Edited by: Paul Koene, Wageningen University and Research Centre, Netherlands
Reviewed by: James Serpell, University of Pennsylvania, USA; Manuela Zebunke, Leibniz Institute for Farm Animal Biology (LG), Germany
Specialty section: This article was submitted to Animal Behavior and Welfare, a section of the journal Frontiers in Veterinary Science
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
Current advances in technologies and treatments provide pet owners and veterinarians with more options for prolonging the life of beloved pets, but can simultaneously lead to ethical dilemmas relating to what is best for both animal and owner. Key tools for improving end-of-life outcomes include (1) sufficient training to understand the valid ethical approaches to determining when euthanasia is appropriate, (2) regular training in client communication skills, and (3) a standard end-of-life protocol that includes the use of quality of life assessment tools, euthanasia consent forms, and pet owner resources for coping with the loss of a pet. Using these tools will improve outcomes for animals and their owners and reduce the heavy burden of stress and burnout currently being experienced by the veterinary profession.
The changing nature of the bond between humans and animals has made pets an increasingly integral part of many people’s lives. This in turn has changed the landscape for the veterinary profession such that the human–animal bond must be integrated into daily veterinary care (e.g., “bond-centered” practice) (
The following commentary looks specifically at the decision-making process in relation to the euthanasia of a companion animal and asserts that this needs to be supported by specific tools that assist the veterinarian in serving the interests of the animal and the wellness of the client and veterinarian.
It has been clearly established that euthanizing animals is broadly stressful for veterinarians (
In one study of 21 veterinary students, several pointed out numerous distressful situations that they had already experienced (
Although euthanasia serves as a method to end suffering in animals, the decision, inevitably, is difficult, and highly bonded owners require more support from their veterinarian at this time (
The ethical and emotional strains associated with euthanasia decisions are often not openly acknowledged or a subject of structured assessment and improvement efforts, despite their importance to the veterinary profession and pet owners (
Engaging in a quality process, e.g., training in ethical deliberation, can have the effect of minimizing distress experienced by veterinarians as a result of routinely performing euthanasia, one of the major reasons for burnout and moral distress (
By emphasizing the quality of the deliberative process (including acknowledging the role of animal-based measures in guiding the decision to euthanize and when), and not merely focusing on the final outcome, veterinarians can have confidence that they are living up to their commitment to provide quality care to their animal patients at the margins of life and that they have provided conscientious counseling to their clients, integrating their clients’ needs and interests into the deliberative process (
In Sandoe et al. (
Although there are numerous ethical models that represent a spectrum of ethical problem solving alternatives (e.g., utilitarian, virtue, and fairness approaches), the authors will focus on a couple of principles from two alternatives. Veterinarians may wish to begin their ethical deliberations by considering two basic principles. Firstly, according to the ethics-of-rights approach (
The ethics-of-care approach (
Veterinarians tend to innately understand both principles. For example, one study found veterinary students approached hypothetical ethical dilemmas trying to achieve a fair outcome for all which and a care-centered approach, being empathetic to the companion animal and human caregiver (
In terms of a deliberate framework to guide veterinary medical interventions, two valuable models are provided by Morgan (
These frameworks have the additional effect of helping clients prepare for their companion’s passing while honoring the human–animal bond. Empathy central in the process of deliberation. However, if excessive, it can also increase the stress experienced by the veterinarian without improving the outcome (
By going through the assessment and deliberative framework highlighted here, veterinarians have the opportunity to communicate with their clients in a way that helps expose and gently resolve conflicts whenever possible, for example, where the medical evidence shows that an animal’s condition is terminal, but the client is still seeking therapeutic treatment; or when clients need to keep the animal in their life but the animal’s quality of life has reached the point where it does not have a life worth living. It may also occur that the animal’s life could potentially be extended from a medical point of view, but this option is not truly available because the owner has an unresolvable obstacle to supporting that option (
When veterinarians are able to explicate their own ethical roadmap confidently, they will also be able to reliably guide a client toward a sound decision and leave them feeling they made that decision in a morally sound way. The two frameworks highlighted here reflect the deliberative and assessment guidelines regarding the morality of euthanasia that can be found in the introductory section of the American Veterinary Medical Association’s (AVMA)
One example of a specific tool consistent with these principles is available from the Markkula Center for Applied Ethics, Santa Clara University. The tool provides a simple framework for ethical decision making that can be accessed
Once clients develop a high level of understanding of the ethically acceptable options, veterinarians may be prompted to expand which options they can make available through continuing education, the use of consultants, or referrals. Veterinary options have increased not only in the area of treatments and techniques but also the manner in which these can be made available to clients (e.g., client training, mobile practice, and veterinary hospice). These caregivers should be folded into the communication system discussed below. Sandoe et al. (
Explicit ethical discussion may also expose less-than-optimal client–veterinarian pairings; for example, clients from religions that do not permit euthanasia may not fit well with a veterinarian unable to accept and work with this perspective. As with physicians or other professional caregivers, while every effort should be made to meet client needs, clients should also be supported in selecting a practitioner that best meets all of their needs rather than choosing them purely on an arbitrary basis of proximity, habit, fear of causing offense, or the desire to retain a customer client.
Given the intricacies of caring for pets and their families during humane endings, robust relationships between the veterinary team, client, and patient can reinforce and maintain the veterinarian’s role as a trusted guide even when unexpected adverse events occur. Conversely, when a companion animal end-of-life experience is poorly handled and this trust is not present, ongoing personal guilt and recrimination can reverberate for the pet owner and grief may become more debilitating (
In many busy veterinary practices, clients only consult a veterinarian when their pets need medical attention and frequently they see whichever veterinarian happens to be available at the time. This approach of treating veterinarians as interchangeable may be implicitly supported when the practice does not clearly record and seek to reconnect clients with their regular veterinarian, and thus undermines the veterinarian–client relationship (
However, regular contact is not sufficient to ensure that a good relationship will develop. Borden et al. (
Communication skills are eminently teachable (
Development and discussion of communication tools and skill sets by the veterinary team as a whole can also help in acknowledging the stress associated with euthanasia decisions for both the owner and staff involved in the patient’s care. One appropriate approach is considering client relationships and emotions as topics for continuing education and team communication during regular staff meetings. This can improve staff interactions with clients and encourage the development of healthy coping mechanisms as part of an overall staff health and wellness plan.
Deciding how to manage a pet near the end of its life can be a very difficult process, and a pre-established habit of honest, respectful, and caring communication reduces stress and the chances of misunderstandings. Engaging established clients in conversations about quality of life and gradually introducing the idea of end-of-life goals for their pets prior to the time when those decisions are needed helps them establish appropriate goals and expectations prior to a time when the pet is already in crisis and the owner’s grief process has been triggered by the realization that their pet has a terminal condition.
Without effective client communication, clients may not be given the time or discussion they need to transition away from therapeutic treatment and toward palliative care, or they may not even realize this has occurred. Clients may inadvertently feel pressured into end-of-life decisions or miss the chance to make decisions about the euthanasia that may differ from the practices more commonly selected, i.e., “default” opinions. For example, it used to be assumed clients should not observe the euthanasia, whereas when clients make this decision for themselves, the majority opted to be present and this was often helpful to them in the grief process (
One specific example of a tool to use during discussions with clients is a quality-of-life assessment. These assessments are like other health and welfare questionnaires or checklist tools for healthy animals (
Quality-of-life tools vary in the circumstances they address, and veterinarians should be familiar with or seek out examples suitable for each patient and client. There are general checklists that might help illuminate whether any animal has “a life worth living” (
Veterinary hospice and palliative care are currently hindered by an inadequate amount of scholarly research to guide clinicians. The increasing use of palliative care and hospice in veterinary medicine necessitates further development of quality-of-life assessment tools for decision making when caring for terminally ill pets (
For vets beginning to use these tools for the first time, a practical example of a simple pet owner quality of life assessment tool is provided by The Honoring the Bond service at the Ohio State College of Veterinary Medicine.
When a decision to perform euthanasia is reached, it should be expressed clearly both verbally and in writing, such as the Model Euthanasia Authorization
As we have discussed, everyone associated with an animal’s death can be strongly impacted, including veterinarians (
A full 50% of medical clinicians—and most likely veterinary clinicians as well—suffer burnout, characterized by emotional exhaustion, cynicism, and negative self-evaluation
Strategies for preventing or dealing with burnout range from insisting on meaningful breaks from practice, such as vacations with no email or phone access to the hospital, a regular exercise program, colleague support group meetings, and opportunities for mindfulness and meditation (
As well as seeking to cope with stress, efforts should also be made to reduce stress to its lowest necessary levels. There is evidence that veterinarians cope better with stress resulting from adverse surgical events when they can learn something from the experience that can benefit their future patients (
If veterinarians ultimately find their employment does not or will not support them with an ethical decision-making framework or workplace wellness efforts, they should consider seeking out a different employment opportunity that will make it easier for them to find meaning and satisfaction in their work—as this is the greatest single factor for reducing workplace stress. Employers finding that they struggle to retain veterinarians and/or clients should include ethical and wellness considerations in their analysis of the problem.
The high rate of suicide among veterinarians (as well as human health professionals) is a matter of extreme concern (
Promoting healthy decision making during the euthanasia process of a companion animal is important for veterinarians’ wellness, for ensuring a humane and respectful outcome for animal patients, for strengthening the human–animal bond, and for maintaining the reputation of the profession. Veterinarians need to develop and maintain empathic, professional relationships with their clients if they are to serve as a partner in dialog when euthanasia is an alternative to continued suffering. Understanding the nature of the bond between the pet and caregiver plays the most important role in determining the outcome for each animal, owner, and veterinarian. Ideally, the occasion includes a shared and compassionate appreciation of the situation, the options, and the likely outcomes of the choices that are to be made. Veterinarians who are not comfortable with addressing the full range of a client’s needs should explore the options for training and collaboration with professionals trained in grief support.
The continued strengthening of the human–animal bond has greatly complicated the ethical conundrum surrounding euthanasia. Euthanasia is an emotional, psychological, and economic issue that every veterinarian must wrestle with. Many in the profession experience extensive stress as they grapple with the conundrum of ending an animal’s life too soon, or waiting too long, in addition to managing the client’s expectations and accommodating their emotional needs. A number of approaches are available to help veterinarians develop strategies for putting end-of-life decisions and experiences into perspective and to help prevent or deal with “burnout” syndrome. Having a working knowledge of ethical values, principles and decision-making frameworks can help veterinarians make decisions with confidence and in turn help their clients problem-solve and confront ethical dilemmas together.
For veterinarians wrestling with the conundrum of euthanasia, this article has outlined a number of ethical decision-making tools and deliberative frameworks that can to help them better manage end-of-life discussions with their clients to produce optimal outcomes. Actively encouraging clients to carry out regular, routine preventive care visits with the same veterinarian will foster the development of meaningful, long-term veterinarian–client–patient relationships. These relationships can be further enhanced when the veterinarian and all of the veterinary hospital staff undergo regular continuing education on client communication focusing on non-verbal communication, reflective listening, open-ended inquiry, and empathic statements. The ethical decision-making frameworks highlighted here facilitate conscientious, humane, end-of-life decisions between veterinarians and their clients in order to promote the best quality of life for animal patients. Finally, it is important for veterinarians to have a standard end-of-life protocol that includes the use of quality-of-life assessment tools, euthanasia consent forms, and pet owner resources for coping with the loss of a pet and that is reviewed at least annually with all of the practice staff.
All the authors contributed significantly to the concept and text.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
This manuscript represents work the authors completed in their role as the members of, or staff support to, the AVMA Steering Committee on Human-Animal Interactions (SCHAI). The authors thank Dr. Lynette Hart, Lindsay Rojas, and Lindsey McKinney for assistance in drafting and reviewing the manuscript.
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