When The Gold Standard Fails: Redefining Best Practice
Questioning the Gold Standard: The Journey to Principle-Based Care
In my years of working in a university veterinary teaching hospital, I observed a common storyline playing out with some regularity in my colleagues’ and clients’ experience. It began with patients presenting to the hospital, often referred there by their regular veterinarian because of the complicated or critical nature of the problem. The clients’ hopes for a cure and expectation of state-of-the-art care come together with the students’ desires to provide the “best” possible care and expectation that the clients will agree with all the expert advice they’re given.
Oriented as the students, interns, and residents are through their medical training and ability, they inevitably make unconscious value judgments when considering or presenting different treatment options. They’re taught to rank potential treatments according to their reported efficacy in the research literature. Bias comes out inevitably in the treatment planning process, where students are taught to “offer the best and let the client decide.” Clinicians’ preferences and fears related to desired and undesired outcomes naturally enter those conversations in the form of phrases like “gold standard,” “if we really want to do the best thing for your pet,” or “if we do nothing, such-and-such is likely to happen,” This is normal if we consider the incredible pressures of learning to be expert care-providers and decision-makers, not to mention the need to gain clients’ trust and consent for us to treat their animals.
On the other hand, the clients enter the relationship in a state of fear and worry for their pet’s well-being or even survival (which is not an ideal state in which to make important decisions anyway). When stressed this way, people inevitably shy away from acknowledging and voicing certain valid and important contextual factors that could help care for their pet. These factors include cost, the possible impact of treatment options on their pet’s quality of life, and their feelings of worth as a pet parent. In the presence of the most sophisticated care available in the profession, clients often feel immense pressure to choose the “best” option (usually the most intensive, expensive, and aggressive).
As the storyline progresses, it takes on an air of tragedy. Both client and clinician become disoriented as they chase after the goal of a cure, increasingly bound to the course of action by feelings of deep responsibility. Meanwhile, the animal patient may develop hospital stress-related problems which complicate the treatment plan and add to the bill and the uncertainty. If recovery becomes less and less likely over time, the natural human indignation that such a situation should exist emerges. For clients, the feelings run along a spectrum of regret and resentment, and they say in perfect truth “I spent eight thousand dollars and ended up without a dog.” For clinicians, the spectrum of feelings runs from moral injury to resentment. On the one hand, they sense the reality of the potential for the “gold standard” to cause harm, and begin to doubt their abilities as healers. On the other hand, when clients express doubts or practical concerns about such things as finances and burdens of care, the clinician forms thinks, “If they don’t want to do the best for their pet, why are they here?”
No one is to blame for this breakdown of the clinician/client relationship, and the human-animal bond. Surgeon and author Atul Gawande summed up the experience of patients and clinicians who don’t feel the freedom to ask basic questions about goals of care, life context, and the impact of imposing the “gold standard” of care: In the end, it “represents a struggle—not only against suffering but also against the seemingly unstoppable momentum of medical treatment.”
A Possible Answer: Spectrum of Care
Also called “contextualized care” (see Resources), a different approach to caring for the human-animal bond exists, inspired by the approach taken by the hospice and palliative care philosophy in the human and veterinary fields. Even when no terminal diagnosis is present, clinicians can learn to engage clients by taking into account their context: their financial situation, practical abilities, and goals of care. By taking the time to understand the client’s perspective, the clinician may present the various possible treatments through conversation and less expert advice-giving. This approach hopes to draw patient, client, and clinician closer together in their decision-making. Of course, it carries its own ethical dilemmas and difficult, painful decision points, but hopefully it reduces the chance of blindly following “best practices” to find that we are actively causing harm.
No one should never feel coerced, whether by training, tradition, or pride, to put an animal through anything just because it’s “the gold standard.” Nor should anyone feel judged for advocating for bond-centered care, especially if a less “optimal” treatment option proves to be a better fit for the family’s life. We might instead hope to change the story’s main theme from extending life to improving life.
Practical Suggestions
- Ask about the family’s goals of care wherever possible.
- Assure clients that financial limitations do not mean they love their pet any less or that they are denying the pet the “best” care.
- Present treatment options in terms of intensiveness, prognosis, and alignment with the family context, not a hierarchy of “good, better, best.”
- Ask about practical things, such as the client’s ability to medicate their pet and their pet’s willingness to participate in treatment.
- Find out the client’s perspective on the potential impact of each treatment option on the family’s quality of life.
- Be very clear on how to determine the “success” of any treatment option.
- Trust that the client will participate in decision-making instead of “selling” them on the “right” decision.
- When someone asks “what would you do if it were yours?” Tell them, but also tell them why and share your vulnerability in the face of a difficult situation.