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Just because we can do something, should we?

Delegates at Vets South debated ethical questions surrounding under- and overtreatment

01 April 2020, at 9:00am

The keynote panel at Vets South 2020, held on 5 and 6 March at Sandy Park in Exeter, triggered a lively debate surrounding the ethical considerations of treatments. Chaired by Jon King, centre manager for the Wales Veterinary Science Centre in Aberystwyth, the session tackled the problems of under- and overtreatment in veterinary medicine and surgery.

Panellist Alison Moores, soft tissue surgeon at Anderson Moores Veterinary Specialists, began the discussion by explaining the straightforward situations: if the surgery is benign, has a good recovery rate and the analgesia is manageable, or if the animal may die today or is in pain, then the surgery is likely reasonable. Unreasonable surgeries are ones which are difficult, have high morbidity and pain, or if the animal would end up struggling for the rest of their lives.

David Williams, ophthalmologist at the Cambridge vet school and regular Veterinary Practice contributor, pointed out that making this distinction may seem easy, but different surgeons may have different opinions on where to draw the line from their experience of the efficacy of the surgery.

Delegates assisting a conference

Agreeing, Alison emphasised that people accept different complications. One example she gave was in the case of feline injection site sarcomas. Usually, she takes a 3cm margin, but there is a paper that reports 5cm margins may be better with a 10 percent complication rate. However, if you look at the scapula region, a third of cases end up dehisced. For this reason, she doesn’t like doing the 5cm margin, but some do.

The panellists then spoke about palliative care. For some conditions, it’s impossible to offer a cure. This is the case for medical treatments, such as chemotherapy, but also some surgical, such as sarcoma removal. The animal may be in pain because of it, so removing it may be beneficial. However, it is likely that it may return – Alison suggests that this form of palliative surgery is acceptable, but only if the procedure has a low morbidity.

Jon then asked the panel, in their opinion, is there a length of extra time a treatment gives an animal which makes it seem reasonable? For example, if the surgery were to give a dog an extra two months, compared to six more.

Ian Ramsay, professor of small animal medicine at Glasgow University, highlighted that it’s important to remember that these are median figures. Half of the animals receiving the treatment or surgery are likely to not live that long, and half are likely to live longer. “Not everyone understands this and it’s one of the hardest things… if you can’t reach that level of understanding with the client, should you be doing the procedure?”

From a medical point of view, his thoughts are always the length of the course and the quality of life whilst on the treatment – if the treatment would give the dog an extra six months, that may seem great, but if those six months are spent suffering it is probably not worth it, and it’s important to ensure that the owner understands this.

But what if the owner wants to go in a different direction to your opinion? An audience member raised this concern: “you can sometimes lead clients with your own opinion, but at what point do you go against their wishes?”

“We always lead our clients to some extent, because we only give them the information we want to,” replied Alison. “It’s important to give them the facts and clearly specify what is your opinion.” Using the example of injection site sarcomas once again, she always gives owners the facts before adding what she’s seen in practice. “Generally, I do what the client wants – unless it’s overtreating. If you say ‘this is not in your pet’s best interest’, owners tend to agree at this point. There are people who choose to have their animals put down when I think we could give them a very good quality of life for very little difficulty, or with a minor operation, and it is OK to choose euthanasia. Sometimes, you can get the impression that that’s what they want to do, but they want you to suggest it. They want you to tell them that it’s OK to stop, as they may feel guilty. Learning to read people in this way is something vets learn with time.”

“Owners are coming to us because of our experiences,” added David. “Sometimes it’s OK to say your opinion, but remember that they know their pet better than anyone… We’re all in this together for the same reason: the welfare of the animal.”

It can be hard to put yourself in the owner’s shoes though, especially if you have never been in that situation. “My favourite line is ‘if it were my dog, I would…’ It’s difficult to imagine how you would react in a similar situation if you have never owned a pet, never had a pet put down or never had a pet go through surgery. Like I say in my lectures, every vet should have to live with a chronically ill animal or have a pet go through surgery – it’s a huge learning experience,” Ian explained. It’s not necessarily just about knowing the facts about the different options, but it’s also about knowing how to have that conversation with an owner, which some vets, especially new graduates, may find difficult.

The panel also highlighted the importance of taking into account individual circumstances, and not just the type of treatment. Different owners have different situations and different budgets, and what may be the best option for one animal may not be for the next, even if they are suffering with the same issue.

An audience member had concerns about the ethics behind performing a mandibulectomy in the case of carcinomas of the mouth – is the animal living just to be there, and as vets, are we doing the surgery just because we can?

The three panellists agreed that dogs are quite happy after the surgery – they don’t even seem to notice and just get on with it. The surgery doesn’t seem to have a morbidity associated with it, but the tumour does. So, by removing the mandible and the carcinoma, you are taking the pain away from the animal. However, you might not do it for a cat as they don’t tolerate it as well. “It’s important to take the differences between species into account,” reminded Alison.

“You have to stop and think: are you doing this for the owner, for you to say you have done something, or are you doing this for the patient?” advised Jo Oakden, BVNA junior vice president. She highlighted that it’s important that animals can live out their natural behaviour and gave the example of a cat with four prosthetic limbs: “it can’t scent mark by scratching, it can’t jump, it can’t climb – the vets may have removed its pain but it can’t be a cat.” On the other hand, dogs can have wheels and run around happily as they have a different focus: being with their owner, the interaction, food, walks, etc. “Cats have their own behaviour and this needs to be taken into account.”

It is important to remember that what works for one symptom, one pet or one owner may not work for another, and there are many factors that need to be taken into account. This is where experience has the biggest role to play, and where senior vets can help newer graduates when possible.