Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Wednesday, November 21, 2007

Futile Care: What a Difference a Species Makes

She's lived a long, healthy, happy, productive life, but now she's failing. Her eyesight is going, she can't get around as well as she used to, and she's started becoming incontinent from time to time. None of that changes your love for her, of course, so you help her get where she needs to go, and do what she needs you to do for her. You clean up after her as matter-of-factly as you can, so as not to embarrass her, because her company is as precious as it ever was.

But then you notice some blood, so you take her to the doctor. Not surprisingly, on the basis of age alone, she has a terminal illness. What happens next, though, depends on the quality of the doctors:

Are you told, "She needs an operation followed by some other treatments that are expensive, uncomfortable and may or may not prolong her life, but without treatment she will die," implying that of course you don't want her to die so this is what has to be done, or are you offered a compassionate discussion about comfort care and quality of life, allowing you the option of taking her home, making her comfortable and letting nature take its course?

AND: How much difference does it really make if we're talking about your aunt or your cat?

There was a time not all that long ago when the first option was the only one given for a person, and the second was the only option for a pet. To our credit, many physicians are coming around to recognizing the limitations of our wonderful craft, realizing that death is not the enemy and compassionately embracing palliative care. On the flip side, as veterinary medicine accelerates and catches up with human medicine in terms of what can be done, there are accusations of some young vets who begin to sound like old-fashioned human doctors: if we can do it, we should do it. After all, you don't want her to die, do you?

Here's the big question, though: Why is it only the veterinarians in this situation who are accused of being coldly calculating, money-grubbing scoundrels? Is it just because people actually have to pay vets for their animals' care, whereas Americans' dependence on the capitalistic system of medical payment brokerage (rendered in doublespeak as "insurance") has effectively allowed them to believe that medical care shouldn't cost anything? In the case of futile care, though, none of that ought to matter.

I am not saying that a human life is equivalent to that of an animal, nor am I espousing euthanasia for humans. But to the extent that ACLS is now an option for animals (despite the fact that cats, for example, don't get atherosclerosis so cardiac arrest is generally a terminal event) it seems that the line between futile care and heroic (ie care with a good outcome) is becoming as fuzzy in veterinary medicine as it is for humans.

Everyone needs to get together on the same page. Futile care is futile care, (edited to add: and shameless, money-grubbing appeals to guilt are, well, shameless) for man and for his best friends.


At Wed Nov 21, 05:44:00 PM, Anonymous Anonymous said...

Futile care is an oxymoron in good veterinary practice. And that said futile depends on what you persoanlly think futile is....If you can buy 25 weeks at a cost of $25.00 a week, and your pet feels good, is that ok? What about 10 more minutes for 10 bucks? What about 6 months for $50.00? I hope you can see where I'm going here. Each person has a different values for diffrent things, what is right for me, may not be for you. My job as a veterinarian is to explain what the gold standard of care is and give you all the options that are less costly, then let you make up
your own mind about what you want for the animal that shares your home. When doing this keep in mind, that if you think about veterinary care, for a dog that has lived 12 years, and you have never spent any money on anything medical other than vaccines, a 2000.00 dollar bill over 10 year life span isn't that much per day to buy some end of life dignity. Remember also that what you pay me 200 dollars for in my hospital would cost you 2000 in a human hospital. While you are mulling that over, also keep in mind that I am using the EXACT same medications, iv fluids, and so forth and my education cost more and I make less and it was harder for me to get into vet school than any doctor in med school. (I had a 4.0 from a IVY league institution, got into every medical school I applied to and got into only ONE of the vet schools I applied to. Let's worry about the state of human health care before we staring fussing over the vet who wants to "help to much" .
Let's get health care for eveyone in this country and expect our doctors to be as good in school as we do our vets.

Dr. Kate

At Wed Nov 21, 07:28:00 PM, Blogger #1 Dinosaur said...

(er, Kate: I'm on your side.)

At Thu Nov 22, 08:48:00 AM, Anonymous Anonymous said...

nice way of throwing in a lot of inflammatory, unrelated points there, dr kate.

does the challenge of admission to vet school versus medical school apply here? are the costs relevant to the discussion? seems like that ivy league education is working out real well for you. in the real world, your income is determined probably at least as much by your business acumen.

maybe the pharma companies need to examine the cost of meds to animals. instead of charging humans so much, they should take r&d costs and apply them to the prices they charge for animals. then we will see pet care rationing. it is interesting different pricing because antibiotics for my dog were 4x the cost of the same antibiotics for my son.

as you know, what you make isn't a reflection of how good a vet you are. i am sure you could make more by being a worse vet.

good luck with things.

At Thu Nov 22, 08:56:00 AM, Anonymous Anonymous said...

just out of curiosity, what did your classmates in vet school do to get in? i find it hard to believe there are nothing but 4.0 ivy leaguers in your class and the other schools. who exactly is going to the other schools that did not accept you?
*this is not intended to upset you, just an honest question from someone who never considered vet school.*

At Thu Nov 22, 09:46:00 AM, Blogger #1 Dinosaur said...

Yo, Anon: chill out. As it happens, because there are fewer vet schools than med schools, it would in fact be entirely possible for all of them to completely fill their classes with 4.0 Ivy Leaguers. FWIW, I admire the hell out of vets. They do indeed know far more than I (who only learned about one species) and are deserving of far more societal acclaim than they tend to receive.

Intelligence is not the issue. We've all seen highly intelligent physicians make asses of themselves espousing Intelligent Design and homeopathy after all.

This was intended as a highly pro-vet post, inspired by some of the response to Shooting up the Cat. I found the vet behaviors in the article I linked are not at all typical of my experiences, and wondered why it is veterinarians who are castigated for actions that are praised when taken by human physicians.

At Thu Nov 22, 07:06:00 PM, Anonymous Anonymous said...

it would be possible to fill out any small group of people with 4.0 ivy leaguers. most groups are not filled with them, however. since i had some time i looked into the admission stats. it certainly is competitive, and maybe more competitive than medical school (can anyone really know?) but clearly not stocked with exclusively 4.0'ers. there must be other considerations they make in their deliberations.

maybe i read too much into the post and i apologize if that was the case.

i too admire vets.

ps-i'm laughing because if you could see me there is no way you would think i need to chill out. such is internet communication.

At Thu Nov 22, 09:11:00 PM, Anonymous Anonymous said...

I understand what you're saying, Dino, and I do understand how Kate could misinterpret.

I, too, am a vet, but not a 4.0 Ivy Leaguer, just a 3.6 Texas Aggie, LOL.

For the cost of our education we make peanuts, but the average Joe thinks we make as much as physicians. Many think we have a 2-year degree like chiropractors and are therefore not *real* doctors. Many days people ignore our advice (which they paid for) to take the advice of a breeder/groomer/teenager at PetsMart.

Yes, we have the abilities to offer top-notch care. Yes, many clients opt for that (we refer many to local specialists). But many people balk at paying the vet. "Can I pay next week?" is a common refrain (and they never do). Many times we're forced to euthanize a pet with a treatable condition because there is no plan B or C to offer. And yes, other times we end up prolonging dying (and suffering) because the owners are in denial and can't let go.

It's tough when the person who thinks a $300 bill (modest if it includes some blood tests) is ridiculous but drives up in a Beemer (I drive a Focus). And I once had a prominent realtor (face plastered on all the signs locally; hailed in the papers as a multi-million dollar salesman) think my $35 office fee was too much because he had 7 dogs and wanted a multi-pet discount (do pediatricians offer multi-kid discounts?).

So yeah, when people question your credentials, complain about fees, and write articles claiming vets are money-grubbing bastards, well yeah, it can grind you down.

Me? I should have been an engineer. :/

At Thu Nov 22, 10:52:00 PM, Anonymous Anonymous said...

The "X only costs $200 in a vet hospital, it's outrageous that costs 800 dollars in a human hospital!" lines never fail to crack me up. It displays a basic misunderstanding of quality assurance and diminishing returns. For cats, 99% is good enough. For humans, it's got to be 99.9% and that extra digit just quadrupled the cost.

At Sat Nov 24, 10:40:00 PM, Blogger The Ethical Miss said...

Home hospice care is one aspect of veterinary medicine that is finally starting to be embraced by both vets and clients. All too often I hear stories of owners saying "I'll just bring Fluffy home and let her die peacefully" - not realizing that they may have just condemned Fluffy to a painful or scary death, not a peaceful one. When my own cat was diagnosed with adenocarcinoma of the common bile duct while I was still a CVT (certified vet tech), I had to beg one of the vets I worked with to help me figure out what kind of palliative care I could do at home until my kitty needed to die. It wasn't easy, but my family and I got an extra week with a comfortable kitty before I had to take her in for euthanasia. And I learned then and there that as a veterinary profession we need to help people bridge the gap between the two options you discussed.

I view our ability to perform euthanasia as a blessing that we can use to truly end suffering in a humane manner. And it kills me to basically force an animal to stay alive through intervention simply because the owners aren't able to give their pet the freedom to die.

At Sun Nov 25, 12:23:00 PM, Anonymous Anonymous said...

I don't think it is fair to compare humans and animals. A human thinks about tomorrow, about living through the holidays or seeing their grandchildren get married. A human may be willing to accept some level of discomfort because a human has a desire to live. In most cases, a human has the ability to express his or her wishes or the loved one have the knowledge of what a person wants.

Cats live here and now. If a cat is in pain now, the cat doesn't think -oh, it's OK, as long as I get to live a week longer. The cat only knows that it suffers now. So when we take some measures to prolong the life of our pets, it's important to distinguish what is better for us because we cannot let go of Fluffy and what is better for Fluffy.

Additionally, we cannot really say if a cat is in pain, can we? Animals instinct is to hide their pain, isn't it? So I do hope, that when my cat gets old and sick, the vet will be honest enough to tell me whether a treatment is likely to be beneficial for the cat.

"I found the vet behaviors in the article I linked are not at all typical of my experiences, and wondered why it is veterinarians who are castigated for actions that are praised when taken by human physicians."
I had, as a whole, a pretty good experience with vets. However, I am not idealistic to think that vets always act in the best interest of the pet. If they did, a barbaric procedure like declawing would be illegal here as it is in England and most European countries. Can anybody see a doctor agreeing to a parent's demand to chop of parts of the child's fingers because the kid damages the furniture? One other thing that is correct in the article is the frequency of pet vaccinations. AAFP, for example, as well as VAS task force and most vet schools recommend vaccinating cats once every three years (except for Purevax and subject to state laws); there is even evidence that in some cases, like Distemper, the immunity lasts longer than that. Yet there are many vets (not all) who insist on yearly vaccinations; there are also vets (hopefully very few) who "forget" to mention that FELV vaccination is not recommended for indoor-only cats as their risk of running away and contact it is way less than 1/1000 per vaccination risk of vaccine-associated sarcoma (VAS). And while we are on the subject how many vets actually discuss VAS with owners? 1/1000 risk of a very aggressive cancer is pretty large if you consider the number of vaccinations a cat gets over a lifetime as well as how many cats this number translates to.

At Sun Nov 25, 04:05:00 PM, Blogger Dr. Deb said...

A beautiful and insightful post.


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