As part of our veterinary oath, we promise to use our skills and knowledge for “the prevention and relief of animal suffering.” Euthanasia offers us the unique ability to aid in the relief of suffering by providing a “good death.” Ultimately, though, the decision to euthanize a pet belongs to their owner. For some, that is not a decision they are ready or willing to make despite receiving a poor or grave prognosis and recommendation for humane euthanasia.
Cases like these can have devastating consequences on the mental health of the veterinary team. Learning to navigate these difficult situations is essential to maximize patient welfare, maintain client connections and preserve the mental health of all team members.
Here are some tools that can be used by veterinary team members when faced with these challenging cases:
1. Prioritize compassionate communication.
Navigating the conversations surrounding euthanasia is considered by many veterinarians to be more stressful than the act of performing the euthanasia.1 Prioritizing compassionate communication and a client-centered approach has been shown to improve client perceptions of end-of-life conversations in both human and veterinary medicine.2 But what does this look like in the veterinary practice?
Client-centered communication involves establishing a relationship between client and veterinarian, and expanding the conversation beyond medical topics to include lifestyle and social topics. In the case of an end-of-life discussion, these conversations could include discussion of the client’s beliefs around euthanasia, their ability to provide hospice care for their pet, the role the pet plays in the client’s family and the client’s expectations for what a peaceful death looks like for their pet.
We must make every attempt to connect with the client and give them opportunities for input. Use of open-ended questions to elicit the client’s concerns, questions and feelings is essential. Combining these with expressions of empathy can strengthen their impact. For instance, you might say, “I know that this is not what you were expecting to hear today. Can I answer any questions about Lucky’s kidney disease for you?” or, “I know euthanasia is very difficult to consider when you love Lucky so much. Can you tell me what you’re thinking/feeling right now?”
Once we have asked these questions, we must stay present in the conversation. Listening to the client’s response without being distracted by thoughts of other patients, how far behind schedule we might be or what we will say next will ensure we do not miss important information. A client may share information that can open an opportunity for connection—or at least an improved understanding—such as the fact that this pet previously belonged to their late partner or that they do not believe in euthanasia. We can build on the conversation to devise a plan that is in the best interest of the pet while respecting the client’s emotional limitations.
While we may feel frustrated when the client does not accept our recommendation for euthanasia, we must control our own feelings and avoid passing judgement. Staying aware of our nonverbal communication is especially important during these conversations as we can easily expose our feelings with our facial expressions, body language or tone of voice.
2. Provide multiple perspectives.
For some clients, hearing the same information and recommendations from multiple sources can help them to understand the true severity of their pet’s condition. In some cases where I feel that I am missing a connection with the owner, I will excuse myself from the room by saying, “I know this is difficult to consider, and I’d like to give you some time to think, if that’s okay.” Most clients are grateful for this opportunity.
I will often then send an experienced veterinary nurse in to check on the client after a few minutes and allow them time to speak with the client. Many clients will elicit the opinion of the nurse, especially if they have met them in previous visits. Sometimes my nurses have been the ones to guide clients to the decision to euthanize.
I have also offered to call specialists or talk to other doctors in the practice to determine if there are any other suggestions for treatment. In some cases, owners have requested referral to the specialty hospital to meet with the specialist in person. In these cases, I try to encourage a direct transfer from my hospital to the specialty center to avoid prolonging pain or suffering for the pet.
3. Provide resources to the owner.
Objective data can be powerful. Providing quality-of-life assessments help some owners in their decision-making. Two of the assessments I use most often for owners come from Lap of Love3 and the Ohio State University Veterinary School.4 Lap of Love’s website also offers excellent client information on end-of-life care that anyone can access, even if there is not a Lap of Love veterinarian in your area.
Additionally, consider providing resources for grief counseling and pet loss support groups. Some counselors and groups are willing to provide support to the owner prior to the pet’s death and can help them process the decision to euthanize. Most veterinarians are not trained mental health specialists and should not try to fill the role of therapist for a struggling owner. Involving trained professionals in supporting the client can help ease the burden on the veterinary team and ultimately be more helpful to the client.
4. Explore hospice options.
Hospice care and in-home euthanasia services are growing areas in veterinary medicine. For clients who will not euthanize their pet, referral to a hospice veterinarian can provide more support for both client and patient. It is very important that owners understand what to expect in the death process and that they are prepared for the nursing care involved. They should also be advised of subtle signs to watch for in their pet that might indicate suffering or distress.
If there are not hospice veterinarians in your area, do your best to provide palliative care to the patient. Some hospice veterinarians will provide “comfort kits” or “crisis kits” to owners which include doses of medications including anti-nausea medications, anticonvulsants, pain medication, sedatives and other products specific to the pet’s disease process. The goal of these kits is to provide short-term support for the pet, including minimizing pain, anxiety and distress, until the owner can get to a veterinary office.
5. Debrief to protect the mental health of the veterinary team.
Finally, it is essential that team members can debrief after the conclusion of the case, regardless of the outcome. Cases where there is disagreement between the veterinary team and client surrounding patient care can lead to moral distress for the veterinary team. This was defined as “the experience of knowing the right thing to do while being in a situation in which it is nearly impossible to do it” in a 2018 study that explored moral distress in veterinary medicine.5 Seventy-eight percent of respondents said that not being able to do what they felt was best for a patient caused moderate to severe distress for them, and 73% stated the same effects were felt by their team members.5
Debriefing offers team members the opportunity to discuss the case and their feelings around it. This can ensure that anyone who is upset or distressed about the process or outcome can get the support they need and know they are not alone.
In a profession with high levels of psychological distress and mental health struggles, having tools and resources for handling situations of moral distress, especially around end-of-life conversations, is crucial. +
References:
- Matte AR, Khosa DK, Coe JB, and Meehan MP. Impacts of the process and decision-making around companion animal euthanasia on veterinary wellbeing. Vet Rec 2019; doi:10.1136/ vetrec-2019-105540.
- Borden LJN, Adams CL, Bonnett BN, Ribble CS, and Shaw JR. Comparison of veterinarian and standardized client perceptions of communication during euthanasia discussions. JAVMA 2019;254:1073-1085.
- Pet Quality-of-Life Assessment. Lap of Love. https://www.lapoflove.com/quality-of-life-assessment
- How Do I Know When it’s Time? Ohio State University. https://vet.osu.edu/vmc/sites/default/files/import/assets/pdf/hospital/companionAnimals/HonoringtheBond/HowDoIKnowWhen.pdf
- Moses L, Malowney MJ, and Boyd JW. Ethical conflict and moral distress in veterinary practice: A survey of North American veterinarians. J Vet Intern Med 2018; 32:2115-2122.
