Last month’s patient had perhaps a 90% chance of survival. Too bad I didn’t find out until after I’d euthanized her.
Just in time for Halloween, I’ve finally decided this scary story is worth telling. Equal parts cautionary tale and vehicle for personal catharsis, this patient’s case began with a near-tragedy: the owner’s.
After a personal medical emergency left her days in the hospital, this dog’s owner returned home to a very sick animal. A female shepherd mix, she’d been acting “funny” before her owner had suffered the healthcare crisis that led to her hospitalization. But it was nothing compared to her present appearance, one her well-meaning temporary caretakers had thought it best not to describe while her owner was recovering.
Cautionary tale point #1: Never leave your pet with people who do not share your views on animal caretaking.
When five year-old Casey finally presented at the hospital (as a new patient), her pulses were weak, her abdomen was painful, her temperature was low, she was desperately dehydrated and she could barely stand. She had been vomiting foamy liquids, unable to keep down even the barest amounts of water.
A previous close call with a chew toy meant that Casey’s owner was convinced of a gastrointestinal obstruction. Indeed, she was suffering all the telltale sigs of a peritonitis (intra-abdominal infection/inflammation), which could easily have been the result of a foreign body lodged somewhere in her bowels, possibly even perforating her intestines.
Cautionary tale point #2: Do not make assumptions.
Inspection of the X-rays showed severe gas accumulation in what appeared to be loops of bowel, but I had other suspicions.
Casey had never been spayed. The close call with the chew toy had left her owner with a bad feeling about her previous veterinarian and by now it had been years since Casey had received any medical attention. What’s more, her owner was not even aware of the small mammary gland tumor and was ignorant of her last heat cycle’s timing.
Cautionary tale point #3: A spay is basic unless you have a specific reason to choose not to have it undertaken. If you don’t spay, you must be aware of the possibility of certain common conditions and be on the preemptive lookout for their signs.
By now, most of you astute pet people will have the same bad feeling I did then: This is probably a pyometra (an infected uterus), which can look just like gas-filled bowel loops on an x-ray and is typically a terminal condition if it’s not treated. Eventually (just as with a bowel obstruction) peritonitis will ensue and basic treatment, once easily achievable via surgery, will now include critical care expenses and their risks.
At this point, I explained my suspicions and the need for 1) referral to a surgeon/criticalist team or 2) if she hadn’t the funds, an ultrasound and/or exploratory laparotomy (abdominal surgery) on site. Further, I cautioned that either problem––whether a bowel obstruction or the more likely pyometra––meant days of critical care ahead and the possibility of death, though far more so if this was the result of bowel obstruction should loops of bowel require resection and fecal material have seeded the abdomen.
The owner, convinced the uterus could not be the problem, deliberated briefly before electing euthanasia: “I would spend the money if I knew she could be saved but I won’t if there’s a high chance she’ll die.
Given her presentation, I couldn’t give her more than a 50-50, though the pyometra likelihood would mean a far better chance at survival. Hence my dilemma: How do I cast this case in a better light so I could change the owner’s mind? Is it even my role to present anything other than the facts?
Knowing, as I did, that my own pets would never lack for aggressive treatment in this case, I felt like shaking this owner out of her apparent stupor by telling her that any reasonable pet owner wouldn’t hesitate at a chance at life if they had the funds. But, as I eventually concluded (and maybe you’ll agree)...that would mean overstepping my bounds.
Instead, I euthanized her and was granted the right to explore her on my own afterwards...“for the improvement of medical knowledge that could be applied to future patients.”
And, of course, I found an uncomplicated pyometra––uncomplicated, that is, but for the extreme accumulation of gas in the grossly distorted uterus. Lacking any apparent peritonitis or any other obvious stumbling block, this dog would have almost certainly lived. But for the standard risk of anesthesia and post-pyo renal failure, that is. That's when the Monday morning quarterback in me identified the failure and chalked it up to chance...until now.
Cautionary tail point #4: Veterinarians should stick to the facts, but it’s OK to offer diverging opinions...even when the owner clearly doesn’t want to hear them.
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The sad reality is that prognostication is the least scientific and reliable element of our assessment. In the best case, we have solid statistics to say what the outcome will be for a group of animals with a given problem. But, of course, that says little about what will happen with an individual patient. And most of the time, we only have a vague, and unreliable gut feeling about how the patient looks to offer the owner.
The longer I practice, the more cautious I am about offering anything that sounds like a precise, reliable prediction, Of course, the client is paying for my opinion, so I will give it, but I always emphasize the fact that I've seen patients I was certain would die go on to recover, and I've had seemingly straightforward cases crash unexpectedly. Ultimately, the decision is not a medical one but one based on personal values and circumstances, so it has to be the client's decision, even if it isn't what we as the doctor would choose.
SkeptVet October 28th, 2009 11:52:07 AM
I had the opposite problem, my bernese mountain dog exhibited all the signs of cancer. She spent a week in the hospital under going ever test they had (this is a well known vet school in MA.) X-rays, lung lavage, you name it. I kept asking if it was cancer, they had no answer. I know without definitive proof, you don't want to speculate but jeepers creepers. Everyone I spoke to said it sure sounds like cancer. Especially in a breed like the bernese mountain dog, you've seen it a hundred times. I worked for a vet for years and I would see the test results and in the back of my mind think 'cancer'. I brought her home and a week later she died peacefully in the back yard. I had a necropsy done and it was Malignant histiocytosis all through her heart and lungs. I personally want my vet's opinion. I want your gut feeling, don't hold back. You are way more experienced in this then I am. I left that well known vet school with the feeling that they knew what was wrong with her but wanted to get as much money as they could.
Betsy October 28th, 2009 12:52:31 PM
I agree with Betsy- I want your hunch, your gut feeling, and I don't need it sugarcoated. I also want to know if it were your pet, what you would do.
agadoresmama October 28th, 2009 01:00:54 PM
I know it won't make you feel any better, but given the dog's previous lack of veterinary attention, there's no reason to assume that the owner would have brought her in any sooner, or that she would have responded differently had you spoken out.
Owners like the readers of this blog would want your unvarnished opinion. In fact, when in the mid 1990s my cat was enduring treatment after treatment for hepatic lipidosis without improvement, I felt as if we were subjecting him to therapeutic torture. I grabbed the vets and just asked them: please tell me, if this was your cat, would you continue treating? Is there really hope? They said yes. I trusted them and they were right. If you really believe your vet is trying to subject your pet to needless suffering, then you need to pick up your pet and walk out.
Susan October 28th, 2009 01:12:37 PM
If the emergency vet had given me even one opinion about what might have been wrong with my dog, I could have made a better choice about whether to try treatment. While it is possible that the vet was so incompetent that they couldn't have come up with the correct diagnosis before it was too late, I wonder if they had a few ideas about what it could have been and how it could have been treated, but were just going along with the horrible 'rules' of the clinic to get payment first. It's not that we wouldn't have paid, it's just that without even one idea of what it could have been - and how serious it was - we didn't know what was going on. There was no sense of urgency, just a "We'll need to do some tests before we have any idea." I figured that since there was no "it could be a, b, or maybe c" that it wasn't that serious, because how could the vet not tell me what they thought - to impress upon me that it was serious, and do so with an example or two?
Dr. K., do you think your client was so fixated on her own idea that you couldn't get her to think of pyometra at all? With an older unspayed female, where 'female problems' would be not too uncommon versus a single case of inappropriate ingestion several years previously as the two choices, I'd think most owners would be less inflexible in their thinking...
KateH October 28th, 2009 01:47:19 PM
I pay my veterinarian (and human docs) for a professional, medical opinion; not moral judgements. Yes, "any reasonable pet owner wouldn't hesitate at a chance at life if they had the funds" goes much too far. Especially so, when, although you retrospectively think 90%, but gave 50/50 at the time. I'm not sure what you really mean by that statement but if it infers one should spend next month's mortgage money or money set aside for a grandchild's college fund to save a pet today because one "has the funds" today and that one would be unreasonable for not doing so, then that's a pretty extreme personal and moral judgment. And, in this case, you're assessing that judgement against someone fresh from her own medical emergency. Would she have had the support system to care for this dog post ICU given her own health problems? Is she supposed to risk her own health as well? Where does long term quality of life come into play or is it just life v. death of the moment? Save now, don't worry if there will be food money for the entire family next month?
Look at the facts, give multiple opinions but please don't take extreme views of owners unless you at least have all the pertinent facts of their situation (and even then I'm not sure it's appropriate if it influences your professional conduct); otherwise, it is their information and knowledge you don't have that must play into their decision making for their pet.
PJB October 28th, 2009 02:06:37 PM
There is so much literature nowadays about intuition. What really makes an expert an expert are their hunches - they tend to guess right even if they don't know why.
So, I would want my vet to share the hunch. I'd want her to tell me it was a just hunch, and differentiate it from what she knew for sure, but I would want to know.
I wouldn't want opinions about whether it was worth paying for unless I specifically asked, however. Whether any given chance is worth the cost in money and discomfort is a personal decision.
So, '50-50, but I feel good about it' or '75% success normally, but she's old and I bet we'll find complications' but not '80% chance, and you should take those odds'
puppynerd October 28th, 2009 02:39:37 PM
Yes, PJB: i still believe that would've been a moral judgment that goes too far. In this case, it also would have been going too far to say, "I would do X if this were my dog." I believe we must wait for that question to be asked before we can ethically offer it. Even then, some believe it goes too far to personalize your opinion in this manner.
To others: My professional opinion is what I'm being paid for, not my personal opinion. Problem is, it's really difficult to draw that line since there are so many ways a purely clinical opinion can be misconstrued as highly negative to some ears, while to personalize it, thereby warming it up, can come off as a too-rosy spin on treatment.
In this case, my point was that I should have drawn the client out more. She was so definite, though. Still, there's nothing as definite as euthanasia and taking one more stab at getting to the heart of the owner's personal resistance may have been fruitful in this regard.
But then, that's the Monday morning revisionist in me talking.
Dr. Patty Khuly October 28th, 2009 03:23:06 PM
I got the impression from your description of the owner that she isn't a person who would go all out to save her pet. Most of us who read and respond to your blog would do many things to save our pets. The flip side of the coin is that there are plenty of people out there who don't hold the same values. There is a spectrum of priorities when it comes to owning a pet.
There are plenty of people who love their pets, get them their shots, feed them and play with them but just don't understand shelling out hundreds (or thousands) of dollars for emergency care. Those are the people who balk at paying significant amounts of money for exploratory surgeries. If this owner has that outlook, there probably wasn't much you could have done. That doesn't mean she isn't greiving the loss of her dog; it just means that you probably couldn't have changed her mind.
Posey October 28th, 2009 03:37:09 PM
This is just a bad situation compounded by bad timing. Perhaps if the owner just hadn't experienced her own medical emergency the outcome would have been better. My own medical experiences have definitely influenced (negatively) my views on healthcare; I trust my vet more so than any other medical professional.
That said, I would want your opinion - personal and medical. Most times I've found the personal opinion of my vet completely in sync with my own. If I don't trust her why should I have her treat my pets?
Carol October 28th, 2009 03:42:36 PM
I frequently find myself in the position of telling clients that certain actions or strategies are NOT worth the expense. However, in this case, the client brought up the issue of whether the odds were worth the expense.
My husband and I are frequently at odds over whether a particular case or tactic is likely to be successful. He is an eternal optimist. I am a pessimist. We are each being absolutely honest when we share our assessments with clients.
I can't imagine that predicting the odds of survival when you don't even have a diagnosis is a precise science. Your professional opinion, based on experience, was that there was sufficient likelihood that it was a treatable pyometra that surgery was indicated. Had you given her better odds than 50-50 and turned out to be wrong, just what would the consequences be? Legally, I imagine, none. You went ahead and did a necropsy without charge. Had you opened the dog up to find a necrotic bowel or a massive tumor, I'm guessing you would have sought the owner's permission to go ahead and euthanize rather than go forward with futile surgery.
If she had then made a fuss that your prediction was inaccurate, the clinic might have -- what -- eaten some or all of the bill rather than spend its time and resources fighting with her? Is that a result you could live with? Would it be preferable to what actually happened? Because we deal with the rough equivalent pretty often. Clients forget the warnings we gave and suddenly develop a case of the "you didn't tell me x could happen," or "I didn't know you were going to charge me for y" or "I had no idea it was going to cost this much" (usually after calling us thirty times a day and demanding that we do legal gymnastics worthy of the Olympics). Though we might be 100% in the right, it is often easier and to our advantage to do something to make them feel better -- cut a few charges off the bill, give them a small discount if they agree to pay the bill off by a certain date, just something to let them know they've been heard.
So, the upshot of all this rambling is, if despite what the books say, you think the odds are better, I would give the better odds. Just be prepared to articulate a reason if later pressed to the wall.
Susan October 28th, 2009 03:52:32 PM
"I felt as if we were subjecting him to therapeutic torture. I grabbed the vets and just asked them: please tell me, if this was your cat, would you continue treating?"
The "therapeutic torture" part is what bothers me most. I've seen all too many humans fall into the gears of intensive care units and then subjected to all sorts of futile horribleness because relatives didn't want to feel guilty. I don't want our cats caught in that. There are worse things than being dead.
A direct "If this was your..." question is a good one, especially if followed up with "Why?". You can tell quite a bit if you watch carefully as you ask it. I've asked it with respect to my father, my wife, and my kids, and gotten good answers on which to base decisions.
(And this blog, its topics, and the comments are more addictive than nicotine, coffee, and pot! Sheesh!)
Will October 28th, 2009 03:56:25 PM
So much is unanswered that I think it is hard to offer an opinion. Hindsight is always 20/20 right?
You did the best to explain your findings & possibilities; it was then up to the owner to decide.
I was just talking to a friend the other day on what I felt was necessary to make an informed decision: diagnosis, prognosis, and odds of successful outcome with recommended treatment(s).A detailed hi-lo estimate , no open end, and no hidden costs. And this is to include national & in-house odds & experience of physician for particular treatment.
I think 50/50 would not sit well with me. I think, but don't know for absolute sure, depending on the situation, that those odds would be too poor to risk a major treatment plan.
I'm thinking back to Dottie's options for her glaucoma at 14+ years of age. Three reasonable options were offered:surgery for lens removal, eye removal, or gentamicin injection; of course there was option of nothing (attempt pain control?) and euthanasia.
Based on age & health (already had probable mammary cancer), we opted for the injection with promising but not perfect odds or lack of possible complications.
It was so wonderful to be offered choices, thoroughly explained, nary judgmental or pressured. This eye doc goes into my forever hero book.
Barbara A./NH October 28th, 2009 04:04:53 PM
There's no point in beating yourself up over this - it's not like vets have crystal balls. The owner made her choice, and the pet was given a humane death. Relief of suffering may not be the best alternative, but it doesn't mean it's not a good one.
anna October 28th, 2009 04:50:31 PM
Like many posters, I want it all--your best medical opinion, any hunches you have (hunches are often based on observations that your brain has made unconciously, but that you can't explain scientifically), and what you would do if it were your pet. This last was crucial to me when I was trying to decide when to euthanize my kidney failure cat recently. However, it sounds as if the owner you were dealing with had already made up her mind, and there may not have been much you could have said to change it.
Sarah October 28th, 2009 05:02:40 PM
One of the reasons I entrust the health and well being of my pets to the vet that I do is because he always has honestly answered the, "If this was your pet what you do?" question and he always tells me why. Most of the time I follow his advice. Sometimes I have not. Once, I was told that, "It was time. We have done all we can do and we need to let Hoop go." I needed to be told that. I never felt he over-stepped. It's why I pay him. It's why I go to him. It's why I recommend him to anyone looking for a vet and often to those who aren't.
Jill October 28th, 2009 09:07:33 PM
The elkhound of my teenage years had pyo at age 8 or 9, had a spay, and lived on five more years. In her case there was no debate about the diagnosis. She had a fever, was drinking gallons of water, and was unspayed. I don't recollect that any x-rays were done, just the surgery, right away. We were told that the risk was because of her age and how good or bad her liver and kidneys would be at clearing the anesthesia. The vet said afterwards she had enough infection in her to kill her and that the uterus was huge. The surgery was in December, in a cold climate. She came home with a shaved underside and a very long incision. She learned to do a kind of flip when she went outdoors on lead so that the bare belliy never touched the snow, but she could roll in it on her back. Of course the fur all grew back and nothing showed.
Miss Kitty's Mom October 28th, 2009 09:09:21 PM
I lost Curly to Urinary Calculi. He was was bonded to me as my "buddy" within the herd. The problem with UC is that by the time you know what it is they are already past doing anything about it.
The first indication looked as though he was constipated, while he is pushing is probably when the bladder ruptures, but he won't die for several days if you let it take its course. When it ruptures, there is a short period of relief and it looks like he is recovering, but there is just more space to fill before his breathing is hampered.
I had to do the deed of putting him out of his misery myself. I validated that UC was the cause in my own autopsy. Taking the needed action without a firm diagnosis, in a timely fashion so as not to prolong suffering needlessly is a tough call.
If a vet were available, simply having reassurance that I was doing the right thing would have been helpful. I took the action earlier rather than later. Had I taken it later, I still would have appreciated hearing that I was doing the right thing to wait.
The right thing is often a subjective call. Therefore the decision taken, with the knowledge available at the time, should be affirmed.
Bob Jones November 3rd, 2009 02:09:25 PM
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