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, ‘The cow that did get up’, was submitted by a reader and is presented and discussed by Fabienne Uehlinger. 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 ‘Confronting bad husbandry’, which was published in the September issue of In Practice, appears on page 543.
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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Fabienne Uehlinger graduated from the University of Berne and went on to complete a PhD in epidemiology from the University of Prince Edward Island in 2008. She is also a diplomate of the American College of Veterinary Internal Medicine. She previous worked as a veterinarian and livelihoods officer for Veterinarians Without Borders (Canada) in Lao. She is currently a senior lecturer at the University of Bristol.
The cow that got up
An eight-year-old, Holstein embryo-donor dairy cow was admitted to a referral hospital because of chronic diarrhoea, but when loading it onto the trailer it had fallen on the ramp, before getting back up and walking on. However, 36 hours after admission, the cow became acutely recumbent. Despite an extensive diagnostic workup to determine the cause of the recumbency, no definitive diagnosis was made. The diarrhoea resolved, but a poor prognosis was issued for the recumbency and euthanasia was recommended.
Students at the teaching hospital began voicing welfare concerns; the farmer refused euthanasia and voiced his desire to give the cow ‘every chance’. As it remained alert and exhibited a normal appetite, he requested that the cow be managed supportively. It was kept in a sand stall and received intensive care. This included lifting with a hip hoist (eventually causing hip sores) and regular turning from side to side while recumbent.
Five weeks later, the cow rose on her own for the first time and 10 weeks after being admitted the cow walked out of the hospital. Should this remarkable recovery affect the treatment of other ‘downer’ cows in the future?
Issues to consider
There is limited literature available on the prognosis of alert downer cows, though certain clinical signs or metabolic disturbances can be used as prognostic indicators. A recent expert review, carried out by the University of Nottingham's School of Veterinary Medicine and Science, agreed that good appetite and bright demeanour were indicators of a better prognosis; however, absence of attempts to rise (even in the presence of stimulation) was considered an indicator for poor prognosis.
The cow in this ethical scenario showed signs of both, heightening the dilemma faced by the veterinarians. In the absence of a diagnosis, veterinarians erred on one side of the spectrum and gave a poor prognosis, while the farmer chose the other. Was either party more or less justified?
As with all ethical dilemmas that depends on the appropriateness of the motivations and values of the affected parties. The veterinarians were concerned about the cow's quality of life while it was unable or unwilling to stand. The recumbency continued for longer than was their experience with other cases – cases that resulted in good outcomes – and also exceeded the timeline in most literature reports that assess prognosis of recovery in downer cows.
Conversely, the farmer seemed to have valued her length of life more highly and may have felt a sense of responsibility for the cow's condition. Financial considerations probably also influenced the farmer's decision, as the cow's value as an embryo-donor exceeded the costs of hospitalisation.
Intensive supportive management, including but not limited to soft bedding, regular turning and appropriate positioning of down limbs, as well as close monitoring of the patient, are considered key factors in ensuring adequate welfare for downer cows. Both the farmer and veterinarians agreed that this level of care could be given in the hospital. Because of this, and because there is a paucity of reliable evidence on the prognosis of alert downer cows beyond the first five-to-seven days of recumbency, the vets agreed to continue caring for the cow, provided that it did not deteriorate and that side-effects could be managed appropriately.
Possible way forward
Formal evidence-based veterinary medicine is able to provide guidance on case management, based on the outcomes of patients in similar situations. However, outliers can be encountered in every situation (‘not every patient reads the textbook’) and there is scarce evidence detailing the prognosis of alert cows with prolonged recumbency. In those cases, veterinarians are left relying on their knowledge and experience. This is unlikely to change in the future and veterinarians will have to continue to critically consider each case of a downer cow within its individual circumstances.
The veterinarians involved in managing this case will add it to their experiences and it is likely that they will, consciously or subconsciously, take it into account when faced with similar patients in the future. This means that they may give another cow more time before recommending euthanasia. Provided the animal's welfare is ensured, this case demonstrates that this could be an appropriate path to take.
Given the positive outcome in this case, the cow's owner felt justified in his initial refusal to allow euthanasia. One could speculate that this could set a precedent for this farmer, potentially biasing him towards overlooking welfare concerns in similar alert downer cows on his farm. It would be beneficial if veterinarians providing services to him in the future were aware of this experience.
Readers with views to contribute on ‘The cow that got up’ should e-mail them toso that they can be considered for publication. The deadline for receipt of comments is Friday, November 1. Please limit contributions to 200 words.
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