Several years ago, an owner scheduled an appointment with me about a week after I’d euthanized their pet. It was an unusual request, seeing as though their pet was no longer alive and in need of my services. I urged the owner to call me or e-mail me with any outstanding questions or concerns. I explained that if they were to schedule a specific time to see me, not only would it take a spot away from another pet in need of treatment, but that I was required to charge them for the appointment spot, while it would not cost anything to talk on the phone or via e-mail.
The owner elected to keep the appointment. We met and talked about their pet and its disease and how it had progressed over time. We didn’t spend a great deal of time together, but it was a significant moment for both of us. As per the policy of the hospital, and our prior discussion, an appointment fee was generated.
Several days later, I received a letter from the owner criticizing the fee on the grounds that it was unethical for me to charge a visit after all they’d been through. An additional suggestion was made that I should provide follow-up appointments, free of charge, to owners who’d recently euthanized their pets as a means for them to obtain closure and to provide a forum where they could process their feelings and/or frustrations.
As I read the letter, a complex mixture of emotions rose within my mind. Empathy, sadness, resentment, and confusion — I felt it all. But my overriding sentiments regarding the words were, “Why had I not accurately prepared this owner for their pet’s death, leading to their compulsive need to talk with me afterwards?” and “Why should I be obligated to give my time for free when a human physician would never face this expectation?” I didn’t feel particularly good about my thoughts, but I’m being honest in my description.
Discussing end-of-life care is something I’m entrusted with nearly every time I enter a new appointment. Invariably, owners want to know what to look for to indicate their pet has reached the end stage of their disease. It’s never easy to consider concepts such as death and dying, planning for end-of-life care, advanced directives, or euthanasia. But experience tells me it’s much better to talk about these topics before we’re in the midst of an emotionally charged situation.
In human medicine, dialogue centered on end-of-life care is frequently entrusted to social workers or hospice providers. Though well trained in these difficult topics, it's a patient’s doctor who is best equipped to do so. They possess the medical knowledge about the specifics of what actually occurs physiologically within the body during measures such as cardiopulmonary resuscitation, or in response to treatment of disease, and how to prepare owners for what lies ahead.
The results of a pilot study presented this year at the annual Quality of Care and Outcomes Research Scientific Sessions showed physicians were reluctant to discuss end-of-life issues with their patients because they perceived their patients or their families were not ready to discuss it, they were uncomfortable discussing it, they were afraid of destroying their patients' sense of hope, or they didn’t have the time to engage in those conversations. The latter example tells us that if a doctor isn’t going to be paid for the time it takes to have an end-of-life discussion, it’s not going to happen. Period.
The good news is that more and more private insurance companies now offer reimbursement to doctors for conversations related to advanced care planning. The American Medical Association (AMA), the country’s largest association of physicians and medical students, recently urged Medicare to follow suit, indicating doctors are not only committed to the cause, but recognize that they are the ones best equipped for the job.
Unfortunately, insurance companies offer lower reimbursement rates to doctors for the time spent talking to people compared to performing medical procedures. If we’re simply sitting around talking, we can’t be ordering tests or administering drugs or performing surgeries, and ultimately, we’re not making any money. Even when doctors try to do the right thing, it seems we manage to be penalized.
It is incredibly sad that innocent animals develop debilitating diseases. I recognize how fortunate I am to work with owners who have the time and resources to treat their pets. And I understand that the loss of a pet is an intensely painful process. None of this changes the fact that being a veterinary oncologist is my job and my source of income. I too must earn a living, pay bills and loans, and support myself.
Was it wrong of me to charge for an end of life/closure discussion? Did this represent detraction from my reservoir of compassion? Worse yet, did it make me a bad doctor? My answer to each of those questions is a resounding “No!”
Years later, I still think about that owner and their letter, and something deeper than being labeled good or bad, compassionate or unethical, or right or wrong continues to weigh on my mind. By gaining a sense of closure and peace for themselves, this owner ironically created a sense of uneasiness in my soul.
Sometimes the toughest cases for veterinarians have nothing at all to do with animals. Sometimes the price we pay for the stress can’t be quantitated in dollars or cents.
And sometimes this is why we work for free, even when we know we shouldn’t, because we hope it will somehow save us from the unyielding pressure of charging adequately for doing out jobs.
Dr. Joanne Intile
Image: Colleen Morgan / Flickr