1. Theme: Discussing options helps address barriers to veterinary care.

All participants shared that discussing options with clients assisted in addressing multiple barriers to care. For example, one participant shared, “normally, they’ll [the client] tell you [about their considerations] once you go through the options” (P13). When asked their thoughts about situations in which clients do not pursue recommended care, participating veterinarians shared how they have used the discussion of options to reach an acceptable quality of care despite client barriers and considerations. These barriers included cost of care, client and patient circumstances, client understanding of the importance of care, and challenges specific to the patient. Participants described utilizing discussion around options for care, when faced with barriers, by offering options that were diverse financially, accounted for the client’s situation and perspective, or addressed the patient’s behaviour or health. Each of these barriers, including participants’ description of how discussing options addressed the barrier, are described below.

1.1 Subtheme: Options help address “cost of veterinary care” (P14) by being financially diverse: Offering acceptable options that cover a range of costs was described by veterinarians as an approach that supported them in helping clients overcome financial barriers. A third of participants shared how discussing options is beneficial in all financial situations and not only with “cost-conscious” (P4) clients. Participants in every interview described instances where client finances restricted the medical options that could be pursued, or where a client’s budget constraints reduced available options or required adjustments of options. Participants provided examples such as prescribing a medication without bloodwork and prioritizing a single diagnostic over multiple. Over half of participants expressed that they believed current inflation was hindering clients’ ability to afford care for their pets and specifically shared the benefits of discussing options to address this current influence (i.e., inflation) on clients’ financial circumstances. Furthermore, a few participants noted that as care has advanced, it has also become more expensive; as such, participants recognized the role options play in addressing the availability of this rapid advancement. As one participant summarized, “by offering multiple options I can cater to the people who want [and can afford] the best of the best and then the people who maybe don’t even have a house or something like that. So, it doesn’t seem elitist…veterinary care these days I feel like is becoming a ‘rich man’s game’” (P6). Addressing when clients shared notable financial barriers, participants also described attempting to assist by presenting available financing options and provided examples such as payment plans and charities that provide financial assistance for veterinary care.

1.2 Subtheme: Options help address the “swirl” (P8) around clients by accounting for context: Participants described options as helping them and their clients sort through patient and client circumstances that can act as a barrier to patients gaining care; as one participant described, “a lot of the time people are coming in with a swirl, like their whole everything that’s gone on in the last few days or hours or decades is all contributing to…what they need” (P8). This participant listed examples: “People are like ‘I’m moving tomorrow’ or ‘I’m going away’ or ‘I can’t handle this because my mom just died, and I’ve got this funeral’” (P8). Almost half of participating veterinarians shared examples where factors limited what was feasible for a client in terms of options. Examples of limiting factors described by participants included logistical considerations such as clients being unable to make the trip to the clinic, client work schedules creating time constraints, and clients balancing other priorities impacting their ability to attend to their animal’s care. By knowing these factors, participants described how, in discussion with clients around options, they could discuss potential solutions, including utilizing clinic resources (e.g., participants mentioned keeping the pet in-hospital for monitoring) or engaging the client in identifying other resources (e.g., friends or family members). One participant articulated these examples: “We talk about other options. So, maybe there’s somebody in the neighborhood who can come over and administer those [medications]. Is it possible for us to do it in the hospital?” (P2) A handful of participants described the emotional connections clients have with their pets and how this influences clients’ interpretation of the impact of care, which can influence decision-making. Participants described clients as balancing the client–patient bond with a patient’s care, with financial considerations and other personal, external barriers. Participants provided moving and caring for a sick parent or child as examples of these external barriers. The client–patient bond was portrayed as motivating both clients and veterinarians to overcome barriers to the provision of care.

Nearly all participants shared that there were few instances, if any, when they could not adjust or find an option appropriate for a context, as long as clients were transparent in providing information regarding relevant barriers. However, one participant opposed this view, commenting on their perception of a veterinarian’s role in finding solutions that fit client-related barriers: “I don’t think [the] veterinarian’s concern should be the…ability of the owner to deal with the problem” (P9). Otherwise, participants expressed benefiting from drawing out client preferences, values, and barriers, where most participants described how this discussion influenced which alternatives they explored in detail. For those that described adapting their presentation of options based on history gathered prior to discussing options, this remained true where information gathered beforehand influenced their presentation of multiple options. A handful of participants expanded on this description to include the importance of maintaining awareness that client expectations, abilities, and situations may change. Almost half of participants described appreciation of client transparency in sharing their perspectives and barriers for consideration. A participant summarized this view, stating “if you’re honest with me up front and we can just incorporate it [information shared], and then we’ll have better success” (P5).

1.3 Subtheme: Discussing the outcome of each option allows veterinarians to manage client preferences: Over a third of participants described, that discussing options allowed them to adapt the options to their clients’ concerns and assist clients in seeing that providing certain care (i.e., in the form of one of the presented options) is important to the health of their animal. Most participants tied communicating the difference in value of care between options to making clients aware of the realistic outcome for each option, and used examples such as a diagnostic test may not reveal as much compared to another, or techniques for weight loss require more time. With this link delineated between the value of care and realistic expectations specific to the outcome of each option, participants described that communicating why a care recommendation is important and the risks of alternatives, including the option of not pursuing care, assists them in communicating the value of care, thereby assuaging client hesitations. One participant summarized that they communicate, “this is what you [the client] should expect and this is what the improvement is going to be for your animal and stuff…So, when I’m presenting options, say you have a cruciate ligament [tear]… [the veterinarian will] give them the option of surgery and [another option]. And [when the client asks about non-surgical options] you [the veterinarian] will say, ‘well, he’ll never walk or be able to run’” (P3). A few participants mentioned clients may be uncomfortable with treatment due to invasiveness for the patient, with participants giving the example of client discomfort regarding their pet undergoing surgical procedures. Exploring options was described as assisting in working with these client concerns, as reflected in one participant’s example: “I find one thing that does happen a lot is they [the client] assume surgery is… super risky, right? But ‘do nothing’ is also super risky” (P12). By exploring client preferences and providing appropriate information, participants aimed to aid clients in understanding why care options are important for their animal to inform client decisions. As one participant summarized, “We have to be candid and direct about what’s possible…I often don’t know what their expectations are until they’ve talked to me” (P15).

1.4 Subtheme: Options allow care to be individualized to the animal: Over half of participants shared that they discuss animal-specific barriers with clients to contextualize options to the patient’s situation, such the patient’s age, behaviour, comorbidities, and work around those barriers by including options that circumvent or minimize the barriers posed by the patient. Participants provided examples of animal-specific barriers, such as an aggressive pet or animal that would be uncooperative regarding a specific mode of treatment administration or cases where a patient’s current health status puts them at risk for a specific option. One participant shared the following example: “If you can’t put eye drops in this dog because he tries to bite you, well then, we’re not doing the best course of treatment for his dry eye, because you physically can’t do it” (P1). As long as participants were aware of the pet’s preferences or related barriers, they indicated that they were able to find acceptable alternative options.

2. Theme: Veterinarians’ description of presenting options varied.

Offering options was discussed in-depth in all interviews, arising organically in conversation around decision-making, prior to probing on the topic further. Participants described that the main benefits of discussing options include A) providing information for informed-client consent, B) offering the opportunity for clients to disclose barriers and other considerations, and C) alleviating suffering and providing care to patients, regardless of client circumstance. As one veterinarian summarized, capturing the view of almost all participants, “If you’re not willing to present options, it’s almost like you’re not willing to take their [the client’s] situation into account to help their pet” (P11).

Most participants initially described presenting all available options, including their respective risks and benefits, as well as other details. After the discussion of options arose, participants were probed further where a divergence in their described approach to presenting options was identified. Some participants shared multiple approaches and highlighted situations where they employed different approaches to presenting options; as such, there was participant overlap in the different approaches described. Almost two-thirds of participants described always mentioning to the client, briefly or in detail, that alternatives are available; whereas approximately a third shared discussing only the first option in detail and not revealing alternatives if the client seemed to believe the first option presented to them was feasible. A couple of participants deviated from all other participants by describing tailoring their presentation of options to a client by basing the options they presented on the history they gathered prior to conversations around decision-making. Another few participants described offering a recommendation and only providing alternatives once their recommendation was rejected. Finally, all participants described situations in which presentations of options were limited by the patient’s medical status. Each of these approaches is detailed as subthemes below.

2.1 Subtheme: Present all available options upfront alongside risks, benefits, and other details: Most participants described the importance of outlining upfront all options (e.g., “lay[ing] out option A, B, or C” (P1)), in some detail including common side effects, risks, benefits, and medical implications, while “checking in and see[ing] how they’re feeling about each of the options” (P5). These participants describe this in contrast to waiting for a client to select or reject an option before presenting the next. These upfront options were described as being presented to clients in a stepwise fashion. Participants described this stepwise fashion as incremental or cumulative options, least involved to most involved, or best to worst, as appropriate. These participants shared that this approach enables them to incorporate their client’s perspective. As one participant described: “We really make a point of always giving people like multiple treatment options and estimates and kind of explaining the difference between them. And then I always tell owners that I look at it as it’s my job to give them all the options and their job to decide which one is right for them” (P4).

After stating that a range of options are generally offered, participants were probed to share specifics of how they present options. In situations when clients were eager to move forward with the first option presented, of participants who stated presenting a range of options, two-thirds indicated that they still shared the remaining options, in detail or briefly with that client. One participant summarized, “I … still feel the necessity to point out their options… I wouldn’t want to seem to be changing their mind, but I’d want them to know” (P15). The other one-third of participants described moving forward with the first option presented only, if the client was eager. Otherwise, if the client did not show overwhelming interest in the first option, these participants also described proceeding with discussing other options and gaining client perspectives on each one. This approach was shared as preventing clients from feeling pressured into an option implausible for them to adhere.

2.2 Subtheme: Make a recommendation and discuss other options, if needed: In contrast to the intention of making clients aware of all available options upfront, as described above, a few participants expressed that they begin by discussing only their primary recommendation (i.e., option). After this first recommendation has been responded to, by the client, and if accepted, no other options are presented. If a client indicates the recommendation is out of reach, these participants described then proceeding to outline or present alternative care options. All these participants, at multiple points during their interviews, expressed that they “always” (P2) offer a range of options, going on to correct themselves by indicating they discuss alternative options only when an initially proposed plan is met with resistance from the client. One participant stipulated that this resistance ranges from client’s verbal disagreement or the veterinarian noticing non-verbal feedback, including client pauses (i.e., non-immediate agreement). A participant who shared use of this technique described this general approach as, “It would be my version of gold standard that I always would like to present first…[then] we get feedback from them [the client] as to whether that’s feasible or not. So, it’s a discussion” (P14).

A couple of participants shared that this suggestion of a recommendation and lack of a discussion around options was done only in some cases, where clients were adamant that they did not want to discuss alternatives. One participant clarified that, for them, a singular option was offered in a few instances with long-term clients, who had previously almost always consented to care. Furthermore, these participants described using this approach of focusing on a recommendation to save time and prevent overwhelming or confusing the client. As one participant articulated: “If they [the clients] are willing to spend money, then you [the veterinarian] don’t always have to spend as much time explaining the value of what you’re doing and giving all the options and like finessing your final plan” (P11). All of these participants shared that they ultimately end up discussing options, because most clients share barriers to their initial recommendation.

2.3 Subtheme: Contextualizing options prior to presenting them: In presenting a range of options, prior to presenting any options to a client, a couple of participants described gathering information from the client to tailor the range of options presented and to avoid assumed or previously discussed client barriers. Specifically, these participants shared that their approach to providing options was to utilize information collected during the history-gathering portion of the appointment, in order to focus on presenting clients with multiple options tailored to the patient and client’s situation. One participant described this method, sharing that “I will be sitting there, getting a fairly good history and then doing a physical and by that time—most times—you have an idea of which way you want to go… I say, ‘this is what you could do.’ I usually give a few options. I don’t get upset or try and force them to do anything, even though I know they could afford it or something like that... But I will sometimes speak up, and say, if I give them three options, ‘this is one I would not want [you] to do.’” (P3)

Some other participants stated that they avoid the technique of contextualizing options in their own mind prior to presenting options. These participants who preferred not to tailor options prior to a decision-making conversation described the approach as part of mitigating their own perception bias of what they perceive their client could afford or would prefer.

2.4 Subtheme: Presenting options is not always possible: All participants identified that there are situations where they are limited by the patient’s case in terms of available options. Participants indicated these situations were often based on case severity. In both mild or severe cases, participants shared that there were only two clear options: basic treatment or monitoring, and euthanasia or surrender. A few participants summarized this concept as cases in which “that middle one [option] kind of goes away” (P6). A few participants shared that options may not be offered for diagnostics in cases where inexpensive and straightforward treatment options are available, with one of the participating veterinarians providing an example of a “puppy with mild diarrhea, that owner gave some human food to yesterday” (P5). Other participants provided a similar example and added that an additional option provided could be to monitor the patient at home. As such, participants often identified that even in discussion of situations characterized as not needing options, more than one option could still be found and presented as needed. Almost half of participants described it in the context of these basic cases, where the options become providing a basic treatment or monitoring. Most participants shared that euthanasia may be the only option in severe cases, with direct and immediate suffering involving intensive injuries, since “in some situations it becomes a question of quality of life” (P2). In these instances, surrender was noted by a couple of participants in conjunction with euthanasia to arrive at the same result of easing severe pain through possible end of life care or intensive measures. A third of participants noted an additional case in which options were limited: abuse. In this case, reporting to relevant agencies or providing care were the only options these participants identified.

3. Theme: Veterinarians and team members face challenges when presenting options to clients.

Participants described multiple challenges to presenting options to clients, including time constraints, client “non-cooperation”, and personal bias held by veterinarians. Veterinarians also outlined the “emotional toll” (P4) they and their team members take on when client barriers prevent the pursuit of care the veterinary team considers acceptable.

3.1 Subtheme: Appointment duration constrains time to discuss options: Two-thirds of participating veterinarians identified time as a challenge for presenting options. One participant summarized this general perspective, stating: “It does take a lot of time to have that informed consent and that is the part I do find challenging is finding the time to go over everything” (P5). A handful of participants described needing to extend the duration of their appointments over their time in practice to accommodate presenting options to ensure they are meeting the requirements of providing informed consent. Others shared that they delegate communication of additional details regarding consent. For example, a couple participants described delegating conversations of cost to support staff.

3.2 Subtheme: Veterinary client “non-cooperation” (P1) when discussing options: Over two-thirds of participants noted “owner non-cooperation” (P1) as a challenge when offering options, which they defined collectively as clients being resistant to hearing options. Participants described non-cooperative clients who immediately decline each option, before opting to take their pet home without care, and some clients who do so in a confrontational manner. As a solution to this resistance, participants described being emotionally prepared for clients who enter the practice frustrated. When engaging clients who participants described were not “willing to listen” (P7) and were inclined to reject care, two-thirds described attempting to discover their client’s bias or limitations regarding care, through asking questions. One of these veterinarians specified that if no information is shared by clients in response to questioning, that they (the participant) do not probe further or provide additional information. Engaging in discussion to identify a client’s bias or limitations was considered helpful by a handful of participants when offering options, as it assisted in addressing client hesitations around care options or preferences, with participants sharing examples of discussions around raw-food diets or with clients having consulted “Dr. Google” (P9). One participant described this approach as “talk[ing] to the client on a person-to-person basis and saying, ‘What are you thinking right now?’ We [the veterinarian and the client] have a real conversation… You’re listening to what the client’s actually saying to you and then incorporating that into what’s best for the pet” (P7). Another participant added that “addressing the [client’s] stress is probably the most important thing to do in an appointment just because if that stress is not dealt with then it’s very hard for them to feel understood and then feel open to making a decision of how to try to fix things [with the pet]” (P13).

3.3 Subtheme: Veterinarians’ “perception bias” (P6) influences options offered: Over half of participants acknowledged their own biases as a challenge to presenting a range of options, of which they tried to maintain an awareness. As one participant described, “where, if I look at one person and they look less wealthy, I may not suggest the Gold Standard as opposed to the person with the iPhone and the Mercedes-Benz” (P6). Mitigating bias was mentioned as being necessary by over two-thirds of participants, in order to offer consistent care to all clients. Over a third of participants, when reflecting on the topic of mitigating their own personal biases in relation to discussing options with clients, shared their belief that recognizing bias is especially important when practicing in rural or demographically diverse areas. These participants compared their experiences discussing options with clients to those of colleagues working in practices where clients were generally financially more well off or motivated by other factors and were more likely to pursue recommended care.

Alongside participating veterinarians’ concern regarding their own bias, a few participants shared concerns with other practitioners who do not provide options. One participant shared: “just seeing my own colleagues, I’ve had a range. So, we have like a locum right now that it’s gold standard or it’s nothing… And they can’t see beyond that. But I think after a while they’ll come to realize that not everybody can do that” (P7). They described experiences within their practices of having clients who were not presented options, expressing that the client felt pressured into a care plan that was not feasible for them to maintain. These participants cautiously speculated reasons why other practitioners may be hesitant regarding discussing options, listing potential causes such as: practitioners’ resistance to change, time constraints, pressures from practices to maintain appointment times and revenue, a lack of comfort in presenting options due to this skill not being taught at veterinary colleges, and believing a range of options is not required due to affluent financial status of the area being served.

3.4 Subtheme: The “emotional toll” (P4) on the team when prevented from providing care to patients: When asked about the impact from clients who decide not to pursue care, two-thirds of veterinarians expressed the frustration they and their staff have experienced when not being able to provide what they believe to be an “acceptable quality of care” (P2). A couple of participants also explained that discussing options to find a way for the animal to have a chance to heal or reduce suffering has reduced their “emotional toll” (P4) and their own risk of burnout. Additional participants shared how their experience and time in practice assisted them in mitigating frustrations by emotionally preparing them for difficulties, as compared to the limited experiences of newer team members.

4. Theme: A shift away from a singular “Gold Standard” option.

All interviews involved a discussion of the GS, with over a third of participants describing a cultural shift away from providing a singular GS option, and moving towards the provision of multiple options.

4.1 Subtheme: A cultural shift toward providing options: Over a third of participants reflected on their experience of veterinary practice changing since they initially attended veterinary college, and described an experienced shift from a time when practitioners were “guessing what [pets and] people need” (P8) to discussing options. Half of those participants described that this change was being driven by current pet owners’ expectations, compared to when they were first in practice. One participant characterized this culture shift, sharing that “at one time you said something, and they [the client] said, ‘OK, this is what we have to do.’ Now, [clients] want a reason why we have to do it” (P9). These participants described comparing options as a means to meet the client expectation of being provided that ‘why’. Participants shared that this culture shift toward options may be connected to financial considerations, with clients portrayed by participants as being more mindful of budgeting due to rising costs of care, and thereby, expecting options that account for differing budgets. A handful of participants, all more recent graduates, suggested veterinary education may be contributing to this culture shift as they have always offered a “range of options” (P8), due to the education they had received. As one participant reflected on their veterinary education: “I think our university put a lot [of emphasis] in terms of client communication and decision-making and making sure that it’s…informed consent. So, I think a lot of us make sure that decisions that are made by the client are informed, and the only way of doing that is taking the time to explain to them all their options and why those options are important” (P13).

4.2 Subtheme: Veterinary practitioners are redefining the Gold Standard: Before being asked, the term ‘Gold Standard’ (GS) arose in discussion, organically, with over a third of participants including the term within their description of how they make decisions with clients. All participants were further probed to share their thoughts on the term, where it was defined broadly by participants as often the most expensive; “best of the best care” (P6); determined by specialists, textbooks, or educational facilities. Most participants shared that it was in veterinary college when they were introduced to the term, with the remaining participants expressing that the term was introduced to them through continuing education attended, where it is also reinforced and further defined. Most participants used the term interchangeably with referrals to specialty hospitals, equating the ‘best care’ with often-expensive options that are unavailable through general companion-animal practices. Participant agreement varied on the GS being “best for the animal” (P9), when discussing their thoughts on the GS. Most participants described a lack of practicality or necessity for the GS; whereas a small number of others viewed the GS as a useful option. A handful of participants emphasized their effort to keep up on the current GS, using literature and other resources to provide GS care. The majority of participants characterized learning about a single GS as a disadvantage, because it encouraged them not to account for client or patient barriers. Participants provided examples, such as patient behaviour, the human–animal bond, client financial constraints, or availability of diagnostics and treatments across veterinary clinics. As such, almost half of participants re-defined the GS to more-so reflect a current “Gold-Centred” (P8) approach to practice, focused on what is best for the patient. These same participants viewed the notion of the GS learned in veterinary college to be the “Ivory Tower” (P11, P12) GS or the “[Veterinary College Name] standard” (P3, P11). A more experienced participating veterinarian shared their view on why practitioners are redefining the GS, explaining “When we’re in school, it’s like ‘we’re to do ultrasound, X-rays, bone marrow biopsies and all these things.’ And these are very fearful situations for these animals and it’s a lot that they go through. So, [in practice] we like to make sure: is it necessary? So, I think that [definition of the GS] shifts, but initially your gold standard is based only on the medicine, it’s not really based on the client experience or the animals” (P12). Most participants shared that experience in practice allowed them to gain comfort in discussing options with clients and deviating from the GS. Over a third of participants described the lack of instruction on presenting options as an area for improvement by veterinary colleges, to ensure students receive education on practical care options relevant to general practice for when the GS may not be accessible for clients. These participants proposed having students practice discussing and prioritizing options as a way to benefit students’ learning about “all [options] that would have been optimal standards for your [client and patient’s] situation” (P9).

Most participants explained that, as they gained experience practicing veterinary medicine, their ability to adjust a treatment plan improved, including addressing the client’s budget and expectations, and being aware of available options. Determining what options were presented to clients for diagnostics and treatment was a matter of veterinarian experience, as veterinarians learn of more available options with increased time in practice and their comfort increases when discussing certain options (i.e., learned techniques). As stated by one participant who held this view, “that’s [determining options] just experience and knowledge that if we’re [the veterinarian] dealing with a condition, I know we could do option A, B, or C” (P1). Veterinarians described presenting clients with options, alongside a GS option, that they themselves considered acceptable (i.e., being able to bring the animal to better health). Furthermore, a few participants added that they may present an option they consider to be of lower acceptability, as a comparator in discussing the value of care recommendations.

4.3 Subtheme: It is still important to offer the Gold Standard: In almost all interviews, the GS or re-defined GS was brought up as being important to include as one of the multiple options presented to clients. Over two-thirds of participants described making the GS their top recommendation due to their desire to maintain consistency of care, mitigate personal perception bias, and ensure informed-client consent by making clients aware of the ideal, recommended care that is considered best for the animal. As well, the majority of participants described including the GS as one option to prevent clients from registering a complaint based on not being offered the GS. Furthermore, in discussing the GS, two-thirds of participants described their fear of missing an essential part of diagnosis or treatment and being at fault for inadequate care, as a result of not delivering the GS. This general fear of not offering the GS alongside other options was summarized by a participant, as follows: “I think the fear is that I’m not being a good vet and fear that if you haven’t verbally mentioned all the options, then you could have backlash… So, it’s the fear [of] judgement from other clinicians, reading your record and being like, ‘Oh my God, why didn’t they do this battery of tests? And then fear that the client or college will see it as a failure on the veterinarian’s part to not offer all of the feasible options” (P11). Nearly half of these participants described this concern as possibly being less notable for them compared to other practitioners, because they felt confident in their practice, as experienced practitioners, and in their documentation.

5. Theme: Participants’ thoughts on the American Association of Veterinary Medical Colleges’ definition of Spectrum of Care.

When participants were asked directly, as part of the interview, about the terms SpoC, IC, and CC, most participants stated that they had not heard of any of those terms. The few participants who had heard of IC or CC, shared that they did not know the definition of those terms. Over a third of participants recalled hearing the term ‘Spectrum of Care’, and of these, a couple of participants produced a description of SpoC in line with the definition provided by the American Association of Veterinary Medical Colleges (AAVMC) prior to being given the AAVMC definition within the interview (Table 1). Before the term was presented to participants, ideas associated with SpoC were mentioned throughout every interview, including in relation to how most participants described their decision-making process for cases in which clients mention barriers or additional considerations.

When presented with the AAVMC definition of ‘Spectrum of Care’ (Table 1), all participants stated that SpoC captured their current practices and their expectations of other veterinarians’ practices. One participant responding to the AAVMC definition, captured the response of many participants, stating: “it’s more realistic and it allows space for the client’s own financial or emotional or personal/spiritual beliefs to come into play. There are just genuinely some people who, even if they have all the money in the world, they wouldn’t do Gold Standard. Because for whatever reason for them or their pet or their beliefs, it’s just not something they would do. So, this opens the doorway for the client to feel supported even though they don’t just go for the gold” (P11). One participant added that they believed there is a limit, indicating that providing space for clients to deviate from recommendations and putting the onus on the veterinarian to address client barriers is not always ideal.