In the dilemma discussed in the March issue of In Practice, David Williams described a scenario where it's late on a Friday evening when a long-standing client arrives at your door with one of her numerous cats – Maximillian, an eight-year-old male domestic short-haired moggie with a urinary obstruction. The practice has recently been taken over by a corporate company, and you know that there is now a standard operating procedure for such cases – a blood workup to check for renal function, a radiograph to localise the obstruction and a urine sample to evaluate what crystals are present. Following this, catheter placement under general anaesthesia should be performed to flush out the sediment and stone. The trouble is that the client doesn't have the money for such workup and treatment (IP, March 2019, vol 41, pp 94-95). What do you do?
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I absolutely agree with Williams on this dilemma. This is a very treatable scenario with a good prognosis, and euthanasia should not be on the radar. I have even placed a urethral catheter in a conscious cat using massage with no bloods, x-rays or urinalysis.
I think the bigger issue is corporate practices instituting practice protocols or standard operating procedures (SOPs) for clinical procedures and trying to kid us all that this is ‘gold standard’, when actually money making is at the heart of it.
In our current climate where veterinary ‘burnout’ and ‘compassion fatigue’ are a problem, I feel these type of SOPs are instrumental in exacerbating mental health issues. Fear of not following them and facing repercussions from those above, or following them and potentially having to euthanase an animal because their owner can't afford the ‘gold standard’ treatment is not what any vet wants to be involved in.
Each case should be dealt with individually, and it is for the case clinician to discuss with the client the pros and cons of doing bloods/urinalysis/x-rays/general anaesthesia for this procedure. What’s important is saving the animal’s life in an affordable way for the animal’s owners. Anything else undermines our credibility as a profession.
No wonder vets are leaving veterinary practice in droves.
In the scenario of being presented with a blocked male cat late on a Friday evening on a tight budget, Williams voiced his concern that student vets are often only taught the gold standard without being made aware of options that may be less ideal, but still appropriate from a welfare point of view. Further to Williams‘s concerns, I would add that the concept of evidence-based medicine (EBM) and the gold standard are often confused. Williams provided us with an excellent example of how EBM can be used 'bedside', and how EBM is not necessarily the same thing as the gold standard. In 1996, Sackett and colleagues wrote a review paper specifically to explain that EBM does not require a 'slavish adherence' to the gold standard (Sackett and others 1996). They stressed that EBM requires the selection of diagnostic and treatment options that are most appropriate to the individual patient’s circumstances, based on the most relevant and up-to-date evidence.
For the cat in this scenario, the gold standard was not affordable. When looking for an alternative option (and far from condemning it), Dr Google and EBM are firm friends. A few minutes on Google Scholar provided an alternative, evidenced treatment with known success parameters. The financial decision on whether to allow a less expensive treatment plan to be carried out remains an obvious choice between negligible turnover generated by immediate euthanasia, or some turnover generated by a cheaper plan and a live patient that will continue to generate turnover during its lifetime.
To my mind, the clinical, ethical and financial considerations in this scenario all aligned to allow the cat to be treated with 'plan B'.
As to why it always has to be a Friday night no-one will ever know!
Everyday Ethics Poll
Last month’s poll asked:
You work in a corporate practice with a standard operating procedure for diagnosis and management of feline urinary obstruction. A client cannot afford this treatment, but you are aware of a less optimal but cheaper management option. What do you do?
5% of respondents said they would recommend euthanasia of the cat, as the client can't afford to pay for the standard practice of your employers.
95% of respondents said they would advise the client of the standard practice and the cheaper but possibly less effective option, so that they can decide their preferred course of action.
Vote for this month’s online poll at:
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