Do you do unto other pets as you do unto your own?

Re: Do you do unto other pets as you do unto your own?

Claire McConnell — Fri, 11 Jan 2013 21:24:15 GMT

[quote user="Elizabeth Billimore"]Yeah the main problem with having a proper discussion with a client is it takes longer than 10 minutes usually.

[/quote]

Agreed

Re: Do you do unto other pets as you do unto your own?

Claire McConnell — Fri, 11 Jan 2013 21:23:43 GMT

[quote user="Hannah Wynne Richards"]

If asked "What would you do?" I refuse to be drawn-and merely list the options in order of clinical efficacy I suppose what it comes down to is you try to please the owner I merely try to cure the animal

Wynne

[/quote]

If you have given all the options - advnatages and disadvantages and costs etc, I do not think there is anything wrong from answering the above question honestly. As long as you aren't forceful or pressurising there is nothing wrong with personally saying "I would have the op, or I would put him to sleep" as long as you have alreday explained the options and the owner wants your personal opinion then that is what you should give. It helps build up a relationship with the client and many clients need your own views to make their decision, especially if you can justify why you have your views.

Re: Do you do unto other pets as you do unto your own?

Claire McConnell — Fri, 11 Jan 2013 21:14:31 GMT

[quote user="Hannah Wynne Richards"]

Arlo If you elected a cheaper alternative I would probably make it clear that it was a clinically inferior option (if it was) and that adverse consequences would be your responsibility not mine I don'tknow if you would call that pressure-I'd call it honesty

Wynne

[/quote]

This post makes me think more about what our real job is about "preventing and reducing animal suffering" - is that not true - our main aim is to protect animal welfare.

Often "inferior" treatments are just as good at preventing suffering...for example, opting not to investiagte a mass (internal or dermal) does not cause suffering as long as owners aware of when euth may be needed if qol deteriorates. etc. however this is obviously far from gold standard in the medical context. I feel our job should also be about supporting the decisions they make (unless it causes unneccessary suffering in which case we should make this clear) and not making them feel alienated for not wanting to pursue diagnostics/treatment.

Re: Do you do unto other pets as you do unto your own?

Claire McConnell — Fri, 11 Jan 2013 21:06:15 GMT

[quote user="Arlo Guthrie"]I am just imagining that there might be (perhaps rare) situations where it might be considered incompassionate to offer something that is obviously well outside the reach of the owner[/quote]

I agree. I have tried to try and write a scenario for this but can't as everytime I write anything I know I will be picked up on something by somebody and pounced on! I will always try to mention all options for owners however I'm sure we all can communicate well enough to know when an owner is just asking for reassurance that it is ok just to put the cat/dog to sleep rather than treat or do further diagnostics or do the minimal treatment rather than gold standard. I'm not saying I wouldn't mention alternatives but I wouldn't go into too much detail on other options all the time as from the clients reaction you can often tell that these things just aren't going to be possible and making an owner feel even worse about not being able to afford a treatment osn't going to help anyone, vet, client or pet.

Re: Do you do unto other pets as you do unto your own?

Rajat — Fri, 11 Jan 2013 18:30:06 GMT

[quote user="Anthony Dennison"]The owner mentions they've noticed a lump at the dog's booster consult (during an extremely busy afternoon on a Friday) it's an older, slightly overweight neutered dog with a mass on its thorax. its just under the skin, very mobile and feels very much like a lipoma. Do you push for taking FNAs to send off to confirm this/going straight for removal, or advise the owner it's most likely a lipoma and just to monitor it.[/quote]

I would definitely recommend and do a FNAB in consult. Either it is a lipoma which anyone can diagnose or its something else in which case owners call to send slides off or not. If it is a MCT masquerading as a lipoma, a few months later it may have gone from grade 1-2 or 2-3 and be more infiltrative/larger and tougher to remove... Diagnosing a lipoma on cytology probably takes 2-3 minutes maximum, owners are grateful they have good service on the spot, and it is good practice for those nights on call when you're the head (cyto)pathologist and you gotta interpret some slides!

[quote user="Anthony Dennison"]Had a 9yr old Gt. Dane in for a booster this afternoon with quiet heart sounds and a grade 2 sysolic murmur. We talked about DCM and the benefits of starting treatment early, strongly pushed for at least pimodendan. All I could get was a repeat appointment in a month to check the heart again. [/quote]

Large dogs, new murmur, predisposed breed= a definitive recommendation for cardiac workup, just like you did. I would not be comfortable starting medications without a workup though. Many owners decline workups which is fine, or may decline our thoughtful suggestions and recommendations - I have no problem with this. I think the 'beef' is with not recommending it or tailoring recommendations based on our judgement (guesswork) of an owners ability or willingness to pay or treat their pets.

Just my 2c

PS arlo I didn't reply to your post as by the time I saw it, there were many others which I thought addressed the points you made..

Re: Do you do unto other pets as you do unto your own?

Hannah Wynne Richards — Fri, 11 Jan 2013 17:26:48 GMT

I'm actually with Micheal this time-both monitoring and FNA appropriate for this lump -but give the owner the choice Don't ever say "leave it be" without giving the option I wouldn't suggest GA and biopsy although more diagnostic than FNA because of small though finite risk of GA for what statistically is PROBABLY a lipoma Decision not to advise a GA made for clinical not financial reasons

That Great Dane definitely needs a full cardiac work up-not suggesting it would definitely be negligent The veterinary surgeons I unequivocally condemn are those who detect the murmur at a consult for something else-and then don't tell the owner the dog needs a cardiac work-up..............because they're the ones who think it too expensive for an unsymptomatic dog

It's really very simple Always advocate what's best for the animal but also try to give a range of options(if applicable)

Wynne

Re: Do you do unto other pets as you do unto your own?

Michael Woodhouse — Fri, 11 Jan 2013 17:14:05 GMT

Anthony - I'd suggest monitor the lump, but say that we can do FNA if the owner is worried. Be in no great rush to remove (unless something like a Boxer or Nufie). Get them to come back if it changes.

The Great Dane more tricky. Big dogs can have quieter hearts. The ProBNP bloods can be useful to encourage the owner to start treatment - and you can do a quick blood sample in the consult. If asymptomatic then may do as you have and check in a month. There are plenty of people walking around with heart murmurs that they are blissfully unaware of.

Re: Do you do unto other pets as you do unto your own?

Anthony Dennison — Fri, 11 Jan 2013 16:47:08 GMT

Sorry to play devil's advocate Wynne,, if giving gold standard care for patients, how about this scenario?

The owner mentions they've noticed a lump at the dog's booster consult (during an extremely busy afternoon on a Friday) it's an older, slightly overweight neutered dog with a mass on its thorax. its just under the skin, very mobile and feels very much like a lipoma. Do you push for taking FNAs to send off to confirm this/going straight for removal, or advise the owner it's most likely a lipoma and just to monitor it.

Had a 9yr old Gt. Dane in for a booster this afternoon with quiet heart sounds and a grade 2 sysolic murmur. We talked about DCM and the benefits of starting treatment early, strongly pushed for at least pimodendan. All I could get was a repeat appointment in a month to check the heart again.

Re: Do you do unto other pets as you do unto your own?

Hannah Wynne Richards — Fri, 11 Jan 2013 09:56:09 GMT

Malcolm Ihaven't thanked you and then ignored what you had to say-just answered Mariette's point I would though hope that the oncology Specialist to whom I would refer would choose the correct imaging method

David You may be right-but at least I try to be both scientific and present all options fairly

What makes me absolutely livid is when veterinary surgeons deliberately willfully and wrongfullywithold what they very well know is the best option-because of their own pre-concieved value judgement as to how much the client would pay No one has the legal nor moral right todo that

Wynne

Re: Do you do unto other pets as you do unto your own?

Hannah Wynne Richards — Fri, 11 Jan 2013 09:26:54 GMT

Now that's what I call a helpful addition to the debate Thanks Malcolm

Mark Perhaps I should have said costly-myapologies

Mariette How far from you is the nearset permanent MRI facility? That has a bearing on order of preferance-but as I keep saying-the choice has to be the owners-and we have no legal right to withold a valid choice just because WE think it costly

Wynne

Re: Do you do unto other pets as you do unto your own?

Malcolm Ness — Thu, 10 Jan 2013 20:43:05 GMT

[quote user="mariette asselbergs"] But in order to take the best decision for the animal an MRI scan would be best[/quote]

I disagree. While CT would better define a bone tumour and a CT met search of the lungs is probably more sensitive than plain radiography, MRI would add little if any useful information to the management and clinical decision-making in a case of suspected osteosarc.

MRI has become a veterinary diagnostic test of abuse. Poorly understood and with far too many performed with only a potentially small diagnostic yield despite its great expense.

Re: Do you do unto other pets as you do unto your own?

David Mills — Thu, 10 Jan 2013 19:49:46 GMT

Whilst Ms Richards displays the purest form of positive physician agency - presenting all the options to the surrogate consent-giver, the owner - I think the approach is no actually practically that applicable unfortunately. For if it is to be a fair comparison of options then one must be in possession of the most recent or highest grade evidence pertaining to that condition's diagnosis and treatment, not simply anecdote regarding what you think is the best or that old adage 'its worked well in the past'. I don't want to cast aspersions on Ms Richards, but this is terrifically difficult to do in GP because of the wide range of conditions and the myriad of papers and research that surround them, all of different merit; to go through these is an endless task: in fact I would say it was nigh-on impossible. In that instance, then, one cannot simply be the objective presenter of options with opinion backed up by independent peer-reviewed evidence. Therefore a judgement on 'best' is subjective.

As an example, cross reference the advocate thread. There is a an double-blinded RCT on the use of advocate for the treatment of lungworm, comparing fenbendazole and imidacloprid/moxidectin:

http://www.ncbi.nlm.nih.gov/pubmed?term=Efficacy%20and%20safety%20of%20imidacloprid%2Fmoxidectin%20spot-on%20solution%20and%20fenbendazole%20in%20the%20treatment%20of%20dogs%20naturally%20infected%20with%20Angiostrongylus%20vasorum

which shows no significant difference between the two (85% effective i/m; 91% fen; no statistical significance). Yet people are adamant that one is better. But anecdotal evidence is nigh-on worthless in the face of an RCT.

Personally, largely because we're human and anecdote takes precedence in our minds cf a paper, I don't think Ms Richards' approach is possible, and I suspect it is infiltrated with subjectivity and judgements even if the end result is not judging what the client can afford. For that reason, it carries bias; this is not inherently wrong, but it needs recognising because it is hard to quantify and often works subconsciously.

Re: Do you do unto other pets as you do unto your own?

Mark Holmes — Thu, 10 Jan 2013 19:04:04 GMT

[quote user="Hannah Wynne Richards"]

Limb amputation fine if eg following very severe RTA and unsuitable for orthopaedic surgery With an osteosarcoma I'd ideally like an oncologists estimation first as I don't think it advisable to amputate if there are metastases so options would be

1) a lot of these cancers spread very quickly so it might be best to give him strong painkillers and spoilhim rotten (cheap)

2) if you want to do something then I could send him toa cancer specialist who would probably do an MRI and blood tests before deciding whether treatment was advisable (expensive )

3) I could Xray the chest and amputate if I can't see secondaries but you've got to understand that the Xray may not show the secondaries and he could have an operation and still die in a few weeks(mid price )

All 3 options given to owner but listed strictly in the order I thinkBEST FOR THE ANIMAL not the order most profitable for me or cheapest for the owner-both equally reprehensible motives

Wynne

Have I made my attitude sufficiently plain

[/quote] But Wynne, you are in saying option 2 is expensive inherently making a value judgement. Something is only expensive if its not worth it's price. Otherwise it's costly. You can rarely make a decision about the right choice for the animal without considering the right choice for the client.

Re: Do you do unto other pets as you do unto your own?

mariette asselbergs — Thu, 10 Jan 2013 18:38:45 GMT

But with all due respect, you coukld send the client for an MRI to one of the referral practices, next day done, which would help you clinically to decide between amputating or giving a good time before PTS. Either one of thiose decisions might be inappropriate without the MRI info. So CLINICALLY the MRI workl up would be the best, no? Our clinical vet experience feeling that the og is doomed anyway doers not weigh up against the extra info of an MRI.

Mariette

Re: Do you do unto other pets as you do unto your own?

Hannah Wynne Richards — Thu, 10 Jan 2013 18:27:07 GMT

Marriette PS to above Judging from what you have said about being uncomfortable with the amount spent in this country I think with an osteosarc dog our order of listing choices would start the same-but our reasoning would be different You would be uncomfortable with a more expensive choice I would consider that none of my business but in this case would not advise it as 1st choice-FOR CLINICAL REASONS

Wynne

Re: Do you do unto other pets as you do unto your own?

Hannah Wynne Richards — Thu, 10 Jan 2013 18:17:04 GMT

No not because it would be expensive but because it would mean a GA and unless the visiting local (once monthly) MRI unit was due imminently-(and I thinkwe all agree that if treament is tobe attempted speed is of the essence)- also transport Those factors which affect the well being of the animal not cost are what would make me put an MRI 2nd for a dog which as you say is probably doomed

Wynne

Re: Do you do unto other pets as you do unto your own?

mariette asselbergs — Thu, 10 Jan 2013 17:55:48 GMT

I agree you have the three options you mention. But in order to take the best decision for the animal an MRI scan would be best, because it would be necessary to take the decision to do 1) or 3), so why not put that as number one? Because it is very expensive for a dog which is probably doomed anyway?

Mariette

Re: Do you do unto other pets as you do unto your own?

Hannah Wynne Richards — Thu, 10 Jan 2013 17:32:13 GMT

The kidney transplant is probably the only case when I wouldn't give the owner all the options -because I am so strongly opposed on ethical grounds-but this is the 1 exception to my rule that I give the owners all the options in strict order of clinicalmerit-then let them decide-never ever attempt to decide for them

Wynne

Re: Do you do unto other pets as you do unto your own?

Hannah Wynne Richards — Thu, 10 Jan 2013 17:09:52 GMT

Back to telling the owners what's best as opposed to jumping through hoops to make what they want to do seem best I would reassure the owners that they had given the cat an excellent life but that it was time to say goodbye-and I hope I have enough influence with my clients that they would listen to me and take on a homeless cat froma shelter-again an instance when the cheap option is the best one

As far as the sums of money spent are concerned-it's the owners money-and their legal right to spend it

With both the osteosarcoma dog and the kidney failure cat the first option on my list would be the one I would chose for my own animal-and would be the cheapest(in these 2 cases )

I have also referred my own animals-and would when presented with a similar case in a patient put referral 1st on my list to owners-even though it was the most expensive option List all the options in order of clinical merit-not cost-and let the owner decide

Wynne

Re: Do you do unto other pets as you do unto your own?

mariette asselbergs — Thu, 10 Jan 2013 16:57:58 GMT

"Effect on the donor cat" I don't understand that because loads of perfectly healthy cats are being PTSed because they can't find a home, so I would think that there would be plenty supply of donors who would never suffer (not more than they would anyway by losing their life prematurely....

(I don't mean to wind you up Wynne, I am just interested in your reasoning on these issues. Having worked for decades ibn situations where people had no access to even the most basic of medical care - including anaesthetics - I still have a lot of reserved feeling about what is spent on animals in this country often not serving the animal's best welfare or the owner's financial possibilities)

Mariette

Re: Do you do unto other pets as you do unto your own?

Hannah Wynne Richards — Thu, 10 Jan 2013 16:56:40 GMT

1) a lot of these cancers spread very quickly so it might be best to give him strong painkillers and spoilhim rotten (cheap)

2) if you want to do something then I could send him toa cancer specialist who would probably do an MRI and blood tests before deciding whether treatment was advisable (expensive )

All 3 options given to owner but listed strictly in the order I thinkBEST FOR THE ANIMAL not the order most profitable for me or cheapest for the owner-both equally reprehensible motives

Wynne

Have I made my attitude sufficiently plain

Re: Do you do unto other pets as you do unto your own?

Malcolm Ness — Thu, 10 Jan 2013 16:45:00 GMT

[quote user="mariette asselbergs"]For an ingrown artificial leg of copurse, or do other orthopaedic vets that too?[/quote]

The technique is relatively simple.

The problem is that the current technology doesn't work - the implants loosen and fail but once that shortcoming has been resolved, there is little reason why the technique shouldn't become widely used. Until then it remains, in my eyes, an experimental procedure in need of significant further development then validation before I would feel comfortable using it in client owned dogs.

Re: Do you do unto other pets as you do unto your own?

Hannah Wynne Richards — Thu, 10 Jan 2013 16:43:28 GMT

I certainly wouldn't refer all kidney failure cats for a transplant-Ihad a major falling out with the then RCVS president (Stephen Ware ) 10 years ago on that very point-I disapprove greatly of transplants due to the effect on the donor cat

Again a silly example

Wynne

Re: Do you do unto other pets as you do unto your own?

Thomas Johnson — Thu, 10 Jan 2013 16:42:28 GMT

[quote user="Hannah Wynne Richards"]

No because in this instance I don't think the expensive option is the best option -due to the very high frequency of early metastases

I would say that the outlook was very very poor and that palliative treatment and early euthanasia would BE BEST FOR THE ANIMAL-so the cheap option would be (imho ) the gold standard-but I would also tell tem that a referral to a specialist was an available option-the specialist might/might not agree with me that euthanasia was the treatment of choice

Quite frankly this is a silly one-very different to advising the cheap option when that isn't the best one

[/quote]

You really wouldn't ever advise that surgery was the right option for a dog with distal limb osteosarcoma? I saw a labrador yesterday that had a forelimb amputation 6 months ago, manages very well, enjoys his exercise, very happy dog, very happy owners.

Re: Do you do unto other pets as you do unto your own?

Hannah Wynne Richards — Thu, 10 Jan 2013 16:40:42 GMT

If I did refer that particular one it would be to an oncologist -because I feel that the tumour not the surgery would be the greater challenge

Wynne