Life and Death Decisions Part IV: Caramel's Story

Dr. Phil Zeltzman is a mobile, board-certified surgeon in Allentown, PA. Find him online at He is the co-author of “Walk a Hound, Lose a Pound” (

Kelly Serfas, a Certified Veterinary Technician in Bethlehem, PA, contributed to this article.

Caramel, a 13-year old Chihuahua, has had a very unusual story.

In 2008, she started to have sneezing fits. She eventually could only breathe with her mouth open.  Then a mass appeared near her left eye. She then had a nasal discharge. She had surgery at her family vet. The biopsy didn’t show much.

In 2009, the mass came back. Her vet did surgery again. This time the biopsy showed… brain tissue!

In 2010, the mass came back.  Caramel was referred to a specialty hospital to meet with a surgeon. A CT scan was recommended before surgery.  The results were consistent with a cancerous tumor.  Caramel had surgery, but again, the biopsy didn’t show much.

In 2011, the mass came back.  Her vet performed surgery again.  The biopsy didn’t show much.

In 2012, the mass came back.  That’s when I met Caramel… and her owner, a dry, demanding and “rough around the edges” lady in her early 70s.  Let’s call her Janet.

The poor lady (and her poor dog) certainly had been through a lot.  She had developed a profound distrust for vets in general and surgeons in particular. She was “sick and tired of getting the run around.”   She wanted answers.

So it is in that wonderful frame of mind that she came to my surgery consultation…

What would you do in my position? Could I ethically recommend a fifth surgery on Caramel?  She was breathing through her mouth – again. The slightest activity would lead to panting and sneezing fits – again.  She had a large mass near her left eye – again.  By now it was pushing her left eye forward, which caused a lot of pain.  And all I had to offer was surgery – again. Should I?  Would I?  What good would that do? Provide another “negative” biopsy?  I had no desire to be the subject this lady’s wrath.

But my job was more to focus on Caramel’s well-being than to worry about being yelled at by Janet. So we had a long heart-to-heart.  As a surgeon, all I could offer is another surgery to remove the mass… as long as we agreed that it was ethical to do that.  In addition, in order to try to “get it all,” we would have to sacrifice the left eye. It was the first time Janet had heard this possibility, and believe me, it was a hard pill to swallow for her.

I continued.  We will then send all of the tissues we remove to the lab for – you guessed it – another biopsy.  She questioned the need to re-biopsy tissue that had been read as benign 5 times before. Janet had “already spent a fortune” in medical bills. “Why would I waste my money on another silly biopsy when the previous ones all showed that this mass is benign?” she asked. “Plus, we’ve been dealing with this for years.  If it were cancer, she’d be dead by now, instead of coming back every year for surgery,” she reasoned.

Despite the apparent logic, I wouldn’t negotiate.  I did think that this mass was cancer. I firmly believe that masses should always be biopsied - based on experience rather than dogma.  Janet eventually understood my point of view and accepted to biopsy the mass.

We slowly came to an agreement that taking Caramel to surgery was ethical.  We could provide lots of pain medications.  Her quality of life would be good, even with one eye.  Janet and I weren’t exactly BFFs, but I felt that we were on the same page.  We both had Caramel’s best interest in mind.

In surgery, there really was not much to remove… We cleaned up unhealthy tissue, got rid of thick nasal discharge, removed the left eye, saved every little bit of material and shipped it to the lab.

Caramel made a smooth recovery and went home on the next day. One week later, biopsy results came back…

I called Janet.  Although I felt that that we had developed a mutual respect by then, I was a little concerned about a screaming session…

The biopsy unfortunately confirmed a type of cancer called nasal adenocarcinoma. Janet was devastated.  The only bit of good news is that it was a “slow growing” cancer.  She took the bad news with philosophy. After all, she had been well prepared psychologically.

We discussed the two standard options for cancer management after surgery, chemo and radiation therapy, but she decided that Caramel had had enough.

I respected her decision and we agreed to help Caramel enjoy the rest of her life comfortably.

I am thrilled to report that one-eyed Caramel is still happy and alive 9 months after her fifth surgery.

If you have any questions or concerns, you should always visit or call your veterinarian – they are your best resource to ensure the health and well-being of your pets.