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Position on Practice of Veterinary Medicine (2014)

Every veterinarian should be familiar with the legal definition of the practice of veterinary medicine as defined in their state or provincial Veterinary Practice Act. The AAEP defines the practice of veterinary medicine for the ethical guidance of its members as the following: 

“Practice of veterinary medicine” means: 

Any person practices veterinary medicine with respect to animals when such person performs any one or more of the following:

a. Diagnoses, prognoses, treats or prevents animal disease, illness, pain, deformity, defect, injury, or other physical, dental, or mental conditions by any method or mode; or
b. Prescribes, dispenses, or administers a drug, medicine, biologic, appliance, or treatment of whatever nature; or 
c. Performs upon an animal a medical procedure, a surgical or dental operation, or a complementary, integrative, or alternative veterinary medical procedure; or
d. Performs upon an animal any manual procedure for the diagnosis and /or treatment of pregnancy, sterility, or infertility; or 
e. Upon examination determines the health, fitness, or soundness of an animal; or 
f. Directly or indirectly consults, supervises, or recommends treatment of an animal by any means including telephonic and other electronic communications; or
g. Represents oneself directly or indirectly, as engaging in the practice of veterinary medicine; or
h. Uses any words, letters or titles under such circumstance as to induce the belief that the person using them is qualified to engage in the practice of veterinary medicine, as defined. Such use shall be prima facie evidence of the intent to represent oneself as engaged in the practice of veterinary medicine.

Approved by AAEP board of directors in 2014.

Position on Roles of Healthcare Providers in Veterinary Medicine (2014)

The AAEP recognizes that quality professional healthcare often requires the services of a Healthcare Team. The attending veterinarian is the leader of the Healthcare Team and is ultimately responsible for all healthcare decisions made concerning an equine patient until that patient is referred or discharged. The attending veterinarian may delegate appropriate healthcare tasks, allowable by state law, to subordinate healthcare providers. Referral, as defined by the American Association of Equine Practitioners (AAEP), American Veterinary Medical Association (AVMA), American College of Veterinary Internal Medicine (ACVIM), American College of Veterinary Surgeons (ACVS), American College of Theriogenologists (ACT), and American College of Veterinary Emergency and Critical Care (ACVECC), is the transfer of responsibility for diagnosis and/or care of a specific problem from a referring veterinarian to a receiving veterinarian. 

The establishment of a valid Veterinarian-Client-Patient Relationship and the examination and diagnosis of the patient by the attending veterinarian prior to the delegation of any equine healthcare task to subordinate healthcare providers is prerequisite to ethical veterinary practice. The attending veterinarian is responsible for determining the professional competency of a healthcare provider before delegating equine healthcare tasks.

The following outlines the appropriate roles of different healthcare providers within the scope of ethical professional veterinary practice:

A. Licensed Veterinarians: The examination, diagnosis, prognosis, treatment, and management of equine healthcare are to be provided and supervised by licensed veterinarians.
B. Credentialed Technicians: Licensed Veterinarians may delegate healthcare tasks that are not restricted to veterinarians, to Licensed/Certified/Registered Veterinary Technicians (LVTs) who are under the employ and supervision of the Licensed Veterinarian. While some states allow LVTs to perform “minor” dental and surgical procedures, the AAEP does not support the delegation of any invasive procedures and procedures with significant risk of complication (e.g. castration, dental extraction and
advanced procedures, reproductive examination).
C. Uncredentialed Assistants: Licensed Veterinarians may delegate ancillary healthcare tasks to Veterinary Assistants (not registered, certified, or licensed) that are under the employ and supervision of the Licensed Veterinarian. The Licensed Veterinarian may delegate direct supervision of a Veterinary Assistant to a LVT.
D. Human Healthcare Professionals (HHP): Veterinarians occasionally confer with or have Licensed Human Healthcare Professionals (MD, DC, DDS, etc.) perform procedures on their equine patients. While the collaboration between veterinarians and HHPs advances healthcare standards, this collaboration is usually only appropriate between veterinary and HHP specialists. The ethical indications for having HHPs perform procedures on veterinary patients are rare, and procedures performed by the HHP on veterinary patients should be performed under the Immediate Supervision of a Licensed Veterinarian. The attending veterinarian is responsible for ensuring compliance with state law before soliciting HHP services.
E. Unlicensed Allied Healthcare Providers (UAHP): (e.g., Veterinary Physical Therapist/Rehabilitator, Farrier, Hospice Caregiver, etc.) While conferring with and inclusion of UAHPs in an equine healthcare team may be appropriate in the treatment of some equine patients, the healthcare services provided by the UAHP should be performed under the order and/or supervision of the Attending Veterinarian, who is responsible for reviewing the training of the UAHP before soliciting his/her services. Ethical practice indicates that services beyond an attending veterinarian’s scope of professional training and competency be referred to an appropriately trained veterinarian who provides he required healthcare services. The AAEP does believe that, in certain situations, working with UAHPs under the proper context and within the construct of a Veterinarian-Client-Patient Relationship can lead to optimum health care for the horse.

Approved by AAEP board of directors in 2014.

Position on Levels of Supervision (2014)

Ethical veterinary practice dictates that members of the healthcare team be supervised by the attending veterinarian. The levels of supervision described are defined as follows:

1. Immediate supervision: A licensed veterinarian is within direct eyesight and hearing range during the performance of healthcare tasks.
2. Direct supervision: A licensed veterinarian is physically present on the premises where animal healthcare tasks are to be performed and is readily available.
3. Indirect supervision: A licensed veterinarian is not physically present on the premises where animal healthcare tasks are to be performed, but has given either written or oral instructions
(“direct order”) for treatment of the animal patient and is able to perform the duties of a licensed veterinarian by maintaining direct communication.

Approved by AAEP board of directors in 2014.

Contingency Fees (1965)
It is not ethical for a veterinarian to enter into agreements with clients which provide that the fee to be charged for certain services will be contingent upon a horse’s successful performance on the racetrack or in the show ring. Such an agreement is unethical in that the veterinarian must at all times render the ultimate in assistance to the patient and charge a fee appropriate for the services rendered. The veterinarian’s fee is not based on a subsequent event, but directly connected with the services
rendered. There are no guarantees in medicine, expressed or implied. 

A fee contingent upon the outcome of a race gives the veterinarian a vested interest in the horse, and the racing rules in many states preclude such practices. In other states where the rules do not exist, such vested interest will be considered as a conflict of interest with the owners of all other horses in the race.

This is not to be confused with attempted surgical repair or treatment of cases with poor prognosis if such efforts promise educational benefit, and of cases that would have been destroyed for economic reasons. In those cases, it is proper for a veterinarian to share efforts on a contingency basis with the client.

Reviewed by AAEP board of directors in 2010. 

Conflicts of Interest (2007)

A conflict of interest, as it pertains to veterinary medicine, is a situation in which the veterinarian has competing professional or personal interests. Such competing interests can make it difficult for the veterinarian to fulfill his or her duties impartially. A conflict of interest can exist even if no unethical or improper act results from
it; however, it can create an appearance of impropriety that can undermine confidence in the person or profession.

The AAEP suggests the following guidelines for its members:
 

1. A veterinarian should strongly consider whether or not to render services to a client if in doing so the veterinarian’s independent professional judgment will be adversely affected by a personal, professional or financial relationship with either the client or a third party. 

2. A veterinarian should strongly consider whether or not to render services to a client if the services to that client will be adversely affected by the veterinarian’s responsibilities to another client, a third party or the veterinarian’s own interests. 

Reviewed by AAEP board of directors in 2010.

Position on Equine Dentistry (2012)

The practice of equine dentistry is an integral branch of professional equine veterinary practice. This discipline encompasses all aspects of the evaluation, diagnosis, prognosis, treatment, and prevention of any and all diseases, disorders, and conditions that affect the teeth, oral cavity, mandible, maxillofacial area, and the adjacent
and associated structures. Additionally, equine dentistry includes the evaluation of the presentation and contribution of systemic diseases within the oral cavity and the contribution of oral conditions to the overall health of the individual horse.

Any surgical procedure of the head or oral cavity; the administration or prescription of sedatives, tranquilizers, analgesics or anesthetics; procedures which are invasive of the tissues of the oral cavity including, but not limited to, removal of sharp enamel points, treatment of malocclusions of premolars, molars, and incisors, reshaping of teeth, the extraction of first premolars and deciduous premolars and incisors; extraction of damaged or diseased teeth; treatment of diseased teeth via restorations and endodontic procedures; periodontal and orthodontic treatments; and dental radiography are veterinary dental procedures and should be performed by a licensed veterinarian.

In states where the Veterinary Practice Act allows, the AAEP supports the use of licensed veterinary technicians under the employ and immediate supervision of licensed veterinarians for specific and appropriate veterinary dental procedures as enumerated in that state’s practice act. In states where the Veterinary Practice Act allows, the AAEP supports the use of licensed human dental healthcare providers under the immediate supervision of licensed veterinarians for specific and appropriate veterinary dental procedures as enumerated in that state’s practice act, only when a veterinary dentist is unavailable.

Revised by AAEP board of directors in 2012.

Euthanasia Guidelines (2011)

The AAEP recommends that the following guidelines be considered in evaluating the need for humane euthanasia of a horse. The attending veterinarian is often able to assist in making this determination, especially regarding the degree to which the horse is suffering. It should be pointed out that each case should be addressed on its individual merits. The following guidelines are guidelines only. It is not necessary for all of these criteria to be met. Horses may be euthanized at an owner’s  request for other reasons, as the owner has sole responsibility for the
horse’s care. Prior to euthanasia, clear determination of the insurance status of the horse should be made as an insurance policy constitutes a contract between the horse owner(s) and the insurance carrier.

In accordance with AVMA’s position on euthanasia of animals, the AAEP accepts that humane euthanasia of unwanted horses or those deemed unfit for adoption is an acceptable procedure once all available alternatives have been explored with the client. A horse should not have to endure conditions of lack of feed or care erosive of the animal’s quality of life. This is in accord with the role of the veterinarian as animal advocate.

The following are guidelines to assist in making humane decisions regarding euthanasia of horses.

  • A horse should not have to endure continuous or unmanageable pain from a condition that is chronic and incurable.
  • A horse should not have to endure a medical or surgical condition that has a hopeless chance of survival.
  • A horse should not have to remain alive if it has an unmanageable medical condition that renders it a hazard to itself or its handlers.
  • A horse should not have to receive continuous analgesic medication for the relief of pain for the rest of its life.
  • A horse should not have to endure a lifetime of continuous individual box stall confinement for prevention or relief of unmanageable pain or suffering.

echniques for Euthanasia – The following techniques for performing euthanasia of horses by properly trained personnel are deemed acceptable:

1. Intravenous administration of an overdose of barbiturates.
2. Gunshot to the brain (Shearer JK, Nicoletti P. Humane euthanasia of sick, injured and/or debilitated livestock. University of Florida IFAS Extension).
3. Penetrating captive bolt to the brain (Shearer JK, Nicoletti P. Humane euthanasia of sick, injured and/or debilitated livestock. University of Florida IFAS Extension).
4. Intravenous administration of a solution of concentrated potassium chloride (KCl) with the horse in a surgical plane of general anesthesia.
5. Alternative methods may be necessary in special circumstances.

Special Considerations for the Insured Horse and Cases Involving 
Multiple Practitioners:
Each insurance policy for a horse is a contract between the horse owner and the insurance company and will dictate the specific terms and conditions concerning the payment of a mortality claim. Careful consideration should be given to possible “conflicts of interest” as referenced in the Ethical and Professional Guidelines in the AAEP Resource Guide and Membership Directory. The attending, consulting and referring veterinarians should follow the Ethical and Professional Guidelines under section IV, “Attending, Consulting and Referring,” as described in the AAEP Resource Guide & Membership Directory.

Reviewed by the AAEP board of directors in 2016.

Guidelines for Equine Veterinary Case Referral (2014)

Executive Summary
The Veterinary Oath obligates practicing veterinarians to use their knowledge and skills for the benefit of society and the prevention of animal suffering. This is often best accomplished rough the coordinated efforts of multiple individuals working on behalf of a single patient to provide the highest quality veterinary care in a professional and collegial environment. This document was developed through the collaborative efforts of the AAEP, American College of Veterinary Internal Medicine (ACVIM), American College of Veterinary Surgeons (ACVS), American College of Theriogenologists (ACT), and American College of Veterinary Emergency and Critical Care (ACVECC) with a goal of providing practical communication guidelines for individuals who collaborate in equine patient care.

Definitions

Referring Veterinarian: The veterinarian (or group of veterinarians) providing care at the time of the referral.

Receiving Veterinarian: The veterinarian (or group of veterinarians) to whom a patient is referred.

Consultation: A communication between two or more veterinarians concerning the diagnosis and/or care of a patient. 

Referral: The transfer of responsibility for diagnosis and/or care of a specific problem from a referring veterinarian to a receiving veterinarian.

Recognized Veterinary Specialist: A veterinarian who is certified by an AVMA-recognized veterinary specialty organization. Only those individuals who have completed all aspects of the specific training and testing required by a recognized veterinary specialty organization can describe or advertise themselves as a veterinary specialist. These individuals are ethically bound to only advertise or claim expertise in their area of board certification. Veterinarians who have completed internships or residencies but have not fulfilled all of the requirements of a specialty discipline (e.g. credentials and testing), may not call themselves veterinary specialists and the terms “board eligible” or “board qualified” should not be used.
The AVMA has stated that only veterinarians who have been certified by an AVMA-recognized specialty organization should refer to themselves as specialists.
 
Legal Owner/Client: The legal owner is the individual or syndicate of individuals who have legal ownership of the horse. The term “client” refers to the agent with legal authority to make health care decisions for the horse at the time it is being examined and treated. This individual may be the legal owner, trainer, caretaker, or other proxy.

It is in the best interests of individual horse health that veterinary professionals work as a team to provide the highest quality of veterinary care possible in an environment of exceptional client service and education. For this to happen, it is imperative that clear lines of communication and responsibility be established between veterinarians, clients, and other interested parties.

Prior to Referral
Prior to referral, it is the responsibility of the referring veterinarian to be aware of specialty referral resources in their geographic area, communicate the option of referral to the client in a timely fashion, and contact the receiving veterinarian to discuss the patient. It is the responsibility of the receiving veterinarian to provide appropriate preliminary visit information to the referring veterinarian and owner or agent of the horse. The referral process functions optimally if the owner or agent communicates clearly their expectations for the horse and the limits of costs that may be incurred. It is important that all parties provide a clear and accurate medical history to the receiving veterinarian. Both the referring and the receiving veterinarian should emphasize a team approach to patient care.
 

During the Referral Visit
During the referral visit, the referring veterinarian transfers the responsibility for health-care decisions to the receiving veterinarian but remains accessible for communication. The receiving veterinarian should clearly explain all aspects of the examination, evaluation, diagnostic, and treatment procedures and options to the client. This process should emphasize support of the referring veterinarian to the fullest extent possible without a compromise of integrity. The receiving veterinarian should communicate with the referring veterinarian and client regularly about case progression and decisions. The receiving veterinarian should limit services to those related to the problem for which the horse was referred. Additional services should be provided only when they are in the best interest of the patient and after consultation with the referring veterinarian. All parties should work together to formulate a follow-up treatment and evaluation plan for the patient that can be implemented effectively and economically. It is the responsibility of the owner to clearly determine and communicate who is legally and financially responsible for the horse and assure that this individual or their legal proxy is available for decision-making during the referral visit and at the time of patient discharge.

After Referral
At the time of discharge of the patient from their care, the receiving veterinarian should ensure that all relevant medical information and instructions for patient care are clearly communicated to the referring veterinarian. In most cases the referring veterinarian will then resume responsibility as the attending clinician for the patient. That individual is responsible for agreed-upon follow-up care as described in discharge instructions. The receiving veterinarians should be informed of the results of follow-up evaluation and care. It is the responsibility of the owner to comply with all discharge instructions to the best of their ability and to communicate in a timely way with veterinarians if they are unable to comply with the instructions and to meet all financial obligations incurred with all involved parties.

Conclusions
For all equine patients, effective communication between referring and receiving veterinarians, clients, farm managers, trainers, and insurance agency representatives is essential to ensure optimal patient care. Despite the best efforts of all involved, there will be times when communication is less than optimal or when difficult information must be discussed. Referring and receiving veterinarians are encouraged to seek training to develop communication skills through any of a wide variety of excellent public and private resources. This type of training is especially beneficial for young professionals at the beginning of their veterinary career.

To see the full guidelines visit www.aaep.org/guidelines.

Approved by AAEP board of directors in 2014.

Equine Veterinary Compounding Guidelines (2005)

The AAEP recognizes the importance of a sound relationship between the equine veterinarian and their pharmacist. Because of the valid role of pharmacy compounding in equine veterinary medicine, the AAEP Drug Compounding Task Force has compiled the following guide to aid the veterinarian in making responsible decisions involving the use of compounded medications.

Veterinarians must understand the differences between the following:

I. FDA Pioneer Drug: A drug that has undergone the scrutiny of blinded controlled studies to demonstrate safety and efficacy in accordance with federally mandated Good Laboratory Procedures (GLP). The active ingredient and product were manufactured under federally mandated Good Manufacturing Practices (GMP) in federally inspected plants. Therapeutic consistency, product quality, accurate drug shelf life and scientifically substantiated labeling are all federally mandated on these products. 

II. Generic Drug: A generic drug is bioequivalent to a brand-name drug in dosage form, efficacy, safety, strength, route of administration, quality and intended use. Generic drug labels display an ANADA # or ANDA # signifying FDA approval of a generic animal drug or human drug, respectively. Generic drugs and their active ingredients also must be manufactured under GMP in federally inspected plants.

III. Compounded Drug: Any drug manipulated to produce a dosage form drug (other than that manipulation that is provided for in the directions for use on the labeling of the approved
drug product).

The veterinarian must realize that the use of bulk drugs in preparation of compounded medications is, under strict interpretation of the Federal Food Drug and Cosmetic Act, illegal because it results in the production of an unapproved new animal drug. Preparation, sale, distribution and use of unapproved new animal drugs is in violation of the Act. The preparation of compounded medication from bulk drugs may be permissible in medically necessary situations when there is no approved product available or the needed compounded preparation cannot be made from an FDA-approved drug. Therefore legal compounding can only begin with FDA-approved drugs in compliance with federal extra-label drug use regulations. International AAEP members should adhere to the rules and regulations set forth by the appropriate governmental regulatory bodies that pertain to the country or province where they practice.

Legal compounding requires a valid veterinarian-client-patient relationship. The veterinarian should limit the use of compounded drugs to unique needs in specific patients and limit the use of compounded drugs to those uses for which a physiological response to therapy or systemic drug concentrations can be monitored, or those for which no other method or route of drug delivery is practical. The prescribing veterinarian should remember that compounded drugs have not been evaluated by the FDA approval process for safety, efficacy, stability, potency and consistency of manufacturing. One should not assume compounded drugs are consistent from one batch to another, contain the stated amount of drug substance or the desired drug substance, or are safe and efficacious for the intended use.

Consider that veterinary compounding pharmacies currently operate in a very dynamic regulatory situation and laws, regulations and guidelines regarding veterinary compounding may vary widely from state to state. Ensure that the pharmacy you use is licensed in the state in which you practice. Proactively seek to educate yourself on regulations concerning compounded medications. Be wary of pharmacies using trademarked brands in the literature to promote “look-alike” compounded products. Be wary of firms that appear to disregard federal, state and local laws, regulations and guidelines concerning disposition of compounded drug products. Be aware that compounding drugs to mimic licensed, FDA-approved drugs is illegal. Assuming there is an FDA-approved product that is in the appropriate dosage form that can be used for the specific patient indication, veterinarians cannot use compounded “look-alikes” as substitutes.

The decision to use the products, in lieu of the FDA-approved product, is illegal and potentially jeopardizes the patient and the veterinarian’s liability insurance. In the long term, this practice by veterinarians discourages new product development by pharmaceutical companies.

Veterinarians are encouraged to contact their state pharmacy boards concerning the re-selling of compounded products. Some state pharmacy boards reportedly require compounded drugs to be dispensed at cost and some allow regular mark up. 

The prescribing veterinarian should consider the legal, ethical and clinical ramifications when making recommendations concerning the use of compounded medications for their patients. They should provide information about the benefits and risks of compounded drugs as it is important to an owner’s decisions about therapy. They should understand the concept of “Standard of Care.” One acts below the standard of care when he/she fails to exercise the level of care, skill, diligence and treatment that is recognized as the standard of acceptable and prevailing veterinary medicine.

The prescribing veterinarian should understand that his/her professional liability policy may or may not respond to allegations of negligence arising from the use of compounded drugs. Veterinarians insured with the AVMA-PLIT may review comments at www.avmaplit.com

Do not miss the opportunity to form a relationship with a pharmacist experienced in compounding who, when medical necessity exists for a specific patient, can produce the best possible compounded product and discuss related product expectations.

Reviewed by AAEP board of directors in 2010.  

Prudent Drug Usage Guidelines (2006)

The health and welfare of horses and their owners is the primary goal of members of the AAEP. We believe that these guidelines merely reiterate the standard of practice and what is common in equine veterinary medicine. The AAEP provides continuing education for veterinarians That focuses on the appropriate use of antimicrobial drugs. Our members are committed to the practice of preventive immune system management through the use of vaccines, parasiticides, stress reduction and proper nutritional management. The AAEP recognizes that proper and timely management practices can reduce the incidence of disease and therefore reduce the need for antimicrobials; however, antimicrobials remain a necessary tool to manage infectious disease in horses. In order to reduce animal pain and suffering, prudent use of antimicrobials is encouraged. The following are general guidelines for the prudent therapeutic use of antimicrobials in horses:

1. The veterinarian’s primary responsibility is to aid in the design of management, immunization, housing and nutrition programs that will reduce the incidence of disease and the need for antimicrobials.
2. Antimicrobials should be used only within the confines of a valid veterinarian-client-patient relationship; this includes both dispensing and issuance of prescriptions.
3. Veterinarians should:
      a. Participate in continuing education programs that include therapeutics and emerging and/or development of antimicrobial resistance.
      b. Avoid antimicrobial use in transient virus associated conditions.
      c. Have clinical evidence of the identification of the pathogen associated with the disease based upon history, clinical signs, laboratory data and experience. 
      d. Select antimicrobials that are appropriate for the target organism and should be administered at a dosage and route that are likely to achieve effective levels in the target organ. 
      e. Make product choices and use regimens that are based on available laboratory and package insert information, additional data in the literature, and consideration of the                  
         pharmacokinetic and pharmacodynamic aspects of the drug.
      f. Use products that have the narrowest spectrum of activity and known efficacy in vivo and/or in vitro against the pathogen causing the disease problem. 
      g. Utilize antimicrobials at a dosage appropriate for the condition treated for as short a period of time as reasonable, i.e., therapy should be discontinued when it is apparent that the immune system   
         can manage the disease, reduce pathogen shedding, and minimize recurrence of clinical disease or development of the carrier state.
      h. Select antimicrobials of lesser importance in human medicine in preference to newer generation drugs that may be in the same class if this can be achieved while protecting the health and safety of            the animals.
      i. Utilize antimicrobials labeled for treating the condition diagnosed, and whenever possible, at the labeled dose, route, frequency, and duration if the available scientific information still supports their            efficacy.
      j. Utilize antimicrobials on an extra-label basis only within the provisions contained within AMDUCA regulations. 
      k. When appropriate, utilize local therapy over systemic therapy.
      l. Be discouraged from using combination antimicrobial therapy unless there is information to show an increase in efficacy or suppression of resistance development for the target organism. 
     m. Protect integrity through proper handling, storage and observation of the expiration date. 
4. Veterinarians should endeavor to ensure proper on-farm drug use.
    a. Prescription or dispensed drug quantities should be appropriate so that stockpiling of antimicrobials on the farm is avoided.

The American College Veterinary Internal Medicine has developed a very detailed and extensive consensus statement for antimicrobial drug use in veterinary medicine. To view this document visit ACVIM’s website at www.acvim.org.

Reviewed by AAEP board of directors in 2010.