Influencing Client Decisions

Do you present options to a client when you would prefer not to push further with treatment because an animal is suffering and its prognosis is poor? Our veterinary culture tells us we should “offer the best” and let the client decide. But a client’s decision is based on many factors in his/her own life that may not have anything to do with what is best for the pet: finances, personal philosophy, home issues, or other obligations (sick parent, child, spouse, etc) all come into play.

As a veterinarian, when you place that white coat on and walk into a treatment room, you become a leader. You are a leader for your clients to help them make decisions about what is best for their pets. Know that how and what you explain to clients will also direct their actions accordingly.

I work with two veterinarians with philosophies at opposite ends of the spectrum. One is a self-titled “eternal optimist” regarding the prognosis of patients and is always hopeful for a positive outcome regardless of how unlikely this possibility is. He often recommends obscure tests on the remote chance that a “cause” and “treatment” plan could be found. The other veterinarian is extremely pragmatic, so the options he offers to clients are guided by the chances that additional tests or pushing forward with treatment will help the pets (ie, if a test will be a low yield he offers it but stresses that it's unlikely to help).

It is interesting to listen to the same information come from each of them because it sounds so different. Their communication techniques and how they present these issues to their clients influence the clients’ decisions accordingly, based on their own personal philosophies. As a result, I have struggled working with both of them at times—because I have disagreed with them in regards to the way that they’ve presented options and given information to their clients.

On the one hand, Dr. A offers hope to clients when their pets are clearly suffering and pushes them forward with a 1% chance that continued treatment will help these animals. In my opinion, the pets’ suffering and quality of life issues should be at the forefront of these discussions and Dr. A should be helping the clients begin to let go—and NOT push forward with treatment. But on the other hand, Dr. B oversimplifies complex cases to owners and does not offer all of the options, leaving them unable to make fully informed decisions.

One case became pivotal for me and helped me develop my philosophy in presenting options to clients with critically ill pets.

An elderly boxer with a number of health problems presented for being ADR again. In the past year he had gone through multiple surgeries and was on countless medications to treat his various ailments. We were uncertain what was causing the current laboratory abnormalities and clinical signs. Numerous tests were run to try and diagnose the problem. He rebounded slightly (enough to go home for a short time and then come back for euthanasia if the owners opted). The only other option was an exploratory surgery that would likely be low yield/high risk—especially with his declining condition.

The owners were having a very difficult time letting go and were not coming to terms with the poor prognosis of their pet. They were holding on to any chance that something could help. Dr. A was the clinician working with these clients—and presented surgery as a viable option. The owners’ unrealistic expectations and willingness to hold on to a 1% chance that this may help caused them to pursue surgery.

My heart dropped as I desperately wanted to tell them, “Take Jake home—spend one or two last nights with him and then let him go peacefully. Don’t put him through yet another surgery—please think of what’s best for him.” But alas, I was not their clinician. Jake went to surgery. He never made a full recovery and arrested one day following the surgery…ALONE in a hospital surrounded by stranger technicians (of whom he had become aggressive towards). When I walked in the following morning and heard the news my heart dropped. I was not surprised he had died, but very saddened that he had to die alone in a hospital surrounded by strangers.

When I think about this months later it still bothers me. I wonder how it would have gone differently with Dr. B. Would Jake have gone home and then been euthanized once the owners came to grips with reality? Would he have suffered at home until he died? Would they still have gone to surgery even with the understanding that it was very unlikely to be successful? Would Dr. B have offered surgery knowing these clients were rather unrealistic and willing to go to any lengths to “help”—to their pet’s detriment?

I know we speak of offering the best and all options to clients so that they can make an informed decision, but who determines what options are realistic? What is realistic to me may not be realistic to you. Is my life philosophy tainting how I present options to clients? Am I an optimist that will push clients too far—or am I pessimist that doesn’t push clients hard enough?

I created my philosophy based on Jake’s case. I would rather euthanize 2% of patients that could get better vs having 98% of my patients suffer. I know that ultimately it is the owner’s choice. But anyone would be lying if they said that we as vets do not influence our clients’ choices by the way we present information. I will always offer the best. I will always give clients all options—BUT I will be realistic when I present them with these options. But then again, this goes back to the question of—what if my reality is likely not yours?