Canine well-being is a series of articles sharing the experience I have gathered while living with and caring for dogs. They will address common canine health concerns. I am not a veterinarian. The contents of these articles are intended to inspire looking beyond conventional ideas and practices. Be responsible and do your own research and seek appropriate veterinarian advice (consider consulting a holistic vet).
Much has changed in human medicine in the past 50 years in regards to the doctor patient relationship. The sick and injured were once regarded as helpless, incomptent and irrational, and expected to comply with medical advice unquestioningly. David Armstrong of Kings College, London, gives a fascinating to read account of this evolution from passive and obedient patients to ones with a sense of agency in his paper ‘Actors, patients and agency: a recent history‘. Entering the 21st century, the word concordance replaced the earlier term compliance to describe the changed idea of patients and doctors sharing treatment decisions, no treatment without the patient’s endorsement.
What about veterinary medicine? The patients themselves are advocated for – like children or comatose adult human patients – they are acknowledged of subjecthood and therefore having interests but deemed incapable of decision making in regards to their health. As experts on animals and their needs, vets are sought out for guidance on how to best promote our animal’s welfare and well-being. The prevalent expectation in vet clinics is that their recommended further diagnostics or treatment plans are being followed unreservedly. Compliance, not concordance.
One of my clients, let’s call her Clara, has over the years increasingly been questioning some of the veterinarian suggestions she was given, having a sense that too often treatments are overkill – like shooting at a darts board with a cannon. As loving pet parents we care deeply and can be afraid of being judged negligent when we question recommended procedures or treatments. We feel vulnerable when it comes to the well-being of our fur children. Hearing the phrase “let’s do xyz just in case” connects with our fear. Fear inhibits clear thinking and we can find ourselves agreeing against our better judgement or without further research and discussion.
Clara’s 5-year old dog Ava had been lethargic lately and sometimes skipped a meal. It was time to investigate what was going on. A blood test pointed towards a possible infection and it was advised to repeat it in a few weeks. In the meantime, Clara noticed with alarm that Ava’s pee had a reddish colour. Clara collected a urine sample and another blood test was done. A sonographic test was suggested. Clara asked for Ava not to be sedated for the procedure and for permission to be present and keep her dog calm. The vet agreed.
The ultrasound showed some abnormalties but it still left a lack of clarity. Now a more invasive diagnostic procedure was suggested that needed sedation and a needle inserted into the dog’s bladder. Clara hesistated to assent. That morning, her unwell dog already had blood taken, her fur shaved for the sonogram and complied to holding still for the exam. Clara decided to take Ava home and wait for the results of the urine and blood tests before doing any more probing.
‘Agency is the sense of control that you feel in your life, your capacity to influence your own thoughts and behavior, and have faith in your ability to handle a wide range of tasks and situations. Your sense of agency helps you to be psychologically stable, yet flexible in the face of conflict or change.‘ *)
It was Clara’s resolve to keep agency, to strive for concordance rather than compliance, on this journey to diagnosing what was making Ava unwell.
Of course, it was Friday afternoon. At about 2 pm the urine test results came back – inconclusive, possibly contaminated. Clara had two phone conversations with the vet discussing her questions and concerns. When she phoned the third time, the vet was unavailable to come to the phone but the vet nurse urged for the decision to bring in Ava for the invasive procedure now. Clara felt taken aback but mostly she felt under pressure and not heard. She had the sense of being preceived as ‘difficult’, ‘precious’ and ‘annoying’. She felt her agency on shaky ground and gave me a call.
I am not a vet and therefore do not give veterinary advice. I have practiced agency when advocating for my animal’s health and well-being for a good two decades. Drawing from that experience, I offer myself as a sounding board and share concepts and questions that have been helpful to me over the years. I suggested to Clara to inquire about the next available appointment for the procedure and what the contraindications for waiting would be.
I reminded her of the wisdom of, ‘If you are in a hurry, slow down,’ to widen her perspective and allow for accessing more objective thinking and therefore better decision-making. Our culture favours action, especially when in crisis. We want to regain control as fast as possible and that can lead to making the end justify any means. It is hard to be still when the call for action is so loud, and wait for clarity about what makes sense next. We have a very low tolerance to see anyone we love in discomfort. This too creates pressure and urgency. Advocacy demands of us to put ourselves aside and make decisions on behalf of someone else. A tall order.
Good questions to ask your vet are
- Is this a life and death situation right now?
- Is my animal in unbearable discomfort or pain?
- Can my animal receive temporary relief of any discomfort or pain?
- What outcome can be expected from the suggested procedure / treatment?
- What are all the possible side effects?
- Are there alternatives?
- What if we do nothing?
After talking for a while, Clara suddenly said with clarity, ‘I will ask if the specalist can do another sonograph on Monday as the regular vet was unsure how to interpret what she saw. But I will opt out of the needle procedure for now.’ By slowing down and taking the time she needed, she had come up with a new possibility. One that felt right to her. She phoned the vet clinic to arrange it.
In the evening Clara received a call from the vet. The blood results had come back and looked alarming. So much so that it was suggested that Ava was taken to an emergency vet clinic right now because two of the possible diagnoses could mean things quickly escalating and her not surviving the night. Clara took a breather. She phoned me and let me know the latest news.
She felt very unsure what to do. What a difficult situation to be in. Taking Ava to an emergency clinic meant an unfamiliar setting and the staff not knowing either Clara nor her dog. In addition, she knew from previous experiences (and I could confirm that from some of my own and what people have shared with me over the years) that emergency vet clinics can be so medically focused that any bedside manners go out the window. Invasive measures are suggested quickly, there is this urgency to find answers. Which makes sense in emergencies.
But Ava’s condition was presently not a emergency, there was only a possibility that it might become one. I suggested to Clara to phone the clinic and ask if they were equiped to do inhouse bloodwork to determine if Ava had one of these two dangerous diseases. Because if they were not, what was the point of going there? If her dog was going to die tonight, would she prefer her being at home or at the clinic?
When Clara phoned the emergency clinic to clarify her questions, she stated her intentions openly: She would bring Ava to do the bloodwork, stay with her while they waited for the results and not do anything that night that was not absolutely necessary to keep her dog alive.
Clara said that the visit at the emergency clinic went really well. She felt that having been so clear on the phone in advance made the staff treat her differently. No extra diagnostics were suggested. The bloodwork was done and showed that they dealt with neither of the two life threatening diseases. Clara and Ava went home again.
The next morning, Clara took Ava to their regular vet because the looks of the urine had taken a turn to the worst and Clara was worried. Another bloodtest determined that Ava was more anaemic than in the previous test. Clara messaged me, ‘They’re starting her on antibiotics 🙁 ‘.
I responded, ‘You mean YOU are starting her on them.’ Smile and heart emoji. Clara reflected that her choice of language was an attempt to distance herself from the decision. She felt very conflicted and afraid that she could be making the wrong decision either way. Temporary loss of agency.
Ava had times when she was her normal self but mostly she was resting more than usual. She was more picky about eating. She passed blood clots in her urine and vomited.
There was talk of doing a CT instead of the ultrasound. But the former requires general anesthesia (greater risk) whereas the latter only sedation. This time Clara was not allowed to stay with her dog. A large mass was discovered on Ava’s right kidney which seemed to have engulfed the whole kidney. Lab tests would take a couple of days. Clara was informed that there was a possibility, if it was contained, and there were no secondary tumours, that one kidney could be removed. Ava stayed at the vet overnight for fluids and pain relief.
The next morning when Clara phone the vet, there was a bit more info available but some results still outstanding until about noon. They suggested to keep Ava there because depending on the further findings midday, she might need a CT scan if surgery was on the cards. Practical as though that might have been, Clara decided to go and get her dog right there and then. Despite some results still pending, it was already clear that in all likelihood Ava’s life would be much shorter than anticipated. Clara wanted to prioritise quality of life over any conveniences.
At home, the waiting began. It was hard not to be overbearing towards her sick fur kid. Clara drew on practicing the Trust Technique she had learned a few years back from me to create peacefulness in this upsetting situation. Instead of giving free reign to the onslaught of worrying and catastrophic thoughts, she focused on the present moment.
The afternoon dragged on, still no word from the vet. At some point Clara couldn’t stand the waiting anymore and phoned, just to learn that there were no news yet. She was assured that they would call her as soon as the results were in.
Finally, the vet rang. From what she learned, Clara decided that palliative care was Ava’s best option. The vet said that he thought that was a very compassionate choice and he respected her for putting her dog’s interests first.
Especially in the light of how all this has played out, Clara is gratified with her actions and decisions. Keeping agency required of her to be with a lot of uncomfortable feelings and inner states. She had to move out of her comfort zone by recognising that even though she doesn’t have the expert knowledge her thoughts are valid and deserving of being heard and considered, and by embracing deceleration when under pressure.
*) Quote from this website.