Hypothyroid following thyroidectomy

Re: Hypothyroid following thyroidectomy

Kate Richardson — Mon, 02 Feb 2015 12:50:23 GMT

I agree Robin, Anthony is suggesting that ALL clients simply want to be told what to do and giving them options is the wrong thing to do as it confuses them. SOME clients want this. That's fine. Some, (and depending on your particular client base I would say a lot) don't- they want to be involved with the decision making in their pet's illness/injury. Personal circumstances will affect what option for treatment or investigation is right for them. Animals temperaments will affect what option is best for them. Even if you are a pretty good judge of character with your clients and can fairly accurately predict what course of action they will take they sometimes surprise you with what choice they want to make and you certainly cannot judge a book by its cover neither can you xray their wallet. Sometimes they do need guiding them towards a particular course of action based on our knowledge and experience. There are some situations where there is only 1 choice (2 if you include euthanasia as an option always). But they all need to know what the pitfalls are of any choices. There are many situations where there are options available. How much you want to confuse them depends on your communication skills and ability to talk to your clients in a language that they understand. It doesn't mean going into the intricacies of each different cruciate ligament repair option. How do you know if the client who opted for a thyroidectomy wouldn't have made a different choice if you has explained the potential problems that may occur? Maybe they wouldn't but it sure makes your life a hell of a lot easier if you had mentioned these risks and they had accepted them. Sadly these days are days of blame when things go wrong and compensation so it is partly about damage limitation, but mostly, in my mind anyway, about advising correctly and treating the client with the respect they deserve. If they choose to hand you the reins then fine. Your experience Anthony may reflect the clients you have worked with, but I think it shows a great deal of naivety on your part as it does not reflect mine nor of others who have responded to this post.

Re: Hypothyroid following thyroidectomy

Julian Earl — Mon, 02 Feb 2015 12:26:52 GMT

That is a five-star reply Kate. It is up to us to offer the information and the interpretation, offer realistic outcomes and let the owners make their choice as influenced by our opinion. I like the comment made above that what we offer is not a menu, we select the dishes, and advise which are the best flavour and best for the cat of course. It is what we do, interpretation and advice.

Re: Hypothyroid following thyroidectomy

Robin Grimmer — Mon, 02 Feb 2015 10:58:10 GMT

The point is there is no 'one size fits all' as Anthony is suggesting. Increasingly there are more ways of treating diseases now, with hyperthyroidism and cruciates being good examples. With a hyperthyroid cat, if say was younger I'd be much more inclined to recommended surgery or I131 as a cure, but if older or has concurrent disease eg chronic kidney disease then I'd be much more likely to recommend medical treatment. It's what is best for the patient and owner, and there are many factors to consider.

Re: Hypothyroid following thyroidectomy

Braden Collins — Mon, 02 Feb 2015 01:27:42 GMT

I agree that clients need to make a the choices, but they should be guided as much as possible by us and our recommendatiions, but most importantly I think we need to find out from the client what their perceived "end point" of treatment is and make sure their expectations are realistic and fair on the animal. I was listening to a TED Talk the other day by a doctor who's wife developed cancer. He said in human oncology it has been shown that when the patient is given choices for their treatment , the long term survival rates drop.

I don't know how you find the balance between clients feeling they had a choice and feeling they got sent down a path that they didn't want to go. And somewhere in the equation we need to work out what is best for the animal too.

Re: Hypothyroid following thyroidectomy

Michael Woodhouse — Sun, 01 Feb 2015 23:56:13 GMT

I agree. You can't just give options and rock back on your chair for the owner to pick one! The cruciate example is a fair one - you NEED further investigation, but once you've done that I'd offer:

1. refer to specialist for fancy surgery

2. do in house stabilisation ( bit less good, but less money)

If absolutely no money then:

3. cage rest & NSAIDS

4. PTS

get thrown in there, but I wouldn't generally encourage them as options in the first instance. If you do genuinely give all options then there's about a dozen different operations I have heard of.....

Re: Hypothyroid following thyroidectomy

Evelyn Barbour-Hill — Sun, 01 Feb 2015 23:38:37 GMT

[quote user="Anthony Todd"]What I am against is this idea that, by giving all the options, permutations possible outcomes etc. etc. you vets [not you Gillian per se] are not giving options but giving bewilderment and confusion so the owner will always say "What would you suggest?"[/quote]

He's got a point.

Re: Hypothyroid following thyroidectomy

Joyce Whitehead — Sun, 01 Feb 2015 23:36:16 GMT

Me too, I seem to have agreed with Anthony when I thought i was disagreeing. Sigh.

Re: Hypothyroid following thyroidectomy

Gillian Mostyn — Sun, 01 Feb 2015 23:01:58 GMT

Yeah...

I know.

Will try. I promise.

Re: Hypothyroid following thyroidectomy

Robin Grimmer — Sun, 01 Feb 2015 22:48:43 GMT

I have only one thing to say - stop feeding the troll !!

Re: Hypothyroid following thyroidectomy

Gillian Mostyn — Sun, 01 Feb 2015 22:15:22 GMT

[quote user="Anthony Todd"]

Better read this too before deciding, or tell the client to do.

http://www.catinfo.org/?link=felinehyperthyroidism

[/quote]

Why?

She is entitled to her opinion. But with statements like:

I will say at the outset of this section on anti-thyroid drugs that I am not a fan of putting any chemical into my own body, or that of my own cats or patients. For every positive action that a drug exerts on a living being, there are plenty of side effects that are very often overlooked by the doctors prescribing the medications.

And

They have a low thirst drive and are designed to get their water with their food. This means that there is no dry food that is suitable to feed to a cat.

She is hardly giving an objective opinion. As with us all, she is being influenced by her own opinion. That is why we have to give the client all the information (preferably evidence based) and allow them to have input into diagnostic and treatment choices.

Re: Hypothyroid following thyroidectomy

Anthony Todd — Sun, 01 Feb 2015 21:54:23 GMT

[quote user="Gillian Mostyn"]And as far as hyperthyroid cats- y/d is an excellent treatment choice in some cats, and surgery is certainly not always the gold standard.[/quote]

PS reading the Hills site it looks as if y/d is, indeed, the new gold standard, or at least owner-reviewer's think so.

http://www.hillspet.com/product-reviews.html?reviewID=PD_FL_D_d_yd_o_O_n_orig

But, I say again, it's you vets who must inform and the clients must decide, although I'd be surprised if surgery is not still performed......

Better read this too before deciding, or tell the client to do.

http://www.catinfo.org/?link=felinehyperthyroidism

Re: Hypothyroid following thyroidectomy

Anthony Todd — Sun, 01 Feb 2015 21:40:52 GMT

[quote user="Gillian Mostyn"]And as far as hyperthyroid cats- y/d is an excellent treatment choice in some cats, and surgery is certainly not always the gold standard.[/quote]

Come on, the client will decide on your inform[ation] which is all I've been saying all along!

The rest, as I've said, is just sugaring the fees.

Re: Hypothyroid following thyroidectomy

Gillian Mostyn — Sun, 01 Feb 2015 21:17:54 GMT

I haven't replied to you Anthony because we disagree completely and that won't change. Maybe we have had a completely different client base.

Incidentally, human doctors frequently give their patients options. My Dad had numerous occasions when his course of treatment and then palliative care were his decision. I was certainly given options when I was hyperthyroid. Maybe patients get little input in acute cases, but they certainly do with chronic cases.

And as far as hyperthyroid cats- y/d is an excellent treatment choice in some cats, and surgery is certainly not always the gold standard.

But we'll agree to disagree.

Re: Hypothyroid following thyroidectomy

Anthony Todd — Sun, 01 Feb 2015 20:59:50 GMT

[quote user="Joyce Whitehead"]I would agree that owners often ask our advice, but not in all cases, and they don't always choose to take it! Anthony, the reason the situation is entirely different for your grandson, is that money was not involved as the NHS was paying! Obviously we can always tell the owner what the "gold standard" is, but often that is not affordable then we have to get to other choices, and the owner choosing what to do.[/quote]

Exactly, I rest my case

Again, and finally, where's the inform. "informed consent" is usually just about money and nothing whatsoever about anything else.

Re: Hypothyroid following thyroidectomy

Anthony Todd — Sun, 01 Feb 2015 20:56:41 GMT

[quote user="Robin Grimmer"]Diagnosis of hyperthyroidism is simple - in most cases a total T4 is diagnostic. [/quote]

So every thin cat is hyperthyroid and the only test you do is a T4?? I doubt it.

Of course if you do a T4 you'll make the diagnosis but from examples I see here all the time the diagnosis is a long process involving many tests and procedures in many cases.

I say again there is almost always one course of examination, diagnosis and treatment. the "gold standard" if you like, it is not an option and the "informed consent" really is about money, or owner's perception of what has been advised..

Read what you've said. This is all your information upon which you give advice which the owner doesn't need to know

[quote user="Robin Grimmer"]where a vet did a bilateral thyroidectomy [/quote]

So, if the vet had warned about possible complications would the owner have changed his or her mind?

Not many owners will stand in front of a vet and imply that the op. will be a disaster..... [nor will many vets....]

Do you now say "Do nothing just feed the cat YD?" I'd be surprised, 'cos there are better things to do and you're the only one who knows this, certainly not the owner.

The only "informed" should come from the vet as the vet is the only one with the knowledge and experience to "inform".

That's why my example of my grandson crystallises my view. If money wasn't in the equation "informed consent" by the owner would confuse, is unnecessary and will mislead.

There is always a best way and that is nearly always known,and desired to be followed, by the vet, the rest maybe just sugaring the fee.

Re: Hypothyroid following thyroidectomy

Robin Grimmer — Sun, 01 Feb 2015 19:14:19 GMT

[quote user="Anthony Todd"]

[quote user="Robin Grimmer"]Example : hyperthyroid cat - straightforward diagnosis. But several treatment options :[/quote]

Again you've got to the diagnosis stage for a start, or did you give the owner all the possible diagnostic options and the possible tests etc needed to reach the diagnosis?

The owner cannot make an "informed consent" at the test and diagnostic and, actually in most cases, even the treatment stage.

The owner doesn't make the diagnostic options or test options; the vet makes the "informed choice" and is the only one who can.

Having given all the the treatment options have you ever, ever, had a client who has not said "What would you do? What do you think? What do you suggest?" [unless you give the informed answer first.]

viz tablets? your "informed" answer "Difficult to give" Surgery? "has risks", "costs a lot" etc etc. so it's the vet who is doing the informing and the answers.

Sure, when it comes to treatment, but only at that stage,there are options which are up to the client and usually concern money or convenience but aren't really part of "informed consent "as it seems to be construed on here.

And, by the way, isn't surgery probably the best option which only a vet would know??

I would almost say that today's "informed consent" is really a subtle way of telling the client what is to be done and how much it will cost. I'm afraid.

Why were my family not required to make "informed consent" as everyone rushed around to save our grandson?

Why? because the doctors were the only ones who could, as are the vets in the case.

Tee, Hee as I understand it ,the American "informed consent" is when the dying patient gives the hospital a credit card number.....

[/quote]

Diagnosis of hyperthyroidism is simple - in most cases a total T4 is diagnostic. So I don't really understand what point you are trying to make there. But who's to say what's the best treatment option? Sure to some owners, tablets might be a no no. But also many owners are not keen on surgery in an older cat. I saw a case once where a vet did a bilateral thyroidectomy and didn't warn the owners about post operative hypoparathyroidism, and sure enough this cat's calcium plummeted and it had to go on iv calcium, oral calcium and vit D - a far worse condition than the overactive thyroid in the first place. And needless to say, the owners were not chuffed. And what about now with yd, you have a risk-free option? And I131 is now much more available and with shorter isolation times so who's to say surgery is best? Times change Anthony.

Re: Hypothyroid following thyroidectomy

Joyce Whitehead — Sun, 01 Feb 2015 19:04:00 GMT

I would agree that owners often ask our advice, but not in all cases, and they don't always choose to take it! Anthony, the reason the situation is entirely different for your grandson, is that money was not involved as the NHS was paying! Obviously we can always tell the owner what the "gold standard" is, but often that is not affordable then we have to get to other choices, and the owner choosing what to do. I know orthopaedics is not as you say always the best example, but I can think of a case a year or two ago with a 9month old terrier with a fractured femur. Owners not prepared to pay for surgery, or even amputation. Now obviously we gave them prices and quotes for those, and also suggested signing over for amputation and rehoming. To our dismay they would go for none of these and opted for euthanasia. Now what I would do in those circumstances was entirely irrelevant to those owners, they had made their minds up. Based on money. Had he been insured the story would have been entirely different. And in Gillian's example you suggested send to a charity. What if there isn't one? We have no charity hospital within 40 miles, and no funds locally available for a contribution. And to my mind we obviously can't give the owner the choice (informed) without the diagnosis so I'm not sure what your point is there. If they choose to not get to a diagnosis that is also their decision. Just to point out too, I graduated 32 years ago, so am by definition a dinosaur. I'm on an iPad so apologies for lack of paragraphs.

Re: Hypothyroid following thyroidectomy

Anthony Todd — Sun, 01 Feb 2015 18:05:49 GMT