When it comes to managing heart failure in cats, it’s difficult to predict the outcome – we simply don’t know how a feline patient is going to respond. And with such uncertainty comes the murky waters of medical ethics, bringing to the forefront questions such as “What are the hard lines when it comes to managing heart failure in cats?” The question of whether to treat a case can weigh heavily on the mind of veterinary team and owner alike. So, how do we decide what cases we should and should not treat?
As part of the dyspnoeic cat stream hosted by the British Small Animal Veterinary Association (BSAVA) for their 2023 congress, a panel of expert speakers from across the veterinary profession debated the ethics of managing heart failure in cats. From attempts to chalk out some hard lines to the effects of long-term treatment and protracted grief on the pet–owner bond, the panel shined a light on the complexities of this ethical dilemma.
Navigating the ethical divide
While some feline patients are left with severe motility issues following heart failure, others can return home a few days after initial stabilisation. However, the stabilisation process can be distressing for all involved, with some cases requiring more intense, expensive and demanding treatments. But when you do see a successful outcome, it can be very rewarding. So how do you decide which cases are treatable?
Jose Novo Matos of Cambridge University explained that there are two perspectives to consider: that of the patient and that of the client.
The patient perspective
Because it is difficult to determine prognosis from admission baselines, Jose believes “every cat deserves the chance to be treated” and will reassess after 12 to 24 hours. Contrarily, Jenny Reeve (Langford Vets) and Elle Haskey (RVN, Royal Veterinary College) draw a more distinct line in the sand: they don’t think cases of aortic thromboembolism should be treated.
Kieran Borgeat (Eascott Referrals) noted that the nursing team is ideally situated to determine if a patient is struggling or in pain as they spend the most time with them day-to-day. To Elle, this makes the nurse’s role crucial in cases of heart failure because they act as an “advocate for the patient”. But ultimately, she revealed, it’s about communicating whether the veterinary team is getting to grips with the condition at the time of discussion.
The nurse’s role crucial in cases of heart failure because they act as an ‘advocate for the patient’
However, as Jose pointed out, this can be hard to assess when you bring stress into the equation as it is clinically challenging to distinguish between stress and pain due to dyspnoea. When it comes to this, making the in-hospital experience as stress-free as possible by minimising environmental components is the way forward, he explained. Adding to this, Elle recommended mechanical ventilation to neutralise the patient’s anxiety surrounding the inability to breathe.
The client perspective
Of the two perspectives, the client’s is the one Jose finds the most challenging to navigate because it is often multifaceted and involves discovering the client’s underlying motivations. And when it comes to the client’s motivation and personal belief systems, observed Richard Corrigan (lecturer in philosophy, Cumbria University), we need to consider one poignant and fundamental question: “At what point do clinicians feel their ethical perspective takes precedence or is in some way superior?”
Because there is often a bigger picture behind that we cannot always see, explained Elle, understanding the intricacy of the client’s situation can help you deliver information in a more effective way. She also suggested mirroring the human healthcare system by bringing nurses into these conversations where appropriate. This is because they have a fundamentally different relationship with the client, thus approach the discussion from an alternative angle.
Understanding the owner’s limitations – whether they are physically, mentally and financially prepared to look after a cat with heart disease in the long term – early on is essential
In any emergency or chronic presentation, Jenny finds it helpful not only to ask the clients how they are coping but to discover their perspectives on disease. Doing so helps her determine any absolute barriers for her clients, allowing her to frame ongoing and future discussions around them. Likewise, in Jose’s eyes, understanding the owner’s limitations – whether they are physically, mentally and financially prepared to look after a cat with heart disease in the long term – early on is essential.
Weighing up the risks – the impact of treatment on the pet–owner bond
Alongside the risks of initial treatment, the veterinary team must also bear in mind the progressive nature of feline heart failure and the likelihood of recurrence. These factors, in addition to the impacts of long-term treatment itself, can have a profound negative effect on the pet–owner bond.
Not only is there the “ticking time bomb” of the knowledge that your pet may suffer again suddenly at any moment but, as Kieran pointed out, the owner might distance themselves from their pet as part of an unconscious defence mechanism against bereavement.
The overhanging possibility of a sudden, serious recurrence and the necessity of administering treatment fundamentally alters the dynamic between pet and owner, observed Richard. To the cat, the owner who was once a safe haven becomes a symbol and origin of potentially uncomfortable treatments. Meanwhile, the owner who once found companionship with the pet finds themselves transformed into a carer, compelled by the necessity of treatment to put their beloved pet into uncomfortable scenarios.
The overhanging possibility of a sudden, serious recurrence and the necessity of administering treatment fundamentally alters the dynamic between pet and owner
Further, what was once valuable bonding time between pet and owner can be transformed into a frightful event by long-term treatment. As Richard explained, the administration of medicine becomes a tangible reminder of the pet’s health, thus amplifying the anticipation of grief. Though anticipatory grief may seem like a positive – the implication being time for preparation in the face of the inevitable – in actuality, it prolongs the grieving process. This leaves the individual suspended in a heightened version of the “adaptive organic response” that helps us regroup and return to functionality after a loss.
So, what can we do?
At the end of the day, listening carefully to what the owner says they can reasonably give when it comes to medication and considering the logistics of administration is a good place to start, observed Jose. But minding your language also plays an essential role when in these difficult conversations.
The decision as a shared process
Kieran noted that complaints following euthanasia commonly contain statements along the lines of “I felt I had no choice”. As a recurring theme, he concluded that this is an issue within the profession. Ultimately, Jenny has found that clients want us to make time for honest conversations that make them feel included in decision making, though she admits this can be challenging at times.
There is also a psychological angle to this, observed Richard. “If we rob the owner of self-efficacy [and] autonomy,” he continued, “it has a huge impact on protracted grief.” Although this sounds counterintuitive, having autonomy over the decision can lessen the burden of responsibility grief and self-doubt. Yet, by ensuring the owner has self-efficacy, we put the onus on the veterinary team. Therefore, we must consider another conundrum – how much time is the veterinary team willing to spend discussing the intricacies of managing feline heart failure so the owner can make an informed choice?
Nowadays pets are regarded as family members, observed Richard: “They have an intrinsic value in our lives that cannot be replaced.” And as veterinary professionals, we have the power to provide “empathy through communication”. By showing understanding of and empathy for the extremity of the decision your client faces when thrust into these situations, you make them feel validated. However, it can be difficult to do so in a clinical setting, so having a bereavement team or staff member – perhaps a nurse or member of the customer care team – professionally trained as a counsellor can help at this juncture. Not only does this bring a fresh perspective to the conversation, observed Jose, but it can do the world of good for the clinical team to know that someone “has their back”.
Mind your language
On the individual level, the veterinary team can practise “empathy through communication” by simply minding their language. It is easy, remarked Jose, to slip into the role of guide rather than giving evidence objectively. Here, Elle observed just how crucial phrasing is when delivering clinical information – by avoiding questions or statements like “if this was your/my cat…” which unintentionally add weight to your opinion, you facilitate a shared decision without projecting your ethics on the client.
By avoiding questions or statements like ‘if this was your/my cat…’ which unintentionally add weight to your opinion, you facilitate a shared decision without projecting your ethics on the client
But why is giving your opinion bad? Well, as Jose observed, opinions and morals are clouded by an individual’s personal experiences and stigmas. This means no matter how outwardly similar a situation is, they are intrinsically different – a difference that makes the question of what you would do in the situation subjective, giving it, as Richard observes, “superficial relevance”. Instead, when a client asks this question, Richard asks us to bear what your client is truly looking for in mind: validation that the decision they have made is the right one.
When you reach the point where your ethical beliefs no longer align with those of your client, Richard recommends a simple yet profound solution: having self-compassion. Though this can feel difficult to achieve, you can start on this path by recognising the level of responsibility you have as a clinician. Begin the process by acknowledging when your ability to effect change has reached its conclusion, and remember that you have done the best you can.
This disjoint in ethics is hard to overcome, acknowledged Richard, but it’s the reality, and by accepting this, you will reduce the effects of burnout and compassion fatigue.