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Overcoming potential barriers to investigating and treating myxomatous mitral valve disease
  1. Zoe Belshaw

Abstract

Diagnosing myxomatous mitral valve disease (MMVD) can be relatively straightforward. However, persuading owners to investigate and treat MMVD, and then maintain adherence to a therapeutic regimen can be significantly more challenging. While heart murmurs are most likely to be detected during the annual health check or booster consultation, recent evidence suggests this might not be an ideal time to discuss MMVD. This article reviews some of the potential barriers to owners following practitioners’ recommendations, and suggests some solutions.

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Zoe Belshaw, Centre for Evidence-Based Veterinary Medicine, School of Veterinary Medicine and Science, University of Nottingham, Nottinghamshire LE12 5RD, UK e-mail: z.belshaw.97@cantab.net

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Zoe Belshaw graduated from the University of Cambridge in 2003. She is a European and RCVS specialist in small animal internal medicine, and has worked in general practice, charity and referral clinics. Her PhD and ongoing research at the Centre for Evidence-based Veterinary Medicine, University of Nottingham investigates how vets and pet owners make decisions. She also coordinates the ‘What your client is thinking’ series in Vet Record.

DIAGNOSIS of any chronic, potentially progressive condition can be a cause of great concern to owners. Some describe feelings of guilt: ‘Is this my fault? Did I do something wrong?’. Others describe a sense of helplessness: ‘I just didn’t know what to do when my vet told me …’ Detection of a heart murmur can come as a big shock to an animal’s owner when it is made at the preclinical stage, before there are any obvious signs of illness. In these circumstances, the routine annual health check or booster consultation unexpectedly becomes something quite different.

Communication with the owner is pivotal to what follows. Whether the recommendation is watchful waiting, investigation or treatment, the owner is now aware that the dog has something wrong with its heart that probably cannot be fixed. For some owners, the relationship with their dog may be irrevocably changed. While many owners will opt for investigation and treatment, others decline. This can be incredibly frustrating for vets, and can be associated with a sense of failure as an advocate for that dog’s welfare.

Recent research describing owner perspectives on managing ill pets has highlighted reasons that owners do not, or cannot, follow recommendations. The rest of this article builds on these data using common scenarios to explore why owners might not wish to investigate or treat a cardiac condition, and suggests alternative approaches that vets can use.

Scenario 1

Owner not engaged in discussion

Mrs Jones, a first-time dog owner, presents her six-year-old female cavalier King Charles spaniel, Poppy, for a routine annual health check and booster. Mrs Jones reports no concerns. During the clinical examination, you detect a loud mitral murmur that is not described in Poppy’s clinical records. You explain to Mrs Jones what you have found and make recommendations for further investigation. Mrs Jones does not seem to engage with your advice and says that she will have to think about it. Why might this have happened and what could have been done differently?

Mismatched expectations

Recent evidence (Belshaw and others 2018a) suggests that owners use previous experience to form expectations of what will happen during the annual health check/booster consultation. Some with little previous pet ownership experience may expect discussion to always focus on preventive healthcare. In addition, different vets include different content in these consultations. If the focus in all previous health checks had been on disease prevention, Mrs Jones might have been unaware that other topics could be discussed.

Communication tip: First time pet owners may have little idea about how veterinary practices work. Ensure your practice website or leaflets, and reception staff, provide clear information about the function and content of annual health check/booster consultations to ensure owners’ expectations match your own. Summarise briefly what you are going to do at the beginning of a health check consultation for a client who is new to you. Read owners’ body language and listen to the client’s response to gauge how your words are being received and taylor them accordingly.

Too little time

The average adult dog or cat health check/ booster consultation in the UK is allocated 10 to 15 minutes, but these consultations might be under considerable time pressure (Robinson and others 2014, 2016, Belshaw and others 2018b). The multitude of topics to cover can mean that a more paternalistic consultation style is necessary where information is delivered without eliciting the owner’s perspectives or concerns. Mrs Jones might have had questions but perhaps she sensed you were running behind and had a busy waiting room or she was already late to collect her children.

Communication tip: Invite the owner to book a separate consultation specifically to discuss your findings in detail rather than trying to deliver a huge amount of information in a short space of time at the end of a health check/ booster consultation. The murmur might have been there for months so may not need immediate action and taking more time to explain and discuss options can improve the likelihood of a successful outcome. Reassure the owner that there is no need to worry, that this is a common problem but that there are several options for what to do next and you would like to have time to go through them in a proper discussion. Give them some reading material or direct them to a website, and ask them to generate a list of questions to bring to the following consultation. You can also suggest they bring a family member to this second consultation if that would be useful for them. By explaining what the consultation will include, owners are likely to be more inclined to rebook, and to not argue with being charged a second consultation fee. If you feel you cannot charge for the consultation, it’s still worth rebooking: if the owner agrees to investigate and treat as a result, the profit will far outweigh any loss.

Unaware of the problem

Heart murmurs are something that even the most vigilant owner cannot easily spot. If Mrs Jones did not know that Poppy was at risk of developing myxomatous mitral valve disease (MMVD), your diagnosis will have come as a total surprise (Fig 1). Lack of knowledge is a significant factor in decision making by owners of ill dogs (Christiansen and others 2016). Some owners can go into sheer panic at the thought their dog might die. Read the owner’s body language to see if the information has shocked or panicked them, and reassure appropriately.

Fig 1:

Owners may be unprepared for their dog being diagnosed with a heart murmur if they are unaware of certain breeds being at risk of mitral valve disease and have not noticed any signs themselves.

Picture: Victor Fitzpatrick

Communication tip: This consultation might have gone much better, and the information been better received, had Mrs Jones known Poppy’s breed was at risk of MMVD. To raise awareness among owners, consider developing a series of social media posts or newsletter articles that are clearly marked as relevant for owners of at-risk breeds providing information on MMVD, its cause, diagnosis and management. Consider running client evenings for owners of susceptible breeds, and perhaps invite some owners of affected dogs to answer questions from the audience. These questions will help develop further social media posts. By proactively educating pet owners it will come as less of a surprise to them should a heart murmur be detected in their pet.

Not their usual vet

Continuity of care isn’t always prioritised for annual health check/booster consultations, so you might be seeing a client for the first time. Some owners will have built a strong relationship with one of your colleagues. Mrs Jones might have preferred to talk to another vet who she knows and trusts.

Communication tip: This can be a tricky one to navigate without undermining your own authority, but if the owner seems disengaged and your records suggest that they often see a colleague, offer to book an appointment with them to discuss the findings and next steps.

Didn’t understand the explanation

It is easy for us to forget how much we have been taught, so we sometimes expect owners to understand relatively complex anatomical and physiological terms. In reality, many will have thought little about science since their schooldays. Mrs Jones might have had no idea what you were talking about.

Communication tip: Ask owners if they have any experience of heart problems in people or animals. This will help you to gauge their medical literacy and previous experiences. If not, start with the basics, such as asking if they have ever heard of a heart valve and build from there, regularly checking that they are still following. If you have a whiteboard or heart model in your room, use it (Fig 2).

Fig 2:

Whiteboards in consulting rooms can be incredibly useful. Use them both to illustrate your explanation and to summarise the plan or options, then encourage owners to take a photograph with their phone so they remember what was said.

Picture: Pinfold Vets

Fear of anaesthesia or sedation during investigation

People can be particularly risk aversive when making decisions on behalf of others (Wroe and others 2005), and this might well extend to their pets (Belshaw and others 2016). Owners are often concerned about the risk of sedation or anaesthesia, particularly in a dog that they now know has a heart problem. Mrs Jones might be thinking about how she would feel if Poppy died under sedation or anaesthesia if you have proposed this as part of your investigations.

Communication tip: If you are recommending sedation or anaesthesia as part of the investigation, proactively ask owners if they have any concerns about this so you can reassure them or seek alternatives.

Costs

The PDSA’s PAW report (PDSA 2017) identifies that owners grossly underestimate the lifetime cost of dog ownership. Poppy’s MMVD is likely to be an unanticipated cost at a time of widespread austerity in the UK. As Poppy had been previously well, Mrs Jones might be worried about the cost of the investigations being suggested.

Communication tip: Discuss costs honestly and openly, describing the benefit to the dog’s treatment that the planned investigations might allow you to make. Decisions about what corners you can cut to save costs can be ethically challenging. Ensure you record fully in your clinical notes anything that was offered and declined.

Not the key decision maker

The person who presents the dog to you for examination could be one of multiple decision makers for that pet. Perhaps Mrs Jones needed to talk to other family members about the decision to investigate Poppy’s murmur further.

Communication tip: Often the person in the consultation room will need to remember what you have said to tell someone else. Summarising a few key points in writing, giving them a leaflet, or referring them to a website can help them with this.

Having a bad day

Broken sleep, worry about other matters and hidden disabilities are just some reasons that make it hard for owners to concentrate on the information they are given. Sometimes it is just not the right time to have a difficult discussion. One of these might have applied on that day to Mrs Jones.

Communication tip: Ask the owner whether this is a good time for them to discuss the heart murmur, and offer to book them in for another consultation if not. They may then disclose some information that enables you to better understand why they were not engaged in what you were trying to say. Be sensitive, and accept that sometimes a dog ends up being low down on a long list of priorities. If that’s the case, ensure the owner knows your door is open for when things get better, and that it won’t be too late to start investigations then.

Scenario 2

Owner says yes to medication but never collects it

You have investigated Colin Skelly, an eight-year-old chihuahua for MMVD. You have diagnosed him with stage B2 of the disease. Based on the results of the EPIC trial, he meets the criteria for treatment with pimobendan despite being asymptomatic. Mr Skelly was happy to pay for the investigation, but now seems concerned about starting treatment.

Based on reports describing the decisions owners made about accepting treatment for their dogs (Adams and others 2005, Belshaw and others 2016, 2018a, Christiansen and others 2016, Locock 2017, Perry 2017, Belshaw and others 2018), here are some thoughts Mr Skelly could be having.

  • Is it really necessary? You have said Colin’s heart is working fine.

  • My last dog with valve problems didn’t have treatment like this.

  • I’m not a fan of drugs. There are always side effects. How can I be sure it’s not doing more harm than good?

  • Are there any alternatives to drugs that I can use instead?

  • How am I going to know if it’s making a difference?

  • How much is that going to cost? You’ve said he could live for years with the condition!

  • I work shifts. I don’t know if I can give tablets to him at the same time every day.

  • Colin’s a fussy little monkey. How am I going to get the medication inside him?

  • How often will I need to come back and what will it involve?

  • What happens if I decide not to treat?

These questions fall into four broad groups: necessity and efficacy; safety; practicality; and treatment alternatives. This is a useful way to think about the range of information that you should aim to provide for any owner when you are suggesting that their pet is started on long-term medication. As with giving information about a clinical condition, try to make sure: that there is enough time for the discussion; that you are using terminology appropriate for that owner; that you regularly check they understand; that you give them the opportunity to ask questions; and, ideally, that you summarise the key information for them in writing. If you spend time now ensuring the owner knows exactly what they are meant to be doing and why, there is evidence (Grave and Tanem 1999) that there is a greater chance that they will persist with adhering to the recommended treatment.

Treatment necessity and efficacy

The articles in this supplement discuss the evidence base for treating MMVD and provide the key information on treatment necessity and efficacy. People who own one dog at a time might have had previous experience of treating a dog with MMVD, and might consider themselves knowledgeable without being aware that more research has been done. Reassure them that their previous dog was not mistreated and explain why you are recommending something different.

Again, be sensitive when discussing the costs of treatment, and try to provide data for roughly how much per week/month each treatment will cost. Be honest about what we do and don’t know about the management and prognosis of this condition and the necessity of treatment, particularly at the preclinical stage of disease. If you are asked questions to which you don’t know the answer, most owners will be very happy for you to give them this information by phone or e-mail at a later date. Ensure owners know what they should be doing at home, when they need to come back, and what will happen when they do.

It is imperative that owners of dogs with stage B2 disease treated before they develop clinical signs understand that they will not see any signs of improvement from this treatment, and that they know treatment will not completely prevent their dog’s heart disease from progressing. This is an unusual treatment indication in small animal veterinary medicine, where more typically medications are given with the intention to prevent, or cure, disease. Ensure that this advice is clearly given and that it is recorded in the clinical notes.

Get owners into the habit of counting their dog’s resting breathing rate, and consider asking them to routinely take video clips of their dog while out on a walk so both you and they can spot any subtle signs of exercise intolerance. Owners of dogs with cardiac disease are fearful of not recognising that their dog is suffering (Oyama and others 2008) so they are likely to be receptive to having both things to look out for and a method of home monitoring.

Treatment safety

Owners’ concerns about the risks of treatment seem to be underestimated by vets, and they might not be willing to introduce the subject themselves (Belshaw and others 2016, 2018a). It is important to openly discuss adverse events, particularly as owners often think they will be much worse than they are, and are likely to search for this information online if it is not provided. Try to proactively provide information about:

  • The relative risks and benefits of treatment, particularly the most common side effects and their likelihood (the product datasheets will contain some of this and the Veterinary Medicines Directorate can provide updated surveillance data if needed), as well as what would happen if the dog was not treated;

  • How the owner will recognise any side effects;

  • Whether experiencing side effects will mean that they cannot continue the treatment;

  • What they should do if they occur. For example, should they stop the medications or not. Ensure that they know to bring the dog in as an emergency if certain things occur. Write this advice in the clinical notes in a place clearly visible to the reception team who would be the people most likely to field any worried phone calls.

Treatment practicality

Vets treating their own pets may develop rapid sympathy with struggling owners. Adams and others (2005) identified that asking owners whether a dosage schedule fitted in with their work/domestic situation was a powerful predictor of compliance. Ask owners to describe specific concerns; for example, if an animal has fussy eating habits or whether they have unpredictable work patterns. Sometimes it helps to go through a typical day with the owner to get them to think about practicalities, such as how they will remember to give the medications. If they are still concerned, encourage them to try for a day, then call you to discuss how they are getting on so that you can help them work through any unanticipated challenges. This should make the prospect of long-term medication seem much less daunting. Practice nurses very often have a whole range of great tips and tricks that can be helpful. Ensure you discuss what the owner should do if a dose is missed, what to do if they need to adjust the timing of a medication within the day and what to do if the animal is sick after receiving the treatment. Again, provide this information in writing or encourage them to write it down.

Treatment alternatives

The internet is awash with stories of pets purportedly harmed by a whole range of treatments, and there are a plethora of plausible but scientifically dubious alternatives. Research suggests that owners are very interested in non-pharmaceutical alternatives as these are often sold as being side-effect free. Engage with owners about this, proactively warning them that they will read about miracle drugs but that many don’t work and some can be harmful. Encourage them to come to you with anything that they may have read about and are considering trying so you can look into it for them. Educating owners about how to fact-check websites for themselves using tools such as www.trustortrash.org would be a useful practice newsletter or social media post.

Scenario 3

Owner stops giving medication

Miss Carter picked up a month’s worth of medication for her dog Freddo, but that was three months ago and she’s not been back in. You know Freddo is alive and well because one of your nurses sees him in the park each morning.

When discussing whether an owner gives a medication, we often use the term ‘compliance’. This, strictly speaking, refers to the owner ‘doing as they are told’. Rather than achieving compliance, we should strive for adherence, which can be defined as an ‘active, voluntary and collaborative involvement in a mutually acceptable course of behaviour to produce a therapeutic result’ (Aronson 2007). Collaboration, rather than instruction, may be the key to successful treatment adoption in many instances. Below are some factors that may have influenced Miss Carter’s decisions.

Relationship with vet

Communication, relationship and time spent with the clinician during the initial consultations have been demonstrated to be important factors in adherence in both human and veterinary medicine (Grave and Tanem 1999, Adams and others 2005, Ho and others 2009, Butow and Sharpe 2013). Poor adherence could perhaps have been mitigated if sufficient time was allocated to discussion before the treatment had started, as described in the scenario above. It may be much more difficult to persuade owners to try again once they have stopped.

Owner factors

There are a range of reasons that owners might stop giving medications, both purposeful and not. The risk of this happening seems particularly high in situations where a disease is asymptomatic (Ho and others 2009). Even where owners deliberately withdraw treatment, this can be with the best intentions for the pet’s health (Belshaw and others 2016). Potential scenarios may include:

  • Lack of understanding of the need to give the medication long term, particularly if their previous experience has always been with a ‘course’ of treatment;

  • Medication regimen too complex or arduous for that owner to follow;

  • Owner expected to see evidence that the treatment was ‘working’, so stopped;

  • Owner finances meant they were unable to continue with ongoing medication;

  • Research online or discussion with other owners after the consultation that has led to the owner deciding that the risk of treatment was greater than the benefits. Peer pressure not to give treatments that certain owner communities, particularly online, perceive to be ‘dangerous’ is anecdotally quite significant.

Pet factors

Sometimes animals are more difficult to medicate than anticipated. Particularly for inexperienced owners, giving tablets can be quite challenging. In addition, some pets may develop a concurrent behavioural or physiological change that their owners, rightly or wrongly, attribute to the medication.

What can you do?

Owners may be concerned at your reaction if they tell you they cannot, or will not, continue treatment, even if their reasons are legitimate. As a result, they may opt to just not come back to the clinic. In the UK, owners have legal rights to determine what happens to their animal, and as long as you have provided accurate information, you should not feel morally responsible for the dog in this scenario not receiving treatment (Yeates 2017). Furthermore, in the case of pre-clinical disease, it is not yet possible to easily predict which animals will go into heart failure, so there may ultimately be no detriment to this individual from treatment being withdrawn.

If you do wish to intervene, check the clinical records to ensure that the owner has not contacted the practice, and perhaps ask reception staff if they have heard from the owner in case it was accidentally not recorded. You could then consider contacting them to find out how they are getting on. Reassure them that you just want to make sure that they don’t have any questions about the treatment that have come to mind since the consultation. Using phrases such as ‘Other owners have been concerned about/heard that/struggled with … Is this the same for you?’ can be useful to legitimise common concerns. Veterinary nurses may be perceived as less intimidating by owners so may be better placed to make the initial contact. As before, ensure if you telephone an owner that it is a good time to discuss their dog’s treatment – a fruitful discussion is unlikely to happen if they are at the supermarket checkout. Even if you don’t persuade that owner to continue treatment, they may provide you with useful insights into why they stopped which you can build into future communication strategies.

Summary

There is no such thing as a ‘typical’ owner. It is important to ensure that your communication style and consultation content is tailored to the person in front of you as much as possible, that you ascertain their knowledge and views, and actively listen to what they are saying. This inevitably takes time. While it is likely that many heart murmurs will be diagnosed during the annual health check/booster consultation, it is unlikely that you will have enough time for a thorough discussion about MMVD. Particularly for dogs with no clinical signs, it is not imperative to rush into diagnostics immediately. If possible, rebook to allow as much time as possible for discussing the situation with owners. Similarly, ensure that discussion of the results of any investigations are not rushed and that the necessity, safety, practicalities and alternatives to any treatment are covered in detail. Spending time here should help to minimise the risk of common adherence problems. Finally, vets must accept that for, a whole range of reasons, some owners cannot, or will not, follow our recommendations. It is rarely your fault and it is often not theirs.

References

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