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When your duty of care extends beyond the patient to the client
  1. Emma Huntley

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Emma Huntley is a fourth-year veterinary student studying at the University of Surrey. She has a special interest in small animal surgery and hopes to pursue a career in veterinary cardiology.

The dilemma

An elderly client comes into the clinic with her seven-year-old diabetic terrier, Charlie. Charlie was on a stable dose of twice daily insulin which, up until recently, his owner has been able to manage. However, within the past year the client has started to develop dementia and now struggles to remember the last time she administered Charlie’s insulin. You note high glucose readings in both blood and urine samples, as well as increased levels of ketone. Your client mentions that Charlie has been urinating in the house and he seems uncharacteristically thin and lethargic. From the consultation it is clear that Charlie isn’t receiving the care he needs and his medication isn’t being administered properly – subsequently Charlie’s condition is deteriorating. You are concerned that Charlie is at serious risk of medical complications if the owner cannot manage his treatment. The owner, who lives alone, often refers to Charlie as her only companion. What do you advise?

Issues to consider

The key stakeholders in this scenario are the dog, the client and the vet. With regards to the owner’s attachment to Charlie, there have been numerous studies conducted that detail the various psychological and physiological advantages of elderly people owning pets, with one of the main benefits being companionship. Loneliness among the elderly is a growing concern and researchers at the University of Rochester found that adults, who had reported feelings of loneliness, were at a significantly higher risk of mental and physical health conditions (Stanley and others 2014). With pet owners being 36 per cent less likely to report loneliness than those who do not own a pet, your client may be at risk if Charlie is removed from her care and, as a result, her own health might be compromised.

On the other hand, Charlie’s condition has worsened due to his owner’s incapability to provide the correct care. It is crucial that Charlie’s treatment is administered consistently and at certain times of the day to coincide with meal-times. The owner must, therefore, be capable of monitoring both blood and urine glucose, as well as maintaining a strict exercise regime and regular vet visits (Behrend and others 2018).

The RCVS Code of Professional Conduct stipulates that a vet must ‘make animal welfare [their] first consideration when attending to animals’ committed to their care (RCVS 2019). Although a vet must respect the circumstances of their clients, it is their duty first and foremost to react on the welfare needs of the animal. If the vet feels that the animal’s best interests are being compromised, appropriate action must be taken to avoid further compromising the animal’s condition.

Possible way forward

Beauchamp and Childress’ (2001) four principles of medical ethics are beneficence, non-maleficence, autonomy and justice. Although formulated for human medical ethics it can be applied to this particular scenario in the following ways:

  • Beneficence (benefiting the patient): it is the primary responsibility of any vet to ensure the wellbeing of animals committed to their care. In this instance, you could first discuss with the owner whether it is practical to keep Charlie at home. Finding someone who is able to assist with Charlie’s care might relieve some of the pressure on the owner. For example, a neighbour or dog sitter in the area who could cater for the twice daily visits could ensure Charlie receives the appropriate care for his condition. Furthermore, a sense of routine may prove beneficial to your client’s dementia. If you still have reservations about leaving Charlie with his owner, suggesting that she place Charlie in a shelter or home, that was able to better care for his needs, may be the only alternative. Some homes or shelters may allow your client to visit Charlie and, therefore, this could be a good compromise between acting in the best interest of the dog and ensuring the owner can still see her companion. If the owner is opposed to placing her dog in a shelter, euthanasia may be an option; however, since Charlie’s condition is manageable – given the correct treatment – euthanasia should only be considered as a last resort;

  • Non-maleficence (avoidance of harm): by not advising the owner to rehome Charlie he could be subjected to a continued life of inadequate care for his condition and that, as a result, causes him greater harm. Taking a passive approach by overlooking the situation will only lead to Charlie suffering. Given that the vet’s primary responsibility is to the patient, they must avoid any situation in which the patient’s health could be compromised;

  • Autonomy of the client: although we, as vets, can discuss the options available, we cannot force the owner to give up Charlie. Therefore, it is pertinent for the vet to have an empathetic yet honest discussion with the owner regarding her limitations for taking care of Charlie, as well as the consequences and risks of providing inadequate care for his condition. That being said, it is important to remain sensitive towards the owner’s circumstances and not to invoke any sense of blame. If the owner doesn’t understand the severity of the problem or won’t comply, it might be worth seeking a second opinion from another vet to reiterate what you have already advised;

  • Justice (fairness): if Charlie is rehomed somewhere that he will be better taken care of, his quality of life will inevitably improve and, as a result, he will receive long-term health benefits. Furthermore, if it were possible to secure a new home that allows your client to visit Charlie, she would continue to have some degree of contact while also interacting with other people in the process, without the responsibility of managing Charlie’s care.

Any thoughts?

We welcome views on this article. Please email your comments by 7 January, 2020 so we can consider them for inclusion in the next issue of In Practice. Please limit contributions to 200 words.

vet.inpractice{at}bmj.com

This section gives readers the opportunity to consider and contribute their approaches for dealing with ethical dilemmas 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 and readers are invited to suggest alternative approaches at vet.inpractice{at}bmj.com.

The section is coordinated by Steven McCulloch, senior lecturer in human animal studies at the Centre for Animal Welfare, University of Winchester. Articles aim to provide a framework that will help practising veterinarians find solutions when faced with similar dilemmas.

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