10 tips for talking to veterinary clients about anesthetic risk

An unbreakable pair. (Getty Images)No anesthesia is 100% without risk. This is something that we are taught as veterinary students on day one of clinical rotations. This mindset carries with us into general practice-we recognize the power of anesthesia. We know that there is a fine line between anesthetic life and anesthetic death. We also know that the potential for risk is not limited to general anesthesia. Sedation is, in and of itself, inherently risky.

Anesthetic risks can be minor and easily managed, such as mild hypothermia. This can be identified by an intraoperative esophageal thermometer and treated with a convective warming unit, such as a Bair Hugger.

However, anesthetic risks can also be severe and/or life-threatening. Consider the following risks, which are well-documented in the veterinary literature:

intraoperative hypotension1-3

cardiac dysrhythmias3

postoperative regurgitation or vomiting and aspiration pneumonia4,5

cerebellar dysfunction6

blindness or deafness in cats7-9

death10,11

These risks may keep our clients up at night or paralyze them into a state of inaction. They may not proceed with recommended care because they are afraid of the unknown.

If we're lucky, they verbalize this to the veterinary team. But more often than not, they stay silent and simply don't schedule Gemini's medically warranted procedure.

How can you open the door to a conversation that needs to take place between you and the client in order for effective care to be pursued?

Here are 10 tips to help you break through the silence and move toward a more complete understanding of your client's frame of mind.

1.Elicit your client's perspective: Tell me about your past experiences with anesthesia.

2. Assess your client's knowledge or desire for more information about the anesthetic event: What would you like to know about anesthesia that can help guide your decision-making?

3. Don't assume you know what's on your client's mind. Ask them: What, if any, concerns do you have about Gemini undergoing anesthesia?

4. Use reflective listening so that clients know that they have been heard. It sounds like…

5. Avoid euphemisms or figures of speech. If anesthetic death is a concern, then you need to be comfortable using the word, death. Avoiding this word does not eliminate the possibility of its occurrence–or the client's fear of it. 

6. Ask for permission to share your knowledge: May I share with you how we monitor anesthesia so that you know Gemini's safety is our No. 1 priority?

7. Be transparent: Yes, it's true that anesthesia is associated with certain risks. This is how we manage those risks …

8. Offer the opportunity for partnership:What can we do to help you to feel more comfortable about going forward with Gemini's procedure?

9. Let your guard down. If you want clients to feel comfortable sharing with you, then you need to leave defensiveness at the back door. Remember that clients are questioning you for the right reason: they are advocating for their loved ones.

10. Take your time. Barring emergency scenarios, anesthetic conversations are not a race to get the client to sign on the dotted line. Recognize the power of the pause-give the client time to process what has been shared and to respond.

Ready to practice? Head to the next page.

Let's see how these tips can apply to a real-world conversation about anesthetic risks. Consider a clinical scenario in which you have just examined a 7-year-old cat, Gemini, at her annual wellness visit.

You: Gemini is in good health overall, but her teeth could benefit from being professionally cleaned under general anesthesia.

Client: Her teeth aren't giving her any trouble. I'll think about it next year.

You: Would you be open to discussing how this procedure could benefit Gemini now, instead of next year?

Client: Sure.

[Insert a conversation about oral hygiene and its link to systemic health.]

Client: And you would have to put Gemini under anesthesia to clean her teeth?

You: Yes, Gemini would need to be placed under general anesthesia.

[Watch for nonverbal signs of client discomfort, such as shifting in her seat or avoiding eye contact.]

You: You seem hesitant to have Gemini anesthetized. May I ask what your past experiences with anesthesia have been?

Client: I've never had to put her under for anything. When I adopted her, she was already spayed.

You: What concerns you the most about anesthesia or the dental procedure itself?

Client: I've heard that anesthesia is risky. I don't want to lose her.

You: It sounds like you are concerned that she could die under anesthesia.

[Insert pause.]

Client: She's my whole world. I don't know what I would do if she didn't make it.

You: I can see how important she is to you. I understand that you are concerned. Your concerns are valid. No anesthesia is 100% safe. But there are measures that we can take to make sure that the procedure is as safe as is possible for Gemini.

[Insert pause.]

You: May I share with you what we do to improve the safety for Gemini so that she is well monitored before, during and after the procedure?

[Insert a conversation about your practice's standard of care and monitoring equipment and the advantages of preanesthetic bloodwork.]

Client: So if we do bloodwork today, then we will know if her organs can handle the procedure?

You: Yes, our ability to test her organs today can help us to create the safest drug protocol for Gemini. We can custom-select the drugs that will be best for her body to handle.

Client: OK.

You: What, if anything else, would you like to know about the process that can help you in your decision-making?

Client: If Gemini were your cat, would you feel comfortable putting her under?

You: Yes, I would, even though I know that it is scary. Anesthesia is not something to take lightly. It is a procedure. The risks are ____, ____ and ______.

[Insert pause.]

You: In my experience, the most common risk we experience is ___________________. May I share with you how we manage this risk?

Client: Yes.

[Insert discussion about how your veterinary team successfully manages the most common issue for your practice.]

You: It's important that you know what can happen during the procedure but also how we are trained to intervene so that we work together to keep Gemini's best interest at heart.

[Insert pause.]

You: What are your thoughts about proceeding with Gemini's dental cleaning?

Client: I feel more comfortable that she's in good hands. I still need some time to think it over.

You: I know it's a big decision. If it's OK with you, I will give you a call within the next few days to see if you have any other questions I can answer.

Client: That would be great.

You: Thank you for being open with me and sharing what's on your mind. I appreciate the opportunity to serve you and Gemini in the best way that I can.

[Result: A follow-up telephone call, as promised, reveals that there are no further questions or concerns. The client commits to proceeding with the dental cleaning under general anesthesia.]

Note that a positive outcome may be different for every patient. Although ideally every conversation will end with the client providing consent to proceed with anesthesia for a medically warranted procedure, that is not true to life. There are going to be circumstances when proceeding is not always possible for the client or the patient.

You need to reframe how you define a positive outcome for the patient.

A positive outcome may be, simply, that you opened the door to conversation. That is often the first and the trickiest step to navigate.

Remember that even if the client elects not to proceed this time, you have created a safe space for discussion so that next time the client has questions or concerns, she is more likely to voice them.

References

1. Iizuka T, Kamata M, Yanagawa M, et al. Incidence of intraoperative hypotension during isoflurane-fentanyl and propofol-fentanyl anaesthesia in dogs. Vet J 2013;198(1):289-291.

2. Mazzaferro E, Wagner, AE. Hypotension during anesthesia in dogs and cats: Recognition, causes, and treatment. Compend Contin Ed Pract Vet 2001;23(8):728-737.

3. Gaynor JS, Dunlop CI, Wagner AE, et al. Complications and mortality associated with anesthesia in dogs and cats. J Am Anim Hosp Assoc 1999;35(1):13-17.

4. Davies JA, Fransson BA, Davis AM, et al. Incidence of and risk factors for postoperative regurgitation and vomiting in dogs: 244 cases (2000-2012). J Am Vet Med Assoc 2015;246(3):327-335.

5. Ovbey DH, Wilson DV, Bednarski RM, et al. Prevalence and risk factors for canine post-anesthetic aspiration pneumonia (1999-2009): a multicenter study. Vet Anaesth Analg 2014;41(2):127-136.

6. Shamir M, Goelman G, Chai O. Postanesthetic cerebellar dysfunction in cats. J Vet Intern Med 2004;18(3):368-369.

7. Barton-Lamb AL, Martin-Flores M, Scrivani PV, et al. Evaluation of maxillary arterial blood flow in anesthetized cats with the mouth closed and open. Vet J 2013;196(3):325-331.

8. Jurk IR, Thibodeau MS, Whitney K, et al. Acute vision loss after general anesthesia in a cat. Vet Ophthalmol 2001;4(2):155-158.

9. Son WG, Jung BY, Kwon TE, Seo KM, Lee I. Acute temporary visual loss after general anesthesia in a cat. J Vet Clin 2009;26(5):480-482.

10. Clarke KW, Hall LW. A survey of anaesthesia in small animal practice: AVA/BSAVA report J Vet Anaesth Analg 1990;17:4-10.

11. Jones RS. Comparative mortality in anaesthesia. Br J Anaesth 2001;87(6):813-815.

Ryane E. Englar, DVM, DABVP (canine and feline practice), is an assistant professor and clinical education coordinator for Kansas State University College of Veterinary Medicine in Manhattan, Kansas. Her teaching responsibilities include designing and debuting a new Clinical Skills curriculum for veterinary students to improve their confidence and competence with professional and technical skills. Her research emphasizes veterinary client communication preferences. You can reach her at renglar@vet.k-state.edu.