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Grappling With Quality Of Life And Over-treatment Issues

Alice Villalobos discusses the ethics topic of the quality of life at the end of life for pets.

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I was asked to speak on some tough topics at the Human-Animal Bond Track and at the Personal/Professional Development Track Ethics Sessions during the 144th AVMA Meeting in DC. The assigned topics for me were: Maintaining Quality of Life at The End of Life during the Human-Animal Bond (HAB) Sessions and Preventing Over-treatment at a Veterinary Cancer Referral Clinic during the Ethics Sessions.

Dr. Richard Timmins, President of the American Association of Human-Animal Bond Veterinarians, selected the theme of Quality of Life (Q of L) for the HAB track. The Bustad Memorial Lecture was given by Dr. Richard Meadows and titled, Practical Ways to Improve Q of L in Dogs. Dr. Frank McMillan compared the scientific view with the intuitive view in his papers, What Do We Mean by Q of L?, and Research Questions Regarding Q of L. Dr. Melissa Bain discussed Behavioral Management to Promote Q of L. Dr. Marsha Heinke, CPA, spoke on Making Q of L the Focus of the Practice Team. Dr. Timmins clarified O of L for Animals in Confinement.

Dr. Bernie Rollins, Ph.D. of Bioethics at CSU, organized the Ethics theme at AVMA meeting, which dealt with conflicts and ethical issues between generalists and specialists and conflicts arising from Over-treatment in the face of Medical Futility. At the end of each of these exhilarating full day seminars, there were panel discussions so the fur could fly.

It seems that these vital issues occupy a significant amount of a veterinarians’ time. However, discussions between veterinarians and their clients are often hurried and disjointed. Because most pet owners must finance the options and procedures elected for their pets’ care, decision making creates further stress in the owner-veterinarian relationship.

When the pet has a poor prognosis, there is a need to have a clear understanding with the pet owner about the concept of medical futility. It is defined in human medicine to prevent patients from falling into the mindless machinery of medicine where many hopeless cases are trapped in the gears that grind down the system. The key point of my presentation was to elevate our profession’s respect for providing the option of Pawspice (pet hospice) to maintain the quality of life at home for pets with a poor prognosis so they can give their families an extended farewell.

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Many of our clients can’t afford and may not want everything that our modernized profession has to offer for their ailing pets. Some clients plan ahead and protect their interests with pet health insurance. Unfortunately, the percentage of pets covered by health insurance is pitifully low when measured against the intensity of The Bond that people share with their pets. Some pet owners are able to make arrangements for third party payment if their pet hospital uses Care Credit and if they qualify for credit. But too many unprepared pet owners are left facing a heart-wrenching dilemma.

Veterinarians are straddled with the responsibility to communicate clearly and with compassion for the pet owner’s predicament. Unfortunately again, not all professionals have the skills, the time, and the patience to successfully communicate with pet owners during emotional situations. In addition, not all professionals are willing or resourceful enough to offer workable or palliative care options that might help restore or maintain the pet’s quality of life yet stay within the family budget.

I lead a discussion with experienced colleagues regarding these very issues at a meeting in Lake Tahoe last April. One member of my Tahoe group expressed his concerns in e-mail. “I've been talking to a number of folks about the high costs of vet med, as we were talking earlier this year.  And more so, how so few vets will even give the option of even trying something at a lower cost if the clients can't afford a $1000 estimate or more. And worse, it seems a lot of young vets don't even know what the heck they're doing!  There's a lack of "common sense" out there, or so it seems.  It makes me sad.” Terry Paik, DVM, San Diego, CA:

Many experienced veterinarians feel the way that Dr. Paik does. The Ethics Program at the AVMA meeting intended to address some of the issues that cause consternation between veterinarians and clients and general practitioners and specialists. Drs. Gary Block, Anna E. Worth, Frank McMillan, James Serpell, and yours truly, delivered challenging talks. Our intention was to present theory and case studies to help veterinarians understand the nature and scope of ethical conflicts that exist between generalist and specialist while respecting the emotional and financial interests of the pet owner, inherent in the treatment of pets with a poor prognosis. Most of the papers presented at these sessions are available through the AVMA. Some of the papers (including mine) can be e-mailed upon request.

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The American Animal Hospital Association has a published statement, AAHA Statement on Meeting the Cost of Pet Care.  It strongly suggests that all pet-owning families assess their financial situation and consider their ability to meet unexpected expenses that may be incurred for veterinary care. AAHA offers suggestions that can be found regarding pet health insurance. AAHA clearly points out to the pet owning community that they must be proactive and make plans to meet the cost of pet care in the event the pet becomes ill or injured. It would be ideal if all families were financially prepared for their pet’s medical needs. It would also be ideal if there were more non- profit programs and more sliding scale animal hospitals that reached out to meet the needs of undercapitalized pet owners such as Dr. Brian Forsgren’s Gateway Animal Clinic in Cleveland Ohio.

The AAHA Senior Care Guidelines were developed to promote the early detection of disease in senior pets. The guidelines recommend more extensive laboratory testing beginning in middle age to establish baseline values and twice yearly examinations and testing once a pet reaches his or her senior years (age 6-8 for most cats and dogs). The guidelines outline common clinical conditions as well as aspects of screening, diagnosis, treatment, anesthesia, pain management and surgery that are particular to senior pets. The guidelines provide a framework to help practice teams evaluate an aging pet's quality of life and assist clients with the end of life decision-making process.

At present, only about 14 percent of senior pets undergo regular health screening. AAHA and AVMA hope that their current campaigns for senior wellness will increase this number. It is hoped that veterinarians will use the published guidelines as a framework to develop senior care and screening programs in their practices. Most continuing education meetings now feature communication skills seminars and workshops to help doctors become more comfortable during conflict and to increase their client relations success.

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Book Review by Alice Villalobos

Rover, Get of Her Leg, is a humourous and informative book for pet owners on how to increase quality of life with a misbehaving pet. Good behavior ultimately leads to a better quality of life for the family and the pet and saves relinquishment at shelters. Author, Darlene Arden gives pet owners lots of information to kindly and skillfully handle common calamities encountered with dogs, including dogs on the counter! She always recommends consultation with a qualified behaviorist for aggression and resistant problems. Available at www.hcibooks.com


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