Sunday, February 12, 2012

When the Cost is Too High

Virtually daily, veterinarians everywhere are faced with clients that can, or will, only afford so much for their animal. I don't like to take an owner's finances into consideration when I make a recommendation because I try to base my plan of action on what is best. As one of the clinical professors at my school always told students: don't try to x-ray your client's wallets. As he once shared, it is sometimes the old farmer in the overalls and no T-shirt that will pull out a roll of $100 bills to pay for his sheep dog's surgery. And, sometimes the person with the Coach bag, iPhone, and Lexus will decline everything and just want a single shot to "fix" their dog.

For several years, I worked at both a general practice and at an emergency clinic. I would often have cases that went back and forth between the two clinics. One of these patients was a cat named Hercules. Actually, it was Hercules II. Hercules I had died after being attacked by a dog. Hercules II was almost identical and the family kept a close eye on him. He even went outside on a leash. However, one day he got into some rat poison that the owners had forgotten about that was hiding in a kitchen cabinet.
The owners were able to get him treated in time and after a month or so on vitamin K, which is an antidote to one of the main types of rat poison, Hercules II was back in fighting form. He spent his days lounging with the owners, an older retired couple that loved him very much.
About a month after he was past the rat poison episode, Hercules escaped from the house. When he got scared, he ran out into the road where he was no match for a passing truck. By the time the owners found him, Hercules was almost dead. When he got to the day practice, the vet there initiated treatment and found that Hercules was not stable enough to be alone overnight. The owners were not wealthy, they were not even middle class. And they were retired, so they had no real income. The veterinarian, who knew these things, offered referral to the ICU overnight facility but did discuss his poor prognosis and gave an estimate of cost for the transfer. The owners wanted to go ahead, no matter the cost.
When the owners brought Hercules into see me, I recognized them. They were very sweet, but also very minimally educated. Trying to explain all of the injuries and treatments that Hercules needed to have a fighting chance took a very long time because the owners didn't really have a concept of basic anatomy or biology. Trachea was reduced to "breathing tube," and muscle was reduced to "meat." I tried repeatedly to give them an idea of his chances and the cost of care, even just beyond the initial stabilization. Hercules had to have a chest tube placed and I feared that he might have a pneumothorax caused by ruptured bullae (where the air pockets in the lungs break open and leak air from the lungs into the chest) and a ruptured trachea as well.
I knew that these folks didn't have the money but they wanted to pay with a credit card. I wasn't worried that the clinic wouldn't get paid, but I was worried that the family would have a hard time paying off the credit card company. I was also worried that Hercules would not make it and they would owe tons of money and have no cat.
The first night turned into a few days of hospitalization. Hercules developed new problems and got progressively worse. At each stage, I discussed euthanasia as an option. I knew that even with radical and expensive surgery that his chances for survival were minimal. I tried to explain it to them, but they hung on to that 10% chance of survival. I gave them an estimate for cost of care, cringing while I did it because I knew that they were going to say yes. When I openly discussed euthanasia as an option, they wouldn't consider it. I even offered to keep Hercules completely doped up while he succumbed to his injuries so he could "pass naturally."
By the morning of the surgery, Hercules had gotten considerably worse. His glucose would not remain normal and kept dropping, possibly indicating a septic infection (infection in the blood). He started having seizures and no matter how much glucose we pumped in him or how much valium he received, it kept on happening. His kidneys were failing, which also might have been contributing to the seizures. These things made him a terrible candidate for surgery.
I called the owners and told them to come out at once because I was fairly certain that Hercules would not make it much longer. When the owners got to the hospital, I rushed them back to see Hercules. He was comatose by that time, either from the drugs to control the seizures or the disease process itself. As I placed him in the owners' arms, they asked repeatedly for me to do something to help him.
Once again, I had an internal war going on. If the owners had been millionaires, I would have still given the same advice: euthanasia. But these people, who could not easily afford what we had done already, wanted to go even further. They absolutely refused to euthanize. Their daughter and son in law had come with them to visit. I pulled them out of the room to try to explain what was going on. They too only wanted to press forward, saying that cost was no object.
I left the family to visit with their pet, telling them to alert me if there was a problem. About 10 minutes later, I heard them screaming in the room and ran back. Hercules had another seizure and then started agonal breathing. At that point, I knew that nothing we could possibly offer would help him. I explained that he was dying and offered to ease the passing with some euthanasia solution. This was a last ditch effort to try to help the owners more than it was to help the patient. Hercules was beyond the need for the injection, but I thought that if the owners had some control over the situation, they might feel better. However, Hercules was gone before I was able to leave the room.
Frankly, I was torn. I felt horrible for the owners. I knew they had poured their heart, soul, and wallet into saving their kitty. I knew they felt guilty because their miracle kitty (which is what they started calling him after the rat poison incident) had escaped the house and gotten hurt. And even though the referring vet and I had been totally honest and upfront about the chances for recovery as well as the cost, I personally felt guilty.

I also felt relieved: the cat was no longer suffering and I didn't have to spend anymore of the owner's money in what I felt was a futile battle. I was relieved because I was also tired...mentally tired to trying to explain the same thing over and over again and getting no where. It sounds awful when I write it down.... I didn't resent the owners for either not being able to understand or just not being willing to understand the situation, I was just plain tired walking that line between offering the top plan and making it plain that euthanasia was an option. Looking back on it, I like to think I would have offered the same thing to a wealthy person. I might not have felt quite as guilty about them spending the money, but I would have offered the same thing. The case still haunts me and it colors every end of life discussion I have with clients.


  1. End of life discussions are always tough.

  2. Well, now my eyes are wet. What a tough decision. I like to think that I am realistic about end of life decisions for pets...don't just off them for convenience (I have hand fed cats and given thyroid pills for years - my son and I gave subq fluids to his beloved pet who HATED vets because she would let us do it, but not them) but when quality of life is gone, then it is time...
    but DANG having to explain and explain and hard.

  3. I am a third year vet student, and this type of situation worries me when I get into practice. These owners obviously loved their cat, but they put their own feelings of not wanting to lose him ahead of the well being of the animal. He was suffering, and even if he had survived, it would mean a long and painful recovery. Most of my experience is in food animal medicine, and I get a lot of flack from my "small animal" classmates about how they think so many things in large animal med are inhumane. However, it seems very inhumane, to me, to prolong the suffering of an animal just because the owners are putting their own feelings first. How do you put aside your feelings and do something that you don't agree with?

    1. I was lucky enough to have a whole arsenal of opioid and dissociative pain medication to give the poor guy (something like butorphanol or even buprenex in the case is not enough). He was reasonably comfortable. If I was unable to keep him comfortable, I would have really pushed for euthanasia. That is the only time I push for it. Otherwise, you have to just lay out the facts and chances for recovery and let the owners decide. In general, pushing someone towards euthanasia is not a good idea. They need to decide on their own. But if a patient is overtly painful, I will mention the words "suffering," "miserable," and "nothing is helping."

      And very little can prepare you for the suffering aspect. And very little can wash it out of your head. After 10 years out in practice, I have compartmentalized to some degree. I have tried to keep my compassion but limit how much I actually take home with me.

    2. I'm three years out in practice and I can tell you it's a tough choice sometimes. However, the way I look at it, as doctors, it's our job to give options and explain the likely results. It's the owners job to decide what is best for their pet and what is best for themselves. You can't tell someone else how or when to let go and you shouldn't. They're the ones who have to be able to live with the decision after you've signed the paperwork and gone home.

      Not to mention, that sometimes you're wrong. An animal with just a 10% chance of recovery still has a 10% chance of recovery. It might not be what you or I is willing to risk additional invasive procedures and treatments for, but if it works, the owner and the pet might feel it was worthwhile. I've seen animals I thought had almost no shot bounce out of my hospital and go on to live happily far longer than I ever expected.

      That said, it's not easy to walk that line. Some cases I feel guilty like the OP for owners who want to go for broke just because I told them there was a tiny chance of survival. Other times, I feel just as guilty when I tell the owners there's a tiny chance of survival and they give up without trying at all. I just do my best to give them the information they need to make an informed decision and respect the decision they make.

  4. You know even though it makes us feel badly knowing that people are spending money they do not have, our job is to advocate for the animal no matter what (which it sounds like you did). We are absolutely bound to give appropriate quotes for our services but at the end of the day we can not feel guilt about the money. The hard part is watching the animal suffer; money can not make the job any harder.
    My two cents.

    1. As I see it, the deep additional difficulty in this case was the apparent reduced ability of the owners to understand the medical aspects of the case. Septic. Kidneys failing. Can't regulate the glucose. The clients couldn't grasp what the interplay of these disorders would/could mean and held to the touching trust that the OP could always help Herc get well.

      Most clients would be gradually getting the gist of it all as the case progressed on its downward trajectory. Very sad case.

  5. I take care of humans, and it's no easier. Maybe harder, because it's not an option to euthanize. And people think you should try harder with their 99yo granny. And religion comes into it. Like, if god is all powerful, why can't he overcome my mistake of taking granny off the vent?

  6. I hate these cases. You know you will fail to save the patient, but you'll do it slowly, and you know they owner can't really afford it. The only way I can get through them without banging my head against the wall is to repeatedly tell myself, "It's not your choice to make. It's not your choice to make".