If you dread these difficult client conversations, veterinary palliative care expert Dr. Katherine Goldberg has straightforward advice for how to use them as opportunities to discuss goals and ultimately achieve better outcomes for the client and the pet.
In sessions on veterinary palliative care, Fetch dvm360 Baltimore speaker Katherine Goldberg, DVM, LMSW, drew from work being done in human medicine. Here's one useful tip to check yourself in conversations with pet owners and one useful tool to download, explore and learn from-both talked about in the session “Goals of care conversations: Why they will be your new best friend.”
Tip: ‘Minimum database for goals of care'
With difficult prognoses, serious illness, quality-of-life and end-of-life conversations. Dr. Goldberg says that palliative care providers (and maybe someday veterinary professionals too) are “trained to take the opening.”
What might this look like? When a pet owner is willing to talk about core issues that will inform the patient's care, that's your opportunity to help, she says.
Use these conversation opportunities to discuss and record in the patient's medical record what Dr. Goldberg refers to as a “minimum database for goals of care.” This database includes the client's:
• beliefs regarding euthanasia
• most important priority
• biggest fear or concern.
The payoff? According to Dr. Goldberg, early goals of care conversations are associated in human medicine with a better quality of life for patients, reduced use of nonbeneficial care before death, positive family outcomes and reduced costs.
“And there's no evidence in human medicine that these discussions increase patients' or family members' stress,” she says, discounting one concern of some veterinarians that it makes things worse to talk about the end.
‘Wish, worry, wonder'
Dr. Goldberg spoke glowingly of language written about by Susan Block, MD, a physician in the Department of Psychosocial Oncology and Palliative Care at the Dana-Farber Cancer Institute and codirector of the Harvard Medical School Center for Palliative Care, that could offer empathy to a pet owner who wants an outcome that's unlikely to happen. Employ “wish, worry, wonder”:
“I wish for [X], too. But I worry that [Y]. So, I wonder if we might be able to talk about a plan B, just in case things don't go the way we want them to.”
This is a way of checking your own emotional reaction to a client who's not seeing the medical facts yet.
“You're trying to avoid flipping your lid about this person's unrealistic expectations,” Dr. Goldberg says. “Take any tough case and try to apply it, and I hope this is helpful to you.”
Tool: A handy look at the right questions
Developed from the “Serious Illness Conversation Guide” from the Harvard Medical School, the “Serious Veterinary Illness Conversation Guide” takes a veterinary approach to a number of core issues.
Kick off with a question like, “I'm hoping we can talk about how things are going with Maggie's illness and where they might be going? Is this OK?” And then consider:
• Understanding. “What is your understanding of where Maggie is now?”
• Information preference. “How much information about Maggie's disease would you like from me?”
This can include the prognosis. “We tend to think this should take up the whole conversation,” Dr. Goldberg says. “But the prognosis is just one out of eight things that make up a full conversation.”
• Goals. “What are your goals?”
Ask this question as often as needed. “As cases change, you're going to re-goal over time,” she says. “Clients will say they want something, but the answers change.”
• Fears. “What are your biggest fears and worries?”
• Function. “What abilities or activities are so critical to Maggie that you can't imagine her living without them?”
Dr. Goldberg suspects some people use strict, numbers-based quality-of-life scales as algorithms for euthanasia instead of evolving discussions about quality of life for that particular animal in that particular household.
“I get twitchy about these quality-of-life scales, which really turn into euthanasia scales,” she says. “We need to be clear when we're talking about quality of life and not ‘yes' or ‘no' to end the patient's life. What does mobility mean for a cat? A German shepherd? A dog with a wheelchair? We do a lot of talking about how immobile patients deserve death.”
• Trade-offs. “If Maggie becomes sicker, how much are you willing to go through for the possibility of gaining more time together?”
• Aid in dying. “What are your beliefs surrounding euthanasia?”
Click here for a link to Dr. Goldberg's recent article about “Goals of Care” conversations (available for purchase). And here's that link again to a printable “Serious Veterinary Illness Conversation Guide.”