Clients, in up to 19% of cases, choose not to return to a practice after their pet has died (Lambert, 2014; Compassion Understood, 2015a). The reasons given include the client not having another pet or having moved away. However, they also include reasons that relate to their experience in the veterinary clinic at the end of their pet's life. Sometimes this may be a result of their experience of euthanasia in the consult room. One study reports that clients who changed their veterinarian after euthanasia had been significantly less-pleased with the process of euthanasia than those who had not (p<0.001) (Fernandez-Mehler et al, 2013).
A notable factor for client satisfaction, as perceived by clients as well as veterinarians in this study, was the ‘compassionate and caring attitude of hospital employees’. (Fernandez-Mehler et al, 2013). The client's impression is drawn from their whole client journey, which includes the initial phone call to the practice, to discuss a pet death or euthanasia, arrival and waiting at the clinic for an appointment, paying for euthanasia and handling aftercare, such as cremation and collection of ashes (Compassion Understood, 2015a).
Much of this impression relates to the customer service experience of a client. To make an overall good impression, the process of customer handling, at all the touchpoints with the practice, needs to be seamless. Communication between team members is essential so that everyone knows their responsibilities and nothing falls through the gaps.
This third article in the series focuses on the client–practice interaction and, in particular, to the non-clinical or ‘front-of-house’ aspects.
Client satisfaction and empathy
Client satisfaction is critical to the sustainability of a veterinary practice. Satisfaction is defined as meeting or exceeding client expectations by the customer's standards or perception (Ackerman, 2013). It must be measured in terms of how the client views the experience: this can include things like accessibility of the service, waiting times, and how they felt they were treated by the practice staff. This latter point is particularly notable. In the measurement of satisfaction, feelings play an important role. The measurement is subjective, as well as objective.
This subjective measurement of satisfaction is closely related to the perception of quality of service. Unlike objective measurements of quality, which in a product may include features such as durability, number of defects and other such measurable terms, the definition of the quality of service is more elusive. The perception of the user or consumer of the service is central to the measurement of quality. One model for assessing service quality is the SERV-QUAL scale (Parasuraman, 1991); along with dimensions such as tangibility, reliability, responsiveness and assurance, a key measured aspect is empathy. Empathy is defined as:
‘the ability to enter into and understand the world of another person and communicate this understanding to him or her
In dealing with clients in an end-of-life situation, the display of empathy becomes particularly pertinent. Sensitive, compassionate communication should form a strategic part of all client communications.
One comment in Compassion Understood's pet owner research illustrates the importance of displaying empathy outside of the consult room (Compassion Understood, 2015a):
‘I always start crying when I call for this kind of [euthanasia] appointment. It's helpful if the receptionist is sympathetic to that. I left my last vet because of the receptionist and her “business-like” approach.’
Clearly, empathy is vital in such conversations, along-side the efficiency needed in the busy and stressful front-of-house role.
The touchpoints
Just as every client journey has a series of touchpoints between client and team member, the end-of-life client journey will be based on some common interactions. It is important to remember that lasting impressions are made from the front-of-house elements of this. Every step on the journey, from the time of the first phone call to request information or make an appointment, through to the collection of ashes, will influence the client perception. While flexibility is needed to tailor the experience to each individual client, much of this journey allows for written protocols and therefore team training.
Initial contact with the practice
Regardless of whether a pet is known to the veterinary clinic or not, in most cases, the end-of-life client journey starts with a telephone call to the practice. This will usually be to make a euthanasia appointment, enquire about a house visit, or request some advice. The team member answering the call will often get early clues as to the nature of the call: the tone of voice, faltering or hesitation in the conversation, a struggle in the choice of words. These clues often tell the person who answers that this is a sensitive call. Sometimes the tone of voice can be one of sadness, irritation or even confusion, reflecting the many presentations of grief (Dawson, 2010).
According to Compassion Understood pet owner research, when respondents were asked how they felt their initial phone call was handled, just 57% answered that they felt they were shown some sympathy and compassion (Compassion Understood, 2015a).
The reception or client care team, and other members that handle clinic telephone calls, lead in making an important first impression (Figure 1). The tone of voice used should be suggestive of care and compassion. A soft tone of voice and a warm greeting to all callers will help ensure that any end-of-life phone calls are immediately started on the right note.
There is a natural reluctance in society to discuss death (Adams et al, 1999); those answering the telephone may therefore feel an awkwardness in conversations of this kind. Further, the nature of a telephone conversation removes clues and feedback from facial expression and body language. When discussing the death or euthanasia of a beloved pet, these two elements may combine to produce even more sensitivity between caller and receiver.
It is important to note that an upset person will often struggle to find the right words to broach the subject they are calling about. Therefore, a conversation might start with a functional, information-gathering question, often around cost, because that is a more comfortable way for them to open the discussion. The temptation is to then answer in a similarly functional way: does the enquirer know the weight of their pet so they can give them an estimate of cost? Would they want their pet to be cremated (which will influence cost) and, if so, what type of cremation: individual or routine?
While the answers to these questions do need to be known, the questions do not allow for a show of empathy, or consideration of the client's emotional state. Rather than simply answer the cost question, or ask further ‘efficient’ questions, recognising that many initial client phone calls will take the format of a cost enquiry can act as a prompt to look out for the true nature of the call and encourage the caller to open up.
A protocol can then be followed, which emphasises empathetic handling of the call. Such a protocol may include:
The following comment was made in Compassion Understood's Vet Professional Research (Compassion Understood, 2015b):
‘Often it simply doesn't come to light that it is a PTS [put to sleep] until the consultation is going. However, we could be discussing [euthanasia] more if a specific appointment is booked, although that will be a receptionist's role as they are more likely to take the call.’
A pre-euthanasia consultation can help to elucidate the client's needs further. Separating this consult from the final euthanasia consultation will allow the veterinary surgeon and owner to discuss the owner and pet's needs in a lessemotionally charged situation.
An owner response in Compassion Understood's research illustrates the benefits of this (Compassion Understood 2015a):
‘As part of the planning we'd already decided what we wanted and this was noted on the system so all the vet did was ask if we'd changed our minds about the previous decisions.’
For further reading on pre-euthanasia consultations, see the first article in this series (Tottey and Sheridan, 2016).
Handling urgent calls
Other situations may present a particular challenge in the initial phone call. A request for the emergency euthanasia of a pet that is severely ill or injured can make it inappropriate to go through a telephone protocol. The client may just need reassuring that someone is at the surgery and ready for them, and to come straight away. However, the same sensitive approach and consideration should always be used in answering these types of calls.
Training in end-of-life call handling is recommended. This can be as simple as allowing reception staff to role-play calls about euthanasia. Different scenarios can be presented.
Home visits
Fernandez-Mehler et al (2013) found that 75% of those who had changed veterinarian following their pet's euthanasia had indicated satisfaction with the process. The authors speculated that one important reason for this is the painful association of the clinic with the euthanasia of the client's pet. This brings up the subject of how to avoid this painful association.
Where everything has been done within the clinic to minimise the association, such as showing empathy and allowing time for these sensitive final consultations, the only other thing that may alleviate such painful feelings would be to conduct the euthanasia outside of the clinic, and in particular, at the owner's home. In this study, this was the second most common wish of the pet owners involved.
Pet owners receiving home visits describe how the home environment can help to alleviate the naturally-stressful event of euthanasia. One pet owner in a veterinary publication article (Lindsey, 2015) describes how she felt:
‘As devastated as I was at that moment, I took and continue to take comfort that I had ensured Douglas was put to sleep with absolute compassion, painlessly and within a stress-free, familiar environment. A process not driven by time, but by pure love and affection.’
This sentiment correlates with comments in the Compassion Understood Pet Owner research (Compassion Understood, 2015a):
‘I would have loved a home euthanasia for my girl. Cost not an issue.’
‘Home visits are less stressful for owner and pet and much preferred.’
Time and resources were commonly mentioned in the Compassion Understood Vet Professional research as barriers to being able to offer everything clients wished for (Compassion Understood, 2015b).
It is understandable that a house-visit takes valuable resources and considerable time away from the practice. However, with a growing number of pet owners requesting home visits, and willing to pay for the time taken, this option should ideally be offered. Where a practice is unable or unwilling to offer home visits for euthanasia, it is worth considering working alongside the growing number of mobile veterinary surgeons in the UK. A directory of mobile vet erinary surgeons who have an interest in end-of-life support may be found on www.dignified-departures.co.uk.
Combining this provision with animal home hospice care is also growing as a service, particularly in the US (Cooney, 2016). The International Association of Animal Hospice and Palliative Care (IAAHPC) currently has members from 14 countries, including the UK, where a branch is soon to be set up (www.iaahpc.org).
The request for a home visit may come in at any time of day, and some of these may be urgent. It is recommended that each day and on each shift-change of reception teams, the practice team knows what the availability is for a home visit that day, if asked.
Directing clients to resources in advance
Responsibility grief (see second article in this series (Sheridan and Tottey, 2016)) is a unique and distinct category of loss, unique to companion animal euthanasia (Dawson, 2007). This refers to feelings of grief arising from owners having had direct personal responsibility for their pet's death. Most pets in the UK are euthanased and it is likely that this grief is common.
Dawson describes how owners' sense of self (as a loving, caring, person) can be lost, sometimes permanently, due to feelings of guilt and doubt in relation to the timing and motivation for euthanasia of their pet. At the same time, she identified that a bond-centred approach to euthanasia (one which recognises and takes account of the close owner–animal bond) will help the individual to come to terms with their loss. Involving them in decision-making, ensuring they have the time and resources to research and become familiar with the procedure that is to take place, and allowing a window for questions and discussion, will all help.
Reception teams can assist with this by directing clients towards information they can access in advance of their pet's euthanasia. Having reliable information, whether on the practice's own website or via links to external sources, can save precious time for the team member taking an initial telephone call. This is also of benefit where the team member needs to relay factual information, for example, about cremation options.
Signposting to websites will allow the client to explore their options and take their time thinking through them. This is particularly important for first-time pet owners. Practices should also have information about their own euthanasia policies or services on their website where possible. This should also highlight any restrictions, or indeed, where the practice makes special efforts, to accommodate home visits for example.
Practices should ensure that they are comfortable with the content of any third-party sites before they recommend them. A list of resources for pet owners is available in the second article of this series (Sheridan and Tottey, 2016).
The client's arrival at the practice
The next step in the client journey, for those coming to the practice for euthanasia of their pet, or to make arrangements for an animal that has died at home, is to visit the practice. Working in veterinary practice can mean that a team member may not have experienced arriving at the clinic for an appointment in the same way that a client does. A team member will know the building, the people working on reception and within the clinical team, as well as the various policies or protocols.
This can make this aspect of the client's journey one that the practice team are most removed from. Often practice members will be animal keepers themselves and will have directly experienced euthanasia with a pet of their own. It is easier for them to understand the emotions involved in decision-making and saying goodbye to a beloved companion. However, arriving at a clinic and waiting for an appointment may not be something they have had to do before.
This part of the client journey was one that respondents in the Compassion Understood Pet Owner research made quite a few comments on (Compassion Understood, 2015a). For example:
‘It was very tough that the receptionists didn't recognise me and why I was there, so I had to say, which of course cracked me up. I did feel pretty exposed crying in front of everyone.’
‘When we arrived we were made to wait in the waiting area — the 5 minutes we waited felt like hours.’
‘I don't know what the [other] customer thought of this family sitting in the waiting room and us lot crying.’
In this survey, 53% of respondents answered that they were ‘Greeted with compassion and acknowledgement of the reason they were there’.
Given that euthanasia appointments are most-often booked in advance, a goal of compassionate end-of-life care might be for the front-of-house team to check every day through the appointment list and prepare for the impending visit. Recognising and greeting the owner, using the pet's name, and being aware of the reason for their visit displays empathy and helps ensure compassionate handling from the start.
Ideally, a team member should act as a designated ‘greeter’ — that is, someone who is ready and prepared to meet the client in the car park or at the door of the clinic. When the client and patient arrive, they can be escorted directly to a private area.
Waiting time is not only stressful for the owner of the pet, but also for other clients observing them who may feel awkward. A popular trend within practice now is the lighting of a candle on the reception desk with a message explaining that a client is saying goodbye to their pet in one of the consult rooms and to ask them to keep noise to a minimum. The authors' experience of this has been a positive one, with it being well received by both the owner saying goodbye, as well as other clients in the waiting room.
Many practices will try to schedule euthanasia appointments for a time when the waiting room is quiet, such as out-of-hours or at the beginning or end of a surgery. Where a dedicated room can be given over to end-of-life appointments, the client may be taken directly there on their arrival to wait. This room may be furnished appropriately to the situation — with softer lighting that can be adjusted for the placement of catheters, soft wall colours, tissues on hand, more comfortable seating for the owner and bedding for the pet, warm pictures — in other words, less clinical in appearance. Where dedicated space is not available and when the waiting room is busy, the greeter can offer to wait with the client by his or her car (this is also likely to be less stressful for the pet).
Taking payment
Taking payment for euthanasia can be upsetting; many receptionists, nurses and veterinary surgeons report that they find this difficult (personal observation). However, given that end-of-life arrangements will involve payment (for funerals, cremation services, etc), the pet owner will, in most cases, be expecting a charge for euthanasia. The handling of this conversation is, however, very important.
Not all clients will prefer the same method or timing of payment for their pet's euthanasia. Where possible, this discussion should be held in advance of the euthanasia appointment to manage client expectations and give them time to consider their choices and prepare. Having this conversation at a pre-euthanasia appointment, where the more practical aspects of the situation, such as disposal options, can take place without the heat of emotions, is less of a strain on the pet owner.
In one study, owner responses regarding their preference for the timing of payment for euthanasia or aftercare, showed that this was highly variable (Compassion Understood, 2015a):
‘[Payment] should be discussed beforehand.’
‘Paying in advance caught us by surprise, but turned out to be really important. It meant that after our cat was gone we were allowed to grieve without having to try to give our attention to ‘business’.’
‘Not on the day of euthanasia … sometime afterwards.’
Requesting payment at the time of euthanasia is perceived by some as insensitive (Dawson, 2010). Where it is practice policy to take payment in advance, consideration should be given to doing so in a pre-euthanasia appointment or over the telephone when the appointment is booked. If it has been decided that payment should be made at or around the time of the euthanasia appointment, then sending the bill a few days after should be considered (perhaps for those clients known to the practice). It is important that this should not be some time after the euthanasia appointment; late receipt of an invoice can lead to upset. The Compassion Understood (2015a) research also found that clients do not want to pay in front of others in a waiting area or busy reception. Comments included:
‘I had to queue to pay for the euthanasia in tears with my empty carrier.’
Payment policies can be discussed by the practice team during a meeting and an agreement made on the protocol for that clinic. Client debt from end-of-life care is common (Pet Cremation Services; personal communication). Having a policy sensitively written within the practice's website or in client written information is a good idea. This avoids payment being sought from the owner when another option has been agreed, or indeed, the opposite situation where no one asks for payment, and the client unexpectedly receives an invoice afterwards, leading to upset.
Handling the pet's body after death
In the time immediately after the pet has passed away, it is important that the owner can, if they wish, spend some time alone with the pet's body. Where possible, this should be facilitated and the client should be given privacy. This gives them time to say goodbye on their own and to compose themselves. The pet's body should not be removed from the room while the pet owner is still present. If the veterinarian is under pressure to continue consulting, switching to another room (where possible), will allow them to continue their clinic, while one of the veterinary nursing team or the reception team maintains the care of the client.
The pet should be handled with respect always, including after death. A protocol should be followed that includes how to take care of the pet immediately after its death, and how to remove the body from the room respectfully.
Careful handling post death signifies to the owner the importance of their pet, and by demonstrating their worthiness of this compassionate aftercare, helps to acknowledge and validate the owner's loss (Dawson, 2007). This will help to minimise any feelings of disenfranchised grief (Tottey and Sheridan, 2016).
Memorialisation and remembrance
For some owners, the ability to memorialise their pet through the enactment of rituals can help them with their grief. While for humans, the rituals around death, involving wakes, funerals and memorial ceremonies, are commonplace, for the bereaved pet owner, this is not generally the case (Chur-Hansen, 2010). Allowing the owner to create a ritual around remembrance can help with their healing. The usage of ‘linking items’ helps to validate the owner's loss as significant, and reinforces the important role that the pet played in that person's life (Dawson, 2007).
Examples of linking items might include things that belonged to the animal — for instance, a collar or lead — or a fur clipping (or in the case of a horse, a piece of tail or mane hair). Clay paw prints, made from an impression of the pet's paw which is then baked to hardness and kept as a momento, are available commercially, and appear to be well received.
The owner's wishes around memorialisation should be explored. Some may wish to link to an item; others may prefer to memorialise through an act, such as scattering ashes, planting commemorative plants or trees, writing a memory book or poem (Williams and Green, 2016). In the planned euthanasia, discussions beforehand will allow the exploration of the client's wishes.
Options for aftercare
This is an area that it is important for the whole practice team to know about, and should form part of the training that the team receives in end-of-life.
Discussion of aftercare can feel awkward, but this is a time for an honest, gentle conversation. In their study of clients' expectations, Fernandez-Mehler et al (2013) found that 88% expected their veterinarian to talk about their pet's destination. Compassion Understood (2015a) pet owner research also found that clients wish to be informed.
Many options are available for disposal of companion animal remains: these will come under regulation, which will vary from country to country. Practices should take the time to personally research the options they choose to offer, and investigate regulations. Some helpful information can be found at https://www.compassionunderstood.com/page/after-life-body-care.
If a crematorium is selected as the primary provider for a practice, personnel should visit the facility and become familiar with the systems in place. This enables staff to answer owner questions with clarity and honesty.
Information regarding aftercare should be freely available at the practice, whether as part of a bereavement pack given in advance of euthanasia or to pick up on a pet's death. In the Fernandez-Mehler (2013) study, needs and expectations relating to the death of a pet and aftercare were similar in most respondents, irrespective of demographic. The clients with the highest need for information were female owners, over 70 years in age.
While 88% expected their veterinarian to talk about the pets' final remains, interestingly, 38% did not only expect this information at the end of their pet's life (Fernandez-Mehler, 2013). This correlated with other research, in which 21% wished to know their options when their pet was still healthy (Compassion Understood, 2015a). Providing end-of-life information outside of the context of euthanasia or the natural passing of the pet may seem mawkish, but for some owners, it is important to have it. Displaying this information on the practice's website or making it available in a leaflet in the waiting room will allow those who would like more information to access it and ask for further help if necessary.
Aftercare options may also need to be relayed to owners over the telephone, for example with a pet who has passed away at home. Compassion Understood (2015a) found that 18% of pets died from causes other than euthanasia. Training and rehearsal in aftercare discussions will ensure that information is relayed sensitively and compassionately.
Administration afterwards
One comment from the Compassion Understood (2015a) pet owner research illustrates the importance of follow-up administration:
‘10 days after my pet was put to sleep, the practice I was with at the time posted a letter to me with a vaccination reminder for my pet. I contacted the practice who said it had not been added to the system that she was deceased. This was very distressing for me.”
Time should be set aside straight away following a pet's euthanasia or the learning of a pet's passing to update the client records. Some practice management systems will already do this and the information is sent automatically when the veterinary surgeon inputs a euthanasia charge. Any reminder system for vaccination or preventative health care should also be checked. Where the practice is not the client's usual one, their regular practice should be informed, with the client's permission.
Sending a sympathy card
A personalised, hand-written bereavement card should ideally be sent 2–3 days after the pet's death. Hewson (2014) recommends following the brief outlined for doctors. Any text should include the expression of sympathy and Dawson (2010) recommends sharing a personal remembrance of the pet. Bills for euthanasia should never be sent with remembrance cards (Dawson, 2010).
One study with veterinary professionals found that 66% of respondents sent sympathy cards to all of their clients, while 26% sent cards to some of their clients following euthanasia (Compassion Understood, 2015b). Generally, cards are well received (Compassion Understood, 2015a):
‘I like the idea of a sympathy card, I received one on the loss of a dog from a previous vet, I still have it.’
Some clients will also appreciate a telephone call a few days after a pet's death. Others may find it intrusive. The owner's preference could be explored at a pre-euthanasia consultation or at the euthanasia appointment.
Collecting ashes
For those clients who have opted for individual cremation, there will be ashes to be returned. Protocols again should be made. Points for consideration include:
Support following euthanasia
Williams and Green (2016) describe the importance of the veterinary team in providing support for owners after their pet's death. In some instances, this support is needed for longer than expected. Every client's response to loss will be individual. For some, it can be particularly traumatic. Given that support from the veterinary staff may be the only type that some owners seek (Donohue, 2005), it is important that team members are watchful for signs that a person may be struggling.
While counselling is a complex skill that requires training, all some owners need is to express their feelings of grief and for them to hear that what they are feeling is normal. It is also helpful to tell them that it may take time for them to return to normal. This can take a year or more for some (Lagoni, 1994). For those where it is identified that extra support may be needed, referral to a bereavement helpline, such as that provided by the Blue Cross Pet Bereavement Support Service (https://www.bluecross.org.uk/pet-bereavement-support) can be an option. For others, referral to their doctor or for counselling may be required. Sources of support for pet owners can be found in article 2 of this series (Sheridan and Tottey, 2016).
Sometimes, the veterinary team may not perceive them-selves as being responsible for client support. Compassion Understood (2015b) Veterinary Professional Research found that in some instances, team members felt that their responsibility ended when the pet died. Others commented that they worried the client's grief could be exacerbated by focusing on it, and so avoided the subject.
In pet owner research (Compassion Understood, 2015a), one respondent group identified a special family member as being most appropriate to offer them support after the loss of a pet. A special grief support service was second, a friend, third, and the member of the veterinary practice, identified as fourth. Rather than providing grief support per se, the wish of the pet owners in this study was to be able to be signposted towards finding help if needed.
‘I wish they had information there on grief counselling, over the loss of a pet. I wish they talked to me about it.’
‘Just [provide] support information re dealing with the grief.’
‘My vet should have mentioned a grief counsellor for dog loss. It's very traumatic, especially [being] my first dog it probably would have helped.’
The comments above stress the importance of ensuring that information is available; while the practice is not expected to provide specialist counselling themselves, information offered to all clients is a must. Written guidance should be included — this is important for those with a controlled response to their grief. Hewson (2014) describes not pre-judging who may or may not need help; those living with others may not necessarily need help less than those living alone; the elderly may not necessarily experience greater grief than the young.
Information should be readily available and a list of resources should be proactively provided. Acknowledging the owner's loss by asking gently how they are feeling, whether at return of ashes or via a phone call, gives them the opportunity to bring up the subject of grief without embarrassment.
Just as offering support is important, it should not be forced on the client. They should have the option to refuse information. Not everyone will experience grief in the same way, and it should be acknowledged that not everyone will need external support.
Getting a new pet
Compassion Understood (2015a) pet owner research indicated that almost two-thirds of pet owners obtained a new pet within 3 years of their loss (48% of surveyed pet owners acquire or adopt a new pet within 1 year, and 13% have a new pet after 1 but within 3 years). Of these pet owners, 15–19% did not return to their original veterinary practice (Compassion Understood, 2015a).
Some of the reasons given were:
‘Different surgery same practice, I could not face going into the same surgery. Still can't.’
‘Didn't feel comfortable at the practise [sic] after my pet died so moved to a practise [sic] that was a little closer.’
‘I felt it was such a business…I know it happens all the time…I just didn't want to feel that way.’
‘Putting Sammy down was so badly handled, I couldn't face going back. They called to say “the dog's here, when can you collect it?’, rather than use her name even.’
While some of this client attrition will not be prevented, for example in the case of an owner who has found a practice that is closer, those aspects relating to a client's poor experience can certainly be improved on through protocols and training. Proactively asking for client feedback relating to end-of-life experiences will help a practice to identify if this is needed.
Conclusion
Thinking through the end-of-life journey from a client's perspective is an important step in moving towards a bondcentred approach to pet loss. This journey for the practice team might start at the time the client first makes contact about their pet needing euthanasia, in the case of the front-of-house team, or a new client. It might start before this time for the clinical team who have an existing relationship with the pet and their owner.
For the front-of-house team, assessing all the interactions on this client journey, and in particular with the reception role, will help to identify where protocols may be of benefit. Being proactive, role-playing compassionate communication, and thinking through protocols which are mindful of the owner–animal bond, will help to ensure a seamless and compassionate pet owner experience.
Practices should look at what support information is available and consider contacting local bereavement support counsellors in their area, details of which can be shared with clients in a bereavement pack or via their website.
With some client losses being directly attributed to receiving a poor end-of-life experience with a pet, getting this journey right is a must for any business.