Abstract
Conflicting demands sometimes confront the veterinarian towards the end of a cat's life. Valuable guidance on end of life issues in feline medicine, which clearly defines the veterinarian's responsibilities, is provided by the AAFP in a position statement, which appears on pages 421–122 of this issue.
First principles
Four principles constitute the foundation for all treatment considerations when determining appropriate patient care. The first of these principles is the most important one, namely that the needs of the patient must always come first. The second principle is an ancient medical principle: above all, do no harm. The third is that the veterinarian is, first and foremost, the patient advocate. Except in rare instances when public welfare supersedes this expectation, the veterinarian must champion the interests of the patient. The fourth principle stems from the third principle: it is the veterinarian's responsibility to provide every opportunity for the patient to enjoy the ‘Five Freedoms’ (see page 366) and to alleviate patient suffering.
The cat has an exquisite and well-developed ability to appreciate quality of life. Courtesy of Dr Deb Givin
Metamorphosis of veterinary medicine
Just a few decades ago, it was very common for a veterinarian to routinely recommend euthanasia for many chronic, debilitating and terminal illnesses such as feline leukemia virus infection, chronic renal disease, diabetes mellitus and lymphoma. Towards the end of the last century, a growing awareness by the general public of the significant importance of our relationship with our pets was recognized. Veterinarians are in a prime position to acknowledge and honour the human-animal bond.
Significant advances in diagnostic and treatment modalities have been introduced in veterinary medicine, allowing elegant and sophisticated techniques to be readily available to the public. 1
Because of the incredible changes in modern veterinary diagnostics and therapeutics, three ethical principles should be applied to decision-making when considering whether to implement these modern procedures. First: ‘just because we can (do something), doesn't mean we should’ (Dr Matt Sturmer, cited by Rollin 2007). 1 Secondly, the existence and availability of a therapeutic or diagnostic modality is not an ethical argument for its use. Thirdly, the ability of the client to commit financial resources to treat their pet or the demand that such treatment be provided does not constitute a moral or ethical mandate or contract to provide such treatment. If the emotional bond between owner and patient is so strong and the situation so confusing that the owner is unwilling or incapable of critically appreciating the prolonged suffering a patient appears to be experiencing, or that a treatment modality might produce, it is the moral and ethical responsibility of the veterinarian to focus the attention of the owner on the patient's quality of life. 2
Quality of life
All veterinarians wish to maintain and enhance the quality of life of their patients. This includes all of the welfare concepts defined in the Five Freedoms — specifically, freedom from physical discomfort, fear, distress, pain, injury and disease.
While quantity of life is an important consideration in human medicine, the veterinarian must understand and accept a different principle: our patients are constitutionally incapable of conceptualizing quantity of life. But the cat has an exquisite and well-developed ability to appreciate quality of life. It is centered on this principle that the veterinarian must focus on being a passionate and compassionate patient advocate.
The Five Freedoms
Freedom from hunger, thirst and malnutrition
Freedom from physical and thermal discomfort
Freedom from fear and distress
Freedom from pain, injury and disease
Freedom to express normal patterns of behavior as long as it does not cause injury to them or another species
The AAFP endorses the above, internationally recognized Five Freedoms 3
A fair and final plan
In order to develop an appropriate and fair treatment plan for the patient with a terminal prognosis, full disclosure of the diagnostic and therapeutic plan should be carefully and thoroughly discussed with and considered by the client. Morbidity, mortality, short-and long-term prognosis for survival with an acceptable quality of life, the potential for continued pain and suffering from the disease or the treatment, the possibility of returning the patient to an acceptable quality of life — all of these considerations must be completely evaluated with the client prior to the initiation of the diagnostic and therapeutic quest. Whenever possible, the client should be afforded a reasonable amount of time to consider all available choices. The confusing and sometimes contradictory information and emotional conflict provide all of the necessary ingredients for the client to make unfortunate and ill-advised choices. It is the veterinarian's moral and ethical responsibility to remain the spokesperson for the patient until the end, and not be swayed by their compassion for, or pressure from, the client.
Finally, there is no acceptable rationalization to avoid delivery of effective pain management at any time necessary in the lives of our patients. At the end of their lives, pain and suffering must be alleviated in every situation.