Recognizing Futile Care in Veterinary Medicine

Consider the case of a 17-year-old domestic shorthair cat with chronic kidney disease (CKD) hospitalized for diuresis and supportive care. After 3 days on intravenous fluids, antiemetics, and appetite stimulants, the kidney values are unchanged. The pet has not eaten in over a week and spends most of its day in lateral recumbency, only lifting its head occasionally when the owner visits. Despite the cat’s condition and grave prognosis, the owner wants to continue hospitalization and is considering placement of a feeding tube to provide nutrition.

Cases like this are distressing for all involved—the patient, the pet owner, the veterinarian, and the veterinary team members who are cage-side providing care in futile situations. In a profession with continued technological advances in diagnostic and treatment options for our patients, we may not find ourselves asking the question of whether we can do something, but whether we should.

But are cases of futile care actually common in veterinary medicine? A recent study in the Journal of the American Veterinary Medical Association sought to answer this question.¹ Nathan Peterson, DVM, DACVECC, associate clinical professor at Cornell University and one of the study’s authors, shared his surprise in the results. “It was a problem I knew I was experiencing,” he says. “We went into [the study] thinking it was a more isolated problem.” Instead, the survey found that 99% of veterinarian respondents—the majority of whom were board-certified specialists—believe that futile care occurs in veterinary medicine, and 85% stated they had experienced a case of futile care within the previous year.¹

“The near unanimity in people’s experiences points to this being a profession-wide problem,” says Dr. Peterson. Because of the amount of distress caused by these situations, learning to recognize and navigate situations of futile care is important to improving mental health and wellbeing for veterinary professionals. A common language is needed to facilitate discussions around futile care and find ways to support patients, pet families, and veterinary professionals.

What is Futile Care?

Dr. Peterson shared a personal case of a German shepherd dog with megaesophagus that was repeatedly hospitalized for aspiration pneumonia. As presentations increased in frequency and hospitalizations increased in length, he advised the client that the pet would eventually die from aspiration pneumonia. Despite this, the owner elected to place the dog on a ventilator during a severe episode. “[This] went against everything I thought was right at the time,” Dr. Peterson says. The dog did survive the ventilator but was euthanized a week later.

While a case such as this or the cat that is nonresponsive to treatment for CKD may be easy to recognize as futile, other cases can be challenging, especially in the absence of a standard definition. The study authors propose the following: “Futile care occurs when the continuation of current treatment or institution of new treatment is not expected to alter the clinical course of the patient, even if such treatment confers some benefit to the owner.”¹

Dr. Peterson notes that the authors “expected this to be an inpatient problem. [We were] surprised by how many people saw this as an outpatient problem.” This raises the question of whether futile care can truly occur in an outpatient setting or if it is being equated with palliative and hospice care by some veterinarians. The key distinction between palliative or hospice care and futile care is whether the patient can benefit from the care being delivered.

“Palliative care is care aimed at improving quality of life,” says Marie Holowaychuk, DVM, DACVECC, a mental health and wellbeing advocate. “Hospice care focuses on comfort and quality of life at the end of life. I believe that veterinarians often conflate futile care with any care that is not going to change a patient’s outcome, which is not the true definition.”

Dr. Holowaychuk recommends 2 questions to help determine if a case is futile: “Has medical treatment not been useful in the last 100 cases I’ve seen or read about? And is this medical treatment likely to result in total dependence on intensive medical care?” If the answer to one or both questions is yes, the situation is futile.

Caring for Clients

Even when care is recognized as futile by the veterinary team, decisions to continue treatment ultimately belong to the pet owner. It is imperative that all members of the veterinary team not only are able to recognize cases as futile but learn how to successfully communicate with these owners. “Compassion, empathy, and patience are key amidst these emotionally charged situations,” says Dr. Holowaychuk.

“Goals of care conversations are incredibly important in these situations,” she continues. “Very often there is a disconnect between the owner’s understanding of the diagnosis and prognosis in relationship to the team’s understanding of the family’s circumstance, beliefs, or goals.” Questions about the client’s goals for the pet, their understanding of the current diagnosis and treatment, and their beliefs about end-of-life care and euthanasia are essential. Exploring these answers with the owner can be a powerful tool to find common ground with the client and move forward together in making patient care decisions.

While empathy is essential in these conversations, Dr. Peterson stresses the importance of honesty as well. He finds that many veterinarians are “reluctant to verbalize suffering to an owner,” but notes that as veterinary professionals, we are trained to recognize subtle signs of suffering that clients may not. “If you think a pet is suffering, you must explicitly state this,” he advises. This honesty may help a client to realize the true severity of their pet’s condition.

Dr. Holowaychuk shares the concept of “Wish, Worry, Wonder” from the Serious Illness Conversation Guide in human medicine²: “I wish aligns with the family’s hopes. I worry allows the team to communicate their truthful concerns in the situation. I wonder is a gentle way to make a different suggestion or recommendation. For example, ‘I wish we could stop the growth of Fluffy’s cancer. I worry that Fluffy’s condition is going to worsen soon. I wonder if we can start to discuss the option of euthanasia.’”

In many situations of futile care, repeated conversations are needed. These conversations do not need to be restricted to veterinarian and owner. In fact, it may be useful to enlist the help of others in carrying on these discussions, including veterinary team members and close friends or family if the client has a support system.

One underutilized resource in veterinary medicine is the use of a veterinary social worker or licensed counselor. These individuals can be especially helpful in navigating situations of futile care for both the clients and veterinary team. While some veterinarians may recommend a grief counselor or pet loss support for clients following the death of a pet, these resources can sometimes be used prior to a pet’s death to help the owner navigate the decision-making process and begin to let go.

Caring for the Team

Cases of futile care create moral distress for veterinary professionals, who know that continued care is of no benefit to the patient—and may actually prolong patient suffering—but are directed to continue treatment. Moral distress is defined as “the experience of knowing the right thing to do while being in a situation where it is nearly impossible to do it.”³ It is one factor that contributes to the mental health challenges that are widely recognized in both veterinarians and veterinary nurses in the profession.⁴ Thus, it is essential that in conversations about futile care, we discuss ways to support veterinarians and team members.

Dr. Peterson has seen first-hand the stress that futile care cases can place on team members. “The real motivation for pursuing this [research] was looking at the effect on the team,” he states. He acknowledges that veterinarians don’t have to carry out the treatment orders. This falls on the shoulders of the nursing team and can result in them feeling they are contributing to patient suffering instead of relieving it, which is a primary driver for many to enter the veterinary profession.

Both Drs. Peterson and Holowaychuk note that identifying and discussing the situation as futile and morally distressing is the first step in supporting those involved. When Dr. Peterson is involved in a futile care situation, he has conversations with affected colleagues and veterinary nurses. “We talk honestly and openly about what we think is wrong and what we think is right,” he says. He also finds value in including team members in conversations with the owners so they can hear first-hand the owner’s concerns and goals. Listening to and participating in client communication can help the team to understand the owner’s decisions and increase empathy and sympathy for the owner.

Even with improved understanding of an owner’s decisions, distress will still be present. Teams should consider having a formal debriefing following particularly distressing cases to allow all team members a safe place to express their emotions. Individual veterinary professionals should also not hesitate to seek support from a counselor or mental health professional. Establishing a strong support system and self-care practices can help to improve overall mental health and may better prepare veterinary professionals for cases that are especially distressing.⁴

Where Do We Go From Here?

“Once we have a working definition, then we can discuss it more,” says Dr. Peterson. “We are trying to open up the conversations [around futile care] outside of specific cases.” He notes that the current survey was mostly distributed to veterinary specialists and that gathering information from both veterinary nurses and general practitioners on their experiences with futile care will be valuable to continuing the conversation. Ultimately, recognizing that futile care is occurring in veterinary medicine and its impact on the mental and emotional health of veterinary team members is only the first step. As a profession, we must work to create ethical guidelines and support our colleagues through these cases to improve outcomes for all involved.