Updated on December 30, 2010
Reasonable Expectations V: Discussion of All Options Regardless of Cost
This is the fifth part of an ongoing series describing how people are developing new expectations when it comes to veterinary care for their pets. Parts one through four can be found at www.speakingforspot.com/blog.
Veterinarians wear many different hats when they are in the exam room. It’s a given they provide medical care for their patients. But did you realize that, for their clients they often assume the role of social worker, calendar planner, grief counselor, and even mediator when there are conflicting opinions between family members (mostly spouses)? Why on earth some veterinarians wish to also become financial planners for their clients is beyond me! These are vets who pick and choose which medical and surgical options to discuss based on what they think their clients can afford.
I don’t work this way- I believe in presenting every option that is reasonable for my patient and then letting my client determine what they can and cannot afford. This means that my client will hear all the same options whether he or she arrives at my hospital driving a Mercedes Benz sports car or a jalopy. The American Animal Hospital Association agrees with my modus operandi- they conducted a study documenting that ninety percent of people want their vets to present every option regardless of cost. Please hear what this is saying: it is perfectly reasonable for you to expect discussion of all options for your precious family member regardless of cost!
Let’s consider the example of a torn cruciate ligament. The knee joint contains cruciate ligaments that are responsible for keeping the upper leg bone (femur) in alignment with the lower leg bone (tibia). Cruciate ligament tears commonly occur in large breed dogs and there are several options for treating this injury. The least expensive option is rest and anti-inflammatory medications, the cost of which might be a few hundred dollars over the course of a several months. This nonsurgical least expensive approach restores mobility and use of the leg, but predictably results in arthritis within the knee and chronic lameness. The most expensive option is one of two highly specialized surgical techniques (referred to as TPLO and TTA) performed by board certified veterinary surgical specialists. Such surgery is the very best bet for restoring complete lifelong soundness to the knee. Depending on where the dog lives (everything is more expensive in California!) the cost for this surgery is $3,000-$4,000. Tack on post-operative rehabilitation therapy (on an underwater treadmill) and add another $500-$1,000 to your bill. The “in between options” include various surgical procedures that many general practitioners perform. While they are less expensive ($1,000 to $2,000) such surgery is less likely to result in an arthritis-free knee. Treatment of cruciate ligament disease is a clear example of, “You get what you pay for.”
Now there are a number of factors to consider when determining the best treatment option for a torn cruciate ligament. Perhaps the dog is ancient and debilitated and the risk for general anesthesia and surgery is too great. Perhaps there are other medical issues that are likely to be life ending soon- in this situation it would be irresponsible to choose surgery. There are many factors to consider, and finances may be one of them. But how would you feel if discussion of medical therapy for your dog’s cruciate ligament tear was purposefully withheld because your vet assumed you could afford surgery? Likewise, what if there was no discussion of referral to a surgical specialist because your vet felt it would be too much of a financial stretch for you? Do you want your veterinarian to be your financial planner or would you prefer to hear about all the options, then decide for yourself? Let me know how you feel about this. By the way, it might be wise to let your own veterinarian know as well!
Now here’s wishing you and your four-legged family members abundant good health.
Nancy Kay, DVM
Diplomate, American College of Veterinary Internal Medicine
Author of Speaking for Spot: Be the Advocate Your Dog Needs to Live a Happy, Healthy, Longer Life
Recipient, American Animal Hospital Association 2009 Animal Welfare and Humane Ethics Award
Recipient, 2009 Dog Writers Association of America Award for Best Blog
Recipient, 2009 Eukanuba Canine Health Award
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Please visit http://www.speakingforspot.com to read excerpts from Speaking for Spot. There you will also find “Advocacy Aids”- helpful health forms you can download and use for your own dog, and a collection of published articles on advocating for your pet’s health. Speaking for Spot is available at Amazon.com, local bookstores, and your favorite online book seller.
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This is one reason I won’t ever go back to my old vet. I owed him money for one dog’s surgery (actually for the complication afterward that I 100% blame him for in hindsight, but I digress) and I wonder if he withheld information about another dog’s options because of that.
Before that dog’s surgery, I had applied to a previous job’s retirement fund to take out the money and I had been waiting for months due to screw-ups. I kept expecting at any moment to get a check for over $20,000 but meanwhile I owed my vet $500 even after paying him well over $2000. I didn’t tell him about the check coming in because it really wasn’t his business.
When my other dog became sick with neurological problems, he said (and I quote) \we could run a bunch of expensive tests but could we do anything anyway? she’s just an old dog.\
I wound up euthanizing that dog two weeks before that $20,000+ came, and in necropsy (somewhere else of course!) I found that she had a middle ear infection & meningitis. Yes, she could have been helped. If I’d known the options and the cost, I might have been able to tap friends & relatives for a loan because they all knew I had a big check coming any day. She might have died during a spinal tap so I know there were not guarantees, but still… She suffered needlessly and I carry the guilt of not doing more for her and a lot of anger toward that vet.
My old vet has lost a lot of money by treating me & my dog that way because I’m a softie for older special needs dogs. I just adopted a lactating mommy from a high-kill shelter and after her mammaries dried up I disovered a bunch of tumors. I’m going to decide how to proceed based on what’s best for her quality and quantity of life, though cost will be something I’ll consider.
And of course none of my friends, neighbors or acquaintances are going to that vet now either.
Absolutely I want to know all of the options and be the one to make the decision – not only about whether we can afford it but which option is the best one for my dog given not only his health but his age, temperament, personality.
This applies not only to treatment but to diagnostics. I have had vets in the past who I felt fell back far too quickly on “Watch and Wait.” I think in most cases they were trying to save me money but I usually prefer, especially if the required diagnostics are not invasive, to KNOW what we are dealing with. If only for my sanity, I’d rather diagnose it if possible as soon as possible.
I’ve paid for a few ultrasounds that didn’t find anything and slept a lot better afterward. And because our vet could do them himself, they weren’t horrendously expensive.
I had to laugh because my favorite veterinarian ever saw our newly adopted dog for hyperflexing pasterns and, without calling me to clear it first, x-rayed all of his hips, elbows, and wrists! Probably would have been better to ask but he knows me well enough to know that I would want it done. And that’s one of the big reasons I love him.
Along the same lines, I want a general practice vet to suggest a specialty vet when appropriate. Our break-the-budget dog saw a dermatologist, a cardiologist, an ophthamologist, and a neurologist and in every single case we learned things about his conditions and potential treatments that were helpful to him because he saw a specialist.
I wholeheartedly encourage people to review their diagnostic and treatment philosophies with their vets. I remind myself as often as I can that they deal with the entire gamut of clients from people who won’t spend a dime to people who will do anything to help their dogs and it’s not fair to expect them to know which one you are. So it can only help the dog and the relationship with the vet to talk about it. I also worked hard to find a vet whose philosophy is in line with mine so I don’t have to fight an uphill battle as I did with vets who went straight to Watch and Wait.
Working with people with diabetic dogs, we have found this approach helpful when it comes to home blood glucose testing, which vets do not always support. That it helps to spell out for the vet the kind of regulation of diabetes they are interested in obtaining and that they are willing and enthusiastic about monitoring their blood sugar. Because it’s easy to default to whatever level of monitoring “most” of the vet’s clients are interested in and not find out what this particular client is willing to do.
My 12 year old Pheona, a 75 lb Choc Lab/German Shorthair tore her right rear crutiate and because I’d had great results with OTC Glucosamine meds I’d given my Nugget when she tore something in her left rear leg I told my vet I was going to try. She is doing very well, with some cracking noise when she walks but we avoided surgery. She also takes Fish Oil caps and is on prescription
Previcox but seems to enjoy life and her siser Noel and brother Dodger, all rescues. Thanks for your great articles.
I don’t know if payment plans were discussed, but it seems that most vets want full payment when they treat someone’s pet. I realize it is a business, but if money is more important than treating an animal, then they should find another career. I hear this over and over from people around the country.
Perhaps some guidelines for vets can be in place to prevent unnecessary tests, wrong diagnosis/treatment without getting paid or the client getting reimbursed, and payment plans.
Our dog, Buckley, a Chi-Pom, also had the ruptured disk twice. The first time, he was about to recover with meds and crate rest for 8 weeks. This last August, had ruptured another disk and had to have the MRI, surgery and the recovery at the hospital. It was close to $6000. Even though we didn’t have the money readily, my husband found a way to pay the bill. We area lucky we live in an area (Philadelphia suburbs) where we can get the best of care for our pets when they are ailing. We were once visiting another state and had to drive all the way back here, 12 hours, because there was nobody to treat one of our dogs’ emergencies. We have 4 adopted dogs and would do anything for them! my vets, Horsham Veterinary and the CARES center in Langhorne PA rock!
What about offering euthanasia as an option? (Only when it is, in fact, a viable option of course!) At what point as a vet should you mention euthanasia along with other possible treatments? Clients often ask if they should?, is it time?, what would you do? etc… but it’s a very tricky question to answer isn’t it? As a vet technician, clients would even ask me but I would never give a concrete “yes” or “no” as I didn’t feel it was my place. Also, I don’t have adequate knowledge of the medical intricacies of the situation as the vet does.
Unfortunately, working in the field I have seen vets continue to perform diagnostics and prescribe drugs when the pet is obviously at the end and in pain. For instance, a client with a 20 yr old cat, who had stopped eating and drinking, came into the clinic to euthanize his long time friend and was of course upset. The vet talked him into doing a full blood workup (chem/CBC/thyroid) instead of putting the cat down. Of course the man came in a mere 2 months later and put the poor cat down. He had to suffer the agony of the thought TWICE and the cat suffered 2 more months. Very unnecessary in my opinion. I no longer work for that vet.
Great article. As a former veterinary hospital manager, I learned that it’s often the client who you’d never think would go for the most expensive option, based on appearance, or the kind of car they drive, or even on previous decisions they made for their pet’s care, who ends up doing exactly that. I think it’s also important how a vet presents the option. They should never apologize for the cost of an option. Veterinary costs are what they are (and compared to human health care, they’re nothing!), and if a vet can’t stand behind them, what is the client supposed to think?
And I love your suggestion to let your vet know that you want all the options – that takes the pressure, and temptation to make assumptions, off on both sides.
I want to know ALL options before I am willing to make any decisions at all, whether financial or medical.
I may be poor, but maybe I’m willing to sell roof over my head (well, if it belonged to me) or my body parts to help my dog. I want to know all options, their pros and cons and then consider the financial aspect if that is necessary. It was a decision we had to make when Jasmine was in ICU and a quote was 7K. What we wanted to know was whether she will recover and regain her quality of life.
There is one funny story related to this. At one time I was pushing for inclusion of enzymes as one of Jasmine’s supplements. The vet kept telling me he normally doesn’t prescribe that because of the high cost, but he was going to look at the products and let me know.
We were in the office and with all the things going on I was rather wound up. He remembered the enzymes and tells me that he found a suitable product which would come to about ninety – to – a – hundred dollars a month.
With everything else on my mind and having been primed for a large number, guess what I heard? Ninety two hundred a month!
My jaw dropped. OMG, that is expensive. At the same time I started trying to figure out what would it take to come up with that money.
Everybody was staring at me, not understanding my frantic reaction. My husband was the first one who figured it out. Then he got quite scared, because he could see that I’m trying to figure out where we’d get that.
Honey, he says gently, he said ninety – to – a – hundred…
Since you ARE my and Molly’s vet, I do appreciate that you keep me aware of all the options, and appreciate all the support you give me and Molly. I am very far from wealthy, but I am one who will find a way, be it beg, borrow or steal – haven’t stole anything yet ;~) – to pay for whatever will give my pets the longest and best quality of life. I cannot, in good conscience, make a treatment decision based solely on money. That being said, one can’t judge who will or won’t, can or can’t pay for the better, maybe more expensive option based on their financial status.
Great topic … with today’s economy I can see where some Vets may think they are removing pressure by with holding some options but I for one, even with my limited resources would appreciate all options. Only I can make a do or die decision concerning my furbaby!
I completely agree with telling the client all options, including Eastern/alternative/dietary ones. I believe in numbering them, as you did with your ligament example: this is the best way to completely resolve this problem and not have resulting arthritis, this is the second best way, etc.
I also strongly believe in sharing all the criteria for “best” results. You mentioned this when you talked about a dog sometimes being too old or frail for surgery or invasive procedures. This also applies when a dog has multiple issues,as sometimes the cure for one can be the cause of another. I did not hesitate with the chemo that gave my beloved Rhodesian cross 2.5 years of happy remission, but I always knew that if my cattle dog cross needed repeated radiation that I could never do that to him, as he had a very hard time going under and coming back. Best result procedures must be tailored to fit your specific animal.
Often zealous vets will urge the expensive and invasive cures. One vet said to me when I did not choose these for my old, arthritic dog with multiple issues that I was “choosing to not treat her”, which was not true at all. Sometimes rest, limited mobility, acupuncture, medicines, etc. IS the best treatment, and in my dog’s case, it was! These vets are not uncaring, but they remind me of fertility doctors, who generally assume their clients will spend thousands of dollars they don’t have to pursue their dream, however dangerous or unlikely it might be.
That being said, IF it was best for my dog, I would spend any amount, and do anything I had to, to get the money!
Dr. Kay, you rock!!! I would definitely require my vet to inform me of all surgery and/or treatment that my furry children may require. I would also ask for her recommendations. The way I would ask would be: “If it were Samson (her beloved dog), what would YOU do?” This would weigh heavily in my eventual decision, along with web research.
Our dog Chip, a chocolate lab, was 12 years old when he was diagnosed with a ruptured disk that had left him paralyzed. Without surgery, he would not have survived. We tried drugs and rest, but they had no effect. This wonderful vet was upfront with us about the risks, the benefits and the costs. The surgery cost well over $5,000 for the MRI, surgery and post-surgical treatment, but the vet felt he would recover and enjoy a good quality of life for at least 2 more years. We could afford the surgery, and wanted to give Chip the chance to recover and enjoy the remainder of his life with some quality. We felt we owed it to this grand and wonderful companion and member of our family. He went through the surgery to repair his damaged disk, recovered and lived with a high quality of life for 2.5 more years. We were grateful for the extra time, for his talented medical team and never looked back from our wise decision.