April 17, 2009
I am frequently pulled into the decision-making process for old pets. One of our elderly feline patients named PP had successful brain surgery twice over the past five years.
At both surgeries the neurologist removed a large meningioma. PP was 18 years old when the tumor recurred. Her family declined further diagnostic work up (MRI) because they did not want her to undergo a third surgery at her advanced age.
PP was circling, blind, very tense, unable to use her litter box and in a two-month decline.
The family was ready to euthanize PP but they met Dr. Katalin Grant, who referred them to me for an end-of-life care consultation.
Six months have passed since then and PP is nearly back to normal. She responded to our Pawspice program's palliative brain tumor and immunonutrition protocols. The family could not be more pleased. Their other family cat is PP's 17-year-old offspring. He is on subcutaneous fluids for chronic renal failure.
The decision-making process is alive and well for these families. But for many pet owners, their decisions can be greatly influenced or practically dictated by paternalistic doctors.
Paternalism is abused when the attending doctor influences decisions based on interests other than those of the patient's needs and the pet caregiver's wishes.
Paternalism is being replaced by self-determined education. Clients gather information and partner with their veterinarian in the decision-making process.
Paternalism is unfortunately abused in money-driven facilities, as with the recent organ transplant scandal at the University of California, Irvine.
When paternalism is used for self-service to keep clients or to feed MRI, CT, radiation therapy and organ transplant programs, etc. it becomes an abuse of professional ethics and a violation of the asclepiad authority.
Donor organs offered to UCI were turned down while patients were told that they needed to wait longer for transplants.
What recourse does the public have?
The good part of paternalism is the special relationship and knowledge that the veterinarian has with the pet owner and the patient. Professional experience is needed to advise clients.
In today's world we are obligated to advise clients of all their options. We need to offer options rather than insist or pressure the client toward a preferred vs. best course of action.
Regrettably and with compassion we must also include the process of humane euthanasia as a final option for helping a terminal or suffering patient find peace.
When pets are elderly or in advanced stages of disease, the decision-making process is difficult for the family. The human-animal bond is strong, but the pet's body is fragile.
We need to educate clients about the patient's needs and quality of life. (See VPN, September 2004, "Quality of Life Scale Helps Make Final Call." The article also appears in the Veterinary Practice News Sourcebook, polybagged with this issue.)
The information explosion may confuse clients so much that they can't make a decision. Our consultations need to be mindful of the best interests of the patient and caregiver.
Veterinarians must juggle several dynamics. These dynamics are framed by the pet's condition, prognosis, chronological age vs. physiologic age, and the financial, logistical and emotional limitations of the pet caregiver and the attending staff.
The human-animal bond prevails over all these dynamics.
On occasion, the bond empowers some patients to outlive their prognosis and surprise us with a longer farewell.
Dr. Villalobos is president of the American Assn. of Human-Animal Bond Veterinarians and is on the editorial review board of the Society for Veterinary Medical Ethics. She may be contacted at firstname.lastname@example.org.
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