What prevents us from practicing a spectrum of care?
Editor’s note: This is a recurring column on the role of the spectrum of care in improving outcomes in clinical practice. Catch up on Kate’s columns, “What is the spectrum of care?” and “Why do we need to talk about spectrum of care?”.
“Sophie,” a 9-year-old intact female mixed breed dog presented to the clinic for her first visit with a 2-week history of PU/PD, intermittent vomiting, and decreasing appetite. On physical examination, Sophie was quiet, alert, and responsive with normal temperature, pulse, and respiration, slightly tacky mucus membranes, and a tense abdomen that the owner thought looked distended. I lifted the tail to find profuse purulent vaginal discharge, confirming the diagnosis of pyometra that I’d already suspected. It was 6:00 pm on a Thursday afternoon, and we were scheduled to close at 7:00 pm.
I prepared to discuss the diagnosis, recommendation for surgery, and pre-operative diagnostics with the owner. Two primary obstacles that we faced were the finances of the diagnostics and emergency surgery that were needed and the time until surgery could be performed.
In an ideal world, Sophie would be referred to an emergency center for surgery, but this isn’t financially feasible for many of my clients. However, it also isn’t reasonable to expect our clinic team to stay several hours after the hospital’s normal closing time to perform an emergency surgery. This brings up the question: Is it okay to wait for surgery?
Barrier 1: Fear of poor outcomes and liability
At some point, most veterinarians have probably heard, “Never let the sun set on a pyo.” Certainly, pyometras are an urgent surgical case. The first time I was in a situation where a client was unable to go for referral and we were unable to perform surgery the same day, I was very uncomfortable with the thought of waiting overnight for surgery. What if the uterus ruptured overnight? What if the pet died—would it be because we delayed surgery by 12 to 24 hours?
In the current world, it is a common, and very reasonable, concern of veterinarians that a poor case outcome could lead to consequences ranging from a negative online review to cyberbullying, a board complaint, or a lawsuit. These things happen, even in cases where we follow the gold-standard approach and do everything “right.” The question is: Do we open ourselves up to increased liability when we offer a spectrum of care?
I’m not a lawyer, but I would argue that if we appropriately educate clients on the condition and range of options, obtain informed consent, and document this clearly in the record, we are doing our clients and patients a better service by offering some treatment rather than none. What options we offer will vary depending on patient stability at presentation and the overall prognosis for the condition.
In this case, we can start by educating the owner on the condition, recommended diagnostics, and need for urgent surgery. We should offer the gold-standard of an emergency referral, but know that if the client cannot pursue it, there are other options. We could start medical management and perform surgery the following day or give the client the opportunity to find another, lower-cost option for surgery, such as at a high-quality, high-volume spay and neuter clinic (HQHVSN). Humane euthanasia is also an option, especially if the pet has comorbidities affecting their overall quality of life or that make her a high-risk surgical candidate or if the pet is deteriorating while waiting for surgery.
If we have discussed the patient’s pain, informed the client of the risks—uterine rupture, sepsis, and death—and that these risks will likely increase the longer surgery is delayed, and have thoroughly documented all client communication, including the options given and discussion of risks, then we have done our best for the client and patient.
Ultimately, whether the client pursues gold-standard care or another option along the spectrum, the best way to reduce the risk of board complaints is through clear communication and prioritizing patient comfort and quality of life. The best way to protect ourselves in the event of a board complaint is with thorough documentation in a clear, legible medical record.
Barrier 2: Fear of judgment from colleagues
Sometimes, when we step out of our comfort zone and offer alternatives to the accepted gold standard, we fear the judgment of our colleagues. While our profession is full of empathetic individuals, I have seen many instances where we are unkind to each other. It is easy to look at a case in retrospect and critique how a colleague managed it. But we were not in the room with the owner, we did not hear the conversation, and we did not see the patient at the time those decisions were made.
While we cannot change what others think of our management of a case, we can change how we view and discuss the cases of our own colleagues. Learning to step back and ask broader questions about the context is essential to build trust with each other. It is okay to ask a colleague why they made a particular decision, and it is okay to disagree with how they managed a case. We can have a civil, open conversation about it to improve future outcomes rather thanberating them to their face or badmouthing them to colleagues and clients. The less we engage in these types of behaviors and the more open conversations we have, the more comfortable our profession can become in offering a range of options.
Barrier 3: Lack of knowledge and/or personal comfort
Finally, our knowledge base and personal comfort levels can also create a barrier to offering a spectrum of care. There is limited—but thankfully, growing—evidence in veterinary medicine for how to manage cases in general, especially when it comes to alternative options to the gold standard. In a profession that values the practice of evidence-based medicine, this can increase discomfort.
Groups like the ASPCA are working to change this. They recently published a series of articles on outcomes in canine and feline pyometra, including cases where treatment was delayed for several days while the owner sought an affordable clinic for surgery. The bottom line was that patients generally did well, even if surgery was delayed. Having studies such as these can help to increase available evidence and improve personal comfort with pursuing options along a spectrum of care. Personal comfort will also change with time as we become more experienced veterinarians and learn from the anecdotes and experiences of our colleagues, who may have pursued many of these alternative options in the past.
Sophie: Case outcome
In the case of “Sophie,” the owner was unable to afford emergency referral. We confirmed the presence of a fluid-filled uterus with a brief ultrasound and ran bloodwork. Because she was stable with an open pyometra, we discussed risks and treated overnight on an outpatient basis with subcutaneous fluids, antinausea medication, pain medication, and antibiotic therapy. She returned the next morning for intravenous fluids and surgery, which was uneventful. She was discharged that evening and has done well since surgery, now over a year ago.
Kate Boatright, VMD, is a small animal veterinarian, speaker, and author in western Pennsylvania. She graduated from the University of Pennsylvania in 2013 and has worked in rural small animal general practice and emergency clinics ever since. She is passionate about inciting positive change in the profession through mentorship and servant leadership in organized veterinary medicine. She writes a monthly column for NEWStat on the role of the spectrum of care in improving outcomes in clinical practice.
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