Over-treatment at a veterinary cancer referral clinic (Proceedings)
"No one should have to chose (in the either/or model of medical care) between fighting their cancer or receiving palliative or hospice care—Care that offers comfort through prevention and relief of physical, psychological, social and spiritual distress. Patients nearing the end of life can, and should receive both at once (in the new simultaneous care model)."
Fred Meyers, M.D., UC Davis School of Medicine
Veterinarians will see more pets with cancer, since our pet populations are living longer. The majority of our top clients want to do what is best for their pets. They feel committed to care for their pets with loyalty at the end of life. The diagnosis of cancer, its treatment and its recurrences and relapses will become a more common clinical dilemma. Generalists will interact with surgeons, oncologists, radiation oncologists, internists and other specialists who support the cancer patient more frequently in the future. What can generalists do to prevent the over-treatment of their patients at a veterinary cancer referral clinic (VCRC)?There is a paucity of literature, training and experience to guide practitioners in the decision-making process that grants wisdom. Intervention against some types of cancer is straightforward. We can review relevant data from clinical trials. But there is not much information to deal with advanced, recurrent cancer, especially in older pets. Therefore, intervention against advanced stage and inherently disseminated cancers, especially in older pets, may cause consternation between the pet owner, the veterinarian and the VCRC.
Attitudes about age and old animals are changing. Caregivers are proud of their older dogs and cats and they want them to live as long as possible. The pet owning public wants more services and preventative medicine for their aging pets. Pet owners are more willing to deal with their pet's age-related medical conditions, such as arthritis, dental disease, renal disease, heart failure, endocrine disorders, neurologic problems, etc., including cancer. The family veterinarian is obligated to refer cancer patients for specialty consultations VCRC's. Clients will find their own way to the VCRC even if they are not given a referral. So what can be done to prevent over-treatment at a VCRC? How can the family practice veterinarian communicate concern without appearing selfish or over protective or backward?
Good communication skills are needed in this situation. It is important to point out the pet's coexisting problems. The presence of one or more concurrent illnesses influences overall survival. This should influence decision making when the pet is diagnosed with neoplasia. The coexisting problems may not be recognized at the VCRC yet they are competing for treatment. The attending doctor must balance the patient's multiple pathologies against the risk benefit ratio of the treatment recommended by the VCRC. When the expected outcome is comparable between two types of treatment, good clinical judgment would elect the least stressful treatment for the pet, especially for older pets.
There are few if any controlled clinical trials addressing advanced stage or recurrent cancer in geriatric pets. The family clinician must communicate with the VCRC and educate the pet owner. Joint decision making involving the pet owner as a partner is the most satisfactory. It is important to look for relevant data, and blend the potential outcome with common sense and patient specific, client oriented decision making. If we can improve the outcomes and/or quality of life for cancer patients, we may satisfy our client's wishes. Both the VCRC and the generalist must preserve the pet's quality of life. The VCRC and generalist should point out the great value of palliative care and Pawspice (pet hospice) end of life care. If all decision making at the VCRC were made in honor of the human-animal bond, the experience for the pet and the family may be very rewarding.
Emotions run wild when a pet is diagnosed with cancer or if there is metastasis, recurrence or relapse of a known cancer. Anxiety, frustration, anticipatory grief, guilt, depression, resignation as well as hope and determination are running wild in the owner's mind and heart. These concerns and the decision-making process are very difficult to deal with. The VCRC specialist may have limited time to spend with the client and much is left unsaid. The generalist can act as an intermediary and partner with the client for decision making. The generalist can offer further options especially end of life Pawspice care that focuses on quality of life in the event that definitive care is declined.
There is no perfect choice. This paper offers suggestions for decision making and weighing probabilities when the odds are contradictory.
The generalist must admit personal bias and remove it from the decision making process. Many pet owners have told me that they felt that their doctor or the VCRC was insensitive to their hope and grief. Some felt that the specialist or their generalist was fatalistic, impatient or rushed. Some doctors exert too much control or they offer only a few options for management of cancer. Clients often feel shocked at the cost of care or abandoned because they could not afford it. Some clients feel that their local veterinarian gave up on their pet. Some clients felt that both their local veterinarian and their VCRC were not responsive when they needed help for home nursing care for their terminal pet.