Recasting the gold standard – part II of II: communicating healthcare options along a continuum of care

Abstract

Series outline

This is the second part of a two-part series on spectrum of care that encourages practitioners to tailor case management to the patient along a continuum of acceptable options. Part I defined the spectrum of care and broadened its approach beyond initial cost-of-care considerations. This second article introduces strategies for initiating conversations with clients about their needs, wants and expectations specific to healthcare options and case management decisions. It will explore how open inquiry, reflective listening, transparency and unconditional positive regard facilitate dialogue between providers and their clients as they collaborate on decision-making along a spectrum of care.

Relevance

Contextual case management prioritizes interventions that are appropriate for both the patient and the client. To identify and explore which healthcare options represent the best fit for those impacted most by medical decisions, veterinarians need to make space for clients to feel comfortable sharing their perspectives. Clients are more likely to be engaged in decision-making when their insight is actively solicited. They have much to share with us as experts about their cat’s overall health and wellness needs. Inviting clients to contribute to the consultation and being receptive to hearing what motivates their choices helps us to structure conversations around healthcare options. The ability to communicate healthcare options is as vital as the provision of healthcare, if not more so.

Keywords

Spectrum of care relationship-centered care communication perspective taking perspective seeking transparency reflective listening active listening regard unconditional positive regard

Introduction

Socioeconomic, geographic and health literacy barriers obstruct healthcare delivery.^1–7 Spectrum of care is an approach to the practice of medicine that addresses barriers to positive patient outcomes.^3,8–12 Spectrum of care was defined in part I¹³ as the practice of customizing care based upon case-specific factors that involve the client, veterinarian and patient (Figure 1).^3,8–10,12

Figure 1

Client-, patient- and veterinarian-specific considerations that factor into the spectrum-of-care approach to the practice of veterinary medicine

By offering a continuum of acceptable options for case management based upon the growing evidence base in the veterinary medical literature, veterinarians can provide contextualized care that is considerate of client needs, wants, expectations and limitations.^8,9 Healthcare providers must be able to offer options that they believe are viable and in the best interest of the patient.⁹ One challenge that veterinarians face with respect to initiating conversations about a Plan A, B and C approach to patient care is the possibility of being burned by adopting an incremental approach to care. They may fear the possibility of missing a diagnosis in a patient that would have become apparent if they had just performed ‘x’ additional testing. Concern about whether incremental care invites liability may prompt veterinarians to routinely perform extensive testing, even if doing so has little chance of detecting something that could alter case management.

A second challenge that veterinarians face is the exponential rise in an ever-evolving body of knowledge, and the ongoing struggle to stay current.¹⁴ When information is not easily accessible, veterinarians may continue to practice as they were taught. For example, veterinarians unfamiliar with the 2019 report by the International Society for Companion Animal Infectious Diseases may continue to advise clients to culture urine after completing antibiotic therapy for a simple urinary tract infection.^14,15 Old practices die hard and the veterinary profession tends not to challenge dogma.¹⁴ Efforts to increase the visibility of updates in research have led to the creation of resources that support a spectrum-of-care approach, including the Evidence-Based Veterinary Medical Association,¹⁶ Royal College of Veterinary Surgeons Knowledge¹⁷ and the University of Nottingham’s Centre for Evidence-Based Veterinary Medicine.¹⁸

Access to new information about the efficacy of alternative healthcare options is insufficient to drive the spectrum of care forward. Options must be communicated to the client in a way that provides context as well as a detailed account of pros and cons, expected and unexpected outcomes, anticipated impact on patient diagnosis and prognosis, the cost:benefit ratio and what next steps should be taken if the patient requires additional support.⁹

Exploring options with clients has historically been challenging for the veterinary profession.¹⁴ One-fifth of veterinarians who participated in a large-scale study in 2018 disclosed that they did not offer treatment alternatives to owners of underserved pets.¹ Of the veterinarians who participated in a 2022 cross-sectional study, 30% disagreed that ‘all treatment options should be presented to owners’.¹⁹ Which options are introduced by veterinarians to clients and how information is presented influence the direction of the consultation.¹⁴

The emergence of communication as a key influencer in the consultation room

Research in human healthcare demonstrates that patients are guided by doctors’ recommendations,^20–24 and it is thought that veterinarians exert the same influence.^9,14 Options should be presented by the provider without allowing assumptions to influence information disclosure.¹⁴ The veterinary client deserves to be informed of diagnostic and therapeutic modalities, the costs of associated care, anticipated follow-up, expected patient outcomes, the benefits of treatment and the potential for adverse effects.^9,14 Evidence must be provided to support forward action so that the client can make informed decisions.¹⁴ Dialogue is central to decision-making because it allows different perspectives to be shared and opportunities to clarify questions or misconceptions. In this way, dialogue provides the scaffolding for both informed consent and shared decision-making (SDM).^14,25 SDM occurs when ‘clinicians and patients make decisions together using the best available evidence’.²⁶ This approach is not new to healthcare. Medical publications about SDM date back at least as far as 1980, when Schain acknowledged that ‘the vision of the parental physician as unilateral authority. . . is dimming. The picture is being supplanted by a new image. . . of personalism and a concept of “shared responsibility”’.²⁷ It was believed that collaboration between provider and patient could improve healthcare satisfaction.²⁷

Recent research suggests that SDM also drives veterinary client satisfaction with services.²⁸ However, past studies assessing veterinarian–client–patient interactions using the Roter Interaction Analysis System have demonstrated that veterinarians tend to monologue in the consultation room and underutilize communication skills that contribute to client engagement and partnership.^29–31 If we are to empower clients with SDM, then we must lean into communication skills that encourage clients to share their perspectives and priorities with respect to healthcare delivery.³²

Communication was once considered a ‘soft skill’ in healthcare³³ that was not seen as influential in shaping patient outcomes.^34–36 This perspective pervaded medical education until the 1980s, when research on healthcare satisfaction demonstrated that human patients valued displays of care and compassion by physicians more so than content area expertise.^37,38 When patients felt that providers communicated effectively, they were more likely to be compliant and experience improved physical, physiologic, mental and emotional health outcomes.^34,38–44

The veterinary profession has been slower to embrace communication skills training.^{33,34,45–48} Veterinarians assumed that on-the-job training would develop essential interpersonal skills.⁴⁵ Subsequent research demonstrated that a significant fraction of board complaints against veterinarians are communications-based^49–52 and that many veterinarians are challenged by clinical conversations^45,53–58 about cost of care,⁵⁹ inappropriate client behavior,⁶⁰ patient weight⁶¹ and dietary modifications.⁶² Workplace stress is often exacerbated by ineffective communication between team members,^63–65 and has been magnified by the COVID-19 pandemic.^66–68

Today’s veterinary clients expect to be included as team members in the delivery of healthcare.^34,35,38 Clients seek acceptance as part of the healthcare team.^33,69 They want their voices to be heard.^33,69 Nowhere is their insight more critical than during times of decision-making in contextualized care, when a continuum of acceptable options is explored.

Communication strategies to navigate spectrum-of-care clinical conversations

Spectrum of care offers a unique lens through which to understand the dynamics of the veterinarian–client–patient relationship (VCPR). Spectrum of care invites the clinician to transition from their ‘sage on the stage’ role to a ‘guide on the side’.⁵ Spectrum of care embraces a team approach to healthcare delivery and the client is central to that team. At the end of the day, it is about relationships and how to engage the caregiver in dialogue about how best to approach cat care. This requires a bilateral transfer of information, with an opportunity for all to share and clarify their understanding of each other’s point of view so that they are on the same page about moving forward. To achieve this degree of mutual understanding, strategic implementation of select communication skills is invaluable. Over 70 communication skills have been identified within the Calgary-Cambridge Guide (CCG), a consultation model that was adapted from Silverman, Kurtz and Draper’s collective work in human healthcare^70,71 for use in veterinary medicine by Radford et al⁵⁰ in 2003. Two of these skills are particularly relevant to spectrum-of-care conversations: open-ended inquiry and reflective listening. This article will address the applications of both and then introduce two supplemental skills: transparency and unconditional positive regard.

Open-ended inquiry, perspective-taking and perspective-seeking

As veterinarians, we bring knowledge into the consultation room about animal behavior and welfare, health and wellbeing, illness and disease progression, diagnosis and prognosis. What we do not know when we initiate a VCPR is who we will meet on the other side of the consultation table. To maximize information sharing with our client, we must actively solicit and understand individual narratives across a diverse clientele.⁷² This requires us to step outside our own agendas to exhibit professional curiosity about another person’s past experiences, present needs and future expectations concerning healthcare delivery.⁷² When we encourage others to elaborate beyond a ‘yes’ or ‘no’, we are inviting them to disclose critical information in their own words without leading them down a certain path.⁷³ This gives us the opportunity to acknowledge, affirm and address their perspectives as we collaborate on case management decisions.

Perspective-taking and -seeking also require us to draw upon cultural humility and recognize that our clients view their patients’ care journeys through a unique lens that may be influenced by personal, familial, cultural and societal perspectives on their relationships with animals, the function and inherent value of the individual patient, as well as the uniqueness of their bond.⁷² These aspects of the VCPR are not often explored, yet the veterinarian must stretch beyond their own sense of self to recognize and accept that the client also operates from within their own distinct worldview. The only way to make sense of another’s world view is to actively solicit and take on that individual’s perspective in a way that inspires dialogue and partnership.⁷²

Open-ended inquiry is the way in which we engage in such solicitation. Statements or questions that elicit the client’s perspective start with:⁷⁴

What. . .

Tell me. . .

Share with me. . .

For example:⁷⁴

‘What concerns you most?’

‘Tell me what’s weighing on you.’

‘Share with me what’s going through your mind right now.’

The connection between open inquiry and spectrum-of-care conversations is perhaps most familiar when discussing the cost of care. In Box 1, the author provides an example of how open inquiry can prompt the client to articulate financial concerns that can then be discussed in concert with dialogue about healthcare options. Note that open inquiry requires the clinician to pay attention not only to verbal statements made by clients, but also to non-verbal cues that might suggest discomfort, inviting further discussion.

Box 1

Example of how open-ended inquiry and perspective-taking connect to spectrum of care through financially driven client-based concerns

Scenario: Jayden, a new client of the practice, presents their 14-year-old spayed female Tonkinese cat, Twix, for preventative healthcare. Physical examination discloses halitosis, gingivitis and moderate calculus associated with the maxillary premolars and molars. Ensuring that Twix is comfortable with additional handling, you take the time to show the caregiver some of the changes you have noted in Twix’s oral cavity. You pause for a moment and engage in choice talk, asking the caregiver open-ended questions about what changes they have noticed that might have caused concern about Twix’s dental health (eg, abnormal breath, changes noted when the cat yawns, different eating style/preferences). This creates space in the conversation for the caregiver to ask questions about what to do next. The caregiver agrees that the cat’s mouth does seem to have a new smell to it and that the cat has been swallowing kibble whole, with increased vomiting immediately after eating. You confirm with the caregiver that this might be related to oral health, pulling their findings into the list of observations related to dental disease and thereby affirming their participation in their cat’s care. At this juncture, you begin exploring options for care/treatment with the caregiver, engaging in option talk. Reviewing options will likely involve preparing and explaining cost estimates.

You, speaking with the client: ‘In most situations like this, we will schedule the patient for dental care under anesthesia, and this is most likely to give positive results and resolve the problem. Since dental disease is painful, if the dental is not an option at this time, we can look at starting Twix on pain medication. As I examine Twix’s mouth, I don’t see any obvious loose teeth or teeth with other disease that need to be removed; I mainly see tartar and gum irritation from the tartar. This means we could also consider trying a dental diet to try to reduce the level of tartar Twix has.’

You listen to the caregiver and observe their body language. Jayden’s eyes tear up as they tell you that they never realized the cat had poor oral health and they feel guilty. Jayden tells you that they do not currently have the money needed for dental care under anesthesia but would like to explore a change in diet and pain medication. The caregiver has now moved the conversation into decision talk, and the two of you work out a plan for analgesia and starting a dental diet, scheduling a medical progress visit in 4–6 weeks, and initiating reminders in the computer system for a veterinary technician to check in with the caregiver by phone every 2 weeks for updates.

The cost of care has been cited as a primary reason why clients do not seek veterinary care,⁷⁵ and veterinarians acknowledge that the client’s burden of financing care frequently limits the types of diagnostic and therapeutic interventions that can be pursued.^7,59,76–79 However, it is important to recognize that cost is not the only barrier to healthcare delivery, despite assumptions on our part that it might play a significant role. Open-ended inquiry reminds us to stay curious and to ask clients what concerns them most, rather than assume we know the answer. Through open-ended inquiry, we may glean valuable insight from our client in terms of what additional considerations we might need to address in our delivery of a continuum of healthcare options. In Box 2, the author provides an example of how open inquiry can prompt the client to articulate concerns that are unrelated to cost of care.

Box 2

Example of how open-ended inquiry and perspective-taking connect to spectrum of care through client-based concerns that are unrelated to cost

Scenario: Ash, a new client of the practice, presents their recently adopted 8-year-old castrated male domestic shorthair cat, Finn, for evaluation of a 3-day history of urinating on the mat outside the litterbox. The first few episodes were overlooked, but today’s puddle of urine left a concerning pink stain on the mat. Finn also vocalized during urination. Physical examination discloses a small urinary bladder. Microscopic examination of sediment from urine obtained by cystocentesis discloses hematuria, pyuria and bacteriuria. Aerobic bacterial urine culture confirms bacterial cystitis in the absence of comorbidities and antibiotic susceptibility to amoxicillin/clavulanic acid. You telephone the client, introduce yourself and ask an open-ended question to solicit from Ash how Finn has been managing at home since his visit. Ash shares that Finn seems uncomfortable still and now resents being picked up, as if his abdomen is tender. You acknowledge and affirm what Ash is describing and disclose that there is a reason for Finn’s discomfort: he has a urinary tract infection. This leads into choice talk as the caregiver asks, ‘What should we do now? Does he need medicine? I’ve never had to medicate any of my cats before. What am I going to do?’ At this juncture, the conversation can move into option talk in terms of ways to medicate cats, the ideal antibiotic choices we want to make based upon the culture and susceptibility results, and openly asking, ‘What are your thoughts about these options?’ Ash expresses concern about medicating Finn based upon their past experiences with other cats. You transition the conversation into decision talk to find an appropriate solution for Finn and Ash.

You, speaking with the client: ‘I understand. Cats can be a bit challenging to medicate. Even though we’re doing it to help them, it’s not always easy to get them to see it that way. This is a medication that will need to be given twice a day, for the next 5 days. You mentioned not having a good experience medicating other cats. Can you tell me more about that so that we can find the best solution for you and Finn?’

Ash: ‘I remember having to give liquid medication to my other cats through a dropper when they were kittens. That didn’t work very well for me. I got more on the carpet than inside them.’

You: ‘There’s also an option available in pill form. Do you think that would that be easier for you and Finn?’

Ash: ‘I appreciate that, but even a pill is going to be hard. I doubt that he’s going to be a big fan of getting something shoved down his throat. On top of that, I struggle with arthritis in my hands. My fingers are quite swollen. It makes it hard for me to grip anything. I don’t know how we can manage this.’

You: ‘Thank you for sharing your thoughts with me about next steps for Finn. I definitely do not want to cause you any pain in the process. My goal is to make this easy for the two of you. Would you be open to discussing alternatives to pilling Finn at home?’

The caregiver expresses openness to alternative solutions to get the medication that is necessary into Finn. Ash shares that Finn is very comfortable with both his carrier and car travel, and they would be willing to bring Finn into the clinic to have his dose administered by your team of technicians. The caregiver has now moved the conversation into decision talk, and the two of you work out a schedule for medicating Finn twice daily for 5 days at the clinic, beginning tonight.

Reflective listening

When we present a continuum of acceptable care options to our clients, we are initiating an exchange of ideas and inviting them to consider each. In the process, communication becomes a feedback loop.⁸⁰ Dialogue exchange is necessary to achieve mutual understanding so that our client can contribute to and ultimately make informed decisions concerning healthcare delivery.⁸⁰ For this frisbee-like approach to be productive, each participant must take turns to be the sender of information and the recipient.⁸⁰ In other words, one person listens when the other is speaking.⁸⁰ Roles reverse as often as is needed to relay appropriate messaging.⁸⁰

Listening is an active process that challenges us to hit the pause button on our own stream of thoughts and shift our focus on to someone else. Effort is required to invest in what another person is saying, reflect on the information exchanged, and prioritize another individual’s needs above our own.^80–84 Eliciting the client’s perspective is effective only if, after tasking the client with sharing their thoughts with us, we actively hear them. Active listening, also known as reflective listening, is one of the most powerful displays of connectivity that a provider can offer within the consultation room. ‘I’m listening’ conveys to the speaker that they have found a safe harbor in which emotions can reside. ‘It is the kind of connection that comes from being present with another, from giving our full attention so that we may listen not only with our minds, but with our hearts as well.’⁸⁵

Reflective listening often takes the form of certain words or phrases that the listener relays back to the speaker. These include the following:⁸⁰

‘It sounds like. . .’

‘What I’m hearing you say is. . .’

‘I am sensing that. . .’

‘So, your main concern is. . .’

We can apply this communication skill to spectrum-of-care conversations. In Box 3, the author provides an example of how we might use reflective listening to clarify that we have understood our client’s reservations about the proposed care plan.

Box 3

Example of how reflective listening can be applied to spectrum-of-care conversations

Scenario: Ryan presents their 12-year-old castrated male Abyssinian cat, Foxy, to an emergency clinic for evaluation of a 3-day history of lethargy progressing to recumbency and a 24 h history of anorexia, with six episodes of vomiting overnight. The client mentions that Foxy’s primary care veterinarian had warned them last year and the year prior that Foxy had consistently elevated kidney values that could progress. Physical examination today discloses obtundation and severe dehydration. Foxy has pale pink mucous membranes and uremic breath. Both kidneys are palpably small, symmetrical and non-painful. Due to the urgency of the situation, initial stabilization is prioritized. Baseline bloodwork and urinalysis are supportive of the diagnosis of chronic kidney disease. You review the diagnosis with the client and discuss that medical management beyond initial stabilization will require significant changes to Foxy’s lifestyle in terms of medication, fluid therapy and diet. You observe the caregiver’s body language as Ryan crosses their arms and averts their gaze. You shift the conversation towards choice talk about how impactful these changes could be to Foxy. This creates a safe, supportive space for the caregiver to express concerns about Foxy’s tolerance of medical interventions.

Ryan: ‘Foxy is a loner. From the day that I first laid my eyes on him as a stray, he made it clear that he would live life on his terms. It was his way, or the highway. I could either accept him as he was or move on. He’s spent 10 years by my side now. In that time, he’s mellowed, but that doesn’t mean that I call the shots. It took the better part of a year for Foxy to let me pet him. It’s still a struggle to apply his topical flea preventative. I understand that you’re saying this is what he needs. I just don’t know how much of this he can take. The very last thing I want to do to him is to force him to play by my rules.’

You: ‘Thank you for sharing what is important to you and Foxy. It sounds as though his independence is what makes him whole, and you’re concerned how he might respond to treatment because that curbs his approach to living life on his terms. It sounds like you’re also concerned about how treatments might impact your bond with him. Is that right?’

Ryan: ‘Yes. I want to help Foxy, but I don’t want to prolong his life – for me – at his expense. Do you really think that he could adapt to the changes that he needs?’

You: ‘I understand, and I respect you for putting him first. I don’t know what Foxy will and won’t tolerate, but I am committed to helping you both.’

Ryan agrees that it is important to work together to prioritize the care that Foxy needs. You acknowledge that the priority is to rehydrate Foxy by admitting him to the hospital for intravenous fluid therapy to rehydrate him, restore electrolyte balance and reduce the degree of azotemia. You disclose that Foxy’s response to treatment will provide helpful information in terms of the level of care that he will require at home. Ryan nods in response and the conversation moves to option talk in terms of what at-home care might look like for Foxy once he is discharged from the hospital. You describe possible avenues for a multimodal approach to therapy. You pause, then solicit Ryan’s perspective.

You: ‘You know Foxy best. Which of the treatments that I mentioned might he be willing to adapt to?’

Ryan: ‘I don’t know how he will feel about being medicated, but he is extremely food motivated. Could we coat any pills with butter or cheese? I think if we can disguise medication as food then he might be more cooperative.’

You: ‘Absolutely, let’s be creative about finding ways to get him to take his medicine without it becoming a fight. We can also consider pill pockets or compounding medication. We contract with an outside pharmacy that can add flavoring to chewable tabs, depending upon his taste preferences. Would that be worth investigating?’

Ryan: ‘Yes, I’m willing to give it a try. But everything you mentioned sounds like a lot of care. If we move forward, do we have to do it all?’

You: ‘In many cases, yes, we approach care from many different angles – medication, fluid therapy and diet. But that doesn’t mean we have to try everything at home all at once. Once we get Foxy through the worst of this episode, we can prioritize which treatments are a “must”. I suspect that he will always need medication to lower his blood pressure and that he may always need potassium supplementation, but his care is going to require us to be flexible. And that means adapting to you and him, and determining what care he will tolerate while still living life on his terms. How does that sound?’

Ryan gives an affirming head nod and has now moved the conversation into decision talk. The two of you work out a plan to hospitalize Foxy and commit to partnership on developing a plan for Foxy when it is appropriate to transition him home.

Transparency

Historically, transparency in human healthcare referred to the medical team’s disclosure of medical errors.⁸⁶ Acknowledging errors helped patients and their families understand what went wrong and why, and how errors could be remedied.^86–89 The definition of transparency in human healthcare has since broadened to encompass the expectation by human patients that healthcare providers will deliver accurate, truthful information^90–93 about diagnosis, prognosis, treatment options, risk: benefit ratios and the potential for adverse outcomes.^90–92,94 Access to information and timely updates can enhance patient coping, wellness, satisfaction and psychological adaptation.^90,95–101

Few publications in the veterinary medical literature have examined what information is preferred by cat-owning veterinary clients and why. In one focus group study, clients shared their need not to have information withheld from them.³³ In a separate study by Stoewen et al,⁹⁰ in-person interviews were conducted with clients who sought care for dogs with life-limiting cancer from a tertiary referral center. Participants shared that they expected to be given truthful information about all aspects of their pets’ disease process.⁹⁰ They ‘did not want the situation “sugar-coated”, “buttered-up” or “made prettier” than it really was. Instead, they wanted “the straight goods”, “the truth”, “the facts – good or bad” so they could “deal with it as best they [could] to avoid surprises” and “disappointment”, and “be prepared”’.⁹⁰

Because they actively require measures to explore the client’s perspective, including information needs, spectrum-of-care conversations are a vital opportunity to address client expectations with transparency. In Box 4, the author provides an example of how we can incorporate the communication skill of transparency into spectrum-of-care conversations.

Box 4

Example of how transparency can be incorporated into spectrum-of-care conversations

Scenario: Arbor presented their 16-year-old spayed female indoor/outdoor Burmese cat, Latte, to an emergency clinic for evaluation of acute onset of vomiting that began 24 h before presentation, after the cat had accidentally been locked in the garage all morning. Arbor presumed that the cat’s emesis was stress-induced. By the following morning, Latte was found laterally recumbent and minimally responsive. Physical examination disclosed obtundation and palpably enlarged, painful kidneys. Baseline bloodwork demonstrated severe azotemia, hyperphosphatemia and metabolic acidosis. Analysis of urine obtained via cystocentesis disclosed proteinuria, hematuria, pyruria and crystalluria, with dozens of calcium oxalate mono- and dihydrate crystals and renal epithelial cells. Ultrasonography demonstrated dramatically increased renal cortical and medullary echogenicity. All parameters were suggestive of the renal metabolic stage of ethylene glycol intoxication. After being informed of the presumptive diagnosis and prognosis, Arbor elected to hospitalize. Treatment was initiated with intravenous fluid therapy, 4-methylpyrazole (4-MP, fomepizole), furosemide, sodium bicarbonate, famotidine and analgesia. By 24 h later, the patient’s condition had worsened. Latte was hypothermic (98.6°F [37.0ºC]), tachypneic (respiration rate: 46 breaths per minute) and tachycardic (heart rate: 186 bpm). Blood biochemical profile parameters showed progression of renal dysfunction and persistent electrolyte imbalance.

You encourage the caregiver to visit Latte in the hospital so that you two can reconvene about the cat’s status. When Arbor sees Latte, their eyes well up with tears. You pause for a moment and engage in choice talk, asking the caregiver what concerns them most about Latte’s decompensation. This invites Arbor to share their concern that Latte is suffering. You acknowledge and affirm their desire to alleviate suffering and begin exploring options for care with Arbor, engaging in option talk. Arbor determines that the most appropriate, humane course of action is to euthanize Latte. You demonstrate regard for the client and support this decision, but when you discuss getting the paperwork ready to proceed with euthanasia, Arbor hesitates. Arbor asks if Latte could survive for a few more days, until the weekend. You demonstrate reflective listening to clarify the caregiver’s request:

You: ‘It sounds as though you are having doubts that now is the right time to put her to sleep.’

Arbor: ‘I know it’s the right time for her, but Latte is a family pet. She’s not just mine. Her heart belongs to my eldest child, Kai, who is out-of-state at college. Kai will be home this weekend. Kai knows that Latte is very sick, but they are in the middle of end-of-semester exams, and I haven’t wanted to upset them. They would be devastated if we moved forward with euthanasia without them. Kai needs to be here.’

You: ‘It sounds as though Kai and Latte have a very important bond, and I value the need to provide all those who love Latte with the time and space to help her pass. I am honestly concerned, though, both about Latte’s wellbeing and also about her ability to survive to the weekend.’

Arbor: ‘Are you saying that she won’t make it?’

You: ‘The truth is that I don’t know. In my experience, based upon her exam findings and the updates to her bloodwork, her body is shutting down.’

Arbor: ‘I don’t want her to be in pain, but I also don’t want to take away Kai’s chance to say goodbye.’

You: ‘I understand. This is not an easy situation for anyone to face and you are trying to balance the needs those you love. We can increase the dose and dosing frequency of pain medications to keep Latte as comfortable as possible. Even so, I would prepare yourself and Kai that Latte is letting go and it would be kinder to her not to prolong her experience. Are you open to any other options that would allow us to intervene sooner than the weekend?’

You acknowledge the possibility of FaceTiming with Kai as the conversation shifts into decision talk. The two of you schedule an evening appointment that will allow you both to virtually connect with Kai tonight to make determinations about how to proceed on behalf of Latte. You prepare the client that if Kai agrees that euthanasia is in the best interest of Latte, then Kai would have the option to be ‘present’ during the euthanasia, through FaceTime, if they choose to be.

Virtual options, such as FaceTime, offer flexibility to bridge geographic and other barriers. Thinking outside the box to provide alternatives to on-site, in-person consultations is particularly critical in end-of-life decision-making. Such decisions often involve multiple people, each of whom has their own unique bond with the patient yet may not be able to physically witness or participate in patient care. A virtual approach provides access to care in a way that enables participation from afar.

Unconditional positive regard

The practice of unconditional positive regard suggests that veterinarians accept clients for who they are and meet them where they are, rather than hold them to impossibly high standards.⁸⁶ Focus group studies that involve veterinarians disclose their tendency to misjudge a client’s willingness to provide what they perceive to be the best care.⁵⁹ Participating veterinarians acknowledged that such assumption-making influences the healthcare options that they identify and explore, despite recognizing the impact of misperceptions on the VCPR.⁵⁹ Veterinarians shared that judgment often centers around the perceived affordability of care, and that it works both ways: veterinarians may both over- and underestimate how price-conscious clients are.⁵⁹ One veterinarian in a focus group study by Coe et al⁵⁹ recalled a consultation in which ‘I did not even give them a cost because it looked like that was what they wanted to do, and then cost became an issue later on’.

Cost aside, veterinarians acknowledge that judgment also extends to choices that clients make with respect to healthcare decisions.¹⁰² Participating veterinarians in a second focus group study by Coe et al¹⁰² admitted the challenge of accepting a client’s choice irrespective of whether ‘it’s a good one, bad one or sideways’. There is an expectation of veterinarians by clients that they support and validate decisions, even when veterinarians disagree.¹⁰² Cat owners in particular want the veterinary team to understand that they are well intentioned, even if their actions may not always be medically appropriate.³³

Yet, fear of judgment may prevent clients from participating in open, honest dialogue about patient care. They may worry about full disclosure if they feel that their actions will be held against them. Clients need to be reassured that we recognize that their words and actions reflect care, even when they are misguided. When interpersonal challenges arise, veterinarians should shift focus on to common ground: what do they and the client both wish to achieve and how can they work together to that end?⁸⁶ The only way to move forward with patient care is with client consent, and that requires partnership. Partnership is reinforced by eliciting the client’s perspective, then actively listening as the client shares it. However, clients seek more than just to be heard. They seek validation and affirmation. They want to know that you understand and accept why they did what they did.⁸⁶

Demonstrating regard for our clients’ past actions may take the form of:⁸⁶

‘I can only imagine that you felt trapped between a rock and a hard place. You did the best you could in a difficult situation.’

‘I understand why you made the choices you did; I might have done the same thing in your situation.’

‘You said you wished you had done more. What matters most is that you brought your cat here during their time of need. Let’s work together to figure out how to help best.’

Demonstrating regard for our clients’ current choices may take the form of:

‘Your decision isn’t easy; thank you for leading with your heart and considering what is best for your cat.’

‘I see that you are struggling with this decision, and I value the care that you are investing to determine what is best for you and your cat.’

‘I appreciate that you want to do right by your cat.’

We can apply this communication skill to spectrum-of-care conversations by being accepting of choices that clients make, even if we might be inclined to make different choices were we in their shoes. In Box 5, the author provides an example of how regard might be employed in clinical practice.

Box 5

Example of how regard can be applied to spectrum-of-care conversations

Scenario (day 0): Madison, a new client of the practice, presents their 2-year-old castrated male indoor/outdoor Sphynx cat, Everett, for evaluation of ingesting string 1 h earlier. The physical examination is unremarkable. Everett is tolerant of an oral examination, and you show the caregiver that there is no evidence of string caught around the base of Everett’s tongue. You engage in choice talk, asking the caregiver open-ended questions about what concerns them most. Madison shares that the cat has eaten a cotton ball and a hair tie on two separate occasions. Both passed without incident, but this morning, they searched online for ‘string ingestion in cats’ and are fearful that Everett could die. Madison asks what needs to happen next to save Everett’s life. At this juncture, you begin exploring options for Everett’s care, engaging in option talk. You discuss the potential for linear foreign body obstruction and that if this occurred, surgical intervention would be indicated.

You: ‘In other circumstances, the string can pass through the digestive tract without incident. We can’t predict which path Everett will follow. We can either take him to surgery now as a precaution for what could happen if we wait; or, we can elect to observe him, here or at home, for any signs that the string is not passing.’

You outline the benefits and risks associated with each option and provide cost estimates for both approaches. The caregiver shares that finances are tight, and they would prefer to monitor Everett at home so as to avoid surgery at all costs. Madison has now moved the conversation into decision talk, and the two of you work out a plan for at-home observation. You instruct Madison to return to the clinic if Everett becomes inappetent or vomits more than once.

Scenario (day 2): Everett re-presents 48 h later after vomiting three times overnight and refusing breakfast this morning. He resents abdominal palpation, and radiographs demonstrate plication of the small bowel, confirming a linear foreign body. You advise that Everett be admitted for exploratory laparotomy. Madison agrees that surgery is indicated and expresses guilt for having made the ‘wrong’ decision. They tell you that they regret not taking a more aggressive approach because now Everett’s condition is serious, and they blame themselves. You recognize an opportunity to demonstrate unconditional positive regard.

Madison: ‘I can’t help but feel that I let him down.’

You: ‘You made the best choice you could for him in the moment during a really difficult time. You did the best you could, and you are here now.’

Madison: ‘I would do anything to make this right.’

You: ‘I know. What I hope you believe is that you never did him wrong. You hoped to spare him surgery. You didn’t want to put him through something if he didn’t absolutely need it in the way that he does now. He has a long road ahead of him. Let’s focus on what we can achieve together to get him back to health.’

Leveling up: additional communication-based spectrum-of-care considerations

This article has introduced several foundational communication skills that facilitate spectrum-of-care conversations by promoting two-way exchange of information in which the client can both share and be heard. The client’s thoughts, beliefs, concerns and expectations are invaluable because these details fill in the gaps that we clinicians cannot discover without perspective-seeking and the client’s willingness to disclose. Disclosure requires a safe, supportive space in which clients feel that judgment from the veterinary team has been replaced with regard.

Spectrum-of-care conversations task us to rethink our understanding of patient care and the ways in which we prioritize it:

How can we offer contextualized care?

How can we broaden the selection of options that we offer to clients to incorporate their needs, wants and expectations?

How can we expand our evidence base to investigate the efficacy of alternative approaches to traditional gold standard care?

How do we convey the value of care, irrespective of which option the client selects?

Is it important to acknowledge that someone’s plan A might be someone else’s plan B or even plan C for reasons that we might not even consider until we participate in a dialogue exchange to discover the context for which one approach to care is appropriate and desirable.

How can we restructure the way we think about and deliver options so that options are presented with an open mind? Should we move beyond our default model of identifying plans as A, B and C, and instead consider a three-step model of SDM? Recent work by Janke et al²⁹ analyzed audiovisual recordings from 60 veterinarians and 909 of their clients. An analysis of these interactions suggested that healthcare providers infrequently practice SDM.²⁹ Veterinarians are legally and ethically obligated to elucidate the pros and cons of each option, including the risks associated with a ‘wait and see’ approach.¹⁰³ Yet, many clients feel that they are not given an opportunity to exercise choice.¹⁰² Choice is particularly essential to clients who are navigating end-of-life decision-making.¹⁰⁴ Clients who participated in a 2017 study by Corah et al¹⁰⁴ expressed a need for reassurance that their decisions to euthanize were supported. Training the entire veterinary team how to apply SDM to consultations could prove useful, potentially raising client satisfaction with healthcare delivery and improving client adherence.^29,105

Elwyn et al¹⁰⁶ suggested that when collaborating on patient care we can move from initial preferences to informed preferences by engaging clients in SDM at three levels:

Choice talk

Option talk

Decision talk.

During the initial phase of the consultation, choice talk, we let the client know that choices exist.¹⁰⁶ To facilitate this discovery phase, we engage in perspective-taking and -seeking to identify client preferences, beliefs, opinions and values. We are transparent about how much time the client has to make the decision and we are clear about whether decisions can be staged.

Option talk allows us to revisit each option and share information.¹⁰⁶ We take the opportunity to assess the client’s baseline knowledge and expand upon it with respect to what choices are available to them, including a cost:benefit analysis. The client in turn is encouraged to share their expertise and point of view. Clients are experts on the patient, the environment, their time commitment/constraints, their emotional investment and the financial resources available to them. Our primary goal during this stage is to support decision-making by delivering a continuum of care options presented in an equitable manner.

Decision talk, the final stage of SDM, requires us to focus on what matters most to the client/patient dyad and link the client’s priorities to the option set.¹⁰⁶ We summarize each option and its implications. We screen for questions and check the client’s understanding to determine whether additional information is needed for the client to decide. If so, we provide the missing data. If not, we partner with the client to come to a mutual agreement.

This process may take one or more consultations to complete and requires us to make use of our four communication skills:

Open-ended inquiry

○ Find out how much the client wants to be involved in decision-making.

○ Value client input and invite it.

○ Explore concerns, values, hopes and constraints.

○ Invite questions.

Reflective listening

○ Check for understanding.

○ Align client preferences with options.

Transparency

○ Provide information about options, including risks, benefits and costs.

Regard

○ Give space.

○ Respect the client’s decision and the journey it takes to get there.

Put it in writing: documenting key highlights of the dialogue

Fear of increased liability may complicate a veterinarian’s decision to offer a spectrum of care.¹⁰⁷ The reality is that any approach to case management can be subject to criticism. Even gold standard approaches to clinical cases can yield negative client reviews, board complaints or even lawsuits.¹⁰⁷ The best approach to mitigate the risk of negative consequences stemming from case management is to be thorough in documenting client communication.¹⁰⁷ This includes embedding client communication notes within medical records. Recall that client communication notes in medical documentation are not limited to summaries of face-to-face conversations, but also include telephone and electronic means of correspondence. It has been said in human healthcare that ‘if it isn’t charted, it didn’t happen’.¹⁰⁸ Records should report which options were given, as well as a summary of the risks vs benefits of each intervention.¹⁰⁷ These details are protective from a liability standpoint. If a board complaint is filed, then the record speaks for itself. There is a record of what was said and done, and why.

Beyond legal purposes, client communication notes are also invaluable prompts for busy practitioners who may not recall the details of conversations with clients days, weeks or months after they took place. Similarly, notes relay critical information about the medical provider’s actions and thoughts to other members of the healthcare team. A written record serves as a reminder of what has been discussed and why decisions were made.¹⁰⁹ In the event that case management requires an adjustment, all one has to do is re-examine the medical record to identify what next steps will be taken. This is particularly true of case management that hinges on incremental care. If treatment ‘v’ does not yield ‘x’ results, then the next step may be either to transition to treatment ‘y’ or go back to the drawing board and perform diagnostic ‘z’.

Medical documentation in veterinary practice typically takes the form of subjective objective assessment plan (SOAP) notes.¹⁰⁹ There is no universal approach to SOAP notes. Expectations for medical documentation often vary between practices, based upon veterinarian and employer preferences, and between states, provinces and countries, depending upon regional law. Historically, it has been considered best practice to document when any diagnostic or treatment recommendation is declined, or if a patient is discharged to the care of a client against medical advice (AMA).¹¹⁰ In the author’s experience, there is a tendency for medical providers to document any action on the client’s part as being AMA other than the client’s adoption of gold standard care. This is concerning in such cases where clients have been offered a selection of options from which to choose and they choose an incremental care approach to case management. Labeling their actions as AMA when in fact they made an appropriate choice, just not one that the provider may have preferred, runs the risk of attaching judgment to a client’s actions (or deliberate inaction). The author’s preference in such situations would be to communicate in writing which options were discussed. Then, the veterinarian can place the emphasis on the client’s final decision and rationale, rather than making declined options a focal point, except in those instances in which the chosen course of action is inappropriate. In Box 6, the author suggests an approach to how to effectively document the agreed-upon plan.

Box 6

An approach to documenting the plan (‘P ’) in a patient’s SOAP note

Scenario: Recall the vignette that was detailed in Box 1, with respect to Jayden and Twix’s first visit to your practice.

Sample ‘P’: Demonstrated oral health findings and relayed concerns about periodontal disease. The caregiver agrees that the patient has developed halitosis and a tendency to swallow kibble whole, whereas in the past it had chewed. The caregiver has noticed increased frequency of vomiting whole food after eating. The caregiver accepts that this may well be due to dental disease. Offered the following options:
• Pre-anesthetic panel (CBC/CHEM/UA), then oral exam, periodontal probing, full-mouth dental radiographs and dental prophylaxis under general anesthesia. Provided caregiver with estimate for pre-anesthetic work-up and procedures as outlined here
• Prescribe analgesia and transition to dental diet to reduce the level of calculus; reassess

The caregiver expressed financial constraints that preclude proceeding with dentistry at this time; amenable to change in diet and prescription pain medication.

Will re-evaluate patient at medical progress visit in 4–6 weeks. Will assign tech to check in with caregiver by telephone at 2 and 4 weeks for progress reports.

An exception to this approach would be if the veterinarian perceives that client decision-making is unethical or inhumane. In this instance, it is incumbent upon us to prevent and relieve animal suffering through ethical practice.¹¹¹ Our professional obligation and oath dictate that we be transparent with clients about our limitations with respect to case management and share when we cannot ethically proceed with what has been asked of us by them. Written documentation should mirror what words were exchanged during the consultation, and identify what, if any, next steps (eg, mandatory reporting) must be taken in accordance with local law. The client should be informed of these steps so as not to be caught off guard, and documentation should capture that this information was conveyed. Sometimes we are challenged by situations that are not blatant animal abuse and cruelty, but instead involve decisions that we cannot honor. In this circumstance, it is essential that we disclose our boundaries respectfully, casting judgment aside, so that we can then partner with the client to find resources who may be better equipped with capacity to assist (eg, referrals to colleagues for a second opinion).

Such exploration should also take care to dive deep into the ethics of not treating. We can each name examples of when diagnostics and/or therapeutics are declined for the benefit of the patient. Although often these declinations are documented as a blight in the client’s medical record, it is vital that we rethink this approach and recognize the unspoken truth that sometimes withholding one or more types of treatment is in fact putting the patient’s welfare first. Accordingly, ethical considerations surrounding end of life have most recently been explored in hospice and palliative care. The 2023 AAFP/IAAHPC Feline Hospice and Palliative Care Guidelines propose that case management in such situations be guided by respect for autonomy, non-maleficence, beneficence and equity in therapeutic recommendations.¹¹² This bioethical framework guides clinical decision-making by applying context and thereby consideration for each specific case as its own entity.¹¹²

Final comments

Spectrum of care is a means by which we as a profession can make care more accessible across the board. At the heart of spectrum of care is a desire to drive patient care forward by deepening the VCPR. By engaging our clients in partnership and initiating open channels of communication, we can see patient care (and our clients’ need for support) through another’s lens. When we take on this newfound perspective, we are better able to provide contextualized care for the patient and client.

As we look to expand the role that spectrum of care plays in veterinary practice, as well as in veterinary medical education, we need to broaden our evidence base and support research that investigates alternative options to classic treatment plans. Evidence is needed to confirm that approaches are acceptable, equitable and in the best interest of the patient. It may also be helpful to consider formulating spectrum-of-care guidelines for veterinarians to draw upon, particularly those early career practitioners who have not yet gathered appreciable clinical experience to serve as their guide.

Footnotes

Acknowledgements

The author thanks multimedia specialist Eric Beasley for partnership in co-designing Figure 1. The author also wishes to thank Teresa Graham Brett, Associate Dean of Diversity and Inclusion, for her partnership in co-designing the longitudinal Professional Skills coursework at the University of Arizona College of Veterinary Medicine pre-clinical curriculum, which prioritizes the conceptual framework surrounding spectrum of care.

Accepted: 23 October 2023

Conflict of interest

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

This work did not involve the use of animals and therefore ethical approval was not specifically required for publication in JFMS.

Informed consent

This work did not involve the use of animals (including cadavers) and therefore informed consent was not required. No animals or people are identifiable within this publication, and therefore additional informed consent for publication was not required.

ORCID iD

Ryane E Englar

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