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The Daily Vet by petMD

The Daily Vet is a blog featuring veterinarians from all walks of life. Every week they will tackle entertaining, interesting, and sometimes difficult topics in the world of animal medicine – all in the hopes that their unique insights and personal experiences will help you to understand your pets.

When Veterinarians and Owners Aren’t on the Same Page

In response to my recent post, The Decision to Euthanize a Pet: A Vet's Perspective, BarbaraA recommended that I do a follow-up article on "how to combat a vet’s ‘objections’ to honoring a euthanasia request." She mentioned that she works with five people who have been talked into "last ditch" treatments, as well as experiencing it herself, and asks if this is a new philosophy that vets share.
 

Now, I can’t speak to those particular situations, of course, but scenarios like this do occur. Let’s look at a couple of reasons why and what can be done about it.

First of all, the answer to BarbarA’s question is "no." Vets aren’t in cahoots when we recommend that owners pursue treatment in the face of a poor prognosis. Veterinary medicine has simply come a long way in the last few decades, and we now have much more to offer in the face of serious disease.

Not too long ago, if your cat had cancer, for example, just about the only reasonable option we had was euthanasia. Now, advanced surgical techniques, chemotherapy, radiation treatment, and complementary therapies are all valid options. It is a veterinarian’s responsibility to put all of these choices on the table, and to strongly recommend any that might offer an animal a reasonable chance at an extended period of good quality of life. In this situation, the doctor’s role is to be an advocate for her patient’s best interests, not always to do what an owner wishes.

Problems arise even between people with good intentions because of the nebulous nature of the words "reasonable," "extended," and "good." What might seem reasonable to one person (e.g., $2000 for a 50 percent chance at four more months) might seem insane to another. When the vet is the former and the client is the latter, questions about motives often arise. But most veterinarians really are not looking to wring out a few more bucks from an owner before euthanizing a cherished family member.

What is the solution? Communication. It’s not a cure-all, but talking honestly about the situation goes a long way towards overcoming these pitfalls. If asked, a veterinarian should be able to present several options for dealing with most situations, and when confronting a terminal disease, euthanasia should always be one of them, in my opinion.

Everybody brings emotional baggage with them to this type of conversation, however. Maybe the veterinarian recently had an excellent outcome with the therapy she is recommending and is eager to try again. Or perhaps she has performed several difficult euthanasias already this week and is subconsciously trying to avoid another. Maybe the client went through an aggressive treatment regime that didn’t go well with a previous pet and is hesitant to enter into that scenario again. These are all reasonable points of view but can make a person’s stance seem irrational if they’re not understood.

So, if you ever find yourself in a situation where you are uncomfortable with a vet’s recommendation, ask "are there any other options available?" Be persistent and honest with your reasons for looking for an alternative. This is a lot to ask of an owner in the face of a crisis, but keeping the lines of communication open is the only way to make sure that your pet gets the best care possible.

Dr. Jennifer Coates

Pic of the day: Waiting on the Dr. by Cordey

Woman and dacshund waiting at a veterinarian's office, poor prognosis in vet medicine, option in pet treatment

Comments  20

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  • Options
    06/20/2011 06:59am

    Once again an article convinces me that I must have the best vet in the world. We always talk about options. Sometimes he stresses that even though there are options, some might not be in the best interest of the animal. He always listens to my concerns and gives them serious consideration.

    He has never led me down a path that I've regretted.

  • 06/20/2011 07:28am

    My first cat developed an abdominal mass at the age of 15. We spent an entire summer trying everything short of chemo/surgery and kept him eating and reasonably happy for 4 months after initial diagnosis, but eventually he refused to eat anything and it was time. We took him in to his vet office, but our usual doctor was not in. The doctor who was refused to euthanize unless we rechecked his blood panel to make sure it was not renal failure instead, since renal failure could be treated. We sat and argued - his bloodwork was fine 4 months ago when his problem started, even if it WAS renal failure this was a cat who dealt poorly with SQ fluid administration, we had a standing agreement with our regular vet that we were to bring my boy in when he stopped eating, etc. No avail, he wouldn't budge. We had to come in the next day (now I wonder why we didn't go to a different hospital, but I was not thinking that rationally at the time) to have our doctor do the deed.

    I've tried to let this experience inform my actions now as a vet. Euthanasia is never an unreasonable option for a pet who is suffering, even if they are not terminal, just in horrible pain that the owner can't afford to treat. I've refused one and only one euthanasia. It's not about whether I can treat the pet, it's about whether the owner can - an emotional and financial decision as much as one about prognosis. That being said, I've also had owners make the decision in either direction and regret it later. "She didn't make it, why didn't you tell me she wasn't going to live so I could just euthanize?" "Why did you agree to put her to sleep, we could have tried X! I wasn't thinking clearly!" It's easy to get burned in these emotional situations and usually it's grief talking more than anything. Life would be much better if there was a crystal ball to let us know which ones we really would save; we've all seen pets with poor prognoses that lived and pets with good prognoses die.

  • end-of-life
    06/20/2011 09:40am

    Wikith: I like your comment having experienced a deeply emotional time and being refused euthanasia. It is a horrible thing for a veterinarian to do after years of ownership and care for your pet.

    I wonder in retrospect if you question this "stand in" vet's motive, now that you are a vet. Was it possible this vet held no DEA license? Was it possible that this vet had no access to controlled substances?

    Well, that is exactly what happened to me. All without prior knowledge of informed consent.

    But the others I know? There is only one reason to suggest "treatment" for a pet that is clearly in the dying process and it isn't an ethical or good one. There are "no miracles" to be had.

  • 06/21/2011 07:43am

    I don't question motives. As much as I disagree with the vet in question and as much as it hurt our family to go through that, I do believe he was hoping to find a way to save our cat, I just wish he'd respected our wishes to not push more diagnostics on our boy. I have felt the same urge, when I really want to not add ANOTHER pet to my tally on a hard day, when I think there might be something more, one more thing we can try before giving up on a sweet pet. In a way I am glad I had the experience because it has informed my compassion as a vet - when I start pushing back on euthanasia requests for sick animals, I sometimes take a mental step back and a deep breath to help recall that exam room ten years ago when I was on the other side of the table.

    All vets at the practice in question are required to have a DEA license prior to their first day of work. Lack of appropriate drugs was not the problem in this case.

  • 06/21/2011 04:38pm

    That's a relief, a LOT of states have put this regulation into place----but not New Hampshire, I guess we WANT to attract the bad bunch, as apparent by the 2008 change in the Veterinary Practice Act---there is big bucks in REHAB---screw the collateral damage victims. As far as money goes, the victim can suffer for life as far as the government is concerned.

    But then again, all the silent bystanders can lump themselves into the same bunch.I'm concerned that these porr ethics are actually "taught" to impressionable students...that is pretty bad also.

    How do THEY all look into the mirror? I'll never understand it and it has been nearly five years.

    Wikith: always search your heart & brain to do right and it will NEVER come back on you.

  • 06/20/2011 12:10pm

    I once worked with an aspiring veterinarian who was incensed at my refusal to take aggressive measures to prolong the life of a terminally ill pet.

    Should she obtain her DVM, it's likely that there would be some serious butting of heads in the end-of-life issues department were I her client. She obviously places a higher premium on prolonging life, whereas I'm more of the quality-trumps-quantity type.

    This is one of those areas where there are going to be strong opinions, strong feelings, and, at times, strong disagreements. Just because two parties disagree on the best course of action, it doesn't necessarily mean that both don't have what they consider to be the animal's best interests at heart.

    I'm not suggesting that there aren't unscrupulous veterinarians out there. There are bad eggs in every profession, and vet med is no exception. But, at the same time, I don't think it's fair to assume that there's only one (reprehensible) reason a vet might be reluctant to throw in the towel.

  • 06/20/2011 12:12pm

    Ack. That was supposed to be a reply to the above comment. Posting FAIL.

  • 06/20/2011 12:46pm

    4_Fab,

    I can't disagree with you more. Pets are property, unfortunately a sad fact. Therefore when a loving owner comes to terms with a humane and kind end for their pet; there should be RESPECT and no arguing or deception involved.

    Who's interest is at heart here? The dying pet? The grieving, sad owner? uhh, uh, I think at that point it is self-serving to the vet only.

    Please do not mistake my comment to include care in the last months of life, I am talking about irreversible "organ failure" and the concept of prolonging suffering in a cage in the hospital or in an oxygen tent, OR telling the owner some miracle surgery can be performed (even though the advancement of the cancer or disease has already taken its course)

    So when an owner makes that difficult request, it is the owner/client/patient that is RIGHT.

  • 06/20/2011 06:47pm

    Deception is never okay, but I do believe that a veterinarian has every right to voice objections or refuse to euthanize an animal in the event that they disagree with the owner's decision.

    It is possible for both parties to arrive at very different conclusions while both believing that they are operating with the pet's best interest in mind. I'm not implying that this was the case in your situation... but I don't think it's fair to imply that anyone who pushes aggressive treatment in the face of a poor prognosis is simply looking to profit off of the pet's suffering.

  • 06/20/2011 07:20pm

    We can simply disagree. I surely would hope that a vet that refuses to humanely end a terminal and very sick pet, would at the very least ask a colleague to stand in, instead of making a stressful & sad day far, far worse for everyone involved, patient included.

    It is one thing to offer options, another to pressure someone into a particular option, and quite another to have no respect for the owner too.

    I'm not exactly comparing to my own experience, that was clearly a s-c-a-m ,.... seriously, who would ever willingly go to or allow treatment at a facility that has NO DRUGS?? OR Vets that cannot get their DEA? That says it all right there. It is called informed consent. But that "place" has lowered the bar in this state to the lowest possible to allow others to do anything.

    Pocket's Story from NH

  • Question
    06/20/2011 12:36pm

    I wonder whether the veterinarians who push continued care in the face of terminal illness tend to be new graduates. Most "older" veterinarians have seen enough animal suffering to take a more pragmatic versus idealistic approach to end of life care.

  • 06/20/2011 12:39pm

    Thanks Dr. Coates,

    Don't veterinarians see enough suffering in training?

  • 06/20/2011 12:49pm

    Veterinary school is a world unto itself. Most of the "hands-on" experience that students get is in the referral hospital rather than in a typical veterinary clinic. So, no, most new grads haven't had deal with too many situations where an animal is suffering and an owner is unwilling or unable to pursue advanced care.

  • 06/21/2011 04:29pm

    Dr. Coates, I tend to think you mean this sincerely, but it is NO excuse to graduate students without a "firm grasp" on basic diagnostics.

    BTW, these vets involved in MY and the 5 NH situations have at least a DECADE under their belt---we are not talking "newbies".

  • 06/22/2011 01:28pm

    I agree with you, but on-the-job training is a huge part of veterinary (and medical) education. I think the primary issue is with learning communication skills versus having a handle on "basic diagnostics."

  • 06/22/2011 03:21pm

    Dr. Coates, I'm going to have to respectfully disagree, if you mean that Veterinarians aren't capable of stating simple facts based on known outcomes of known diagnostics.

    A veterinarian or any medical professional, has no need to embellish, with hold information (as in many cases), or soften harsh reality. It does no one any good at all, but may often be harmful.

    And if there are any reservations at all, one just needs to hand over a simple diagnosis, prognosis, and percent of success in treating any condition. I would avoid the 50/50 percent like the plague, because often that is used to induce someone also.

    The time is coming for the profession. It can't go years of high inflation (just as education & the human medical field) without responsibility to the consumer-client, even though the living, feeling patient is no more than a used appliance (in the legal sense).

  • 06/20/2011 07:35pm

    I've run into this on occasion at the emergency clinic (heavily staffed by recent grads) we use when one of my cats decides to give "mom" an after-hours coronary.

    They see a young, happy, affectionate, relatively healthy-looking animal, and I think it can be hard for some of them to accept that he can't be fixed. One doctor pressed for an MRI so we could discuss the possibility of brain surgery. This cat has a number of chronic and potentially life-threatening issues, including a progressive neurologic condition for which there is no effective treatment available. His entire body is giving out. He's a horrible surgical candidate. When I sit down and discuss my reservations with these vets, we invariably end up on the same page- especially once they've had a chance to digest his medical history... but there is almost always some initial push to be overly aggressive.

    The more experienced vets we've worked with seem to have a much easier time striking a happy balance between accepting what can't be dealt with and addressing what can.

  • What about...
    06/21/2011 12:37am

    ...the other side of the coin? In my experience rather than vets talking owners into extreme treatments, it seems more common for pet owners to delay euthanasia, sometimes to extremes. Either because they want to try any and all treatments that might buy a few more precious moments, or because they want the pet to "die at home" - but they are NOT talking about having a vet make a home visit for euthanasia, but rather they want nature to take its course. Vets rarely come straight out and say "you need to put this animal out of its misery NOW" - that seems to be a very hard thing for them to say outright, even if they are thinking it.

  • 06/21/2011 06:59pm

    BB: I can only guess, but I think that scenario is more of a rarity with a vet that has seen this pet for life.

    Sure, there will always be those guardian/owners that feel guilty until the last moment & effort. And in that case, i THINK THE VET IS BEING HONORABLE to follow that clients wishes along with the precluding statement" there is very little chance, short of a miracle, OR 99.9% never survive, etc." I would even have that client sign such a statement and then see how they "feel".

    As far as at-home hospice? Well done right with palliative care & serious pain relief, I don't see that as much different from human hospice.

    (PAIN RELIEF A MUST)

  • My opinion
    06/26/2011 08:25pm

    My English Mastiff was found to have cancer. He was 7 years old. The vet wanted to amputate his front leg. I explained that due to age(Mastiffs live average 8-10 years), likeihood the cancer would still spread and that as a breed that carries their weight in the front, that would have been out of the question. I have learned I have to firmly state my preference. I expect she will give me her opinion but I also want my vet to respect my decision and not press it.

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