Monday, December 30, 2013

Hanging In - Cancer Cat Episode 4

Neelix gets a pill every day except Sunday. Monday, Wednesday, and Friday it is the Palladia, and we have to wear chemo gloves. It's a small pill and not much of a problem. Maybe the feel of the gloves opening his mouth is distracting.

Tuesday, Thursday, and Saturday, he gets Piroxicam. It is a capsule and not as easy to get down him. One dose turned into a mushy ball before we could get him to swallow it, it had been spit out so often.

He went back to the oncologist today. He weighed in at 9.6 pounds, problematic, because he was 9.94 just two weeks ago and 10.1 six weeks ago. He still seems to eat as much as he always did. He developed a craving for raw catfish, which our oldest female cat likes, so now I have to buy enough for two and he is rejecting his usual food waiting for catfish. The oncologist said the bump on his nose was actually a little smaller and has not broken through into his mouth or eyeball.

My husband thinks he is more "wound up" when he's awake. I think he sleeps more and sleeps sounder than before. I think both of us are exaggerating how he's always been.


2003 when he was one.

Tuesday, December 17, 2013

What To Do, What To Do - Cancer Cat Episode 3

I got an email today from the foundation saying "the medical advisory board denied your application because Neelix's prognosis could not be determined."

I wrote back to verify what that means, because we weren't told when he is going to die? As if something like that is knowable? Apparently so. They need to be told your pet has four months or less to live.

Then I was offered $306.60, which would be sent to the oncologist. That would cover almost one more two-week round of medications and testing. But the contract I have to sign to receive that also says I still have to volunteer 120 hours. That's 120 hours away from Neelix and values my time at barely $2.56 an hour, but it's volunteering after all. Still, it seems like the volunteer time should be prorated based on the amount of assistance you're awarded. 

I don't know what to do.

Yesterday Neelix started the Palladia, which he gets on Mondays, Wednesdays and Fridays. The Piroxicam is on order. We got the pill down him on the second try.

If you would like to donate, dear reader.

Wednesday, December 04, 2013

Trip to the Oncologist - Cancer Cat Episode 2

SUMMARY:
·         Primary Complaint:  Nasal Adenocarcinoma (biopsy diagnosis)
·         Assessment:  Neelix’s assessment confirms the presence of a nasal adenocarcinoma. We discussed the biologic behavior as locally aggressive with a low potential for metastasis. We discussed staging with chemistry/CBC/UA, thoracic radiographs +/- abdominal ultrasound. Local therapy with radiation is the treatment of choice (Linear Accelerator or Cyber Knife) but systemic treatment options including chemotherapy (alternating doxorubicin and carboplatin has proven efficacy in a small number of dogs but has not been evaluated in cats), metronomic therapy, or Piroxicam alone are also reasonable. Additionally, symptomatic therapies can be instituted.
Plan: Chemistry/CBC is pending. Owner is considering staging tests and therapeutic options


History: Neelix presented for evaluation of recently diagnosed nasal adenocarcinoma. The owners noticed a swelling on the right side of Neelix’s nose in early October 2013. He was otherwise acting normally. The owners monitored it for a couple weeks thinking it might be an abscess or bite of some kind. There was no change in the mass and he was seen by a local veterinarian for the mass in mid-October. He seemed uncomfortable when his mouth was opened and swatted at the doctor and owner. A tooth root abscess was suspected and he was started on a 10 day course of azithromycin. There was no change in the mass on the antibiotics. (Evaluation 10-29-13). A Cryptococcus titer was negative and a biopsy was recommended. Neelix had an incisional biopsy on 11/8/13. Histopathology results were a nasal adenocarcinoma.

I am sorry now I even mentioned Neelix fighting me at the first vet, because I really think it was more about my making him wear his sweater and not bringing the carrying case than a pain issue.

Past Pertinent History: Had severe URI as kitten and has always had stertor since then.

I learned a new word. We always called his breathing Darth Vader.

Current Medications:  None


Physical Examination:  T= 97.5 F, P= 240 bpm, R= 32 bpm. Wt. = 4.64 kg (10.2 lbs.) Bright, alert, and responsive. Body condition score of a 5/9. Pink and moist mucous membranes with a normal capillary refill time. Stertor noted. Normal air flow from both nostrils. Mass effect (~1cm length) on right side of nose. No mass effect noted intraorally. Significant dental calculus with multiple resorptive lesions noted. Both eyes retro pulse normally. No murmur or arrhythmia ausculted. Lungs clear with referred upper airway noise. Unremarkable abdominal palpation. All peripheral lymph nodes within normal limits. Small (2-3mm) dermal mass left ventral abdomen. The remainder of Neelix’s examination was unremarkable (rectal, ophthalmic, musculoskeletal, and neurologic). 

Diagnostic Tests:
  1. Review of medical record and biopsy:
    1. Cryptococcus antigen titer 10/30/13: negative
    2. Biopsy (incisional) of the right nasal cavity mass 11/13/13: Nasal adenocarcinoma with features that suggest possible adenoid cystic salivary carcinoma of the soft palate.
                                          i.    The specimen from the nasal cavity consists of a malignant neoplasm derived from the epithelial cells most likely respiratory mucosa, i.e. a nasal carcinoma
                                        ii.    The neoplastic cells vary from round to cuboidal have small amounts of eosinophilic cytoplasm and round to ovoid nuclei containing finely granular chromatin and a single small nucleolus.
                                       iii.    Neoplastic cells are present in varying sized nests and nodules surrounded by a thin fibrovascular stroma. In some of the nodules, neoplastic cells are forming small glandular or acinus-like structures.
                                       iv.    This neoplasm has some features that suggest a salivary gland origin, a finding that makes it possible that this could be a so-called adenocystic nasal carcinoma that arises from the salivary glandular tissue of the soft palate rather than the nasal mucosa.
                                         v.    The neoplasm extends into the margins of the specimen submitted
  1. Chemistry 12/2/13: unremarkable
  2. CBC 12/2/13: Eosinophils 2580, otherwise unremarkable
  3. Diagnostics discussed for staging but declined at this time: 3 view thoracic radiographs and an abdominal ultrasound
    1. The abdominal ultrasound is a low yield test with regards to metastatic disease and is recommended to look for concurrent disease that may affect treatment decisions.

Diagnosis:  Nasal Adenocarcinoma  

Treatment Administered: Convenia 37mg SQ for significant resorptive lesions in the mouth to protect against secondary bacterial infections and discussed oral Buprenex as the resorptive lesions are likely painful

Medications Recommended: none

Assessment/Tumor Biology: 
Recommendations are below in order of preference priority:
1.  Definitive radiation therapy
2.  Chemotherapy (alternating carboplatin/doxorubicin)
3.  Palliative radiation therapy 
4.   Metronomic therapy
5.   Piroxicam alone

Neelix was diagnosed with a nasal adenocarcinoma on biopsy samples. Feline adenocarcinomas are cancers that arise from epithelial/glandular cells. Tumors are locally invasive and extend into adjacent normal tissues. In addition to the local disease, feline adenocarcinomas have the potential to metastasize, although this is usually less of a problem and generally occurs late in the disease course; regional lymph nodes and the lungs are the most common place of disease spread. We recommended staging with thoracic radiographs prior to radiation therapy or chemotherapy. Prior to radiation it would be indicated to evaluate both local lymph nodes (submandibular) to better plan the radiation therapy in case the lymph nodes will need to be included in the radiation field. There is limited information in the literature regarding treatment of this tumor type in cats and more is known with regards to its treatment in dogs. The most information available is in regards to radiation therapy. 

Radiation therapy
Given the behavior of nasal adenocarcinoma, local therapy, consisting of radiation therapy +/- surgery is the foundation of treatment. Prognostic variables associated with this tumor type in dogs are histologic subtype, advanced tumor stage, and presence of metastatic disease but these variables have not been reported on in cats. Surgery alone rarely improves survival times (1-4 months survival time) while definitive radiation therapy alone can result in median survival times of about 1 year.

A year? I know that is several years in cat time, but not much for the expense and pain considering Neelix's lack of a sense of time and my budget.

Unfortunately, radiation therapy is not offered at this locality at this time. Radiation therapy is about $5,500 and would require daily anesthesia Monday-Friday for about a month with a definitive protocol. A palliative protocol with the intent of stabilizing the tumor for 2-6 months would be about $2,500 and would be significantly fewer treatments and could be considered if the tumor seems to be causing Neelix discomfort. A CT scan would be recommended for radiation planning and costs around $1,500. Side effects of radiation include acute effects (skin irritation, oral irritation, ocular irritation, and oronasal fistula) and late effects which occur in roughly 5 percent of cats on average 5 years after radiation (bone necrosis, a new tumor developing, and cataracts). Acute side effects are more likely to occur with definitive radiation than palliative radiation but can be seen with either type or protocol. Cats typically tolerate radiation well and experience fewer side effects than dogs.The type of radiation protocol is dependent on the radiation oncologist in discussion with the owners.

Holy cow, this is not going to happen. Neelix and I are not roadtripping to torture-ville in Maryland or North Carolina, neighboring states where radiation is available. He would not understand the whys of that at all.

Chemotherapy
In one study of 8 dogs, chemotherapy alone (alternating doxorubicin and carboplatin) resulted in 50 percent of dogs having a complete response and an additional 25 percent having a partial response to therapy. Both of these agents have been used in cats with other types of carcinomas with varying effect (depending on tumor type). This specific protocol has not been evaluated in cats with nasal adenocarcinomas so expected response rates for cats are not available but it would be reasonable as an attempted therapy in Neelix. As discussed, monitoring responses in the dogs required repeated advanced imaging so we would recommend completing the protocol as long as he tolerates the chemotherapy well and he does not show signs of progression. Neelix is very nervous here in the hospital. It is possible that he may need sedation for chemotherapy in order for him to be still while it is being administered and minimize the risk of the agents getting outside of his vein which could damage the surrounding tissue. Side effects with chemotherapy include a 1:10 chance of vomiting and diarrhea and a 1:100 chance of life threatening side effects including severe WBC suppression that would put Neelix at risk of infection. Routine thoracic radiographs +/- abdominal ultrasound are recommended throughout therapy to assess response. Please be aware that Neelix will be shedding chemotherapy metabolites, which can be carcinogenic (cancer causing) in his urine, feces, and saliva for 48 hours after each dose of chemotherapy. Please wear gloves when handling his urine or feces and wash your hands well. Please do not allow pregnant women, women planning to become pregnant, immunocompromised people, or young children to handle his waste products.

Not only is Neelix very nervous here at the hospital, he would be a toxic waste dump for 48 hours after each treatment. 

Metronomic therapy
An alternative, less aggressive option to radiation and injectable chemotherapy, is metronomic therapy. Metronomic therapy involves the administration of one or more oral medications (Piroxicam, cytoxan, chlorambucil, Palladia, doxycycline) aimed at disrupting the blood supply to the tumor and thereby inhibiting tumor growth. Additionally, piroxicam (an NSAID) alone is likely of some benefit since nasal adenocarcinomas in dogs can overexpress COX-2 (81 percent of canine cases), although again this has not been evaluated in cats. However, NSAID’s can cause renal damage in cats so Neelix would need to be monitored really carefully to make sure we do not cause acute renal failure. The most common side effect from oral Cytoxan is sterile hemorrhagic cystitis (irritation to the bladder wall), which would make it uncomfortable for him to urinate. This side effect is extremely rare in cats since they have access to a litter box so they can urinate frequently. Chlorambucil is very well tolerated in cats but can cause bone marrow suppression with time. The palladia can cause damage to the kidneys as well but it is usually glomerular damage rather than tubular damage.  As discussed, there is no information available regarding the length of time that is the most beneficial with this therapy and the recommendation in humans is to continue until progressive disease is seen.  

I have been Google-searching these drugs and have yet to find anything exciting and encouraging. One cat, whose owner started a blog for her pretending to speak in her voice -- I find this really annoying story-telling, because cats are not humans and do not think that way -- was dead three months later despite the Palladia or Piroxicam. The blog just stops, and then there's one more entry three YEARS later explaining the cat died. I feel the Cytoxan is going to be too much, but I so much want the other drugs to keep the tumor small. The drugs themselves do not cost that much, but the office visits and blood work they insist you do every two weeks or monthly or whatever is what runs your bill up to the equivalent of a car payment every month.

I filled out all the paperwork for Fetch-a-Cure. If I got the maximum grant, that would buy us three months treatment, I think, but then I have to volunteer 10 hours a month for a year, which isn't a problem except being immersed in cancerland so intensely for so long. I cry in the shower so no one can see me.

Needed a nap in his favorite chair after exhausting visit to oncologist.


Friday, November 15, 2013

Clouds Gather - Cancer Cat Episode 1

After watching and wondering what was going on with a bump on the side of Neelix's face, which was tender to the touch, I took him to the shopping mall vet that was open late on Friday. Their behavior should have clued me in that it was not good. They gave me a week's worth of antibiotics and warned me Neelix would probably need to be sedated and the bump examined. Maybe it was a dental problem. He was so furious about having the bump touched, about being in the sterile room, that he clawed my arms until they bled. He hissed all the way home. He normally tolerates car rides better than that.

I wish that was true now, that it was just a dental problem. After another two weeks, and the antibiotic making no change, I went to who is now becoming my most trusted vet. I took a day off from work to have an appointment during the calm daytime hours, not the crazy evening clinics two nights a week. They said surgery. They said $500.

So I brought him back a few days later. He was not happy. I had to leave him. They kept him all day. He hissed all the way back home. His face looked like they had just extracted with a needle some of whatever was in the bump. That was Nov. 8. The results came back Nov. 13. He had cancer. Nasal adenocarcinoma, and immediately my stomach tightened. Can it be cured? No. If you've got cancer, it is always there, just waiting. You buy time. Time is expensive to buy and the treatment is as grueling as the disease. It's just a matter of choosing how Neelix should die, and I have no idea when he will die from it naturally, so how will I ever know if the investment in care actually added time or not? It is one giant unknown. The only thing for sure is it will cost money. And Neelix will not like it.

Just finding out what treatment will entail and how much it will cost costs $200. That's how much an oncologist charges for a introductory examination.

This is the valley of the shadow of death and it is suffocating. I feel like I can't be happy about anything until this story is over. I feel guilty about anything I buy, thinking, maybe I should have spent that money on trying to save Neelix.

The vet recommended a support group that provides funding for cancer pets, but the application is daunting. I would have to pay for the first visit with the specialist to get the treatment plan. The specialist would have to be willing to provide me with all kinds of lab tests and paperwork. I have to give this organization all my financial data. We probably make too much money, and the fact that we owe too much money is our fault. Then I would have to volunteer 10 hours a month for a year for the organization. I don't have a problem with that except that I would be volunteering for a pets with cancer organization; I would be immersed in the despair of not only my situation, but everyone else coming to this organization for help. It would be hours spent separated from my own dying pet.

I don't know how strong I can be. It's already so hard, so unbearable, and this is only the beginning.


Sunday, September 01, 2013

Sophie's Choice (Although It Turned Out Not What You'd Expect)

As long as we had seven cats, and one of them very elderly, I was able to control my need to take in the feral cats who came around for food. I didn't want the most senior cat to be bothered by the squabbling of a newcomer when she was in her declining years, which seemed to last for two years, from the time she was 15 to when she finally died at 17.

I had made that mistake once before, although I couldn't help it. I had a unaffectionate 16 year old cat when my boyfriend moved in with his two year-old cats, and she didn't like it one bit. Her last year was spent just avoiding them in our tiny apartment. I am sorry for that, Yoda.

I am not above temptation, though. I tried to bring in Blackie once last year and put him in a big cage, thinking once all the other cats got to smell him, all would be well, but he was so horribly terrified, I felt bad for him and let him out. After that, he never let me touch him again until he got sick a year later. Then it was too late. He was on our front porch faithfully in the early morning when we left for work and when we came home from work, waiting for food. Then he would leave. He tried moving into our backyard at night and sitting on the upper deck, but Kira, one of my semi-house cats, went out on the deck in the middle of the night often, and I guess it became territorial, not that she would have minded the company. He did mind. And sometimes there was even a possum up there, so there was that.

Blackie was a tuxedo cat, mostly black with a white chest and white feet, his back legs white like knee socks, his front legs just a little like ankle socks. He was small, but muscularly built like most unfixed male cats. He was friendly, but not if you tried to touch him. Then he cringed and backed off.

It was hard keeping track of the tuxedo cats who came around. For a couple of years, there was the first one, Sylvester, who was always very vocal and never hung around for food or tried to get too close. Kira liked him and would go out on dates with him, following him wherever he went when he came around in the early evening. He would bring her back by bedtime and go on his way. Then we stopped seeing him. 

When Blackie starting appearing, more willing than Sylvester to take a hand-out, we thought maybe it was Sylvester's son. There was another one, too, also an unfixed male with similar black and white coloring, and a much larger head (aka, Whiteface, he still passes through as of 2014). Blackie didn't like him, and he only came through one winter season with Hitler, a gray and white unfixed male with the mustache inspiring his name. I once saw Hitler and the big headed tuxedo across the main road in a yard that was often frequented with a variety of cats, so I assumed after Blackie made the winning bid to eat at our house, they moved on.

Over the past year, we've seen two dead black and white cats on the main road that goes past our neighborhood, so there might have been others in this tuxedo tribe that tried living several blocks down and didn't have much luck. For weeks after each sighting, I'd have to find another way home so I didn't drive by the spot.

Then came the little solid black female we called Black Girl, and later BeeGee because Black Girl is so inappropriate. She came by every few days, always so hungry, she was willing to hang in when Blackie tried to shoo her away, so we would put her bowl on one side of the driveway and his on the porch. We thought surely she belonged to someone. After she had been coming around periodically throughout a winter and spring season, and never seemed to be pregnant, we figured she was fixed. 

The neighbors claimed she belonged to a house halfway down the block, and that house had been abandoned for just about the same amount of time BeeGee was running around the block looking for hand-outs. Did the owners move out and leave their cat behind? That sad possibility made my husband feel more affection for BeeGee than trying to rescue any of the males, so he became my partner in crime again as we tried bringing her in. Every time we gave in to her cries to go out, she disappeared for days, but then would come back. Did she live with other people somewhere else?

At the end of this summer, Blackie rejected all the food we offered. He didn't want the leftovers from the house cat's bowls. He didn't want dry food. He didn't want fresh out of the can food. We tried everything, and he didn't eat. He showed up out of habit, but didn't eat. He didn't roll over with happiness when he saw us. He just walked dejectedly up to the porch, stared at the food and left. I felt he was sick. Two or three years outside usually is all a feral or abandoned cat can do.

I tried bringing him in again, but with BeeGee closed up in my spare bedroom -- she and the resident cats had not made peace yet -- I was running out of room. I put Blackie in the laundry room, but he was clearly miserable and still didn't eat. When my husband came home, he was not happy that I had yet another feral in the house, and then we found he had befouled the laundry room with some pungent diarrhea and was in hiding. When I opened the laundry room side door to the outside, he came out and took off. 

I feel like he's dying. Our 17-year-old cat, Red, stopped eating on a Tuesday and was dead by Friday, so I figured this was Blackie's end, too, and I wanted to offer him the laundry room as a hospice, but I guess that was too terrifying for him. I feel so sad that he is meeting his end under someone's porch or in the woods, but there's nothing I can do. I can't spend hours searching for him throughout this whole neighborhood. And even if I found him, he doesn't want me picking him up, and he is afraid of the house, not comforted by it. So what can I do? Nothing.

With Red gone, we had room for one and we made the Sophie's Choice to pick BeeGee, who is not terrified of the indoors, just annoyed that there's other cats here. If she can adjust to that situation, she might have a home.

Update: Blackie recovered from whatever it was that made him tired and as of November 2013, still shows up morning and evening for meals. BeeGee, meanwhile, still has not adjusted to the other cats and lives alone in my office/bedroom, closed up all day. In the spring, I will have to let her back out to live the life she wants.

Second Update: It may not be Sophie's choice after all. In the winter of 2014, I was able to actually catch Blackie one day and get him in a cage. It was surprisingly easy. I forgot all about being home sick and went into action, calling every vet and rescue group in the area looking for someone who could neuter him and get him some shots that day. The only one who came through was Locke Taylor DVM, a group that's becoming my go-to vet. They got him in and out that same day. He hid under a sofa when he got back home to recover and we let him out the next morning. He was back for dinner that evening, apparently fine without his testicles.

As the months progressed, he became more and more friendly and we've been bringing him in at night. Sometimes there's some hissing, but mostly the other cats are adjusting. He's adjusting better than BeeGee, actually, who still won't walk on the floor or get near the other cats. She's moved her bed from my office to our walk-in closet where she sullenly sleeps when not making attempts to get near the back door and make her escape. She goes back to her original house now that the weather is warm and stays under the porch or in the backyard until my husband goes to get her.

In honor of being absorbed into the collective, we have changed Blackie's name to the more politically correct Mackie.
Blackie now Mackie and without his testicles

BeeGee



Monday, July 08, 2013

Red 1996-2013

Because Red came when she was called, she earned the right to go outside whenever she wanted to when we were home. Everywhere we lived, she figured out the geography immediately, knew the perimeters of our property, knew our house, and knew how to find her way back to our front porch.

Even when we lived in the city above a dress shop, she knew how to circle the building without getting in the way of cars or dogs. She was especially responsive to a noise my husband made to call her, a combination of a loud purr and a motor boat putter.

Red never had any use for the indoors. When she was inside and awake, she stood by the door and called out for someone to open it. If no one came, she tried pulling the door open herself. If that didn't work, she'd go into a closet and get in a box, even if the box had stuff in it, and take a nap. I seldom saw her eat. I seldom saw her in the litter box. She paid no attention to the other cats. She was either outside or asleep in the closet.

She had a lot of things to do outside, many things to examine or observe. At one house we rented for five years, she kept busy digging up and eating voles. She was so light and moved so gracefully, she practically flew. She walked with a prancing step. She didn't like to be held, but if you straddled her across your forearm so she thought she was flying, she let you walk around with her.

She was named after the Kiss song, "Hard Luck Woman," although everywhere I've searched for the lyrics, it says the woman's name is Rags. My husband claims the lyrics are mistaken. The band is singing "Red." Red was hardly a hard luck woman. She was very lucky all her life.

I've heard the story of how Red and Bobby met many times. It's one of his party and family gathering staples. He and his sister lived in their childhood home in deep, heavily wooded suburbia. He was coming home late one night from band practice when he saw a flash of orange moving in a roadside ditch. He pulled over and walked back and couldn't find the kitten. Then he heard meowing, frantic and insistent. The kitten of about eight weeks had climbed a tree so she was eye level with him and calling to him. He plucked her off the tree and put her inside his jacket where she immediately settled in and purred all the way to her new home.

Where she came from, how she came to be in the woods…all that is only known to her. She stayed with Bobby almost 18 years, adapting to every place he moved. He was her one true love, although she seldom sat in his lap. When he went outside, she'd wrap herself around his legs. I couldn't always get her in at night, but all he had to do was go outside and stand there.

I first met her on my first visit to his house in 1996. She managed to pack herself into my purse. Most orange cats are males, I'm told. She was a rare orange female, with a swirl of white so she looked like a Dreamsicle. She had a fluffy Maine Coon neck and tail. She could easily come and go from his house through a broken window in the basement, so when they moved into my city apartment in February 1997 with Bobby's other cat, Merly, I thought she'd have a difficult time adjusting to being an indoor cat.

The first order of business was to get Red and Merly fixed. When I picked them up from the vet, I was surprised by a higher bill. Both of them had been pregnant. That was the closest Red ever came to motherhood. By spring, she made the decision she wasn't going to be an indoor cat, even in the city. People on S. Dooley Avenue became accustomed to seeing her sitting out on the second floor brick ledge when the window was open. I don't know how it came about that we finally let her out, but soon she was the master of the block. 

In front of the parking lot next door to our building was an elevated strip of trees and mulch, which she made her yard. She figured out how to safely cross the street and jump over a high fence into the yard of a house on the corner. Concerned she might get lost or killed, I tried putting a collar on her with our address and phone number. She came back without the collar. A few days later, some helpful person found it and left it in my mail box. So much for collars.

In 1999, we moved to a great little cottage in Mechanicsville, back from the road and surrounded on two sides by woods. On the other side was a house used as a daycare center, so in the evenings and weekends, no one was around. There was a fenced, sanded play yard, which must have seemed like a giant litter box to her. A stream ran through the woods behind the daycare. She loved it there. From the time we got home from work to bedtime, she was out in the yard or the woods, hunting voles, or surveying her domain. I often found her in the front yard of the daycare center in the evening, or sitting on the rail of the daycare porch. She preferred the daycare to our house. She could dissect a vole as precisely as a surgeon, leaving just the neatly arranged internal organs on the sidewalk.

When we moved to a house in a crowded, old suburban neighborhood in Dumbarton in 2004, I thought
it was going to be a big come-down for her. The woods were behind the houses across the street, not around our house. The yards were all small and fenced in. The voles were few and far between. She was eight years old, approaching middle age. She limited herself, by choice, to our front yard. When my husband came home from work at 4:30, she went out and sat on the hood of his car until the heat faded away. Then she did a perimeter check and took up a sentry position on the cement front steps. At some point I acquired a rectangle shaped wicker basket with low sides, and left it on the porch. She used it to rest her head on the rim and keep an eye on the street until we went to bed.

Rarely did she leave the yard. When I went up and down the block, or across the street, behind the houses to the field at the edge of the woods looking for another one of our cats, she'd trot along with me. But for the most part, she patrolled the small front yard diligently. The last year of her life, when she couldn't go out because she moved too slow to dodge a car, she watched the front yard from a second floor window.

She was not the least bit interested in the other cats that came and went in our lives, some for many years, some for brief stays. She didn't fight anyone. She took her meals separately in another room from the others. She kept calling us to follow her with her food bowl to ensure she always dined privately. She liked warm. She liked napping on the top of a printer. 

We knew things were changing when she moved to the floor in my office and never jumped to any high spots anymore, or expressed any desire to go outside. She thinned out, alarmingly so in the last year. She stopped grooming herself two years before the end, and I had to help her along with warm, wet washcloths, brushing -- which she hated -- and finally just clipping the mats out so she looked like a ragamuffin. She started walking with a constant bobbing motion, as if she was continually ducking something flying over her head. She was constantly hungry, but ate very little.

July 4 she was restless and cried out several times in the morning when my husband tried to pet her, which upset him to the core. But we had waited too long to establish a relationship with a vet who would come to the house. So far we hadn't moved past emails and she didn't have an available slot for a home visit until the following week. So we had no one to call to put her down. We waited. She quieted down, but every hour or so, she laboriously moved herself from one corner of the room to another. Sometimes we couldn't even figure out where she was, then she would appear in another corner an hour later from out of nowhere. Her eyes were darkened slits, and she only lifted her head if she heard my husband's voice. 

The morning of July 5, even though I had been awake since 3 a.m., dreading what I would find, I waited until my husband woke up at 6 to look for her. We found her curled up in a litter box that just had a puppy pad in it. It was damp with pee. After using it, she had been too tired to move. We moved her to a canvas basket bed with supportive sides. I sat with her, hand to paw. Three hours passed. Until the death rattle, she didn't make another sound. She'd lift her head once in awhile, but just to slightly change position. She stretched her arms out. She pushed up against the side of the basket at times. Her body would twitch periodically. She was getting cooler to the touch. I put a little blanket over her. I opened the windows to let her hear the birds and smell the warm, summer morning air. She didn't notice either.

Around 10:30 a.m., she took a few noticeable breaths, rested, then a few more. Then she tilted her head back and made a final squeaky sound. Even then I wasn't sure. Her jaw went slack, but her paws and shoulder kept twitching for a few more minutes. It was so quiet, so easy. I was reading my iPad at the time, trying to figure out how to know, what to expect, and I was reading this strange essay about a woman who claimed the room filled with spirit cats at the time her cat died and lifted her cat's spirit up with them. I wish I had seen that, too.