Ethical Decision - Acute splenic bleed!

Re: Ethical Decision - Acute splenic bleed!

Rob Loxley — Thu, 19 Jan 2012 17:17:03 GMT

[quote user="james herriot lied"]How to demonstrate informed consent?[/quote]

I'd hope my contemporaneous clinical notes would stand up in the small claims court, if it came to that?

For future maybe get them to sign an amended consent form, or if that's not practicable then getting someone else at the practice to witness your conversation. It'd be a sad day when we start recording our phonecalls...

Re: Ethical Decision - Acute splenic bleed!

james herriot lied — Thu, 19 Jan 2012 17:00:51 GMT

[quote user="robloxley"]

Also worth a quick look at the heart.

[/quote]

Funnily enough, I think the reverse is also often true: with dysrhythmias, I'll often look for splenic masses. I guess also that where these are found, I'd tend to assume that they'd be malignant, but now I'm wondering whether this is automatically the case.

Wren, that sounds like a classic case of 'the debt dies with the dog' on the part of the owners. We all get them - and after all, why euthanase if you can get more treatment without needing to pay for it - but I've yet to find a way of avoiding the situation completely. How to demonstrate informed consent?

Re: Ethical Decision - Acute splenic bleed!

Hannah Wynne Richards — Thu, 19 Jan 2012 16:38:18 GMT

Roboxley It would actually have been the insurence companies money but I think the owners thought if they didn't know then there was a 33% chance it was OK and they would hang on to that as opposed to a 66% chance of knowing it was malignant

I supose it depends if they are a 1/2 full or 1/2 empty type of people

Wynne

Re: Ethical Decision - Acute splenic bleed!

Wren — Thu, 19 Jan 2012 15:50:40 GMT

I operated on one in a GSD a few months ago giving the owner a very guarded prognosis (although the ones I have done in the past seem to outlive the statistics). Op went well, dog bounced back until 2 days later (the evening before it was due to be discharged) when it suffered a ?cerebral embolism (looked similar to a severe human stroke). Although the dog was unable to stand, eat or drink the owner wouldn't let us euthanase it until it had had a further 3 days nurse and every conceivable treatment. Eventually the dog was PTS.

The owner refuses to pay a penny of the (considerable) bill as they maintain I should have euthanased it at the first consultation and saved all the stress (and, I guess, money). I gave them the options at the time, they chose to operate. We'll never see the money.

Re: Ethical Decision - Acute splenic bleed!

Rob Loxley — Thu, 19 Jan 2012 15:39:03 GMT

[quote user="Hannah Wynne Richards"] I didn't submit it for histology as the owners were adamant they didn't want chemo so no point[/quote]

Except if it was a benign tumor they could be pretty happy the dog is cured and not be constantly worrying that the dog is going to keel over; though agreed it's their £50 to spend if they want, if it won't change the treatment otherwise

Re: Ethical Decision - Acute splenic bleed!

Hannah Wynne Richards — Thu, 19 Jan 2012 10:44:10 GMT

The last one I did certainly looked like haemangiosarc, although I didn't submit it for histology as the owners were adamant they didn't want chemo so no point It was on 30th Sept and the dog is still well which is why I'm cautiously optimistic

Wynne

Re: Ethical Decision - Acute splenic bleed!

Braden Collins — Thu, 19 Jan 2012 01:13:12 GMT

I've been told that we look at the double 2/3rds rule for splenic masses - about 2/3rds are haemangiosarcs and about 2/3rds of them have spread at the time of diagnosis.

With any splenic mass, I will always stage before removal. Chest rads should be an asolute minimum, but if you have an ultrasound machine then abdo scan is indicated too. Since taking this approach I have definately removed less spleens as I have found mets on multiple occasions.According to Winthrow and MacEwans, median survival for straight plenectomy is 19-86 days, which may be exxtended up to 6 months with various chemo options.

Also remember that as a very general rule, the bigger the splenic mass at the time of bleed/diagnosis, the less likely it is to be a haemangiosarcoma - this is because haemangiosarcomas are more friable and more likely to bleed early and when small than other splenic masses.

In this case, if they have no money for treatment, euthanasia is definately the right optioin. Even if it stablises short term, it will bleed again very soon.

Re: Ethical Decision - Acute splenic bleed!

David Mills — Wed, 18 Jan 2012 22:05:50 GMT

Do people auto transfuse?

I know the argument for seeding of tumour cells but is that so important as they've likely spread already?

Re: Ethical Decision - Acute splenic bleed!

Rob Loxley — Wed, 18 Jan 2012 20:54:56 GMT

[quote]

would run a scanner over the liver in any case

[/quote]

Also worth a quick look at the heart.

There was a paper in JSAP that reported about 50% neoplastic and of those 50% haemangiosarc (though I think they included some spleens that were just biopsied, not just huge spleens removed entirely). There was also a paper in JAVMA that reported on dogs with a splenic mass needing transfusion because of haemabdomen, and over 75% were malignant, almost all haemangiosarcoma.

Yesterday's spleen removal weighed in at over 3kg, will be interested to see what it comes back as, and the owners are aware of the potential poor prognosis but decided they wanted to go for surgery.

Re: Ethical Decision - Acute splenic bleed!

Julian Earl — Wed, 18 Jan 2012 20:34:27 GMT

[quote user="Lorna McHardy"]

[quote user="Julian Earl"]

According to Improve surgical CPD notes, only 50% of splenic masses are neoplastic and the verbal advice was to operate on them all (although personally I think there has to be some leeway there!).

[/quote]

Ruptured ones, or all masses? Because of those that rupture and cause the dog to turn the colour of your average bedsheet, I'd be surprised if only 50% were neoplastic. If it's all splenic masses regardless, then that still sounds low, but much more likely; which is why I'm also much more likely to recommend surgery if I find one that hasn't ruptured.

[/quote]

All. The suggestion that ruptured ones asre more likely to be malignant sounds reasonable but the take-home message won't don't automatically PTS these cases, they may be fully operable. If you have an abdomen full of blood, then that in itself alters your choices of course.

Re: Ethical Decision - Acute splenic bleed!

Hanna Bennett — Wed, 18 Jan 2012 20:16:24 GMT

Tried chemo on one - doxorubicin ev three weeks for four doses - was still dead at six months (confirmed haemangiosarc)

I think any ruptured spleen assoc with trauma (and i don't mean rta but the missing the car boot is a classic example) is worth operating on as think these are more likely to be haematomas and so happy endings

Re: Ethical Decision - Acute splenic bleed!

Fiona French — Wed, 18 Jan 2012 19:23:45 GMT

I was taught at uni that 50% of splenic masses that present not bleeding are malignant neoplasms, but 90% that present ruptured and bleeding will be malignant. From my experience, this sounds about right.

Re: Ethical Decision - Acute splenic bleed!

plantagenet — Wed, 18 Jan 2012 17:57:38 GMT

My experience (tin hat on) is that the figure is more pessimistic. I am always curious to know on what population these figures are based.

Re: Ethical Decision - Acute splenic bleed!

Hannah Wynne Richards — Wed, 18 Jan 2012 16:25:33 GMT

Has anyone tried chemo? I haven't but just wondering what you all think

Wynne

Re: Ethical Decision - Acute splenic bleed!

Lorna McHardy — Wed, 18 Jan 2012 16:23:35 GMT

[quote user="Julian Earl"]

According to Improve surgical CPD notes, only 50% of splenic masses are neoplastic and the verbal advice was to operate on them all (although personally I think there has to be some leeway there!).

[/quote]

Re: Ethical Decision - Acute splenic bleed!

Mark Rowland — Wed, 18 Jan 2012 16:00:25 GMT

I dont disagree with what was done here, however they are not all haemangiosarcs. I have a client with a border collie whose spleen I removed 6 years ago with a rupture. It was a spindle cell sarc, I gave it chemo and its still here, Another dog had the biggest tumour I have ever removed from a dog (another splenic spindle cell sarc). I had to incise along the dogs flank to get it out , It was a staffie with a football inside it!

Scanning for secondaries is a good idea imo

Re: Ethical Decision - Acute splenic bleed!

james herriot lied — Wed, 18 Jan 2012 15:40:39 GMT

I'd tend to veer away from surgery also, but would run a scanner over the liver in any case - had a little terrier in last week clinically pretty well but MASSIVE spleen. Quick scan of liver showed secondaries, so no surgery but running around with pain relief as though nothing was wrong. At some point it will go bang, but owners - extremely enlightened farmers - aware of both sides of the debate and happier with this approach.

Median survival time often given at just shy of six months, but I'd agree that three months is closer to the mark; incidentally, about the same for reasonably distal limb osteosarcs post-amputation.

Re: Ethical Decision - Acute splenic bleed!

Julian Earl — Wed, 18 Jan 2012 15:36:50 GMT

According to Improve surgical CPD notes, only 50% of splenic masses are neoplastic and the verbal advice was to operate on them all (although personally I think there has to be some leeway there!).

Re: Ethical Decision - Acute splenic bleed!

Hannah Wynne Richards — Wed, 18 Jan 2012 15:05:44 GMT

Hannah Further ethical dilemma That sounded like a typical puppy farm pup Is it better to accept puppy farmers as clients (given that helps perpetuate the problem ) or refuse to have anything to do with them?

Wynne

Re: Ethical Decision - Acute splenic bleed!

plantagenet — Wed, 18 Jan 2012 15:01:40 GMT

Sounds like you did the right thing. Most of them will die from mets in a couple of months - just after they've recovered from surgery.

Re: Ethical Decision - Acute splenic bleed!

HMC — Wed, 18 Jan 2012 14:47:48 GMT

From the sounds of it I would have euth'd the dog too, if that is what the owners wanted, given all the options.

But then we could get into a debate about which animals to be heroic with. I had some owners sign over their springer spaniel puppy, which they had owned for all of 2 days, because they could not afford to pay for anything (she was dehydrated and had HGE). I just didn't want to put a puppy down. Now she belongs to my in-laws and is very sweet and healthy . One of the joys of being a vet when you save an animal from the brink.

I remember commenting at the time that I would not have done that for a staffordshire bull terrier puppy... (call me cruel if you want)

Re: Ethical Decision - Acute splenic bleed!

Hanna Bennett — Wed, 18 Jan 2012 14:02:30 GMT

Always difficult cases - I often advise euthansia in any GSD type I have to admit given the poor long term prognosis. Having said that I've had my far share of haematomas on histo rather than haemangiosarcs, and remember the 14 yo collie cross who after much deliberation we took to surgery that we euthanased three years later so... Problem is that you often have an elderly animal with pre existing problems that is not insured and so the decision inevitably descends into the odds of long term survival. But then I did a splenectomy on a 7 yo collie a couple of months ago which turned out to be a haemangiosarc and she's dead two months later. Oh for the crystal ball....

Re: Ethical Decision - Acute splenic bleed!

Hannah Wynne Richards — Wed, 18 Jan 2012 11:30:06 GMT

I think you definitely did the only thing possible in this case

Splenectomies in general-as others have said -give the owners all the facts

I'm cautiously hopeful about my last one again elderly lab, but on NSAIDs for it's arthritis, insured, and fortuneately didn't quite make it when jumping into back of landrover, hit ventralabdomen on edge and in obvious pain later, so brought in at earlier stage than yours-no 2ys seen, so I'm hopeful I got it in time

I always get euthanasia permission before starting surgery just in case

Wynne

Re: Ethical Decision - Acute splenic bleed!

Bob Russell — Wed, 18 Jan 2012 11:20:43 GMT

This was not a particularly difficult case to make a euthanasia decision - elderly, arthritic dog, clearly major bleed and no funds. I am not particularly worried about the technicalities of the surgery but with staple guns, blood transfusions and 24 hour nursing I suspect the survival level is better than for those of us still ligating blood vessels the old way! Hence the referral option!

I have a very good surgical survival rate perhaps because I am very selective about those that are operated on but am running at about 50% survival at six months.

I asked the question because I am uncomfortable giving up at the first fence in any case!

Re: Ethical Decision - Acute splenic bleed!

Mark Holmes — Wed, 18 Jan 2012 11:03:57 GMT

Sometimes euthanasia is the best option as a result of one big factor. Sometimes because of a collection of smaller ones each of which is managable in isolation.