Oh, Crap! My Patient is Better!

Oh, Crap! My Patient is Better!
September 9, 2015 (published)
Dennis Ngo

Oh, Crap! My Patient is Better!
July 15, 2013 (published)

This is going to take a little finesse.

Every doctor everywhere, be they a dentist, veterinarian or MD, takes some sort of oath. Witch doctors and Time Lords may be excluded, I don’t know. Usually this oath contains some verbiage to the effect of “I promise to only do the good stuff and never to do the bad stuff and only work to make them better and stuff.”  It can be encapsulated by the phrase primum non nocere, which translates to ‘first do no harm.’ For vegetarian doctors, it is amended to 'first, do no ham.'

I, too, took this oath and I live by it. So we will start with my allegiance to the oath as the ethical underpinning of what I am about to say:

Sometimes, when patients get better, things get worse.

By worse, I really mean, ‘more complicated.’ Notice I didn’t say when patients get well – I said when they get better. And in the gulf between those two words – better and well – is where all the confusion and dismay lies.

Well means they are eating, happy, running about and ready to go home from the hospital. That’s well and that’s what all the wellness business you hear bandied about is all about. They are back to normal, whole again and hallelujah! the healing has been delivered and the oath has been upheld.

Better – that’s a different story altogether. Let’s say you have a dying patient, three feet in the grave and one foot on a banana peel, and the patient makes a slight improvement - that’s better. As in “your dog is desperately ill, has low blood pressure, gastrointestinal bleeding, kidney failure and can’t clot their blood, or, really, breathe and I am afraid that he may just shuffle off this mortal coil and join the choir invisible any moment now.”   And then, say a few hours later, one of those items in that litany of lethal abnormalities starts to perhaps reverse itself a bit – say the kidneys open up and start working, or the lung function improves by 10%. That’s better, but it’s still a far sight from well. Better is the first couple of steps on the journey of 10,000 miles, while well is getting there, checking in to your room and unpacking your suitcases.

Let’s also say that while the patient was in the throes of the crisis – deep in thickets, stuck in the medical quagmire – the family had decided that it was best to (and pick your favorite euphemism, here) let the patient go or let him pass or let nature run its course. To euthanize and not let them suffer anymore. Totally defensible decision with a desperately ill pet, and one that I usually wholeheartedly support.

But then…better happens. Not well better. Are you with me now?

Better, sometimes, sucks.

With a dying patient, if they are obviously not doing well and the writing is pretty clearly scribbled upon the wall that well is not going to happen, people can stop with a clear conscience and usually feel good about the decision to do so – as good as you can feel about the decision to take a life, but be at peace with the decision and live with it.

But when that patient gets a little better – it all goes to hell. No ones like to give up, and better makes them feel like they are giving up. Just when he was getting better, we pulled the plug – we gave up. I see people torture themselves with this all the time. The only way to get to the hotel located at well is through 10,000 miles of better, but sometimes that road dead-ends right at better and well ain’t never gonna happen. Here are a couple of examples of cases where better has thrown a spanner in the works:

  • The dog who was desperately ill with hemolytic anemia and who had not responded to medication for 3 days, three blood transfusions and about $3,000. On the morning that the family had decided to euthanize, he decided to make his red blood cell count about 3% better, thus throwing the family’s carefully considered plans into disarray. The 3% did not represent real, durable improvement, but they had to wait for an extra day to see the numbers worsen, and had to go through the agonizing process of deciding to euthanize all over again.
  • The cat with septic abdomen (widespread infection in the abdominal cavity, usually due to an intestinal perforation) who had a list of problems about a yard long. After a weeklong struggle, the family had finally decided that his suffering was in vain. The problem was…you guessed it: a few of the twenty or so things wrong with him got better overnight, but he still had lots of life-threatening complications on his list. The family and the cat had been through enough, they were out of money, and the improvements were minor, but it still gave them false hope that he was ‘turning a corner.’ They didn’t want to give up when there was the possibility he was getting better, so they kept on keepin’ on and were in exactly the same place about 3 days later when he died on his own, at 2 a.m., with no family members around.

I could go on and on. Sadly, there is no shortage of this phenomenon occurring in veterinary ERs and ICUs.

Now, I don’t want to give the impression that I am not fighting for my patients and that I don’t hope they improve.  That’s far from the case! I strive to make them get well every day – that’s what doctors do, and that’s why we take the oath and live by it. It’s just that if the family has made the right and hard-fought decision to euthanize or stop treatment, I want them to be able to do it with a clear conscience and no second guesses. I want them to feel in their bones that they made the right decision. Better shakes the foundations of their resolve at just the moment when they are most vulnerable, and makes them doubt their decision, or (worse, in my opinion) keep going with a case that is hopeless.

I think the answer, or part of it, lies in an accurate realization that, even if one or two things start to get better, often the patient is still doing poorly and decisions to stop are justified. Many just never make it all the way to well, despite everyone’s best intentions; those are the miracle cases and hoping for a miracle often leaves everyone feeling unfulfilled.

So when your pet is really sick and you are trying to make 'the decision,' remember that better does not equal well, that miracles rarely happen, and know that your veterinarian is going to support your decision.

9 Comments

Liz
December 4, 2015

Really nice article. I'm an ER doc and going through this with my own dog. The article helped explain the process to my husband a bit.


Debbie 
August 27, 2013

To me, it all depends on quality of life.  If the animal still seems to enjoy eating, drinking and being with his/her people, that's worthy of life.  When the animal quits eating (even the good stuff), he/she is letting you know it's time.


Jen 
July 17, 2013

WOW! Well written! I have been a technician for a long time and have seen this happen time and time again. The emotional roller coaster is almost a bad as that final goodbye.


Liz Hughston, RVT, VTS (SAIM, ECC) 
July 17, 2013

Amen to this article!  I'll add the corollary, "Just because we CAN doesn't mean we SHOULD."  Thank you for taking on a difficult subject.


Kathy 
July 16, 2013

Great article, great insight.  As someone who has had to make this decision for my pets many times, I can attest to the agony we go through with "better".  I'm always grateful for the DVMs who walk me through this painful process.  Thank you!


Jana Connell, RVT, CVT 
July 16, 2013

I soo hear you on this one Doc! I can't count the number of times a patient has done this and we all get a little more hopeful. Just as they get a little bit "better." Just like the cat that was rattlesnake bit and sat up on day three and started eating then was dead in it's cage the next morning.
I feel you and hear you loud and clear!! It's a real dilemma isn't it?
So sad too. I have been on both sides of the fence so I know this all too well.
It is good to know that you can recognize it but heartwarming to hear that you care enough to not let owners go home and second guess themselves into depression. It happens to us all.
Thank you so much for caring...


Amy 
July 16, 2013

I had to euthanize my beloved 15-1/2 year old cocker spaniel due to pericardial effusion that the best ER vet in the region (I drove quite a ways) didn't think would respond to treatment.  While we were discussing his condition and I was mulling the inevitable, they were giving him oxygen and he perked up quite a bit.  It's so much easier to put down a dog that wants to die.  My boy was feeling pretty good but I knew it wouldn't last.  I asked for a can of A/D to give him a tasty last meal, and the vet gave him his final shots.  Thanks for writing about that tough final hour or day when no alternative seems like the 'right' one.


Deb 
July 16, 2013

This is akin to running a code on a patient, call owner they finally tell you to stop...and yep, heart starts barely and perhaps a few breaths and then you have to call to euthanize.


Peggy Langford 
July 16, 2013

I am ever so grateful that I have a vet who I trust completely....luckily most of my guys ( dogs) lived long lives and when the time came , my decision was agreed by my vet ....but there was one time one of my young (6 yrs) bcs was diagnosed with acute pancreatitis...she only "got better" with massive IVs....without putting her thru an MRI etc my vet felt that something else was going on (cancer) and sadly a decision was made. I will never forget her putting her hand on my shoulder as I was visiting my baby girl ( who wagged her tail and tried to look at me) and said that it was time...she was right...I wept, but it was time


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