Case study: Client communication and informed consent

these case studies demonstrate how complaints and other concerns are managed by the vet council, and what the profession can learn from them background an 11 year old dog was assessed by a veterinarian to be in good health with no concerns two months later, the dog was taken back to the vet with a swollen abdomen, a growth on their left eyelid, and stiff hindquarters the veterinarian assessed the dog and observed that the eyelid growth was a papilloma, with no discharge or conjunctivitis homeopathic treatments, including thuja and rhus tox, were prescribed to reduce the wart growth and improve joint mobility no anti inflammatory medication was prescribed during the visit the dog was later brought back to the clinic with vomiting and diarrhoea and was prescribed scourban (for diarrhoea) and colchicum ( an off label use of a prescription medicine for the treatment of acute gout) that same month, the dog was seen by a locum at the same clinic, where the client reported their dog was still having diarrhoea and vomiting, and had experienced a seizure the veterinarian said these symptoms were not recorded in the clinical notes and that the locum veterinarian thought the dog’s condition had improved a blood test and an abdominal ultrasound were recommended, with the blood test results confirming an ultrasound was the next appropriate diagnostic step the client reported that the previously prescribed anti inflammatory medication had been stopped and took the dog to a different clinic for a second opinion based on the differential diagnoses being considered, the veterinarian recommended an abdominal ultrasound, administered buprenorphine, and prescribed gabapentin following the ultrasound, the dog was brought back to the second clinic, where the differential diagnoses included cushing’s disease, splenic neoplasia, and a liver or gallbladder stone the dog was later euthanised the complaint the dog’s owner made a complaint to the vet council, alleging that the first veterinarian made unprofessional and inaccurate comments about the dog’s health they also complained that the veterinarian did not explain the dog’s possible health issues or the potential side effects of the medication the client said the veterinarian did not properly examine the dog and was dismissive of its symptoms the complaint was referred to the complaints assessment committee (cac) the cac is a preliminary screening body, which decides what should happen after a complaint has been made about a veterinarian the cac can conduct a formal investigation and decide what steps, if any, need to be taken to ensure a veterinarian is fit to practise and public interest is protected the cac will determine if there are any concerns about the veterinarian’s fitness to practise, and if these concerns require taking further action what professional standards are expected the veterinary services part of the code requires veterinarians to provide evidence based services to a high standard, meeting both client needs and the welfare and healthcare needs of animals under their care section5 6 specifies that when considering alternative or complementary diagnostic or treatment methods, the client must be able to make an informed decision about whether to proceed this requires the veterinarian to inform the client about the nature of the alternative treatment and explain how it is consistent with conventional medicine competency standards to consider in this case include competency standard 2 which requires veterinarians to conduct a systematic physical and clinical examination of the animal, including performing or arranging diagnostic tests to reach a diagnosis if needed competency standard 3 which requires veterinarians to analyse clinical information to provide an accurate diagnosis and develop an appropriate treatment plan, including obtaining the client’s informed consent before proceeding competency standard 7 which requires veterinarians to communicate effectively, clearly explaining clinical findings, treatment options, and likely outcomes in language the client can understand vets must also ensure the client understands the information provided how it was managed the cac noted that veterinarians are expected to conduct a physical examination of the patient and discuss the likely or potential diagnoses, along with any ongoing diagnostic or treatment options, with the client if a veterinarian decides not to do an examination, the reasoning must be communicated to the client so they can make an informed choice in this case, the cac felt the veterinarian should have investigated the abdomen and confirmed the diagnosis of a papilloma on the dog’s eyelid the cac determined that based on the information available at the time, the diagnosis was reasonable while there were omissions in the process, the cac decided that these did not meet the threshold for taking further action a key concern for the cac was the lack of clear and structured communication the issues raised in the complaint were largely attributed to the lack of clear communication, the veterinarian’s approach to explaining their clinical findings, and how they explained the recommended treatments when clients are choosing between conventional treatment and alternative or complementary options, the cac emphasised that vets must provide information that includes an explanation of the available treatment options and the associated risks, side effects and benefits, and costs, so the client can make an informed decision in this case, the veterinarian had prescribed rhus tox to support the dog’s mobility and thuja as a homeopathic treatment for warts, but the cac could not determine how well the use of these treatments had been explained or understood by the client the cac also expressed concern about the absence of an appropriate informed consent process although the clinic uses complementary medicine alongside conventional treatment, no consent form was provided to the client, and there was no documentation of informed consent in the clinical records the professional standards expect that when consent is provided verbally, both the discussion and the client’s decision must be documented in response to the cac, the veterinarian provided reflections and confirmed they would ensure discussions around treatment options are documented, and that written informed consent is obtained overall, while some aspects of the informed consent process were sub optimal, the cac determined that this case did not meet the standard for further formal action the cac also considered the owner’s complaint about the veterinarian’s communication the concerns centred on alleged inappropriate comments and a failure to explain the potential side effects of the anti inflammatory medication and the treatment prescribed for the dog’s eyelid growth the cac noted that it was difficult to determine exactly what had been said during the consultation or how well the information regarding the medication had been communicated in this case, the cac considered that the veterinarian could have communicated more clearly about the medication being prescribed and the reasons for deferring further diagnostic testing however, these omissions also did not meet the threshold for further action under the act decision overall, the cac felt that the veterinarian met the expected standard of a competent veterinarian during their investigation of the complaint, the cac identified some aspects of the veterinarian’s practise (and the clinic’s processes) that did not meet the expected standard of the profession that being, what would be reasonably expected of a competent veterinarian in a similar context while these omissions did not warrant further action under the act, the cac commented that they could be a risk to future patients if left unaddressed the cac felt that the omissions around gaining informed consent and adequate clinical record keeping could be addressed through recommendations, which are a form of education that the vet council uses to help veterinarians improve their practice they are specific and time bound requirements that a veterinarian must meet in this case, the cac recommended that the veterinarian include a specific reference in their cpd plan to upskill in conventional veterinary medicine and provide a cpd plan to the vet council for quality assurance at the end of the cpd year the cac also recommended that the veterinarian provide a copy of an informed consent form that shows a client’s understanding of when complementary medicine is being recommended or used the veterinarian was also asked to provide five examples of clinical records that include a copy of this signed consent form learnings for the profession the cac noted that under section 4 of the code, veterinarians must maintain clear, accurate, and sufficiently detailed clinical records, so that another vet could take over the management of a case at any time in this case, the consultation notes were brief and had fallen below the expected standard the informed consent process was also not adequately documented records must capture all relevant communication between the veterinarian and the client, particularly discussions about clinical decisions and consent