The most recent Petconsent blogs can be read on the main School of Law and Social Justice blog:

• February 2021 — Research on consultations involving euthanasia
• January 2021 — Veterinary Humanities UK special interest group launches
• December 2020 — Do vets and pet owners want to share decision-making?
• November 2020 — Research in Pet Patients

As part of her ESRC Fellowship, Dr Carol Gray has been researching and writing monthly Petconsent blogs since the end of 2019.

You can read Carol's ten previous blog posts (December 2019 - October 2020) on this page below:

This month I’ll be taking a look at the General Medical Council (GMC)’s new guidance on decision-making and consent for doctors. Can it offer anything to the veterinary professions?

Due to come into force on 9th November 2020, the new guidance is already available on the GMC’s website, and it makes fascinating reading. It replaces the previous document “Consent: patients and doctors making decisions together” which was in place from June 2008. Reasons for the update include the decision in the Montgomery case, which reinforced the need to consider what information should be given to the “particular” patient that the doctor was dealing with, rather than the generic “reasonable” patient.

First, let’s look at the changes. To start with, the guidance acknowledges that every situation is different. What applies to one patient may not be relevant for another. So already, we are seeing a move from the “typical” patient to the “individual” patient. We can see how this might apply to veterinary clients, and their different relationships with their animals (I’m thinking about companion v. working v. food-producing animals, for example).

However, it’s not enough for the doctor/vet just to predict what a patient/client may want. The basis of this new guidance is that the doctor should engage in a dialogue to discover what this particular patient wants. In other words, the guidance focuses on the individual patient, and how the doctor can find out what matters to this patient. This allows the doctor to share the information that this particular patient needs to make the decision about which treatment is best for them (or in the case of the vet and client, best for the animal).

Photo by Anna Dudkova on Unsplash

Next, the guidance lists 7 key principles to be followed when doctors are guiding patients to make decisions that are right for them. We’ll come back to these in a moment.

There is also a section that looks at how other members of the healthcare team can help with providing information and working with patients to support them to make the best decisions. For veterinary practice, this brings in the important role of veterinary nurses in discussing options with clients and providing information that they need to help them with decision-making.

So, let’s go back to these 7 key principles, and imagine what these might mean for vets, vet nurses, clients and animal patients if the veterinary guidance was changed to something similar.

Principle one: all patients have the right to be involved in decisions about their treatment and care and be supported to make informed decisions if they are able.

Translated for veterinary practice, this would read “all clients have the right to be involved in decisions about the treatment and care of their animals and be supported to make informed decisions, bearing in mind animal welfare requirements.” I’ve added the last statement as client decision-making is always limited by animal welfare law. As human patients, we can decide not to accept life-saving treatment and just let nature take its course. As animal owners, we have a responsibility to prevent suffering, so cannot just leave an animal with a disease or injury to ‘either get better or die’ without treatment.

Principle two: decision-making is an ongoing process focused on meaningful dialogue: the exchange of relevant information specific to the individual patient.

For veterinary practice, this would remain exactly the same, except that the meaningful dialogue is between the veterinary professional and the animal carer and is specific to the unique human-animal relationship.

Principle three: all patients have the right to be listened to, and to be given the information they need to make a decision and the time and support they need to understand it.

Here, we could simply replace “patient” with “client”. The important thing here is that, where possible, clients are given enough time to think about the information about options for treatment and to do their own research, before coming to a decision.

Principle four: doctors must try to find out what matters to patients so they can share relevant information about the benefits and harms of proposed options and reasonable alternatives, including the option to take no action.

Again, we can just replace “doctors” with “vets/vet nurses” and “patients” with “clients”. This principle stresses the importance of finding out what ideas, concerns and expectations the client may have, and using these to tailor the information given, which fits nicely with the goal of shared decision-making between veterinary professionals and clients.

Photo by Marina Hanna on Unsplash.

The final three principles address capacity to make decisions.

Principle five: doctors must start from the presumption that all adult patients have capacity to make decisions about their treatment and care. A patient can only be judged to lack capacity to make a specific decision at a specific time, and only after assessment in line with legal requirements.

Principle six: the choice of treatment or care for patients who lack capacity must be of overall benefit to them, and decisions should be made in consultation with those who are close to them or advocating for them.

Principle seven: patients whose right to consent is affected by law should be supported to be involved in the decision-making process, and to exercise choice if possible.

Now, assessing client capacity to make decisions is a thorny issue in veterinary practice. Although consent can only be given by someone with capacity, current veterinary guidance gives fairly broad advice on what to do if it appears that a client lacks capacity to consent. Ideally, the vet would try to find a legally appointed substitute (with a valid power of attorney). If there’s nobody with that power, the vet should act in the best interests of the animal, although discussion with the client’s family members, friends or carers is suggested.

For human patients, doctors need to spend time trying to support them to make a decision, for each separate decision, before deciding that someone else (who must have legal authority to make decisions on their behalf) should make the decisions. Decision-making for human patients follows a pattern that looks at whether a proposed treatment is in line with the patient’s previously expressed wishes, values and priorities, and is of overall benefit to them. For animal patients, vets are not required to spend a long time in supporting the client to make decisions. Instead, an assessment that the client lacks capacity leads to either decision making by someone else who has been legally appointed, or to the vet making a decision on the basis of what is in the “best interests” of the animal patient.

It's good that we have ended up here. ‘Best interests’ should be the basis for all decision-making on behalf of animal patients, not just in cases where the client is judged to lack capacity. I think it should be central to shared decision-making approaches too. In practical terms, this means that the client shares what is important in terms of their relationship with the animal patient, is given the relevant information about options, risks and benefits and is given time and support to make a decision that is in the best interests of the animal in that particular situation.

My view of the new GMC guidelines, if applied to veterinary practice, interprets ‘individual’ to mean the individual human-animal relationship and circumstances, rather than the individual client. It’s not a new approach, but it is one that centres decisions on the animal patient. I’d love to see this adopted as the cornerstone to professional guidance for vets and vet nurses! 

This month I’m going to discuss the latest piece of published research from my PhD (which now seems a long time ago!). I loved doing my PhD, and I am so happy to write about it in more “normal” language!

Have you ever wondered why you have to sign a consent form when you take your pet in for specialised treatment or surgery? What is the purpose of that form? We know that we have to give consent for any treatment, but most of the time, we just tell the vet or vet nurse that we’re happy to go ahead (for example, with a vaccination or treatment). If our pets need surgery or need to be kept in hospital for any reason, we will probably be asked to sign a consent form.

Photo by Kelly Sikkema on Unsplash

My article, “The role of the consent form in UK veterinary practice,” reports on the analysis of a number of consent forms that I collected from practices across the country. I was looking at these forms to see how well they could act as a record of the discussion about treatment or surgery that takes place between vet/vet nurse and client. I looked at the language used on the forms, which topics are covered and how the forms can act as a record of the client’s consent to procedures.

What did I find? My first task was to identify what was recorded on the forms, starting with the actual procedure that the animal patient was having. However, the space provided on most forms to describe the procedure/s was tiny (either a single line or box), so the description would need to be quite limited. The other surprising finding was that there was no space provided on any of the forms to list options for treatment. If options are discussed, then they are certainly not recorded on the consent form.

Of course, there was often plenty of space to note procedures that the practice offered alongside surgery, at additional cost. I’m talking especially about pre-op blood tests; these can certainly make things safer for older patients but are still a controversial “add-on” for young, healthy animals. I hope that clients are given extra information and guidance about whether they are really needed for their animals.

Photo by Daria Nepriakhina on Unsplash.

Next, I looked at the form’s role in the consent process, and how well it could record the discussion around the procedure, risks, costs etc. Most forms didn’t provide enough space for all of this. In particular, there wasn’t enough space for a detailed description of exactly what was going to be done to the animal. There was no room to include options for treatment. If risks were mentioned, they were hidden in a broad statement that assumed that the client would know the usual risks of the surgery and GA.

Did the forms perform better as contracts? Well, no – not really. Many forms did not even include space for estimated costs. Some forms included a sentence that gave the vet permission to carry out any additional procedures without the client’s consent, which invalidates their role as a contract.

Finally, all forms would have benefitted from using plainer language. I think they all tried to sound like legal documents (designed, perhaps, to give protection to the veterinary practice?). If forms are to play their part in consent, they need to be written in terms that everyone can understand. They need to provide space to record what is actually said between the people involved. Finally, they need to be given to clients in advance of the day of surgery if possible, allowing time for any questions they’d like to ask before leaving their pets for surgery.

I enjoyed writing this paper, and I hope that you will have a look at the full version, which can be read on the British Medical Journal's (BMJ) VetRecord website

What we call things is sometimes very important. I’ve been thinking about the relationship between companion animals and their owners recently, and the debate regarding the term “ownership”. To describe yourself as the owner of your pet may imply that you regard him or her as a part of your “property” or your “belongings.” Those who campaign for animal rights regard ownership as the biggest hurdle to obtaining these rights. But ownership may also imply a sense of responsibility and care.

Photo by Kelly Sikkema on Unsplash

Of course, legally animals are considered property, hence the ongoing petition to have pet theft regarded as theft of more than just property (see the petition on Change.org). Pets are sometimes given status as more than property, for example, in custody cases where the pet’s preferences are sometimes taken into account when deciding where he or she should live following a couple’s break-up (this is common in the USA, see this overview on pet custody). At most, this gives animals status as a special type of property. Staying in the US, some states and municipal regions have actually changed their laws to replace the term “animal owners” with “animal guardians.”  However, changing what you call the person who cares for the animal doesn’t change the animal’s legal status. Does a change in terminology make any difference? Well, perhaps surprisingly, yes it does – a study from 2006* found that pet owners who consider themselves as guardians rather than owners tend to make better decisions about the care of their animals. 

The recent upsurge in adoptions from rescue organisations is very welcome and brings in another aspect of the owner/guardian debate. Most rescue organisations refer to the rehoming of an animal to a new owner as “adoption,” acknowledging this term’s connotations of care when applied to children. The rescue organisation may insist that the animal should be returned to them if there are any problems or if the new adopter cannot continue to care for the adoptee. In essence, this is a type of “guardianship,” even though the payment of a rehoming fee means that ownership of the animal is transferred to the adopter. The use of terms such as “adoption”, and “fostering” (caring for a rescued animal on a temporary basis) by animal rescue organisations reinforces their links with child welfare. Now, we’d never think of calling ourselves the “owner” of a child, but historically, children were regarded as their fathers’ property. Child and animal protection have been closely linked in the past, and today the Links Group works to promote cross-species detection of abuse. Animal protection legislation relies on having someone identifiable as the owner of the animal with the responsibility that this entails.

Photo by Hutomo Abrianto on Unsplash.

With the idea of “ownership” in mind, it was interesting to investigate the growing trend of “dog-sharing”. Now happening all over the world, the idea has morphed from one of “borrowing” someone else’s dog for a few hours or days (perhaps looking after the dog while the owner is at work or on holiday) into a full-blown shared ownership scheme. Which is fine, until the difficult decisions have to be made. For example, the shared dog is ill, and requires expensive treatment. Who makes the decision for that treatment? What if the decision that needs to be made is the hardest one of all (see May blog below) – will the decision be put off until all owners/guardians can be consulted and have agreed? I can see the advantages of dog-sharing in a busy world where we all have too little time, but I do worry about the effects of this type of arrangement on the animals involved and the care that they receive. Dogs are not like cars, or holiday homes, where it’s sensible and appropriate to share ownership. I really don’t think it matters whether we call ourselves owners or guardians, as long as we have the best interests of our animals at heart and take responsibility for the decisions that we make on their behalf.

*Carlisle-Frank P, Frank JM (2006) Owners, guardians, and owner-guardians: Differing relationships with pets. Anthrozoös 19(3): 225-242

I’ll start this month’s blog with a quote from Sir Liam Donaldson, the UK’s ex-Chief Medical Officer, changing one word to suit the veterinary context,

“the client who is armed with information and who wants to ask questions, even difficult and awkward ones, should be seen as an asset in the process of care not an impediment to it.”

Why do we need to even say this? Why are vets traditionally suspicious of the ‘informed client’? Why do they belittle any research the client carries out via Google?

There’s a famous quote on a mug that can be seen in many vet practice kitchens, proudly stating “Please do not confuse your Google search with my veterinary degree” (insert other profession as required). However, the backlash may have started, with one birth charity responding with their version of the mug, “Please do not confuse your medical degree with my informed consent.”

Mug image © improvingbirth.org

The answer, of course, lies somewhere in the middle. Ignoring the client’s research, prior knowledge and experience means that the consent conversation is going to be the same for every client. That’s problematic for both parties.

For clients with prior knowledge (either through research or previous experience), starting from square one will be tedious, will tell them things they already know and will disregard their life experience.

For veterinary professionals, there is a real danger of going into “autopilot” and just reciting the same old spiel. This will mean potentially missing non-verbal cues, failing to pick up on questions about what really concerns the client, and failing to achieve a truly shared decision.

It’s important that clients share the knowledge that they have about their animal’s condition, so that any misconceptions can be corrected. Perhaps this gives us a clue as to why vets and RVNs are so sceptical about Google research. There’s a lot of poor and blatantly incorrect information out there. However, it’s always important to acknowledge the time that the client has spent in performing their own research, no matter how poor the results may seem.

So how can we achieve this? The answer is in a technique that we have been teaching in veterinary communication skills training for years: enquiry about client ideas, concerns and expectations (ICE). As vets or vet nurses, we should regard asking clients about their knowledge and experience as a fabulous basis for a consent discussion. As clients, we should enjoy sharing what we have learned, and welcome the confirmation that it is correct, accept feedback where we’ve gleaned incorrect information, and recognise that the vet or vet nurse is interested in our experience.

How would this type of consent conversation start? Let’s choose a fairly common procedure, surgery to repair a ruptured cruciate (knee) ligament in a dog. In this case, we will assume that the vet who will perform the surgery is also responsible for the consent conversation. The vet could start by asking if the client has any previous experience with this type of surgery (either in a previous dog, or in human friends or family). The client may say no, they haven’t any previous experience of this. Now, the vet could ask “and have you found out anything about the various techniques used to repair this injury?” The client may reply yes, they have read about three different techniques and the success rates of each. The vet could then ask what the client thinks of the options. This is an opportunity to correct any false information, to answer any concerns that the client has, and to explain the risks and benefits of each method. We now have a good basis for explaining why the vet recommends her proposed method of repair, which may depend on the vet’s own experience, the equipment available, and of course the client’s finances.

Photo by Murilo Viviani on Unsplash.

Offering choices is always a good component of consent conversations and in this case, offering referral to a specialist practice for techniques that are unavailable at the primary practice is part of the discussion. Although the client’s prior research may lead to them choosing to be referred to another practice for an alternative technique, that’s no bad thing. Both parties should feel that the consent conversation has led to a shared decision about what is best for the patient.

So, in conclusion, let’s get over this “us” and “them” approach to veterinary consent, and work together as advocates for the best interests of the animal. Shared decisions need to incorporate the knowledge, experience and concerns of both parties, and to focus on the best solution for the animal. If we need another reason to embrace shared decision-making, remember that the animal patient’s care, both financially and practically, is dependent on the client. Why shouldn’t clients be involved in making decisions, and why wouldn’t they do some research to help them to make these decisions?

Sparkle is Peter Taylor's young female cat. He finds her one morning in obvious distress, dragging one of her back legs. She is bleeding from a wound on her leg, and from some of her claws. Peter scoops Sparkle into a cat carrier and rushes her to his usual veterinary practice, where she was neutered three months ago. The vet explains that she has probably has several fractures to the injured leg and may also have a fractured pelvis, probably caused by being hit by a car. She's given pain relief and the vet gives Peter options for treatment.

1. The practice can take X-rays to find out the extent of the damage and repair the fractures. This will be expensive, in the region of £700-900 for the initial treatment
2. The vet can refer Sparkle to a specialist practice for fracture repair. This will be even more expensive.

Peter explains that he cannot afford the proposed treatment, his work hours have been reduced recently and he doesn't have pet insurance for Sparkle. He doesn't qualify for treatment by one of the vet charities.

So, the vet offers two more options. Peter can sign ownership over to the practice, they will repair Sparkle's leg and she will then be rehomed to a new owner. Or Peter can opt for euthanasia.

Do these options suggest that Sparkle's ‘best interests’ are being given priority?

(Photo by Joenomias M. de Jong on Unsplash)

This month, I thought I'd share with you the latest article that has been published from the Petconsent project. We discuss this case example in the article to illustrate how the animal patient's best interests could be calculated in similar situations.

We explain that decisions for animals who need veterinary treatment cannot be made using the same branch of medical ethics that doctors use when making decisions about human patients (based on four principles which include autonomy and justice). This is because autonomy (which means that a human patient has the right to decide what happens to his or her own body) is often the most important consideration in human medicine. It's difficult to apply the same principle to animal patients as we can't work out what their wishes are (or we just don't have enough knowledge in that area yet). It's important that we don't just transfer that autonomy to animal owners as sometimes their wishes don't promote the welfare of the animal patient (for example, in Sparkle's case, Peter could have decided that he wouldn't take her to the vet's - if owner autonomy was the most important principle, that would be okay). Sometimes, as in Peter's case, owners would like to choose the best option for their animal but can't afford the suggested treatment.

We wondered if substituting 'best interests' for autonomy would work, despite the difficulty in assessing best interests for a patient who isn't able to tell us how they feel about what's planned. We ended up looking at 'best interests' decision-making for young children. Perhaps surprisingly, there's still a lot of discussion about how to calculate a child's best interests. The United Nations Convention on the Rights of the Child (CRC) seemed promising. We used the CRC's tips on calculating best interests for children to create a 'best interests' calculation for our animal patients.

Of course, there are major differences between decision-making for children and decision-making for animals, the first being the legal status of each of these patients. While children are legal subjects, animals are still regarded as their owners' property. Also, children will be able to participate more in decision-making as they grow, so our comparison is limited to very young children who can't tell us what they want.

Despite these differences, the CRC's list of 'best interests' considerations can be applied quite well to animals. Using the example of Sparkle the cat, we showed that her best interests would be served by the practice agreeing to treat her injuries for a lower fee, allowing Sparkle to remain with her family and, perhaps more importantly, on familiar territory. (We admit that we ignored the economic effects on the veterinary practice, which might adversely affect the best interests of other clients and patients.)

The table that we used in the article is reproduced here, with the individual interpretation of each element for Sparkle.

In summary, we suggest that the UN CRC was useful in giving us a list of things to take into account when trying to act in the 'best interests' of animal patients. By substituting 'best interests' for autonomy, we were then able to use medical ethical principles to underpin veterinary treatment decisions.

Read the full article

The full article is available in the journal Animals, and is "open access," meaning that anyone can read it online using the following link:

• MDPI - Legal and Ethical Aspects of ‘Best Interests’ Decision-Making for Medical Treatment of Companion Animals in the UK
  
  

This is a difficult topic to tackle in a blog. Each human-animal relationship is different. Each animal is different, with particular preferences and dislikes. If you are having to think about the euthanasia of a beloved pet, my first bit of advice is to talk to other people, especially your vet, about it.

Your vet will have lots of experience in advising pet owners about euthanasia. I've heard pet owners say that they didn't involve their vet at an earlier stage because they thought that the vet would make the decision for them. In my experience, that's not true. The only time a vet will strongly influence the decision is if the pet is obviously suffering and it has become an animal welfare problem, but that's really rare. It's your decision, and it's a huge responsibility. Talk to any friends who have been through a similar experience - they will understand and support you.

So how do you make the decision for, say, a geriatric pet with multiple health problems, gradually deteriorating and at the point where you wonder whether the pet is still enjoying life? With thanks to the US site Pets Web MD, here are a few pointers that may help your thoughts about the decision.

1. Have you adapted your home to make it as comfortable as you can for your pet and easier for you to care for them? Here, I'm thinking about comfortable beds for dogs and cats, putting rugs down on hard floors in the living spaces, making sure that food and water bowls are accessible (e.g. putting on stands), and having tiled or lino floors in rooms adjacent to the outdoors in case of accidents. You may need to help larger dogs to get into the garden to empty themselves, and a purpose-made sling or blanket can be used for this.
   
   
2. Do you know what makes your pet's life worth living? For example, does your dog look forward to walks and these are the highlight of their day? Does your rabbit love grazing, and being outside? Does your cat enjoy playing with toys on sticks, or catching beams of torchlight?
   
   Some people advise that while your pets are younger, you should make a note of which activities/lifestyle factors contribute to their quality of life and use this as a guide to quality of life in later years. The only problem with this approach is that we tend to "move the goalposts" as our pets age - we expect them to lose interest in their 'hobbies' due to advancing years. What happens is that their activities may change as they adapt to ageing, so we may need to update our lists each year.
   
   
3. Most pet owners want to avoid the thought of their companions being in pain. This is where talking to your vet is important. Modern pain relief is effective and can be given long-term, especially for cats and dogs, whose pain can translate into behavioural problems such as aggression.
   
   Other signs of distress can include hiding away and sleeping in odd places.
   
   
4. Some signs of disease in old age are alarming and may force a more rapid decision. For example, a pet that is having difficulty breathing does need urgent attention from a vet. The condition may be treatable (for example, fluid build-up in the lungs) or may require a rapid decision about euthanasia (for example, a tumour in the chest) - but you will only know which one you are dealing with if you consult your vet. Similarly, if your pet has suddenly lost the use of their hindlegs you need to get them to the vet. A word here about lumps and bumps - some owners leave doing anything about these until the lump is huge, sometimes because they don't want to know if it's cancer, or sometimes because they think the vet will tell them that the pet needs to be put down. Cancer treatment in pets (as in humans) has moved on considerably from the days when it was a death sentence. Please consult with your vet at an early stage, consider the options, but of course ultimately it is still your decision. Palliative care for pets is increasingly available to ensure that they are free from pain and comfortable for their remaining time.
   
   
5. So, how do you make the decision when the time comes to end your pet's life? My advice here is to make the decision that is in the best interests of your companion. That means putting their interests above your interest in still having them around. A useful scoring system is the 5H, 2M scale that has been developed by experts in pet end-of-life care.
   
   Using this scale, the first question should be, is my pet in pain that can't be controlled by painkillers, or obviously suffering? If the answer is yes, you don't need to go any further as the right decision for your pet is obvious.
   
   Second, can your pet eat and drink enough to maintain energy levels and hydration? If not, then you may find that they lose weight and their skin does not feel as mobile as it should. Assisted feeding may help, but you should keep asking yourself if this is maintaining an adequate quality of life for your pet.
   
   Next, is your pet still able to do things that make them happy? (see 2 above). This may include having human companionship and affection, playing and going out for exercise.
   
   Can your pet keep their coat clean and groomed? You may need to help with grooming, or by cleaning if they are incontinent, but keep checking for sores caused by urine or faecal soiling.
   
   Can your pet move around? Again, you may need to help with this, using some form of support, but does your pet seem reluctant to allow this support, or show no interest in moving?
   
   Lastly, does your pet have more good days than bad days? A good day would be one where your pet eats and drinks on their own, can walk (aided or unaided) for enjoyment, seeks affection, perhaps plays a little, and can rest comfortably. An odd 'bad day' where these things are not happening is acceptable, but when most days look like this, then it's probably time to make the decision.

Finally, it's not easy. I've been through it several times, and it doesn't get any less difficult. Each of my pets has been a unique personality with different criteria for their own individual quality of life. I like to think that I've made each decision in an unselfish way and in the best interests of my beloved companion. I hope that you can do this too.

Other useful sites:

• Compassion Understood (useful advice and lists vets who have had special training on end-of-life care)
• Blue Cross - Pet Bereavement and Pet Loss (Blue Cross Pet Bereavement and Support Service)

As most of us are spending much more time with our animals at the moment, I thought it would be a good idea to consider the effects that this extraordinary situation is having on our pets' health.

First of all, we may be paying more attention to our pets and their habits, looking at them for longer and more intensely than usual. We may pick up minor health problems that would have escaped our notice back in normal times. We may view this period as a time to catch up with preventative health measures such as vaccination and worming, which we may have neglected for a while. As a result, we may actually want to contact our vet practice more often than we would normally do.

But our vet practices are only seeing emergencies - how can we decide when to contact them? The British Small Animal Veterinary Association has produced a guide on when dogs and cats should be seen by a vet. Translating this into advice for owners, health problems can be assigned to the following categories:

No need to do just now:

Routine nail clipping, routine anal gland emptying. Unless these become problematic (nails growing into pads, for example), these will need to wait until the situation returns to normal.

Non-urgent, can be dealt with by teleconsultation (consultation by phone or video link):

Discharge from eyes or nose, minor cat fight injury, new mild lameness (limping), updates on long-term health condition, prescribing repeat medication.

Potentially urgent, can be dealt with by initial teleconsultation, but may need to be seen: 

Minor bleeding, minor injury, new skin swelling, vomiting, diarrhoea, increased thirst or urination, excessive itchiness leading to skin damage, worsening of a long-term condition.

Urgent, needs to be seen:

New seizures or fits, collapse (unable to stand), difficulty breathing, major bleeding, major injury (e.g. broken bone), eaten known poison, retching without producing anything, difficulty passing urine, difficulty giving birth, severe vomiting and diarrhoea, severe allergic reaction.

For urgent cases, the vet or nurse will conduct an assessment over the phone and advise whether the pet needs to come into the practice. What about maintaining social distancing if your pet needs to be seen? Most practices will ask you to remain in your car and will work out a way of transferring your pet from there into the practice. You will not be allowed to go into the practice with your pet. The vet or nurse will then contact you by phone to ask you questions, give you treatment options and ask for your consent to the treatment. When setting off for the practice, check that you have your mobile phone with you, your dog on a long lead, or your cat in a basket that can be handed over easily.

Practices are often willing to do primary vaccination courses for puppies; some are doing annual boosters - these decisions depend on local disease risk, which means how likely your pet is to come into contact with the disease. Again, social distancing measures are being used so you will need to hand your pet over to a member of practice staff to have the vaccine done.

Above all, if you are worried about your pet's health, especially if the situation isn't covered by the list above, please do contact your vet for advice.

These are difficult times for everyone. Vet practices are often working with less staff than usual, and demand may be increased because many people are at home and watching their pets closely. Please respect your vets and nurses when you need to contact them. Be good pet owners!

Useful reference:

• BSAVA Triage Tool for Dogs and Cats

Things have changed beyond recognition for the world of veterinary treatment in a few short weeks. Because of the COVID-19 pandemic, all routine veterinary visits have been cancelled. All practices are now running “emergency only” surgeries, with steps taken to minimise face-to-face contact. This means that if your companion animal requires urgent attention, you will not be allowed into the practice with him/her. You may be asked to remain in your car, and your animal collected from you and taken into the practice. The consultation will then take place between you and the vet via video call or telephone call, with your animal being examined while the vet or veterinary nurse talks to you to find out what’s been going on.

I thought it might be useful to give you some tips on video consultations, with acknowledgement to the Barts Health NHS Trust, whose advice for their patients I have amended for veterinary clients. As in the original advice, I’ve used a question and answer format.

How do I get ready for a video consultation?

Video calls can be done using Skype, Facetime, WhatsApp, and Zoom. You need to have downloaded the relevant app, and set up a user account, so it’s a good idea to have two or three of these “ready to go” with your username and password sorted if required.
You need a microphone, speakers and webcam – these will all be built into your Smartphone or tablet, which is probably what you will be using for the call (if you are doing the call from home, then a laptop or desktop can be used, so make sure that all the above are working okay).

You need to make sure that your data plan is sufficient to cover the usage of a video call.

What happens at the start of a video consultation?

The first few minutes will probably be a technology check, with questions such as “Can you hear me? Can you see me?” If there are problems with the technology, the consultation can be converted to a telephone call. The consultation itself will start with the vet or nurse asking, “Can you tell me what has been going on with (pet’s name)”?

How do we know whose turn it is to talk?

Sometimes it is hard to tell who should be speaking. This can happen with both video and telephone consultations. The solution is to stop, to acknowledge the problem, to work out whose turn it is to speak, and to continue.

What about technical glitches?

Video consultations can be less fluent than face-to-face or telephone consultations, due to latency (delays between the person’s lips moving and the sound being heard) or frozen screens. It’s a good idea to repeat the main points, or to ask for clarification. If the connection is lost, when reconnected you can start from the last thing that was clearly heard or said.

How do I capture important information?

You can ask the vet or nurse to repeat important information, for example medications or dosages, so that you can write them down, or you can ask them to send this information as a chat or text message.

How does a video consultation end?

It’s important to summarise the main points of the consultation at the end, and to ensure that both parties are aware of the next steps. You should check again on anything you are unsure of, and the vet or nurse should give you the opportunity to ask any questions.

The call ends when one party (usually the veterinary professional) presses the “end call” button – but it’s a good idea for this person to say “I’m going to end the call now” so that you don’t get cut off abruptly!

Follow-up

The practice will probably send you an email to confirm any arrangements for treatment, with clear estimates for costs etc. They may require a consent form to be completed and returned, or they may have asked for your consent during the video consultation. It’s important to ask for clarification if there is anything that you were not expecting.
We are all getting used to a new way of working, but I hope that this information may make things easier if you do need to seek veterinary advice during this time.

With best wishes to everyone and their animal companions, and sincere thanks to Barts NHS Trust for their video consultation guidance, available at:

• Barts Health NHS Trust Video Consultations FAQs 

As a pet owner, do you arrive at vet appointments in a state of total panic, or feeling totally relaxed and glad that your beloved family member is in the hands of an expert? For most people, the truth lies somewhere in between. We all feel slightly anxious if there is anything wrong with our pet, but this feeling is balanced with some relief that at least we are trying to do something about it.

How does your vet involve you in decision-making? Are you given all the options and left to make the decision on your own? Or, does your vet present one strong recommendation for treatment, then explain why you should agree to it?

Both the above approaches are found in practice. The first (consumerism) recognises that it’s your money and your animal, and so you should be the one to make the decision. In medical ethics, it’s called “autonomy.” It’s the ‘ideal’ situation in human healthcare, where as a competent adult, you are the person best placed to make decisions about your own body. Consumerism is found in practices whose culture recognises that the client is fundamental to the care and wellbeing of the animal patient.

But do clients really want this much autonomy? Not really, according to my research. Animal owners that I interviewed appreciated being told about all the options available, with their risks, benefits and financial costs too. They liked to do their own research. They liked to be fully informed. But when push came to shove, they also wanted help from their vets in making these difficult decisions, and sometimes just wanted to be told what the vet would do in their situation.

Which brings me on to the second approach. If the vet has already made the decision for you, or suggests that there is only one decision to be made, it’s called “paternalism” and it’s frowned on in modern (human) medicine. However, we are not talking about decisions about your own health here, we are talking about the health of your pet. In this case, paternalism is not the correct term. Paternalism means over-ruling or restricting the choice of an adult patient who can decide for themselves. When we are referring to an animal patient, a better term would be “beneficence” which just means deciding based on the best interests of the patient, who can’t decide for themselves.

Consumerism/autonomy and paternalism/beneficence are the two extremes of medical decision-making. Ideally, we should be looking for a happy medium, something in between. That middle ground is shared decision-making.

How does shared decision-making work in the vet world?

First, it needs both human participants (vet and client) to focus on making a decision that is in the best interests of the animal, in the circumstances in which the client and animal spend their lives. It needs the vet to offer all reasonable options for treatment at the start of the decision-making discussion. It needs the client to be given all of the information associated with each option, in terms of risks, benefits and costs. It needs the vet to ask appropriate questions about what is important to the client, and whether there are any constraints to treatment (e.g. limited financial resources). It needs the client to share concerns, beliefs and values with the vet.

It needs the vet and client to work together to come to the best decision for the animal and for the client.

So, these shared decisions are difficult. They take time. Ideally, the decision is made over more than one visit, if that’s possible, to allow any research or follow-up by both parties.

They take honesty on the part of both client and vet. For the client, being honest about finances and time available for care. For the vet, being honest about their knowledge of alternative treatment options, about the availability of resources or technical expertise at the practice.

But they’re worth it. For each animal patient, the decision should be in the best interests of that animal, in these circumstances, at that point in time. As a pet owner, wouldn’t that make you feel better?

Welcome to the first Petconsent blog! I thought I would give a fuller introduction to the “Petconsent” project. It’s funded by the ESRC, a UK research council, to develop the ideas from my doctoral studies on informed consent in veterinary practice. My main aim is to promote shared decision making as a way of obtaining informed consent, by involving pet owners in the deliberation around treatment choices, and ensuring that the decision made is the best one for the animal patient and for the patient’s carer (and, therefore, for the veterinary professional, as a result of a happy client and proper informed consent!)

To fully involve pet owners in decision-making, I felt that we needed to have reliable and accurate information about treatment and alternatives. Providing this information (in advance of any decision, if possible) encourages pet owners to think about what matters to them, to their animals, and whether there are any constraints on treatment choice (for example, financial concerns, limits to insurance cover, inability to give treatment etc.). By providing quality-assured information, I hope that pet owners (myself included) will be better prepared to ask specific questions focused on their main concerns.

The decision to include a website for pet owners as part of the Petconsent project wasn’t really so difficult. We all know that there is an abundance of information on the internet, via social media, websites, blogs etc. The main barrier to its use is the lack of quality assurance for each source of information. What I’ve tried to do is to select good sources of information from the multitude of sites available. I have reviewed each resource with two hats on – as a veterinary surgeon, and as a pet owner. As time passes from my last period of clinical work, I consider myself, first and foremost, as a pet owner these days, and constantly worry that my knowledge is not up to date. Reviewing pet health resources has helped to calm my worries a little! It was difficult to choose between resources sometimes, so I eventually chose user-friendly presentations (I do love a Question and Answer format, probably a legacy from reviewing information sheets for research participants!)

Health conditions are listed alphabetically on the site, with an indication of species (currently dog, cat and rabbit, with rodents to be added soon!). The usual warnings about the resources not replacing veterinary advice are prominent on the website. I have used some resources that are produced by, for example, food companies, but their use should not be regarded as endorsement of their products.

What do I hope the Petconsent site will achieve? It would be great if people sent me ideas for inclusion on the site – at the moment I have just skimmed the surface of disease conditions. For example, I have not yet included much on preventative health care, apart from neutering.

Next, it would be wonderful if pet owners found the site useful and passed this on to others. My work will be (almost) done if clients arrive at appointments with a list of questions that they have drawn up having read some accurate information on-line.

Finally, if more veterinary professionals instigate a shared decision-making approach in every consultation, and if they lose any fear of fully involving clients in decision-making, I will be very happy indeed.