Bartonella henselae and Cat Scratch Fever: Part 3 of 3

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Photo courtesy of Pinterest.

The Enemy

With regards to any adversary in our lives that we must confront, be it in politics, business, or bad health—ESPECIALLY HEALTH—I believe with every once of my being in knowing as much as humanly possible about the enemy! You must be a warrior on your own or a love one’s behalf: Know what the enemy looks like, what its habits are, its history, and what you need to do to fight it. You may not be able to answer all of these questions, but at least you’ll know what it is you’re fighting. I hope this humble blog will be of some help in your personal battle.

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Enemy #1: The Bartonella Bacteria. Photo by: public health alert

Just A Bit of Science

For those who fear science, I promise to make this as painless as possible. Every known living thing on the planet has at least two Latin (sometimes Greek or Arabic) names: A genus (which can be thought of as a broad “family” name) and a species (which describes an individual in a “family.” )

For example, a red oak tree is Quercus rubra. The genus is Quercus and the species is rubra. Humans are Homo sapiens; a common turnip is a Brassica rapa; the common dog tapeworm is Dipylidium caninum. The reason science uses such specific terms is not because we are elitist trying to impress the everyday person, but rather to avoid confusion when communicating with each other. That is, a doctor in Bangladesh, China, or Iceland will all know exactly what each other is talking about. This leads to the point of this blog: The bacteria that causes cat scratch fever is called Bartonella henselae.

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An True Unsung Hero

How the bacteria that causes cat scratch fever got its name is quite an interesting story. There is a disease (known by its medical term as verruga peruana) that has effected humans living in the high Peruvian Andes Mountains for over 5000 years. Pre-Inca pottery and stone carvings show victims with numerous, red, wart-like skin nodules all over their bodies.

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Ancient Inca Pottery Showing Carrion’s Disease: Photo by xsierrav.blogspot.com/

Fast forward to 1885: a young Peruvian medical student convinced that there was a link between that disease and another fatal disease known locally as Oroya fever, inoculated himself with blood taken from a patient with verruga peruana warts. Dr. Daniel Alcides Carrión Garcia subsequently went on to acquire symptoms of Oroya fever (severe fever and anemia (low red blood cell count), muscle pain and jaundice) and shortly thereafter, diedfrom his experiment.

But he had proved that Oroya fever was just the early phase of the chronic disease, verruga peruana. In honor of his sacrifice for the good of science and humanity, the combined sicknesses are now known as Carrión disease. October 5th, the day he died, is known as Peruvian Medicine Day.

 

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Highway where Dr. Carrion made his discovery. Photo by: itg.author-e.eu/

Dr. Bartonella

Moving ahead a few more years: In 1905, a disease characterized by high fever, anemia and quick death broke out among railroad workers building a railway between Lima and La Oroya, a mining town in the Andes. Another Peruvian scientist named Alberto Leonardo Barton determined that the outbreak was another form of Carrión disease.

As a result of his studies, he was able to isolate and identify a bacteria that whose genus (part of its scientific “family” name) ultimately went on to be called Bartonella. Scientist have so far, by my last count, identified 14 other species of this bacteria.

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Photo by: http://www.pitt.edu/

The Last Part of the Puzzle

It then wasn’t until around 1985 that a microbiologist named Diane Hensel , while working with AIDS patients at an Oklahoma Hospital, identified and isolated the specific agent responsible for causing cat scratch fever. In honor of this discovery, the science community named the new species of Bartonella after her, Bartonella henselae.

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Emerging Infectious Diseases. 2008 Jun; 14(6)

Cat Scratch Fever in Cats and Humans: Part 2 of 3

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Now the hard part: Humans and cat scratch disease.

Cat Scratch Disease is no longer as simple a topic as when I first learned about it 30 years ago in veterinary college. Even worse, I’m surprised at how little medical science—in spite of the tons of research being done—can still tell us with absolute certainty about the problem. A bit of personal disclosure before I begin. Firstly, one of our many jobs as veterinarians is to be constantly on the look-out for zoonotic diseases. These are diseases that can affect both humans and animals.

As a matter of fact, this public health aspect of our business morally and ethically takes precedence over saving the lives of cats and dogs. Second, even though I can’t (or won’t) legally give human medical advice, my clients will still often seek my opinion anyway. And so I try to keep up on this stuff. Other than medical conferences, my main sources of information when wanting to further expand my knowledge of zoonotic diseases are the Centers for Disease Control (CDC) and the American Academy of Family Physicians (AFP) websites. For the bulk of this informational blog, I shamelessly rely upon—but try to simplify—their advice.

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Bartonella Rash: Photo from http://www.Lyme Disease.org

Cat Scratch Disease in Humans and Adults

In children and adults with healthy immune systems, the first and foremost thing to remember is that most cat scratches do not result in cat scratch disease. If this was indeed the case, caring and loving, health-conscious, mothers would long ago have eliminated the domestic cat from the planet! With the exception of one of the vet technicians who worked at the practice where I interned at, in the whole of my 25 years since I’ve hung up my shingle I’ve not heard of a single case of the disease. I have, however, suspected it a few times in cats.

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Enlarged Lymph Node; Photo by CDC

That having been said, it is estimated that there are up to 24,000 cases a year in the U.S. that require some degree of hospitalization. Although anyone of any age can catch cat scratch fever, people less than 21 years old are the most likely to become infected. As a general rule, symptoms of the disease appear 3 – 14 days after a scratch, bite, or lick. And because they state the symptoms of cat scratch disease in humans so clearly, I’ll use the following quote from a CDC website:

“About three to 14 days after the skin is broken, a mild infection can occur at the site of the scratch or bite. The infected area may appear swollen and red with round, raised lesions and can have pus. The infection can feel warm or painful. A person with Cat Scratch disease may also have a fever, headache, poor appetite, and exhaustion. Later, the person’s lymph nodes closest to the original scratch or bite can become swollen, tender, or painful.”

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Enlarged Lymph Node: Photo by CDC

 

My recent researches of the human medical literature suggest there is some controversy regarding treatment of cat scratch fever. I’ll again quote a CDC webpage: “The use of antibiotics to shorten the course of disease is debated. Most cases of cat scratch disease (CSD) resolve without treatment, although some patients may develop complications from disseminated disease [my emphasis]. The antibiotic azithromycin has been shown to decrease lymph node volume more rapidly compared to no treatment.”

A Defense of My Human Physician Colleagues

Even after 25 years of practicing veterinary medicine, every once I still get that mysterious sick dog or cat where I have to stand back, scratch my head, and ask myself, “what in the heck (not the exact word I use) is going on here. Before continuing on with my sharing of what I know about complicated cases of cat scratch fever in both healthy and immune compromised people, I need to make a bit of an editorial.

“Some patients may develop complications from disseminated disease.” This innocent-looking, little sentence fragment from the above mentioned Centers For Disease Control’s quote is what makes me thank our dear God daily that I decided to go into veterinary vs. human medicine.

After much very in-depth reading of the seemingly infinite and contradicting diagnoses possible as the result of an infection (or not) with Bartonella henselae, I don’t envy my physician counterparts one bit in their struggle to come to some sort of conclusion with regards to cat scratch fever and their affected patients. The absence of a consistently reliable test, the fact that there are so many other diseases that can mimic (look like) the disease, and the even the lack of agreement as to how the disease is spread or of how it should be treated—all of which has to be filtered through our present-day “managed healthcare” system—makes a doctor’s job, in my opinion, nearly impossible to accomplish.

Disseminated Disease In People With a Healthy Immune System

“Disseminated disease” (as stated by the Centers For Disease Control’s quote above) is a medical term referring to a disease that is spread throughout an organ or the body. In people with a healthy immune system, the American Academy of Family Physicians’ website mentions that the following are rare complications of cat scratch disease:
●encephalopathy, a broad term for any brain disease that alters the brain’s function, which in cat scratch fever can manifest itself as severe headache and acute confusion one to six weeks after the onset of the enlargement of a patient’s lymph nodes. Seizures may occur, and some patients may have focal neurological deficits (nerve disease that affects a specific location in the body such as a tongue, either arm, one side of a face, one eye, etc.) that are self-limiting, but can last up to one year.
●endocarditis, an infection of the inside of the heart, usually involving the heart valves.
●meningoencephalitis, an inflammation or infection of the brain and/or spinal cord.
●Parinaud oculoglandular syndrome (POS), a severe conjunctivitis “pink-eye” that involves the lymph nodes of the neck. [I’ve tried to make the description of this eye disease as easy to understand as possible. POS is a lot more complicated and has many more causes.]
●Neuroretinitis, is an inflammation of the nerves of the retina of the eye and the optic nerve, leading to partial loss of vision.
●And probably a lot more as-of-yet undiscovered disease connections.

Disseminated Disease in People Who Are Immunosuppressed

Besides any of the above ailments, Immunosuppressed people who are unfortunate enough become infected with Bartonella henselae and/or its “cousin” Bartonella quintana potentially can fare much worse. The two most frequently mentioned diseases are:
●Bacillary angiomatosis, a disease characterized by the formation of red, round, nodules in the skin cause by the uncontrolled growth of blood vessels. While this skin form is the most common, it can occur in other parts of the body as well including the respiratory and GI tract, the brain, bone marrow, lymph nodes, liver and spleen.
●Bacillary peliosis, a not-well-understood disease in which the liver and/or spleen become affected by cystic, blood-filled cavities.

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Ticks: Photo from http://www.jamestownri.gov

Bartonella henselae and Ticks

This is one of two other considerations to keep in mind with regards to cat scratch fever: the first is the possibility of Bartonella henselae being spread by ticks, and the other is the concept of Bartonella henselae co-infection with Lyme disease. I’ll start off by saying that the evidence for cat scratch fever being spread by ticks is quite strong, but there is no objective scientific proof that transmission of the disease actually can happen. The greatest proof of this spread being a real possibility is that researchers in both the U.S. and Europe have found the organism in the Ixodes Scapularis tick (the species of “deer tick” responsible for Lyme disease.)

Bartonella and Other Co-infections

Finally, I would like to end this brief summary of cat scratch fever by calling attention to the concept of co-infections of Bartonella henselae (as well as other tick-borne diseases) and Lyme disease. (Co-infections means being infected with two or more diseases.) I must again make it clear, that as of this writing, medical science is still undecided as to whether Bartonella co-infections (as well as the other tick-transmitted organisms) can result in more serious illness.

In a 2013 survey of over 3000 critically affected Lyme disease patients sponsored by LymeDisease.org, tick-borne co-infections were confirmed by serological testing in over 53.3% of the individuals who responded! The rate of co-infection with a Bartonella species was 28.3%. As an aside, here was the co-infection breakdown for the other tick-borne diseases.
●Babesia, 28.3%
●Ehrlichia, 14.5%
●Anaplasma, 15.1%
●Mycoplasma, 5.1%
●Rocky Mountain Spotted Fever, 5.6%
●Tularemia, 0.8%

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Author’s Cat Tuxie

My Humble Conclusions

In conclusion, I’d like to share my thoughts on these last two issues. Yes! it is frustrating how little medical science can give us with regards to a straight answer as to the concept of co-infections; even something as seemingly simple as to whether or not animals and humans can catch the disease from a tick bite! But this is because the problem is not simple! Ticks have been on this earth for over a hundred million years an they’ve learned to adapt to every situation the world has presented them with. Scientist have even found a Borrelia species (the bacteria that causes Lyme disease) in a 15 million year old tick that had been preserved in amber!

But with that having been said, in the course of my daily life as both a veterinarian and a living, attentive person, I see an awful lot of very sick people (and a few animals) who have been diagnosed—or not—with Lyme disease, whose doctors just can’t seem to help them any longer.

Therefore I close with what I believe is the most prudent advice I found as it pertains to cat scratch fever, ticks, and co-infection with Lyme disease. It is given on the Columbia University Medical Center-Lyme website and I quote it directly. It is presented, somewhat, in medical jargon, but the last sentence brings it all home:

[The bold emphasizes are my own.] “The clinical manifestations of tick-transmitted bartonellosis are essentially unknown. They may resemble cat scratch disease, take other clinical forms, or be benign. It is also unclear if Bartonella co-infection with other tick-transmitted organisms can result in more serious illness; some of the few reported cases of concurrent B. burgdorferi (the bacteria that causes Lyme disease) and B. henselae (once again, the bacteria that causes cat scratch fever) infection in the medical literature appear to suggest this could be the case. Thus, it may be prudent to consider the possibility of Bartonella co-infection in cases of poorly resolving or apparent relapsing Lyme disease.”

A few More Resources

Cat-Scratch Disease in Children

The Official Lyme Disease.org Report

A Non-veterinarian Resource For Cat Owners

 

Dear Reader: Thank you. If you feel this article can help a friend who may be suffering from Lyme disease—any of the tick-borne diseases—please share.

Cat Scratch Fever in Cats and Humans: Part 1 of 3

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Author’s Cat Tuxie

Cat Scratch Disease

Before beginning, I need to make it clear that this article is NOT about Ted Nugent’s famous/infamous rock and roll classic that our parents in the late 1970s forbade us all from listening to. Regrettably, this is something much more serious. The original idea for this article on cat scratch disease began as a request from a client of my veterinary practice. Because of a large amount of research she had done on the internet, she was convinced that she and her dog were both infected by cat scratch fever. Thankfully, subsequent testing by her doctors proved that her concerns were not true, and dogs don’t catch cat scratch fever. But her panic from all of the misinformation that’s out there in cyberspace made me want to share what I know on the subject.

A second inspiration was some of the recent  information I’ve been seeing in my readings on the concept of co-infections of cat scratch fever with that of Lyme disease! In my business and personal life, I’ve met—or have heard about—maybe a hundred people who have been disabled or who have died from complications of Lyme disease. All of this misery in spite of the hard work and loving care by my human physicians counterparts. I can’t seem to get it out of my mind that one of the millions of possible reasons medical science just couldn’t seem to cure these lovely people is perhaps the notion of  the co-infection link was never considered.

My Sincerest Wishes

My hopes for this series of three articles is to increase the general awareness of cat scratch fever and to provide readers with a general resource to help people better battle health issues that can affect both themselves and their pets. Trying to explain this stuff won’t be easy; that’s because the subject isn’t easy. And to further complicate it, medical science, for all of its wondrous advances, can’t explain it all either.

The Disease Is Not What It Used To Be.

Cat scratch fever was one of thousands of diseases in animals and humans that I’d learned about in vet school. Back in those dark ages of the late 1980’s, the causative agent of sub-acute regional lymphadenitis (a medical term for cat scratch fever) had just been discovered! We basically learned back then, that with the exception of immune-compromised people (patients on chemotherapy or people who have AIDS), the disease was—and still is (somewhat)—a self-limiting.

That is, it’s a disease that usually goes away without treatment. In the years since then, however, after attending many medical conferences and doing some extensive research, things have changed. One of the more curious and potentially valuable information I found in my studies was its link to Lyme disease. Please see Part 2.

Cat Scratch Fever In Cats

Cat scratch fever is a disease that affects both cats and people and is caused by an infection with a bacteria called Bartonella henselae. Because I believe in the personal survival concept of “always knowing as much as possible about your enemy” I have created a separate blog page (Part 3) in which I discuss the bacteria at some length. This way people who are affected by this disease can actually see and understand more about just what it is that’s making them sick.

First, here’s some information on cat scratch fever disease in cats. This part of the story is pretty simple. Most of the time, cats don’t obviously suffer from the disease. A very observant owner may notice a decrease in their pet’s appetite or the cat may seem reluctant to move for a few days. A veterinarian exam may demonstrate a mild fever or enlarged lymph nodes . . . which are symptoms of about a million other different diseases. Estimates of affected cats range from 40 – 60%.

The most important thing to remember regarding how cats become infected with the disease is that the bacteria (Bartonella henselae) that causes cat scratch fever lives in the digestive tracts of fleas and is excreted on to the cat’s skin in the flea’s feces. Cats then become infected with the disease as they consume infected flea poop while they groom and scratch themselves. Another way they can catch the disease is through fighting with an infected cat. Although the medical literature is still completely undecided, there is a third possibility that ticks may be involved as well. More on this later.

Your Cat’s Main Enemy

Therefore, the best way to prevent your cat from getting infected with the bacteria that causes cat scratch disease, IS TO CONTROL THEIR FLEAS. Excellent flea control products are available everywhere. Be sure that the product you are using is labeled for cats! Check the pet regularly with a flea comb. [I will mention the possibility of the disease being spread by ticks later.]
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Enemy #1: The Cat Flea: Photo by http://www.petsandparasites.org/

 

Be sure she sees her veterinarian at least once a year to not just check for fleas, but to insure her good health overall. Be sure to trim his nails regularly. (With regards to being around immune-compromised individuals–and keeping in mind that it may be a bit controversial–declawing the cat may be warranted.) Other general commonsense recommendations are to wash cat bites and scratches with soap and running water, don’t allow cats to lick open wounds, and don’t pet or handle stray or feral cats.

There is a test for cats suspected of being infected with Bartonella henselae, but it is not very specific. Cats with symptoms of the disease usually cure themselves.

 

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An Excellent YouTube Video Showing Fleas

 

Summarized List of Tips to Help Avoid Cat Scratch Infection

-Trim your cat’s nails frequently. Consider declawing in extreme circumstances only.

-Apply veterinary approved flea control products to all cats and dogs in your home monthly.

-Control fleas in your home by frequent vacuuming and by preventing non-flea-controlled animals from contacting your flea-free pets. Severe cases of flea infestation may require a pest control expert.

-Insure your pet’s overall good health by seeing her veterinarian at least once a year.

-Do not allow contact with other stray animals.

-Consider adopting older cats especially if you have young children or people living in your household with weakened immune systems.

-Always try to wash your hands after playing with your pet. Never allow cats to lick an open wound.

-Avoid situations where a cat may be tempted to bite or scratch such as playing rough or by handling feral animals.

In Part 2, I discuss the disease in humans and co-infection with Lyme disease.

Euthanasia For A Beloved Pet: 11 Questions You Should Consider

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Dedicated to Suzie: The Best Cat To Ever Walk the Planet

Stranger by the roadside, do not smile
When you see this grave, though it is only a dog’s.
My master wept when I died, and his own hand
Laid me in earth and wrote these lines on my tomb.
-Anonymous Greek Poet, 300 BC

Making the Decision to Euthanize a Beloved Pet: a Quick Checklist

The decision as to when is the right time to put our beloved furry friend to sleep has to be among the hardest of questions an individual or family will ever have to make. This is because the answer as to the right time is loaded with what seems like an endless amount of complications and emotional contradictions. That is, there are so many sources of information and input that are involved in making this most difficult of choices that it is almost impossible to list each question and then summarize every one.

Therefore, in this quick checklist, I provide only the most basic of thought-provoking questions. And that is all that anyone can do. Ultimately, the final determination you make still rests with you, the precious pet’s loving owner.

In closing, I’d like to remind the gentle pet owner that this guide represents only my personal observations on this very sensitive subject. There are probably as many ways to approach this difficult task as there are stars in the sky. My sincerest hope is that this guide will help make your path just a little bit easier.

1. Who is the dog or cat’s primary care-giver?

As simple as this question sounds, the answer is probably the most important one that needs to be decided. And it needs to be decided early in the process because sometimes the owner and the primary care-giver are not the same person. It is important to know the answer because someone, ultimately, will have to make the final decision. The answer to this question can be a real can of worms; however, if the pet is lucky at this end-time of its life, the primary care-giver and his or her owner will be one in the same and all will go smoothly.

2. Has a recent, objective, overall-health assessment of the pet’s condition been made by a veterinarian?

As the primary care-giver of an aged (usually), chronically ill, or mortally wounded pet, you may instinctively feel that you know what’s best for your pet. But unless you are a practicing veterinarian, you really can’t; especially if you and the animal are very close. Because you’re often too emotionally involved.

This question also serves a double purpose. A visit to a veterinarian will help to confirm your instincts with regards to your pet’s actual quality of life from an objective, medical point of view. Or, as is frequently the case, it may also yield some suggested drugs or therapy that may greatly improve your pet’s quality of life and will then allow you to have more time with them.

***An important side note: As a primary care veterinarian who has practiced front-line veterinary medicine and surgery for twenty-five years, I often see pet owners who have waited too long before bringing their pet in to see me, at which time I’m no longer able to reasonably help the animal. When asked why they waited so long, the answer without fail is: “Doc, I was afraid you were going to force me to put my beloved Fido or my sweet little Fluffy to sleep.”

Although I talk about this problem at some length in the book, I now will SHOUT the following statement as simply and as strongly as I can! Most beloved and gentle reader, at least here in America:

TO THE BEST OF MY KNOWLEDGE AND EXPERIENCE AND PROVIDING YOU ARE OF SOUND MIND, THE ONLY PERSON WHO CAN FORCE YOU (AS THE ANIMAL’S OWNER) TO PUT YOUR PET TO SLEEP IS A JUDGE VIA A COURT ORDER. YOUR NEIGHBOR CAN’T, YOUR KIDS CAN’T, YOUR VETERINARIAN CAN’T, OR YOUR MOTHER-IN-LAW CAN’T!

3. Do you feel you are being forced in one direction or another with regards to euthanizing your pet? Or worse, are you being made to feel guilty?

Are you considering putting your precious pet to sleep because you, as the dog or cat’s primary care-giver, feel that their time has come? Or is it because a visiting mother-in-law, a well-meaning friend, or some other person who may have absolutely no business to do so tells you that the pet is “suffering.”

4. Have you considered the dog or kitty’s quality of life from your pet’s point of view?

The term quality of life has as many definitions as there are people on our planet. This is because everyone has their own worldviews that are based upon their individual life’s experiences, their basic personal natures and sensitivities, their maturity (or lack of maturity), and, sadly, their social and political circles. There are people who feel that as long as there is life, then everything possible (which also is a confusing term) should be done to extend it. There are others who feel that animals should not have to suffer any misery or discomfort at all.

Additional Questions to Ask When You’re at a Veterinarian’s Office

5. As your pet sits on an exam table between you and a veterinarian, are you and she sharing at least a few common values and opinions?

This is important on many levels. This is because, when all is said and done, regardless of whatever decision is finally made, it is important for your peace of mind that both you and the veterinarian should come away with some sense of the right thing having been done.

6. Do you feel you’re being pushed in one direction or another into doing something you’re not comfortable with? Is the doctor clearly sharing and explaining to you his reasons and thought processes?

If you find yourself feeling uncomfortable with whatever discussion is taking place, there’s a chance you’re probably correct. Be cautious, but don’t always first assume you’re being taken advantage of. People often confuse sinister intentions with a simple lack of communication; you may have an opposite worldview from that of the veterinarian with regards to end-of-life issues, or you’re simply both just a bad fit.

It’s important to remember that veterinarians are people, too. We all have our hopes and dreams, our life’s experiences, and our points of view. We have mortgages, student loans, kid’s braces, and family obligations that must be filled.

7. As the pet’s primary care-giver, are you willing or able to perform any aftercare that may be required to save or extend your dear pet’s life?

This is a huge concept to keep in mind. This is because very often, in the passion and desperation of the moment, difficult and sometimes lengthy aftercare needs are frequently not factored into your decision.

8. Have you seriously considered your precious dog or cat’s age, their personal temperament, or their tolerance for the possible demands of hospitalization and/or long-term care that is about to be thrust upon him or her?

This is a question very few pet owners ever consider. Even if you’re willing to sacrifice yourself for your pet’s sake, will he or she be willing or able to go along with your wishes? Because we humans are thinking and rationalizing creatures, we have the ability to project our lives into the future. That is, if we are sick or injured, we are able to have reasonable expectations that whatever medical procedure is going to be performed on us, we will know that someday we will be better.

Dogs and cats don’t. All they know is that somebody who has always treated them with nothing but loving kindness is now jabbing them with needles every day, is making them  eat a special diet that they absolutely hate, and is forcing them to spend time in a hospital with other people who are jabbing them with needles, etc., as well.

9. Can you afford any heroic lifesaving or life-extending procedures for your pet?

This is a devastatingly difficult question that the vast majority of my treasured clients have had to grapple with when confronted with lifesaving or life-extending treatment for their aged or injured pet. Yes, it is unfair that money has to come into the picture, but that’s just the way the world works.

10. Is the ultimate decision you are trying to make in your dog or cat’s best interest, or are you doing (or not doing) it for your own sake?

This is a tough, tough question! From both my personal and professional experiences of having to confront both sides of the realities of pet euthanasia, I know that this question—at least on its surface—may sound a bit insensitive. But it still needs to be asked. If I didn’t ask, I would not be fulfilling the oath I took when I became a veterinarian. Sorry.

11. Finally, when all has been said and done, and you find yourself still confused and/or undecided, what should you do now?

This is a tough question as well, and I discuss this common aspect of the euthanasia decision-making process and make some detailed suggestions in the body of this book. But for now I will just say this: The question as to whether it is the right time to put your beloved pet to sleep can never be answered absolutely. Except in the most obvious of cases, there will always be doubts and second-guessing. All we mere mortals can do is the best we can with the resources and information we have at the time, and then move on.

However, having just said that, it has been my experience that if you are still completely baffled as to what to do, don’t do it. Period! At least not yet. If after going back and forth, and back and forth, and back and forth, and you still can’t come to a reasonably clear decision, my experiences have been that it is best to wait.

 

My Sincerest hope:

My sincerest hope is that this short checklist has been of some small help in deciding if your beloved pet’s time to “cross the Rainbow Bridge” has arrived (or not, hopefully.) If you have found these questions helpful, please share this link with your friends. It really is nice to know that people actually read my humble posts. If you have any thoughts or comments, please find the comment link below.
This checklist can be downloaded by clicking on the PDF download below. I also have a personal request: These questions were designed to go along with a book I’ve written specifically to help pet owners at this most difficult time. I have examples and comments on all eleven of these questions. Purchasing it, either as a Kindle or Amazon paperback, will help me pay for the costs of these blog posts.
Thank you,
Dr. Richard Orzeck
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PDF Download of this article

 

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