2. Veterinary care

Introduction

2.1  The Codes of Professional Conduct state that veterinary surgeons and veterinary nurses must provide veterinary care and veterinary nursing care that is appropriate and adequate.  

2.2  Veterinary surgeons and veterinary nurses are personally accountable for their professional practice and must always be prepared to justify their decisions and actions. When providing care, veterinary surgeons and veterinary nurses should:

1. take all reasonable care in using their professional skills to treat animals;
2. ensure that a range of reasonable treatment options are offered and explained, including prognoses and possible side effects;
3. make decisions on treatment regimes based first and foremost on animal health and welfare considerations, whilst providing contextualised care and exercising professional judgement about what is best for the animal in each individual case, taking into account the needs and circumstances of the client. For more information please see the RCVS Knowledge’s guidance on contextualised care;
4. where organisational protocols are in place, consider whether applying these in each individual case is appropriate;
5. obtain the client's consent to treatment unless delay would adversely affect the animal's welfare (to give informed consent, clients must be aware of risks) (see Supporting Guidance Chapter 11);
6. consider the welfare implications of any surgical or other procedure and advise or act appropriately;
7. provide an environment in which animals are subjected to minimum stress and provided with optimal care; 
8. ensure a hygienic and safe environment;
9. where possible, check that the care or treatment provided for each animal is compatible with any other treatments the animal is receiving (it is recognised that it may not be possible to do so in emergency situations); 
10. keep within their own areas of competence, save for the requirement to provide emergency first aid;
11. consult suitably trained colleagues, either within or outside the practice, when novel or unfamiliar procedures might be under consideration or undertaken;
12. facilitate a client’s request for a referral or second opinion and recognise when a case or a treatment option is outside their area of competence (see Supporting Guidance Chapter 1);
13. comply with animal welfare legislation and relevant Codes of Practice in the jurisdiction(s) in which they practise;
14. comply with relevant legislation, guidance and Codes of Practice if involved in research or teaching (see Supporting Guidance Chapter 24 and Chapter 25)
15. be familiar with any special rules or requirements of the particular industry in which they practise, for example, the meat hygiene industry or animals used in sport; and
16. keep their skills and knowledge up to date.

*There may be additional considerations for owners of animals kept for commercial or production purposes. Whatever the circumstances, the overriding priority is to ensure that animal health and welfare is not compromised.

Support in surgery

2.3  A second suitably trained person other than the surgeon must be in attendance for the specific purpose of monitoring the patient and maintaining general anaesthesia (except in emergency or very short procedures e.g. cat castrate).

2.4  Evidence of suitable training must be provided if the team member is not a registered veterinary nurse. In-house training is acceptable.

Communicating investigations and treatment options to the client

2.5  Having reached a provisional diagnosis, taking into account the animal’s age, the extent of any injury and disease and the likely quality of life after treatment, veterinary surgeons should make a full and realistic assessment of the prognosis and the options for treatment or euthanasia and communicate this to the client. 

2.6  Veterinary surgeons and veterinary nurses should use language appropriate for the client and explain any clinical or technical terminology that may not be understood (see Supporting Guidance Chapter 11 Communication and consent). 

Hospitalisation and in-patient care

2.7  Veterinary surgeons and veterinary nurses should provide appropriate and adequate in-patient care.

2.8  Clients are entitled to have their animals housed in a comfortable environment, monitored and treated commensurate with the animal's condition, by persons with the requisite level of knowledge and expertise.

2.9  Before leaving an animal at a practice, the owner, keeper or carer should be made aware of the level of supervision that will be provided to the animal, particularly the level of supervision outside normal working hours. Different levels of care required arise in differing circumstances.

2.10  Clients should be made aware of the cost of providing in-patient care. A veterinary surgeon may decide that nursing care can be provided at home by an experienced owner. 

2.11  Protocols for in-patient care should be in place for on-duty staff, who are responsible for the care of in-patients. It is recognised that each practice will have its own policy and standard arrangements for dealing with in-patients. But, despite different patient needs and circumstances, there are basic areas, which protocols should cover such as: 

1. Transfer of information: to ensure that staff responsible for taking over the care of in-patients have all the necessary information when shifts change during the day or during periods outside normal working hours.
2. Detail and frequency of patient checks: to ensure that staff responsible for the care of in-patients are aware of any specific instructions about what needs to be checked or monitored and with what frequency, for example, temperature, pulse and respiration rates or signs of post-operative pain; instructions for any medicines to be administered; any special care requirements; and any changes in condition or status to look out for.
3. Clarity of roles and responsibilities: to ensure that staff responsible for the care of in-patients are aware of the legal and professional limitations on what they can do. For example, veterinary nurses and student veterinary nurses should not administer medicines unless they have been directed to do so by a veterinary surgeon. Protocols should also clarify the limitations on what unqualified lay staff are permitted to do (see Supporting Guidance Chapter 19 for more information on unqualified staff).

Continuity and co-ordination of care

2.12  Veterinary surgeons and veterinary nurses should facilitate the safe transfer of patients between veterinary practices, including outside normal working hours.

2.13  When an animal is admitted for examination, procedures, surgery, hospitalisation, observation or any other form of consultation, the veterinary surgeon should make an initial assessment and attempt to predict the likely course of events and any potential complications. This is essential for the purposes of informed consent and financial estimation. This thought process should establish for approximately how long the animal is likely to need to remain under veterinary care, at what level of intensity, and should consider where this is likely to be provided and whether the animal is likely to be moved between practices / premises.  

2.14  If the expectation is that the period of veterinary care might straddle a change of personnel (e.g. staff duty rota changeovers) or even a change of practice or premises (e.g. transfer to a dedicated out of hours provider or to a referral facility) it is imperative that a plan is developed to manage this and a contingency plan considered should circumstances change. Such a plan should encompass:

1. the transmission of relevant clinical information
2. the availability of the necessary staffing, equipment and medicines
3. the method of transportation and any necessary ancillary considerations (e.g. oxygen therapy, continuous fluid administration, pain relief, professional staff in attendance)
4. the likelihood that the period of care will exceed that available at the place of transfer i.e. the animal should be subjected to the minimum number of transfers appropriate to that animal and owner.

2.15  Informed consent from the outset should, as necessary, include the arrangements to be made in the event that an animal needs to be hospitalised, including clarity about the level of supervision and possible transfer arrangements.

2.16  At all times the welfare of the animal should be the fundamental priority. There will be occasions where the best interests of the animal may be served by remaining at the original premises with suitable contingency arrangements for staffing or even euthanasia.

2.17  A veterinary surgeon should not carry out elective surgery in the knowledge that the animal will require significant and immediate aftercare which cannot be provided in-house. Arrangements should be made for the procedure to be carried out at another practice / premises where appropriate aftercare can be provided without the need for the animal to be moved between practice / premises in the immediate post-operative period.

2.18  For the avoidance of doubt, this applies to all practices, including first opinion and dedicated out-of-hours service providers.

2.19  If a veterinary surgeon delegates the care of an animal to a colleague, they must be satisfied that the person providing care has the appropriate qualifications, skills and/or experience to provide safe care for that animal. This is also pertinent when peripatetic services are provided and aftercare is undertaken by the host practice.

Discharge planning

2.20  Discharge planning is the process used to decide what a patient needs for a smooth move from one type or level of care to another. Effective discharge planning is important to providing good continuity of care for animals, but this needs to be managed well.

2.21  Protocols for discharging animals should be in place for on-duty staff. It is recognised that each practice will have its own policy and standard arrangements for discharging patients. But, despite different patient needs and circumstances, there are basic principles of planning for discharge that protocols should cover, such as: 

1. Plan the date and time of discharge early: this means that the client knows what needs to happen and when their animal is likely to be discharged. Veterinary surgeons should agree with the client a realistic expected discharge date and there should be appropriate support in place. 
2. Identify whether the patient has simple or complex discharge needs and consider how these will be met: discussing these needs with the client at an early stage in the process means that appropriate action can be taken and plans arranged. 
3. Review the clinical management plan regularly, take any necessary action and update this towards the discharge date: discharge needs may change and evolve and therefore plans should be updated accordingly. Clients should be informed of any changes. 
4. Co-ordinate the discharge process through effective leadership and handover responsibilities: this includes handover to different staff within the practice or to dedicated out of hours services or other practices. Where it is anticipated that a third party could become involved, transmission of clinical notes / information (directly or via the client) in advance might be helpful.
5. Confirm that clients have been provided with necessary information on discharge: this might include care plans and instructions for ongoing management, signs to look out for, explanations of any surgical or medical complications, restrictions on physical activity and practice contact numbers, including emergency service details, details of follow up appointments or any information leaflets. 
6. Confirm that clients have been given any required medicines or items (e.g. collars, bandages) on discharge: staff should ensure that clients are provided with any necessary instructions. This might include instructions on frequency and method of administration where medicines are prescribed.

Team responsibilities when discharging animals

2.22  Senior veterinary surgeons should ensure efficient systems and processes are in place to support discharge and care transfer. They should ensure that all members of staff are aware of their roles and responsibilities in the discharge process.

2.23  A veterinary surgeon should decide whether an animal is clinically fit to be discharged. Persons responsible for handing over animals should check that they been cleared for discharge by a veterinary surgeon before they are released into the care of the client. If the animal’s condition has changed or any concerns are identified, a veterinary surgeon should be consulted before the animal is discharged.

2.24  Veterinary surgeons should ensure that support staff are instructed to discharge animals only on the instructions of the duty veterinary surgeon.

Legal restrictions on certain procedures

2.25  From time to time, veterinary surgeons and veterinary nurses may be asked to carry out procedures on animals which may not have a legal basis in the UK (e.g. purely cosmetic procedures or procedures sought for the sole convenience of the owner). Veterinary surgeons and veterinary nurses should be aware that UK animal welfare legislation legally restricts mutilations to animals (i.e. procedures which interfere with sensitive tissue or bone structure) unless they are carried out for the purposes of medical treatment:  

1. In England and Wales, the Animal Welfare Act 2006 prohibits mutilations “otherwise than for the purpose of its medical treatment” or permitted by specific regulations (Section 5). 
2. In Scotland, the Animal Health and Welfare (Scotland) Act 2006 prohibits mutilations except “where they are carried out for the purpose of the medical treatment of an animal” or permitted by specific regulations (Section 20).
3. The Welfare of Animals (Northern Ireland) Act 2011 provides that a prohibited procedure is one which involves interference with the sensitive tissues or bone structure of the animal, except in relation to (i) any procedure carried out by a veterinary surgeon; (ii) any procedure carried out for the diagnosis of disease; (iii) any procedure carried out for the purposes of medical treatment of an animal; (iv) any other procedure which is specified in regulations made by the Department (Section 5).

2.26  There are some procedures which are technically mutilations, but these are exempt from the ban due to reasons such as long-term welfare or animal management benefits, control of reproduction or identification purposes. These procedures are listed in the regulations for the relevant UK jurisdiction:

1. the Mutilations (Permitted Procedures) (England) Regulations 2007
2. the Mutilations (Permitted Procedures) (Wales) Regulations 2007
3. the Prohibited Procedures on Protected Animals (Exemptions) (Scotland) Regulations 2007
4. the Welfare of Animals (Permitted Procedures By Lay Persons) Regulations (Northern Ireland) 2012

2.27  These regulations also include additional requirements on how the various procedures should be performed (for example, requiring the administration of an anaesthetic, specifying the required age for an animal or setting down husbandry or conservation requirements).

2.28  Veterinary surgeons and veterinary nurses asked to perform procedures, which they consider may not have a legal basis, should consult the regulations and seek advice from the RCVS where necessary.

Conscientious objection

2.29 Veterinary surgeons and veterinary nurses may only refuse to carry out specific procedures or treatment or provide specific services based on a conscientious objection where it is reasonable in all the circumstances and animal welfare is not compromised.

2.30 Where a veterinary surgeon is satisfied that animal welfare is not affected, they should make alternative arrangements for the animal, or where this is not possible, ensure the client has enough information to seek assistance from another veterinary surgeon. When exercising a conscientious objection, veterinary surgeons and veterinary nurses should ensure that they communicate their position sensitively and treat the client with respect.

2.31 Veterinary surgeons and veterinary nurses should inform employers of their conscientious objection at the earliest opportunity so that, if necessary, contingency plans can be made.

2.32 Veterinary surgeons and veterinary nurses should be open with colleagues about their conscientious objection and explore with those colleagues how they can practise in accordance with their beliefs without compromising patient care and without overburdening others.

Information and advice-only services

2.33 Veterinary surgeons regularly give advice as part of their work and in a variety of contexts. Advice can range from very general, for example, writing in a magazine column, to very specific, for example, to an existing client as part of an ongoing course of treatment.  Veterinary surgeons may only give advice to the extent appropriate based on the information they have about the animal and should bear in mind the general guidance on veterinary care and in relation to prescribing medicines. Where advice is given remotely and there is no ability to monitor the animal, for example, because it is provided as part of an online-only service, veterinary surgeons should ensure that the client understands the limitations of this service and that animal welfare and/or subsequent veterinary care is not compromised.

2.34 General information taken from standard texts or articles (source acknowledged and subject to copyright law) may be disseminated via the internet, either by way of a distance-learning CPD project for veterinary surgeons, or for the general public who are seeking information about a particular condition, treatment or medication.