The role of the veterinary nurse comes into its own with owners of pets nearing the end of their life. Veterinary nurses are particularly known for being empathetic and a team member that pet owners relate to. This role of intermediary between the clinical information imparted by the veterinarian, and the ‘take-home’ impression by the client is an important one. Every conversation around end-of-life needs to be undertaken with sensitivity: terminology and compassion is key.
This series of articles will explore the end-of-life journey for a pet and their owner to support veterinary practices in communicating compassionately. The aim is to help ensure that clients feel supported along the way and are comfortable with returning to their practice in the future, or recommending it to others. The subject is broken down into four parts: preparing for and nearing end-of-life; the pet's passing; the client journey; bringing it all together.
This first article will focus on the period running up to the pet's passing and will look at how practices can help prepare pet owners for their impending loss.
Careful conversations
One of the authors recently experienced the loss of her elderly and much loved dog. When calling her clinic to cancel her pet's vaccination reminder, she was asked in a brisk tone, ‘and the animal's name?’. While the phrase was undoubtedly used innocently, the impression made was a negative one. These brief and often ‘efficient’ conversations/touchpoints can touch a raw nerve when an owner is anticipating the loss of a pet, or has been recently bereaved. In one study, reported important factors for client satisfaction, as perceived by clients themselves, as well as veterinarians, included the ‘compassionate and caring attitude of veterinary employees’ (Martin et al, 2014). Conversations, together with other small but significant experiences will add up to an overall impression of the clinic, good or bad.
In a survey of pet owners conducted as part of their research for the Pet Loss Support Training Programme, Compassion Understood (a veterinary endof-life training company) found that 14% to 19% of owners did not return to their old clinic when they got their new pet (Compassion Understood, 2015). These figures correlate with other research around the same topic (Fernandez-Mehler et al, 2013; Lambert, 2014).
The causes of this client attrition are multi-factorial (Hewson, 2014a), but small, seemingly innocent, comments and interactions take on a special significance at end-of-life. Thoughtless exchanges or even a lack of mindfulness of the client's situation can make a lasting impression (Compassion Understoon, 2015a). Consideration and proactive planning and training for support of clients around this time, through providing exceptional client care, can make a difference to this outcome (Fernandez-Mehler et al, 2013).
Client feelings are based on actions and interactions, which are tangible. At this time in the owner–pet journey, thought should be given to communicating compassionately. Training and setting protocols for interactions around end-of-life will help to ensure that all these client touchpoints are handled sensitively. Words and actions, chosen carefully to respect the client's response to the loss of their pet, will help to validate their feelings (Adams et al, 1999; Adams et al, 2000; Silverman et al, 2004; Dawson, 2010; Lagoni and Durrance, 2011), and, together with focus on good client skills, should result in fewer negative impressions of the clinic being made.
A special bond
The reason for this sensitivity at the end of a pet's life will be familiar to veterinary professionals, many of whom will have decided to pursue a career in veterinary nursing or medicine as a result of the way they feel about animals. Many veterinary professionals will be pet owners themselves. Often a close bond with animals in childhood leads to a career in which the human–animal bond and animal welfare is central (personal experience). As well as an undoubtable feel good factor, there is much written about the medical benefits of pet ownership (Takashima and Day, 2014). It:
There are countless organisations that encourage and provide other practical pet benefits. Assistance dogs, medical detection dogs, pets as therapy and many other charities harness the closeness of the human–animal bond to support the health and wellbeing of people.
It is also well recognised that owners see their pets as more than just ‘animals’. Recent studies in the US and UK confirm that up to 99% of pet owners see their pets as full family members (Petplan pet Census, 2011; AVMA, 2012). This makes it all the more difficult in communicating around end-of-life; emotions run high, particularly when the pet is elderly and the bond has been cemented for a long time.
A common scenario
The death of an animal is very commonly witnessed in practice: in fact, veterinary professionals are the instrument by which this happens in most cases. In one retrospective published study of owned dogs in England, 86.4% were euthanased and 13.6% had an unassisted death (O'Neill et al, 2013). The majority of euthanasias are planned. In Compassion Understood's pet owner research, only 18% of pets were not euthanased (for example, natural deaths, road traffic accidents, sudden deaths) (Compassion Understood, 2015b).
Despite death being an extremely common scenario, it is one which is often accompanied by feelings of awkwardness on the part of the veterinary staff. Team members may be reluctant to discuss end-of-life. In the authors' experience, based on feedback from practices as part of the background research for Compassion Understood, this appears to stem from a fear of upsetting clients (Compassion Understood, 2015b). Death is often not brought up until it absolutely needs to be, and this is often right at the end when planning euthanasia. This finding correlates with a general reluctance in society to discuss death and grief (McCarthy et al, 2009), and in the case of the veterinary professional, might seem at odds with their role of care giver; the goal of most veterinarians and veterinary nurses is the wellbeing of the animal in their care (as well as the support of the owner), from birth until the end-of-life of the pet. This lifetime will include the period running up to the pet's passing (and beyond for the owner). Interestingly, the end-of-life is considered a life stage in itself by many hospice vets, and those working solely in this area. Some have coined this, ‘the fourth life stage’ (Vogelsang, 2014). This fourth life stage in pet hospice involves a focus on both the pets' needs as well as the owners' (International Association for Animal Hospice and Palliative Care, 2016).
Disenfranchised grief
Disenfranchised grief is common with the loss of a pet. This is grief that is not acknowledged by society (Wikipedia, 2016). Societal norms dictate that the loss of a pet is somehow less significant than the loss of a person; pet owners are expected to ‘get over it’, to ‘get on’, and to ‘not dwell on it’. Unlike the death of a person, the death of a pet is not associated with a standardised set of rituals that allows the bereft person to seek solace from others (Adams et al, 1999). In one study of owner responses to companion animal death, participants struggled with the contradiction between how they felt after their pet had died and the perceived absence of support for their feelings from others, or society in general (Adams et al, 1999) (Figure 1). A comment from one pet owner participant in the Compassion Understood research illustrates this, ‘He was just a little bunny but I loved him and his life was important to me’.
Factors, including what takes place at the veterinary clinic before, during and after the pet's death, how the client is spoken to, and methods of returning the pet's body or ashes to the pet owner all indicate the veterinarian's perception of the significance of the situation (Adams et al, 1999). The aforementioned reluctance by veterinary staff to talk about death and their hesitation to engage with clients about end-of-life, may be unwittingly reinforcing the feeling by some pet owners that they should be able to cope, and enhancing this feeling of disenfranchisement.
By actively engaging with clients around the time of pet loss, offering support, including information about grief, and other resources, the veterinary professional can help to validate pet owners' feelings. In one study, respondents ‘believed there was a high association between their ability to deal with their pet's death and a veterinarian who was supportive around the time of that death’ (Adams et al, 2000). Further, a study by the same group found that lack of attention to the details of pet death by the veterinarian and staff had a negative impact on the client (Adams et al, 1999). This lack of support may have a direct impact on the levels of client attrition noted earlier.
Anticipatory grief
Grief does not just happen after a pet is gone. Anticipatory grief is the term given to feelings of grief that occur in some people who are expecting a death, even though the animal is still alive (Dawson, 2010). These feelings are similar to the feelings of grief after a loss, but in addition might include feelings of fear about what life might be like without a beloved companion. Anticipatory grief does not, however, mean that the owner is giving up on their pet by thinking about their pet's passing. It is a normal emotion, and helps to prepare the owner for what is to come. Veterinary professionals need to be aware of anticipatory grief and by opening opportunities for discussion, owners can be helped to find ways to deal with their feelings and fears and be supported in their decision of ‘the right time’ to say goodbye, which is a common dilemma.
When to start the conversation
Research shows that many owners welcome endof-life information sooner rather than later (Fernandez-Mehler et al, 2013; Conpassion Understood, 2015a). In the Compassion Understood research, which saw over 500 responses from pet owners, when asked when they thought the time was right to receive end-of-life information, the findings were:
The figure of 21% of owners that said they would want to know this information before their pet was ill, correlates with other research: in one study, this figure was even higher with 38% of respondents expecting information on the final destination of their pet's remains early on in life (Fernandez-Mehler et al, 2013). Only 12% of respondents in the Compassion Understood study answered that they did not want to receive information ‘until it is necessary’ (Figure 2). Yet this is a common point at which veterinary professionals will feel comfortable bringing up the subject (Compassion Understood, 2015b).
During Compassion Understood's research with veterinary teams, a similar question (regarding timing of end-of-life information/discussion) was posed (Compassion Understood, 2015b). The general finding in this research was that veterinarians did not want to start this conversation until quite late on in the owners' pet loss journey. One respondent comment illustrates this point succinctly: ‘I don't instigate [a] euthanasia discussion as soon as I diagnose a terminal illness!’
However, acknowledging that end-of-life is approaching has the advantage of helping the owner to prepare, make decisions, and make the most of the time that is left with their pet. One pet owner response illustrates this point: ‘Each pet is different, but when your dog is seriously ill, you need support to know you will need to enjoy the time you have left’; and another, ‘I was glad to be informed as to what would be expected for him to live a happy quality of life’ (Compassion Understood, 2015a).
Looking again at the percentages above, the top three responses can be grouped together in a ‘preparation’ phase: 62% of pet owners want to be prepared for this part of their pets' life. This is an area that veterinary nurses are in an ideal position to be able to help with. Their working day is often less time-constrained by appointments than veterinarians, allowing more opportunities for client interaction. Veterinary nurses also are required to demonstrate empathetic communication as part of their core skills (file:///C:/Users/Libby/Downloads/rcvs-day-one-skills-list-sa-2016-.pdf). These factors help them to inform and support owners throughout this emotional journey so that the pet's end-of-life and their client's personal journey is as stress-free and gentle as possible.
How to bring up death
Bringing up the subject of death can be tricky, as often the client's need for information is unspoken. A proactive approach is needed that gently explores what each client wants.
One starting point can be scrutinising the clinic appointment diary. Often there will be some detail of the reasons for a client's impending visit. With their experience and knowledge, the veterinary nurse is able to make a judgement in most cases as to whether that scenario is likely to be one in which end-of-life discussions might be appropriate. While euthanasia discussions might be a bit too early for many, setting a benchmark for quality of life (QoL) measurement can help to give both the veterinary surgeon and the owner something to measure against later on when deciding on ‘the right time’. QoL benchmarking allows a gentle and valid reason for bringing up the subject of death.
These assessments can be started at any stage of the pet's life. Entering the senior life stage is a common starting point as a benchmark can be set at that stage against which comparisons can be made as the pet gets older.
QoL assessments
QoL assessments can capture both a pet's health status as well as, importantly, what a pet enjoys. A diary can be kept by the pet owner, or they can utilise some of the electronic QoL tools that are starting to appear. Pet Dialog® (Zoetis), (www.petdialog.co.uk), is an app which is administrated through the veterinary practice. It allows the pet owners to track their pet's health as well as emotional status. Vetmetrica, a health-related quality of life assessment tool, developed by the University of Glasgow, also includes a pain scale for dogs. A cat scale is under validation at the moment (www.newmetrica.com).
Introducing a QoL assessment tool to the owner early on in the human–pet relationship can be beneficial. For example, if the pet has an accident or is diagnosed with a life-limiting illness at a young age, having some information already about the pet's habits, likes and dislikes can help both the owner and the veterinary surgeon to make any relevant decisions. Compassion Understood research found that 21% of pets died before their eighth birthday (Compassion Understood, 2015a). Traditionally, this is not an age at which one thinks the owner might need end-of-life information. But this 21% statistic makes the case for starting to benchmark early and before a senior life stage is reached.
Another simple QoL assessment tool is the HHHHHMM Scale developed by veterinary surgeon, Dr Alice Villalobos (2011). This scale was developed for use by hospice veterinary surgeons with pet owners. Again it can be introduced when it is felt appropriate. The acronym stands for (measuring) Hurt, Hunger, Hydration, Hygiene, Happiness, Mobility, More good days than bad.
Veterinary professionals can, of course, develop their own tool for QoL assessments. Whichever tool is applied, it is important that it is used consistently and understood by all of the practice team. Implementation through practice protocols is ideal. The goal is to help the client decide on the aspects of their pet's life that make it a happy and comfortable one. Knowing these factors helps when the time is getting near, or the owner fears the time is getting near, to say goodbye, and opens up the opportunity for them to discuss their concerns and worries. A QoL discussion together with an update of the pet's profile can be built into the annual vaccination visit or ideally into a health check several times a year.
This QoL assessment should be offered to all. One should not try to pre-judge which client does or does not want to have assessments, or which pet should or should not have it. Offering the tool to all pet owners as part of a standardised approach, will help them to see it as a normal part of pet care; this assessment will provide valuable help in providing information for the healthcare of the pet in various scenarios throughout their life, for example, in assessing changing levels of mobility or cognitive function as they get older.
The same principle of proactive discussion, without bias, equally applies to the help and support offered to clients whose pets are entering their final life stage. As an emotion, grief is unique to the individual: some people may have a controlled response to grief that, on the face of it, may lead others to think they do not need or want support or self-help information. Offering assistance and information to all, in a gentle way that allows those that feel they do not need it to decline it, and those that do, to take up the offer, will ensure that no one is missed out. Many veterinary professionals mistakenly pre-judge which clients need or do not need support, and in doing so, miss out owners who could benefit from their help (Hewson, 2014b).
Conclusion
In conclusion, actively engaging with the pet owner during the end-of-life period of their pet is beneficial for both the owner and the practice. The owner is supported in their grief and this may lead to decreased client attrition following their loss. Recognising that this is an important time helps to validate their feelings and provides comfort when society at large may not acknowledge the pain of their loss. This engagement with owners should begin early, and the same level of support offered to all clients.