5 questions on the most difficult decision

Editor's Note: DVM Newsmagazine asked Cheryl Weber, a grief counselor from the University of Illinois, to share her expertise and advice when a doctor is asked to euthanize a sick animal.

DVM: What should every veterinarian understand about the subject of euthanasia?

Weber: Learn to do it well. Done with skill and compassion, clients will loyally return and tell their friends. Done poorly, euthanasia can result in you losing business or facing complaints or possibly a lawsuit.

First, a young veterinarian needs to become technically competent at humane euthanasia. One memorable story I've heard is how a dog chewed out of its cadaver bag in the cooler because it wasn't dead. Learn from the mistakes of others.

Second, expect that euthanasia will be incredibly emotional. Be prepared to respond to each individual's emotions with empathy and compassion. Give yourself permission to grieve. Work through your own emotions and maintain a perspective about the good that you're doing.

Third, communicate, communicate, communicate! Continually educate clients about what's going on, before, during an after the euthanasia. Empower them with knowledge and choices. Be respectful. Show them you care.

What do clients look for in a veterinarian? The May 1999 Executive Summary of the KPMG Market Study (online at www.avma.org) found clients said they wanted a veterinarian who is "kind and gentle." It is never more important than when you are euthanizing a companion animal.

Remember this quote: "People may not remember exactly what you did or what you said, but they will always remember how you made them feel." (-Author unknown)

DVM: What are healthy ways to approach clients about the subject of euthanasia?

Weber: Bring it up when you see it as a treatment option. Put it in the context of the diagnosis and prognosis, quality of life, pain and suffering.

Be honest. Be truthful with clients, especially when you have bad news to deliver.

Clients never want to hear bad news. It's hard for them. I've seen clients sob, scream, swear, wail, vomit, pass out and talk about suicide. Show sensitivity for their distress. Walk with them through the emotional times. Recommend resources to them if they need more help coping than you can provide.

What's not helpful? Practicing avoidance, offering false hope or communicating with too much medicalese, in other words talking beyond a client's understanding.

It's neither healthy nor helpful to avoid telling a client that his or her animal is dying because you think he or she will be upset.

It's not healthy to give false hope or set unrealistic expectations to surgical or therapeutic intervention. It might come back to bite you.

It's estimated that veterinarians deal with death five times more often than physicians. Become skilled at delivering bad news and bringing up euthanasia in an honest, sensitive and compassionate way.

DVM: What are your recommendations to veterinarians following euthanasia?

Weber: Several things you can do if the owner was present:

• Pronounce the animal dead.

• Stand or sit silently while the owner reacts. Be present.

• Listen. Don't nervously chatter to fill the silence.

• Offer tissues if there are tears.

• Acknowledge the client's emotion, i.e. "I can see how painful his death is for your family."

• Normalize the client's grief by saying something like: "It's normal to be upset when you're saying good-bye to such a special girl."

• Gently touch the animal and use its name.

• Offer the client time alone with the body (some people want that and some don't).

• If you have some time, listen if they want to reminisce.

• Support the client's decision if appropriate.

• Offer pet loss information.

• Prepare the body for transport if they're taking it home.

• Get payment if that wasn't done ahead of time or will not be billed.

• Walk the client to the door.

Offer your condolences. My experience has been that clients are deeply touched by a sympathy card personally signed by doctors and clinic staff that highlights something personal and special about his or her pet. Clients have shown me hand-written letters of condolence from their veterinarian (for great examples of letters, see the books I Still Miss You; Letters of Comfort for Cat Owners and I Still Miss You; Letters of Comfort for Dog Owners by Jack Titolo, DVM).

Some doctors make a follow-up phone call the evening of the euthanasia to offer support, dissuade feelings of guilt and reassure owners it was the right decision. A memorial donation serves a dual purpose; it supports a worthy cause and memorializes the pet. A bouquet of flowers or a plant may be appropriate for special clients.

Second, consider "linking objects" to give clients something to remember their pet by. Clay paw prints are popular at our hospital (World by the Tail Inc. offers these products Clay Paws™). We use them for bearded dragons to thoroughbreds. An ink paw print serves the same purpose. Clippings of hair, feathers or a braid of mane or tail can be a treasured keepsake.

Clinics that keep digital photos of their patients during their lifetime may give the family a photo. Of course, make sure to return to the family any of the pet's belongings that are at the hospital such as a collar, blanket or toy.

DVM: Do you think veterinarians play a role in helping clients grieve?

Weber: Absolutely. Consider this: "Veterinarians must realize their approach to caring for a client whose pet has died has the potential to alleviate or aggravate grief."

That was a conclusion of a study by Cindy Adams, PhD, MSW, Brenda Bonnett, PhD, DVM and Alan Meek, PhD, DVM called "Predictors of owner response to companion animal death in 177 clients from 14 practices in Ontario" (J Am Vet Med Assoc 2000; 217:1303-1309).

When the doctor gives the vision-impaired woman time to say goodbye to her guide dog before the euthanasia, she helps her cope. When the doctor encourages the parents to involve the teenagers in the decision about whether to euthanize the family Springer Spaniel that is "like a son," he helps that family cope. When the elderly widow who's become depressed after his dog died following surgery gets to sit down and go over the case and get his questions answered, the doctors have helped him cope.

Many clients tell me that friends or family don't understand. "It's just a dog" is what they hear. But at the hospital, every person on the veterinary team can convey to the client that they understand and care.

DVM: Are veterinarians at risk for developing compassion fatigue?

Weber: I think they can be depending on the type of work that they do. The more emotional the work, the higher the potential for compassion fatigue. The challenge of facing death, trauma possibly abuse and upset clients or staff can drain one's compassion if it's not protected and replenished.

Other professions that have been studied in relation to compassion fatigue are emergency-room nurses, disaster workers, policemen, mental-health workers and physicians.

A 2003 survey of veterinarians by the Humane Society of the United States found compassion fatigue impacted all members of the veterinary team, from doctors to technicians to office staff. It was not limited to the people who euthanized animals. Results were reported in the book "Compassion Fatigue in the Animal-Care Community" published in 2006 by the Humane Society Press.

A survey given at the 2003 AVMA conference in Denver and reported in the April 2004 AVMA Wellness Report found that 84.6 percent of respondents surveyed identified stress, burnout and compassion fatigue wellness issues facing the profession. Other wellness issues identified included depression, anger management, anxiety disorders, alcohol abuse and drug dependency.

DVM: Are there steps to preventing compassion fatigue?

Weber: There are many steps that can be taken to help prevent compassion fatigue. The general rule is to take care of yourself. If you give and give to others without filling up your own cup, your cup empties. Learn and use healthy stress management skills daily.

Some steps include:

• Maintain a balance between your work life and personal life.

• Be able to say no. Set boundaries to protect time for yourself and time for family.

• Eat healthy, exercise regularly, and get enough sleep.

• Find the healthy level of emotional involvement in cases (called "detached concern"). Avoid the extremes of emotional over-involvement and over-identification, on the one side, and a cold, insensitive, callous detachment on the other.

• Build a strong support system of people inside and outside the profession.

• Keep your eye on the rewards of your work and celebrate your achievements.

• Avoid self-medicating with alcohol, illegal drugs or prescription drugs as a way of coping with stress.

• Know when you're getting stressed out, burned out and fatigued. Have self-awareness to know when your gas tank is low and find ways to refill it.

A good book is The Resilient Physician by Wayne and Mary Sotile. Published by the American Medical Association (2002) for physicians, it offers good advice for veterinarians. This compassion fatigue article on the Family Practice Management Web page also is helpful: www.aafp.org/fmp/20000400/39over.html