New-3 y/o sheltie-Tinkerbell (Updated: RIP Tinker)

[Tinkerbellsmom]

Thank you for having/participating in this forum. It is a comfort for those like me who come looking for info in a panic.

Tinkerbell is a 3 year old sheltie that I have had for about a little over 2 years. She came into my rescue with a large group from a hoarding situation. I fell in love with her and she is mine now. After losing my seniors over the last several years, I was hoping for a reprieve from health issues, but alas, we are here. We are not diagnosed yet.

First year I had her, she had socialization issues but played nonstop and was happy. I started noticing a change in her activity level last year not long after my 14 year old sheltie passed of insulinoma (that is one tough road!). They were BFFs so I attributed her change to her losing her sister. We also moved several months later so I have dismissed a lot of this as situational.

At this point, she is very mopey and depressed, doesn't play with toys or other dogs. She is starving 24/7, almost an obsession. I have also noticed she pants a lot with little activity. She has stopped jumping on the couch and up to the bed too. She has started having accidents in the house and is peeing a lot more and often. I'd say with a mild increase in water intake.

I took her to the vet over the weekend thinking she had a uti and/or bladder stones. Vet took a quick look by ultrasound at her bladder and no stones. Urine sample (taken about 3pm) was normal except for specific gravity of 1.005. Regular panel of bloodwork came back good except for ALT of 407 (118 is high end of range) and ALK PHOS 175 (131 is high end of range). My vet went down the list of things that could cause this and when she hit Cushings.....I connected the dots of things I had been dismissing.

The vet said we could wait and retest in a couple of weeks, or give her a short course of antibiotics in case it was some sort of liver "infection", or get an ultrasound. I chose to get the ultrasound. We have an appt with a speciality clinic the 25th with an internal medicine vet that will also do the ultrasound.

She doesn't have hair loss, as you can see in my avatar. And I don't think she has a pot belly. So I may be premature in thinking this might be Cushings. Any thoughts are appreciated!

[Tinkerbellsmom]

Oh, and she is tiny for a sheltie. She normally weighs 8 or 9 lbs but was 11 at the vet this weekend.....so maybe there is a pot belly hiding under all the fur. :)

[judymaggie]

Welcome to you and Tinkerbell! Tinkerbell is absolutely beautiful -- thank you so much for giving her a forever home. I wanted to get things started by giving you the link to one of the posts in our Resources section where you learn a lot about Cushing's and, in particular, the different diagnostic tools available:

http://www.k9cushings.com/forum/showthread.php?t=180

We have found that the best outcomes come when an owner is knowledgeable about Cushing's and works with a vet who is either knowledgeable or is willing to learn about Cushing's. For me, reading as much as I could helped me know what questions to ask my vet as well as understand the various tests used to test for Cushing's. In light of all the symptoms that you are seeing as well as Tinkerbell's lab results, I am surprised that your vet didn't suggest running an ACTH or LDDS diagnostic test. His suggestion to start a course of antibiotics seems a bit odd to me ...

I am glad that you are scheduled to have an appointment with an IMS. Try to do some reading before your appointment -- the IMS might run tests that day in addition to the ultrasound.

With regard to Tinkerbell not showing all the frequently seen symptoms, this is not unusual. Some dogs show a couple, some a lot.

[Harley PoMMom]

Hi and welcome to you and Tinkerbell!

Dogs with Cushing's generally have a very elevated ALP and only a moderate increase in the ALT levels. With your girl's ALT being high I would be more inclined to believe that something else is going on instead of Cushing's. I gather that when the vet performed the ultrasound the liver and adrenal glands were not visualized?

Going to an IMS and having the IMS perform an ultrasound, I believe, is the best way in figuring out just what is going on with your dear girl.

Has a thyroid issue been ruled out?

Hugs, Lori

[Tinkerbellsmom]

Thank you Judy! I'm doing a lot of reading!

I thought the antibiotics were odd too. I haven't used this vet very long, so it may be that we end up going elsewhere.....or sticking with the IMS.

Something I came across in some posts was that dilute urine won't necessarily show a uti with the standard dipstick. She ruled out a uti based on the dipstick test. I'm wondering now if we should get another sample and send it off for a culture??

[Tinkerbellsmom]

Thank you Lori!

The vet only took a quick look at the bladder when she did the ultrasound this weekend. At that point, we weren't thinking anything was wrong other than a uti or bladder stones.

We haven't done any thyroid tests.

[judymaggie]

Something I came across in some posts was that dilute urine won't necessarily show a uti with the standard dipstick. She ruled out a uti based on the dipstick test. I'm wondering now if we should get another sample and send it off for a culture??

Hi! This is true -- I would put this down as something to ask the IMS. He/she may want to get a sample via cystocentesis and do their own testing.

Many here use the IMS for their Cushing's issues and a regular vet for everything else. This may be something that you can consider doing if you have been pleased with your vet for non-Cushing's treatment.

[molly muffin]

Hello and welcome to the forum from me too.

When your vet did the ultrasound, was she able to also look at the kidneys, liver, gall bladder, adrenal glands? (even though looking at bladder, she could perhaps see other organs)

The ALT is significant for the liver, but as Lori mentioned we normally see a higher ALKP and moderate increase only in ALT. Typically - you can never say never.

Thyroid definitely needs to be looked at and hopefully your vet can send a copy of the ultrasound over to the IMS office for them to look at in case they can see something of significance. Although it could be they will want to redo the ultrasound if everything wasn't visualized clearly.

Diabetes appears to have been ruled out since nothing like that showed up on the blood work.

A culture certainly might be of value, if her urine is very dilute. Something is certainly going on for her behavior to change so much.

While it is rare to see cushings in a young dog it too is not unheard of, you just want to make sure of what you are dealing with and an IMS at this point seems to be the best thing to do. So very glad you got an appointment.

I would first want to concentrate on kidneys and liver I think and rule out thyroid as possible culprits.

[Tinkerbellsmom]

Hi Sharlene, thank you for the welcome.

The vet didn't mention looking at any other organs, only the bladder.

The IMS is doing a full ultrasound on Tuesday. I'm also going to request another urinalysis with culture while we are there. I'm hoping the u/s will point us in the right direction of what we are dealing with.

I'm not the most patient person in the world and waiting two weeks for this IMS appointment is driving me crazy!! Thanks again everyone for the help.

[Tinkerbellsmom]

Update:
We saw the internal medicine vet yesterday and she did the ultrasound. Ultrasound showed one adrenal gland to be a tad enlarged. The liver was a little bit "bright" which she said is usually some inflammation. Everything else looked great.

She took another urine sample and her specific gravity was 1.006 this time so about the same as before. We did send this sample off to culture just to be safe.

She suggested the next step to be a bile acid test and an ACTH test. We were going to do that yesterday but I live in Oklahoma and the weather was turning bad so we decided to do it another day.

She thinks we are looking at the early stages of Cushings, or a liver disease or shunt. Should the bile acid and ACTH be the next step?

[lulusmom]

The bile acid test is a liver function test that is not routinely done in dogs suspected of cushing's, unless primary liver disease or a non adrenal illness is suspected of injuring liver cells. The ACTH stimulation test is a cushing's diagnostic test which is not usually the first choice as a fair amount of dogs with cushing's will have false negative results. The LDDS test is the first choice as it is less likely to yield false negative but is more likely to yield false positives in the face of non adrenal illness. If your vet suspects more than cushing's may be causing Tinkerbell's liver enzyme elevations, the ACTH stimulation is less likely to yield a false positive in the face of non adrenal illness. Are you confused yet? :D As Dr. David Bruyette once said; "If any of the tests for cushing's were worth a darn, we wouldn't be talking about so many of them. Does your vet want to do the bile acid test and the ACTH stim test on the same day? The ACTH stim test is not inexpensive so you may want to speak to your vet about doing the bile acid test first to rule out primary liver problems. If the bile acid results are high enough to rule in liver disease, I personally would opt to focus on the liver first and cushing's second. That's just my two cents worth.

Glynda

[Tinkerbellsmom]

Thank you for responding Glynda. Yes! This stuff is confusing!

They had planned on doing both tests the same day and both are about the same price with the bile acid being slightly more. The IMS said that if the bile acid test was sky high we were looking at liver disease. It seems to be the more black and white test so I think going with it first is the smart thing to do. Thanks for suggesting that!

Though, I keep coming back to the fact that her symptoms point directly at Cushings and seem to be the opposite of what you would see with liver diseases.

[lulusmom]

I would agree with you that the symptoms you mentioned are commonly associated with cushing's but cushing's and liver disease can have some overlapping symptoms as well as shared blood lab abnormalities. Did your vet do a complete blood count and if so, were all blood counts normal? Cushing's is a graded disease so unless Tinkerbell has hypertension of protein in her urine that is concerning to your vet, you have plenty of time to rule out liver disease and liver shunt before launching into a full blown cushing's diagnostics. With the ALT being much more elevated than the ALKP, which is very unusual with cushing's, I think it would be a good idea to get Tinkerbell on a liver supplement such as Denamarin and retest the liver enzymes in a month or two. If you see a significant improvement in ALT after that time, that would be an indication that you are not dealing with liver disease or a shunt.

Glynda

[Tinkerbellsmom]

I really appreciate your thoughts Glynda. Everything else with CBC/CMP was perfect except for the ALT and ALKP.

We received the results from her urine culture and it was normal, no growth.

The bile acid test was done yesterday and the vet called and said it was completely normal also.

When my vet (regular vet) called with the results, she asked me why the IMS suggested the ACTH instead of the LDDS test. So I didn't even have to bring up that question. She called the IMS to discuss and just called me back saying the IMS suggested that one because she hadn't ruled Addisons out of the possibilities.....news to me! That her low heart rate and thirst/urine sypmtoms could also go with Addisons. My regular vet is suggesting doing the LDDS because it's cost is lower and it's more specific?

[molly muffin]

When do they plan to do the LDDS?

[Tinkerbellsmom]

We did the LDDS test yesterday and the vet called a few minutes ago and said she was positive for PD cushings. She is emailing me the actual test results so I'll post those as soon as I get them.

She is suggesting 5mgs twice a day of trilostane. Tinkerbell weighs 10lbs. And then wants to run the ACTH in 10-14 days.

She quoted me a price of $47 for 30 pills (14 day supply).

I asked about compounding and she said that most IMS agree that it isn't as effective as the brand name pills. I'm thinking that isn't exactly correct since we have people on here that buy the compounded version.

I told her that I would do some research and get back to her on the meds.

Tinker is so young. I'm devestated. :(

[Tinkerbellsmom]

Pre 10.2 (1.0-5.0)
Post1 1.6 (0.0-1.4)
Post2 4.9 (0.0-1.4)

[DoxieMama]

Oh, I can only imagine how hard it was to hear that, especially given that your little one is only 3 years old. But please know that this is absolutely treatable!

As for the medication itself, given Tinkerbell's weight, a total of 10mg per day is the perfect starting dose. But Dechra recommends starting with a single daily dose, which I would think might save a bit on the cost.

Is your IMS completely against the idea of compounding, or just does not recommend it (would she be willing to have you try it, if you wish)?

Big, big hugs!!
Shana

[Tinkerbellsmom]

Thanks Shana!

She gave me the option of the 10mg pill once a day but said she preferred the twice daily dosage. I'm having major anxiety over giving it to Tinker so I ended up going with the 5mg pill. That way if she has a reaction, at least it's at the 5mg dose.....which probably isn't rational, but makes me feel better. :p At some point I'm sure I'll switch to the 10mgs. I gave her the first pill this morning with breakfast and so far so good.

She just doesn't recommend it, but would do compounding if I wanted.

[judymaggie]

Hi--it can be nerve wracking to start treatment but we can all help you through it. I wanted to suggest another option to save some money on the trilostane. I purchase 10 mg capsules from California Pet Pharmacy (877/554-4797). They are a distributor for Dechra and do not repackage the trilostane so your vet might be more willing to provide them with a prescription. I expect their significantly lower costs are due to their volume. They also sell 5 mg capsules. You can check them out on line. I also get 4.5 mg compounded capsules from Diamondback Pharmacy and my dog's cortisol has been very stable.

All that said, you might want to continue getting trilostane locally until after the 30 day ACTH just in case Tinkerbell's dose needs adjusting. For example, if she needs an upward adjustment to 15 mg a day, you might want to purchase 10 mg and 5 mg capsules in order to avoid having to give Tinkerbell three capsules each day. I did this, purchasing trilostane at Sam's whose cost was much less than my vet's.

[Tinkerbellsmom]

Thanks for the support and tips on suppliers Judy. Good point on waiting until after the 30 day mark.

After reading some more.......we haven't done an ACTH test. Should we have done one before starting the trilostane (as a baseline I guess)?

[judymaggie]

Hi -- it is helpful to have the pre-treatment ACTH results for comparison purposes but not essential. Dechra has set out very specific guidelines for treatment goals--here is a link for the Dechra technical brochure from our Resources forum:

http://www.dechrace.com/pdfs/vetoryl/VETORYLTechnicalBrochure.pdf

Page 11 has a flowchart which is really helpful in determining how treatment should proceed.

Have you discussed follow-up ACTH dates with your vet? Dechra recommends the first testing at the 10-14 day mark after treatment has started. We are seeing many vets who forego the ACTH at this point and others who extend the time frame out. Also, as you may know already, the test is expensive. I wanted to do things "by the book" to get the best possible outcome so did the first ACTH on day 14. Regardless of the results, if there are no signs of low cortisol, there is no change in dose until after the 30 day ACTH (done 30 days after treatment is started). On the same day as the ACTH it is recommended that electrolyte (in particular, potassium and sodium) levels should also be checked (either by themselves if your vet's lab will do that or as part of a super chem panel). These levels are checked to ensure that cortisol has not dropped too low.

[Tinkerbellsmom]

Okay, good, thanks. I printed the pdf to have on hand. I need an app to help me keep up with this stuff. :p

Yes, she must be using the Dechra guidelines because she specifically said 10-14 days and we would do the ACTH.

[DoxieMama]

I need an app to help me keep up with this stuff. :p

Isn't that the truth?!! I wonder how people that have multiple dogs and/or numerous issues and medications to address manage to keep it all straight.

I didn't have an ACTH test done before starting the medication either. I'm sometimes curious what his levels looked like then, but I guess it's sufficient to know they were "high" based on the symptoms he exhibited at the time.

You're doing a great job for Tinkerbell. :)

[Tinkerbellsmom]

Thanks Shana :)

Well, day 2 of 5mgs and all seems to be okay. She is pooping more times a day than she normally does but it's normal looking. I started splitting her meals to give her the medicine in the am so I'm thinking that is why her pooping schedule is off.

Also, we have been taking agility classes. Do you think it's okay to continue or should I put it on hold for a while? The last several weeks I have been taking several breaks with her during the 1 hour class and letting her drink and rest. She starts to pant really easily. I had told her teacher that we were in the process of testing for Cushings but haven't been back since we now know for sure.

[Renee]

I need an app to help me keep up with this stuff. :p


An app would be awesome! I do use the notes feature in my iPhone. I record every symptom, vet visit, test results and dosing changes. That has come in handy so many times. Especially when we've had to go to pet emergency. It's so helpful having exact figures and dates.

[Tinkerbellsmom]

Good suggestion Renee!

I finally got brave enough to give Tinker the 2nd 5mg dose with dinner last night. So far she seems to be tolerating it just fine.

[molly muffin]

Glad to hear Tinker is doing well on the 5mg dose.

I use a spreadsheet to track some things. An app sure would be handy for us that use our smartphones for most things.

[Tinkerbellsmom]

Thanks Sharlene!

To recap, we did 3 days of 5mgs and then 10 days of 10mgs. I saw no change in symptoms at all. We went ahead and did the ACTH on Friday because of the holiday weekend. Here are her results:

Pre - 9 ug/dl (1.0-5.0)
Post- 20.4 ug/dl (8.0-17.0)

Vet is recommending that we increase to 20mgs and do another ACTH in 10-14 days. This big jump is making me nervous (I haven't increased it yet)......but we have already established that I'm a big chicken. :) I would feel more comfortable at 15mgs. Thoughts??

[judymaggie]

Hi! First, the range that is next to Tinker's pre and post is the range for dogs not being treated. The range you are aiming for with treatment is 1.5-5.4 for pre and post. If symptoms are controlled, the post can be as much as 9.1.

Since cortisol can continue to drop during the first 30 days, Dechra does not recommend any changes until after the 30 day ACTH test. If I were in your shoes, I would keep Tinker at the 10 mg./day dose for the next two weeks. If the post is still higher than 9.1 and if symptoms are not controlled, then an increase would be warranted. How much of an increase can be evaluated at that time based on the numbers and symptom control. If an increase is needed, there is certainly nothing wrong with going up by small increments, i.e., 5 mg. versus 10 mg. increase. The only downside is that this might involve the need for additional ACTH tests and symptom control might be slowed down. Your peace of mind might well be worth that!

I don't think you are being "chicken" but rather you are being cautious -- a trait that is great for a Cushing's Mom!

[DoxieMama]

I wouldn't change the dose right now, either. It might take longer to get the cortisol under control, but going "low and slow" has its merits. :)

[molly muffin]

I'm a fan of the low and slow too
I just feel it is a safer way to go when you don't know how they will react over a 30 day period to medication.

[Tinkerbellsmom]

Thanks guys!

I decided to keep it the same. I think I have seen a slight change in her this week. She did much better at agility practice Wednesday night. You could tell she felt better.

Something that happened yesterday morning though has me really upset and concerned. Tinker sleeps in a bed right next to ours, in front of my nightstand. When my feet hit the ground, she is right behind me in the mornings. Yesterday morning, she didn't follow me. I had to go back and call her to go outside. I always go out with her and she peed and pooped like normal. But as she was doing her morning sniff around the yard, she looked at me (I was 10-15 ft from her) and started staggering down the slop in our yard. It was like she was looking at me and wanting to come toward me but couldn't. At first, I thought she was getting ready to have a seizure (My first sheltie had them towards the end of her kidney disease.) but she didn't. I ran to her and picked her up and she wasn't shaking or disoriented. I was a mess, but she seemed fine. I brought her in and fed her, she scarfed it up like usual and was fine! I still took her to the vet. She checked her electrolytes, which were completely normal, spun down a quick hemocrit and it was good. She also did a quick blood pressure check and ekg (she didn't charge me thank goodness) and that was fine. She walked fine and has been normal since. Me, not so much lol, but she is fine.

[molly muffin]

Well that is very strange behaviour. I can completely understand why you would be concerned.

I know my Molly who use to wake me up in the mornings if I wasn't up when she was ready now sleeps in and I have to call her repeatedly sometimes to get her up. She is fine once she is up too

It's good that the electrolytes where fine. Did the vet have any thoughts?

[Tinkerbellsmom]

Just an update....Tinker is now up to 35mgs a day of trilostane. The lowest we have seen her ACTH post number is 11. She is 11lbs.

We have had another thing happen that I'm wondering if anyone has any advice for us. Friday afternoon I noticed that her left ear looked like it was hanging low, but it was more of "am I imagining it or is it really hanging low". Saturday morning, woke up and her left eye is watering and her looks off, left ear is definitely hanging low. I take her to the vet Saturday afternoon and they see a small amount of yeast in her ears and her eye is red so they give me ear and eye creams thinking maybe allergies or some irritant. Saturday night I keep thinking something isn't right and finally figure out that she isn't blinking that eye! I try not to freak out too much. Sunday morning is the same symptoms but then I notice her food is falling out the left side of her mouth when she eats her breakfast. I finally put it all together and realize it's facial nerve paralysis. Off to the 24/7 vet clinic and they confirm my fear. The vet said it could be idiopathic, which most cases are, or it could be an inner/middle ear issue (felt this was least likely since she didn't exhibit the other symptoms) or it could be that there is a macrotumor on her pituitary gland. I'm just beside myself. She seems happy and content and unaffected by it all.

The only other thing that has been off is that the last 2 months, her leg/legs will shake when she is standing. Not a certain one, could be anyone at any given time.

Anyone have any advice. :( I'll do some searching on the forum too.

[labblab]

I'm so sorry Tinker is having these problems! I'm afraid I don't know anything about the facial paralysis, though :(. I'll surely be hoping it will resolve all on its own, and before too long!

Knowing more about the Cushing's part of things, though, can you tell us how long she's been taking the 35 mg. and how recently her cortisol level had been checked? If she is still running higher than 11 ug/dL after having been on the 35 mg., then unfortunately she may need even a bigger dose. That does seem like a lot of medication given her weight, but we've seen that every dog does metabolize the drug differently and there can be a wide variation in dosing needs.

Please do keep us updated as to what is going on with Tinker, OK?
Marianne

[Tinkerbellsmom]

Thank you for responding Marianne and the input.

She has been on 35mgs for about 6 weeks (so 6 weeks since her last ACTH). She is due for another ACTH. I have been putting that off because it's $250. We have been battling a UTI, which is clear now, but that was after several urinalysis, urine culture and 4 weeks of antibiotics....and well, you know how expensive all this gets. I may just have to put it on a credit card though. Ugh, I hate this.

Anyway, the vet had actually suggested 40mgs after her last ACTH but I was reluctant to go that high so we settled on 35mgs. She was at 30mgs previously. It just seems like such a high dose considering her weight, but the vet has assured me that it's still within the recommended range.

She still has the facial nerve paralysis today. I'm trying to keep the gel/moisturizer in her eye so she doesn't develop an ulcer from not being able to blink. I clean her face after she eats and make sure she doesn't have a bunch of food lodged in her cheek. Other than that, not much else we can do at this point....unless I wanted to do a CT scan but considering the cost of that the vet and I both think it's best to give her a week or two to see if it resolves on it's own.

We also checked her thyroid on Saturday and it was 1.5 which is low normal. All her other bloodowork remains good, except for the elevated ALT but that has remained at the same level as when we originally did bloodwork in March.

[Tinkerbellsmom]

Tinkerbell passed away on October 15th. I was/am still absolutely devastated. I just haven't been able to face this thread and even now I'm crying but I wanted to update.

Tinkerbell recovered probably 85% from the left side facial nerve paralysis within 6 months of my last post in November of 2016. I did take her to the nearby vet school and had the IMS look at her case. At that time they recommended watching and waiting to see if any other neurological symptoms started. Thinking that if it did, we were dealing with a tumor. Nothing else happened so we went on with life. In April 2017, the right side of her face was affected by the facial nerve paralysis. My regular vet contacted the IMS at the vet school and they still felt like it was idopathic. She did regain most of her muscle movement as time went on.

During all of this, she was on 40mgs of Vetoryl and we still couldn't get her post number below 10. My vet was a little reluctant to up her dosage again considering she only weighed 10lbs. Her bloodwork stayed about the same as it always had been. We treated a couple more UTIs along the way.

She was totally normal on the morning of October 14th. When I came home from grocery shopping, she wouldn't stand and had labored breathing. I rushed her to my regular vet....put her in the o2 chamber, did bloodwork and ekg and xrays. All was fine except for the xrays looked like she had fluid in her chest. We started lasix and moved her to the 24 hour ER vet so they could keep her in the o2 chamber overnight. I left her about 8pm that night and they called me early Sunday morning, the 15th, and told me she had gone into cardiac arrest and died. I wasn't there with her and it's absolutely killing me, still, that she went without me by her side telling her I loved her and that she was going to be okay.

My regular vet reviewed everything on Monday morning and feels certain Tinkerbell had a blood clot in her lungs. She said there wasn't anything we could have done. I didn't realize that blood clots were a complication of Cushings, maybe I read it and just glossed over it, too worried about tests and medicine dosages. And of course I blame myself, thinking I should have taken her back to the specialist or something, or upped her dosage quicker, or we missed something......or that I should have stayed all night with her at the ER vet.

Anyway, I appreciate the support and input you guys provided. Give all your furbabies extra hugs today.

[Joan2517]

That is so sad, I am so sorry. That's how my Lena went...at the Emergency clinic without me. They think she was throwing clots. I left around 2am and got a call at 5am that she was in cardiac arrest and did I want them to keep her going until I could get there. It would've taken me too long and I couldn't do that to her, so I had them hold the phone to her ear and I told her over and over how much I loved her. I didn't realize until later, I had forgotten that she was deaf. I hope she heard me anyway. I blame myself for the same things you mentioned. I should have stayed, or taken her in sooner, or put her down while I was there...

I am truly sorry for your loss.

[labblab]

I, too, am so sorry about your sweet Tinkerbell. What a tragic situation and what a hard loss, especially at this time of year. Thank you so much, though, for coming back to tell us. This way, we can help you honor Tinker here, always. She has now been added to our special memorial thread, and I’ll also soon contact you privately to see whether it would please you to add a photo link to her memorial line.

http://www.k9cushings.com/forum/showthread.php?8383-Remembering-All-Who-Have-Left-Us-(2017)

I surely understand why your heart is hurting so much right now. I think it’s impossible not to have doubts or regrets when we lose a loved one so suddenly and unexpectedly. But in truth, it sounds to me as though it was just her time. Based on the info at hand, you’d made the best decisions you could with the knowledge you had. And most importantly, you loved her. Always. Whether physically close to her or from afar, your love was unbroken.

I worked in a hospital for a number of years, and not infrequently witnessed the experience you describe. Families would hold vigil for hours upon end at the bedside of a mortally ill loved one. And wouldn’t you know it. The weary family might take a ten-minute coffee break and it would be during those moments that their loved ones passed. Understandably, the families were distraught that they had been separated. But I came to wonder whether there was some unknowable dynamic at play — whether the patient somehow “chose” that very moment to depart, as though they were freeing their own selves in some way. I do understand why you wish you’d been there. But I do believe that at that time of passage, Tinker was already forging ahead on her own private journey. But even then and even from a distance, still cradled in your love where she forever remains.

Please do return to us at any time that you may wish to talk, or cry, or to share special memories, OK? We will always remain here for you, in loving memory of your sweet Tinkerbell.

Marianne

[pibblesandbits]

I am so sorry for your loss. It is so impossibly sad to go through this and watch the ones we love suffering. I am going through all of this now as my dog suffers and declines so rapidly. I just can't believe it's happening. Anyway, just wanted to offer my condolences. RIP Tinkerbell.