One survey of dog and cat owners’ perceptions of anesthetic risks identified common themes. Their pets are children: “My cats are my kids. If something happened to them under anesthesia, I do not know how I would survive their loss.” During a checkup, you identify dental disease in a senior pet and explain the need for treatment. The pet owner declines care. In situations like this, veterinarians often blame price as the obstacle when fear of anesthesia may be the culprit. Although veterinarians have good intentions, clients hear a parental “don’t worry.” Instead, pet owners need a safe, open environment to share their concerns. Clients deserve more than trite responses that superficially address the elephant in the room. Rather than assuming less information reduces stress, veterinarians need to dive headfirst into concerns. Doctors and clients must make educated decisions together to benefit patients. What are anesthetic risks? The most common anesthetic complications in companion animal medicine are intra-operative hypotension, cardiac arrhythmias, post-operative regurgitation, aspiration pneumonia, dysphoria, cerebellar dysfunction, and blindness or deafness in cats.1-12 Risk of anesthetic death in dogs and cats is 0.17 percent and 0.24 percent, respectively.13 When categorized by health status, risk of anesthetic death in healthy dogs and cats drops to 0.05 percent and 0.11 percent.13 These percentages are higher than those reported for people.14-16 What increases anesthetic risks? Patient breed and body weight also contribute to anesthetic risk.17,18 Brachycephalic breeds are prone to airway obstruction, and sighthounds metabolize anesthetic agents differently than most.19 Patients weighing less than 5 kilograms are at increased risk, as well as pets age 12 and older.20,21 What concerns clients most about anesthetic risks? A 2016 Midwestern University online survey of dog and cat owners’ perceptions of anesthetic risks identified common themes: Their pets are children: “My cats are my kids. If something happened to them under anesthesia, I do not know how I would survive their loss.” Their pets have had adverse reactions to medication or anesthesia: “The first time he was put under general anesthesia his heart rate was really low and his blood pressure was bad.” They fear the unknown: “You never really know what kind of reaction they will have when they are under.” What are clients told about anesthetic risk? Respondents said 1 in 3 veterinarians and 1 in 2 technicians did not mention anesthetic risk. When teams initiated conversations, word choices were vague: “Anesthesia is never 100 percent safe, but we will do our best.” Doctors and technicians didn’t share details about how anesthesia would be monitored. “Nothing was said until I asked,” one respondent said. As a result, 97 percent of those surveyed were dissatisfied with the team’s failure to acknowledge or address anesthetic risk. Many felt their concerns were unwelcome. One pet owner said that the technician turned her back and held the exam room doorknob while addressing her concern: “It became clear to me that the conversation was over. She was done.” Clients may be reluctant to express concerns and decline procedures if they feel you’re too busy to listen. Another respondent said, “They probably assumed it was all about the money, and I couldn’t afford to pay for care. Actually, I didn’t trust that care would be adequately provided.” What do clients want to know about anesthetic risk that we aren’t telling them? Companion animal owners want details. Specifically, clients need to know: Risks of anesthesia and the frequency with which these risks occur What can be done in advance of, during, and after the procedure to reduce risks How the team will respond in the event of an anesthetic crisis Clients get frustrated when asked to pay for services they don’t understand. They need you to share the value of professional services: “I don’t know what anesthesia involves, so explain it to me.” “Tell me what I’m paying for and how it will benefit my pet.” “Making blood work optional doesn’t explain why I should do it. Tell me how it helps you anticipate problems and solve them before they happen.” Vague terms bother clients: “Don’t tell me my pet will be monitored. What does that mean? What equipment are you using? Who will be monitoring, and have they been trained?” “Don’t say anesthesia carries risk. What does risk mean? What could go wrong? If something does, how will you fix it?” “Don’t say my pet will be given drugs to make her sleep. Which drugs will be given and why? How will they help? How might they hurt?” Clients want to know what to expect: “How will she act when I pick her up? What is normal? What is not?” “How long will it take for my pet to recover?” “How will I know if there is a problem when I bring her home? Who do I call?” Who does the talking? Dog and cat owners have different preferences about who communicates information. A 2015 study suggests dog owners want medical details from a veterinarian.22 When other healthcare team members reach out, dog owners perceive the veterinarian does not value them enough as clients to make time.22 Cat owners are more accepting of a team approach to patient care. It matters less to cat owners who reaches out to them and more that someone does.22 How do you incorporate anesthetic risk discussions into everyday conversations? it is important to establish clear protocols that the entire team can describe and support. Develop talking points in layman’s terms that receptionists, technicians, and veterinarians will use in client conversations. Say, “We will monitor your pet’s blood pressure, body temperature, and level of oxygen in the blood during the procedure” instead of “We will hook your pet up to a pulse oximeter and electrocardiogram.” Periodically audit the process from patient intake to discharge. Identify missteps along the way, including shortcuts that are not in the best interest of patients. Clarify procedures as needed. Create messages every client should hear about anesthesia. Practice conversations until they become second nature. Client handouts are supplemental educational tools rather than substitutes for face-to-face discussions. Allow time for anesthetic discussions. Describe how anesthesia will impact patient care. Ask whether their pet has been anesthetized before, and address their concerns before transitioning into yours. Use clients’ questions about patient safety to segue into how your team reduces risk. Highlight how the diagnostic workup helps you to anticipate patient needs. Use client-friendly explanations for diagnostic tests you consider essential: “Blood work and urine tests show us how well Darcy’s liver and kidneys are working, and whether they can handle the drugs we want to administer.” “X-rays of Darcy’s chest will let us see her lungs and airway to confirm she can breathe effectively while under anesthesia.” “An ultrasound of Darcy’s heart will help us identify the cause of her murmur, and then select safe medications for her heart.” Show clients behind-the-scenes care. Create photo books, digital slideshows, and videos to illustrate steps of procedures. Take a photo of each professional service listed on your treatment plans, from your in-house lab to patients receiving nursing care during recovery. Pictures and videos are valuable teaching tools because few clients have seen pets under anesthesia. Engage clients with positive body language. Remove physical barriers between you and the client. Rather than talk across the exam table, stand or seat yourself next to the client or at the end of the exam table, forming L-shaped body language. Lean forward to indicate your interest in what the pet owner has to say. Make eye contact. Plan ahead to reduce client stress. Which tests could you perform today so the patient will be ready on the day of the procedure? Sharing diagnostic test results before the day of the procedure may give clients peace of mind and know what to expect. This is particularly critical when patients have pre-existing disease that could complicate anesthesia such as cardiomyopathy. Describe what the client can expect on admission day. When clients book procedures, schedule 15- to 20-minute admission appointments with technicians or doctors. This face-to-face time serves as a final check-in with the client to clarify last-minute concerns and prevent misunderstandings. Medical staff, not receptionists, should admit patients in exam rooms where clients can ask questions about medical care in private. Show clients where procedures will happen. Offer to walk clients through your in-house laboratory, surgical suite and treatment area, or post a virtual tour on your website for easy client access. Invite questions and be honest. Ask open-ended questions such as, “What questions can I answer about your pet’s procedure and our anesthetic protocols?” These require clients to provide more than a yes/no response and may be more likely to stimulate conversation. Validate clients’ concerns. If a patient is at increased risk, acknowledge it and explain how you will try and reduce the risk. Say, “I share your concern that Darcy reacted poorly to acepromazine when she was spayed. Her medical records show that she experienced a drop in blood pressure. We will use a different medication that is less likely to affect blood pressure. We will monitor her blood pressure, heart rate, and body temperature throughout the procedure. Darcy will have an IV catheter to let us administer fluids for hydration and give medications to increase her blood pressure should it drop.” Clients want to be valued as decision-makers and partners when it comes to their pets’ health. When clients are heard, they not only feel respected, they are more inclined to proceed with recommended care when reservations are addressed and the plan is clear. Transparency is key to addressing the fear factor rather than letting it fester. References Gaynor JS, Dunlop CI, Wagner AE, et al. Complications and mortality associated with anesthesia in dogs and cats. J Am Anim Hosp Assoc. 1999;35:13-17. Iizuka T, Kamata M, Yanagawa M, et al. Incidence of intraoperative hypotension during isoflurane-fentanyl and propofol-fentanyl anaesthesia in dogs. Vet J. 2013;198:289-291. Mazzaferro E, Wagner AE. Hypotension during anesthesia in dogs and cats: Recognition, causes, and treatment. Comp Cont Educ Pract. 2001;23:728-+. Davies JA, Fransson BA, Davis AM, et al. Incidence of and risk factors for postoperative regurgitation and vomiting in dogs: 244 cases (2000-2012). J Am Vet Med A. 2015;246:327-335. Ovbey DH, Wilson DV, Bednarski RM, et al. Prevalence and risk factors for canine post-anesthetic aspiration pneumonia (1999-2009): a multicenter study. Vet Anaesth Analg. 2014;41:127-136. Becker WM, Mama KR, Rao S, et al. Prevalence of Dysphoria after Fentanyl in Dogs Undergoing Stifle Surgery. Vet Surg. 2013;42:302-307. Vaisanen M, Oksanen H, Vainio O. Postoperative signs in 96 dogs undergoing soft tissue surgery. Vet Rec. 2004;155:729-733. Light GS, Hardie EM, Young MS, et al. Pain and Anxiety Behaviors of Dogs during Intravenous Catheterization after Premedication with Placebo, Acepromazine or Oxymorphone. Appl Anim Behav Sci. 1993;37:331-343. Shamir M, Goelman G, Chai O. Postanesthetic cerebellar dysfunction in cats. J Vet Intern Med. 2004;18:368-369. Barton-Lamb AL, Martin-Flores M, Scrivani PV, et al. Evaluation of maxillary arterial blood flow in anesthetized cats with the mouth closed and open. Veterinary Journal. 2013;196:325-331. Jurk IR, Thibodeau MS, Whitney K, et al. Acute vision loss after general anesthesia in a cat. Vet Ophthalmol. 2001;4:155-158. WonGyun S, BoYoung J, TaeEog K, et al. Acute temporary visual loss after general anesthesia in a cat. Journal of Veterinary Clinics. 2009;26:480-482. Brodbelt DC, Blissitt KJ, Hammond RA, et al. The risk of death: the confidential enquiry into perioperative small animal fatalities. Vet Anaesth Analg. 2008;35:365-373. Kawashima Y, Seo N, Morita K, et al. [Annual study of perioperative mortality and morbidity for the year of 1999 in Japan: the outlines--report of the Japan Society of Anesthesiologists Committee on Operating Room Safety]. Masui. 2001;50:1260-1274. Biboulet P, Aubas P, Dubourdieu J, et al. Fatal and non-fatal cardiac arrests related to anesthesia. Can J Anaesth. 2001;48:326-332. Eagle CC, Davis NJ. Report of the Anaesthetic Mortality Committee of Western Australia 1990-1995. Anaesth Intensive Care. 1997;25:51-59. Clarke KW, Hill LW. A survey of anaesthesia in small animal practice: AVA/BSAVA report. J Vet Anaesth. 1990;17:4-10. Bednarski R, Grimm K, Harvey R, et al. AAHA anesthesia guidelines for dogs and cats. J Am Anim Hosp Assoc. 2011;47:377-385. Krein S, Wetmore LA. Breed-specific anesthesia. Clinician’s Brief. 2012:17-20. Brodbelt DC, Pfeiffer DU, Young LE, et al. Risk factors for anaesthetic-related death in cats: results from the confidential enquiry into perioperative small animal fatalities (CEPSAF). Br J Anaesth. 2007;99:617-623. Hosgood G, School DT. Evaluation of age as a risk factor for perianesthetic morbidity and mortality in the dog. J Vet Emerg Crit Care. 1998;8:222-236. Englar RE, Williams M, Weingand K. Applicability of the Calgary-Cambridge Guide to Dog and Cat Owners for Teaching Veterinary Clinical Communications. J Vet Med Educ. 2016;43:143-169. Ryane E. Englar, DVM, DABVP (Canine and Feline Practice), is an assistant professor and clinical education coordinator for Kansas State University College of Veterinary Medicine. Her teaching responsibilities include designing and debuting a new Clinical Skills curriculum for veterinary students to improve their confidence and competence with professional and technical skills. Her research emphasizes veterinary client communication preferences. Reach her at renglar@vet.k-state.edu. Wendy S. Myers owns Communication Solutions for Veterinarians in Castle Pines, Colo. She is a certified veterinary journalist and the author of “101 Communication Skills for Veterinary Teams.” Reach her at wmyers@csvets.com or csvets.com.
