Confronting Grief

"Death is something we, as a society, have grown more comfortable not talking about. It is only after personal loss that death becomes a reality. Grief is a difficult journey indeed, one that could use some kind words and light shed upon it."

— RYANE ENGLAR, VETERINARY STUDENT AND CO-PRESIDENT, PET LOSS SUPPORT HOTLINE, CORNELL UNIVERSITY

Perhaps Barbaro's owner, Gretchen Jackson, said it most eloquently: "Certainly, grief is the price we all pay for love." The impact of Barbaro's Jan. 29 death on horse enthusiasts can't be underestimated, experts say.

The horse's injury and subsequent euthanasia captured the media spotlight and focused the world's attention on veterinary care.

It's a high-profile example of an issue that equine veterinarians confront routinely: trauma and humane euthanasia. Understanding the grieving process will help doctors offer resources and some guidance to clients on healthy ways to heal from their loss.

The veterinarian's response to loss

The birth of a foal is a welcome event, perhaps bringing hope for a Thoroughbred champion or new trail companion. But a critically ill patient, or one that suffers a life-threatening injury, may stir thoughts of an "unsuccessful" outcome — the loss of a client's horse and faithful companion in the balance.

The veterinarian strives for wellness and caring, so his or her compassion is at the essence of the profession. "Success takes place every day as each patient's quality and quantity of life is extended. It takes place when clients are genuinely supported through difficult times," says Carolyn Butler, counselor, Impact Communications LLC. "It is important to remember that, with veterinary medicine, success cannot solely be defined as cure, nor can failing be defined as recurrence of illness or death," Butler says.

Still, it is no surprise that veterinarians often struggle with grief-related issues after the death of a patient, particularly with their role in euthanasia. This is especially true when the relationship to a client's horse extends over many years.

"Although medical training teaches the importance of exhibiting detached concern — a component of practicing medicine that is key to veterinarians' survival — the reality is that a veterinarian may find himself or herself mourning the loss of a patient," Englar explains. That dichotomy, between what is taught and what is practiced, is sometimes difficult to weather.

On one hand, a veterinarian might feel he or she needs to be "strong for the client," and therefore not express emotions. To a degree, that is true. Throughout the doctor-patient relationship, but especially at the critical moments surrounding patient death, the veterinarian's role is to be there for the client. "One must always take caution never to make those final moments about yourself or your needs," Englar says. "It is always about the client. It would be inappropriate to be overly emotional or over-involved.

"But at the same time, we as professionals need to be open and honest to ourselves, and to our feelings, if not in the room with the client, then certainly at the end of the day. Try as we might to distance ourselves from our patients, we are only human," Englar says.

The veterinarian who has watched a foal grow to adulthood naturally will miss that presence and that patient. Veterinarians need to accept that about themselves, and to recognize when cases have affected them. It is important that they and their staff communicate those feelings to one another, and recognize whether they are in fact grieving.

"The manifestations of grief occur on physical, intellectual, emotional, social and spiritual levels," Butler explains. They may include crying, shortness of breath, sleep disturbance, anorexia, denial, confusion, inability to concentrate, a need to reminisce about the loss, a sense that time is passing too slowly, sadness, anger, depression, self-doubt, feelings of withdrawal, feelings of being overwhelmed, alienation, rejection and shaken religious beliefs.

Most people enter veterinary medicine, not only because they appreciate the technical challenges, but also because they are "natural caregivers." There is a melding of skills and talents, as most clients want both aspects of care from their veterinarian. "However, if veterinarians don't recognize the pitfalls of supporting others emotionally, while not caring for themselves, they are at high risk of emotional depletion," cautions Kathleen Ruby, PhD, a licensed clinical counselor at Washington State University veterinary school.

"Psychological research is now recognizing such depletion as compassion fatigue," Ruby says. Life-and-death battles are not always won, and that places a burden on the person in the battle. "Most often, such losses are unavoidable, and yet vets who constantly walk the line between life and death tend to castigate themselves for the loss," says Ruby. This is destructive. "Just as clients need empathy and emotional support, vets must provide the same supportive dialogue to themselves and their staff," Ruby advises.

The deeper the bond between the client and their horse, the more need there is for emotional support from the veterinarian and staff. These more highly bonded clients seek ever more technically sophisticated care for their animals. "This creates an ever-upward spiral of intensified, emotional interaction between the veterinarian, the staff and the client," says Ruby. These "emotionally charged client/patient interactions, although very satisfying and beneficial, can leave practitioners and their teams with empty emotional buckets," she cautions.

"Each time a veterinarian cares for a companion animal, and it dies or is euthanized, this must be looked at as a critical incident," Ruby says, defining critical incidents as events with a high degree of "emotional charge" for vets, staff and clients.

"It also must be recognized that the impact of critical incidents compound if they are not somehow discharged. This is why adopting a practice philosophy of keeping your emotional bucket full is important to a long, successful career," Ruby says.

She offers the following tips for ensuring that a veterinarian's emotional bucket does not become depleted:

• Make peace with the reality that, as a caregiver, you cannot respond as an emotionally responsive, compassionate medical professional without it impacting you emotionally. This is a human reality, not a weakness. If you give, it can drain your bucket. You must, therefore, adopt a plan that will periodically replenish your emotional capacity.

• Knowing and accepting this reality, find a trusted colleague with whom you can talk through these feelings and express your distress. Take turns listening and supporting one another through difficult cases. Being a "lone ranger" is not helpful or advisable.

• Establish an atmosphere within your practice that is open and accepting of the impact patient death and euthanasia may have on your staff. Encourage them to honor and respect this reality with one another and to provide support to each other and to you.

• Establish realistic boundaries within your practice to ensure you have times when you can get away, regroup and rejuvenate yourself.

Although loss, sadness, grief and self-doubt are part of being a compassionate medical practitioner, developing a lifestyle and practice style that buffer the impact of these emotions is key to a healthy professional (and personal) life. "Just as an elite athlete must train to endure the rigors of constant athletic pressure, so too must the veterinarian train to remain the exemplary healer and practitioner," says Ruby.

In responding to loss, the veterinarian also must consider the needs of staff members. For them, grieving is necessary, unavoidable, and is a healthy response to a patient's death. Compassion of staff members makes the atmosphere of a practice sympathetic to grief and animal loss, though expression of grief may be more challenging for staff members.

It might be difficult to provide direct staff support, so mental-health professionals outside the practice often can provide counseling. If you treat grief as a normal process, everyone in the practice will begin to feel that expression is acceptable.

Permission to grieve is as important for staff as it is for the veterinarian. Cheryl Weber, MSW, client counselor/ grief specialist at the University of Illinois Veterinary Teaching Hospital, suggests some actions that may help the compassionate veterinary team to stay emotionally strong when facing the euthanasia of an ill horse:

• Informing staff that have been involved with the horse's care that euthanasia is planned.

• Giving staff the chance to say goodbye to horse and client.

• Having staff support clients during euthanasia.

• After the euthanasia, having staff prepare any keepsakes clients may request, like a braid of mane or tail or the horse shoes.

• Allowing staff to sign condolence cards to the family.

• Debriefing a case as a team afterward, reflecting on what was done well, what could have been done better and supporting without judgment of each others' reactions.

• Accepting that different staff may have different reactions — one may be sad, another relieved, another angry.

• Reviewing the compassionate care given to both horse and owner.

• Seeing euthanasia of an ill animal not as a failure, but as a relief of suffering.

• Praising staff for their efforts to comfort clients during a difficult time.

• Reflecting on lessons learned or special meaning found from knowing the horse and owner.

Grief support to clients

Veterinarians can help clients with a loss by providing support, acknowledging the loss and showing sympathy toward their clients' reaction to it. A heartfelt understanding of what the client is going through will help not only the client, but also help sustain the staff during a difficult transition.

Veterinarians can demonstrate their compassion for the person's suffering, just as they do for the animals in their care. A kind expression, such as, "I know you're experiencing much pain. Would you like to talk about it?" can bring some comfort.

"The veterinary team's skillful use of empathic communication can help clients cope with grief," Weber says. "Empathy includes the ability to listen, to understand the client's perspective, to sympathize with their experience and to express understanding, respect and support.

"The importance of empathy as a core competency for physicians is well recognized. In human medicine, empathy is seen as a key component of professionalism. A doctor's empathy can facilitate trust and reduce stress and anxiety. There is also evidence that a physician's professional satisfaction may be correlated to empathy," Weber says.

Veterinarians may feel that they need to be stoic for the client. To a degree, this is true. But at the same time, unnaturally stifling emotion may make one seem aloof and uncaring. "Try to strike a compromise," Englar suggests. If tears are welling and you feel comfortable being "open," then allow the tears to come. Tears are acceptable, as long as you maintain composure.

"Remember that it is not your role as the veterinarian to 'take over,' but it is OK to show your human side. It is OK to show the client that you care," Englar says.

While many practices may not have grief-support services in-house, they can inform clients about helpline call-in services or refer them to mental-health professionals.

According to Englar, "It is common for the bereaved to feel that their grief is in some way at odds with the fast-paced world around them. They find that, after a loss, the world does not stop to meet them halfway. What they are not told by friends and family, and what they need to hear, is that there is no timeline for grief. Grief is individual. It is, at its core, about who we are inside. It is about our internal process, our own attempt to regain understanding of a world that has shattered around us."

It is the veterinarian's role to assist clients in their struggle to accept their loss. They may find it difficult to grieve openly the loss of a companion animal; conversations with friends and family might not have gone well. Englar adds, "Many clients come forward with frustrations that their grief journey has been minimized. 'He or she was just a pet,' they may have been told. Or 'you can always get another horse.' "

Because clients need someone to validate what they are experiencing, a veterinarian's relationship with the client should not end with the death of a companion animal, but should continue through the grieving process. The veterinarian should emphasize that the bond between owner and horse is irreplaceable, and that the horse will be missed.

"We as veterinarians may empathize with their pain," Englar says, "but we will never truly understand the depth of loss the client is feeling. Only the client knows the magnitude and the enormity of his or her loss. It is our duty to be there for them, should they feel a need to express that, and to point them in the right direction when they articulate their need for assistance."

Veterinarians may also want to follow up with clients after a loss, by sending a sympathy card, making a memorial donation or a phone call to see how they're doing. Sometimes all the client needs is to know that their horse is remembered, that the memory did not die right along with the horse. In doing so, veterinarians can help to heal themselves as well as their clients. "Their grief is not one and the same, but the ability to share in the life of the horse and in the horse's memory is a strong bond that can help both parties through," Englar suggests.

The practitioner should realize the components of grief and understand that each client will handle it in his or her own way and time. Denial, anger, depression and acceptance all take different forms and time for each person.

Dealing with anger

A veterinarian especially needs to understand client anger, which might be directed toward him or her. Clients often turn anger toward themselves (guilt) for not doing enough for their horse, or direct it toward the veterinarian for "not doing enough," or "the right thing," sometimes only because the veterinarian is an easy target, readily available. The client really is angry "because the animal died, and may even be angry at the horse for dying, but it's difficult to be angry at death or at one's beloved horse," says Sandra B. Barker, PhD, professor of psychiatry, director of the Center for Human-Animal Interaction, Virginia Commonwealth University. "Blaming and accusing others or trying desperately to find out precisely what happened are two ways that an owner can focus on others and facts, not on the death that has occurred and their own grief reactions," Barker says.

Veterinarians can help angry clients by realizing that anger is a normal part of grief, and letting the client know they understand their feelings. "A vet's empathic response will help defuse client anger," Barker says, and demonstrates compassion. "However, our natural response to accusations is to become defensive, which is not helpful. Veterinarians who understand that anger is a natural grief response can set aside the tendency to defend themselves and provide needed support. Simply acknowledging, 'You're angry because I wasn't able to save her. I wish we could have saved her, too,' can be supportive to clients. When clients are intensely angry, veterinarians can help calm them by talking slowly and softly and keeping a safe distance."

Healing

Veterinarians play a key role in the life and death of their patients. "It is important to work through what one is feeling rather than to try to shove it under the carpet," says Englar.

Veterinarians enter the profession because they care. It is important to know that their emotion doesn't just "turn off." They may blame themselves for an animal's death. They may feel guilty that they "could have done more," or that the horse would have pulled through had they been a "better vet."

Such feelings are normal, "but practitioners need to find a way to work through them, in a way that enables them to continue to provide compassionate service to themselves, to their clients and to their patients," Englar suggests.

Client care cannot be sacrificed because the veterinarian is hurting. Veterinarians need to learn to take better care of themselves, so that they can be available in every way to their clients during difficult times and the decision-making process. "Veterinarians need to remember to practice compassion with restraint, so as to avoid potential burn-out," Englar says. They also need to practice balancing compassionate distancing with over-involvement. Veterinarians may be hurting, too, but as a group they must remember that this is not their moment. It is the horse's and the client's moment to share.

"Veterinarians are merely facilitators in the process that paves the way between life and death," Englar adds. "To ensure that they are there for their clients in the way that they ought to be, veterinarians need to accept what they feel and seek help when they are in need of it," Englar counsels.

What can veterinarians, students and technicians do to heal emotionally after one of their patients has died?

"The most important thing is to be honest and truthful with themselves and their emotions," says Englar. Veterinarians, as professionals, need to accept that some days will be harder than others, and that some patients will be hard to let go. Vets may be taught to distance, but as humans they may fall short. "That is OK, so long as, at the end of the day, the client comes first — that veterinarians are the ones comforting the client, not the other way around," Englar says.

To be strong for clients day after day, it is important to step back occasionally and consider the toll that losses may have on them. "Veterinarians need to find some common ground, some means of taking care of themselves," Englar says. They may experience loss more than other professions, because of their role in euthanasia. "The most vets can do, for themselves and for their clients, is to provide compassionate medicine, right through to end of life, when their clients and their patients need it most," Englar advises. By listening and being open to clients' concerns, fears and loss, vets are reminded of the power of the human spirit, of the power of love and how those who live inside their hearts are never truly forgotten.

Veterinarians can help those memories live on, simply by being there in times of need.