Friday, February 18, 2011

A question of ethics and professional responsibility.

So, if you read my last post, then you have been introduced to the concept of caval syndrome - a massive overload of heartworms found in the right heart leading to right heart failure. As I outlined, there is only one way to treat it - extract the heartworms manually from the heart. This is done by isolating the jugular vein, cutting into it, and placing a long, long pair of forceps into the heart. The worms are grasped and removed via the hole. It is a bloody, messy procedure, and it has a 50/50 shot at working. Further, I have never done the procedure.

Here is my question for you, readers. If a patient comes through the door suffering caval syndrome, the owners are appraised of the risks, outcome, my inexperience with the procedure, and the prognosis, and they want me to TRY to remove the worms, should I attempt to do it?

My colleagues and I recently got into a heated debate about this. I have seen 3 caval syndromes in 18 months. Two of them have died within 30 minutes, the last was euthanized. None of them would have survived to go to a referral facility where the worms could be removed by specialists. It was me or nobody. If the owners had wanted me to try, I would have done it - as I see no other option for the pet, save rapid death or euthanasia. My colleagues say that I shouldn't be doing something like that without experience. I argue that I am the pet's only chance for survival, and it is my job to intervene if I can.

If we, as veterinarians, didn't do things outside our comfort level, no GDV would ever be fixed, no pericardium would ever be tapped, no foreign body would ever be removed. I still remember vividly every time I did all 3 of those things for the first time. It was nerve-wracking, but it was necessary. If I could refer these cases to a specialist, I would do so. However, as I said, all 3 lived less than 30 minutes from the moment they arrived on our doorstep.

So, what do you guys think? Intervene or push euthanasia?

21 comments:

Kerry said...

Intervene! You just need to get that first one out of the way. As you said, veterinarians need to do things out of their comfort level to get experience with a new procedure or technique. As long as the owner knows that you have never done the procedure and that there is a 50/50 chance of success, and they still want you to do it, then GO FOR IT!

Shannon said...

If it were my pet who needed a procedure the vet had never before performed. And if the alternative was a speedy and unavoidable death. And if you could assure me that my pet wouldn't be in undue stress or pain during the procedure, you'd definitely be getting my consent to at least try. If I said no, I think it would make me a 'bad' (for lack of a better word) pet owner.

Elizabeth said...

Intervene. If the patient is going to die without your intervention, you can't have a worse outcome.

HDsheena said...

Intervene!

The Snowboarding Vet Student said...

As long as you're straight with the owners about the risks, then definitely go for it. The animal would die anyway, right?

Anonymous said...

Intervene please!! I'm a human health care provider and a pet owner who went to hell and back trying to save a sick dog who confounded the experts. I asked the vets to do just that.... and it was unsuccessful. I still mourn this dog today, but it was his only chance and I (and my dog's wonderful vet) got a degree of comfort knowing we gave him every chance.

Megan said...

Intervene. If you can't perform the procedure without experience, then how on earth will you ever get experience? Like you said, you have to have a first time for everything- GDV, R&A, etc.

Karen Whiddon said...

I have to agree with the other posters here. Intervene. If you have given the owners the truth and they are well aware of the risks and still want you to try, then yes, by all means, try.

sarahMTSBB said...

Another vote for intervene... how many veterinarians are actually extremely experienced in such a thing anyway (and those that are weren't at some point, too). The procedure sounds terrifying though...shudder...and you can bet I won't forget to give my Charlie his hw prevention faithfully now that we live in NC!

Brittney said...

Go for it. As long as the animal is not suffering from the procedure (i.e it is under anesthesia with pain control)then I think it is okay to try even though you haven't done it before.

voguevet said...

Agree, agree, agree. I would certainly intervene and give the pet a fighting chance, but not without letting the owners know exactly what was going on and the risks involved. Ultimately, it is their choice, however.

Life in vet school said...

I would absolutely intervene -- if the alternative is euthanasia, then they're DEFINITELY going to die if you do nothing, whereas they have a CHANCE of surviving if you intervene.

Ideally, I think there would be a mechanism in place to discount the price for a "practice" procedure. Even though the client knows it's something you have very little experience with, I would probably prefer to do it at cost if it were something I was basically experimenting at and wasn't really proficient/experienced with.

Elizabeth said...

Intervene no question!

Nicki said...

If they have all the facts and want you to try then I see no reason not to. I'm sure practitioners in rural areas get to try a lot of things that only specialists do in bigger cities for many of the same reasons.

TheCuriousCorgi said...

Yeah, intervene. You weighed the risks of doing it against those of not, informed the owners and got consent. All bases covered, why not try?

Lisa said...

Intervene. I find it strange that your colleagues feel that anything less would acceptable, especially after fully advising the owners on the situation. It's you or nothing - go!

elizabeth said...

Intervene, so long as the owners are aware that you're inexperienced at the procedure. My guess is that even if owners know that this will be your first, they will almost always be happy to have the option.

Jennifer said...

I think it is a "business decision" in the end. If by doing some it would increase your chance of success dramatically, then I would offer the opportunity - at the cost of Euthanasia - as a learning opportunity for the vet. If practicing would not appreciably change the chance of survival (which it sounds like the case here) then I'm not sure it is worthwhile pursuing...because it wouldn't be worth the clinic's or the patient's money to do. ie; if there is a 99% chance the dog will die while you are "practicing", and still a 95% chance another dog will die after gaining experience then, it doesn't sound worth doing. But if experience drops it to 65% or better, then it seems worthwhile for the clinic to cover costs to get the practice in. One question - can you practice post death? Do the euthanisia and then practice?

BSDVM12 said...

I too am wondering if any of these dogs' owners would allow you to do a necropsy or "educational postmortem exam" after recent death or euthanasia, at least so you could go through the motions of the heartworm extraction even though certain aspects would obviously be significantly different on a live patient with blood flow? Otherwise, I feel it's appropriate to discuss the situation thoroughly with the owner, so that you feel they can give informed consent with the knowledge that you've never done this procedure before and it is sort of a last resort that may offer a small chance of survival in a patient that will otherwise die on its own or by euthanasia.

I also like the idea of exploring some way to minimize cost of this procedure to the owner, given that you're not skilled in the technique and this may be as much of a learning experience for you as a salvage procedure for the patient.

CEVC said...
This comment has been removed by the author.
The Homeless Parrot said...

Thanks for the all the thoughts, guys. I am surprised that no one argued against intervening, as my colleagues seemed adamant.

My difference of opinion springs from the belief that I don't KNOW with 100% certainty what will happen with any patient, therefore if an owner wants to go for it - fully appraised of the likely outcome/prognosis - then it is not my place to stop them.