What would you do?

Re: What would you do?

Dagmar Steele — Tue, 10 Feb 2015 15:21:15 GMT

I've learned one thing over the last 25 years: If you do an owner a favor against your better judgement it nearly always backfires. In these cases they come back complaining because they realise it was their fault that the cat had to suffer but are not prepared to face it. I'm being a bit sarcastic today because I just had a letter from a solicitor (someone I did a favor doesn't want to pay the bill)....shouldn't have touched the dog in the first place!

Re: What would you do?

rachaelyost — Tue, 10 Feb 2015 14:08:28 GMT

I had this before xmas. Cat came in with the owner's partner. Adv euth due to fluid on lungs and heart failure and massive ascites. He refused and said wasn't an option. I am normally pretty good at persuading people with the whole 'drowning in fluid' etc. He wasn't convinced so I drained some abdo fluid and sent him home on frusemide letting him know if was very unlikely to help at this stage (temperament wouldn't allow thoracocentesis and I had no nurse to help sedate). Cat was then euth'd 4 days later at OOH and the owner came in complaining we had killed the cat and that the medication didn't work. Unfortunately these cases often don't die nicely if the owner choses not to pts when advised

Re: What would you do?

Gillian Mostyn — Mon, 09 Feb 2015 15:18:03 GMT

I do think that experience makes you more likely to be blunt with owners, as what you say can be very different to what they CHOOSE to hear.

I have a lot of cases like this with reptiles. Brought in 9/10 dead after not having eaten, or moved, in weeks. My options of a) hospitalise and do everything necessary or b) euthanase, are sometimes surprising to clients. They want a bottle of medicine and 'see how it does', but that isnt always fair to the patient. Animal welfare dictates our actions, regardless of what the client subsequently thinks of us.

Anthony...don't beat yourself up about this. I'm sure you feel bad about what happened to the cat but you didn't make it ill, you simply tried to make it feel better for a while. Your intentions were good. Hindsight is a wonderful thing....and will help your decision making in the future.

Re: What would you do?

Hannah Wynne Richards — Mon, 09 Feb 2015 15:06:05 GMT

I've been guilty of hanging on too long with one of my own animals. With hindsight, I wish for the animal's sake that someone would have threatened me with prosecution. The greatest regret of my life.

Wynne

Re: What would you do?

Hannah Wynne Richards — Mon, 09 Feb 2015 15:04:06 GMT

Apology accepted

Wynne

Re: What would you do?

Anthony Dennison — Mon, 09 Feb 2015 14:57:51 GMT

[quote user="Stephen Courtney"]When I have cats with pleural effusions or similar situations , where the end is nigh but not immediate necessarily, I always tell the client they need to MONITOR the animals breathing,and that includes counting the resting respiratory rate. I also warn that the animal may deteriorate suddenly and that they are at risk of needing urgent OOH attention, and that the animal may die unpleasantly if they delay the inevitable beyond a certain point, and knowing where that point is going to arrive is all but impossible.[/quote]

This was discussed even before I did the thoracocentesis, in a way trying to encourage the owners to think more about euthanasia. It may have come across to them as a treatment option rather than a explanation of why it wouldn't be good in the long run. I will have to look at how I approach end-of-life discussions in the future.

[quote user="Stephen Courtney"]Your criticism of Wynne comes across as rather rough - she does write in black and white, but i doubt very much she would be so undiplomatic as to threaten a client as her first attempt to get them to do the right thing.[/quote]

You are right. Apologies Wynne, I'm still feeling a little raw that I let this happen to the cat; I should have put it to sleep on Friday and I know it. I get ticked off at clients when their guilt turns into frustration, and I've just fallen in to that trap.

[quote user="Stephen Courtney"] But it doesn't stop me doing my best for clients and their pets, and sometimes you need to use your training and experience to tell people what is the right thing, not offer a few extra options that confuse the client and don't actually help the animal at all.[/quote]

Spot on once again. Key word is experience; now that I've gone through this once I can utilise it in my decision making in the future, and make it easier to explain to clients. It's probably the reason why I posted in the first place... I knew I should have pushed harder for euthanasia but didn't.

[quote user="Gerry Henry"]

If Conn's syndrome why no adrenectomy at diagnosis? I've done a few, not too difficult, animal recovers v well, survival times 2yrs +.

[/quote]

High systemic BP and high Na:K ratio was only discovered at the same time as a chest full of tumours that had spread to both eyes. Interestingly, I have read reports on pulmonary adenocarcinomas metastasising to the eyes, and one report of it spreading to the adrenal glands in a dog. If I had euthanased the cat on Friday, I probably would have asked to do a PM to figure out where all the masses were and which was the primary tumour site.

We live and learn.

Re: What would you do?

Gerry Henry — Mon, 09 Feb 2015 13:32:31 GMT

If Conn's syndrome why no adrenectomy at diagnosis? I've done a few, not too difficult, animal recovers v well, survival times 2yrs +.

Re: What would you do?

Stephen Courtney — Mon, 09 Feb 2015 12:47:31 GMT

[quote user="Anthony Dennison"]

[quote user="Anthony Todd"]Breathing doesn't suddenly deteriorate so the owners weren't the most attentive, mind you they may have had other problems, one never knows.[/quote]

But many owners don't understand or know about the early signs of respiratory distress in cats, especially older ones that spend most of their time sleeping. They contacted me thinking he was in pain, so had noticed something wasn't right. Not all clients have as much training as we do

[/quote]

Yes we have the training, And we need to use it to guide people to a suitable plan. that doesn't mean being heavy handed, necessarily, but sometimes you do need to have the balls to spell it out. Very few clients are so obtuse they need to be brow-beaten, but if they want hospice type treatment, that should be hospitalisation, on appropriate medication to prevent distress, anxiety and pain, and oxygen if need be. And they need to know what that level of treatment will cost, and be happy with it.

When I have cats with pleural effusions or similar situations , where the end is nigh but not immediate necessarily, I always tell the client they need to MONITOR the animals breathing,and that includes counting the resting respiratory rate. I also warn that the animal may deteriorate suddenly and that they are at risk of needing urgent OOH attention, and that the animal may die unpleasantly if they delay the inevitable beyond a certain point, and knowing where that point is going to arrive is all but impossible.

Your criticism of Wynne comes across as rather rough - she does write in black and white, but i doubt very much she would be so undiplomatic as to threaten a client as her first attempt to get them to do the right thing. comparing this situation with your own loss isn't really the same at all, an old animal dying horribly of cancer has very little in common with a young animal RTA. And the emotions of grief and guilt and what-ifs are all different too. We all lose our pets, I lost mine last year and was in bits for weeks. But it doesn't stop me doing my best for clients and their pets, and sometimes you need to use your training and experience to tell people what is the right thing, not offer a few extra options that confuse the client and don't actually help the animal at all. Draining the cat's chest allowed it a few good hours followed by severe dyspnoea and then, bluntly, choking to death in fear and anxiety. No doubt the clients feel they ' did all they could' and are glad the cat had a few extra hours at home? that should have been avoided.

Re: What would you do?

David Mills — Mon, 09 Feb 2015 12:36:06 GMT

What follows is not a criticism of the OP of their actions, but rather a framing in veterinary ethical thinking.

There were two issues here.

1. The fate of the cat. I assume we all think the cat would have been better off dead i.e. euthanased at presentation. That bit is black and white, as evidenced by its avoidable and pretty horrible death shortly after intervention.

2. Influencing clients. I also think this is clear cut, but less so. There are competing influences at work here. Financial/business - these may be valuable clients, are willing to spend money, and not to be upset unnecessarily for fear of losing them in future. Personal - the owners were obviously hoping for a miracle. Historical/emotional - their previous cat had died fairly recently. Ignorance - of the severity of the condition, inappropriate point reached on the 'grieving' process. There are likely others too.

It depends where we draw our lines in the sand. I have been in similar situations in the past, usually with similar or near-similar outcomes, to the point where I won't even consider palliative tx in these cases anymore - because despite pleas to the contrary, owners don't come back straight away, they normally leave it too late, and they often turn out like in this case. Keeping 1) in mind, I am a consequentialist about this and immovable - because of previous experience, and because in the weight I place on the animal's welfare trumping any personal, owner, financial, or business influences (I accept that working for a charity, the client care aspect is less; similar to Ms Richards's case in that she can afford to, and will, lose a client in the pursuit of immediate euthanasia for the cat). Part of the problem with this case is the cat improved so markedly with treatment, as expected - however this may not help the owners long term as it provides some false hope (regardless of how sensible they seem at the time). How much pressure you apply to the client is one's own judgement, and it can be difficult to gauge. However, I disagree completely that it is a pyrrhic victory to 'bully' clients into this - partly because I don't think it is bullying, and partly because I am a consequentialist (or, to look at it another way, a believer in the right ('animal rights' ) to equal consideration in terms of avoiding suffering above all else). Perhaps it's easier for me - I'm male, northern, and fairly abrupt at times (and there may be more sympathetic ways of going about it than I do, I agree). But I think if we believe 1) then everything else is second best, all other influences pale by comparison, and any other intervention greatly increases the chances of very poor welfare for the cat. Is it worth upsetting, losing, enraging a client, boss or whoever for? To me, yes. Someone said on here a while back something along the lines of 'put the animal's welfare first and everything else will be OK', and I think it's a useful moniker. Don't expect thanks or beatification, and be prepared for anger and denial but with responsibility comes difficulty and distasteful experiences.

Again, not a criticism of the OP. But just an attempt to formalise my take on it, having been there and experienced the same. I think sometimes, unintentionally, we lose sight of 1) when trying to please everyone - it would be much simpler if people agreed with us on these things.

There's a nice review of 2) here:

http://www.ncbi.nlm.nih.gov/pubmed/20673104

Will need subscription to AVMA - happy to forward on to anyone interested.

Re: What would you do?

Anthony Dennison — Mon, 09 Feb 2015 12:26:57 GMT

[quote user="Anthony Todd"]Breathing doesn't suddenly deteriorate so the owners weren't the most attentive, mind you they may have had other problems, one never knows.[/quote]

Re: What would you do?

Anthony Dennison — Mon, 09 Feb 2015 12:24:55 GMT

[quote user="Hannah Wynne Richards"]

I can't understand why I was red-starred on this one. A stern talking to to the owners would have saved the poor poor cat unnecessary suffering.

Wynne

[/quote]

Because Wynne, the owners were incredibly upset; a stern talking to in the way you were describing 'possible prosecution case' is not the most tactful way of doing things. Yes you do hold animal welfare at high regard, however these people presented their cat for veterinary treatment once it was unwell; they did not ignore it and let it to die. As they have sought treatment there is no case to be brought, end of.

I appreciate that I am younger than you and have not had as many years in practice as you, but currently I do not have your black and white view of the world and everything that goes on in it; in certain situations leniency and a bit of tact go a long way. Yes, I probably shouldn't have offered thoracocentesis as a treatment option and said there is nothing I could do, but then I would be lying and not giving the owners enough information to give informed consent. Throughout the whole process I told them it wasn't good news, we could euthanase at any time, but considering the difference it made to the cat for that short period and allowed the owners to spend one last night saying goodbye to their beloved family pet. Who knows, there could be some other emotional attachment to the cat, like a lost family member that made it harder to say goodbye.

My dog was run over in front of me last year. My last words to him were that he was naughty for running across the road, not nice words whilst he was cuddled. I didn't get to say goodbye to him properly, and even know when I think about this it makes me well up. Because of this experience I try to make sure at the end of an animal's life the owners have a chance to say goodbye properly - spoil them for one last night, or a few days. I provide analgesia, make sure they're comfortable and do everything I can so owners can have those extra few precious moments that I never got. Not all clients accept this offer, most will go for euthanasia there and then but by offering it, there is some compassion that owners appreciate.

If that makes me a bad vet then fine, report me, red star me. But if you take one thing away from this Wynne, remember there are factors that affect decision making not only for the owners, but also the vets sometimes too. Trying looking at the world in greyscale for once.

Re: What would you do?

Anthony Todd — Mon, 09 Feb 2015 11:22:07 GMT

[quote user="Hannah Wynne Richards"]

I can't understand why I was red-starred on this one. A stern talking to to the owners would have saved the poor poor cat unnecessary suffering.

Wynne

[/quote]

Just another argument supporting the banning of red-stars without attached explanation. Mind you, at least the cat had the fluid drained so at least it had some oxygen.

And sometimes you can sort them out but better when they're pink rather than blue.

Breathing doesn't suddenly deteriorate so the owners weren't the most attentive, mind you they may have had other problems, one never knows.

Re: What would you do?

Hannah Wynne Richards — Mon, 09 Feb 2015 11:17:53 GMT

I can't understand why I was red-starred on this one. A stern talking to to the owners would have saved the poor poor cat unnecessary suffering.

Wynne

Re: What would you do?

Stephen Courtney — Mon, 09 Feb 2015 11:02:34 GMT

[quote user="Hannah Wynne Richards"]

Poor poor cat.

Wynne

[/quote] Totally agree. Better a week too early than a day too late. Now their last memory of their cat is watching it gasp its last during a totally avoidable dash to an OOH service.

Re: What would you do?

Hannah Wynne Richards — Mon, 09 Feb 2015 10:52:27 GMT

Poor poor cat.

Wynne

Re: What would you do?

Anthony Dennison — Mon, 09 Feb 2015 09:22:36 GMT

[quote user="Kate Richardson"]As an aside, why Conns- was it hypokalaemic? Just you mention the bradycardia which (if potassium related) should be hyperkalaemic?[/quote]

Bloods were taken at the referral centre, haven't actually got values (though I will do as using the case for my certAVP), Na:K ratio was high at 37. Hyper-aldosteronism was one of the differentials; BP was 230mmHg. 3rd degree AV block was noted on ECG, it may have been completely unrelated.

I thought I would put this scenario out to see the general consensus. Not surprised at Wynne's response, but remember, the world isn't as black and white as you think. These owners had owned the cat since a kitten, and had lost it's sibling about 18 months previously. They didn't want the cat to suffer, but they didn't want to feel like they were just giving up on it. It did have some degree of neck ventroflexion though.

I had a frank discussion with them; draining the chest is palliative only and will more than likely refill, it may give some comfort though. Euthanasia at this point is perfectly acceptable and I wouldn't argue with that decision if they were to make it etc. We were chatting for about 10 minutes.

In the end I drained the cat's chest. Took 120mls of the right side of the chest, nothing to come from the left. They watched me put the needle in to drain and they saw the amount of fluid that was there. As I was draining it I pointed out how much was coming out and it will almost definitely re-fill. However, the cat went from paradoxical breathing, neck outstretched, to sitting up, looking around and purring. Owners decided to take the cat home, gave them the emergency number to call if breathing went again.

The cat deteriorated Saturday evening, owners were heading to the OOH centre with him open mouth breathing, and he was dead on arrival.

Re: What would you do?

Lindsey Edwards — Sun, 08 Feb 2015 22:50:12 GMT

I'd drain as a temp measure, inform clients of palliative nature and impress keeping on 'morphine' type as is familiar with human cancer patients. The owners need to realise but also to accept inevitable loss of their cat and hopefully to become proactive in managing his suffering including euthanasia, informed consent for heavy analgesia to allow procedures to the point that it may be too much for cat often alertss owner to critical nature. Rapid decline after intervention often allows them to accept the end also.

Re: What would you do?

Stephen Courtney — Sun, 08 Feb 2015 20:46:11 GMT

[quote user="Neil Wheadon"]Crikey, the RSPCA would be busy if every case was treated like that suggested here. Put yourselves in the owners position. I'd drain the chest, saying this is palliative and use the expression 'life is about quality over quantity' If the condition is that severe, then the cat will quickly return to a chest full of fluid. At this point the owners are usually prepared to PTS, and have felt that they have tried something. Neil

[/quote]

I got the impression from the first post that the clients were dithering about what to do. Treatment is palliative, euthanasia is the inevitable end point unless the client lets the animal suffer all the way to the end. Palliative treatment is fine so long as you cover all the bases, analgesia especially, and warn them the results are strictly temporary, and that the procedure is not without risk either.

Doing nothing is a whole nother issue, that's where welfare becomes the overriding concern

Re: What would you do?

james herriot lied — Sun, 08 Feb 2015 18:37:47 GMT

Don't railroad these people - they're misguided, not evil, and its our place to educate them. Helping them to understand the level of suffering involved will bring a better - and more rapid - solution for everyone.

If you're looking for the right phraseology to use, I've always gone for, 'we're no longer helping him to live; now, we're forcing him to live'. It acknowledges that everybody involved wants to help, but implies that perhaps what we're doing is the opposite of helping.

Bullying a client into euthanasia is, nine times out of ten, a pyrrhic victory.

Re: What would you do?

Kate Richardson — Sun, 08 Feb 2015 18:37:40 GMT

I'd drain the chest to make the cat (hopefully) more immediately comfortable, keep it in hospital for obs and treatment as necessary eg oxygen/pain relief and spend as much time as needed talking to the owners to make them understand its not about them being ready for PTS, its about the cat.

As an aside, why Conns- was it hypokalaemic? Just you mention the bradycardia which (if potassium related) should be hyperkalaemic?

As another aside, did the referral centre talk them about euthanasia?

Re: What would you do?

Virginia Campbell — Sun, 08 Feb 2015 18:25:35 GMT

[quote user="Anthony Dennison"]b) Do a thoracocentesis, show the owner how much fluid is in the thoracic cavity, repeat the grave prognosis and try and bring the conversation around to euthanasia[/quote]

I'd do this. Use the word "cancer" not "masses" and "drowning" several times and write "pleural effusion cat" down for them to look up on youtube if they insist on not euthing the cat today, under the guise of education. There are a couple of human doctors explaining what pleural effusion is, but their eye will hopefully taken by the ginger cat that comes up as one of the first search results, clearly having a rough time and with some helpful comments underneath from people whose cats have had thoracic neoplasia, got the chest drained and fluid returned within days necessitating euth.

It's a pity the poor things don't vocalise enough till the last minute in these cases.

If you need to be even harder, do the thoracocentesis in front of them and let them catch a good eyeful of the needle. Use a big syringe. Do a decent big clip and scrub with iodine; let them get a good look at you setting up the T piece for flow by oxygen and leave your emergency ET tubes, laryngoscope etc in a prominent position. You get the picture.

Re: What would you do?

Anthony Todd — Sun, 08 Feb 2015 16:09:07 GMT

[quote user="Neil Wheadon"] If the condition is that severe, then the cat will quickly return to a chest full of fluid. At this point the owners are usually prepared to PTS, and have felt that they have tried something. Neil[/quote]

+1, assuming the cat is eating. May be able to control fluid build up with diuretics.

Draining the chest is easy pain-free and makes such a difference, particularly when breathing is "paradoxical"........

As Neil says, gets the owner to the stage of PTS if necessary.

Re: What would you do?

Neil Wheadon — Sun, 08 Feb 2015 15:35:04 GMT

Crikey, the RSPCA would be busy if every case was treated like that suggested here. Put yourselves in the owners position. I'd drain the chest, saying this is palliative and use the expression 'life is about quality over quantity' If the condition is that severe, then the cat will quickly return to a chest full of fluid. At this point the owners are usually prepared to PTS, and have felt that they have tried something. Neil

Re: What would you do?

Stephen Courtney — Sun, 08 Feb 2015 14:15:29 GMT

If the cat can't breathe properly either you PTS or admit for treatment. There is no middle ground that doesn't leave the cat suffering. The owners are allowing suffering, sometimes you have to point this out. Give them two choices, either treat the cat to the extent of your abilities, including draining the chest but also analgesia - it's riddled with Mets and must be in as much pain over this as a human would be - or put it to sleep. I would tell the clients quite bluntly that they were increasing this animals suffering - and if need be would get an RSPCA inspector involved.

Re: What would you do?

Anthony Dennison — Fri, 06 Feb 2015 17:12:13 GMT

Perhaps I was being a bit dramatic describing them as agonal gasps. Cat was sat in sternal, and had the occasional open mouth gulp of air.