August 31, 2016
Client communication is an important part of what we do daily as veterinarians. When a cancer diagnosis has been made, this communication can be challenging in many respects due to the emotional shock of diagnosis, preconceived notions about cancer and cancer therapy, and difficulty with end-of-life discussions.
Some additions to our communication tools can help ease the struggle of these challenging conversations.
When cancer is highly suspected or confirmed, a veterinarian must deliver the news to a client who may be in shock from the unexpected diagnosis.
In some cases the client may have difficulty absorbing information about the disease and the course of action.
Repeating main points and recommendations can be helpful in these cases, as is providing a second line of communication. A written visit summary that includes the diagnosis and recommended tests or treatment options gives pet owners information to reference once they are home and able to think clearly.
The written summary also serves as documentation in the medical record of the recommendations made, and it can be helpful when a referral to a specialist is necessary.
In lieu of a written visit summary, a phone call from the veterinarian or a staff member to the pet owner two or three days after the appointment can be helpful. This affords the opportunity to answer any questions and to reiterate recommendations made during the appointment.
In my experience, these secondary communications improve the chances of a client following up as recommended after the initial cancer diagnosis.
As veterinarians, we may recommend cancer treatments such as surgery, radiation, chemotherapy or immunotherapy, depending on the cancer type. Cancer is a scary word for many, especially clients who have had personal experiences with the disease.
Many clients associate cancer treatment with pain and lengthy recovery periods after surgery, radiation burns after radiation therapy, or severe nausea and vomiting after chemotherapy. It is important that veterinarians take the time to educate clients about the differences between cancer treatment in pets versus humans. We can explain that the goals of cancer treatment in pets are very different than in people and that quality of life is of utmost importance.
Humans can rationalize that side effects from chemotherapy or radiation may be worth it so they can live longer, spend more time with family and do things they enjoy. In contrast, our pets cannot rationalize that feeling sick now may give them more time later.
I educate clients that, as a profession, we feel strongly that less aggressive cancer treatment is more appropriate for pets and that we do our best to maximize quality of life during cancer treatment.
When prescribing chemotherapy, for example, we use doses that are approximately half of what a human of similar weight would receive. We also aim for less than 15 to 20 percent of patients experiencing any side effects.
When side effects do occur, they are usually mild enough to be managed at home through diet and medications. We also can reduce chemotherapy doses in sensitive patients so they don’t experience repeated events during treatment.
The tradeoff of using lower doses is, of course, shorter remission rates and survival times, but most will agree that this tradeoff is the best way to achieve optimal quality of life for our pets. We also can communicate to clients that, when starting a chemotherapy or radiation plan, they are at liberty to stop treatment at any time if they feel their pet is not benefiting as expected.
We rely heavily on the client as the best person to assess daily quality of life throughout cancer treatment and welcome communication with them about this topic.
An important part of cancer discussions between pet owners and veterinarians is setting realistic expectations about the outcome with or without treatment. Veterinarians know that some cancers are curable or treatable while others are aggressive and lethal, but to some clients, the word “cancer” implies “impending death.”
It is essential that we educate clients based on published data about their pet’s specific cancer. A dog with metastasis from osteosarcoma or hemangiosarcoma has only weeks to live, but a dog with metastasis from anal sac adenocarcinoma or thyroid carcinoma may live another year or two due to the slowly progressing nature of those diseases.
Impressing upon owners that cancer is not always a death sentence is important in these cases. Particularly with the advent of anti-angiogenic therapies and targeted therapies such as Palladia, we have begun to recognize that some incurable cancers can be managed for weeks, months or even years with excellent quality of life. By educating clients about the specific cancer their pet has, we can give them realistic expectations.
I do my best to provide general estimates of how much time clients may have left with their pet based on published research, but I also communicate that median survival times are of limited value when an individual pet may fall anywhere below or above that median.
Instead, identifying symptoms and signs that the owner can watch for at home can be helpful in giving the client a sense of responsibility and purpose during cancer treatment.
In pets with advanced cancer or when clients decline definitive cancer therapy for financial or other reasons, the veterinarian can serve an important active role in the management of palliative and end-of-life care. Owners can benefit from an explanation of the goals of palliative medicine, which are to focus on symptoms related to the disease when the disease itself is not curable. We shift our expectations from diagnosis and treatment to working toward maximizing quality of life.
Both the client and patient benefit from regular recheck exams, at which we discuss quality of life at home, assess pain levels and control, and make treatment modifications as needed. Even patients receiving only pain-control medications or antibiotics should be rechecked regularly.
For example, I recommend that a cat with oral cancer managed with antibiotics and pain medications recheck briefly every two weeks. I may identify poor grooming, weight loss or dehydration that the owners have overlooked, and I can make recommendations for a diet change, subcutaneous fluid therapy or additional pain medications.
Owners also benefit from being told exactly what signs and symptoms to watch for in their pet’s last days or weeks. Owners can be taught to monitor for symptoms such as increased respiratory rate, pale gums and dehydration, and clients can be given benchmarks to watch for that should trigger a recheck.
Veterinarians play an important role in helping clients make the difficult decision to euthanize their pet, and this is an essential part of end-of-life care. When beginning palliative care visits, I recommend that owners identify three things that make their pet happy. For some pets, this may be running on the beach or playing with house-mates, while others might prefer lying on their bed in the sun and eating treats.
Clients can use these “happiness factors” to help gauge quality of life moving forward. I ask them to keep a calendar on which they document each day as a good day or a tough day overall for their pet. I advise them that when tough days outnumber good days on the calendar, it is time to consider euthanasia.
When a veterinarian plays an active role in end-of-life care, this puts us in a position to advocate for the pet when the cancer symptoms progress too far. My experience is that, after the fact, many clients whose pets had cancer feel they waited too long to euthanize. The veterinarian can play an important role in helping avoid that feeling of regret.
Discussions related to cancer and its treatment can be some of our most challenging conversations with clients. Informing clients about the diagnosis, treatment and prognosis can empower them as active partners in their pet’s medical care. Taking an active role in end-of-life care and euthanasia decisions is of huge value and strengthens the bond we have with clients.
Dr. Katherine Skorupski is an associate professor of clinical medical oncology at the University of California, Davis, School of Veterinary Medicine.
Originally published in the August 2016 issue of Veterinary Practice News. Did you enjoy this article? Then subscribe today!
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