Balancing act

On a weekly basis, I struggle with the balance between being a good colleague, and being honest with clients.  Veterinary medicine has grown so much in the last 20-30 years that some older standby "treatments" are simply outdated and no longer recommended, and in some cases downright harmful.  Further complicating the situation is that, in the exam room, it's impossible to know if what I'm being told by the client is the actual truth, or just their interpretation/memory of the truth. As a result, I try really hard not to judge the medical decision made by others, until I see the medical record and/or speak with them about the case.  Unfortunately, sometimes, it's impossible to sort out why things happen the way the do.

Case and point -
A 6 year old Chesepeke bay retriever, "Grizly" presented as a transfer to me one afternoon.  The dog had started to have hematemesis, or bloody vomiting.  3 weeks prior, the dog had been lethargic, vomiting and not eating.  Blood testing had showed very severe liver disease; this was confirmed with abdominal ultrasound.  The dog was not placed on any medications, and was basically sent home for "observation" with re-testing of labs to occur weeks later.  Unfortunately, Grizly didn't make it to that recheck.

On presentation Grizly was weak, pale and listless.  He was thin, having lost 6lbs in the last 2 weeks.  He hadn't eaten or held down a full meal in weeks. His clients wanted every possible intervention for Grizly, and agreed to aggressive supportive care, with the eventual goal for liver biopsy to gain a definitive diagnosis and plan the perfect treatment strategy.  Unlike many cases, cost was no object; they only wanted to give their dog a chance to recover.

Unfortunately, by the time I saw Grizly, it was much too late.  He was debilitated, and having severe GI bleeding; we could not stop this bleeding and he quickly progressed to a comatose state.   In the last few minutes before he died from his disease, his clients were with him and allowed euthanasia to ease the passing.

A post-mortem exam was performed, and confirmed a bleeding stomach ulcer, which ultimately lead to his death.  His liver was also diseased, and the original source of his illness.  I am left to wonder - if he had been placed on the appropriate GI protection, liver supportive, and proper medications weeks earlier, could he have survived? If referral to a 24 hour care facility like ours had been offered originally, would he have had a recovery and normal life span?  Had the clients given some indication to the original doctor that they did not want these things and only changed their minds once he fell more seriously ill?

I'll never know.