Is your treatment on target?

What would you think if you walked into an exam room and observed a veterinarian throwing darts around the room (Figure 1)? Wouldn't you look for the target? What if you did not see a target? Would you ask the person where the target is? What would you think if the person said, "The target is wherever the dart lands."? Would you have confidence in this person's cognitive process? On the other hand, what would you think if the person identified a clearly defined target with several darts in the bull's-eye (Figure 2)?

Figure 1: Aimless dart throwing results in frustration. (IIlustrations by Lori Koehler, CVT, Minnesota Urolith Center)

The goals of treatment we provide to our patients are analogous to a dart game. For ethical and moral reasons, we should have a clearly defined therapeutic target. We should be able to describe exactly what treatment (if any) we are providing and the rationale for it. Why? Because goal-setting fosters precision, and precision fosters high-quality patient care. Recall the medical axiom, "No patient should be worse for having seen the doctor." Always keep in mind that there are some patients we cannot help but there are none we cannot harm.

Figure 2: Targeted dart throwing equals a good outcome.

What are the possible goals of therapy?

Picture your treatment goals as concentric circles on a target (Figure 3), and then take aim where it is most appropriate.

Specific treatment, the bull's-eye of the target, is given to eliminate, destroy or modify the primary cause or causes of a disease process. Examples include antibiotic therapy for bacterial infections, antidotes to counteract toxins, replacement hormone therapy and surgical correction of anatomic anomalies.

Figure 3: The goals of treatment.

Supportive treatment consists of therapy that modifies or eliminates abnormalities that occur secondary to one or more primary diseases. Treatment designed to correct abnormalities in fluid, electrolyte, acid-base, endocrine and nutrient balance caused by primary renal failure is an example. Successful specific therapy is often dependent on successful supportive therapy.

Symptomatic treatment consists of therapy given to eliminate or suppress clinical signs. Examples include using antiemetics to control vomiting and glucocorticoids to control pruritus.

Palliative treatment consists of therapy chosen to suppress the clinical signs of patients with diseases for which the underlying cause cannot be cured and that are likely to be progressive.

Inappropriate therapy consists of therapy that is not needed by the patient or therapy for which the risks associated with it outweigh the probable benefits.

The choice of therapy should encompass knowledge of the patient's history of adverse drug events (e.g., rash, tremors, anorexia, vomiting, diarrhea). To minimize adverse drug reactions, it is usually best to avoid unnecessary combinations of drugs.

Keeping your eye on the target

Once the goal of therapy is defined, the feasibility of such therapy must be assessed. In many situations, the final choice will represent a balance among the optimum therapy for the problem or problems, the availability of the optimum therapy, the type of therapy clients can or are willing to afford and the ability and desire of the clients to comply with therapeutic recommendations. There should be no misunderstanding about what is wanted and what is given. In some circumstances, we must also determine clients' willingness to pursue treatment for their pets and advise them based on their pets' needs and their level of motivation. Once this information is obtained, with appropriate input from the client, follow-up plans should be devised to best monitor the patient's progress.

Dr. Osborne, a diplomate of the American College of Veterinary Internal Medicine, is professor of medicine in the Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Minnesota.