Spinoff: Economics and "Standard of Care"

[eventualeventer]

This is a spinoff thread so that cowgirla's thread about prophylactic gastropexy does not get derailed, but I'd be interested to hear more opinions on how economics plays in to standard of care. We have discussed before the difference between el cheapo spay at the humane society or discount clinic vs the spay at the top of the line private practice (monitoring, pain meds, etc.). Now let's talk about non-elective care.

I will put myself out there and say that there IS a certain cost for treating most conditions below which you can not go and still be ethical in treating an animal instead of deciding to euthanize it. E.g., doing colic surgery on a horse and not putting it on IV fluids afterwards.

Obviously, that is an extreme example, but there are others. Is it OK to set a complicated fracture or do major abdominal surgery with only NSAID's for post-op pain control? Is it OK to undo a colon torsion but leave a huge impaction in there for the horse to work out himself, now having an 18 inch incision in his abdomen, because the owner didn't want to spend the additional money for an enterotomy? Is it OK to keep drugging a horse with a surgical colic, put them on fluids, and hope that they work it out themselves?

I'm not disagreeing that there are ways to help out clients with money restrictions -- using older/cheaper drugs, teaching them how to do after-care so that they can take the animal home sooner, etc. From a perspective of thinking about the animal, though, I think there needs to be someone to say sometimes, NO, you need to either commit to spending the money or quit now without putting the animal through a half-assed treatment for a poor(er) prognosis. Am I hopelessly naive?

BTW, on a related note, I've noticed that some "cheap" treatment options - like putting a really impacted horse on fluids instead of doing surgery - end up spending the same amount of money, or more, as the definitive treatment for a dead animal. I guess people around here are willing to spend more money when they realize that, yes, their animal really IS going to die if they don't spend money on vet care.

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[libster06]

That is a tough dilemma... but I feel like in some cases, it would be ok if you explained the situation to whomever client you're wanting to do X surgery to their animal. I think if you have an animal, you should be able to take care of it, or at least live with getting whatever care it is you can afford. I think some/most people would be ok with doing at least SOMETHING to relieve their animal's discomfort and pain, even though it may not be the entire surgery, but I think those times should be when the problem is not severe. I really get upset when people keep their animals around when they can't take care of them and the quality of life is so diminished the animal is just suffering minute by minute.

That is one thing I am not looking forward to, having worked in clinics where people just expect things for free. It really quite amazed me the things these people would come in and want done with no intention whatsoever of paying for them... like I don't go to my doctor's office and expect my bill to be discounted.

 

[Bill59]

Is it OK to set a complicated fracture or do major abdominal surgery with only NSAID's for post-op pain control?

No. If the client can't afford the surgery, then a less expensive option may be appropriate -- cage rest, even euthanasia. But if you agree to do the surgery, you owe it to the patient to provide adequate analgesia. Would it be ok to do the surgery with the patient awake if the client can't afford anesthesia? Besides, for a $1000+ orthopedic surgery, you can't afford a couple of dollars worth of morphine?

There's a well known case of a veterinarian in Minnesota who was called out by the board for routinely not providing adequate post-op analgesia. Basically he graduated 60 years ago and still practiced like we did 60 years ago.

Is it OK to undo a colon torsion but leave a huge impaction in there for the horse to work out himself, now having an 18 inch incision in his abdomen, because the owner didn't want to spend the additional money for an enterotomy?

I'm gonna say no. Why give the client the option on how you do the surgery? Do you give them the option of deciding whether you use aseptic technique or not? My approach is I decide how we're gonna do surgery, the client decides if we're gonna do surgery.

Is it OK to keep drugging a horse with a surgical colic, put them on fluids, and hope that they work it out themselves?

That one might be OK, depending on the details. If the client can't afford an exlap, medical therapy might be appropriate depending on the details. A lot, probably most, horse owners can't afford a colic surgery. Many cases will respond to conservative therapy.

IMO

 

[Veracosa]

This is the sort of stuff I see the vets that I currently work for struggle with.

Most of the vets at my practice believe in the highest standard of care. Some won't budge from it. The older vets will be more willing to make concessions (ie not doing IV fluids or pre-op bloodwork). The practice owner obviously can make quicker decisions about whether he will make financial concessions for clients, while the other vets have to go through him or our office manager.

We do keep a section of free meds for hard-luck cases. Recently expired drugs, drugs from patients that died, etc.

What I see happens most often is that each vet has a base guideline for what is required for a procedure to be okay.
Most vets will recommend the "Best Care" estimate, and if the client balks, they can provide an "As limited as I am willing to do" estimate. And if the client still won't go for everything, then they can go elsewhere for the most part. Depending on what it is obviously; we won't let a blocked cat walk out because an owner doesn't like our estimate!

I think that for each case and procedure, you have to consider what would be bare minimum neccessity for that procedure to be safe and comfortable as is reasonable. *shrug*
I try to imagine it happening to me: I mean, thinking of having a spay surgery is pretty traumatic to me. I am surprised most only go home with only NSAIDS. Can you imagine a human getting an OVH with only Ibuprofen? Yeah, right!

But it is a balancing act between doing what you think is right, and trying to make the animal comfortable and the client happy. And a lot of the times it seems those 3 things do not meet in the middle.

 

[breenie]

I see my bosses struggle with this, too.

Our clinic somehow manages to be at the border for a very well-to-do (not necessarily rich, but I'd say upper middle class area) and a not-as-well-to-do area. We get a pretty wide range of client "types" and checkbook sizes.

We also keep an expired/donated/whatever medicine area if someone really needs something and they just can't afford it.

Vets aren't usually trained to be business people. We're supposed to take care of the animals, and it's hard when you're presented with a situation where someone can't afford the highest level of care. In my experience, I've seen vets try and scrounge together what they THINK the client can afford, without actually leaving the financial choices up to the owner. It's not our job to decide what the person can/cannot afford, yet a lot of the times I think vets end up accidentally making this call for people.

But it's hard. We had a case the other day of a dog that was seizing, and the man clearly cared about his dog a lot, but really couldn't afford anything (I'm talking about just an exam fee). Sometimes people rally. He gave us what he could, one of the other clients in our waiting room subtly slipped us some cash, and we managed to work out a payment plan and some other options. Sometimes it works out, sometimes it doesn't. We've been pretty successful with payment plans/Care credit type things for people.

 

[crittergal]

And if the client still won't go for everything, then they can go elsewhere for the most part. Depending on what it is obviously; we won't let a blocked cat walk out because an owner doesn't like our estimate!

I think that for each case and procedure, you have to consider what would be bare minimum neccessity for that procedure to be safe and comfortable as is reasonable. *shrug*

I can see problems with the blocked cat situation. Here's a case from work for you to chew on:

~3yr MN DSH seen for urinary obstruction, laterally recumbent on presentation. This was the pt's first obstruction. Client was a waiter. Most anyone who has ever waited tables knows you live from one day's tips to the next. Disposable income for emergencies is tough to come by. Pt needed immediate medical care- he would die by the time the pt was shipped somewhere less costly or by the time the client called all friends and family to beg for money. A different client pulls the receptionist into an exam room, gives a credit card for carte blanche treatment for the stranger's cat. Cat lives. All is well, right?

Cats who have obstructed before frequently reobstruct and PU surgery for these guys isn't uncommon. (I don't have stats and won't make them up, but it seems to be common). This is exactly what happened. The cat returned less than a week later. He said we could proceed forward with treatment. I overheard him mumbling the money he was spending was his rent money. I informed the Dr she might want to go talk to the guy again about the potential for another reobstruction or possible PU sx. Not that he hadn't already been told, but just an honest heart to heart about long term prognosis and costs associated with repeat FLUTD problems. Even just the costs associated with the rx diets can be significant to some people.

Long story short, the cat was euthanized. As wrong as some of you may think this decision was, the client would not have been reasonably able to continue with aftercare. He knew he would have been facing eviction if he spent that money because he had no ability to recoup the finances and pay rent.

Why do I know his occupation? My husband and I went out to eat about a week later and he was our waiter. He almost broke down crying in the middle of the restaurant because he was so grateful we could help him and his cat. Help? We helped both him and his cat? Yes. Although the decision was financially based, euthanasia was the best option for the situation as a whole. Sadly, that's the reality of veterinary medicine. Care costs money.

 

[sumstorm]

We do keep a section of free meds for hard-luck cases. Recently expired drugs, drugs from patients that died, etc.

This isn't legal in some states. It goes against acceptable dispensary.

 

[david594]

This isn't legal in some states. It goes against acceptable dispensary.

I was kind of thinking that.

But on the same note the president of our state pharmacy board came and talked to our class regarding laws and regulations. He explained to us what laws apply to us. He then also explained what would actually be enforced in the veterinary context.

The two lists were very different.

 

[sumstorm]

I was kind of thinking that.

But on the same note the president of our state pharmacy board came and talked to our class regarding laws and regulations. He explained to us what laws apply to us. He then also explained what would actually be enforced in the veterinary context.

The two lists were very different.

I agree the lists are different, but if the concern is the ethics of doing less in treatment, I would think providing drugs that have had unknown exposures or may have reduced efficacy would cause the same concerns. Also, while it may not be enforced legally, if an animal dies while on meds that weren't provided correctly, it can be submitted to the state board and may be a liability issue. Criminal vs civil.

For me, in the overall question, a lot will fall on 'it depends.' It will depend on the case, the situation, the animal, the owner, etc. I pulled my own dog off of pain meds early following her spay because I didn't want her pushing full force. Just like, as a runner, I won't take pain meds for a sprained ankle, because the pain will remind me to take it easy. Do I think it was horrible? She wasn't in so much pain that she wasn't eating, or wasn't moving, but I am sure it hurt to make big, dramatic movements, which I really wanted her to avoid, and this was a dog that can bounce off the groun, during a normal walk, without pulling on the leash, just because she is a dramatic, showy, energetic dog.

 

[Bill59]

From a legal standpoint, expired drugs are adulterated, misbranded and unsafe for use. Administering an expired drug to a client-owned patient is bad practice and would be indefensible if it ever ended up in court.

 

[VeganSoprano]

I see what you are saying and it's always important to take into account what is and is not technically legal. From a moral standpoint, though, what you have is a client who is severely financially constrained and trying to help his pet. I feel like informed consent may be morally acceptable here. You might say "Mr. Smith, we have this medication that expired last month. While we expect it is still safe and potent, we can't guarantee that and we cannot legally sell it. However, I will give it to you for free and hopefully it will help Fluffy out. Is this okay with you, or would you prefer to purchase a new prescription or have me write a prescription so you can price shop in the morning?". Or for donated meds, you can say "Ms. Jones, we have this medication that was donated from a pet who passed away. However, since it has left our hospital we cannot be certain it contains the original prescription and was not tampered with. I can give them to you for free, but there is a small risk that it might be the wrong drug, or that someone might have stored it improperly, or even that someone may have deliberately sabotaged the drug. I think it's a small risk but you have to decide if it's acceptable to you. Otherwise I can fill the prescription here or write a prescription for you to price shop."

Of course, it's the one time in a million that something like that does come back to haunt you and leaves you convinced that no good deed goes unpunished!

 

[VeganSoprano]

Duplicate post. Sorry.

 

[eventualeventer]

Hmm, interesting. At my current job, I presume they throw out any expired drugs (but we go through a lot of inventory, so it's unlikely that much expires), but unused doses of medication are returned to the pharmacy, credited to the client, and potentially used on another horse (e.g., tubes of oral meds with only one dose taken out, or fluids that were spiked for one patient who was subsequently taken off fluids). We still adhere to expected lifetimes of opened drugs and fluids. Since they are credited to whoever bought the drug originally, though, it does not provide the next client any advantage, just prevents people from having to pay for fluids or drugs their horse did not use.

I'm gonna say no. Why give the client the option on how you do the surgery? Do you give them the option of deciding whether you use aseptic technique or not? My approach is I decide how we're gonna do surgery, the client decides if we're gonna do surgery.

Bill, that was my thought, but I saw it done several years ago and was put off by it then. I guess you could sum up my thoughts as "go big or go home".

On a tangent re: pharmaceutical laws, don't get me started on how the veterinary profession blatantly ignores FDA regulations regarding legal compounding of drugs. Expense is NOT a legal reason to get a drug compounded, and if it is less expensive than the stuff on the market it is without a doubt compounded with bulk drugs (which is an illegal practice with the exception of a VERY few drugs which can not be obtained any other way, i.e., pergolide). I can't tell you how many times I have seen vets buying in bulk (another no-no) and re-selling compounded flunixin (Banamine) paste, bute powder, and similar drugs which are readily available in the same concentrations and forms that are being compounded.

 

[Bill59]

A couple of points for your consideration.

Selling the drug is not the point. If you administer or dispense an adulterated drug at no charge it's still illegal. Not technically illegal, just illegal.

Also realize that professional liability insurance will not cover you when you do something illegal. You are own your own should the feces hit the fan.

From an ethical/moral standpoint, while I understand the desire to help the patient and client, aren't we morally and ethically bound to follow the law? If veterinarians are going to ignore the laws regarding drugs, why should we be entrusted with the authority to prescribe drugs and controlled substances in the first place? Why not just let clients buy whatever drug they want straight from the wholesaler?

When you give an adulterated drug to a client are you going to tell them what you're doing is illegal? After all, that would be part of informed consent. Would you trust a doctor who said that to you?

If you really want to help the patient/client, why not just pay for the drug yourself?

 

[GatoGris]

From a legal standpoint, expired drugs are adulterated, misbranded and unsafe for use. Administering an expired drug to a client-owned patient is bad practice and would be indefensible if it ever ended up in court.

Just want to second this.

It's not just about efficacy, though that's what I usually hear people worry about if they are considering giving expired medications. It's also about safety. We cultured many of our frequently used drugs just to see if they grew anything. The medications WITH PRESERVATIVES started to grow bacteria at five days. Those without preservatives, sooner. So that extra injectable clindamycin (that says "single dose, preservative free"), is definitely not safe to use.

I see what you are saying and it's always important to take into account what is and is not technically legal. From a moral standpoint, though, what you have is a client who is severely financially constrained and trying to help his pet. I feel like informed consent may be morally acceptable here. You might say "Mr. Smith, we have this medication that expired last month. While we expect it is still safe and potent, we can't guarantee that and we cannot legally sell it. However, I will give it to you for free and hopefully it will help Fluffy out. Is this okay with you, or would you prefer to purchase a new prescription or have me write a prescription so you can price shop in the morning?".

I understand where you are coming from, but I'm not sure that constitutes informed consent. For one, you cannot expect that the medication is safe and potent. Second, the client is not being presented with all the risks and thus cannot make an informed decision.

Truly informing the client would be more like (using an antibiotic as an example), "Mr. Smith, your pet is ill with "x" and requires "y" antibiotic. If purchased from our practice, it will cost "z" amount. We currently have a supply of "y" antibiotic that is expired. We can attest neither to its safety nor its efficacy. Because "y" is expired, it may only partially treat your pet's infection. Your pet's infection may return, and may be resistant to "y" antibiotic. If this is the case, we may have to treat your pet with a more expensive antibiotic. Additionally, we cannot ensure that this medication is sterile. Though it is never our purpose to do harm, this product may contain bacteria. If this is the case, we may be giving your pet an additional infection, which may require further treatment and cause you to incur further expense. Also, because the pH of the medication may have changed, it may burn, sting or cause other discomfort to your pet when administered."

Saying, "We think it's safe, it's free and it might help" does not paint a clear picture.

 

[VeganSoprano]

GatoGris, you're right - that's a better and more accurate way to put it.

I believe all laws are there for a reason, but there are times when it may be morally acceptable to act outside of the law. For example, ferrets are illegal where I live and pit bulls are illegal in a neighboring jurisdiction. I don't think that makes it morally wrong to own a ferret or a pit bull, or for a veterinary hospital to treat one. Obviously these are two separate issues, but the law shouldn't ever be the final arbiter of morality. It should always be carefully considered, but there are and have been many circumstances where what is legal and what is right have not coincided.