Preparing owners for the death of a pet

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How do you know when it is time? Veterinarians are commonly asked this question. According to Lynn Hendrix, DVM, CHPV, owner of Beloved Pet Mobile Vet and cofounder and outgoing president of the World Veterinary Palliative Medicine Organization, sometimes it is asked because the owner is looking to an expert for permission to go ahead with a decision they’ve already made, and sometimes it is because they truly do not know. During a recent Fetch dvm360® virtual conference, Hendrix discussed how veterinarians can help their clients prepare for the death of their pet.

The psychology of end-of-life decisions

Hendrix said that the reactions to decisions surrounding the death of a pet are often driven by fear. This fear may be about the impending loss, the cost of treatment, of waiting too long to help their pet, or of feeling shame about their decision.

This fear can manifest in many ways, usually through the fight, flight, or freeze response seen when the body is under stress. Those whose fear manifests as anger are usually in fight mode. Those in flight mode may leave the clinic without making a decision or even taking medications. The last group are those who seem to be in denial but who are experiencing the freeze response. In Hendrix’s experience, “most people who seem to be in denial are not. They are fearful.”

She encourages veterinarians to give owners time to process and take the time to discuss with them what they may be fearful of. It is essential for the patient’s well-being that the veterinary team and client be on the same side. Trust must be established, and judgment withheld. This can be difficult when you and the client are seeing different things when looking at the pet.

Hendrix reminded the audience that perceptions vary among individuals and are influenced by past experiences. She differentiated the idea of suffering from distress. Those without medical training may not perceive that their pet is suffering as we might. Distress, on the other hand, can be observed. We can advise owners on clinical signs to watch for, such as changes in respiratory patterns or posture that may be indicative of respiratory distress or pain. Once an owner can recognize signs of distress in their pet, they are more likely to be open to a conversation about palliative options.

Patient assessment

The first step in guiding owners through end-of-life decision-making for a pet is an examination. Pain assessment is crucial, as Hendrix finds that “many diseases have pain at the end stage.” It is important that the veterinarian identify signs of pain and help the owner to recognize them as well. Hendrix recommends utilizing validated chronic pain assessments. For dogs, the Helinski Brief Pain Index and Canine Brief Pain Inventory provide good options. For cats, the Feline Musculoskeletal Pain Index is useful. Hendrix noted that the Feline Grimace Scale was recently validated for acute pain but may be useful in end-of-life situations as well.

When it comes to quality-of-life assessments, Hendrix said many exist but most are not validated. She does not use the current scales as she feels many of them miss the more subtle changes in the patient, emotional impact on the family, the patient’s will to live, or considerations of the family’s quality of life in caring for the patient. Quality of life is multifactorial, nuanced, and influenced by the client’s perceptions, so assessing it should be done through conversations between the family and veterinary team.

Advanced planning

When Hendrix works with families, she encourages them to have a plan in place for how they want their pet’s death to happen, regardless of whether it be euthanasia or palliated death. She encourages veterinary teams to discuss several factors with clients:

• Where will the pet’s death happen, and what items would the family like to have around the pet in this place?
• Who will be present? This decision should include both family and veterinary team members. Hendrix recommends that families have a backup plan in case the primary veterinarian they have chosen is unavailable when the time comes.
• How will the death happen? Will it be euthanasia or a palliated death?
• What discussions need to happen with children and other family members before and after the death?
• What plan does the family have for grief or spiritual support, if desired?
• What are the aftercare plans?

Another component of planning is to develop an advanced directive for the pet. Just as humans have advanced directives for their own medical care in the event of an emergency, this plan can be determined ahead of time to avoid the family having to make difficult decisions during an emergency. Factors that should be considered in the advanced directive should include what the family wants their pet to be able to do, what they don’t want their animal to experience, the amount of acceptable medical intervention, and considerations around the family’s quality of life in caring for the pet (eg, waking throughout the night, nursing care).

Be prepared: Crisis kits

For families whose pet in a hospice situation, Hendrix provides a crisis kit that contains medications and instructions for when they might need to be used. These instructions are specific and explicit and include when to give the medication, how to administer it, how long it will take to have its intended effect, and when the next dose should be given if needed.

Crisis kits are also known as comfort kits and should include medications that anticipate potential emergency situations the pet and family might face during the end stages of the disease. Pain management for acute, severe, or unrelenting pain is a must. This is often in the form of an opioid that can be given by injection or via the transmucosal route.

Medications to manage anticipated signs of the disease should be included as well. The make-up of each kit will vary by patient and disease but may include these components:

• For management of respiratory distress: a short-term oxygen supply, such as Pawprint Oxygen, sedation to relax the pet, or nebulized medications
• For acute seizures: benzodiazepines, gabapentin, and honey or karo syrup in case there are concerns for hypoglycemic seizures
• For hemorrhage: aminocaproic acid and Yunnan Baiyao
• For sleep disturbances, anxiety, and agitation: Acepromazine, melatonin, or a benzodiazepine
• For nausea and vomiting: maropitant (Cerenia; Zoetis), ondansetron, or metoclopramide
• For diarrhea: metronidazole and clay products

Finally, for owners who have planned a palliated death, items to prepare for caring for a recumbent pet should be included, including lubricating eye drops. For those who have planned for euthanasia, higher doses of sedatives can be included and administered when the owners feel it is time to euthanize. The goal of these medications is to sedate the pet enough for a peaceful and safe transport to the veterinary office or until a house call veterinarian can arrive.

Palliated death

While most veterinary professionals would prefer a pet in the end stages of disease to be euthanized, not all owners are comfortable with or ready to make that decision. A palliated death allows the pet to die from the disease, but with interventions to control pain during the end stages.

In many cases, palliative sedation is used, which maintains life while providing pain relief and keeping the patient subconscious to unconscious for the remainder of the disease course. It is important to discuss with owners that for many palliated deaths, 24-hour recumbent care and extensive nursing care are needed. In Hendrix’s experience, once owners are educated on this process, many elect euthanasia for their pet.

The gentle euthanasia

For owners who choose to euthanize their pet, minimizing distress and providing a gentle euthanasia experience should be the veterinary team’s priority. Hendrix encourages veterinarians to consider how each drug and step in the process make the client and the patient feel. She recommends administering sedation and/or pain medications via a subcutaneous or intramuscular route prior to placing an intravenous catheter. The use of topical numbing gels should be used during the placement of the catheter to minimize discomfort for the pet. She noted that some clients prefer their pets to become sedated gradually, allowing them to spend time with their beloved pet, while others prefer a fast experience. These preferences can influence choices of sedation and route of administration.

Take-home points

For each family, Hendrix says, the decisions they make are related to their relationship with their pet during life. Having a veterinarian who can help them through the process and the many decisions involved in creating the best possible death for their individual family and pet is invaluable.

Kate Boatright, VMD, a 2013 graduate of the University of Pennsylvania, is a practicing veterinarian and freelance speaker and author in western Pennsylvania. She is passionate about mentorship, education, and addressing common sources of stress for veterinary teams and recent graduates. Outside of clinical practice, Boatright is actively involved in organized veterinary medicine at the local, state, and national levels.