As a professional, I can treat pain -- as a steward of the pet, you need to tell me when there is suffering. - Dr. T. Catanzaro

As Shakespeare said in the Merchant of Venice, "...the quality of mercy is not strained...", which parallels the medical treatment charter taught to the new residents at the New York City Animal Medical Center, "First, do no harm." Our job and the oath we swore on graduation as veterinarians, is to prevent pain and suffering, but often we forget that they are different.

Client Communications

We tell our clients that our function is to help their pets, to prevent pain and suffering. In the 1970s that meant vaccinations and treating the illnesses and accidents. We entered the 1980s and started to recommend extensive preventive medicine programs for the welfare of the companion animals. It is interesting to note that as competition increased and the economy got tighter, the selection of essential or "critical" preventive care elements expanded. What a significant coincidence!

Most practices have improved our practice client communication methods and are training our paraprofessional staff to follow all the best methods of client communications. Training aids like the AAHA We Care video series help practices train their paraprofessional staff, but we often lose sight of the initial premise of our profession. Patient advocacy is more than just offering the most care, or the best care. It includes offering the appropriate care.

Prevention and Suffering

The animal's pain is what we can treat. The osteosarcoma that is forcing the periosteum to expand causes acute pain to our patients. This is the pain we can treat with the drugs on our shelf, and we charge by the injection, tablet, or pill. This is a pain we can chemotherapeutically or surgically eliminate for the welfare of the patient.

Suffering is a mental condition that we cannot directly treat, such as perineal adenomas that destroy the anal sphincter, where the dog starts to leak and soil the house. The dog knows that this violates the cardinal rule of the pack leader (owners). You do not soil the pack den. This medical condition causes something akin to an anguish or suffering that we cannot directly treat in our patient.

The ability to use active euthanasia methods is a veterinary privilege that we often take for granted. There have been multiple studies in the mid-1980s that showed that in excess of seventy percent of the patients that have a regular veterinarian die by euthanasia at the hand of that healthcare provider. This is the only method we have to stop the suffering associated with many debilitating diseases that prevent the animal from enjoying a traditional quality of life.

The Decision

The interesting feature of preventing pain and suffering is that they are different, and require different values to be evaluated effectively. In pain, we can do our best. In suffering, we have to do what is best for the patient. In pain, we can bring all our scientific skills to bear on stopping the cause of the ailment. But with suffering, we must bring our ethics and feelings into the healthcare delivery setting.

To compound the problem, in preventing pain, the owner's limiting factor is generally cost. But in preventing suffering, emotions come into the critical decision process. Given adequate resources, most every pain is correctable. This cannot be said for suffering.

In most cases, euthanasia is the most cost-effective method to control pain and suffering, but the client's decision process is not the same. As the family veterinarian, there is a clear responsibility to the family of the pet. The feelings of each member of the family must be addressed. If we disregard the emotions of the non-paying family members, we are not much better than paid killers. If we help all the family members accept the euthanasia alternatives as best for the pet, we are facilitators of the perpetual death process.

Euthanasia can be the best alternative for multiple reasons, cost being only the most obvious. The suffering, the decrease in the quality of life for the animal, or pressures and demands placed on the family members that must care for the pet at home are all reasons to consider euthanasia. But few veterinarians have learned to effectively discuss all the alternatives to make the family's decision a more acceptable behavior.

Resources

 The Delta Society has a vast library of resources (call 1-800-869-6898). This is the international clearing house for all information concerning the human-animal bond. They have over two decades of research on file, as well as a history of programs and customized literature review packages to meet most any need in any area of the human-animal bond.

 The best small animal practice audio-visual staff training system for euthanasia situations is the AAHA-produced video series on Pet Loss and Bereavement. This three-tape series discusses the process of grief and the associated stress in tape one. Tape two addresses the role of each staff member in helping the client through the toughest of the healthcare decisions. Tape three is a client-directed tape, although too long for a client in stress. It is exceptionally good for training the staff in methods to use, when the animal is first diagnosed with an incurable disease process, to include geriatric conditions, or after the euthanasia, when the client can't get past the feelings of loss and isolation.

 In 2003, AAHA published the new Standards for Accreditation, as well as the data from the 2003 Compliance Study. Both of these documents provide timely and targeted patient care guidance, as well as practice delivery expectations, and as discussed earlier, move the bio-ethics of the last century into veterinary-specific public policy for the new millennium. Any attempt to ignore these landmark references is a bio-ethical decision each practice must address, whether the practice is AAHA accredited or not. Like the May 2000, AVMA position that pain management is as essential as anesthesia, veterinary practices adopt veterinary public policy at different rates, since the liquidity consequences are minimal.

 In the text Promoting the Human-Animal Bond in Veterinary Practice, May 2001, Iowa State University Press, we discussed the different factors that impact the grief process, as well as the client relations aspects that must be understood by the practice team.

 In the tough decision times, these resources and tapes are welcomed resources in the practice library. The rest, the bio-ethics of pain and suffering, is a function of leadership and team support. Euthanasia is not an easy procedure mentally, and peer support is critical in the coping process. Leadership understanding about the bio-ethical stresses is also needed. This is the environment every member of a veterinary practice deserves. Make it happen this week in your practice!

The Key Questions

It is often said that issues of bio-ethics fall into two categories: some concern procedures for decisions, others the substance for decisions. The distinction, while intuitive, is not easy to sustain. How do we know which values should be followed unless we know what values should to be sought?

In biomedical ethics, there are usually five basic decision-making agents that require the veterinary practice to consider:

1.  The hospital has arrived at a series of policy judgments over the life at the practice, often based on facilities, equipment, and staff limitations or capabilities.

2.  The nurse technicians and staff often prefer certain types of cases or admissions, and certain treatment modalities that allow them a comfort zone of operation.

3.  The client may wish to be involved in, and not merely informed of, the decisions being made in the case. The values of the client may or may not match the values of the practice.

4.  The patient has certain needs and the animal's welfare must be considered, when extending any morbid state. The arguments concerning an animal's "rights" are certainly bio-ethical issues.

5.  The veterinarian not only makes the policies of the hospital, but is also bound to interpret them on a case-by-case basis in light of state-of-the-art veterinary medical knowledge, as well as fiscal management concerns of the practice and client.

There is a traditional adage in medicine, that is, "First, do no harm." In the previous bio-ethical issues, some would feel that the solutions were clear and definitive, that ethical issues do not exist. The areas discussed illustrate veterinary medical situations, where there is room for reasonable people to disagree. The reason for this discussion is to make the concept of ethics in biomedical decisions become a reality, to show that bio-ethics do apply to veterinary practices, and to offer the opinion that bio-ethics should be an element of the decision-making process in quality healthcare delivery in the veterinary practice.