To Battle for a Patient

I have had 368 Mondays in practice. Today is one that I just don’t think I’ll soon forget. I had to stand up for a patient and have one of the most uncomfortable conversations I can remember. Today, I got a taste of that “moral distress” we discuss in veterinary and medical circles.

I saw this client 4 years ago for a few reproductive needs, but haven’t seen the client since. An emergency request came in for radiographs on a horse that has been struggling to move and intermittently laying around for 2 weeks. It was a full day and the farm is 50 miles from home base, but that is a very long time for a horse to be struggling to stand comfortably, so we worked it in.

The owner was not present, but a neighbor came over. We examined the mare and it was clear that she was in distress. She had a fever and was sweating in her stall, breathing hard, her heart rate was rapid, and she stood shifting her weight back and forth trying to find a comfortable foot. Her forefeet were stretched way in front of her, the classic stance of a horse with laminitis. Her gums were pale and her capillary refill time was delayed. The mare was displaying concerning vitals that we see with septic horses.

I removed a wrap from her hooves to see serum oozing from an open coronary band, and I could easily feel her pulse bounding in her feet. Therapeutic clogs and pads were screwed to the feet, and a metal hoof cinch was wrapped around the hoof wall. She had bed sores over her hip bones and a large volleyball sized abscess that had developed beneath one of them. The bony prominences of her face were abraded from where she had been laying her head on the ground over the past 2 weeks.

We gently worked with her to lift each foot onto a block to take a radiograph, revealing a P3 or “coffin bone” that had sunk and rotated within the hoof capsule. There was also evidence of a fracture to the coffin bone. The oozing coronet band was indicative that the hoof capsule was unstable, blood flow to the hoof was compromised, and the hoof capsule was likely to slough away entirely. She was so uncomfortable on the other forelimb as well, there was simply no humane way forward for her.

I phoned the owner to let her know that the mare was in very grave condition and explained my findings. I arrived at the point where I recommended that mare be humanely euthanized. It seemed so logical and an easy decision given the lengthy problem list and poor prognosis. I was gentle and factual. There were many questions, “can’t you regrow a hoof in 9 months?” “How do you know she can’t survive this?” “Isn’t there a surgeon that could put a pin in the fracture? Surely there’s someone that works on these horses.” “Money isn’t a problem.”

I answered the questions and went through all the reasons, including that the mare was unlikely to load on a trailer as she couldn’t even walk to a water bucket in her bedded stall. I thanked her for her care and dedication to the mare, it was obvious by all of the farriery that she had spared no expense in trying to help the mare, but I encouraged her to think with her brain more than her heart and do what is right for the mare.

She wanted to think about it. She had been discussing the case with another veterinarian out of state who offered guidance. To be fair, the veterinarian had not examined the horse, and certainly couldn’t have been informed of what I was seeing in person today. I assume the veterinarian rightfully pushed to get radiographs to help guide the case – but things had just progressed beyond repair. This veterinarian would certainly want the horse to be euthanized if she were fully informed of what I was witnessing. I left the owner with my recommendation. I understood that she might need some time to say her goodbyes after work. I was going off duty at 5pm, so I informed the owner that the on-call veterinarian would be available for euthanasia and again, I strongly urged her to do the right thing for the horse.

I left the farm feeling terrible, physically nauseated thinking about the mare’s past 2 weeks, and the response, “I’ll think about it”. I had to squeeze a goat into my schedule with a urinary blockage on the way home, and had another goat waiting for me at home…two additional add-ons for the day, and I still had to feed my horses and make it to dinner with my wife and a vet student we mentor. I told the student in my backseat that I honestly have never seen an animal suffering so badly and had an owner be so oblivious of the severity. It made my voice crack saying it to him, so I stared ahead quietly. I’ve seen a lot of really traumatic cases and sad cases, but this one rattled me – an owner in complete denial and I had to leave the horse not knowing if she would actually follow through for the horse.

I silenced my pain and anger and put on my happy face for the new client with the goat who couldn’t urinate. I got lucky and found the stone blocking the distal urethra, gave the goat relief and hopped back in the truck to head home to the goat in my driveway. Goats have crummy timing.

The horse owner called again just as I was getting off the interstate. My low fuel light came on in the truck, with that chime coming from the dash, a sign straight from the heavens. Yes, Lord, I’m aware that I am running on fumes in more ways than one. I’ll fuel it tomorrow, I decided as the owner bounced around her questions in my ear. She wanted to know exactly how I knew that the horse needed to be euthanized and wanted another view of the radiograph that I honestly couldn’t get due to the horses discomfort. I repeated much of what I had already said, highlighting the signs of sepsis, poor circulation in the hoof, the chronicity of her issues, the findings of the radiographs we took. I finally had enough. No matter how many times I repeated myself or explained it, she just couldn’t accept it. She was grieving. She was in denial. I lost my cool. I told her that doing anything except putting the mare to sleep would be selfish and inhumane. I told her she could refer it anywhere in the world and the veterinarian would wonder what primary veterinarian would force a horse like that into a trailer and to a hospital as euthanasia is the only option. No amount of money will fix it. The horse would literally have to be suspended from a ceiling for months, treated for sepsis, and the opposite foot still may give way in a few days. I was not forcing her to put her horse to sleep, but trying to get her to understand why it is the only logical option. I told her that I don’t just willy-nilly recommend people to put their horse to sleep! I told her I have to advocate for this horse, regardless of how it makes her feel about me. If the horse was not taken to a hospital or euthanized by 8am, I would call animal control, something I have never done in practice. I told her I was nearly in tears over her mare as I left without being able to relieve her pain and that I would go to bat for her any day and would recommend the same thing for my own horse.

Finally, she saw it. She agreed to take the on-call veterinarian’s number. She thanked me for being so candid and honest and for taking time to assess the horse. She made sure to tell me that if she finds out that there was something that could have been done to save the horse that should would be mad at me. I can live with that. I won’t even get into the other horse at the farm who is in nearly the same condition, but has an inkling of a chance if he can get to a clinic with a surgeon and reputable farrier. Barely an inkling of a chance.

So. This is moral distress. Punch you in the gut, kick you in the nuts, drag you through the mud, moral distress. It was a brief few hours of needing to do the right thing but being impeded by the owner. It’s that feeling of “do i care more about this horse than the owner?” I’d be lying if i said it didn’t ruin my evening. My associate looked at the films and caught me holding back tears of frustration in the office and reassured me of the decision. The on-call vet called to let me know that the horse was at rest following the euthanasia. As I sit here typing all of this so I can turn my mind off to get some rest, I get a message from my associate to remind me that I did the right thing. Thank God for these supportive colleagues. I am blessed to work with them.

All of the good things you can do in a day are quickly erased by cases like this. Admittedly, I am my own worse critic. I hate that I felt forced to get so ugly with her, but that horse deserved someone to stand up for it. I can’t think of a single time I’ve had to fight so hard for a patient against its owner. And the crazy thing is the owner had nothing but good intentions – she took a kill pen horse, sunk time, tears, and money into it, but let her heart override her brain. Ahhhh. We’re all guilty of letting this happen sometimes.

I’m tired today, but I’ll struggle to rest. I’m frustrated with my job today, but it’ll be a fresh day tomorrow. I will allow myself to feel these things – they are real, necessary emotions. I’m going to forgive myself for how I reacted when I ran out of grace to extend. I have forgiven this owner for how she made me feel. I know she must be heartbroken tonight, and she will feel pain over the next few days as she sees her empty paddock. I acknowledge that pain. I hope that she’ll continue fighting for the horses in her care, but remember the lessons this mare taught.

I do not need consolation. I do not need sympathy. If you are reading this, I just want you to think or say, “I hear you” , “Man, I felt that in my bones”. I want you to be mindful of your emotions and grief and get a good grasp on them and work through them. For me, I just needed to write it down. I will be ok. I just had to fight for a patient today. It sucked. It hurt. But, it was the right thing to do.