The Value of Caring
Melissa Leaf, DVM
The patient’s case in this article does not fall under HIPAA
When people hear that I’m a veterinarian now in medical school, the obvious question is, Why did you decide to switch from animals to people? The short answer, the elevator answer, is that I want to be able to do more. It’s an answer that satisfies most people by lauding human medicine as the pinnacle of technology and research. Which isn’t wrong, but it is incomplete. Occasionally, perhaps when speaking with someone who’s pursued advanced treatment options for their dog with lymphoma or cat with hypertrophic cardiomyopathy, they’ll question that response. “But can’t you do just about anything in veterinary medicine that we can for humans?” And that’s the issue. Because while we can, we very rarely do. The value of caring, both economically and emotionally, is vastly different for humans and animals.
Jake, an approximately one-year-old male domestic shorthair cat, presented to me one Sunday at the emergency clinic where I still work. He came in with the classic veterinary chief complaint of ADR. ADR stands for “ain’t doing right”; it’s our shorthand for the vague presenting complaints of an owner who knows something is off with the animal but isn’t exactly sure what. Usually, it involves a combination of lethargy and hyporexia, barely narrowing down the list of differential diagnoses. Jake was a young, friendly cat who started his life out on the streets – maybe in a barn, maybe under someone’s porch. Two weeks prior to presentation, he was taken in and given a home. His new caretaker took him to his first vet visit 11 days ago, where he was vaccinated, dewormed, and neutered. She noticed that for the past few days he’d seemed slower, more lethargic. He slept next to her in bed per their usual routine, but he barely moved all night and didn’t get up when she did in the morning, not even to be fed. She thought he could have an infection from his surgery, which seemed like a plausible explanation.
On physical exam Jake was afebrile. He had an increased respiratory rate but normal respiratory effort and his lungs sounded clear. He was tachycardic with a soft systolic murmur. His abdomen was soft and non-tender, and his surgical site was healing well. The owner approved bloodwork, which we ran on our in-house machines. His serum appeared icteric and he was profoundly anemic. His tbili was elevated.
Ignoring the species differences, what would you want to do next? We have a young, previously healthy individual with symptomatic hemolytic anemia a week and a half after a medical visit where he received vaccines, anesthesia, possibly antibiotics, and surgery. Isn’t an intriguing case presentation like the opening chapter of a good mystery novel? Now we can puzzle through the list of suspects. This could be an error of metabolism, a kitty version of G6PD deficiency, causing RBC oxidative stress. Or a hapten-induced process leading to RBC destruction. He was previously an outdoor kitty; how about an infectious cause like Mycoplasma haemofelis leading to feline infectious anemia?
For those who prefer action/adventure to mysteries, we could treat the poor guy first and then sort out the details. Jake’s lethargy, tachypnea, tachycardia, and heart murmur were likely all due to his profound anemia. He looked like he would really appreciate the oxygen-carrying capacity of intact red blood cells. With that in mind, I started by recommending a blood transfusion, followed by further diagnostics to figure out the underlying cause of his anemia.
The complicating factor was the scarcity of cat blood to transfuse. Under the best of circumstances, cat blood is a rare and precious commodity. Animal blood banks exist, but supplies are limited and the price of a unit can be cost-prohibitive. Most vet clinics rely on staff members’ pets to act as donors. It had been a busy month and we had no more eligible donors to bring in.
I suggested taking Jake to the veterinary teaching hospital in Blacksburg, about 45 minutes away. He could be admitted through the ER, get his blood transfusion, and be transferred to the care of their Internal Medicine service first thing Monday morning. Jake was stable enough to make the trip, but the sooner he got his transfusion, the better.
Jake’s owner made the decision to euthanize him.
She had adopted him into her home and given him a chance, but that chance ended when he developed a complicated and somewhat expensive condition. Jake’s medical needs exceeded the value of caring for him. He was a lovely animal but there were other cats that needed her, potentially healthier cats that could be saved and adopted.
Did I have to euthanize him?
My options were to end this cat’s suffering or to take responsibility for him myself. I likely could convince the owner to sign him over to me. Jake would hang out in a cage until the end of my long shift, then I could drive him to Blacksburg for his transfusion and IM work-up. I would pay for all his care and then have another cat.
That’s always the option I give myself when an owner decides to end a pet’s life. I can take responsibility and do all the things myself. For a brief moment, the pet’s owner and I are shared guardians of that creature’s life as I silently consider whether I can take on another animal. And if I’m not willing to assume the full responsibility of the pet, can I fault the owner for making the same decision? Each patient’s death seems like a small failing on my part. If I cared more, I would find a way to treat them instead of killing them.
Jake became one of five animals I euthanized that shift.
I practice veterinary medicine conservatively and apologetically, feeling personally guilty that medicine costs money and doing everything I can to keep costs down. I quickly present all the options—from the recommended diagnostics that should lead to a fact-based treatment plan to just empirical therapy—hoping to catch the owners before they’ve already decided to “not put him through all of that.” This hasn’t always been the case. For two years I practiced in Iraq and Afghanistan, taking care of our highly-trained explosive detection dogs contracted by the Department of State. Anything these dogs needed they received. I never once had to discuss the cost of treatment or give cheaper options. I provided the best medical care I could under the circumstances and no one questioned the value of caring. That was when I realized how difficult it would be to return to private veterinary practice.
During my pediatric rotation, I loved that no one told me how much they paid for their child or how easy it would be to replace her with a new one. No one said, “He’s not really our kid; he just showed up and we’ve been feeding him.” I loved that the residents have no idea how much a coagulation panel costs, and even if they did, why would that change how they practice? The benefits of knowing about a coagulopathy are obvious to everyone involved. No one has to worry that pre-op testing will dissuade patients from having the surgery performed. For good and bad, medical students are protected from knowing the harsh realities of the costs of medicine. We learn to make decisions unapologetically for the best interests of the patients.
To be honest, I don’t intend to fully make the switch from veterinary to human medicine. The skill sets of caring for human or animal patients, especially when they are unable to speak for themselves, are inextricably intertwined. I hope to use my perspective to improve the lives of humans and animals in a profession where caring is universally valued.
Melissa Leaf, DVM
Class of 2024