What is the spectrum of care?

A new column for NEWStat by Kate Boatright, VMD, will regularly discuss topics related to the role of the spectrum of care in improving outcomes in clinical practice.

By Kate Boatright, VMD

Last week, Mr. Smith came to my clinic with his 12-year-old female spayed Shih Tzu, Misty. She presented for a progressive cough and lethargy. On further discussion, I learned that Misty’s appetite had been a bit off and she had lost weight. As we talked, I watched Misty nestled in her father’s arms, breathing with a slight increased effort. On physical examination, I auscultated a grade IV/VI systolic murmur and fine crackles on the left side of her chest. I shared my concern with Mr. Smith that Misty’s clinical signs might be due to heart failure and recommended we start with radiographs to further investigate. 

Mr. Smith hugged Misty a little tighter and the concern in his face grew. He shared that he had a previous dog with heart failure who had been under the care of the local cardiologist for years. But he was now retired and living on a fixed income and caring for his wife who had several health issues of her own. Finances were tighter than they once were, and he was worried about his ability to care for both his wife and his dog. He didn’t know what to do for Misty because he couldn’t care for her like he had his previous dog. 

Beyond the financial barriers to care 

Cases like this are not uncommon in veterinary medicine. Many clients care deeply about their pets but are unable to provide the recommended veterinary care, if any. The Access to Veterinary Care Coalition’s 2018 report found that 28% of pet owners had experienced a barrier to care in the preceding two years. The most common reason was financial. Other reasons included not knowing where to seek care, not having transportation, fear of judgment, and language barriers.  

When more than 1 in 4 pet owners is unable to obtain veterinary care for their pet, our profession needs to do better. Practicing a spectrum of care offers a way to provide care for more pet families by getting creative with our diagnostic and treatment plans. The spectrum of care is the idea that veterinary care exists along a continuum instead of requiring us to always exceed a set baseline or follow a prescribed “gold standard.” At one end of the continuum is the most extensive, more expensive, and often most invasive diagnostic and treatment option. At the other end is the less expensive, least extensive and invasive option. In some cases, this may be symptomatic treatment, palliative care, or economic euthanasia. Between the two ends of the spectrum, a large range of options exist. Within this range, we will find the best fit for each individual patient and client. The best choice will meet the patient’s medical and quality-of-life needs within the client’s limitations and goals while maintaining the veterinarian’s moral, ethical, and legal obligations to the pet and their family. 

In Misty’s case, we discussed that referral to a cardiologist is not required for every dog with heart disease. Even though that option was what the Smith family had previously pursued, there were other options. When practicing a spectrum of care, it is essential that we recognize that a client who chooses a more conservative option does not love their pet any less than the one who chooses the gold standard. The choice a client makes is not a reflection of the strength of their bond with a pet. 

Exploring Mr. Smith’s options 

Mr. Smith approved radiographs, which did confirm heart failure. We discussed options for assessing kidney function and electrolytes before starting medications and decided to do a smaller blood panel to focus on the most important information instead of running a full senior panel. If Mr. Smith hadn’t been able to afford any diagnostics, another option would have been to do a trial of furosemide based on the clinical suspicion.  

While the limitations we work within are often financial, clients may have other reasons to seek alternative options for their pet’s care. Even if Mr. Smith hadn’t had financial limitations, he still had concerns about his ability to care for Misty related to administering medications and potentially needing to travel to a specialist while balancing his wife’s care. We discussed his concerns around medicating Misty and selected liquid formulations to make them easier to administer based on her temperament.  

Ultimately, the spectrum of care offers veterinarians a way to work with clients and treat pets who may not have received care if we abided by traditional recommendations. While this may seem intuitive and natural for experienced veterinarians, this is not a concept many students have been exposed to in veterinary school—and even seasoned veterinary teams may unintentionally create a judgmental atmosphere around what has traditionally been considered “substandard” care. As a profession, we must make spectrum of care the standard way to practice so that we can help the greatest number of pets and pet families.  

 

 

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