Futility in Veterinary Medicine and Its Impact on Wellbeing | Episode 21 | Reviving Vet Med

Recent surveys demonstrate a perception that futile care is common in veterinary practice and contributes to distress among team members. However, the definition of futility in veterinary medicine is unclear and we need to better understand these situations to ameliorate psychological distress and improve wellbeing. 

In this episode, I share my own experiences with futile care, as well as the definitions used in human medicine, and how these insights combined with personal reflection can help to reduce moral stress and foster wellbeing in veterinary medicine. 

Blog Post

Defining Futile Care and Its Impact on Wellbeing in Veterinary Medicine: https://marieholowaychuk.com/2022/08/03/futile-care-and-the-impact-on-wellbeing-in-veterinary-medicine/ 

Related Articles

Ethical conflict and moral distress in veterinary practice: A survey of North American veterinarians: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6271308/ 

Medical futility is commonly encountered in small animal clinical practice: https://pubmed.ncbi.nlm.nih.gov/35584050/ 

Medical Futility: Its Meaning and Ethical Implications: https://www.acpjournals.org/doi/10.7326/0003-4819-112-12-949 

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Transcript

Hi, everyone. Welcome to another episode of Reviving Vet Med. In today's episode, we're going to be talking about futility in veterinary medicine. And you might be wondering what does this have to do with mental health and well-being? Well, there have been some recent posts on social media that drew my attention to this, and this is a topic that I've definitely been involved with previously from a well-being perspective.

I'm also an emergency and critical care specialist, so the work that I do also lends itself to some futile situations. And recently on social media, there have been some research studies that have been shared and some discussion around futility. And it was interesting on one of the posts that I shared, there was there was quite a lot of comments with regards to individuals' perceptions of futile care and some people referring to, you know, owners wanting to palliate their pets rather than perform euthanasia. And it really led me to just kind of take a step back and really think about what the definition of futile care is and what this means for our well-being. I think this also ties in really nicely with another topic that has been frequently discussed on social media lately, which is spectrum of care.

And spectrum of care is really this idea that our clients want to do a whole spectrum of different things for their pets. We have those clients that want to do the bare minimum, that their pets may be seen more as service providers or, you know, fixtures in the home rather than, members of the family or, individuals, you know, that they would go to the ends of the earth for. And so, we need to be able to accommodate that as veterinary professionals and to recognize that while we might do things differently and while we might not choose the same treatments that our clients would choose, that we still have to find a way to support them. Now in the context of well-being, psychological distress really stems from not fully understanding something or making sense of it in our lives. And that's why in today's episode, we're really gonna focus on making sense of futile care, what it means for us and our well-being as veterinary professionals, and how we can deal with these situations when they arise in practice.

So, let's go ahead and get into today's episode. This is the Reviving Vet Med podcast, and I'm your host, Dr. Marie Holowaychuk. My mission is to improve the mental health and well-being of veterinary professionals around the world. So, as a criticalist, when you ask me about futile care, I immediately think of having a patient on the ventilator with no reasonable chance of recovery. I've definitely experienced this in veterinary practice.

I actually wrote a blog recently, sharing this story. And I was locuming at a referral hospital and, long story short, there was a little Yorkie that had had severe tracheal collapse during its life. It had been stented. It had been stented actually a couple of times, and the stents, had had some complications. But, unfortunately, because of the dog's persistent and severe tracheal collapse, the dog had also developed mainstem bronchial collapse and laryngeal collapse.

So, we ended up actually doing a tracheotomy on the dog. And, even then, the dog was not able to breathe on its own and maintain oxygen levels without having a tube in his airway. And so, in a situation like that where the dog is ultimately reliant upon ventilation, or intensive care to survive, that is considered a futile situation. And, you know, you can imagine in this situation, what my team was experiencing, it was very distressing, you know, to have a patient on the ventilator that you knew was never gonna be going home. And, you know, there were all sorts of comments like, why are we doing this?

You know, what's the point? What if another pet needs the ventilator and we can actually save them? You know, why can't the owner see that there's no hope and that this is futile? And, you know, the situation was quite clear to us, and ultimately, it became clear to the owners as well. And they did make the decision to euthanize their pet, which I know was a very difficult one after everything that they had invested.

And it was hard on the team as well. The surgery team had been quite involved in this little dog's care. And, you know, it's interesting. I bring up the situations of futile care and have discussed them with others who are in veterinary practice. And what's interesting is the different situations that people also share when they think of futile care.

I've heard people say, yeah. You know, I don't think that chemotherapy should be offered to an old dog that has other diseases. You know, to me, that seems futile. Someone else might share, yeah, you know, if I've got a really, really old cat with chronic kidney disease and it's, you know, gets diagnosed with diabetes, I think it's futile to try and regulate that. And certainly, in the context of the ER, you know, where I most of my experiences, you know, I hear a lot of emergency doctors, you know, this dog has a hemoabdomen, and why are we bothering to take it to surgery when we can see metastasis, you know, in the body?

And so, you know, there's varying degrees of what individuals consider futile. What's common in each of these situations, though, is how the team feels. So, when the team member feels that something is being done that they would not recommend as a care provider, as an advocate for the patient, that's very distressing, and that creates what we refer to as moral stress. Morally stressful situations where we're doing something that we feel goes against our moral capacity or moral belief system. Now what's interesting about this in the context of futility is that these examples that I shared just now, the last three of them are actually not futile situations.

That these are situations, yes, where we might not recommend that. We might think that, you know, the odds of helping the patient are going to be very low. However, there is still a chance of benefiting the pet. Now you might be wondering, well, how is the pet gonna be benefited by just prolonging the inevitable? Not to get very morbid here, but the inevitability is we're all going to die, and our pets are all going to die.

It really is around the circumstances in which that is going to happen. So, I'll talk more about that and really the definition of futile care. But I first wanna just share that there has been some research, in this area, which is really what prompted my blog post and my podcast episode that you're listening to now. And this all started, about five years ago. There was an online survey that was sent to, veterinarians in The United States and Canada asking questions about futile care and its impact on well-being.

And I'll link to this paper in the show notes, but the results were published in the Journal of Veterinary Internal Medicine and showed that it was about 22 of the approximately nine hundred veterinarians who responded, who had rarely or never managed cases where they felt a pet owner was requesting treatments when those efforts were considered to be futile. So, it was about one in five vets that really felt you know, I've never been in a futility situation. But almost all of them reported feeling conflicted or upset because there were times that pet owners had refused to do what they believed to be in the best interest of the patient. And I think that's where we have to recognize that distinction is we may not all be experiencing situations of futile care, but we are absolutely all going to be in situations where we recommend what we feel is best for the patient or the pet, and the pet owner decides otherwise. And this is really hard.

We know that studies are demonstrating that psychological distress is on the rise among veterinary teams, so we really need to be diligent in identifying what's causing that and how can we prevent it. So, what was really interesting to me, was not so much that first study, which made a lot of sense. It, you know, brought this issue to the forefront. It helped to remind us, you know, the importance of these morally stressful situations among veterinarians. But more recently, there was a survey that was published in the journal of the American Vet Med Association.

It was a survey of 500 veterinarians in small animal general and specialty veterinary practice, and it revealed that ninety nine percent of those respondents said that they had encountered futile care within their veterinary careers, and eighty five percent had encountered it within the past year. And sixty one percent said that the encounters had occurred in both inpatient and outpatient settings. So, for me, I hear this, you know, these statistics and I'm shocked by it because it's really hard for me, first of all, as a criticalist to conceptualize how would we be extending futile care to a patient who's at home. You know, if they're able to go home, then they're able to continue to live. And, you know, what it was just perplexing to me.

And it was just it was extraordinarily high compared to the research that had been done a few years before. And so, the authors who conducted this research also emphasized that, gosh, these statistics were quite high, and maybe we need to take a step back and really educate veterinary team members on what exactly futile care is. So, I dug some digging into this myself, and I came up with a definition for medical futility that I prefer that makes sense to me and that I'm gonna share with you today. Now this was proposed more than thirty years ago in the Annals of Internal Medicine. And they state that futile care is any effort to achieve a result that is possible, but that reasoning or experience suggests is highly improbable, and that cannot be systematically produced.

So, what they recommended as the authors of this definition is they basically said that if you share this experience or this case with your colleagues or you delve into the research and you find that whatever the recommendation is, whatever the treatment that the author want, pardon me, whatever the treatment that the owner wants or that anybody on the team is advocating for, if it has been shown to be useless in the last 100 cases, then it should be regarded as futile. So, the last 100 cases of trying to manage this particular situation have not been successful, then it should be considered futile. And again, very often these situations, we have to tell owners, we don't have the research. We don't know.

You might consult with a specialist to get their opinion, or you might contact some of your colleagues to see what they think. But very often, we don't have the research studies to know, but you might have a lot of experience yourself to draw from. Now another situation, which is one that I definitely faced in the ICU, is that any treatment that preserves permanent unconsciousness or fails to end total dependence on intensive medical care should also be regarded as futile. So, the Yorkie that I shared with you, that case, the fact that that dog was going to be completely dependent on positive pressure ventilation for the rest of his life, we knew that that situation was futile. So, I'm curious, you know, as you hear me talk about these definitions and what futility actually is, I wanna make sure that it's clear, and I want it to be clear to you that futile care is different from care that is simply not going to change a patient's outcome.

And I think this is where we get stuck. And I'll be honest with you. If you were to ask me what my definition of futile care was a few months ago, I probably would have said to you, well, it's something that we do that's that doesn't make a difference. It's not gonna change the situation. And that might be true in certain circumstances.

You know, putting that dog, the Yorkie, on the ventilator, with an airway that was never going to be able to breathe without it, yes, that is considered futile. However, and if you think back to one of the other situations that I shared, you know, attempting to regulate a diabetic cat that has, you know, is old and has concurrent kidney disease, that may change that. You know, it might not it's not gonna change that the cat is going to die probably from its chronic kidney disease or from a diabetic crisis. However, that doesn't mean that treatment could be possible in that situation. And if you talk to all the internal medicine specialists that I know, they will say that they've managed lots of very old cats with, you know, severe chronic kidney disease who do have concurrent diabetes.

Now is it easy? No. Does it take a very committed owner? Yes. Is it going to cost a lot of money?

Yes. That doesn't mean that it's futile. So, recognizing, you know, I think sometimes in veterinary medicine, we get stuck, and we think that, you know, discharging a patient with a terminal illness instead of performing euthanasia is engaging in futile care. And that's not true, you know, if you think about situations of palliative medicine in the veterinary space whereby, we might have that chemo abdomen dog that has visible metastasis. I mean, let's be honest.

It's probably hemangiosarcoma, and they pretty much all have metastasis, you know, even if it is microscopic. That family may want more time with that pet. And so, yes, it's not gonna change the fact that that dog is probably going to die or will die from its hemangiosarcoma. However, if that is the wish of the owner, even though it's perhaps not what we would choose to do, can we take a step back from that and recognize that it is not going to hurt the animal to go to surgery, to remove, you know, the visible tumor, the large tumors, whatever is bleeding, if they can stop the bleeding, and to discharge that patient potentially to, you know, live days or weeks or maybe even months with his family. Now don't get me wrong.

Again, I'm not trying to advocate for certain ways of managing these patients and saying that one way is right or wrong. What I'm trying to share is that if you feel yourself reacting to these situations and feeling that moral distress and feeling like what the owners are doing is wrong, this is one exercise that you can do to take a step back and just reevaluate that. And that might help you to get a handle on your moral stress, and to put some context to the situation. Or I should say, you know, enhance your perspectives around the situation. So, here's what I would recommend for you.

The next time that you find yourself in a situation that you believe is futile, I want you to consider two questions. The first question is, has medical treatment not been useful in the last 100 cases you've seen or read about? And number two, is medical treatment likely to result in total dependence on intensive medical care? K? So, if the answer to these questions, either one of them, doesn't have to be both, if either question the answer is yes, then the situation is considered futile.

And when you have a conversation with the owner, it's important to share that with them, to say, look, you know, when we think about situations that are futile, meaning that, you know, that there is no chance of, extending life that is comfortable for this patient. This is what I've come to understand, and this is what my experience has been in these situations, however wording it, you know, feels comfortable for you. Now if the answer to these questions is no, then technically speaking, by way of medical definition, the situation is not considered futile. And perhaps the owner could be assisted with achieving their goals for their pet. So, this is where, you know, a lot of the palliative care folks really have a wonderful language around goals of care conversation with owners.

So, speaking with owners where, you know, we look at the patient and we think, oh my gosh, if this was my dog, cat, rabbit, horse, you know, insert whatever species, I would be euthanizing it. I would not be doing anything else for this pet. But yet the owner is insistent. So, get curious. Talk to the owner.

Ask questions. What are they hoping for in this situation? And the reason it's so important to ask those questions is twofold. Number one, they might be very out of touch with reality in terms of what their wishes are and what is actually possible for their pet. So, for example, if they have the hemoabdomen dog that is going to surgery to have the bleeding stopped, and they're hoping to get another several years that's their goal.

Well, you know, we want him to live till he's 12 and he's only 10. There needs to be a conversation. Look, you know, the last thousands of cases that have been documented in dogs that need to go to surgery to control bleeding with hemoabdomen is that ninety percent of them, you know, have, metastatic disease, and the median survival time for those dogs is such and such, you know, so that you have this conversation with them. Now if their goal is, you know what? Our friend is or not our friend, maybe, but well, maybe it is a close family friend who's attached to this pet, but maybe it's a family member.

You know, our son is overseas on a European vacation, and we really want him to be home to say goodbye. How can we make that happen? How can we meet that goal? And in many situations, we can make that happen or meet their goals with palliative care, with anti-nausea medications so that they maintain their appetite, with pain relievers so that they stay comfortable and with whatever else that you can do so that they are not in distress, they are not suffering, they are not in pain, but they're also not getting euthanized. Okay?

So, you know, that's something to consider there. So, you know, again, I really go back to this idea, that I mentioned in the introduction around spectrum of care. And I think we are not only seeing spectrum of care in the context of, you know, different relationships that pet owners have with their, pets or different amounts of money that they're willing to spend on their pets, but also different ways that owners are viewing end of life care for their pets. I think gone are the days of, you know, an animal is healthy until it's not. And then if we can't fix it readily, then it gets euthanized.

I think that we, similar to in human medicine, are really embracing palliative and end of life care. And I think that this is something that we would benefit from exploring more with some of our clients who really seem reluctant to perhaps consider euthanasia or do some of the things that we're offering, but could we consider something else on the spectrum that will put our moral stress at bay and recognizing, you know what? The situation is not futile. This animal is not suffering. I can take a step back and recognize this is not what I would do in this situation.

However, I feel putting these treatments in place and checking in with the owner, you know, at set intervals and having a conversation with them so that they really fully understand what these treatments may be doing. They're not gonna cure the disease. They're not going to give them years of additional life, but perhaps they will allow them to meet those goals that are most important to those owners at the end of life. And I really believe that if we can engage in those thought processes in these situations, that that will really help to lessen our moral distress in these situations. Remember, even just recognizing, and fostering well-being.

So, and fostering well-being. So, in summary, some key points from today's episode are to really think about these situations that you would typically regard as futile care and ask yourself, are they truly futile care? And if the answer is no, it's just different care than you would recommend or do for your own pet in a similar situation, then maybe taking a step back and recognizing and being compassionate with yourself that, yes, these are stressful situations. Nobody wants to feel that they're doing something that they shouldn't be doing. And I'm not asking anyone to do something that they feel very strongly against doing.

But perhaps in these situations, after having a conversation with the owner, you might find a common ground whereby you can help the owner to meet their goals, and you can also mitigate your own feelings of veterinarian who maybe has, more long-standing practice, either in specialty care or in palliative care or end of life care. So really encouraging you to consider that, and I hope that helps you in these situations to really manage those feelings of distress when they come up. So that's it for this episode of Reviving Vet Med. I'm really curious as to your thoughts and takeaways. I know this was a big episode, somewhat controversial compared to some of the episodes that I typically record.

And I would just love to know what you're thinking. Was this helpful? Have you had similar situations where in hindsight, it probably wasn't futile? It was just about, you know, maybe changing your perspective on the situation or having a more open conversation with the owner as to their goals. You can find this episode on social media and share in the comments there.

I'm most active on Instagram, Facebook, and LinkedIn. So, find me there, or you can also email me directly, info@marieholowaychuk.com with your thoughts and comments. And if you have any ideas for future episodes. You know, these situations are tough, and I really do urge you to recognize the toll that they can take, especially if you are feeling that sense of moral stress and take extra care of yourself when you experience these episodes. And know that you're not alone, that clearly based on survey research that's been done recently, that this is a very, very, very common experience in veterinary medicine.

And self-compassion is gonna be key for all of us getting through these situations. Once again, if you're interested in the resources for today's episode, please check out the show notes for those. And before I go, I'd love to thank my amazing assistant, Jamie, for producing this episode, and you for taking the time to listen. I hope you'll tune in next time. And in the meantime, take care of yourself.

Bye now.