The aim of this article is to look at ways the veterinary team can improve on handling euthanasia cases, ensuring that clients do not feel like ‘just another number’ to the veterinary team. Small gestures such as paw prints, fur clippings, sympathy cards and follow up phone calls can go a long way in improving the client experience during this very difficult time. However the real key is how veterinary professionals act and behave, before, during and after the experience. This behaviour is what the client will remember and the aim is to guide them through the stages of grief (Figure 1), being able to finally reach acceptance as smoothly as possible (Watkins, 2014). Myers (2015) stated that: ‘A team that demonstrates compassion and kindness will help clients turn sad goodbyes into loving memories’.
Booking the appointment
The initial phone call is key to whether a euthanasia is going to run smoothly or not. Get this part wrong and you could end up with a very stressed client and veterinary team; and a rushed non-compassionate euthanasia. Tait (2003) stated that two of the most important veterinary visits are the first visit, where an initial impression of the veterinary team will be made; and the final visit which will be remembered for a long time afterwards. This phone call will likely not be like the usual call to book in a booster. From experience the author has found that clients will often not go straight to the reason for the phone call; they will often talk about costs, or not mention the reason at all and just want to book a check up appointment. This is when the veterinary team should first show how compassionate they can be using appropriate communication skills such as active listening and showing the client that they care about their animal by using personal anecdotes. For example, the author always likes to use the pet's name straight away and ask how they are getting on after a previous consultation, which can often lead into the real reason for the phone call. This subtle way to lead into the discussion can show clients that you know about their case and it does not automatically jump to the euthanasia conversation which can be upsetting for the client.
The need for euthanasia is not always black and white, and this grey area is where empathy and compassion are needed to help the client gather their thoughts (Poli, 2016). Allow time for the client to discuss their thoughts, ideally move to a quieter area away from reception to ensure that the client gets your undivided attention during this call (Gardner and McVety, 2016). Show active listening (McMurray and Boyson, 2017), engaging with the client without cutting them off and allowing them to speak freely. Although the waiting room may be full of people and there may be lots of tasks to complete, make the client feel like they are the only thing at that time that matters, use phrases such as ‘I understand how hard this must be for you’, and ‘no need to rush we have plenty of time’; this makes clients feel that you are listening to them. Throughout the conversation refer to the pet by name (Myers, 2016), never use phrases like ‘OK I will book your animal in now’ as this removes the personal approach. During this call the client may never actually use the word ‘euthanasia’, as this is likely to make the reality hit harder for the owner. By the end of the conversation make sure you have confirmed that this is the reason for the call by using the word yourself (Gardner and McVety, 2016). Some clients can mix up ‘put to sleep’ with meaning sedation or anaesthesia, therefore definite confirmation of euthanasia as death is important to avoid confusion and awkward moments. The author has found such phrases as ‘putting the animal to rest’ or using the term ‘pass away’ as less ambiguous phrases which people do not misconstrue, because these are terms often used when discussing human death.
If possible the appointment should be booked during a quieter period to avoid lots of people in the waiting room while the client is grieving. The SPIKES model of communication (Figure 2), used in human medicine and set out by Baile and Buckman et al (2000), can be a way of organising the initial telephone conversation to give more structure.
- Setting up the interview
- Assessing the patient's Perception
- Obtaining the patient's Invitation
- Giving Knowledge and information to the patient
- Addressing Emotions with empathetic responses
- Strategy and summary.
This model is usually used in human medicine for delivering bad news, however it can be adapted for veterinary use (Shaw and Lagoni, 2007). It would allow the client to book the appointment, understand their perceptions of why the euthanasia needs to be carried out, inviting them to know more about the euthanasia process and ascertaining at this point if they need this information at that point in time, allowing them to discuss their emotions and finally plan the actual appointment itself.
Pre-euthansia information
From anecdotal experience in practice the author's team has found that explaining to the client what will happen before, during and after euthanasia during the euthanasia appointment itself can sometimes lead to confusion and upset. Preparing the client for what will happen either over the phone during the appointment booking (read the situation and ensure appropriate) or inviting them for a free of charge pre-euthansia appointment (this can be nurse led) where the process is discussed can be invaluable (Kerrigan, 2014). The euthanasia appointment itself is a very emotionally charged time, and clients do not often want to talk about the clinical side of euthanasia during the last few moments they will be spending with their pet. Preparing clients at a pre-euthanasia appointment can also help them come to terms with the booking and make them feel more comfortable attending the appointment, knowing what will happen. This may also be a good time to complete the consent form, discuss cremation or burial options and talk about cost. Having recommendations of cremation companies to hand or recommending from personal experience is always useful as this can be an overwhelming time for owners, therefore guiding them in their decisions will make the process easier.
Again, as with the initial phone call, try and make this discussion as personal as possible. Devote all your time to the client in a calm and non-rushed fashion. If they opt to come to the practice for this discussion, try and have it away from a clinical area. Have a comfy chair and tissues prepared as talking about the forthcoming euthanasia appointment is often when reality hits and clients can get very emotional. Avoid using jargon (Kelley, 2016) in this conversation, even the use of ‘intravenous catheter’ can confuse some clients so ensure your conversation is pitched correctly to avoid confusion and misunderstanding or upset when the time of euthanasia arrives. It is also important during this conversation to reassure clients that they can always change their mind at any moment and although they are having these discussions, they are just for preparation when the time comes and that nothing is set in stone.
During euthanasia
This is a time when it is really important to be perceptive and tune into the client's body language to be able to understand what they want from the experience and determine how to adapt our behaviour and approach to accommodate their needs. Each euthanasia that is performed is very different; from the owners who do not want to be present, to the appointments where more time is needed to give the clients time to say goodbye and grieve. However despite the differences in approach, each client should be treated with respect and compassion at the decision they have made. Many clients who opt not to be with their pets can feel guilt and upset at their decision, and it is not the veterinary professional's place to judge the reasons for their choice (Pierce, 2019).
Research has suggested that many clients may prefer euthanasia to be carried out at home (Gregersen, 2020) as it can be more personal and comforting for the client and pet. If practical for the veterinary team they should endeavour to carry out home visits if the owners request this, however if this is not an option or the client does not wish for a home visit, a more homely setting within the veterinary practice can be achieved. Practices in the USA often have euthanasia rooms, with comfortable chairs, calming music or ambient lighting to create a less clinical setting. Devoting a set room is not always practical, especially in a busy practice, therefore making the consultation room look less clinical with blankets and even some music and removing obviously clinical items can help to achieve this. During the appointment an appropriate time slot of at least 30–40 minutes should be booked, to make sure that clients do not feel rushed or feel that they are taking up your time. Go at their pace, answer their questions, let them talk to you and give them the time they need to say goodbye. Some owners prefer their pets to stay with them while you place an intravenous catheter as they want to spend every last minute they can with their pet to be able to comfort them. Gregersen (2020) highlights how important this time is and removing the animal can break the vital human–animal bond. Make sure provisions are ready for this so there is minimal disturbance going in and out of the room. Ideally keep the euthanasia drug syringes out of sight or in a pocket until just before you need them, as the sight of these can often be upsetting. How much you communicate with the owner during the euthanasia is often up to the owner themselves. Communication does not always mean talking. Some owners need physical contact such as a gentle hand on their shoulder, or some even want a full embrace. This is a skill that comes with experience of reading what is appropriate in different situations. Even a small show of emotion from the veterinary team is not a bad thing, as long as it is not over the top (Gardner, 2019), as it shows that although this is something that is carried out in the practice often, veterinary professionals are still emotionally attached and do care. Ideally all staff should be aware of a euthanasia appointment happening, so a quiet environment without excess noise or talking can be maintained. Some practices use signs and symbols on the desk or consultation room door, such as candles or rainbow signs to let others in the waiting room know there is a euthanasia taking place and to be respectful (Gardner, 2019). While the pet is being put to sleep, talk to them using their name and stroke them. This lets the client know they are cared about on an individual level and they are not ‘just another pet’.
Post-euthanasia
The time post-euthanasia can be just as distressing for the owner as the actual euthanasia itself as it is a time when they have to leave their animal and it all becomes very real. Again being able to read the situation is key, with some clients just wanting to leave straight away, and others opting to stay with their pet until they are ready to leave. This time should be factored into the appointment time, ensuring the client does not feel rushed. If a client opts to leave straight away then let this happen. In terms of finances, these can be discussed and organised during the pre-euthanasia appointment or even a few days later if the owner comes to collect any ashes. At this stage the practice needs to avoid being seen as business orientated. Although the money is important to the practice, it can seem off putting and impersonal to ask for money straight away and could affect client retention in the future (Dawson, 2007). Many clients fear that their pet will be left alone after they leave. It is often the nurse's job to reassure them that their pet will be treated with respect and dignity, and it can often help to let clients know that you will treat their pet as if they were your own. Before the clients leave ask if they would like a paw print or a hair clipping (Figure 3). This can be given at the time, or if the client wishes to leave rapidly then it can be sent with a sympathy card or given when the owner comes back to collect any ashes. Shaw and Martin (2014) looked at the effect such mementos can have on clients and it was shown that the majority of client feedback was positive and they felt it was a nice way to remember their pet. However it should again be remembered that each experience is different and not all clients react the same, so giving the option of a memento is a good idea. Once the client has left the pet can be moved in accordance with the wishes for cremation. A pet should never be moved and placed into a collection bag while the owners are present, as this can be very distressing.
Aftercare
After the euthanasia has been carried out and the client has left, there is still more work to carry out. At this time the team can show that the client that they ‘were not just another client’ and take the chance to retain that client if they have other pets or may get another pet in the future. Take 5 minutes out of the day to give a follow-up call a couple of days later (Lagoni, 2013). This conversation can vary and is often lead by the client's feelings, but the essence of the conversation is that your team is thinking of the client during their time of grief and that you are available as a port of call if they need someone to talk to. During this call, some clients will ask about finances, this is fine if the client mentions it first, but it can be seen as unsympathetic if it is brought up by the veterinary professional, as if that was the real reason for the call. From personal experience the author has bonded with clients during this call in mentioning that they experienced loss of a pet recently and that there was an understanding of their grief. This again can make the veterinary professional seem more human.
A sympathy card is also a fantastic aftercare tool. A hand-written card with a personal message can go a long way in showing the clients that the practice cares. Avoid using stock phrases from the internet, and really personalise the card with experiences of the pet while they were with the practice. In the author's practice Christmas cards were sent to clients this year whose pets had been put to sleep. This gave the clients the feeling that they had not been forgotten about, even though they no longer visit the practice. This may not be practical in a bigger practice, however if it is possible it is definitely a good idea, and one which received great feedback.
Although the client may find it comforting to hear from the practice after euthanasia, care should be taken that any communication does not cause offence or upset. This is mainly in regards to sending booster reminders or unnecessary communication. It is the job of the team as a whole to think about the administrative side which the client will not see, and ensure this is dealt with in a timely fashion after euthanasia. Client retention is important in veterinary practice and clients do not often stay with the practice after the euthanasia of their pet. Compassion Understood research states that: ‘20–25% of pet owners change vets after pet bereavement’ (Compassion Understood, 2020). There could be a few reasons for this, such as clients having a bad experience because of poor communication or handling of the situation from the veterinary team, or simply that the client feels it would be too painful a memory to return to the practice. In some circumstances it must be accepted that regardless of how perfect the practice makes the euthanasia, it may just be too painful for that client to return. However, the practice should be trying to retain as many clients as possible and a study by Dickinson et al (2014) suggested that clients who felt their veterinary practice was caring and professional, suffered fewer negative emotions surrounding the loss of their pet, therefore showing that veterinary professionals may be able to make a difference and improve retention.
Conclusion
Euthanasia is a very personal and client-lead journey. The clients are inviting the veterinary practice into a very intimate and private moment of their life and this should be treated in a respectful and compassionate manner. Business sense and client retention is important but should not be at the forefront of the team's mind at this time. Although each euthanasia is different, nurses can build up a range of skills over time to help them make that moment personalised to the client. The question that should be asked after each euthanasia is ‘would I be happy if that was the euthanasia of my own pet’. Reflect on this and how the veterinary practice as a team carries out euthanasia appointments. Make regular reviews a topic of practice meetings, as this is where veterinary nurses can really excel in their customer service skills.
KEY POINTS
- Client and animal bond focused euthanasia can improve client retention.
- Treat client's pets as you would wish your own pets to be treated.
- Take your time with clients, make them the number one priority in that moment.
- Small gestures can go a long way in making the client feel cared for.