Spectrum of Care in Veterinary Medicine and the Role of the Veterinary Nurse

Empowering veterinary professionals and clients to consider a wide range of treatment strategies, from technologically advanced and expensive to more traditional and inexpensive, has the potential to improve access to needed medical care for all pets. This article will focus on the spectrum of care (SOC) approach and how the entire veterinary team can be included in discussing the pros and cons of different treatment options and placing those options in the context of the client’s ability to obtain care.

What Is a Spectrum of Care Approach?

A SOC approach entails the development of an appropriate care plan that best meets the unique needs of a client and patient. For most veterinary patients, multiple therapeutic plans will provide acceptable care. Additional considerations in an SOC approach include the patient’s diagnosis and prognosis as well as initial and long-term costs and logistics of ongoing treatment. A patient’s individual characteristics (e.g., temperament, lifestyle, activity level) should be considered as they affect its quality of life and a client’s ability to comply with treatment recommendations. In addition, clients should consider their own lifestyle factors such as the ability to provide treatment, return for recheck appointments, and give supportive care at home. Overall, this approach makes veterinary care more accessible, which can ultimately improve animal and community health, through a range of treatment options with different goals and costs (Resource 1).¹

How Does Spectrum of Care Compare to Other Approaches?

Before the concept of SOC was introduced, most veterinary regulatory boards required veterinarians and their staff to adhere to a reasonable and appropriate practice of medicine known as the standard of care, which is defined as “the same degree of humane care, skill, and diligence in treating patients as are ordinarily used in the same or similar circumstances.”² An SOC approach requires a shift from the singular focus of providing the gold standard of care, which is the care plan that is widely deemed to be the best available.³ Substandard care is below the minimum standard of care and may not lead to a diagnosis, better prognosis, or improved quality of life for the patient. For some patients, substandard care may be futile treatment that enables continued or increased pain or discomfort. If the patient is in pain and the client is unable or unwilling to pursue treatment, euthanasia should be recommended. Depending on the practice’s policies, a veterinarian may discuss relinquishing or rehoming an animal for it to receive care. Documentation of all conversations regarding care options and client consent is essential.¹

What Is a Clinical Example in Which the Gold Standard of Care May Not Be the Best Care Option?

One clinical example is a dog that presents for seizure activity. A thorough history is collected and blood analysis is performed; no causative agent for seizure activity is detected. Yet, while collecting the history, the veterinary nurse learns that the purebred dog has relatives with idiopathic epilepsy. The client cannot afford a complete neurologic evaluation for seizure activity, which typically includes baseline labs and general anesthesia for magnetic resonance imaging of the brain and possibly cerebrospinal fluid analysis. However, those tests may yield little insight into the cause of epilepsy for this patient. Thus, a treatment plan of anticonvulsant therapy for presumptive idiopathic epilepsy would be acceptable.

Are There Any Downsides to a Spectrum of Care Approach?

Some veterinary professionals have concerns that providing an SOC—rather than adhering to the gold standard of care—introduces greater risk for disciplinary action from a board of veterinary medicine. However, veterinary regulatory boards only mandate that veterinary professionals provide a range of care options that are at or above a minimum standard of care when providing an SOC and that informed consent is obtained and documented.¹

How Does a Spectrum of Care Approach Affect the Veterinary Team and Improve Patient Welfare?

Providing an SOC encourages a practice’s sustainability by expanding the services offered, thus minimizing the likelihood of financial losses, especially during times of economic downturn when clients may be forced to reduce or avoid treatment for their pet due to financial constraints. Acknowledging a range of care options also has the potential to improve the client–veterinarian relationship as well as job satisfaction and retention within the veterinary profession. The veterinary team is empowered to provide care options and remove the stigma from less costly interventions. By considering the resources (e.g., time, finances, emotional/psychological investment) required for each care option, a client can make an informed decision alongside the veterinary team. This collaboration ensures the patient’s welfare is the utmost priority.³

How Does This Change of Care Options Affect the Veterinary Profession?

Significant scientific and technological advances have been made in veterinary medicine over the past several decades. Thus, more specialized treatment options are available to veterinary patients. These advances can improve the quality and length of patient life; however, they can also increase the cost of care. Increased costs of care negatively affect the ability to obtain veterinary care. Of the 28% of pet owners unable to receive veterinary care in the Access to Veterinary Care Coalition report, finances were the No. 1 barrier to every kind of veterinary care (e.g., preventive, nonemergency/sick, emergency, specialty).⁴ This inability to obtain veterinary care negatively affects not only a patient’s health but also the mental health of the client and veterinary staff members who are treating the patient.

In addition to increasing the cost of care, the availability of advanced, specialized care has shifted professional viewpoints regarding appropriate care. The gap between standard of care and gold standard of care has increased, and what was once considered a reasonable, pragmatic approach to care is now considered substandard by some; however, this viewpoint often arises from a faulty assumption that the gold standard of care always provides the best outcome for a patient. In clinical practice, less advanced treatment options may provide similar outcomes at a lower cost that elicits less patient stress.⁵

Ultimately, more advanced diagnostic and treatment options are not always the better care options for a patient. Some instructors are now teaching clinical care through the perspective of a “least harm” approach. This approach indicates that multiple care options can be encouraged and that the best care option is the one that best fits the circumstances of the patient and client.⁶ The veterinary staff must consider cost as well as a patient’s stress level and the client’s values, finances, transportation limitations, and available time (FIGURE 1). Alternative approaches to patient care are needed to account for a patient’s and client’s limitations and preferences.⁵

Figure 1. An integrative model of client factors and contextual factors. Courtesy Richard A. LeCouteur.

What Communication Strategies Can Facilitate a Veterinary Team’s Efforts to Offer the Most Appropriate Care for a Patient?

An essential component of any level of care is effective communication that focuses on building the veterinarian–veterinary nurse–client relationship. Positive communication strategies, including a tone of empathy and perspective of partnership, are critical with an SOC approach. Specific relationship-centered communication strategies include the use of open-ended questions and reflective listening as well as a clear presentation of the treatment options and moments of summarization. Other helpful communication tactics include signposting, the use of phrases that indicate the continuation of or transition from a topic, and “chunk and check,” a term used to describe the breakdown of complex information into smaller, manageable pieces.^6,8 In an example published in JAVMA, a value matrix is used as a decision-making aid by creating a visual representation of the options as well as the advantages and disadvantages of each option.⁹

The importance of core communication skills has been reinforced by the incorporation of training into the curriculum of many veterinary and veterinary nurse education programs as well as continuing education opportunities. Every member of the veterinary team should be encouraged to address socioeconomic and other barriers to veterinary care, discuss strategies to remove these barriers, learn how to perform financial triage, and engage in difficult discussions about the ethics of pet ownership and financial hardship.¹⁰

How Can a Veterinary Nurse Contribute to Effective Communication While Providing a Spectrum of Care?

A veterinary nurse is often the key individual collecting the history from a client, and they should ensure that this critical data includes not only information about the patient but also its environment as well as the client’s values and preferences, specifically relating to what they deem important to caring for their pet.

In addition, a discussion about the client’s goals enables the veterinary team to determine what will be considered a successful outcome from the client’s perspective and which care options are most likely to achieve that outcome. A few examples of questions that may be asked during this discussion about the goals of care include:

• What are your biggest concerns about your pet’s condition?
• How do you think your pet will tolerate being in the hospital or returning for multiple visits?
• What is your ability to come back for recheck examinations?
• What is your budget for your pet’s care?

Giving clients time to process information and prepare for the next phase of a discussion is essential. Checking in with clients, asking whether they are ready to continue the conversation, and using questions to ensure comprehension demonstrate that the veterinary team is sensitive to the client’s feelings and willing to spend the necessary time to make them feel at ease.

Lastly, including a client in the process of paring down the array of care options enables the client to consider all of the choices in addition to what is best for their pet. An inclusive communication style empowers the client and ensures that their decisions about their pet’s care are closely aligned with their goals, expectations, abilities, and financial considerations.^8,11