While euthanasia is a procedure that veterinary staff encounter and carry out on a regular basis, in the human world it is rare indeed, with just a handful of countries permitting it in law (NHS Choices, 2014). Over 80% of pets in the UK are euthanased at the end of life (O'Neill et al, 2013). This procedure is carried out against a backdrop of emotions. The nature of the human–companion animal bond has evolved to the point where many pets occupy a central role in their owners' lives, often seen as a family member (American Veterinary Medical Association (AVMA), 2012). The term ‘companion animal’ itself implies a mutually beneficial relationship akin to friendship (Lagoni et al, 1994).
At the same time as the status of pets has risen, so too have owner expectations. The veterinarian is expected to provide a high standard of clinical care and make every effort to keep the animal healthy, yet is also responsible for identifying when the quality of that animal's life is unacceptable. A switch of focus is then necessary to help navigate the animal's owner through a decision-making process that may end in euthanasia.
This task is made even more difficult when the owner is unaware or unable to identify that their animal's welfare is compromised (Wojciechowska and Hewson, 2005). The phrase ‘his tail is wagging so he is fine’ is one with which many veterinary professionals are familiar.
The dilemma of this dual role is one that veterinary professionals face regularly. Euthanasia is one of the most common clinical procedures carried out in practice. A recent poll in veterinary practices conducted by pet end-of-life training company Compassion Understood found that 24% of clinical and non-clinical staff estimated that they held end-of-life discussions on a daily basis (Compassion Understood, 2016a).
At the same time, the fact that euthanasia features regularly in complaints to the profession's regulator, the Royal College of Veterinary Surgeons, shows the challenging nature of managing the end of life in practice (RCVS, 2014). As with many complaints, poor communication is often at the core of the problem.
This is not surprising given the emotionally charged situation of euthanasia; veterinary professionals report that they can struggle to find the right words when speaking with owners about the end of life (Compassion Understood, 2015a).
Learning on the job
Veterinary professionals have reported having had little training on euthanasia at veterinary school. Comments include:
‘I had no training; I didn't even know the dose [of barbiturate for euthanasia].’
‘I'm better at euthanasia now than I was before – [it's] so stressful — when you start as a vet, they're the scariest thing.’
Many veterinarians will learn and hone their euthanasia technique on the job, often within the confines of a consulting room with the owner present (Compassion Understood, 2016b).
They will have little knowledge of how colleagues carry out the procedure. Veterinarians find themselves having to learn very quickly how to perform technically under pressure, while giving empathic advice and support. This is particularly important in helping to mitigate pet owner guilt and grief (Adams et al, 1999).
Supported decision making
Before any euthanasia procedure, decisions between the owner and veterinarian as to what is best for the patient have to be made.
Two models have been proposed for the clinician's role in this: agency-based; and informed treatment (Gafni et al, 1998).
Under the agency-based model, the veterinarian acts an ‘agent’ for both the pet and the client — i.e. the practitioner makes carefully considered decisions. The veterinarian gathers all relevant information about the pet. This can include, but is not limited to, the illness and its impact, the animal's quality of life and the owner's concerns — which can be financial, social, value based and emotional — and the owner's expectations and preferences. After carefully considering all information gathered, the veterinarian then proposes a decision.
Taking the informed treatment approach, the veterinarian is a provider of technical and professional information and the client makes the decision. Here, the veterinarian is the source of all the necessary medical and technical information, shared in such a way that clients can make an informed decision for an animal without necessarily disclosing their motivations, preferences and financial situation or other issues.
Each approach has its merits and clients will have different preferences. Whatever approach is chosen; the veterinary professional plays a key role. It is important to remember that the non-technical role, using communication and interpersonal skills, is as important as the technical role of performing the euthanasia. During the decision-making stage, clients want to have their emotions acknowledged and their concerns heard.
The decision-making process should be flexible and adaptable. If possible, both clients and veterinary staff should be given the opportunity to change their mind at any time during discussions.
The right time
Making a judgment on the right time for euthanasia is a common source of angst and one that can cause difficulty for both veterinarians and owners.
Only 35% of veterinary professionals feel they are well equipped to answer questions about ‘the right time’ (Compassion Understood, 2015a). Using quality-of-life assessment tools actively throughout the life of the pet and, importantly, in its senior years, helps to provide a useful benchmark and paves the way for open communication between the veterinary professional and the owner around the end of life. Owners can work collaboratively with the veterinarian to identify factors that contribute to the pet's enjoyment of life. This gives the opportunity for a partnership to develop between the pet owner and the veterinary professional, which has subsequent benefits (Dawson, 2010).
This collaborative approach to decision making can help owners to deal with ‘responsibility grief’. This is a type of grief that psychologist Dr Susan Dawson in her doctoral thesis identifies as being unique to the situation of pet death (Dawson, 2007). It is a distinct category of loss affecting pet owners and, to a degree, veterinary professionals. She identifies some common characteristics of responsibility grief. Examples, which have been abbreviated, include:
Helping to lessen the grief
The guilt and doubt felt by some owners can lead to them questioning their own sense of self (Adams et al, 1999; Dawson, 2010). This is compounded within the larger context of societal beliefs that influence the behaviour of a pet owner around the time of the loss of their pet. Many perceive that they do not have the same level of support or understanding following pet loss from others as they would have following the death of a person. This disenfranchisement is commonly expressed with the owner apologising for their grief, typically saying: ‘I felt silly for being so emotional’ (Compassion Understood, 2015b).
Adams et al (1999) found that, for most owners, the time spent grieving following pet loss was short: what was not clear was whether this was due to the actual process being shorter or whether it was driven by the owners feeling external pressures to get back to normal quickly.
The previous article in this series discussed the importance of veterinary professionals not reinforcing this sense of disenfranchisement by avoiding the topic of pet loss with owners (Tottey and Sheridan, 2016). This may be due to worry about upsetting the owner or even extending their grief (Adams et al, 1999; Compassion Understood, 2015a). It is important that staff in veterinary practices are open and proactive when providing support.
Responsibility grief can be lessened by addressing certain factors during the decision-making process (Dawson, 2010). By extension, the authors believe, this focus may also help to mitigate disenfranchisement. Some of these factors are:
The need for thorough discussion is highlighted by comments from Compassion Understood's pet owner research:
‘I was fortunate to have such as supportive vet who was open from the beginning about everything but always remained sensitive and gentle when having the discussions [about end-of-life]. This allowed me to trust his decision as I felt safe in the knowledge that he was constantly hoping for the best outcome and genuinely cared about my cat's welfare from the very beginning.’
Sensitive discussions, helping the owner to feel that all appropriate options have been explored, along with opportunities to ask questions, are important. Palliative and animal hospice care, the latter of which focuses on care for both pet and owner at the end of life, should also be discussed. While not every owner will desire palliative or hospice care, some that will want that choice. Veterinary professionals should familiarise themselves with this emerging field of care (Cooney, 2016a, 2016b; Goldberg, 2016).
One comment from Compassion Understood's pet owner research highlighted the need to discuss all options:
‘I always want to know every aspect of care, particularly palliative, for my bunnies, so I can make an informed decision on what is best for them at every stage of their lives.’
It is important that enough time is set aside for end-of-life discussions. Within the pressurised environment of a veterinary clinic, time is precious, and a lack of time is a common source of frustration for staff. Within the common confines of a 15–minute appointment, a knowledge of the key factors that will help the client the most at this time is important.
Knowing the right time
The timing of euthanasia (too early/too late) is a common source of stress for both owners and veterinary professionals. It also contributes to responsibility guilt (Dawson, 2010). Owners question the appropriateness of their choice and the motivation behind it — was the decision for the benefit of the pet or for the benefit of themselves?
One respondent quoted in Compassion Understood's veterinary professionals research put this into context:
‘A lot of our clients appreciate a truthful answer; our vets often use the term “if it were my pet” … this helps the client to understand that the time is right and helps to prevent feelings of guilt. Discussing the patient's quality of life also helps.’
Two other comments from Compassion Understood's research highlight the sometimes conflicting expectations of veterinarian and client.
A veterinarian said:
‘I usually tell them that they will know when the “right time is” — they understand better than us.’
In contrast, a pet owner said:
‘[I]wished I knew beforehand that my vet wasn't going to tell me when it was time and the decision was mine alone to make when ready.’
Owner expectations around euthanasia
While most pet owners wish for a natural, peaceful death for their pet, this is sadly not the end point for most pets. The majority of pets are euthanased, and most cases are planned rather than carried out suddenly or as an emergency (Compassion Understood, 2015b).
A study by Fernandez-Mehler et al (2013) aimed to clarify the expectations of owners about euthanasia. This found that 92% (1173 out of 1272) of owners reported satisfaction with how their pet's euthanasia was managed overall. Respondents who were dissatisfied gave reasons such as: not being able to be present during euthanasia; treatment was quick and too cold; insufficient information about the procedure; staff treating owners inappropriately; and too detailed explanations.
Having the choice of whether to stay with their pet was an issue for pet owners. For most people, it is better for them to stay with their pet but there are few reports of owners citing regret at staying with their pet at the time of their passing (Dawson, 2010). Staying with a pet at the time of euthanasia may act as a protective factor in enabling the owner to have a sense of continuing care from the practice and have trust in the euthanasia decision, as well as allowing them to know what happened at the time of death, which provides reassurance (Dawson, 2010). An understanding of the nature of the human–companion animal bond and the substantive facets that make up that bond can be valuable in helping veterinary professionals to understand how an owner feels about their pet and how this might influence their behaviour (Dawson et al, 2007).
The opportunity to discuss aftercare options such as cremation or burial was also deemed important by pet owners (Adams et al, 1999). Discussing these options before the pet's death helped the owners to feel that they were sharing decisions. Similarly, a lack of attention to this area by veterinary staff had a negative effect on the client. Fernandez-Mehler et al found that 88% of owners expected information about their pet's final destination from their veterinarian; furthermore, 38% expected this to be given early in the pet's life (Fernandez-Mehler et al, 2013).
It is interesting that just as a lack of information caused stress, so too for some can overly detailed information. Interpersonal and communication skills can help in making a judgment regarding how much information is needed by individual owners. If unsure, gently asking owners how much they understand and how much they would like to know will help the veterinarian to get some sense of what is appropriate. At the same time, assumptions should not be made; expectations should be explored as part of a collaborative approach.
The need to spend time with owners discussing issues relating to the death of a pet was highlighted by Adams et al (1999). This included, in the case of planned euthanasia, the opportunity to review with the veterinarian whether they were making the right decision.
One pet owner's comment reflects this need:
‘I know the appointment was specifically for putting my dog to sleep but the vet didn't discuss the condition she was in. I realise that the vet cannot be seen to influence your decision in any way, but it would have been nice to know their thoughts on her health at the time.’
Where different veterinary staff are involved in the management of a case or where the owner's regular veterinarian is not able to carry out the euthanasia, this is especially important. It should not be assumed that this issue has already been addressed. Even if this has been discussed, reinforcing the choice of euthanasia as a compassionate and caring decision at the time of the procedure will help the owner to process any guilt.
Understanding the euthanasia process
Recent research has found that 41% of owners were not given any information on euthanasia or end-of-life care; 35% received no discussion of palliative care (Compassion Understood, 2015b). Furthermore, 31% said that they did not feel very well prepared for their pet's euthanasia appointment. This highlights the need, even with experienced pet owners, not to assume prior knowledge. With first-time pet owners, this is even more important.
The euthanasia process should be explained clearly and sensitively, avoiding euphemisms such as ‘put to sleep’, especially if children are present. The use of this term can cause confusion on their part; many misunderstand the permanency of death. ‘Helping to die peacefully’ is a suggested replacement (Dawson, 2010).
Checking owners' understanding and giving them the opportunity to ask any questions about the procedure or aftercare or their pet's condition is important (Adams et al, 1999). The authors of this article suggest that setting aside time for a pre-euthanasia consultation at some point before the final appointment itself will help the owner to feel supported and unpressurised. Pre-euthanasia consultations are covered later in this article.
Standardising aspects of end-of-life
While every owner's reaction to the loss of their pet is unique and complex and it is essential to use interpersonal skills to identify how best to support each individual, certain elements of the pet owner journey at the end of life can be standardised (Adams et al, 1999). With any regularly practised procedure, the use of protocols helps to ensure that everything that should be considered actually is covered.
In veterinary practice, euthanasia or end-of-life protocols are not always drawn up or considered. Only 40% of respondents in a recent survey of veterinary professionals and practice staff said they had an end-of-life or euthanasia protocol (Compassion Understood, 2016a). The lack of a protocol or even some focus on how a practice should support clients at the end of their pet's life can lead to important owner satisfaction criteria being missed; a lack of attention by staff to a pet's death can have a negative effect on the owner (Adams, 1999). Dawson (2010) includes a euthanasia emotional support protocol. Some elements of a standardised approach could be:
Information on grief and bereavement support, or at least telling clients where they can find additional support should they need it, should be offered to all. A short list of sources for client support is given at the end of this article.
While the experience of grief is unique to each individual, there are many common aspects; the decision to euthanase commonly causes feelings of guilt, sadness, shock and disbelief (Dawson, 2010). Providing owners with some information about how they may feel both before (anticipatory grief — see first article in this series (Tottey and Sheridan, 2016)) and after the loss of their pet may help to negate feelings of loneliness or disenfranchisement, and demonstrates a caring, compassionate and bond-centred practice approach.
Pet loss veterinarian Caroline Hewson highlights that bereavement support and information on grief should be offered to all owners, regardless of how they may appear to the individual veterinary team member; erroneous assumptions about who may or may not be able to cope with the loss of their pet or who does or does not need information can lead to some owners who need support missing out (Hewson, 2014).
In Compassion Understood's pet owner research, 52% of respondents said that they would have welcomed information on feelings and stages of grief (Compassion Understood, 2015b).
Having practice protocols, supplemented where necessary by practice team training, can help to ensure that no owners slip through the net without the support they need.
Building protocols
Protocols can be developed to help standardise several stages of pet loss:
In addition, protocols to look after the front of house aspects of the client journey are important. These will be examined in the next article in this series.
Pre-euthanasia protocols
The pre-euthanasia time is an important one in helping the pet owner to prepare for the loss of their pet. Taking the time to go through all aspects of pet loss, before the final euthanasia consultation itself, allows the owner to reflect on the practical aspects they need to consider without the duress of upsetting emotions they may experience when their pet is euthanased.
Aspects to be considered include:
Unfortunately, these conversations are not often held until the euthanasia consultation itself. The emotional toll of the procedure can mean that the owner is unable to process the great deal of information presented to them. Time pressures and the need to stay within appointment times or move on to other tasks also risk the veterinarian not being able to address all of the aspects they need to. In addition, having to focus on the practical aspects, such as discussing consent and aftercare, to ensure that they are all covered, may come at the expense of being able to display empathy and compassion.
The ‘routine’ nature of euthanasia within practices can compound this: repeatedly carrying out euthanasia risks emotional burnout or compassion fatigue (AVMA, 2013; Williams and Green, 2016), which to the pet owner may be perceived as lack of empathy.
‘Vets need to be more sympathetic and less robotic. I understand they have to do this often, but it's not every day this happens to you and your family. More time too, less of a rush.’
Aspects of self and team care to help minimise compassion fatigue will be addressed in the fourth article in this series.
Offering a pre-euthanasia consultation allows time and space for all these aspects to be considered, as well as time for the owner to go home and think through their choices afterwards. It allows for arrangements to be made for someone else to be there to help the owner through the emotional process, and to consider and make informed choices as to whether children should be present.
Tait (2003) has suggested that the two key elements influencing a pet owner's relationship with their veterinary clinic is the first visit to the clinic, likely to be for vaccination, and the very last visit, for euthanasia.
It is critical that the final visit is handled well, not only for maintaining the clinic–owner bond, but also so the owner feels supported in their grief. Adams et al (1999) identified that the way that a veterinary practice deals with animal death can have a profound effect, positive or negative, on the client. Pre-euthanasia consultations are likely to help clients to grieve normally (Adams et al, 1999; Hewson, 2014). Clarifying key information with respect to the course of the animal's disease and the process of euthanasia can help to manage owners' natural fears about ending their pet's life.
Deciding what should be discussed in a pre-euthanasia consultation is up to the individual practice. However, it should be as comprehensive as possible, and offered to all. Some clients will want to take up the offer and others not.
Euthanasia protocols
The clinical side of euthanasia is outside the remit of this article. Veterinarians will use their clinical judgment to decide the exact way in which euthanasia is to be carried out. RCVS guidance states: ‘It is recommended that all practice staff involved in euthanasia are fully trained and a planned, rehearsed and coordinated approach is taken’ (RCVS, 2012).
Dawson (2010) provides a comprehensive overview of euthanasia support protocols. Hewson describes how to ensure a supportive setting: no time pressure on the client, the importance of prior discussion between the veterinarian and veterinary nurse about the procedure; gentle patient handling, wrapping the body in a shroud of new fabric, allowing the owner private time with their pet afterwards, and offering grief and support resources (Hewson, 2014).
Unplanned euthanasia
Not every euthanasia will be planned. Pet owner research identified that 31% of pets were euthanased without being planned, at their own clinic or an emergency clinic (Compassion Understood, 2015b).
In this stressful situation, having a protocol for euthanasia that ensures that both practical and emotional aspects are covered can help owners.
Discussing and developing team communication protocols for owners whose pet is being or has been euthanased on the operating table will ensure that, on their arrival at the practice, they are recognised and swiftly escorted to a private place, rather than having to stand in reception. This will be covered in more detail in the next article.
Offering pet bereavement support
Many veterinary nurses and veterinarians will be familiar with owners regularly visiting their clinic even after the loss of their pet. This is not surprising and may be seen by the owner as a natural extension of the care-giving that the clinic provided before the loss of the pet. However, not every practice will be comfortable with this. Compassion Understood's found some veterinary professionals saw their responsibility for the owner ending at the time of the pet's death (Compassion Understood, 2016a).
The authors suggest that this may be related to not wishing to upset their client by saying the wrong thing or, in some instances, through a misconception of wanting to avoid prolonging the client's grief by talking about the pet loss. This is a natural response; most veterinary staff are not trained in counselling. Furthermore, focus group research with a small number of veterinary staff found they did not want to be trained in counselling (Compassion Understood, 2016a).
Research carried out with pet owners agreed with this (Compassion Understood, 2015b). In this study, owners did not expect their veterinary team to offer counselling. However, they did expect their clinic to be able to inform them where they could find help should they need it. This resonates with the need for practices to provide post-loss support but not necessarily counselling itself.
Veterinary practices should identify local counsellors who are able to work with pet bereavement and actively provide this information to pet owners so that they know where to access help should they wish to.
Pet loss support can and should be provided in practice (Dawson, 2010; Fernandez-Mehler et al, 2013). This includes: pet owner education about aspects of grief; help with practical advice on memorialisation; talking about the pet and the bond that the owner shared with their pet; and highlighting the very good care that the owner took of their pet, including taking positive action when needing to make decisions, including euthanasia, in the best interest of their companion.
Some owners need ongoing support; they will often stop attending themselves. The opportunity to meet a practice member after the loss of their pet, though, will help to leave a positive impression of the veterinary practice. The practice will be associated with a feeling of support, which may help to counter the painful and possibly more negative experience of the euthanasia itself. This may help to decrease the high attrition rate of up to 20% referred to in the first article in this series.
Conclusion
In conclusion, the end of a pet's life will be an emotionally challenging time for its owner. The conflicting situation of prioritising and ensuring the health and wellbeing of the pet throughout its life but then having to address ending the same pet's life through euthanasia is also challenging for the veterinary professional.
The owner's unique situation of participating in life-ending decisions may also result in them experiencing responsibility grief, which can compound their feelings of loss. Having protocols that encourage open, active discussion of both the practical and emotional aspects of euthanasia will ensure that every owner feels supported through their companion's end-of-life journey and in their decisions.
Key Points
Sources of support for pet owners:
Disclaimer: This list contains suggestions only and is not exhaustive; practitioners are encouraged to investigate these sources for themselves before referring clients.