Just Say NO to Bad Medicine
For those readers not from Ontario, the CVO is the College of Veterinarians of Ontario and is the body that regulates our profession in this province (www.cvo.org). In June of 2009, the CVO published guidelines on Informed Owner Consent. Here is a link to my recent post on the subject – https://vetdentedu.ca/2023/04/21/informed-owner-consent/.
In this post, I want to discuss the situation in which we have informed the owner, but they do not give their consent. Specifically, what do you do when you have given the owner all the medically appropriate options and they request another, inappropriate plan? This is page 10 of the CVO newsletter from December of 2009 – UpdateDecember2009.pdf. The link at the beginning of that page in the CVO document to the paper on informed consent seems broken, but this one is good.
In essence, this statement tells us that we have a responsibility to provide the client with the various appropriate diagnostic and therapeutic options, with the pros, cons and expected outcomes of each. We similarly have a responsibility to refuse to provide care that would be considered medically inappropriate even if this is what the owner requests. In other words, if the owner requests a treatment plan that is not appropriate, your responsibility to the patient dictates that you refuse.
The example that the CVO provided was that of a dog with a fractured leg. I will offer a dental one. A dog presents with an intra-oral swelling. You recommend a detailed dental examination with intra-oral dental radiographs to assess possible causes of the swelling (endodontic disease, periodontal disease, foreign body, neoplasia, cyst). The client declines the plan and asks for some antibiotics. As this is not a medically appropriate plan, we have a responsibility to say ‘no’ and to refuse to dispense the medications. At this point in the process, we do not know if the swelling is the result of infection or neoplasia. Even if it is the result of a dental infection, no amount of antibiotics will remove the source of the problem and so will provide no lasting relief. For more on why antibiotics are not appropriate, see this post.
Rather than allowing ourselves to be talked into a plan that has little or no chance of providing effective relief, we must advocate for the animal and insist on getting a diagnosis first so that we can then develop an appropriate treatment plan and finally, carry it out.
But what if the client flat-out refuses to consent to a medically appropriate plan? This happens sometimes, and it causes veterinarians a great deal of distress when it does. We feel a strong obligation to do something, anything to try to help the patient despite having our hands tied. But doing the wrong thing is worse than doing nothing.
When faced with a recalcitrant client I end our relationship. I point out that the Doctor-Client relationship is based on mutual trust. If the client does not trust that I know what I am doing and that I have their interest and their animal’s interest at heart, then we have no relationship. If I cannot trust that they are going to follow my medically-appropriate recommendations, then we have no relationship. If we have no relationship, they must seek services elsewhere.
Faced with that, some clients will certainly leave your practice. Others may decide that they are interested in building that relationship of mutual trust and may ultimately allow you to provide proper care for their pet. Either outcome is preferable to a stand-off that consumes time, energy and financial resources with no hope of achieving a satisfactory outcome for any of the parties involved.
In the worst scenarios, where an animal is in serious and/or emergent distress and the owner refused proper care, you may be compelled to involve the local humane or animal welfare authorities. Fortunately, it rarely comes to that, but it is our obligation to report serious animal neglect or mistreatment.
Here is the link to a pdf version of this post – Just Say NO to Bad Medicine