The Venom In The Terminology

A message came to me from a colleague about a post on LinkedIn drawing some attention. 

The post centered around what we (the veterinary profession) calls "futility of care." 

It was hard for me to read. Hard for me to internalize. Hard for the words to carry so much gravity and deliver so little of what our clients need from us. 

I don't know when it exactly happened. When that pivot point was. But somewhere along the way our message about treating out veterinary patients like family became treating them in the way we allowed.

I want the profession to start to pay attention to their words. I plea for the profession to also pay attention to their intentions. The gravity of the judgement within them;

Here are some of the most offensive;

"Pets are a privilege, not a right." Why would poor people deserve something to adore them? Someone to make you feel loved back.

"Futility of care." We decide when you stop caring, and, therefore,, stop looking for hope. Some pet parents struggle with grief and loss on a level veterinarians have refused to comprehend. People should be allowed to feel as they feel. Our job, well, that is to provide them the tools to do so. Hope is as integral in medicine as vaccines. Hospice is absolutely an acceptable avenue in medicine. Every kind of medicine. We, the veterinary profession, want to follow in the footsteps of our human counterparts and offer every billable option to our patients, so, why is it then that we also won’t offer hospice? Why are we so intent on being morally superior and yet still not empathetic to those we are here to serve? 

PS futility care is most often seen as cold and uncompassionate. Why would we ever use that term? Small animal medicine is about taking care of family members. Nothing is futile here right?

"Economic euthanasia" The fact that the profession has increased the cost of care so staggeringly fast that this is the last vestige of care we will permit, affordably. You cannot advocate for your patients to be treated like family and then decide they aren't worth options that work for the rest of the family. In 20 years of practicing medicine I have (hopefully) never denied care because it didn't work for me. It has taken me time to understand how different we all are. There have been clients who don't value their pets in a way congruent with care. 

"Replacement value" There are people who see pets much like food animals. They have a value that is defined by "replacement value." That dollar figure where it is cheaper to replace them than to fix them. Ask me to expose my soft vulnerable underbelly and help your pet out of a difficult situation and I will jump in. There isn't one person at the vet hospital who wouldn't jump in with me. But, don't ask me to look into that disposable pet and see them as replaceable. 

Elsa.. recently rescued and adopted

This blog comes from a post from a fellow veterinarian who started the post with;

"Today I had a client for which I refused treatment." The veterinarian went on to describe an elderly patient at the end of their disease. The pet parent bringing that pet is was back at their vet hospital, again, seeking help. The parent did not see the pet in the same light, the same degree of dying, that the veterinarian did. The pet parent wanted help. With that plea for help, with nothing more to offer that was feasible in helping the pet get better, with only euthanasia left, the vet posted that they were refusing treatment because watching this pet show up at the clinic was stressful for the staff. Like so many other instances this is a veterinarian who refuses to see the pet in the light we make such financial gains from and meet them where they need us to be. The parent wants to feel hope. They are aren't ready for the passing of their family member. Futility or not, there is absent compassion here for what the pet parent needs. We are turning our back on them when they need us most. Why can't anyone say, "what can I do to help?" When is declining a hand of empathy abandoning our responsibility?

I replied; "Today you decided to stop being a doctor."

For more on my veterinary hospital please follow us on our Facebook page; Jarrettsville Veterinary Center.

YouTube channel here.

For more information on the non-profit work we are doing to help save pets from economic euthanasia please follow us on the Pet Good Samaritan Fund page.

Pawbly.com for pet questions and pet care cases with cost of care included.

When The Veterinarian Decides Who Is Worth Care

"I need to talk to you privately."

It is the beginning of another chaotically busy day and this is my least favorite preamble to start it off with. I tell myself to stop what I am doing and just go face the discussion head on. Rip that band-aid off and then return to GO. It is the only way I will get to the end of the day intact.

Magpie

She is the vet hospital floor manager. She has been here for about 9 months. (New to us by the law of averages that the rest of the staff holds. Most have been here for over 5 years). She is the Sergeant who keeps the cadence. Monitors the staff and doctors to stay on time. Ensures the blood tubes are labeled and the diagnostic table stays organized and orderly. She fills in to hold a patient, address a problem with a client to keep the vets on schedule. Picks up the phone to answer the random, often completely inane question. (Like yesterday's; "my dog ate a treat toy. What do I do?" No idea of size of dog, size of treat toy, what said treat toy was made of, or how well their dog chews before swallowing). She is on her feet, in everyone's business, and still keeps a smile on her face and an optimistic cheer in her stride. She used to manage race horses. She is ideally qualified for this crew of, (authors note; I wanted to use the analogy about 'busy as a beavers' but it just might be construed aberrantly.. ;-) ),, let's say ants... yes, or bees, or thoroughbreds, they all substitute to make my point. 

Storm, morning naptime

The conversation centered around one of our oldest clients. Old in both age and years with our practice, (must be about 70, as he is about 85). His family has farmed the lands in this county for over a hundred years. He is known by every person who has lived here for more than a few months. He is an indelible character. Always a farmers baseball cap atop his head, (which I have never seen naked). Always a pair of pants missing fabric in key places. And, always a long tale about some physical ailment of his unrelated to the cat he has brought. And, yes, always a cat. He used to have dogs, farm dogs, (of course), but cats, he has  decided are far easier to care for, and he far prefers their company. He lives in an equally old, equally worn out, farm house. Every room of his home has been converted into a cat dormitory. Every room is sectioned by feline family. All of his cats, 40-something in total, are related. He is as old school rural farmer as they come. He absolutely, unequivocally loves his cats. They are his family. 

"I don't understand why you didn't tell him that he had to put the cat down?" She is referring to his cat that we saw late yesterday. His cat was pitiful. Dying, and in horrific shape. He was matted, foul-smelling from feces that had caked on his back end, and emaciated. He was also sweet, gentle, purred the whole time, and knew only love from a human. His cat needed help, he knew it, and he was here looking to us to provide it. We are, after all, doctors. This is, afterall, a hospital.

Her question is so heavy you can reduce to a few minutes and a clock that ticks impatiently. 

I know that I have to try to answer this for her. Find some analytical reasoning in her black and white perception. I also know that her question comes from a place of respect that she trusts me, and concern that she is a part of a patients suffering she doesn't feel right about. 

The answer to this question is seated in the ethos of who you are. It comes down to this; who are you here? Specifically, who are you in veterinary medicine. 

The successful small animal veterinarian is able to keep their business open because they understand every pet parent sees parenting differently. Veterinary medicine exists in a place of whim and will. Every pet in every home is there as a guest in the eyes of the law. While they may have some basic rights in a few states they are still considered property. Pets are the reason veterinarians worked so hard to attain a degree. They are our purpose. They influence us. When you are so deeply invested in something it becomes painfully purposeful. It becomes ingrained in who you are. This is a curse as much as a blessing. Understanding the emotional seat of pets is imperative. 

Frippie. Also morning naptime

If my purpose is to help pets I have to provide it within the confines of what works for their family and caregivers. Veterinary medicine is forgetting this. We are getting judgemental and restrictive as we become more profitable. We have influence tied to our preferences and our gate-keeping for their health. It leaves people like this farmer in a place where he now will not go to the ER, and he will not go to other veterinarians. They have judged him, lectured him, reported him, and he will not share his life and the dearest individuals he adores. His cats are his family. He will protect them as such. 

A practitioner who wants to stay in the community they live, work, and practice in, needs to meet our clients where they are, not where we want them to be. This is the key difference that specialty medicine is lacking. You cannot be a part of someone's story without being embedded within it.

His cats are crowded. He has too many. He knows this. He spends all day everyday cleaning for them. Feeding them. He treats them the way the rest of the world treats the animals they eat. Crowded and housed like they cannot have freedom to pursue free-will. Why do cats and dogs deserve different standards of care? Different living standards? Why if you think they are more deserving of minimum standards of care and yet not deserving of end of life care like humans are? Every hoarded started with love and good intentions. Every pet under their care still deserves care.

This is what she didn't recognize yet.

The view from my kitchen window

For every client that I see who doesn't want to euthanize their pet because they do not feel it is their place, their right, their duty, their decision to make, the profession has to be respectful of this. Hospice is their right as much as it any other aspect of dying is. This farmer has never put a cat down in my clinic. Whether or not I can do the same with my beloved pets is not relevant to his decision. He loves them. He cares for them. He dedicates his life to them. Do his cats love him back? Yes? Is he wealthy, influential, hold some power over others that can afford him a different set of rules or standards? Is this the country we live in now?  Is this yet another instance of inequity deciding who is or isn't worth empathy? How many cats are looking for homes in my county? (Hundreds). Do these facts influence our compassion?

A decade ago we had a long, hard conversation about his colony. It took me years to convince him to spay and neuter. It has been a decade of no kittens, which was very difficult for him to give up. It was what his cats needed. It took him a while to see their world from this perspective. There has been a huge decline in respiratory infection, illness, and death outside of old age from this. He needed to see the colony from this vantage point before he could give up the joy of having kittens. This is medicine. This is the emotional glue trap that having pets causes. This is the life every veterinarian chose even if we couldn't see, or comprehend it during the early years or vet school.

For more on veterinary care, my diary entries, and the current state of vetmed please follow this blog, see me on YouTube, Instagram, BlueSky, and our Jarrettsville Veterinary Facebook page. 

Pawbly.com for pet care questions and cost of care cases.

We also just started our non-profit Pet Good Samaritan Fund. See our stories of helping pets in critical need there.

The Dilemma. What do you do when you don't think it's time to euthanize?

 

There was still a tag attached.

That’s what I remember most vividly. There was still a big cardboard tag, the kind that keeps you from being able to fit the merchandise in your pocket as a theft deterrent device, still attached to the obviously brand new toy she held so proudly in her mouth. It was the kind of tag that allows it to be hung on a rack for easy display whilst also providing the descriptor that announces the features of the toy that your pup might find most exciting and enjoyable. The colorful cardboard backing to allow plastic ties to prop up mouthpiece rope from the stuffed animal body and prohibit easy pilfering. That tag was hanging out of one side of her mouth as she clung to the beloved toy that dangled from the other. Toy and tag in tandem swinging from one end of her while the other wagged tail so hard it made her bony hips hula.

Her name was so endearing it made me stop to smile. Her name, a blossom in springtime, a flower in the glimmer of an eye, the baby of a movie star who wanted to be cool and still maintain cute. I’ll call her Honey. She was bright-eyed, exuberant, bubbly, bounding and exploding with joy to be around people. She is the lab pup every Labrador-lover dreamt of. She is pure love and kisses in your face the minute she gets close enough to steal your cheek unguarded. She is the reason I became a veterinarian. She is the reason every pet loving person grieves for decades when they lose their beloved pet. She is perfect. BUT, she is also old. 11 years old to be exact. She has not been to the vet in many years and her very dapperly dressed dad is sitting quietly in his designer loafers without laces, cross-legged in pressed, creased herringbone tweed pants. Where Honey is outgoing and energetic, he is stoic and reserved.

There is a foot of snow on the ground outside and every inch of landscape is slush and snow. I look at his buff-tan-kidskin leather loafers and wonder how he got from his car to our exam room on this yacht shoes missing soles. I look for an assistant who must have carried him in, knowing Honey wouldn’t have permitted an easy passage and yet he shows no sign of snow or wet.

I sit on the floor next to Honey and she cuddles up in my lap immediately. 

I am here in this room with them both, on the floor embracing Honey and delivering the hardest conversation I ever have to be present for.

This is Biscuit.. she reminds me of Honey.
I adore this girl,, and she knows it

I look at Honeys overdressed dad and say, “I’m sorry but the veterinarian doesn’t feel right about this.” He is quiet, his eyes narrowing and his composure tightening. He is waiting for me to dig in, and I see him returning the favor.

You see Honey is here, brand new toy in tow, wagging, happy and excited to be with us, to be euthanized. Her dad is here, holding her tight on a short leash, stoic, reserved and yet determined to make this a one way trip for her.

I go on to say; “We have a terrible problem with burnout, suicide and mental health. I do not force anyone to do anything they don’t feel right about.” I let the words fall around him hoping they landed softly enough to allow a crack in the façade to let the light in just a little bit?

I waited. I stroked Honey’s head and whispered a mental “I love you,” knowing I would likely never see her again.

These are the moments of the days of my veterinary life I despise. The moments that remind me to be brave and stay true to my heart,, even if I am alone in this.

I was the fourth person to enter this room with Honey today. The first had been our vet tech who had placed both in the Comfort Room as his appointment with Honey had been scheduled as a “QOL” exam, short for quality of life. We do not book euthanasia appointments with out a veterinarians prior consent. This is not a slaughterhouse. You do not drop off to pick up remains later. We are a family who loves pets as our own family. We take this request as a discussion and a decision not lightly agreed upon. If pets are truly property there is no conscious of grief to surrender yourself to. But we all know pets are so much more than this to all of us. We know that they are our truest friend. Our most adoring confidant, our reason for early wake-ups and long walks. When everything else in life seems questionable and unreliable your pets will remind you they are your constant. We don’t need much more than the belonging they inherently give us.

The technician came back to the treatment area to report that Honey was walking well, seemed happy as a lark, was carrying a toy to show us how delighted she was to have it, and that she was deeply concerned that Honey looked A-OK. She couldn’t imagine what kind of quality her dad was in search of. Honey had bounced up to her, thrust her toy in her face, dropped it to the ground and planted a big wet kiss on her face. The technician was smitten with Honey.

The second person to enter the Comfort Room was the veterinarian. In less than a minute Honey had given her the same welcome, and after a brief exam it seemed that Honey had aging back legs and might benefit from an analgesic and NSAID. The veterinarian also offered to run some routine diagnostics and see if we could provide some options to help improve her quality and spare her life. A discussion ensued about cost, benefit, possible side effects, and after a few moments Honeys dad said, “the family has decided. We are ready to put her down.” It hit like a blow. The veterinarian countered. “Would you consider surrendering her?” He nodded, she left and the office manager entered.

In the bowels of the hospital the staff gathered to hear what the veterinarian recalled. “He’s going to sign Honey over to us. Call Heidi, see if she will come down and meet Honey.” We started to make plans to find Honey a new home, and we started to draft a list of diagnostics to run to make sure we knew what Honey had going on inside. The techs were excited, bustling and congratulating each other on their interventional good deed. There was a levity that spread, it was hope packaged in healing hands and warm hearts. It is the lifeblood that feeds the marrow of a place like this. It is the small miracles that fill our long days with purpose and stories and the passing of intentions into matters that build our souls and fill our sails. For a place like our veterinary clinic it is the small wins to help make the inevitable tragedies more palatable.

A few minutes later the office manager came into the treatment area. We all knew by her quiet entrance that the news was bad. “He won’t surrender her.” The girls begged for a “why!?” She replied; “He doesn’t want her to be with anyone else.”

None of us could accept it. They all argued with how the hopes had been dashed so quickly. Had she asked the wrong question? Had it been lost on him in translation between a vet and a manager? Should we send the vet back in?

The girls suggested alternatives to save her life, spare her from being disposed of so coldly and unconscionably, ..

“Can’t we just say we euthanized her? He doesn’t want to be with her anyway?” The first option they threw out.

“What if we only give a little bit of the solution?” Like adding a splash of water to the euthanasia solution might dilute it to the place where it wasn't effective.

Desperate pleas for a desperate place. 

There were no answers left to offer. We only had one choice left.

Honey's dad wasn't going to let her have any other option than the one he walked into our door deciding she deserved. These places, these cases, these are the ones that kill you. For some of us, literally and completely. They destroy lives that care and our ability to care again.

I looked at the other veterinarian. She looked back at me. We both didn’t want to be the other persons answer. The mirror of responsibility to the staff who always had their hearts on their sleeves and worked so hard to just be a kind heart to a pet in need. We didn’t want to put the other in a place of heart-wrenching decision making.

“I can’t do it,” she said. “I just can’t.”

I looked at the office manager. “He is not going to surrender her.”

That left me. Alone, and with a Honey of a problem to reconcile alone. 

I walked into the room with Honey. The fourth person she brought her new toy to. The fourth person she was as excited as the first. I sat on the floor, she flopped, toy in tow bouncing with its cardboard tag alongside her tongue into my lap.

I whispered silently to her longing eyes of love, “I love you.” 

Honey is not alone. She has me rooting for her. Alone in a quest to remind her father, her family, whoever, that there has to be compassion, even in times of mercy, and we have to remember how precious each day is and fight for our chance at seeing tomorrow with love, hope, and kindness in our hearts.

Honeys dad tried to argue our stance. He made phone calls, he stood fast in his decision. When I cam back into the room some minutes later I handed him two bottles of analgesic hope and a paper that said Honeys treatments had been on the house. I added that I hoped it help her feel better and that we were here if we could help her again.

I extended an olive branch of defiance. I stood by my staff who would have been balling and questioning my cruelty had I chosen Honeys  family’s side. I stood by being kind when it wasn’t the right thing for me to do for her family. I stand here now not knowing if it was the right thing for Honey, and why I should be asking about it being anything other than that.

Here's more on Honey's case;

..and so the question remains? What would you do?

I posted this story within a few days of it occurring. I had to find a place to put the heavy heart I was carrying. This job, this heart on your sleeve, and this degree of emotional investment has a cost.

Three months later (to the day) we got a phone call. Honey was still alive and her family wanted to surrender her to us. We were blown away, excited, and relieved. We just didn't know what condition she would be in. We knew that her dad had been back once to buy more analgesics for her. He also wanted to surrender the other dog she was with. (WHAT!? Another dog)? We said yes!

Honey with her new friend Emma, on her first day in rescue

After I posted this blog, and the follow up news, the local social media pages blew up with stories about these two dogs. Here are some of the excerpts;

Here is the place Honey spent most of her life. I have heard from multiple people that she was either locked up in the cage outside or in a crate in the garage.

I want to reiterate that it kindness to bring her to us. To surrender her took effort and compassion. I am going to hold onto this.

What Am I Supposed To Do?

The question plays on repeat. Over, and over. And, over again.

It is inescapable. Perplexing, vexxing, and excruciating. All of these and sticky beyond excision. 

Nana, broken leg, ER advice; "surgery 10k, or euthanize"
my advice; "cage rest" 
she is alive and doing well today because her dad refused to have only two options for her

There are fixable veterinary problems all around me. In my effort to provide exposure to these treatable and yet often ignored veterinary issues, encouragement to face and fix them, I seem to have made myself the wailing post. I have become the beacon for hope and last place for help when there is none to be found at the footsteps of present veterinary provider. 

My question isn't why I have become this person, my question is how do I keep from becoming the only vet who cares enough to put the patient before the profits and the fear?

And all of those blocked cats..

I have spent a great deal of  time asking me how I got here? Why I feel so alone here, and what the hell I do about it? 

I have spent so much time in the problem that I cannot walk away. I cannot shutter it, suffocate it, stow it, or sacrifice it. I am in it, wholly and without reserve. 

What would you do if you knew there were answers, some of them ridiculously easy to solve,  answers that would save lives, save human hearts from being crushed, and right a wrong that just grows more egregious as it  consumes the caring around it.

What do I do?

And all of those PU surgeries

Today it was another desperate plea. A question on the Pawbly, the pet care site asking for help. They are always the same. 

"I love my pet. They are my whole world. They have this problem..... I have been to so many vets, no one cares. I saw your video. Is there anyway you can help me?" .. and there is always a photo. A photo of the pet. So sweet, innocent, and fragile and in desperate need. How do I turn away from those faces?  How do I stay in this profession if I sacrifice my ability to have compassion so strong it compels?

Babybear

Veterinary medicine is about taking care of animals. Somewhere along the day to day grind this got lost. It became about money, and egos, and trying to be bigger than our britches. We became distant from our purpose, and divided from our clients. When it was not profitable, or easy, or worth our time we blamed them, the clients, the people who make all of this possible. We used cruelty to remind pet parents that this illness, this unforeseen accident, disaster, (albeit treatable), isn't worth us intervening if they can't pay us handsomely for it. The cost of care has skyrocketed, the treatment for all of the ailments remains what it was decades ago when everything was a few  hundred dollars, or less. 

.. and so I remain here. Asking myself the same question and dedicated to finding, exposing, and disrupting the same problem.

Want to see what I am talking about?

See my YouTube channel 

or Pawbly.com