FIP and the ethics of "chemo"

Re: FIP and the ethics of "chemo"

Claire McConnell — Mon, 17 Oct 2011 19:51:27 GMT

[quote user="robloxley"]Does the end justify the means?[/quote]

I dont think there is an answer to that question and I think it would vary hugely between vets and between owners.

We have all met the insured dog whose owner does not want to put the animal through intensive surgery/treatment even though finance is not an issue and likewise the owner that would do everything and anything to keep their pet alive (even against veterinary advice)

Re: FIP and the ethics of "chemo"

Rob Loxley — Mon, 17 Oct 2011 19:37:47 GMT

Indeed, maybe because we aren't expecting a cure with chemo are we more likely to pull the plug if the animal isn't doing well, and maybe more likely to persevere with intensive/invasive treatment when we expect a cure - though the dog/cat doesn't know that is the case (the brain/spine/tetanus cases are good examples)? Does the end justify the means?

Re: FIP and the ethics of "chemo"

Claire McConnell — Mon, 17 Oct 2011 17:29:56 GMT

Some of the most distressed dogs I have seen are those with spinal problems and disc disease. I hated my rotation at university where I had to care for these virtually paralysed patients. Some made good recoveries after surgery in a few weeks, but one that sticks in my mind is a 9 yo Weimeraner which was hospitalised and "walked" (dragged about in a trolley) for months with minimal imrpovement. Due to finishing university I don't know whether this patiient ever made a full recovery but I would be doubtful.

Even on a suffering vs beneft ratio I feel it is difficult to know what is best to recommend in many of these patients and usually leave the decison to the owner (I feel biased towards pts and try not to put this into my work) but try to be as honest as possible with length of recoveries etc.

Re: FIP and the ethics of "chemo"

Mark Holmes — Mon, 17 Oct 2011 16:52:49 GMT

I think this whole thread could be extended beyond chemo. Is there a limit to the total quantity or level of treatment an animal should receive? Or what should an animal "go through" in order to get well, given that it cannot be explained to them.

A case I witnessed some years ago involved a Rottie which experienced some neurological insult. Possibly a cartilagenous embolus, possibly a cervical prblem, I cannot remember the specifics. That dog was tetraplegic for about 3 weeks before improvement was seen. It was turned every 1-2 hours and was clearly very distressed by the process. It eventually recovered and I understand it is now doing fine. So the prognosis turned out very good but the dog did suffer for it. I am still fairly confident I would have euthanased it and would my own dog even if I knew (with certainty) that the eventual outcome would be positive given the length of treatment required and the distress experienced in receiving it.

Re: FIP and the ethics of "chemo"

David Mills — Mon, 17 Oct 2011 15:11:46 GMT

Yup let's have specifics, backed up with objective evidence about which conditions in particular and which treatment methods rather than unfounded, again financially-driven cynicism. Really don't see why insurance comes into it any more than any other area of practice.

Re: FIP and the ethics of "chemo"

Gillian Mostyn — Mon, 17 Oct 2011 15:00:36 GMT

[quote user="Anthony Todd"] I just sometimes have the thought that perhaps[/quote]

you seem to discussing theoretical situations and decisions without any basis in experience or fact....I am not sure why?

Re: FIP and the ethics of "chemo"

Anthony Todd — Sun, 16 Oct 2011 23:59:52 GMT

[quote user="Anne Seawright"] It is quite obvious to me that he means the treatment options available for that animal, which cost will have a bearing on.[/quote]

At last, someone sees the wood despite the trees.

I just sometimes have the thought that perhaps and possibly in a few cases insured animals have more expensive treatment options available to them than the uninsured, with a very small, or no, improvement in either diagnostic accuracy or prognosis.

Re: FIP and the ethics of "chemo"

Julian Earl — Sun, 16 Oct 2011 21:02:29 GMT

[quote user="Anne Seawright"][quote user="robloxley"]

[quote user="Anthony Todd"]just facing the fact that treatment options are sometimes dictated by cost[/quote]

Surely the treatment options available are independent of cost; cost may however influence the treatment option selected ? Or are we back to xraying the client's wallet before offering the options?

[/quote] It is quite obvious to me that he means the treatment options available for that animal, which cost will have a bearing on. I do not understand why so often on this site people want to pick fault and argue semantics when that is not as far as I am concerned the point.

[/quote]

Well if the treatment improves the QOL for the animal, but the owner could not have afforded it without the insurance, then yes, it obviously affects the owner's decision. That's why people insure their pets, to increase their options. Is there a problem with that?

Re: FIP and the ethics of "chemo"

Anne Seawright — Sun, 16 Oct 2011 15:47:17 GMT

[quote user="robloxley"]

[quote user="Anthony Todd"]just facing the fact that treatment options are sometimes dictated by cost[/quote]

Re: FIP and the ethics of "chemo"

Rob Loxley — Sun, 16 Oct 2011 10:12:51 GMT

[quote user="Anthony Todd"]just facing the fact that treatment options are sometimes dictated by cost[/quote]

Re: FIP and the ethics of "chemo"

Anthony Todd — Sun, 16 Oct 2011 02:06:47 GMT

[quote user="robloxley"]Where did insurance come into things? Are you trolling?[/quote]

No not trolling at all, just facing the fact that treatment options are sometimes dictated by cost and insurance may eliminate the cost element.

Re: FIP and the ethics of "chemo"

Rob Loxley — Sun, 16 Oct 2011 00:21:22 GMT

[quote user="Anthony Todd"]simple and, I hoped, obvious answer[/quote]

Maybe it is fundamentally such a simple and obvious answer, referring back to the oath we all took, that people here take it as granted?

[quote user="Anthony Todd"]I do hope insurance is never a factor in treatment options.[/quote]

Where did insurance come into things? Are you trolling?

Re: FIP and the ethics of "chemo"

Anthony Todd — Sat, 15 Oct 2011 23:22:16 GMT

[quote user="Gillian Mostyn"]The same place most of us have always drawn it - where the suffering outweighs the benefits. Only the treating vet alongside the owner can decide when that is.[/quote]

That's where I've always been, but I've had to use extreme and historical examples to try an extract what is a simple and, I hoped, obvious answer.

My impression is that the line may sometimes be pushed back towards the suffering and away from the benefit a bit too much, because the protocol used is regarded as the "gold standard" and therefore best practice influenced in part by the increasingly sophisticated human procedures where the suffering/benefit ratio is disregarded.

I do hope insurance is never a factor in treatment options.

Re: FIP and the ethics of "chemo"

Gillian Mostyn — Sat, 15 Oct 2011 19:06:10 GMT

[quote user="Anthony Todd"]Ok, one example I can remember. Animal in at Penn in the 70s for 6 months, in a cage having "chemo for cancer", no details other than that, and it died.[/quote]

You seem to be arguing that something that nobody does shouldn't be done.....

[quote user="Anthony Todd"]

No, not really, in that if protocol A involves in patient I/V treatment for a month and a best survival time of a month more than, say, oral pred at home then it's obvious.

If protocol A gives a survival time better by three years than the oral pred then it's also obvious.

[/quote]

Animals have no perception of time. As long as quality of life is maintained at all times, where is the problem?

Most humans have chemotherapy in order to try to cure cancer - the drugs are nasty and the doses high. Side effercts are therefore usual and bad. Most animals are treated palliatively to prolong life but we do not (as far as I am aware) put them through what people go through. Or have you personal experience that indicates otherwise?

Where do we draw the line? The same place most of us have always drawn it - where the suffering outweighs the benefits. Only the treating vet alongside the owner can decide when that is.

Re: FIP and the ethics of "chemo"

Gillian Mostyn — Sat, 15 Oct 2011 17:52:51 GMT

[quote user="newgradvet"]

[quote user="robloxley"] Many patients on NSAIDs will experience side effects but we wouldn't not use them[/quote]

Although we do stop using them in those patients that experience side effects, as a general rule anyhow.

[/quote]

And that differs from chemo how....

The only difference I can see is that with chemo deciding not to treat will lead to PTS to prevent suffering....deciding not to give NSAIDS in the abscence of substituting something equally effective can lead to increased suffering...

Re: FIP and the ethics of "chemo"

Claire McConnell — Sat, 15 Oct 2011 13:02:01 GMT

[quote user="robloxley"]But if their lymphoma is in complete remission for months and months on such treatment are they not in a better state than before we started? [/quote]

This I am unsure of and so leave it down to the owners to decide when I just present the facts.

[quote user="robloxley"] Many patients on NSAIDs will experience side effects but we wouldn't not use them[/quote]

Although we do stop using them in those patients that experience side effects, as a general rule anyhow.

[quote user="robloxley"]Also I'd be interested to see a comparison between the side effects of COP and Palladia/Masivet
[/quote]

When I referred to the use of Palladia at our practice I did not mean to infer that it had few side effects, only that for staff personnel there is minimal to no health and safety concerns.

As I said in my original post I always discuss the facts with the owners so they can make a decision for themselves as to what is appropriate or allowable side effects in their patients. I was merely explaining how I feel personally, but try to stop that interfering with my day to day work.

Re: FIP and the ethics of "chemo"

Simon Neuhoff — Sat, 15 Oct 2011 12:44:49 GMT

[quote user="robloxley"]

So I'd suggest it really does come down to evaluating each patient, each protocol, the benefits and risks and re-assess during treatment to ensure we are doing the right thing by our patients.

[/quote]

Agreed. That said the more chemotherapy I do the more ambivalent I feel about it. We tend to stick to COP style protocols for lymphoma and have had some moderately good results (we also refer some for more aggresisve treatments). Side effects wise we don't see too many issues but I feel even the amenable animals do start to resent the repeated injections and blood samples. I try to give the owners as much information as possible and a balanced view point and allow them to make the correct decision for their pet. That said I would not do chemo on my cats.

Re: FIP and the ethics of "chemo"

Rob Loxley — Sat, 15 Oct 2011 12:28:56 GMT

[quote user="newgradvet"]most patients on COP and even more on CHOP experienced mild side effects of either vomitting, diarrhoea or lethargy and a few more serious side effects[/quote]

But if their lymphoma is in complete remission for months and months on such treatment are they not in a better state than before we started? Many patients on NSAIDs will experience side effects but we wouldn't not use them (stretching the analogy I accept). Agreed, if the side effects of treatment are worse than the disease, then can we really be on the right track, but I'm not sure many people would disagree with that or would continue with such a treatment?

[quote user="newgradvet"]I do not feel based on my experience of oncology at university that I would choose to treat any of my pets (cats and dogs) with chemotherapy[/quote]

I can't necessarily disagree with your own personal decision but would ask a few things - does the university's case load differ from that in general practice (were the animals sicker, more complicated, or referred for protocols that while maybe more effective had greater side effects e.g. MW vs. COP?), and what were the owner's perceptions of treatment of their pet (many published surveys reveal good owner satisfaction with chemotherapy).

[quote user="newgradvet"]At my practice we do not perform chemotherapy past prednisolone or palladia due to concerns about health and safety for staff personnel as we do not have a fume cupboard.[/quote]

But we deal with plenty of other potentially nasty or hazardous drugs, ionising radiation and chemicals every day.

Also I'd be interested to see a comparison between the side effects of COP and Palladia/Masivet
(from the Palladia datasheet "Palladia has been associated with diarrhoea or gastrointestinal bleeding which may be severe and requires prompt treatment; In rare cases, serious and sometimes fatal gastrointestinal complications including gastrointestinal perforation occurred in dogs treated with Palladia;
Adverse reactions:
Very common (more than 1 in 10 animals)

Mild to moderate:•Diarrhoea, neutropenia, weight loss, blood in faeces/haemorrhagic diarrhoea/gastrointestinal bleeding, anorexia, lethargy, vomiting; lameness/musculoskeletal disorder, dehydration, dermatitis, pruritus; increased alanine aminotransferase, thrombocytopenia, decreased albumin, decreased haematocrit.

Common (more than 1 but less than 10 animals in 100 animals)

Severe:•Vomiting, diarrhoea, anorexia, lethargy, dehydration, pyrexia, blood in faeces/haemorrhagic diarrhoea/gastrointestinal bleeding, duodenal ulceration, nausea, septicaemia, skin necrosis, weight loss; increased alanine aminotransferase, decreased haematocrit.

Mild to moderate:•Localised or general pain, nausea, tachypnoea, polydipsia, flatulence, pyrexia, nasal depigmentation; changes in coat colour, alopecia, urinary tract infection; increased bilirubin, increased creatinine.

Palladia may impair male and female fertility and embryo/foetal development. Avoid skin contact with the tablets, faeces, urine, and vomit of treated dogs.
Children must not come into contact with the product. Keep children away from faeces, urine or vomit of treated dogs)

Also, not all chemo needs a fume cupboard (e.g. oral medications).

So I'd suggest it really does come down to evaluating each patient, each protocol, the benefits and risks and re-assess during treatment to ensure we are doing the right thing by our patients.

Re: FIP and the ethics of "chemo"

Claire McConnell — Sat, 15 Oct 2011 11:54:15 GMT

I find this a very interesting forum to see the highly differing views.

I graduated from RVC in 2010 and had a rotation in chemotherapy at university where we helped prep patients for their treatments, witnessed the chemo admin and cared for them as inpatients. We also got to talk to owners about how they felt treatment was going, any side effects they observed etc.

I also investigated CHOP/COP protocols and the incidence of side effects as part of my final year reasearch project. I will happily state this was not a comprehensive peer reviewed study and had lots of weaknesses. However my general opinion on examining patients files was that most patients on COP and even more on CHOP experienced mild side effects of either vomitting, diarrhoea or lethargy and a few more serious side effects.

With the knowledge that animal's do not fear or have knowledge on upcoming death, I do not feel based on my experience of oncology at university that I would choose to treat any of my pets (cats and dogs) with chemotherapy. However I would always present owners with the facts so they could choose whether this is the right choice for their pets.

I do wonder how well many patients cope with regular blood tests, IV catheterisation and hospitalisation but I'm sure there is the odd dog or even cat that tolerates this well.

My other concern is that we all know that cats and dogs often are poor at showing us when they are in pain (look at the amount of dental disease seen in patients that are eating well with no problems) or feeling sick (and equally some owners may fail to pick up some of the signs) so it can be difficult in assessing whether a patient is having mild side effects from their chemo.

At my practice we do not perform chemotherapy past prednisolone or palladia due to concerns about health and safety for staff personnel as we do not have a fume cupboard. However we will happily refer for this if we find the right patient and client.

Re: FIP and the ethics of "chemo"

Rob Loxley — Sat, 15 Oct 2011 10:40:53 GMT

[quote user="KathW"]

[quote user="Anthony Todd"]

I'll make it stupid simple for those who can't get the question.

Would any of you, today, October 15th 2011, keep an animal in a cage giving it whatever chemo protocol drug or whatever you fancied for 6 months if the prognosis was terminal?

[/quote]

Before I answer and there is more confusion Are you actually asking the question saying that the animal is kept in a cage for the entire 6months -presumably in a veterinary practice?

[/quote]

I may stand corrected, but I think that's what he means. And if so, it's a pretty insulting question to ask, IMHO.

Re: FIP and the ethics of "chemo"

Rob Loxley — Sat, 15 Oct 2011 10:34:52 GMT

[quote user="Anthony Todd"]

[quote user="robloxley"]Are you really commenting on veterinary chemotherapy in the 21st century based on a case from the 1970s???!!![/quote]

It was an example and my impression of the ethics at that time at that place was that it was believed to be acceptable veterinary practice.

[/quote]

I think from the replies you've had it would be very clear that this (if we understand you correctly) would not be acceptable now, and further it is clear people trying are to explain that this is not what happens now.

It seems that if this is your idea of what current 'veterinary chemotherapy' involves you are way out of touch with modern clinical practice.

Therefore to anguish over the ethics of a treatment/practice that doesn't happen seems worrying.

You haven't answered mine (and other people's) questions that might give us a better idea of you experience and knowledge of current veterinary chemotherapy??

[quote user="Anthony Todd"]try and find where the humane line is[/quote]

The ethics of treatment, quality of life etc. when considering chemo is little different to, say, considering treatment/management of terminal renal failure. Yes there are chemical/biological hazards to consider, but when considering where we draw the line, the ethical thought process is essentially the same.
This is in contrast to your original post which seemed to imply that chemotherapy was de facto unethical because the condition was incurable, that vets were causing unnecessary suffering to animals through use of chemo, and that vets in cases were pursuing such treatment against their wishes. That's a pretty damning view of your fellow vets.

Re: FIP and the ethics of "chemo"

KathW — Sat, 15 Oct 2011 09:46:39 GMT

[quote user="Anthony Todd"]

I'll make it stupid simple for those who can't get the question.

Would any of you, today, October 15th 2011, keep an animal in a cage giving it whatever chemo protocol drug or whatever you fancied for 6 months if the prognosis was terminal?

[/quote]

Before I answer and there is more confusion Are you actually asking the question saying that the animal is kept in a cage for the entire 6months -presumably in a veterinary practice?

Not that the animal is in the cage once a week (say) for treatment then home the same day (but this happens on a regular basis over 6 months)

Re: FIP and the ethics of "chemo"

Anthony Todd — Sat, 15 Oct 2011 08:56:11 GMT

[quote user="robloxley"]Are you really commenting on veterinary chemotherapy in the 21st century based on a case from the 1970s???!!![/quote]

It was an example and my impression of the ethics at that time at that place was that it was believed to be acceptable veterinary practice.

I'll make it stupid simple for those who can't get the question.

Would any of you, today, October 15th 2011, keep an animal in a cage giving it whatever chemo protocol drug or whatever you fancied for 6 months if the prognosis was terminal?

[quote user="robloxley"]That would not be ethical IMHO [/quote]

Ok, beginning to establish a line, boy, it's hard work though! [doesn't matter if it was 1850 and it was given arsenic injections, it's the principle I was trying to get across and, having established that there is an ethical principle to try and find where the humane line is]

[quote user="robloxley"]Some on long term oral medications just come in for monitoring blood samples and checkover.[/quote]

Well above the line I realise.

Re: FIP and the ethics of "chemo"

Rob Loxley — Sat, 15 Oct 2011 08:11:38 GMT

[quote user="Anthony Todd"]Animal in at Penn in the 70s for 6 months, in a cage having "chemo for cancer", no details other than that, and it died.[/quote]

Are you really commenting on veterinary chemotherapy in the 21st century based on a case from the 1970s???!!!

It seems your impression of chemo is from another age; when did you last, as a practising vet, see an animal for chemo or that might have been a candidate for chemo?

[quote user="Anthony Todd"]But if the animal is being force fed, I/M injections, restrained by a leg brace for the drip and a CAT, sorry left that out, in a kennel of barking dogs what would your view be?[/quote]

That would not be ethical IMHO - but it's generally NOT WHAT HAPPENS!!! Our chemo patients are usually seen on an outpatient basis - most of ours don't spend any time in a kennel - maybe every 1-4 weeks (depending on protocol). Some on longterm oral medications just come in for monitoring blood samples and checkover.

[quote user="Anthony Todd"]My point, or question originally, is do we now draw a line and where do we draw it?[/quote]

Maybe one starts with the facts; maybe with an understanding of the current chemo protocols in use, the data on their effectiveness and their side effects?

Re: FIP and the ethics of "chemo"

Anthony Todd — Sat, 15 Oct 2011 01:22:33 GMT

[quote user="Gillian Mostyn"]I do not see how you can seperate the ethics of chemotherapeutic treatment of cancer without discussing individual experiences of it.[/quote]

Ok, one example I can remember. Animal in at Penn in the 70s for 6 months, in a cage having "chemo for cancer", no details other than that, and it died.

[quote user="Gillian Mostyn"][quote user="Anthony Todd"]If the protocol makes the patient feel better in the short or medium term then obviously the period of treatment can be longer even if the prognosis is unchanged, I mean, we all die eventually.[/quote][/quote]

But if the animal is being force fed, I/M injections, restrained by a leg brace for the drip and a CAT, sorry left that out, in a kennel of barking dogs what would your view be?

That was my original question.

[quote user="Gillian Mostyn"]when you ask what criteria are used, the protocols and drugs are paramount in that decision making process. [/quote]

No, not really, in that if protocol A involves in patient I/V treatment for a month and a best survival time of a month more than, say, oral pred at home then it's obvious.

If protocol A gives a survival time better by three years than the oral pred then it's also obvious.

My point, or question originally, is do we now draw a line and where do we draw it?