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, ‘Slipped disc and dyspnoea in a French bulldog’, was submitted and is discussed by Laura McLellan. 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.
The series is being coordinated by Dr Steven McCulloch, acting director of the Centre for Animal Welfare, University of Winchester. It aims to provide a framework that will help practising veterinarians find solutions when facing similar dilemmas.
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Laura McLellan qualified from Bristol University in 1996. She has worked in practice since qualifying, and currently works in a small animal practice in east Leeds. She has a strong interest in animal welfare and ethics, and has previously worked for the RSPCA, and co-ordinated a cat welfare project at Leeds PDSA.
Slipped disc and dyspnoea in a French bulldog
During evening surgery at a private clinic a four-year-old female French bulldog, ‘Bella’, is presented to you as an emergency, with acute upper airway obstruction syndrome (UAOS). Bella is also suffering from hindlimb paresis and back pain, for which she had been seen earlier in the day at a charity veterinary clinic. A grade 3 intervertebral disc extrusion was diagnosed and Bella had been prescribed strict rest and non-steroidal anti-inflammatories (NSAIDs). UAOS had developed later in the day, and appeared to have been triggered by the stress of hindlimb paresis and possibly the visit to the charity clinic.
How do you proceed and advise the owner?
Issues to consider
One question to start with is should you advise treating Bella at all, or should you advise euthanasia immediately? Upper airway obstruction syndrome (UAOS) is an extremely stressful condition for a dog and Bella’s suffering needs to be relieved urgently. Bella may recover from this episode of UAOS, but one of the most likely inciting causes, the stress of hindlimb paresis, will probably be present for several weeks at least, so there is a risk of further episodes. It’s also possible that Bella may never recover from the disc extrusion – most dogs with grade 3 extrusions do recover with conservative treatment (Schubert 2010), but some do not – in which case Bella is likely to be euthanased.
Bella may respond to medical treatment for UAOS, but if she doesn’t then the only other way to relieve her suffering, other than euthanasia, is to perform a tracheostomy. This procedure will cost several hundred pounds at least, and aftercare will be substantial both in terms of cost and, possibly, home nursing requirements. Moreover, is it ethically justified to perform an invasive procedure on a dog which has a separate pre-existing condition from which it may not recover?
Conversely, if we consider the best possible outcome, Bella may respond well to conservative treatment for UAOS, have no further episodes, and make a full recovery from the disc extrusion.
A final consideration is that the owner is registered at a charity clinic and in receipt of state benefits. Hence, they may have difficulty paying for treatment.
Possible way forward
Bella is in significant distress and as veterinary surgeons, our primary responsibility is the welfare of animals under our care. Therefore, the priority is to initiate emergency medical treatment for Bella to relieve her suffering. Discussions around potential euthanasia should, wherever possible, not be rushed, and so conversations should only commence once emergency medical treatment has been started. We can briefly explain the severity of Bella’s condition to her owners and gain permission to hospitalise her and initiate medical treatment (ie, oxygen supplementation, sedation, intravenous steroids, and cooling if necessary).
Readers with views to contribute on ‘Slipped disc and dyspnoea in a French bulldog’ should e-mail them to email@example.com so that they can be considered for publication in the next issue. The deadline for receipt of comments is May 18, 2018. Please limit contributions to 200 words.
We need to be able to give a rough estimate for the cost of the medical treatment. Whether we continue to treat Bella if the owners say that they cannot afford to pay for the treatment is debatable. However, the only alternative to treatment is euthanasia (Bella is in no state to be transported back to the charity clinic), and the owners have had no time yet to consider finance options. Medical treatment for UAOS is not expensive and so the fair and compassionate course of action would be to continue treating Bella medically.
The next concern is to establish whether the owners wish for a tracheostomy to be performed on Bella if her condition worsens, or if she has not responded to medical treatment within a reasonable period of time.
As is usual in veterinary medicine, there are no certainties in her medical conditions. Despite this, there are probabilities: the likelihood is that Bella will recover from the disc extrusion, although it may take weeks to months of nursing which the owners need to be willing and able to carry out if we are to continue treating Bella.
We cannot know yet whether Bella will have recurrent UAOS during recovery from the disc extrusion. If we knew that Bella would have repeated bouts of UAOS then it would be questionable whether we should continue to treat her, as the quantity of suffering that she would have to endure may be unacceptable. Euthanasia might then be the most humane course of action.
Conversely, if we knew that Bella would have no more episodes of UAOS we might recommend continuing to treat her, surgically if necessar y. Since we do not have based on an informed consideration of the most likely outcomes.
Although tracheostomy tubes have a high rate of complication, the majority are managed successfully, with most dogs surviving until removal (Nicholson and Baines 2012). We do not know at this point whether Bella will need to be managed at home with a tracheostomy tube; it may be removed before she returns home.
Taking the above prognostic factors into account, we should recommend tracheostomy if the UAOS worsens.
The final decision, sadly, may be determined by financial considerations. If the owners cannot afford the cost of tracheotomy and aftercare, then euthanasia will be the only reasonable option if Bella doesn’t respond to medical treatment.
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