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  • Dr. Liz Bales

The #1 Cause of Death for Cats? We are Not Treating it, or Educating About it

Our clients have no idea what “environmental enrichment” means. Most of them are not providing it, and that is killing our patients. Yes. Killing. The #1 cause of death for cats is the one we are not treating, or educating about. The #1 cause of death for cats is euthanasia. The #1 cause of euthanasia is being surrendered to a shelter for behavior problems. We know why the behaviors happen, we know what cats need to minimize or eliminate these behaviors. And, still, we avoid even bringing it up.

Imagine not treating or educating about cancer or kidney disease. Unthinkable, right? And yet, your feline patients are less likely to lose their life to either of these. So, why are we ignoring it?

The evidence is clear that it is not just euthanasia. Failing to meet cat’s needs in the indoor environment makes cats sick. It contributes to obesity, lower urinary tract disease, GI disease, dermatologic disease, endocrine disease and more. And still, we avoid even bringing it up.

Is providing for a cat’s needs really enrichment? If lacking these resources is killing cats and contributing to most of the diseases they face, shouldn’t we redefine minimum cat care requirements? And educate our clients about what they are and give them the tools to do it?

In our profession, we suffer from compassion fatigue.  I get it.  I really do. Our clients break our hearts and wear us out. They come in full of enthusiasm for kitten vaccines and we never see them again, until they are at the end of their ropes because their cats are chronically urinating outside of the litter box. Then, they might implore us to perform a convenience euthanasia.  When their cat has destroyed their furniture and they just can’t deal with it anymore, they ask us to perform a declaw.  When their cats keep fighting with each other we drain their abscesses, sew them up and talk about re-homing.  Some days it is just too much to bear.

This is a vicious cycle.

Cat needs are not intuitive to humans and when things start to go wrong, our clients do not know where to turn for behavior and cat care counseling. They guess, ask a friend, turn to google or just don’t try at all. When the behavior is intolerable, they take the cat to the shelter or simply put them outside.

We have lost a patient and a client. We have lost the opportunity to listen to this cat’s heart, palpate their abdomen, perform a dental and engage with an informed, and grateful client.

But, my colleagues, we CAN get in front of this problem. We can save lives.  After all, isn’t this why we became veterinarians?  Our clients are looking to us for education and support at their first kitten visit.  They are looking for more than vaccines and screening blood work at their annual visits.  The time to inform and educate our clients about minimum cat care needs is before the human-animal bond, and our professional spirits, are broken.

The science is there. The American Association of Feline Practitioners has beautifully laid out the 5 pillars of feline environmental enrichment, why they are important and the consequences of denying our cats the resources that they need to be physically and emotionally healthy in the indoor environment.

In case you have not had the opportunity to read this entire paper, here’s my favorite bit..

“Many behavioral and physical disorders that are seen in cats are often secondary to stress from lack of appropriate stimulation. Environmental enhancement should be part of the overall treatment plan for these disorders. As part of the wellness exam, it is the responsibility of the veterinarian to discuss the current state of the environment and to provide resources for EE to indoor cat owners.

It is well known that if an appropriate environment is not provided for indoor cats, they are at greater risk of stress induced illnesses such as the following:

Feline lower urinary tract disease 1, 2


Different forms of aggression4

Over grooming and other compulsive disorders5

Upper respiratory infection 6,7

In an attempt to prevent the above conditions, it should become routine for the veterinary team to inform owners of the importance of EE and to provide resources to owners. It is also important to consider EE in shelter cats for the same reasons.”

The cats are counting on us to get this information from the pages of the veterinary journals and textbooks to their caretakers.  One way or another, this is a veterinary job, our job!

We study kidney disease, endocrine disease, ophthalmology, oncology, etc. so we are prepared for those cases when they walk through our exam room door.  But do you know what every cat in our care has in common?  Every cat is our care is completely dependent upon their human to create an environment where they stand a chance of being physically and mentally well.  We need to be prepared with information and resources to treat and cure this.

And how are we going to manage this?  We are already squeezed with the amount of information, and procedures that we need to cram into a 15-20 minute appointment. I know it will be hard, but we can do it. It is our responsibility to educate every feline appointment about minimum cat care needs and the physical and behavioral consequences of not providing for them. Ideally we will train technicians, add time onto every office visit and review this information with all of our clients. We should increase our exam fee to cover the cost of this service. Additionally, there are resources available both digitally and in print that we can email to our clients or hand out in our waiting rooms or at check out.

As a profession, we can figure out how to incorporate this into our practice.  I know we can.  And the time starts now, with a very simple question.

“Can I show you what we have found out about minimum cat care needs?”

Copyright Dr. Liz Bales, VMD 7/20/2020


Alley Cat Allies. (n.d.). Cat Fatalities and Secrecy in U.S. Pounds and Shelters. Available at:

American Association of Feline Practitioners. (2013, July). Bayer-AAFP study reveals half of America’s 74 million cats are not receiving regular veterinary care. (News release.) Available at:

ASPCA. (n.d.). Pet Statistics. Available at:

Association for Pet Obesity Prevention. (2019). 2018 Pet Obesity Survey Results: U.S. Pet Obesity Rates Plateau and Nutritional Confusion Grows. Available at:

Bradshaw, J.W.S, Casey, R.A., & Brown, S.L. (2012). The Behaviour of the Domestic Cat, 2nd Edition. Boston, MA: CABI: 16-40.

Buffington, C.A.T. (n.d.). Pandora Syndrome in Cats: Diagnosis and Treatment. Today’s Veterinary Practice. Available at:

Buffington, C.A.T. (2011). Idiopathic cystitis in cats--beyond the lower urinary tract. Journal of Veterinary Internal Medicine, 25(4): 784-796.

Dorsch, R., Teichmann-Knorrn, S., & Lund, H.S. (2019). Urinary tract infection and subclinical bacteriuria in cats: a clinical update. Journal of Feline Medicine and Surgery, 21(11); 1023-1028. Available at:

Ellis, S.L.H, Rodan, I., Carney, H.C., Heath, S., Rochlitz, I., Shearburn, L.D., Sundahl, E., & Westropp, J.L. (2013). AAFP and ISFM feline environmental needs guidelines. Journal of Feline Medicine and Surgery, 15(3): 219-230.

iCatCare. (2018a). Feeding Your Cat or Kitten. July 24. Available at:

iCatCare. (2018b). The Social Structure of Cat Life. October 5. Available at:

iCatCare. (2019). Understanding the Hunting Behavior of Pet Cats. January 15. Available at:

Karagiannis, C. (2016). Stress as a Risk Factor for Disease. In Rodan, I., & Heath, S. (Eds.), Feline Behavioral Health and Welfare. St. Louis, MO: Elsevier: 138-147.

Purina. (2015, December 8). Meet Generation Meow: New Purina Study Shows Nearly Half of Millennials Surveyed See Cats as a Purrfect Pet. PR Newswire, St. Louis. Available at:

Rodan, R. (2016). Importance of Feline Behavior in Veterinary Practice. In Rodan, I., & Heath, S. (Eds.), Feline Behavioral Health and Welfare. St. Louis, MO: Elsevier: 1-11.

Salman, M.D., Hutchison, J., Ruch-Gallie, R., Kogan, L., New, J.C. Jr., Kass, P.H., & Scarlett, J.M. (2000). Behavioral reasons for relinquishment of dogs and cats to 12 shelters. Journal of Applied Animal Welfare Science, 3(2): 93-106. Available at:

Steve. (n.d.) U.S. Pet Ownership Statistics 2018/2019. Daily Dog Stuff. Available at:'s%20latest,statistics%20from%20each%20year's%20survey.

Zito, S., Morton, J., Vankan, D., Paterson, M., Bennett, P.C., Rand, J., & Phillips, C.J.C. (2016). Reasons people surrender unowned and owned cats to Australian animal shelters and barriers to assuming ownership of unowned cats. Journal of Applied Animal Welfare Science, 19(3): 303-319.

Further reading:

American Association of Feline Practitioners. (2004). Feline Behavior Guidelines. Available at:

Buffington, C.A.T., Westropp, J.L., & Chew, D.J. (2014). From FUS to Pandora syndrome: where are we, how did we get here, and where to now? Journal of Feline Medicine and Surgery, 16(5): 385-394. Available at:

Lund, H.S., Sævik, B.K., Finstad, Ø.W., Grøntvedt, E.T., Vatne, T., & Eggertsdóttir, A.V. (2015). Risk factors for idiopathic cystitis in Norwegian cats: a matched case-control study. Journal of Feline Medicine and Surgery, 18(6): 483-491. Available at:

Author Bio

Dr. Liz Bales, VMD is a 2000 graduate of The University of Pennsylvania School Of Veterinary Medicine who has gained a special interest in the unique behavioral and wellness needs of cats. Dr Bales is a writer, speaker and featured expert in all things cat around the globe including appearances on Fox and Friends, ABC News, SiriusXM The Doctors, NPR’s How I Built This, The Dr. Katy Pet Show and Cheddar. Dr. Bales has been a speaker at The Penn Annual Conference, at The University of Pennsylvania School of Veterinary Medicine and The University of California Davis School of Veterinary Medicine. She sits on the Dean’s Alumni Board at The University of Pennsylvania School, the Editorial Board for DVM360, the Advisory Board for AAFP Cat Friendly Practice, The Vet Candy Advisory Board and the Advisory Board of Fear Free. Dr. Bales serves on the Human Animal Bond Social Media and Continuing Education committees and the Pet Professional Guild Feline Committee.

Dr. Bales is a prolific writer and regular contributor to Fear Free Happy Homes, Modern Cat Magazine, Pet MD, and will be featured in the upcoming September edition of Barks Magazine with the cover story.

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