More than 99 percent of 474 veterinarians surveyed said they'd encountered useless or nonbeneficial veterinary care in their careers, according to a new Cornell-led study that documents the prevalence of futile care for the first time.
The authors use a working definition of futile care as continuing treatment when relevant goals can no longer be reached.
“Before Cornell, I was in private practice in Los Angeles for 11 years. When faced with a dilemma like this, I had an obligation to advocate for what I thought was in the best interest of the pet,” said Dr. Nathan Peterson, associate clinical professor with the section of emergency and critical care and lead author of “Medical Futility is Commonly Encountered in Small Animal Clinical Practice,” published May 18 in the Journal of the American Veterinary Medical Association.
“But I also had an obligation to the owner,” Peterson said. “I couldn't just do what I thought was right. It's really quite distressing for the veterinarian and for the technicians and nurses who have to carry out the care.”
The study, co-authored by researchers at Harvard Medical School's Center for Bioethics, also found that 89 percent of veterinarians said they had administered futile care, and 42 percent said it occurs frequently, more than six times per year.
The veterinarians' sense of obligation to pet owners was reflected in the data, with 60 percent of respondents agreeing that every treatment option be presented to owners, 76.3 percent agreeing that futile care benefited owners in some way, and 56.6 percent saying they sympathized with the owners' feelings and wishes.
Paradoxically, the owner-centered approach, the authors write, can exacerbate moral distress for veterinarians and care teams. Previous research by co-authors showed that futile veterinary care was responsible for frequent and severe moral distress in the veterinary community, which they said occurs when a clinician believes they know the right thing to do but are prevented from doing it.
“We're in the midst of a mental health crisis in our profession, and we're very interested in whether futile care contributes to that, which I suspect it does,” Peterson said. “We felt that a first step is documenting that it happens. My hope for the research is that it opens conversations around futile care, and hopefully professional organizations can take a leadership role and try to provide some guidance for how to resolve these conflicts.”
Factors that influenced veterinarians' decisions to provide futile care included allowing time for owners to arrive to be present for euthanasia, satisfying an owner's request that all treatment options be exhausted, and responding to the owners' failure to understand the severity of the pet's condition.
Peterson said these dilemmas have become more prevalent in recent years, as medical advances used for humans have become available in veterinary care. “Now that we have dialysis, mechanical ventilation, a lot of technologies to keep patients alive – that's really stretching the line about what kind of limits we are going to set around what's in the best interest of the patient,” Peterson said.
To bring clarity to these gray areas, the authors suggest establishing a definition for futile care in the profession – respondents were not in total consensus about what futile care means – as well as guidance around how decisions for care are made. A shared decision-making paradigm, where all stakeholders can agree on goals for treatment and whether or not they can be reached, could help, as well as a transparent, systematic approach to evaluating an owner's ability to discuss and understand a diagnosis. Guidance and discussions are also needed around positive autonomy – the right to demand treatment.
“I think as a profession we have focused for so long on alleviating suffering by continuing treatment and making animals healthier,” Peterson said. “And we're not as prepared to strongly advocate for euthanasia, to have those conversations, even when we think that's the best way to alleviate suffering.”
In future research, Peterson hopes to investigate the impact of futile care on support staff. “That feeling of powerlessness for the veterinarian is certainly magnified for the technicians who are often not involved in the decisions and who are directly responsible for providing care,” he said. “That really motivates me to look at the toll this is taking on them.”
Read more at the Cornell Chronicle.
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