W. Dunbar Gram, DVM, DACVD, MRCVS, is Service Chief and Clinical Associate Professor of Dermatology at the University of Florida College of Veterinary Medicine in Gainesville, Florida, USA.
Rowan J. Milner, BVSc (Hons), MMedVet (Med), PhD, DECVIM-CA, DACVIM, is Professor and Chair of the Department of Small Animal Clinical Sciences at the University of Florida College of Veterinary Medicine in Gainesville, Florida, USA.
Remo Lobetti, BVSc (Hons), MMedVet (Med), PhD, DECVIM-CA, is an internist at Bryanston Veterinary Hospital in Johannesburg, South Africa.
Communication, Caregiving, and Chronic Disease
Disease is often conceptualized as a temporary state and recovery as close as a single dose of medication, a round of antibiotics, or a few days of rest. Sometimes the "quick fix" doesn't resolve the issue. Instead, we are left with the realization that sickness and death do not happen because medicine fails. Sickness and death happen because breakdown is the natural aging of biology.
Veterinary medical schools are designed to prepare their graduates for the practice of medicine. How prepared they are is directly related to how those institutions define that practice. Is it merely the ability to apply diagnostics and treatment protocols, surgical preparedness, and so forth? Or does the practice of veterinary medicine include something more: the ability to define and seek an optimal outcome when there is no quick fix or any fix at all?
Veterinarians need to graduate with the knowledge, experience, and resources clients need and expect to properly handle these situations. Veterinarians must learn and apply other nonmedical skills if they expect their medical knowledge to be put to good use, particularly in situations of chronic disease management. These nonmedical skills include displaying empathy and active listening. So what is the importance of learning these skills and methods that go beyond veterinary medical science? Simply put, these tools are needed when treating patients with chronic diseases.
Empathy, active listening, and other nonmedical skills form the solid rock upon which the veterinarian stands when implementing medical knowledge to the highest potential allowed by the client. Only by establishing rapport and trust with clients will veterinarians help them expend their financial, emotional, time, and physical resources to make the investment necessary to improve the health, well-being, and quality of life of their pet.
Managing chronic disease brings a great deal of change for both the patient and the family. This change can happen both quickly, in the form of a terminal diagnosis, and/or subtly, in the form of symptomatic changes evolving over a period of time. Establishing this solid trust-based relationship is particularly important. Therefore, how a veterinarian establishes a relationship with a client, then delivers the news of change, and finally manages the emotions surrounding the change may determine whether medical treatment is facilitated for the well-being of the pet. Because veterinarians have the obligation to deliver the best medical care to patients, which hinges almost entirely on the veterinarian-client relationship, they must develop and utilize the skill sets necessary to communicate with, find common ground with, and persuade their clients.
This first chapter will explore how veterinarians can properly implement techniques to communicate the ideas learned in medical school to the client to improve the treatment and/or supportive care for the betterment of the chronically/terminally ill or aging pet. We will then discuss various specific skills that will aid the veterinarian in setting up the conversation appropriately, ensuring all parties are on the same page, learning how to adjust one's communication under certain difficult situations, and, finally, having the conversation about potentially ending a pet's life to mitigate pain and suffering.
It would be interesting to investigate how veterinarians may be impacted in situations where the client could not serve as legal proxy.
In veterinary medicine, our clients served as proxy for their pet's wishes in almost every interaction they have with a veterinarian. As veterinarians, we have two parties to serve; the owner/client and the patient. (Shelter medicine is the only exception to this rule, as treatment of animals in a shelter setting rarely include an owner.) In human medicine, the client and the patient are generally one person. Even in pediatric medicine, the parent is the guardian of the child, not the owner of the child. The parent generally has the levity to make decisions, but if that decision is not in the best interests of the child (as reasonably determined in a court of law), then the parent will lose the ability to make decisions for that child. In fact, it took a groundbreaking case in 1984 (In re Guardianship of Barry, 445 So.2d 365 (Fla. 2d DCA 1984)) to determine that a parent can serve as proxy for their dying infant child's wishes, allowing the removal of life support in this case.
And particularly in cases involving chronic disease, we remove "life support" frequently in many different ways. Legally, clients are owners of the patient and our communication and established rapport with that owner is imperative if we are to gain the trust such that our medical knowledge will be put to use for the betterment of the pet and/or the treatment of a disease.
You are more likely get back on a horse if your dismount is smooth rather than if you are bucked off. The trauma of a difficult dismount may hinder your desire to return to the saddle; pet ownership is similar. When clients have a peaceful end-of-life experience with their pet, they will heal more quickly, return to pet ownership more quickly, and more readily be back in your clinic. The clients that feel that the loss of their pet is "so traumatic, there's just no way I'll ever get another dog" are usually the ones that we want to have adopt another animal! Those are the clients that truly care for their pets, providing good medical care and giving animals safe and loving homes.
This end-of-life experience applies to more than the actual euthanasia process. The experience begins much sooner, when a chronic or terminal condition arises, even if that condition is simply "old age." The presence of an undesirable situation leaves the client feeling cornered. Emotions are heightened. There is more sensitivity to a veterinarian's communication. Each may contribute to the client's difficulty in making a decision on a treatment plan. Therefore, how veterinarians respond and adjust their communication in this tense situation will impact whether treatment plans are accepted, productive, and helpful to the pet and client.
In this chapter, we will first explore the mentality of clients by understanding the emotional impact of chronic disease. We will explore how to establish relationships with clients, how they respond to stress, how to best approach clients, and finally how to adjust your verbal and nonverbal communication to reach maximal effect and avoid conflict.
Impact of Chronic Disease on Quality of Life for Both the Patient and Caregiver
Veterinary medicine aims to recognize and effectively manage pain in a way that decreases suffering and increases the patient's quality of life for those pets with chronic conditions. In assessing and determining quality of life, the term "quality" has many meanings. Essentially, "quality" signifies a "general characteristic or overall impression one has of something" (Welmelsfelder 2007). Veterinary professionals recognize quality as a separate entity from quantity, as the concept "more is better" is not necessarily true. Therefore, to optimize an ill patient's quality of life, the veterinarian might encourage treatments that favor the patient's perception of welfare rather than longevity.
Illustration of the above concept is seen through the treatment options for a pet diagnosed with cancer. The characteristic methods of cancer treatment are typically surgery, chemotherapy, and/or radiation. Upon evaluating the type of cancer, how quickly it grows or spreads, and its location, a veterinarian must weigh the effects of treatment to the patient's quality of life. This information is then shared with the caregiver, and together, they make an informed decision based on the client's ability to pay for, provide, and emotionally handle the care associated with extended treatment.
For instance, when deciding whether to perform surgery, the veterinarian should determine whether the costs to the animal outweigh the benefits. If the removal of a large tumor also requires removing a vital organ, thus resulting in the loss of an essential bodily function, the costs largely overtake the benefits. If the patient must live in anguish to increase lifespan, it is best to choose an alternative route that allows instead for comfort and contentment. However, if the treatment offers longer life expectancy in addition to a positive prognosis with only acute adverse effects, it is worth further exploring. Often, those associated acute conditions can be remedied with medication or simple lifestyle changes, generating a wise investment in exchange for long-term well-being.
To understand how chronic diseases impact a companion animal, there must first be a clear understanding of what quality of life is and how it is assessed. We can expand on the previous definition of the term "quality" by defining "quality of life" as "the total well-being of an individual animal" (August et al. 2009). Although definitions of the term vary, most can agree that quality of life encompasses the physical, social, and emotional components of the...