Participants
Beth Venit, VMD, MPH, DACVPM, American Association of Veterinary State Boards, Washington, District of Columbia
Kate Boatright, VMD, Write the Boat, Grove City, Pennsylvania
Sarah L. Babcock, DVM, JD, Animal & Veterinary Legal Services, Boca Grande, Florida
Moderator
Katie Berlin, DVM, Instinct Science
Key Takeaways
Communicate diagnostics, treatment options, and risks to clients in a way that can be easily understood. These conversations should be well documented in the medical record.
Provide a range of treatment options and work with clients to develop the best approach according to their budget and the patient’s quality of life.
Clients should be asked to provide written consent (eg, signing discharge papers) when a treatment approach differs from the highest standard of care.
Dr. Katie Berlin: I became interested in spectrum of care in my first year of practice, when I was presented with a 1-year-old male cat with urinary obstruction. He was a gorgeous orange boy and had his whole life ahead of him, but he was blocked, and his owner couldn’t afford hospitalization. We were required by our practice guidelines to euthanize a patient when the owner couldn’t afford treatment. I didn't know there was a gray area, and I was too new to fight the policy, so I euthanized that cat. I will forever remember the moment I injected the euthanasia solution and he urinated on the table. It was heartbreaking, and I decided I'm never doing that again unless a client says, this is what I want because we will not take care of him.
However, there could have been a potential for liability if I had taken a spectrum-of-care approach and pursued outpatient treatment. For example, if I decided to treat the cat as an outpatient following a long conversation with the client who didn’t understand everything I said, and the cat did not recover well or passed away, the client could bring a board complaint against me because they felt I mishandled the case. What would be the best way to help prevent a situation like that from happening?
Dr. Kate Boatright: First and foremost, communicating clearly with the client and documenting the discussion is key. The medical record should say something along the lines of, these 3 options were discussed, and the risks of each option were assessed with the client. An increased risk for reobstruction with the outpatient route was noted.
The client could also sign the discharge statement, saying they understand additional care may be needed. If it isn’t written down, it didn’t happen.
Dr. Berlin: How can you best communicate so that the client feels comfortable with your recommendation?
Dr. Boatright: Be honest and empathetic and explain things in a way the client can understand. I wouldn’t use words like azotemia and hyperkalemia with a client. I would say, Bladder obstruction can harm the kidneys, so blood work is needed to look at kidney function.
Dr. Berlin: How do you have these conversations meaningfully and without rushing the client?
Dr. Boatright: That is a common concern when presenting all the options. I'm a huge proponent of including the veterinary team in client conversations. Sometimes I'll say, I need to step out and check on another patient, and I want to give you some time to process what we've discussed. I will send a technician in to check with you in a couple of minutes and then I'll be back to follow up. Having another person come in and reiterate recommendations in a different way can be helpful.
Templates and predetermined estimates can also be useful, but sometimes you have to be okay with running a little behind. I want to give the client in front of me the attention they deserve. These conversations take time, but once you get used to having them, they usually take less time than you would think.
Dr. Beth Venit: Establishing the client's goals can make conversations more efficient. Start by saying, I understand you are looking for alternative options to hospitalization. You should know that I believe hospitalization would provide the best chance for a positive outcome, but let's discuss your goals first.
Dr. Sarah Babcock: You should also let the client know when their lack of resources isn't necessarily going to change your plan.
Dr. Boatright: I agree; funds do not always dictate the outcome. For a critically ill patient, the condition may not have a good outcome, even with unlimited funds.
Dr. Babcock: We are seeing more civil suits in which clinicians thought they were doing the best thing for the client by keeping costs down, when really the best thing would have been to present all available options. For example, a client claimed they were assured a mass wouldn't be a problem and diagnostics weren't offered, but the mass became a problem, and the client said, If only I had known, we would have tried to treat it.
A range of options—from doing nothing to doing everything—should be provided and documented in the medical record, then work to determine the best plan. Best practices are still being supported but along a spectrum.