In this evidence-based world, the challenge for palliative clinicians is to find evidence that can pass the critical appraisal filters to be deemed statistically significant and clinically important as well as generalizable to our population. There are a host of issues related to the planning and implementation of any study for the palliative population—not to mention the additional ethical concerns of mounting a clinical trial to gather real data. The uniquely compelling situations that we encounter are often relegated to either the compulsory “N of one” study joke or dismissed as anecdotal.
Even in the realm of scientific methods and wet labs, generalizability is not an insignificant issue. Conditions and results of in vitro experiments cannot be assumed to mimic in vivo situations. Interventions in rat models are also not considered to be directly applicable to humans. Nor would many people imagine that there might be anything in the human realm that we would want to apply directly to rats. These foundational tenets ingrained in me by my scientific background were shaken recently as I was reluctantly drawn into the circle of care for my son's dying pet rat.
As far as rats go, Sushi would have been considered attractive. She had a pleasant face; eyes filled with curiosity and cute pink Mickey Mouse-like ears. Her gray-black coat had an irregular white streak running down the length of her belly—very much like the rice falling out of the seams of one of my badly rolled sushi—hence the name. She and her cousin joined our household at 6 weeks of age as a result of a careful and protracted negotiation with our youngest son. Ever since he could speak, he had expressed a wish to have a creature smaller than himself, over which he would have dominion and in return be adored. His requests actually started out big, that is, with physically big animals. Over the years, we noticed that he was working his way through smaller species and then down the phyla of the animal and insect kingdoms. When he finally exhausted this list and announced to us, with a huge sigh that he would even be willing to consider a sister—he is the youngest of three boys—we decided that we had to negotiate something with which we could all agree.
As it turned out, next to a dog, which would not have been feasible in our house, he had his heart set on rats. Knowing his determined nature, there was no point in going through my rather extensive list of reservations, which were all more or less synonymous for my own discomfort. Under the parental guise of nurturing character development, my husband and I decided that we would seriously consider his request once he had proven that he could work responsibly toward some goals, such as staying focused on his school work to improve his grades and doing some research on rats as pets. Meanwhile, it bought me time to accommodate to the notion and to study up on the anatomy and physiology of rats and more importantly their common health afflictions. When he eventually presented us with his improved marks and his major Grade 6 research project on “Rats as Pets”, complete with an amazingly comprehensive coverage of bio/psycho/social issues, we were forced to begin our search for a rat breeder.
To my son's delight, we found a breeder who not only bred for pleasant nature, but also socialized her charges to interact with humans. As a result, our girls (I insisted on the gender) were equally comfortable playing tag with each other in the cage as they were exploring all the nooks, crannies, and pockets of my son's sweater while he did his homework. He was greeted every single day with great excitement and affection. So it saddened all of us to see that at 2 years of age, Sushi had started to develop two suspicious lumps—one in her right axilla and the other in the left lower quadrant of her abdomen, which, based on my assessment and limited knowledge, were likely mammary gland tumors. This is apparently common among female rats and, although this was recognized in the rat care literature, there was never any accompanying recommendation. My son, however, very aware of my own recent experience with a diagnosis of DCIS (ductal carcinoma in situ) and subsequent wedge resection and radiation, could not understand why we would not apply the same standards of care for his beloved little girl. Initially the “wait and see” approach worked because we were not certain what it was or how quickly things would progress. However, as is characteristic of exponential growth, once we had noticed the lumps, it did not take long for Sushi to become physically encumbered by their presence. We were shocked one day to discover that her abdomen had dehisced—apparently caught on any one of the edges of the ramps of the multilevel cage.
All of my training and experience with families seemed to have vanished as I contemplated having the “goals of care” discussion with him to prepare him for the inevitable. Would anything we do change the outcome? Would a vet operate? What would be her prognosis with and without the surgery? Is she suffering? How much would it cost? How does one call up a vet to book an appointment to request that a rat be put to sleep? I finally decided that we would go together to request help with care decisions.
When we arrived, every effort was made by the staff to get to know Sushi—her general nature, her functional status, her relationship with us—and also to get to know what our concerns as caregivers were and what outcome we expected given her condition and what we expected that they could do. As it turned out, we were advised that surgery was a reasonable option because it would buy her 2 to 3 more months of life. This would not only be significant in rat years for Sushi, but would also be meaningful to her cousin with whom she was raised to be a lifelong companion. Because rats are meticulous with their grooming, I also needed assurance that closure would be intradermal and with a fine gauge absorbable suture, so that the risk of further dehiscence would be minimized. Not only did the vet acknowledge these concerns, he reassured me that he utilized microsurgical techniques for this very reason. The experience was, for me, one of those life-affirming events—only slightly diminished by the reminder from my husband that delivery of client-focused care tends to be more visible with direct payment for service options.
Surgery went well and Sushi recovered quickly, rediscovering her exercise wheel and the many levels of their cage. All too soon, however, we noticed that she was spending more time sleeping. Her appetite declined and eventually her weight loss became apparent. She also did not run as quickly to the cage door to greet my son. As she got weaker, I found myself mentally conducting Palliative Performance Scale assessments—50 … 40 … 30 … until one weekend, I rallied the family together to further prepare them for end-of-life care. Because she was still making an effort to move around the cage, albeit with great difficulty, we decided to transfer her over to her own space in the smaller cage and offer food and water at intervals by hand. We took turns doing this during the day and by evening it was clear that she would not likely live through the night. She was so weak that she could barely lift her head, but when my son came to the cage door to wish her good night, she mustered all the strength she could to put her head on his hand. It was very clear to us that she wanted to be held.
So everyone helped to pull together all that I would need at my fingertips to get me through the overnight vigil. She settled on my chest in a comfortable position, as she would have done had she been napping on my son. However, soon she shifted into a fetal position and her breathing became shallower. It was not long before it transitioned into a more mechanical pattern, accompanied by little squeaks and periods of apnea. Ten squeaks … four seconds of silence, then repeated—she was cheyne-stoking! As I continued to hold her and stroke her little head, her breathing became shallower and shallower. At one point it became barely discernable and I started to gently rub one of her paws. As if in response to this, she suddenly sat up, looked at me, squeaked and then fell back against my chest exhaling her last breath. Sunday morning at 0450 h … the moment for me was so profound that I sat there in silence for another hour before I could get up.
My son was the first to come down. He caressed her while we went over every detail of her last hours. We took her to her cousin to give her the opportunity to acknowledge the death. Then he carried her off to each member of the rest of the family to retell what will become the beginning of one of the most important narratives of his life.
What touched me deeply regarding Sushi's decline and death was just how closely the process paralleled the human condition. Thankfully, there were indeed some aspects of my knowledge and expertise with humans that were directly applicable and helped me to be present to our little rat. Once engaged, I felt inextricably drawn in trying to bring comfort to, if not this little creature, at least to the person who loved her best. As many of us human clinicians know, on those rare occasions when we have a patient who is difficult to serve, we take on the challenging task of seeking out that unique quality that engenders in us respect, and ultimately enables us to confer some aspect of dignity upon that person. I remember once hearing Harvey Chochinov speak about his work on the dignity model. He described the process of conferring dignity as the ability to convey to our patients an understanding of them that reflects how they view themselves. Although I was slow to warm to the notion of rats in our home and there was definitely a verbal language barrier, the eventual task was probably not so difficult because Sushi thought that she was human.
Is the information from this “N of one” rat model generalizable to other rats? It is difficult to know. Have I added another layer of learning to my repertoire of palliative experiences from which I will one day need to draw, to be present to another human being? Absolutely!
