I read about an Ethos Discovery clinical trial regarding misinformed euthanasia after a canine splenic rupture. Did you know that the likelihood of benign disease, often cured with surgery alone, is much higher than we once believed, at about 40 to 50%? Additionally, 96% of these older large-breed dogs recover and are discharged from the veterinary hospital within 40 hours after surgery, a much better statistic than commonly quoted.
I saw those statistics and instantly flashed back to moments that almost every veterinarian in small animal canine practice has experienced: the collapsed large-breed dog presenting as an emergency, accompanied by emotional family members vehemently attesting that their pet acted perfectly normal just a few hours before. I’ve been there hundreds of times, waiting for the results of the patient triage, only to find an abdomen full of blood on a FAST scan and a potential splenic mass. Within minutes, the most challenging and draining conversation of the day begins, and we start deliberating life-changing decisions for the patient and family.
Veterinarians are central to decision making multiple times a day. While the purpose is sometimes minor, like recommending a grooming salon, more often we’re involved with cases in which we directly influence whether continued therapy or humane euthanasia is best for the patient.
However, the Ethos Discovery study opened my eyes to different internal questions.
- Was I always as accurate as possible when delivering objective decision-making information?
- Did I stay collaborative, or did I just tell the owner what I would do one-directionally?
Those are critical pieces to consider, not just for the families who entrust care to us but also for veterinarians and team members in an industry challenged by mental illness and compassion fatigue.
Let’s explore the ethics around client communication and how supporting the pet owner more in such moments can improve our quality of life as veterinary professionals.
Knowledge Is Power
In 2015, Dr. Stine Billeschou Christiansen led a study examining the decision-making challenges between veterinarians and owners of seriously ill companion animals. While many studies looked at such situations from the veterinary side, the Christiansen study (bit.ly/42INWGA) placed more weight on the client’s perspective and, more specifically, on the factors influencing treatment choices.
Not surprisingly, one crucial factor needed in the pet owner’s decision-making process was knowledge. It wasn’t just knowledge of the disease process but also the treatment options, patient outcomes and quality-of-life assessments from an animal welfare perspective. While veterinarians typically take time to deliver enough information, many clients in the study confirmed that one of the obstacles to decision making: the inability to absorb or understand all the information given. Here, it’s essential to consider additional resources, like handouts, models, animations and other visuals that might reinforce the conversation.
However, veterinarians don’t always have all the information at hand, and that disclosure can be helpful.
For example, take the statistic above about the potential for benign disease (and cure) in almost half the cases. The veterinary team might not be privy to the family’s budget, ability to provide care or ability to process a diagnosis of neoplastic disease and emotionally deal with the trauma around the emergency. Clients appreciate transparency, making for a perfect opportunity to collaborate with them on well-informed decisions. When that happens, the door opens to one of the hardest questions in our industry.
“What Would You Do?”
How many times a week are we asked that question? Some veterinarians might feel comfortable sharing a personal view supported by medical facts. Others are quick to recuse themselves from answering. “What would you do?” generates a more complex set of thoughts to consider. Even if you’ve felt comfortable engaging with a pet owner, I want to encourage two points of consideration before answering this question again.
For one, the primary veterinarian’s perspective and the client’s life situation might differ, as could each person’s ethical values. The latter is often recognized when the client makes a decision that isn’t ethically acceptable to the doctor or veterinary team. The realization can lead to compassion fatigue and, eventually, burnout. The other critical factor here is accountability and ethical considerations. Who is responsible for making the final decision in a case? The veterinarian? The client? Or is it a shared effort?
In the clinical decision-making process, two extremes exist. One is paternalism, where all the decision-making lies on the veterinarian’s shoulders. That approach has apparent challenges, sending the pendulum to the opposite end: pet owner autonomy. In that case, the owner takes full responsibility for patient care decisions. Some experts in veterinary ethics argue that pet owner autonomy is preferred so that veterinarians avoid blame for the decisions made and the client is allowed more personal growth.
A More Active Role
The flip side of that argument spotlights situations where the veterinarian must take a more active role in protecting animal welfare when an owner is reluctant to end a pet’s suffering or is emotionally overwhelmed.
According to a 2006 study (bit.ly/3CCExpr), the ideal strategy is shared decision making, where objective information and goals and preferences are discussed between the veterinarian and client until an agreement is reached. Remember that agreement here stands for the readiness to proceed with a particular decision, not necessarily that the choice is the best option for either party. Such a strategy is appropriate for the collapsed large-breed patient when at least two reasonable options (surgery or humane euthanasia) exist, and the client’s values and the patient’s quality of life are weighted variables.
Our Responsibility
Does the situation seem a bit overwhelming when we break down the essential communication components? Many clinicians didn’t study veterinary ethics and weren’t trained in communication role-playing. Yet, we feel responsible for shaping the direction of our patients’ lives every day, especially in life-threatening cases.
Instead of second-guessing our statements or retreating from being an active participant in the veterinarian-client relationship, we should think about four ways to be most helpful to clients during shared decision making.
- Provide up-to-date, accurate and relevant information to the pet owner. If the case is outside your comfort range, be humble and phone a friend for guidance. While generalists pride themselves on their knowledge across many subject areas, they can’t keep current with every recent breakthrough.
- Do your best to support client decisions. Remember that an agreement doesn’t mean you necessarily approve of the choice. Instead, you accept the chosen option.
- Listen to and validate the client’s considerations. Many owners caring for pets with chronic diseases often ignore how the conditions affect their own quality of life.
- Provide specific guidance when necessary. Sometimes that means suggesting a decision-making deadline. In other cases, you might recommend alleviating patient suffering, even if you need to consult another expert.
The objective should be to create an environment of shared decision making and offering the best support to the client.