Case study: Diagnostic decision making and client communication

background a dog was taken to a companion animal veterinarian for a routine vaccination and health check during the consultation, the owner raised concerns that the dog had vomited earlier that day and had not been eating well for several days the veterinarian performed a physical examination and noted that the dog’s abdomen was tense on palpation other parameters, including heart and lung sounds and mucous membranes, were within normal limits the veterinarian formed a presumptive diagnosis of gastroenteritis or dietary indiscretion, with differential diagnoses including pancreatitis, liver disease, and kidney disease supportive treatment was provided, included antiemetic medication, antibiotics and a recommendation for a bland diet blood testing was also recommended and agreed to by the client, who then requested an ultrasound the veterinarian advised that advanced diagnostic imaging should be considered after fluid therapy and once the dog’s blood test results were available, noting that other potential conditions needed to be ruled out later that evening, the veterinarian contacted the owner to advise them that the blood test results indicated kidney disease other results, including the canine pancreatic lipase test, were normal the veterinarian and client agreed that the dog should come back the following day to be hospitalised for intravenous fluid therapy during that consultation, the veterinarian informed the client that the proposed treatment plan included intravenous fluid therapy, urinanalysis and sediment examination, blood testing for sdma, monitoring of blood pressure, injectable antiemetics and monitoring these results supported a diagnosis of renal failure because the diagnostic pathway was not complete, the final diagnosis and whether the renal failure was acute or chronic in nature was not confirmed with the client the veterinarian discussed the findings with the owner and recommended continued hospitalisation, monitoring, and supportive care the dog’s care was handed over to another veterinarian later that day the following day, the dog was taken to a referral clinic, where it was diagnosed with a plasma cell tumour the complaint the dog’s owner made a complaint to the vet council, which 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 the owner complained that the veterinarian misdiagnosed the patient with stage 3 chronic kidney disease they also complained that the veterinarian failed to do an ultrasound test and overall check up, and gave the dog the wrong intravenous fluid therapy, making its condition worse there were differing accounts about discussions relating to ultrasound imaging the client stated that multiple requests for an ultrasound were denied the veterinarian said that an ultrasound was not refused, but that it was not clinically appropriate at that stage due to the risks associated with sedating an unwell and dehydrated patient what professional standards are expected? the guiding principle of the veterinary services part of the code expects veterinarians to deliver evidence‑based veterinary services of a high standard, appropriate to meet the needs of their clients and the welfare and health care needs of the animals under their care the client relationships part of the code requires veterinarians to communicate in a way that educates and empowers clients to make informed decisions about the care of their animals several competency standards are also related to this case competency standard 2 expects veterinarians to do a thorough and systematic physical and clinical examination of the animal presented and to carry out, or arrange for, diagnostic tests and procedures needed to make a diagnosis competency standard 3 relates to analysing information to enable accurate diagnosis and the development of appropriate treatment strategies indicators for this standard include providing an accurate analysis and diagnosis, fully informing the client of treatment options, likely outcomes, risks and costs, and obtaining informed consent before proceeding competency standard 4 requires veterinarians to recognise the limits of their knowledge and experience and to know when and how to refer cases for advice or treatment competency standard 7 deals with effective communication veterinarians must provide clear and accurate explanations of clinical findings, treatment options and likely outcomes in language that clients can understand they must also confirm the client’s understanding of the information how it was managed when reviewing a complaint, the cac measures the veterinarian’s conduct against the standard that is expected of a veterinarian practising in similar circumstances, and also refers to published professional standards the cac reviewed the diagnostic pathway and considered that the veterinarian’s approach was logical and appropriate blood testing, urinalysis, and hospitalisation for intravenous fluid therapy were reasonable and evidence‑based steps the cac noted that a definitive diagnosis could not be expected at an early stage and that the veterinarian only had sufficient information to reach a presumptive diagnosis the cac found no evidence that the intravenous fluid therapy was inappropriate the clinical records noted that the dog was dehydrated and that fluid rates were appropriate for the dog’s size and condition the cac considered it more likely that the dog’s deterioration was due to the underlying disease rather than the treatment provided in relation to the ultrasound, the cac was unable to determine precisely what was said between the veterinarian and the client however, it accepted that sedation would have carried risks and that an ultrasound would not necessarily have provided a definitive diagnosis at that stage the cac acknowledged that there may have been confusion regarding the distinction between acute and chronic kidney disease, and that clearer explanation may have assisted the client’s understanding the veterinarian reflected that clearer communication and documentation would be beneficial in future cases the cac suggested that, in future, the veterinarian could consider the use of client handouts or information sheets this would allow the client to take information about what was discussed home with them, and to digest the information in their own time decision the cac decided that the veterinarian’s care met the standard reasonably expected of a competent veterinarian practising in similar circumstances while the case was complex and distressing for the owner, the cac did not identify misconduct or competency concerns that met the threshold for disciplinary action or further regulatory steps no further action was required under the veterinarians act 2005 learnings for the profession under section 5 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 vets must also ensure proposed diagnostic pathways are communicated with clients in a way that they can understand their understanding must be confirmed and recorded in clinical notes