How much pain is too much? And when has it gone on too long?

Dear s.e.,

We have a cat that's 18 and nearing the end of his life. His biggest problem is chronic pain that makes it harder to walk. Right now we have it managed well enough through the vet and various medications and a PMF device*. We had a scare where he was having trouble walking at all and just staying on the floor. Chronic pain is one of the hardest things to judge, I think, and I was wondering if you have any advice on determining when the pain has gotten too much.

*Shockingly effective, given using electromagnetic pulses for pain management immediately makes me think of pseudoscience cures. It's backed up by research and recommended by the vet.

— Painful Pondering in Ohio

Hello Painful Pondering,

18 years is a long time to spend with a comrade! I'm so sorry, and I hope you are getting lots of good time together as you both prepare for this big transition in your lives. I've also been in the position of trying to assess my cat's pain levels and wishing he had one of those little pain scales to point a paw at, so I know how hard it is.

Chronic pain in cats is, as you know, so tough because they are experts at being secretive and not signaling what's going on with them very well. Especially for an older cat who may have been slowing down in general, I know it's challenging to gauge "is he not really moving around much today because he's tired and low-energy, or is he really hurting?"

There are a few things that I tend to look out for, and obviously every cat is different. You know him better than I do but things that might indicate a high pain day are: Not being very active; walking very stiffly or wincing when he moves; missing the litterbox or not getting up to use it at all; hunching or sitting in another awkward and abnormal position; not being interested in food, even when it's the fancy stuff he usually goes ham for; not interacting with you like he normally would; not playing or sitting with favorite toys or objects (my old cat Mr. Bell had a spatula he LOVED and he would drag it around the house with him—when he started turning up his nose at it when I put it down next to him, I knew that was a sign); hiding from you or sitting in weird places; or meowing in discomfort, especially if you touch or pick him up.

It sounds like you have some good pain management options, and probably already know that it's important to stay ahead of pain, rather than to play catch up. If you're noticing more pain before it's time for his next dose, that would be concerning, as it would suggest breakthrough pain that the medication is not controlling. That might mean a trip back to the vet to talk about dose size and frequency, or exploring other medications.

As with all species receiving palliative care at the very end of their lives, sometimes discussions about pain management involve some frank conversation and thinking about the fact that many pain management drugs depress the respiratory system, so it's possible that a very high dose of opioid pain medications might cause him to stop breathing...like the high doses of barbituates used in euthansia. At times, this may be a not necessarily intended, but welcome or acceptable, outcome. If you are not okay with that, you should make sure your vet knows.

One thing I find especially helpful when I am thinking about pain and quality of life is just taking notes every day in a place that's easy for you to keep up with. For me that's my paper daybook, for you maybe it's your electronic calendar or a sheet strapped to the fridge or a chalkboard wall in your kitchen (I've always wanted one of those). Anything, as long as it is something that you will actually use. There are actually some quality of life scale tools you can use that come with worksheets, if that's your jam, although I'm more of a DIY person. Unless you're using the royal "we" here, I am guessing you have at least one other person in the house, and if BOTH of you can write down observations, that's really helpful to get some balance and perspective.

Whatever it is, make it something that will work for you. Every day you're going to write a sentence or two about what you observe. This is really helpful for looking at long-term wellbeing rather than trying to remember how he felt on Monday, or last Thursday, or the week before. Just a note like "wasn't very active today, and was sitting in a hunched position" or "ate well, was a little playful." You can also rate his days from 1 (very obviously not having a good time) to 5, or ten, or whatever feels right for "a really good day."

Over time, I think you'll see some trends. Day to day you may notice fluctuation from good days to bad, and you may start to see the scale tip more towards bad over time. If he's alternating between days, and he's doing really well on good days, that's probably a sign that his quality of life is okay, if not what it once was. If you're seeing a string of bad days, and some of them are very bad, that might be an indicator that the pendulum is swinging the other way: If you're looking at a 3, 3, 4, 2, 7, 3, clearly he's having an occasional good day, and really struggling on the other days.

Especially on those scary days. Putting an asterisk on there to remind yourself that hey, this day was really bad will also help you check in with yourself about how he's doing.

Cats, dogs, and everyone else often experience a phenomenon where there's a string of real bad days and then a random really good one. And then some more bad days, and a rally for a couple of days. Pet guardians sometimes get caught in a loop of "he's really clearly suffering and not doing well, I think it's time to let go...oh but he had a good day today, he wants to hang on a little longer!" This is where a lot of remorse about waiting too long tends to come from, because things might get very bad, or even reach a crisis point that means an abrupt trip to the vet (or, worse, an emergency vet visit) instead of a more peaceful end of life. I don't want that for anyone in your household.

That's where a pain/activity diary can be really helpful, because it gives you an opportunity to be honest with everyone in the household. It can also be useful for your veterinarian when you're talking about pain management. They know your cat better than I do, and they may pick out some threads they observe as they look through your notes.

These tools may start to give you the answers you need all on your own—if it sounds cold and weird to rate your cat's day, I feel you! This isn't a pass-fail situation or some sort of rubric, though, it's just one among several tools.

I apply these in the same way I do mood journaling, to create a record to help me reflect on long-term trends and think things through. You don't have to set a hard limit around how many bad days are too many bad days, but if you're caught in a several bad days, one okay day, several bad days cycle that seems to be slowly declining, with more and more bad days between good, and he's not responding to changes in his medication, that is probably putting you in the "too much" place.

Cats are subject to this weird mythos where people say "they'll tell you when they're ready" while also saying "but cats are so good at hiding pain!" This can leave people feeling a little at sea, like, okay, which is it?? Tracking trends can help you see the things your cat might be hiding, but also, sometimes animals really do make it clear when they're done—and it's usually a day when almost all of those pain signs I mention above are happening all at once.

Hopefully, keeping track over time means you never hit that really bad, terrible, no good, awful day.

Tell your cat I said...

May all of your remaining days have bright and good things in them