THIS series gives readers the opportunity to consider and contribute to discussion of some of the ethical dilemmas that can arise in veterinary practice. Each month, a case scenario is presented, followed by discussion of some of the issues involved. In addition, a possible way forward is suggested; however, there is rarely a cut-and-dried answer in such cases, and readers may wish to suggest an alternative approach. This month's dilemma, ‘Anaesthetic death: who pays?’, was presented and discussed by Anne Fawcett. Readers with comments to contribute are invited to send them as soon as possible, so that they can be considered for publication in the next issue. Discussion of the dilemma ‘Is flirting with clients taboo?’, which was published in the April issue of In Practice, appears on page 287.
The series is being coordinated by Siobhan Mullan, of the University of Bristol. It is hoped it will provide a framework that will help practices find solutions when facing similar dilemmas.
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Anne Fawcett graduated from the University of Sydney with a BA in philosophy in 2000, followed by BSc(Vet) and then a BVSc. She currently teaches veterinary ethics at the University of Sydney.
A six-month-old apparently healthy female cat presents to your practice for a routine ovariohysterectomy. On physical examination the kitten is bright and alert, in excellent body condition, normothermic and without any audible heart murmurs or abnormalities.
Anaesthesia and surgery are performed as per routine, but the animal suffers cardiac arrest during the procedure and cannot be resuscitated despite lengthy attempts to do so. The owner is informed and is understandably distraught. He is adamant that he should not pay the bill. How should you address this?
Issues to consider
Anaesthetic deaths in healthy small animal patients are increasingly rare (0.05 to 0.11 per cent [Brodbelt and others 2008]), but devastating to the owner and veterinarian alike. This scenario raises a number of questions. The client may blame the veterinarian – after all, they admitted a healthy animal, which subsequently died following treatment.
If we assume the veterinarian took care during the pre-operative evaluation of the patient, anaesthetic administration and monitoring, it is unlikely that the anaesthetic death was the fault of the veterinarian.
Where it comes down to liability, there is no way to apportion blame based on the facts presented alone. In cases of anaesthetic death, clients should be offered a postmortem examination, which might reveal a pre-existing disease that contributed to the anaesthetic death and was not detected on physical examination (Bednarski and others 2011). However, the client must be advised beforehand that, like all other diagnostic modalities, postmortem examination is neither 100 per cent sensitive or specific, and may not yield a definitive diagnosis.
The client feels it is wrong to be required to pay the bill, but this raises the question of what they are paying for. The owner in this situation may refuse to pay because the outcome was not the expected one. However, in veterinary practice the owner pays for the service, not the outcome. While the veterinarian must strive for the best possible outcome for the animal treated, such an outcome cannot be guaranteed.
One means of testing a particular decision is to ‘universalise it’. In this case, few would argue that it is fair for a veterinarian to bear the costs of every anaesthetic death regardless of fault. No one, surely, would expect veterinarians to bear the costs of every poor outcome. It seems fairer that the client pays for the veterinarian's service – their attempt to do the best job possible for each particular animal within constraints imposed by the owner.
A separate question is whether veterinarians should profit from an anaesthetic death. In these cases they have provided a service for which they are entitled to charge. There is a legitimate concern that discounting or waiving fees in such circumstances might be perceived as an admission of liability.
On the other hand, a veterinarian can express sympathy for the outcome without admitting liability (Feinmann 2009). This is an important acknowledgement of care for the animal, the client, and the bond between them.
The majority of poor outcomes in veterinary practice are due to biological variation, low probability risks and side effects and unrealistic expectations rather than negligence (O'Connell and Bonvicini 2007). However, owners may not be aware of how we evaluate and weigh-up the risks and benefits of interventions unless we make our decision-making process explicit.
Possible way forward
The distraught client, when presented with a bill, may feel that the veterinarian is more interested in money than the client or the deceased patient. He has just received shocking, unexpected news and may require time to process this.
The most important step is to take the time to explain the outcome to the client, when the client is ready to discuss this. It is helpful to explain what was done to monitor complications and address them in this case, including a review of the preanaesthetic examination. Quite often clients are not aware how hard veterinarians and support staff work to revive an animal, or how upset or disappointed staff are when an animal dies. This is also an opportunity for the client to ask questions and seek clarification.
One of the guiding principles of health care is non-maleficence, or seeking to avoid harming the patient. Yet, most owners can appreciate that all veterinary intervention carries some risk, however small, of harm to the patient.
Regardless of perceived fault it is important to ensure that all anaesthetic procedures are reviewed following an anaesthetic death. Advising the client of this may give them some reassurance that their animal's death is being taken seriously, that the practice is transparent in addressing any risk factors which might have lead to the outcome, and that the veterinarian is not simply concerned with charging money and moving on. It is also important for staff – who may also be very upset about the unexpected death – to feel that all potential contributing factors are identified and assessed.
Where an anaesthetic death is unexpected, it may be reasonable to offer a ‘compassionate discount’, which is specified as such, charging costs to ensure that the practice does not lose money, but also acknowledging the client's loss. With the client's permission, it may be possible to perform a postmortem examination, also at cost, on the grounds that a definitive diagnosis may provide some closure and may benefit other animals, (for example, littermates of the affected animal which may have the same congenital abnormality) and provide further education to the veterinarian.
Readers with views to contribute on ‘Anaesthetic death: who pays?’ should e-mail them to firstname.lastname@example.org so that they can be considered for publication in the next issue. The deadline for receipt of comments is Friday, May 31. Please limit contributions to 200 words.
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