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.

The Need for Family Practice Skills

Pet owners openly define their pets, to themselves and others, as a member of their family. The pet as part of the family has evolved into a social consensus ethic (Rollin 2005).

Most veterinary colleges parallel the pediatrician's model for small animal practice, whereby the pet is considered a member of the family. Veterinarians enter practice with excellent textbook and disciplinary knowledge. But most don't know how to act and what to do in situations of complexity and high client need. Interacting with clients as they work with a VCRC can be complicated. Good communication skills are needed to keep everyone satisfied.

Veterinarians have the increased obligation to understand attachment and acquire good communication skills. Contemporary practitioners must keep apace and assume a multidimensional role as family practice veterinarians (Timmons 2005). Dr. Rick Timmons of UC Davis has proposed a number of proficiency skills for members of the Society for Family Practice Veterinarians.

If we could have perfect practices and remove the communication barriers between veterinarians and pet owners, there would be less distress. Often, clients experience profound insensitivity on the telephone or at the front desk, when speaking to hospital personnel. The receptionist might leave a client on terminal hold. Staff might fumble with finding charts or sending copies of the record and overbook the doctor with appointments. The brisk attitude of a receptionist or an officious office manager can extinguish a client's trust. Short appointment times limit conversation and leave caregivers deprived of valuable practical wisdom and advice that they so desperately need.

Ethics, Economics and Empathy Issues

Bernard E. Rollin, Ph.D., exposes and ponders some insightful questions in a paper titled, Oncology and Ethics (2004). "What are the animals' best interests? Given the nature of animal consciousness, it is above all else not-suffering, not prolonging life at all costs. The oncologist must be careful not to put the client's interest in prolonging life above terminating the animal's suffering. In addition, currently trendy talk in veterinary circles may seduce the veterinarian away from that ideal; to wit, the claim that veterinarians serve the human-animal bond. This, in my view, is wrong and dangerous, for it treats an abstraction as a reified (enforced) entity. Veterinarians serve the animal and must work through the client. They do not serve, in the end, 'the bond.'"

Rollin asks us to answer this as a fundamental question of veterinary ethics-. "To whom does the veterinarian owe primary allegiance; owner or animal?" (2004). Veterinary oncology services have expanded rapidly in the past 10 years. Has the demand for cancer care been raised higher than seasoned practitioners are prepared or willing to offer? The topic of this paper adds a contentious layer for discussing the issue of preventing over-treatment at the VCRC. Can the VCRC and the generalist team up and properly educate caregivers to make informed decisions for treating the various types and stages of cancer in their pets? Can we trust caregivers to know or want what is best for their aging pet? Should the family veterinarian bear the burden of animal advocate? When does the generalist intervene and prioritize quality of life vs. over-treatment at a VCRC?

Should the local veterinarian become the shoulder and the counselor for distraught pet caregivers who would do anything to save their aging pet from cancer? What can be done for pet owners who are caught in 'analysis paralysis' or religious or cultural factors and cannot make a decision? What about deeply bonded clients who want to continue treatment at the VCRC despite the local veterinarian's recommendation to stop?

Rollin believes that veterinarians owe primary allegiance to the animal. In contrast, I believe that veterinarians in private practices all around the world do, in fact, serve the human-animal bond. I believe that veterinarians owe their primary allegiance to honor the human-animal bond. It is The Bond that confers a tremendous societal and personal value on a particular pet patient.

The Bond does not diminish with a pet's age or medical history. Some clients say that the bond with their pet grew stronger as they nurtured their pet during an illness and especially during treatment for cancer. Honoring the human-animal bond inherently includes reverence and respect for quality of life as a personal ethic and as an appreciated and highly valued social aesthetic.

Fear of losing The Bond motivates people to seek care for their pets with cancer at the VCRC. The Bond is the force that created the demand that elevated our medicine to today's high-tech level. Our personal and professional ethics should always serve the patient's needs while honoring the human-animal bond. We must help the family balance the pet's needs for quality of life when evaluating the recommendations from the VCRC for recurrence, relapse or metastasis. Use the Quality of Life Scale (Table 1) to evaluate the patient during every phase of treatment and during end of life care.

Table 1

An Inherent Conflict of Interest

Rollin and various esteemed colleagues asked haunting questions in a series of lively panel discussions at major professional meetings across the nation. Rollin insists that we ask ourselves these revealing questions about conflict of interest.

Has the high-tech mega VCRC ascended into a new realm of economics and ethics considerations? Does the staff in super practices that have the mega facilities and rotating schedules make decisions that favor the pet or the pet owner? Or do they make decisions that favor their practice's financial interests and their own personal percentage of gross income as per payroll arrangements? Are we redrawing the line of pet advocacy in the emergency room and at the VCRC? When does the local veterinarian need to exert their professional opinion and become the advocate for their patients to avoid unnecessary suffering, prolongation of life and expense at the VCRC?

We must juggle ethical, economic and empathy issues in daily practice. Conflict of interest is inherent in running a business and practicing medicine. This conflict of interest is unavoidable at the VCRC and enters in the decision-making process for cancer patients needing treatment.

Every private practice has an inherent conflict of interest; it just might be magnified at the VCRC. We are caught up in a financial web of a "pay for services rendered" profession. Most hospitals display a sign saying: "Payments are due when services are rendered." Essentially, we tell our clients, "Pay as you go."

Concerns about school loans, living expenses, personal ethics, evidence based medicine, scientific references and the limitations of the in house pharmacy. All these considerations influence decision making and the choices we make. Will we become a money-driven profession?

Conflict of interest emerges between the healer and the wage earner, entrepreneur and/or researcher must also be the decider. These deep personal conflicts of interest and biases exist at your clinic and at the VCRC. Your biases, personal baggage and pressures impact every decision you make and have the potential of steering your decision-making process onto the wrong course.

As the attending doctor, you will have to wade through these issues concerning personal ethics, practice philosophy, multilevel economics, empathy and modern contemporary medicine. If the atmosphere in your clinic or at the VCRC is rushed, the result will be a lot of dissatisfaction on both sides of the exam table.

There is another conflict of interest issue that places a layer of professional disconnect between associates and their clients. Some associates feel resentment against their private or corporate employers. They might feel that the boss only cares about "the bottom line." Some veterinarians have trouble integrating their ideal personal ethics into the established practice philosophy. Practice owners, associates and VCRC staff, who feel overbooked and overworked; may reprioritize their time in ways that diminish client relations and patient care.

How do these conflicts of interest affect patient care when associates and seasoned veterinarians encounter an emotionally and ethically charged consultation? It takes time to help relieve client confusion and emotions in the area of decision making. These deliberations may occupy the single largest portion of a practitioner's time (Rollin 2004).

Schedule enough time to carefully discuss all of the available options. For patients with recurrence, give your original level of care and concern. For patients with disseminated or advanced stage cancer, it is wise to offer a wide range of options and referral to the VCRC for specialty consultation. Consider the needs, the physiologic condition and the personality of the pet along with the wishes and financial ability of the owner. If the family veterinarian fails to consider all of these issues, it diminishes the special doctor-client relationship that has the potential to work wonders for the pet's well being.

Are We Going Too Far?

Many generalists, including veterinarians from other countries and specialists from other fields, feel that American veterinary oncologists in particular may go too far in the management of cancer (Rollin 2005). They may have entrenched feelings that it is wrong or inappropriate to treat cancer in animals, particularly if the pet is geriatric or if the cancer is advanced or inherently disseminated as with splenic hemangiosarcoma. Others feel that older pets are too fragile or do not have the life expectancy to justify cancer treatment as worthwhile. These doctors may also eschew radical surgical oncology procedures such as amputation, nosectomy or mandibulectomy for healthy cancer patients. They may feel that these aggressive surgical procedures are disfiguring, or unfair to the pet, especially if the cancer patient is older.

There are some veterinarians who openly express negativity about all VCRC recommendations for chemotherapy and/or radiation therapy for their cancer patients. A high percentage of these same doctors are also less likely to support quality of life care at home. They might not offer SQ fluids, feeding tubes, immunonutrition, mobility carts or Pawspice care for terminal cancer patients.

The Patriarchal Practitioner

Practitioners need to refrain from insisting, pushing, converting or controlling their clients with only two choices, either aggressive care or euthanasia. This patriarchal approach is dictatorial and sends the message, "I am practicing 'My way or the highway' medicine." Many pet owners flee from this style of practice.

Patriarchal veterinarians unwittingly impose their biases on their clientele. They might claim that their approach to medicine is down to earth and practical. They tell the pet owner what to think and what to do rather than helping clients make their own decisions. They often use expressions such as, "You should let nature take its course." Or, "You need to put him out of his misery."

More progressive doctors have termed this approach as "minimalist medicine." Minimalist doctors might be surprised or offended when their client consults the Internet, another hospital or a VCRC for a second opinion, for palliative care or Pawspice care services. Increasingly, pet owners want to keep their terminal pets comfortable at home. They want sophisticated supportive quality of life care until the end of life. They often want their pet to die painlessly and peacefully ("naturally") at home or they want to have home euthanasia.

When the doctor is indifferent, overwhelmed, rushed, patriarchal, or has a negative personal bias against treating cancer, a very narrow scope of options is provided for treatment of cancer. People are more aware that they must be their pet's advocates. Many pet owners automatically seek second and third opinions and consult the Internet. Many pet owners investigate alternative medicine therapies for more appealing options.

Use a Framework for Decision Making

A useful framework for ethical decision making was presented by McDonald in a 2003 SVME newsletter. http://www.ethics.ubc.ca/people/mcdonald/conflict.htm. In summary: Always ensure that all parties, including you as the attending doctor, the VCRC, the hospital staff and the family, must have consensus and comfort with the final decision. If there is reluctance or disagreement, work to provide the family with more options. Always present palliation, quality of life and Pawspice care with a positive professional attitude. There is no perfect choice, but the course taken should feel reasonably acceptable by those involved under the circumstances (McDonald 2003).

Resources

Khanna, C., Advances in Our Understanding of Cancer: Explanations for Your Clients, AVMA Convention Notes,2004.

McDonald, M., A Framework for Ethical Decision Making, SVME Newsletter, Vol.9, No.3, October 2003.

McEntee, M., Radiation Therapy: What You and Your Clients Need to Know and What Your Expectations Should Be, AVMA Convention Notes, 2004.

Milani, M., Clear and Present Diagnosis, Vet. Forum, June 2001,p42-43.

Moore, A., Nutrigenomics and the Food Bowl, Small Animal, Veterinary Practice News, Vol. 17, No. 8, August 2005, p17.

Morrison, W.B., Clinical Evaluation of Cancer Patients, Ch 7,and Principles of Treating Chemotherapy Complications, Ch. 25, Cancer in Dogs and Cats, 2nd Ed., Morrison, Teton New Media, 2003.

Modiano, J.F., Helfand, S.C., et al., Personal Communication, Innovations in the Diagnosis of Canine Hemangiosarcoma, VCS NL, Vol. 29, No. 1, 2005, p4-5.

Myers, B. Anticipatory Mourning and the Human Animal Bond, Research Press, 2000.

Mutsaers, J.J.,Mohammed, S.I., DeNicola, D.B., Bennett, P.F., Knapp, D.W., Metronomic Chemotherapy in Veterinary Oncology: A Pilot Study, VCS Proceedings, 2001, p41.

Ogilvie & Moore, Managing the Veterinary Cancer Patient: A Practice Manual, Veterinary Learning Systems, Trenton, New Jersey, 1995.

Repetto, L., Venturino, A., Gianni, W., Prognostic Evaluation of the Older Cancer Patient, Ch 26, Balducci, L., Lyman, G.H., Ershler, W.B., Extermann, M., eds. , Comprehensive Geriatric Oncology, 2nd Ed. Taylor & Franks, 2004,

Rollin, B.E., Animal Happiness, A Philosophical View, Mental Health and well Being in Animals, ed. McMillan, F.D., 2005, p235-242.

Rollin, B.E., Personal Communication regarding the Asclepiad Authority and Ethics at the 137th AVMA Convention, Salt Lake City, 2000.

Rollin, B.E., Ethics, Midwest and AVMA Convention Notes, 2003.

Rollin, B.E., Oncology and Ethics, AVMA Proceedings 2004.

Rollin, B.E., Ethics in Veterinary Practice, SVME Newsletter, Vol. 10, No. 2, May 2004.

Rollin, B.E., Ethics and the Human Animal Bond, NAVC Proceedings, January 20, 2004.

Timmons, R., Family Practice, American Association of Human Animal Bond Veterinarians Newsletter. Vol. 12, Winter 2005.

Villalobos, A.E. "Pawspice" an End of Life Care Program for Terminal Patients, Ch. 16b, Withrow, McEwen & Vail, Small Animal Clinical Oncology, 4th Ed., Saunders, 2007.

Villalobos, A., with Kaplan, L., Canine and Feline Geriatric Oncology: Honoring the Human-Animal Bond, Blackwell Publishing, 2007.

General References

Ganz, P.A., Quality of Life Considerations in the Older Cancer Patient, Ch 24, eds., Balducci, L., Lyman, G.H., Ershler, W.B., Extermann, M., Comprehensive Geriatric Oncology, 2nd Ed. Taylor & Franks, 2004.

Kennedy, B., J., Aging and Cancer, Ch. 1, Balducci, L., Lyman,G.H., Ershler, W.B., Extermann, M., eds., Comprehensive Geriatric Oncology, 2nd Ed. Taylor & Franks, 2004

Withrow & McEwen, Small Animal Clinical Oncology, 3rd Ed.and 4th Ed. with Vail, Saunders, 2001,2007.

Web site References

[www.uptodate.com] see oncology viewers page or subscribe for current information on specialty and oncology topics in human medicine.

[http://www.ethics.ubc.ca/people/mcdonald/conflict.htm].

McDonald, M., Ethics and Conflict of Interest.

[www.purinavet.com], user name: purinavet, password: nutrition, for the 1-9 body condition system chart for dogs and cats.