Before the End:Prepare highly attached clients to face their pets’ death Sarah J Wooten, DVM

The importance of animals in the lives of humans has
never been so pervasive or celebrated—spend two
minutes on the Internet for countless examples. It
seems this emotional public perception of animals as
connected to humans, seen also in the aversion to
animal deaths and killing, will inevitably become more
emotional and more contentious.
In many ways, animals are playing a larger role in
peoples’ lives. People are more isolated. The growth
in one-person households (people living alone) is
responsible for most of the increase in non-family
households over time — and the corresponding decrease
in family households1. But people still need
companionship and emotional support, and they are
finding it in their pets.
This personal and emotional attachment—even a feeling
of being more bonded to their pets than they are
to their human family—can make end-of-life decisions
for these beloved pets overwhelming. In order to
guide pet owners through difficult decisions, veterinarians
need to be able to navigate the relationships
people have with their pets and understand the current
expectations and needs that pet owners have regarding
humane euthanasia and end-of-life decisions.
I recently attended a session on euthanasia and endof-
life care by Elizabeth Colleran, DVM, DABVP (feline)
at the CVC in San Diego and came away with the following
thoughts on this arguably most difficult aspect
of practice.
“Doctor, what would you do?”
Pet owners give us remarkable trust and authority, and
during loss, look to us to provide strength, guidance
and leadership. Given these expectations, compassionate
communication should be considered both a
core clinical skill and a standard of care for veterinarians,
says Colleran.

But when a client asks a veterinarian for advice, what
do we do? Veterinarians usually choose from three
basic options when guiding clients on end-of-life decisions:
• We deflect: “It’s your decision. I can’t decide this
for you.”
• We give options: “You can try steroids …”,“I can
send you to hospice care …”, “You can elect amputation
…”, “Humane euthanasia is not a bad option.”
• We tell them what to do: “Your pet is suffering.
You should euthanase.”
All of these can be the right way to handle the question
depending upon the circumstances. For the client’s
sake, and ultimately for our own, Colleran says
we must not try to solve the owner’s problems by
making decisions for them, rationalising their choices
or rescuing them. What becomes essential to assisting
clients is our ability to educate, support, guide and
facilitate during this often-difficult time.
The emotional toll
On the one hand, euthanasia is a tough subject that
we face almost every day and don’t talk about enough.
Clients are stressed and emotional and looking to you
for guidance. In one study, more than one-third of
pet owners said that their major source of emotional
support was their veterinarian. Mental and emotional
stressors associated with euthanasia take their toll on
veterinarians as well. We have a saying at our clinic:
no one cries alone. I almost always cry at a euthanasia,
even when I don’t know the clients very well.
Euthanasia is hard
• First, recognise the moral stressors involved in euthanasia
that can affect you
• Convenience euthanasia. Euthanasia for reasons
we can’t accommodate in our minds (e.g. “My cat
doesn’t match my drapes”).
• Severed relationships. The client has ended
the mental and emotional relationship with the
pet before they have arrived, leaving nothing on
which to base decisions.
• Financial constraints. The ability to afford—or a
lack of desire to pay for—the care a pet needs
causes a client to choose euthanasia.
• Client guilt. Veterinarians often deal with client
guilt associated with euthanising too soon or
causing suffering by waiting too long.
• Technology zeal. Just because we can continue
to treat and diagnose doesn’t mean we should,
even if the client desires it.
• Inability to let go. Client won’t stop or won’t quit
seeking treatment even when the pet’s condition
cannot be cured or managed pain-free.
Second, realize you have little to no control over
these moral stressors, and take care of yourself mentally
and emotionally.
• Take a time out.
• Talk to someone who understands.
• Learn mindfulness-based stress reduction techniques
(i.e. breathing, meditation).
Uncertainty and grief
The strongest desire of highly attached pet owners
facing the loss of a beloved pet is to do what is best for
the animal. It is an elusive goal and one that requires
the owner’s interpretation of the animal’s state. There
is no easy answer, particularly because we advise our
clients based on proxy. As the pet’s proxy, the owner
makes the decision for euthanasia based on uncertain
anticipated events rather than what is known. Uncertainty
makes the decision more difficult.
Also, highly attached owners who recognize that their
pets have a life-limiting medical condition that cannot
be cured or managed pain-free experience strong
emotions called anticipatory grief, says Colleran. Anticipatory
grief is the psyche’s way of preparing for
impending loss and is a normal reaction, but unfortunately
it can blur judgment. This is often the beginning
of a period of powerful emotions, and end-of-life
planning should be done before these emotions take
over, advises Colleran.
Quality of life vs. prolonging life
In euthanasia, it is best to let clients make decisions,
says Colleran, but in order to do this, they need to be
able to accurately assess their pets’ quality of life before
their judgment is impaired by emotion. According
to Colleran, “…one core belief that must be developed in
clients is that preserving quality of life takes
precedence over measures to prolong life.”
Medical and surgical therapy that was previously unattainable
can now prolong suffering, making it more
important than ever to educate clients on the importance
of quality of life over quantity.
Colleran says the best practice is to teach people early
on how to recognize quality of life with assessment
tools and diaries, even as early as puppy and kitten
wellness visits. At the end, we want to be able to remind
people with that point of reference what quality
of life looks like in their pet, instead of trying to teach
them about quality of life during an often-emotional
moment. Quality of life assessment tools give clients
power and confidence by allowing them ability
to quantify something that is typically unquantifiable. I
use this quality of life scale.
Helping a child say goodbye
Seeing a pet euthanised can be traumatic for young
children, even if it is peaceful. If there are young children
involved, help them say goodbye, and advise
the parents to excuse them for the euthanasia, Colleran
says. Be mindful in the way you communicate
with kids: children younger than 9 or 10 will not understand that “I am putting your pet to sleep” means
death. Colleran advises veterinarians to use concrete
language: “I am helping your pet to die because she
is suffering and we can’t control her pain any longer.
This is really hard and sad thing for us, but it is a good
and brave thing to do for your pet. It is OK to be sad.”
Plan for the inevitable
Planning ahead also involves making sure that clients
have access to medical records and a plan in place if
something goes wrong or timing is wrong, says Colleran.
In addition, it can help the client to decide ahead
of time if children or other pets should be present,
where the euthanasia will occur (at home, at the clinic,
outside), body care and more.
We may be the only person in that client’s life that
recognizes the human-animal bond between the client
and the pet. We can plan to honour that connection
and provide emotional support for the client after
the pet has passed on. Celebration of life ceremonies,
telling funny stories about the pet, a funeral, special
mementos, art work, music or candles can all help
a highly attached client cope with the loss, so don’t
be afraid to ask how the client will be honouring the
passing of his or her pet. If your client doesn’t have
any ideas, don’t be afraid to give some suggestions.
In doing so, you may be giving that client permission
to grieve in a healthy way that he or she may not have
considered. Ritual can bring comfort and closure.
By preparing the client for end-of-life decisions, helping
the client plan and providing emotional support
to your client, you have the opportunity to provide
exceptional service and protect the human-animal
bond. The manner in which a veterinarian provides
care for a client whose pet has died has the potential
to alleviate or aggravate grief and influence client and
veterinarian satisfaction—even create or destroy longlasting
relationships, says Colleran.
Presenting options gives families control over the
process of inevitable loss by helping them define for
themselves what constitutes the best way to care for
their animal. I believe a sense of control—even if limited—
correlates with healthy grieving and emotional
healing. Just as humane euthanasia is a privilege to
end suffering, guiding clients through the process can
be a privilege as well.
Reference
1. Vespa J, Lewis JM, Kreider RM. America’s family and living
arrangements: 2012. United States Census Bureau. Available
at http://www.census.gov/prod/2013pubs/p20-570.
pdf

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