Saying goodbye — measuring quality of life, deciding, and after

First, why this chapter sits near the front of the book.

CKD is found late. A cat's blood values do not start to rise until roughly two-thirds of kidney function is already gone. So we hear this often: "I was just beginning to understand it, and there isn't much time."

If goodbye is the last chapter, then for those families it is a chapter that never opens. So we put it here.

If you don't need this chapter today, skip it. But when you do come back, we would rather it not be the first time you're reading it.

1. Putting a number on quality of life

"Is she still okay, or is she already struggling?" This is hard to answer on feeling alone, because the people who see a cat every day are the least able to notice change. Yesterday and today always look the same.

So we use the HHHHHMM scale, developed by veterinary oncologist Alice Villalobos. Score seven items from 1 to 10.

The number matters less than the slope

The real value of this scale is in scoring repeatedly against the same yardstick.

• Score once a week, same day, same time
• Write down only the date and the score. One line is enough
• After about four weeks a line appears — flat, drifting down, or suddenly bending

"38 today" tells you far less than "41 three weeks ago → 33 today." Memory overweights the good days. A written record doesn't.

2. Cats hide pain

In the wild, showing weakness was dangerous. That instinct remains, so a cat in real pain often does nothing more than sit quietly, hunched. "She isn't crying, so she can't be hurting" is almost always wrong.

Reading the face — the Feline Grimace Scale

Developed and validated at the Université de Montréal in 2019. Score five facial features at 0, 1 or 2.

A total of 4 or more out of 10 indicates pain relief is needed. In validation it correlated 0.86 with another validated pain instrument, with inter-rater reliability of 0.89.

Why a CKD cat hurts

• Uremic stomatitis and gastritis — sore mouth, burning stomach. Walking up to the bowl and turning away may not be lack of appetite; it may be pain
• Nausea — not pain, but the single biggest drain on quality of life. And treatable
• Arthritis — very common at CKD age. Sometimes the real reason the mobility score is falling is joints, not kidneys
• General malaise from dehydration

Of these, nausea and joint pain respond well to treatment. Don't let them be filed under "that's just the kidney disease" — ask for each to be addressed. The quality-of-life score often gains several points.

3. What palliative care can still do

"There's nothing more we can do" and "treatment can't reverse the disease" are different sentences. Even when the disease can't be fixed, making her comfortable remains possible to the end.

Changing the house is care too

• Litter box closer, sides lower. Accidents are usually about the journey, not laziness
• Water bowls in several places — shorten the walk
• Raise the food bowl slightly — bending down gets harder
• Steps or a stool so she doesn't have to give up the window spot

4. What the body signals near the end

This list isn't here to frighten you. It's here because knowing in advance means not panicking, and not panicking means better decisions.

Breathing difficulty is an emergency. It may be pulmonary edema or a cardiac problem rather than the kidneys — and those can sometimes be treated. Go to an emergency clinic even at night.

5. How to decide

There is no correct answer here. There are, though, a few frames that make the decision less lonely.

Frame 1 — the ratio of good days to bad

The final M of HHHHHMM. When bad days outnumber good ones and the balance doesn't come back. This is the most widely used marker.

Frame 2 — who is this care for now?

The hardest question and the most honest one. The assisted feeding, the daily fluids, the medication. Are they making her comfortable, or postponing the goodbye?

For a long stretch it is both, and during that stretch you carry on. But there comes a point where you can feel that only the second one is left.

Frame 3 — is "one more day" one more day for her too?

For a person, a day is a day. For a cat who is suffering, a day is much longer.

Don't decide alone

• Ask your vet outright. "If she were yours, what would you do?" Many vets are waiting for that question — they just find it hard to raise first
• Talk to your family in advance. Decisions made in a rush leave wounds between the people left
• Decide the line early. Agreeing "when she reaches this state, we let her go" while things are less hard protects her on the day your judgement is clouded

6. What actually happens on the day

Not knowing makes it more frightening. Knowing leaves you room to be present with her.

1. A sedative comes first — usually subcutaneous or intramuscular. She falls comfortably asleep. Consciousness is already gone at this point
2. The injection is given once she's asleep. It is an anaesthetic at very high concentration, usually intravenous
3. The heart stops within seconds to under a minute. Because she is asleep, it does not hurt

Worth settling beforehand

• Whether you stay to the end — either choice is fine. Not being able to watch is not a failure of love
• Home or clinic — some vets make house calls. Home is familiar and less frightening for her. Find out in advance
• Afterwards — cremation type, whether you want ashes returned. Deciding that on the day is brutal
• Who drives. The journey home is hard to drive
• A lock of fur, a paw print — ask the clinic ahead of time if you want them

7. Afterwards

About guilt

Nearly every owner feels it. "If I'd caught it earlier." "If I'd run that test." "Was it too soon?" "Was it too late?"

One thing only. Anyone still reading this far is someone who did what could be done. CKD is a disease already two-thirds advanced when it becomes visible, and no owner could have prevented that.

If there are other cats

• The remaining cat may search, vocalise, or stop eating. This is normal
• Where possible, many consider it helpful to let them see the body
• Keep the routine. Meals and play at the same times speed recovery
• If not eating for more than two weeks, see a vet — stress can trigger hepatic lipidosis

Grief has no timetable

If someone says "it was only a cat," let it go. This was a relationship of daily meals, daily medication, daily fluids. The loss is not small.

8. What to ask your vet

• "Could she be in pain right now? Can we trial pain relief?"
• "Can we try something for nausea?"
• "Is anything we're doing now only making things harder for her?"
• "I've been scoring quality of life — 41 down to 33 in three weeks. How do you read that?"
• "If she were yours, what would you do now?"
• "Is home euthanasia possible? If not, where should I look?"

9. Related

• The day of diagnosis — what to do today
• When a cat suddenly stops eating
• Subcutaneous fluids, safely at home