Expired meds for no-charge surgeries: An ethics violation?

Expired meds for no-charge surgeries: An ethics violation?

Veterinarian is challenged by a colleague about his use of out-of-date drugs for procedures when owners can’t afford to pay.
Apr 11, 2016

Getty ImagesHope Veterinary Hospital had a mission statement: “Help all that we can with the tools that we have.” The three veterinarians, five technicians and three receptionists were a long-term team. For 11 years they had balanced the needs of their mixed clientele, which consisted of both indigent and wealthy pet owners, with compassion and commitment, holding unswervingly to their mission statement.

Dr. Keets, the practice owner, did most of the surgeries while his associates handled nonsurgical cases. Dr. Keets had a personal wrist surgery coming up, so he hired Dr. Han, a local relief veterinarian, to do his surgeries while he was incapacitated.

On his first day of relief surgery at Hope Veterinary Hospital, Dr. Han had five routine procedures scheduled. He noted when reviewing the records that two of the surgeries were marked “No charge due to financial constraints.” He thought to himself that charitable surgeries were something he did not see very often in his relief veterinary travels.

A diligent surgeon, Dr. Han oversaw all aspects of his procedures. He approved anesthetic protocols, checked the dosage calculations, and administered all IV medications. He was a bit obsessive, but this style resulted in very few surgical mishaps. He noticed that his first procedure was one of the two “no charge” surgeries. He reviewed the anesthetic and analgesic agents and noticed that several were expired by about 30 days.

He brought this to his surgery technician’s attention. She replied that Dr. Keets used these meds on all of his no-charge patients. Dr. Keets believed that recently expired nonreturnable medications were still effective, and at the same time it saved him some money when offering charitable procedures at no charge. Dr. Keets had told his staff that these expired meds were simply no longer guaranteed to perform as claimed yet were still very effective.

Dr. Han was startled. He understood the rationale but did not agree with it. Dr. Han then asked that all of his procedures for the day be performed with properly stored and dated anesthetic and analgesic medications. He advised the staff that he would discuss his decision with Dr. Keets when the practice owner retuned to work.

The following week the two men had a discussion. Dr. Han was diplomatic—after all, he wanted to maintain a good working relationship with Dr. Keets. He said that he understood that Dr. Keets was well-intentioned but that substandard care of indigent patients was unacceptable.

Dr. Keets replied that the care was not substandard. All his patients were monitored during and after surgery. If any animals showed signs of pain or inadequate anesthesia this was addressed immediately. He went on to say that offering charitable services required realistic monetary considerations. If he could not use recently outdated medications, he could not afford to offer these much-needed services.

He went on to say that Dr. Han traveled from practice to practice assisting veterinarians and pets on a short-term basis. He on the other hand had a responsibility to a clientele that day-in and day-out needed services they could not afford. As a result, he had to be creative in order to assist them.

A bit frustrated, Dr. Han finally said that Dr. Keets’ practices were a violation of practice statutes. Dr. Keets’ reply? “I’ve never had a complaint, and I have scores of grateful pets and pet owners.” With that the conversation was over, and Dr. Han never returned to that practice.

Do you agree with Dr. Han or Dr. Keets in this scenario?

Rosenberg’s response

Shades of gray can make life difficult! It is absolutely true that the use of expired medications is a violation of the veterinary practice act in every state. Dr. Keets was aware of this but chose to help those in need and also manage any complications that may have arisen from the use of the expired medications.

There is no doubt Dr. Keets was well-intentioned. But he could have solved his medication issues in other ways. Advising vendors of his charitable efforts and asking them to participate would have been an option, as well as soliciting his more affluent clients and enlisting them in an effort to help his good works.

Rules and laws exist to prevent abuse and protect our patients. Dr. Keets gets an “A” for effort but does not pass the profession’s ethical standards test. I must side with Dr. Han and draw the line when it comes to violating the practice act.

Dr. Marc Rosenberg is director of the Voorhees Veterinary Center in Voorhees, N.J. Although many of his scenarios in “The Dilemma” are based on real-life events, the veterinary practices, doctors and employees described are fictional.

Expired drugs

So, how is it explainable that the FDA can just arbitrarily extend the expiration dates, by TWO years, on drugs that are known to be fairly stable including controlled injectable drugs? Also, how is it explainable that COST is the FDA's reason to be able to revalidate the national stockpile of drugs by testing efficacy of those drugs- thereby EXTENDING the expiration date? While I respect the laws of our country and state, I have serious questions about some of the drugs we use and their actual stability in use, in practice. Someone commented about Euthanasia solution in particular. I would like to know other thoughts, data, opinions on this subject. There are obviously MANY drugs that do change over time and as practitioners I think we need to be much more questioning about these things. I am not advocating use, but there are situations that could be very justified, and we as a country have gone so PC that now it's still ok to send expired fluids overseas to third world countries but those very same fluids are a liability here? I am not seeing the logic here. Not looking to start a war, just a good dialog here.

Specific rules regarding expired drugs

FrancaisFeline asked about specific rules in a Veterinary Practice act for certain states. I would remind that veterinarians are subject to Federal laws and rules, as well as Pharmacy board laws and rules. Often the Veterinary practice act stipulates that we are to comply with ALL applicable local, state and federal laws.
My understanding, based on conversations with the Ohio Pharmacy Board, is that an expired drug is considered "adulterated"; therefore it would be illegal to administer this drug under any circumstances. Furthermore, it would be illegal to keep the expired drug in your pharmacy, for the purpose of administration or distribution. It is allowable to remove expired drugs from your pharmacy, and to store them separately while awaiting their disposal (rules governing how we are to dispose of expired drugs have become more complicated as well).
Having a "good Samaritan" box where returned, expired drugs are kept to dispense to folks who cannot afford the medications is no longer legal in Ohio.
I encourage anyone who is storing, dispensing, or administering expired drugs to contact their own Veterinary licensing board as well as their state's Pharmacy board for clarification.

Please cite specific rule

Your article states that it is against the Act to ever use expired meds within the hospital in ALL states. Can you please cite the specific rule in the Texas and Oklahoma Practice acts that state it is a violation to use expired meds on a patient (for a medical condition unrelated to euthanasia).