maia's appetite had never decreased (except the morning I took her for urgent care, but that was due to difficult chewing and swallowing), I wasn't needing to see an increase. I was, however, already seeing Maia's hind end weakness worsening after stopping the Novox, so for that reason I was eager for the prednisone to kick in.
I waited. And waited. Nothing. Meanwhile, Maia got weaker and weaker. She wasn't vomiting, she didn't have diahhrea, so it didn't appear to be the chemo that was at fault. It didn't seem to me that the prednisone was having any beneficial effect. I took Maia back to the clinic on January 12th for one-week-post-chemo blood work. I discussed my concerns about prednisone with the oncology tech; she was surprised I wasn't seeing any benefit. On January 13th, Maia again was willing to go for a walk, but now she moved so slowly that I took her without Meadow coupled to her, as I didn't want Meadow tugging and causing Maia to fall. I was a short walk with no enthusiasm from either of us.
In the wee hours of January 15th, Maia's whimpering woke me up. I stayed with her through the night, laying on the living room floor with her, massaging her, doing what I could. I gave her a Tramadol - the pain med provided by the oncology tech - and eventually Maia quieted down. I noticed that the swelling in her throat was coming back, her voice starting to get raspy again. Her hind end was incredibly weak.
January 16th, I gave Maia a Tramadol with dinner, and she slept better that night, but that day I noticed that she had even more trouble getting up, and when was walked, she stumbled like a drunk. Now, rather than struggle to get up to go pee, she just peed where she was. The Tramadol made her loopy.
Not acceptable.
Maia handled it all with supreme dignity. Oh, the lessons I learn from that girl.
On January 16th, I called Stacy to ask about the prednisone, about getting Maia off of it and back onto Novox. Stacy was surprised I hadn't seen any benefit from the prednisone, and noted that as far as she knew (she doesn't do chemo in her practice), it was standard with the doxoribicin. She suggested I ask the oncologist if I could continue the chemo without the prednisone, and with Novox. I called SVS, and explained my concerns to an employee who said she'd email the doctor, who would then likely call me that evening from Wisconsin.
Late that night, the phone rang. When the oncologist asked to speak with Maia, another red flag went up; he wasn't completely on the ball. I explained my observations and concerns. He seemed to think I was saying I was done with chemo, although I'd never mentioned the chemo treatment or a desire to stop; I simply said I wasn't seeing any benefit from prednisone and wanted her back on Novox. He mumbled something about quality of life and understanding my "choice." I told him her throat swelling was returning; he said that meant the cancer wasn't in remission and I should consider another needle biopsy. HUGE red flag; he still wasn't listening to me. Maia's throat symptoms had completely abated on the antibiotic, but it was only a five day course; now that she was nearly 10 days post-antibiotic, the symptoms were returning. I realized at this moment that the oncologist saw only cancer; he was treating the disease, not the dog or her underlying infection (whatever its cause). I asked for another prescription of Clavamox. I could tell he thought it was pointless, but he said okay, he'd email it in the next morning. I then asked him, pointedly (because of the original dosing instructions), "Can I stop the prednisone cold turkey?" to which he said yes. The call ended there.
That last answer didn't sit right with me. Replaying the conversation in my head that sleepless night (I'd been having a few of these), I realized his answer might be based on his mistaken belief that I was giving up on treating Maia's lymphoma altogether coupled with his additional mistaken belief that it was far more advanced than it was. Upon reflection, I had the distinct sense he thought I meant for Maia to die of her cancer soon, without any treatment. He was so, so wrong.
The next morning (January 17th) I called Stacy, who validated my concern about the oncologist's advice, saying that you don't stop prednisone cold turkey but taper off because the drug basically encourages the body's adrenal glands to produce more of its own hormones; stopping abruptly can confuse the glands' ability to produce necessary hormones on their own again. Later that morning, I verified this with the SVS oncology vet tech I'd come to trust when I went in to the clinic to pick up the re-issued Clavamox. The tech was surprised that the oncologist had told me it was fine to stop cold turkey. She instead suggested I give Maia at least two more half doses. This was still a pretty abrupt taper, but she hadn't been on the drug long.
The oncology tech then answered my two most urgent questions: Can I continue Maia on chemo without prednisone? Yes. Can Maia take Novox while getting chemo? Yes.
I thanked the tech for the information, and left for home. Furious - with the oncologist. I grew up with the axiom If it ain't broke, don't fix it. I was incredulous that, in an old dog like Maia whose owner reports she's doing well with Novox, the oncologist would insist on switching her to a different anti-inflammatory - one potentially with much more harmful side effects - rather than keeping her on Novox and seeing how she does for a week or two. He was also ignoring the amazing reduction in lymph node swelling after just two days on antibiotics; there wasn't any remaining swelling to be treated with prednisone! I had assumed prednisone was required as part of the chemo protocol, based on his instructing me how to get her off Novox, wait 48 hours, then start prednisone and stay on it until finished, then go back on Novox.
Now, armed with better information from Stacy and the oncology tech, I have no faith whatsoever in the oncologist. Stacy later explained to me that as far as she knows, prednisone is the common treatment along with doxorubicin. But I still say - so what? We're not treating the average dog. We're treating Maia. She - and I - went through hell for no reason because the expert just followed his typical protocol regardless of the patient in front of him. He didn't listen.
I tapered Maia off prednisone. She got her last partial dose of prednisone on January 17th. I then had to wait another 48 hours before Maia could restart Novox. I knew this scheme of returning to Novox was somewhat of an experiment - my own experiment - but I also knew in my heart, based on close observations of Maia over the past two years and more particularly the past two weeks, that her lack of mobility was related to stopping Novox, not the cancer or the chemo.
Needless to say, during these stressful days, Maia wasn't going for walks. She couldn't. Even moving from one part of the house to the other was an effort, and she often stumbled and fell. It broke my heart to watch her struggle, even though she never seemed too bothered and didn't cry out in pain. By the 17th, I was beginning to prepare, to have to find someone to come to the house to put Maia out of her misery. It was that bad.
I started Maia back on Clavamox, the antibiotic, on January 17th. Within 12 hours, her throat was back to normal, and within 24 hours, her raspy voice was gone and her energy returning. She hadn't been walking more than a block at a time, and that much only because I didn't want her to lose any more of the small muscle mass she still has in her hind legs. But now I had hope that I could build her strength back up.
To celebrate her throat issues improving, the afternoon of January 18th I treated all the dogs to marrow bones.
A couple of hours later, Maia made sure I knew which bowl was hers as I gave all three dogs a big dollop of salmon meat on top of their usual kibble.
Finally - finally - on January 19th, I started Maia back on Novox. By this time, she'd been back on Clavamox for three doses (one dose every 12 hours), and was feeling great. She walked about 3 blocks with more enthusiasm.
Friends Per-Ola and Beth came to visit Maia that evening.
The morning of January 20th, I came downstairs to find something odd on the floor in the living room. My initial thought was, Uh oh, Maia threw up last night. But I hadn't heard anything, and normally I wake up when one of the dogs is sick like that. I turned on the light to get a closer look.
It was a toy, clearly destroyed by Maia overnight. I laughed out loud! I couldn't have received a better Thank you! from Maia, a clearer sign that she felt much, much better after a dose of Novox the night before. Throughout her life, Maia has loved destroying tennis balls. She would peel off the fuzzy cover, then rip and swallow the rubber ball. I quickly learned to supervise tennis balls around her. Recently, I had made some toys for dog camp and my own dogs by wrapping tennis balls in fleece, tying off each end so it looked like a piece of wrapped candy. Maia liked this toy - she could chomp the ball between her jaws - but she hadn't ever tried to destroy it...until that first night back on Novox. She'd chewed a hole in the fleece, pulled out the tennis ball, stripped off the fuzzy outer layer, and apparently eaten the rubber because I couldn't find any of that part of the ball! I wish I'd been a fly on the wall, watching her joy in doing it.
I was a little worried about Maia having eaten the rubber, but decided I'd wait and see which end of her it came out. I found bits of rubber in her poop over the next couple of days.
As Maia and I worked our way through this ordeal, several friends checked in regularly on her progress. A few asked if Meadow and Finn behaved any differently toward her. Mostly, they treated her as they always have - the eldest, who deserves deference and respect. But I did notice this: a couple days after Maia started to feel sick and whimper a bit in the night, I got up in the middle of a night to let her in (or out; can't remember). I was surprised to see Finn sleeping on the dog bed in the living room. I've lived in this two story townhouse since the summer of 2009. My bedroom is upstairs. Meadow and Finn have always slept up there with me. Maia slept downstairs, even before her knee gave out, making stairs difficult. Throughout her life, Maia has been the one willing to sleep outside, alone, or in a room other than my bedroom. But now, suddenly, Finn was sleeping downstairs with her! Paying closer attention over the next several nights, a pattern emerged: Finn would come upstairs with me when I went to bed, Meadow following a bit later while I was still reading. Sometime after I fell asleep, Finn would move downstairs; if I came down in the middle of the night to let Maia in or out, Finn would watch from the dog bed, without moving. Around 4:00 am, shortly after Maia usually came inside for the rest of the night, Finn would rejoin me and Meadow upstairs.
Finn's changed nocturnal routine ended around January 23rd, after Maia returned to normal health. He now stays in my room all night, as before.
That's my boy! Keeping an eye on poor Maia when she wasn't feeling well. I would never have guessed Finn had that degree of sensitivity. It warms my heart to see it.
Every day after January 19th - when Maia went back on Novox - has been an improvement in terms of her mobility. Her walks have increased slowly - she's eager, but still weak so we're building a day at a time - and she's back engaging in life the ways she did before prednisone. After a 180 degree turn for the worse (off Novox, on prednisone) she's made a complete 180 degree return back to health (off prednisone, on Novox).
The second prescription for Clavamox that I demanded from the oncologist, the one he thought worthless, was also for a five day dose. After talking to Stacy, and given Maia's repeat stellar improvement on it, we decided to be proactive and keep Maia on the antibiotic for a few weeks. It was clear to me that whatever infection Maia was fighting hadn't been defeated by the first five day dose, and after nearly 10 days off antibiotics and symptoms returning, another 5 day dose might not be enough. Stacy - brilliant Stacy - did a little research and discovered that Augmentin is the same drug for people and, as it turns out, one third the cost. (Five days of Clavamox was $85 plus tax at the clinic; three weeks of Augmentin was roughly $100 plus tax.)
Life has returned to normal. Maia is happy and healthy, and I'm sleeping through the night again.
This journey is evolving, a day at a time. I've gone from the deep depths of despair, certain Maia's remaining days could be counted on one hand, to the joy of watching her bounce back to health, my gut sense regarding her true health issues and best treatment options validated. Her future is bright, and my all-too-precious time with her has been happily extended. What a gift. Hard fought, but so worth it.
I've been reminded of a big, big lesson: people are fallible. Me, you, doctors, vets - all of us make mistakes, fail to pay attention or listen, feel rushed to give recommendations or make decisions. It's too easy to rely on studies and their averages, on the most common treatments or most likely outcomes. When it comes to getting the best health care - for us, for our loved ones whether pets or people - we must be proactive, ask questions, do our own research and ask more questions, then demand what our pet or person needs rather than what the average pet or person usually gets or simply relying on a recommendation from an expert who may or may not have your particular pet's or person's best interests foremost in mind. We are all truly experiments of one, and should demand that we be treated as individuals.
Yesterday, January 26th, Maia had her second dose of chemo. I didn't see the oncologist, and didn't ask or want to. I did see his discharge note, however. He has now proclaimed Maia's cancer in remission, her lymph nodes normal.
My own assessment is that Maia's cancer is indeed in remission, but that it was never at the advanced stage the oncologist said it was. The infection, that taxed her lymph nodes, was the serendipitous event that led to the discovery of the cancer. So my next decision will be whether or not to go the full five doses of chemo, or stop early - say, at four doses - because Maia may not need the last dose.
Early in this bizarre journey, I began to see Maia's cancer diagnosis as a sort of gift. Crazy, huh? Here's why. The closer she got to her fourteenth birthday the more I wondered about the where, when and how of her final time on this earth, and my last days with her. I think we all hope our aged dogs will simply go peacefully in their sleep when they're ready, but reality is rarely that tidy. Now - because of the lymphoma - I know with some level of predictability what lies ahead, and can begin ever so slowly and cautiously to prepare myself. It still will not be easy, or welcome, but somehow, I can now contemplate that time without the level of fear I had before.
My goal is to finish chemo treatments, then take all three dogs for some extended time in Idaho, where Maia can live out the rest of her life sunbathing on the deck or the lawn, watching the deer moving in the field, sleeping outside under the moon and stars while listening to owls hoot and coyotes yip in the distance. That can be my final gift to her.
It's been a hell of a ride these past four weeks, and it's not over, but things are definitely much better now. The future is bright again. I've learned a lot.
This is a long post. Hang with me. There's lots to share. Ultimately I hope the lessons I've learned can help others avoid finding themselves in similar situations.
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| Maia on December 31st with her new New Year's Eve toy. |
But Maia had also grown increasingly clingy since Christmas, seeking my attention, demanding it. I'd massage her all over, seeing if she reacted to being touched in any particular spot, but no, she seemed to just want a good massage and lots of love.
Just before New Years I noticed her voice becaming a little raspy, like you or I getting laryngitis. Her quiet woof! to come inside took on a hoarse quality. She also seemed to pant more, breathing loudly without having exerted herself. She was often restless. I noted all of this as odd, and started to become concerned in a vague way, but didn't have anything concrete to go on. Her appetite, thirst, energy, and peeing/pooping were all normal. On New Year's Day I gave all the dogs a marrow bone as a treat, and Maia enjoyed hers as much as ever.
The nights of January 1st and 2nd were especially restless for Maia, and so for me as well. I could hear her pacing during the night, both outside on the deck and downstairs in the living room; she couldn't seem to get comfortable. Rather than lay on her side to sleep, as usual, she mostly remained on her chest, head up, breathing loudly. Eventually she'd put her chin on the ground as if to sleep, but within minutes, raise her head and start the panting again. A couple of times in the wee hours she let out a small whimper. I could not figure out what was bothering her. I did my best to provide comfort and tried to not wig out.
The morning of Thursday, January 3rd, Maia didn't want to eat her breakfast. Skipping breakfast isn't that unusual for her, or malamutes in general. Usually, with Maia, it means an upset stomach, and the cure is to walk a block down the street to where that type of grass all dogs like to eat when their stomachs ache grows. I grabbed the leash and took both Maia and Meadow down to that spot. Rather than practically dragging me in desperation to get to the grass as she usually did, Maia's pace was very slow, lagging behind me. When we got to the grassy spot, Maia didn't eat a blade. That got my attention. Still, I couldn't see anything obviously wrong, but now I was on high alert and watching her closely.
Later that day, she accepted some treats. By dinnertime (around 4:00 pm) she was eager to eat. But I noticed she was eating more slowly than usual, chewing differently, carefully. I wondered if, when gnawing on that bone New Years Day, she broke a tooth. I kneeled in front of her, wanting to inspect her teeth.
That's when I saw it: her throat was swollen, at the back of and underneath her lower jaw. Dramatically swollen, now that I looked closely. Malamutes have very thick fur, so to be noticeable underneath her fur, the swelling had to be serious.
I immediately put Maia's old dog harness on so that I could help her get in the car. I drove her to Seattle Veterinary Specialists, a 24/7 vet ER. They're just five minutes away. Maia had been there once before, when she got a piece of rawhide stuck in her throat. They're awesome for urgent care.
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| Maia waiting to be seen by a vet at SVS January 3, 2013. |
The vet explained that Maia could either be fighting an infection, or - more likely in old dogs - had lymphoma, cancer of the lymphatic system. Hearing that was a shock; I hadn't even dreamed it could be something like cancer. The vet said I could try a course of antibiotics and see if that cleared things up. I could also have them do an aspiration of the nodes to test for cancer. I could do both, or start the antibiotics and come back for the biopsies if the swelling didn't go down. Or I could do nothing. I opted to start antibiotics - if it was an infection, best to attack it right away - and do the needle aspiration while she was there, since it's an ordeal getting Maia into the car now that her hind end is so weak. Besides, now that the possibility of cancer had been put on the table, I wanted an answer, yea or nay. I also asked that they do a blood panel, as long as were they going to treat Maia like a pin cushion anyway. The more information about her overall health, the better, I figured. After a 30 minute wait for the aspirations and blood draw to be done, Maia came back out to me, looking none the worse for wear but happy to leave. I was given a five day supply of Clavamox, a broad spectrum antibiotic. Lab work would be back by the end of the next day, Friday. I started the Clavamox Thursday night.
Friday morning, January 4th, Maia tucked into her breakfast like usual. Already her neck looked better. She got her second dose of Clavamox with her breakfast. Maia seemed a bit tired, though, so I didn't take her for a walk that afternoon. Meadow, however, needed some exercise, so we went out into very cold and clear weather that afternoon. I brought my phone. About a mile into the walk, the phone rang. The vet said the lab results confirmed lymphoma.
Shit.
Given Maia's quick response to the antibiotic, I had convinced myself it wasn't cancer. I told the vet about her response to the antibiotic. She said that did seem to indicate some sort of infection, but beyond that, couldn't comment.
Shit, shit, shit.
The vet then informed me that the SVS oncologist visits every third weekend from Wisconsin where he teaches at a vet school. He happened to be in town that weekend; did I want to schedule an appointment? I did. Maia and I would see him the next day, January 5th, Saturday afternoon.
In the meantime, I worked my connections. My friend Joan, a nurse, whose own malamute Nisqually had sadly succumbed to a different sort of cancer in recent months, shared lots of great information, including a book titled The Dog Cancer Survival Guide, by Demian Dressler, DVM. (I highly recommend it if you find yourself in similarly challenging circumstances with your own dog.) I did some research online. I called my friend and vet Stacy Steele. I learned that because lymphoma involves the immune system, which includes all lymph nodes and thus basically the entire body, surgery isn't an option. Oddly, that was comforting. At 13 years and 10 months of age, I did not want to have to decide whether to put Maia through surgery. The other thing I learned is that while there's no cure for lymphoma, it has one of the highest remission rates when treated with chemotherapy. And dogs handle chemo much better than people (mostly because the doses are much lower for dogs).
The Dog Cancer Survival Guide does a fabulous job of laying out the three primary treatment options for lymphoma, with the expected remission rates and durations for each.
The options:
1. A multi-drug chemo protocol called COPLA. This requires hospital visits once per week, three out of every four weeks, over a total of 19-24 weeks. Prognosis: survival of 6-10 months, with an absence of symptoms for 6 months. (The author notes that this protocol was developed by the oncologist Maia will be seeing. I take this as a good omen; Maia's specialist studies lymphoma. He should know his stuff, right?)
2. A single drug chemo protocol. Hospital visit for chemo once every three weeks, with follow-up blood work one week after each of five chemo doses. Four of five dogs respond, kicking the cancer into remission that can last as long as 9 months, with many dogs making it a year. The author noted that this treatment is gaining popularity.
3. Prednisone only, to reduce inflammation. Dogs on this protocol, or without any treatment, typically live 4-8 weeks after diagnosis.
Except for this unexpected diagnosis of lymphoma, Maia is incredibly healthy. Still, she's two months shy of her 14th birthday. My first malamute, Opus, died in 1999 at the age of 14 years and one month. I've always said that if I get Maia, and Meadow, to age fourteen, then every day, week and month thereafter is a bonus and a gift.Torn ligaments in Maia's left knee are her only general issue; with the support of massages and Novox (generic Rimadyl) for the past two-plus years, Maia has continued her activities - including daily walks of 1-2 miles in recent months, down from 2-4 miles in 2011 and most of 2012 - since her knee gave out in September 2011. Her quality of life is high.
[A slight aside that's relevant to this story: I understand that many people think Rimadyl - and by extension, its generic, Novox - are poison. Horrible; should be taken off the market. Google it; you'll see what I mean. But I know Novox to be a very beneficial drug that has helped Maia enjoy her life and stay active. She's the equivalent of a 90 year old woman, yet a very spry oldster. I'm convinced Novox has helped her immensely along the way.
As I tell people who get a little hysterical about these things, We're all an experiment of one. This applies to our pets as well. What works for one may not work for another; what's poison to one is an elixir of health to another. Do your due diligence, make an educated decision, and proceed with caution, willing to change course if the signs warrant.]
Saturday, January 5th, Maia and I set out to visit the oncologist. I've pretty much made my decision - the single drug protocol - based on my earlier research, but I'm willing to listen and be swayed in another direction. My decision is based on these factors:
1. Maia has responded so significantly to the Clavamox/antibiotic, by Saturday afternoon her lymph nodes are back to normal, after just 3 doses. This tells me she has been fighting some underlying infection (cancer wouldn't respond to antibiotics). The fact that lymphoma was discovered was a by-product of the infection causing her neck lymph nodes to swell so much and the vet saying that in old dogs, that's often because of lymphoma. This sequence of events made sense to me - if cancer is lurking, even in low levels, in the lymphatic system, the lymph nodes probably have to work even harder to fend off an infection. That caused the extreme swelling, which led to doing the biopsies.
2. Maia's age and expected life span without cancer. She has already exceeded the average for her breed, by a long shot. Her heart and lungs are strong, so she's got several months of happy life ahead of her, but...how many? If she responds to the single drug protocol, then the months of remission the treatment buys her will likely get her to the end of her best case scenario lifespan. If the cancer progresses without treatment, it could shorten her life significantly, and cause discomfort and pain.
3. Her appetite and thirst and bodily functions all remain normal, despite the apparent infection. She's happy and healthy and getting over the infection.
As my father used to joke in his later years, If you live long enough, something will eventually kill you.
The oncologist didn't offer any information or options that I hadn't already read or heard and spent a sleepless night considering. He seemed to be biased toward the multi-drug protocol, but then, he's one of the researchers that created it, so that didn't surprise me. He was nice enough, but...brisk. He spent 10 minutes with me and gave Maia just a cursory exam. I said I wanted to try the single drug protocol. He accepted that, and noted I could start that day. He then said that because Maia had been on Novox, I would have to stop that drug for 48 hours before I could start giving her prednisone, which went along with the chemo but would also address her arthritis and knee issues. He added that when the one month course of prednisone was done, I could put her back on Novox. I knew only that prednisone acted as an anti-inflammatory. The oncologist explained that Novox is a non-steroidal anti-inflammatory, while prednisone is a steroidal one, and the two don't mix. He didn't say, and I didn't ask, why the anti-inflammatory had to be prednisone. He never indicated I had the choice of leaving her on Novox.
I regret not asking.
Maia received her first dose of chemo (doxorubicin) the afternoon of January 5th. She was discharged with a five day supply of an anti-nausea medication. I was also told to finish the course of antibiotics. I asked the oncology vet tech what to do about pain, now that Maia wasn't going to get her Novox. The tech gave me some Tramadol for pain management. When I got home, I read the clinic notes from the oncologist: lymphoma, stage III-a. My friend Joan had warned me to ignore any stage designation - it's just a guess - but this was my first red flag that the oncologist didn't seem to grasp that Maia was already responding to the antibiotic, before any chemo; by the time the oncologist saw her, her lymph nodes were virtually normal, so his declaration of stage could only be based on the description of swelling from the initial vet visit on Thursday, when Maia presented with huge lymph nodes.
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| Maia home after first dose of chemo, January 5, 2013. |
Maia eagerly ate her dinner after that first dose of chemo, a good sign. She seemed to prefer laying on the deck outside, despite the very cold temperatures. She still kept her elbows out, but the previous night, she was finally willing to sleep on her side again. Her breathing was back to normal, as was her voice. Huge improvement in just 48 hours - all of them before she got her first dose of chemo - so clearly (to me, at least) a result of the antibiotic.
Believe me, Maia wasn't the only one resting easier.
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| Maia the evening of January 6th, feeling great, even playful after three days on antibiotic and first dose of chemo. |
Prednisone's protocol is a full dose for a week, then ever decreasing doses over the next three weeks until finally stopping. Joan and Stacy both told me that the prednisone usually makes a dog feel wonderful, like a puppy, giving them a huge boost especially if they have any pain from arthritis or anything else. It improves their appetite and makes them drink a lot. Since Maia's appetite had never decreased (except the morning I took her for urgent care, but that was due to difficult chewing and swallowing), I wasn't needing to see an increase. I was, however, already seeing Maia's hind end weakness worsening after stopping the Novox, so for that reason I was eager for the prednisone to kick in.
I waited. And waited. Nothing. Meanwhile, Maia got weaker and weaker. She wasn't vomiting, she didn't have diahhrea, so it didn't appear to be the chemo that was at fault. It didn't seem to me that the prednisone was having any beneficial effect. I took Maia back to the clinic on January 12th for one-week-post-chemo blood work. I discussed my concerns about prednisone with the oncology tech; she was surprised I wasn't seeing any benefit. On January 13th, Maia again was willing to go for a walk, but now she moved so slowly that I took her without Meadow coupled to her, as I didn't want Meadow tugging and causing Maia to fall. I was a short walk with no enthusiasm from either of us.
In the wee hours of January 15th, Maia's whimpering woke me up. I stayed with her through the night, laying on the living room floor with her, massaging her, doing what I could. I gave her a Tramadol - the pain med provided by the oncology tech - and eventually Maia quieted down. I noticed that the swelling in her throat was coming back, her voice starting to get raspy again. Her hind end was incredibly weak.
January 16th, I gave Maia a Tramadol with dinner, and she slept better that night, but that day I noticed that she had even more trouble getting up, and when was walked, she stumbled like a drunk. Now, rather than struggle to get up to go pee, she just peed where she was. The Tramadol made her loopy.
Not acceptable.
Maia handled it all with supreme dignity. Oh, the lessons I learn from that girl.
On January 16th, I called Stacy to ask about the prednisone, about getting Maia off of it and back onto Novox. Stacy was surprised I hadn't seen any benefit from the prednisone, and noted that as far as she knew (she doesn't do chemo in her practice), it was standard with the doxoribicin. She suggested I ask the oncologist if I could continue the chemo without the prednisone, and with Novox. I called SVS, and explained my concerns to an employee who said she'd email the doctor, who would then likely call me that evening from Wisconsin.
Late that night, the phone rang. When the oncologist asked to speak with Maia, another red flag went up; he wasn't completely on the ball. I explained my observations and concerns. He seemed to think I was saying I was done with chemo, although I'd never mentioned the chemo treatment or a desire to stop; I simply said I wasn't seeing any benefit from prednisone and wanted her back on Novox. He mumbled something about quality of life and understanding my "choice." I told him her throat swelling was returning; he said that meant the cancer wasn't in remission and I should consider another needle biopsy. HUGE red flag; he still wasn't listening to me. Maia's throat symptoms had completely abated on the antibiotic, but it was only a five day course; now that she was nearly 10 days post-antibiotic, the symptoms were returning. I realized at this moment that the oncologist saw only cancer; he was treating the disease, not the dog or her underlying infection (whatever its cause). I asked for another prescription of Clavamox. I could tell he thought it was pointless, but he said okay, he'd email it in the next morning. I then asked him, pointedly (because of the original dosing instructions), "Can I stop the prednisone cold turkey?" to which he said yes. The call ended there.
That last answer didn't sit right with me. Replaying the conversation in my head that sleepless night (I'd been having a few of these), I realized his answer might be based on his mistaken belief that I was giving up on treating Maia's lymphoma altogether coupled with his additional mistaken belief that it was far more advanced than it was. Upon reflection, I had the distinct sense he thought I meant for Maia to die of her cancer soon, without any treatment. He was so, so wrong.
The next morning (January 17th) I called Stacy, who validated my concern about the oncologist's advice, saying that you don't stop prednisone cold turkey but taper off because the drug basically encourages the body's adrenal glands to produce more of its own hormones; stopping abruptly can confuse the glands' ability to produce necessary hormones on their own again. Later that morning, I verified this with the SVS oncology vet tech I'd come to trust when I went in to the clinic to pick up the re-issued Clavamox. The tech was surprised that the oncologist had told me it was fine to stop cold turkey. She instead suggested I give Maia at least two more half doses. This was still a pretty abrupt taper, but she hadn't been on the drug long.
The oncology tech then answered my two most urgent questions: Can I continue Maia on chemo without prednisone? Yes. Can Maia take Novox while getting chemo? Yes.
I thanked the tech for the information, and left for home. Furious - with the oncologist. I grew up with the axiom If it ain't broke, don't fix it. I was incredulous that, in an old dog like Maia whose owner reports she's doing well with Novox, the oncologist would insist on switching her to a different anti-inflammatory - one potentially with much more harmful side effects - rather than keeping her on Novox and seeing how she does for a week or two. He was also ignoring the amazing reduction in lymph node swelling after just two days on antibiotics; there wasn't any remaining swelling to be treated with prednisone! I had assumed prednisone was required as part of the chemo protocol, based on his instructing me how to get her off Novox, wait 48 hours, then start prednisone and stay on it until finished, then go back on Novox.
Now, armed with better information from Stacy and the oncology tech, I have no faith whatsoever in the oncologist. Stacy later explained to me that as far as she knows, prednisone is the common treatment along with doxorubicin. But I still say - so what? We're not treating the average dog. We're treating Maia. She - and I - went through hell for no reason because the expert just followed his typical protocol regardless of the patient in front of him. He didn't listen.
I tapered Maia off prednisone. She got her last partial dose of prednisone on January 17th. I then had to wait another 48 hours before Maia could restart Novox. I knew this scheme of returning to Novox was somewhat of an experiment - my own experiment - but I also knew in my heart, based on close observations of Maia over the past two years and more particularly the past two weeks, that her lack of mobility was related to stopping Novox, not the cancer or the chemo.
Needless to say, during these stressful days, Maia wasn't going for walks. She couldn't. Even moving from one part of the house to the other was an effort, and she often stumbled and fell. It broke my heart to watch her struggle, even though she never seemed too bothered and didn't cry out in pain. By the 17th, I was beginning to prepare, to have to find someone to come to the house to put Maia out of her misery. It was that bad.
I started Maia back on Clavamox, the antibiotic, on January 17th. Within 12 hours, her throat was back to normal, and within 24 hours, her raspy voice was gone and her energy returning. She hadn't been walking more than a block at a time, and that much only because I didn't want her to lose any more of the small muscle mass she still has in her hind legs. But now I had hope that I could build her strength back up.
To celebrate her throat issues improving, the afternoon of January 18th I treated all the dogs to marrow bones.
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| Maia enjoys her bone January 19th. Because she's still so weak in the hind end, she wears the harness all day and night so I can help her up and steady her as she walks. |
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| Meadow works on her bone. |
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| Finn, too. |
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| Maia in a state of bliss, working her bone. She also made sure Meadow's and Finn's bones were totally clean before coming back inside. |
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| Maia points to her bowl - front left - as she waits for her dinner on January 18th. Her appetite is just fine, as always. |
Finally - finally - on January 19th, I started Maia back on Novox. By this time, she'd been back on Clavamox for three doses (one dose every 12 hours), and was feeling great. She walked about 3 blocks with more enthusiasm.
Friends Per-Ola and Beth came to visit Maia that evening.
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| Finn takes advantage of a visit by Per-Ola, getting him to toss the toy. |
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| Maia watches Per-Ola play with Finn, thinking "There's a sucker born every minute!" Note how Maia is laying normally again. |
The morning of January 20th, I came downstairs to find something odd on the floor in the living room. My initial thought was, Uh oh, Maia threw up last night. But I hadn't heard anything, and normally I wake up when one of the dogs is sick like that. I turned on the light to get a closer look.
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| The remains of the toy. |
It was a toy, clearly destroyed by Maia overnight. I laughed out loud! I couldn't have received a better Thank you! from Maia, a clearer sign that she felt much, much better after a dose of Novox the night before. Throughout her life, Maia has loved destroying tennis balls. She would peel off the fuzzy cover, then rip and swallow the rubber ball. I quickly learned to supervise tennis balls around her. Recently, I had made some toys for dog camp and my own dogs by wrapping tennis balls in fleece, tying off each end so it looked like a piece of wrapped candy. Maia liked this toy - she could chomp the ball between her jaws - but she hadn't ever tried to destroy it...until that first night back on Novox. She'd chewed a hole in the fleece, pulled out the tennis ball, stripped off the fuzzy outer layer, and apparently eaten the rubber because I couldn't find any of that part of the ball! I wish I'd been a fly on the wall, watching her joy in doing it.
I was a little worried about Maia having eaten the rubber, but decided I'd wait and see which end of her it came out. I found bits of rubber in her poop over the next couple of days.
As Maia and I worked our way through this ordeal, several friends checked in regularly on her progress. A few asked if Meadow and Finn behaved any differently toward her. Mostly, they treated her as they always have - the eldest, who deserves deference and respect. But I did notice this: a couple days after Maia started to feel sick and whimper a bit in the night, I got up in the middle of a night to let her in (or out; can't remember). I was surprised to see Finn sleeping on the dog bed in the living room. I've lived in this two story townhouse since the summer of 2009. My bedroom is upstairs. Meadow and Finn have always slept up there with me. Maia slept downstairs, even before her knee gave out, making stairs difficult. Throughout her life, Maia has been the one willing to sleep outside, alone, or in a room other than my bedroom. But now, suddenly, Finn was sleeping downstairs with her! Paying closer attention over the next several nights, a pattern emerged: Finn would come upstairs with me when I went to bed, Meadow following a bit later while I was still reading. Sometime after I fell asleep, Finn would move downstairs; if I came down in the middle of the night to let Maia in or out, Finn would watch from the dog bed, without moving. Around 4:00 am, shortly after Maia usually came inside for the rest of the night, Finn would rejoin me and Meadow upstairs.
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| Finn comforts Maia, January 14th. Pre-illness, Maia would not have tolerated Finn or Meadow laying so close to her; she would have gotten up and moved away. It's a malamute thing; they have a very strong sense of personal space. |
Finn's changed nocturnal routine ended around January 23rd, after Maia returned to normal health. He now stays in my room all night, as before.
That's my boy! Keeping an eye on poor Maia when she wasn't feeling well. I would never have guessed Finn had that degree of sensitivity. It warms my heart to see it.
Every day after January 19th - when Maia went back on Novox - has been an improvement in terms of her mobility. Her walks have increased slowly - she's eager, but still weak so we're building a day at a time - and she's back engaging in life the ways she did before prednisone. After a 180 degree turn for the worse (off Novox, on prednisone) she's made a complete 180 degree return back to health (off prednisone, on Novox).
The second prescription for Clavamox that I demanded from the oncologist, the one he thought worthless, was also for a five day dose. After talking to Stacy, and given Maia's repeat stellar improvement on it, we decided to be proactive and keep Maia on the antibiotic for a few weeks. It was clear to me that whatever infection Maia was fighting hadn't been defeated by the first five day dose, and after nearly 10 days off antibiotics and symptoms returning, another 5 day dose might not be enough. Stacy - brilliant Stacy - did a little research and discovered that Augmentin is the same drug for people and, as it turns out, one third the cost. (Five days of Clavamox was $85 plus tax at the clinic; three weeks of Augmentin was roughly $100 plus tax.)
Life has returned to normal. Maia is happy and healthy, and I'm sleeping through the night again.
This journey is evolving, a day at a time. I've gone from the deep depths of despair, certain Maia's remaining days could be counted on one hand, to the joy of watching her bounce back to health, my gut sense regarding her true health issues and best treatment options validated. Her future is bright, and my all-too-precious time with her has been happily extended. What a gift. Hard fought, but so worth it.
I've been reminded of a big, big lesson: people are fallible. Me, you, doctors, vets - all of us make mistakes, fail to pay attention or listen, feel rushed to give recommendations or make decisions. It's too easy to rely on studies and their averages, on the most common treatments or most likely outcomes. When it comes to getting the best health care - for us, for our loved ones whether pets or people - we must be proactive, ask questions, do our own research and ask more questions, then demand what our pet or person needs rather than what the average pet or person usually gets or simply relying on a recommendation from an expert who may or may not have your particular pet's or person's best interests foremost in mind. We are all truly experiments of one, and should demand that we be treated as individuals.
Yesterday, January 26th, Maia had her second dose of chemo. I didn't see the oncologist, and didn't ask or want to. I did see his discharge note, however. He has now proclaimed Maia's cancer in remission, her lymph nodes normal.
My own assessment is that Maia's cancer is indeed in remission, but that it was never at the advanced stage the oncologist said it was. The infection, that taxed her lymph nodes, was the serendipitous event that led to the discovery of the cancer. So my next decision will be whether or not to go the full five doses of chemo, or stop early - say, at four doses - because Maia may not need the last dose.
Early in this bizarre journey, I began to see Maia's cancer diagnosis as a sort of gift. Crazy, huh? Here's why. The closer she got to her fourteenth birthday the more I wondered about the where, when and how of her final time on this earth, and my last days with her. I think we all hope our aged dogs will simply go peacefully in their sleep when they're ready, but reality is rarely that tidy. Now - because of the lymphoma - I know with some level of predictability what lies ahead, and can begin ever so slowly and cautiously to prepare myself. It still will not be easy, or welcome, but somehow, I can now contemplate that time without the level of fear I had before.
My goal is to finish chemo treatments, then take all three dogs for some extended time in Idaho, where Maia can live out the rest of her life sunbathing on the deck or the lawn, watching the deer moving in the field, sleeping outside under the moon and stars while listening to owls hoot and coyotes yip in the distance. That can be my final gift to her.