Straight talk

NATIONAL REPORT — According to the recent "Compassionate Care Online Survey" from Virbac Animal Health, 47 percent of veterinarians have end-of-life discussions with their clients more than 11 times per month. How these conversations unfold, experts say, is key to a client's comfort with their choice in extending or ending a pet's life.

It's a crucial conversation, experts say, and practitioners should take the time to find common ground with the client when addressing the pet's quality of life and/or the realities of caring for a terminally-ill animal.

Clients can be resistant to the idea of terminating a beloved pet's life, and in broaching the subject, timing is everything, says Cindy Adams, PhD, MSW, associate professor of veterinary clinical and diagnostic sciences at the University of Calgary.

"Even though the vet may want to dispel their belief that the animal is suffering, the timing needs to be attended to," Adams says. "That often lands way too early on and the client's ability to process information is (inhibited), so the client becomes resistant or angry."

Spend time understanding the client's perspective, Adams suggests. "Try to secure some common theme between the doctor and the client," she says. "Often that is (accomplished by showing) interest in the patient. Show you understand (the pet's) struggle, and that you are both committed to ensuring it doesn't suffer anymore."

Learning, or already knowing, an animal's quality-of-life indicators aids the discussion as well, says Dr. Kate Knutson of Pet Crossing Animal Hospital and Dental Clinic in Bloomington, Minn. With her clients, she says, "We talk about quality of life and what the client perceives is important to the pet."

Knutson provides the example of her own Doberman, which died of heart failure last November. "I knew she didn't want to be bed-ridden," she says. "I knew she had to have certain happiness quotients for her to feel life was worth living—to go outside and run around without me stopping her ... and to eat food with gusto." Focusing on those quality-of-life indicators, she says, will help clients and veterinarians chart the most appropriate course for a patient. "Every pet is different, just like people," she says. "Some people would be fine in a wheelchair and some wouldn't want to live. Pets are the same."

To that end, a quality-of-life scale can be a useful communications tool. While Adams cautions that some clients may not be receptive, others find it helpful.

"It may be useful to sit down and go through it, but manage it appropriately," she says. "Don't send them off with it." As a discussion tool, she says, it can be an enabler when it comes time to make a decision. "If a vet sees something different than the client when scoring alongside them, it can be facilitative," she adds.

Money matters

These days, money is tight for many Americans, and when presented with the prospect of thousands of dollars in surgeries or other treatments for a pet, it's an insurmountable obstacle for some clients. Difficult conversations can ensue when a client inquires about euthanasia due to the potential economic burden. "Economics are important no matter what," acknowledges Knutson. "On the human side of medicine, as we age, there may be a point in time where either you take your medicine, or you can't afford to and you don't."

In dealing with similar situations with pets, Knutson again advises having a quality-of-life discussion. "Is this something that absolutely needs to be fixed to have the quality of life the pet would want? If the answer is yes, and the client can't afford it, we try our best to adopt the pet out to someone who can afford the procedure," she says, before moving on to potentially euthanizing the pet.

When, perhaps, a puppy is suffering from parvo, and it will cost $10,000 to $15,000 to fix it, and even then with uncertain results, this, Knutson says, can put some clients in financial ruin, and a frank discussion needs to occur. "You need to sit down with them and ask, 'Does this really make sense?' A lot of times, the answer is no," she says.

Adams encourages veterinarians to be open and proactive about costs. "Clients are frustrated when cost discussions aren't initiated by the veterinarian," she says. "Both the cost from a well-being (standpoint) and also the future prognosis of the client are important." She advises vets to be attuned to verbal clues about financial considerations and then acknowledge these.

For Knutson, who has the luxury of seeing many of her patients five times a year in her practice's wellness center, open and honest discussions are commonplace, and many of her clients are willing to go the extra economic mile for their pets.

"I've had a lot of clients who say they'll get a second job—clean houses or work in a coffee shop—to pay for their pet's care," she says. And it's not just her clients, but Knutson herself who made economic changes for her pet. "I had a cat that was really sick and had to take it to Wisconsin (for treatment)," she says. In making a decision, Knutson remembers thinking, "If I give up my Starbucks for this many years, I can do it. And that's what I did."

However, Knutson acknowledges that this isn't always the case. "It's easy for me to give up a vacation if it means I can keep my pet alive," she explains. "But to some people that would not be acceptable."

When a veterinarian is steadfast in his or her belief that a pet can be saved, Adams suggests continuing the discussion. "Acceptance doesn't always mean agreement. Tell the client, 'Thank you for being honest about cost issues. I'm struggling with being asked to euthanize him because I know we can make him better."

Adams recommends offering the option of trying to place the pet with another family. But, if a client is insistent, she says it is important to fully grasp the philosophy of a practice. Some practitioners, she says, will work hard to determine alternatives to euthanasia, but others may easily perform the procedure. "More long-standing practitioners may be more willing to euthanize because they have seen so much more and can't be in the business of saving everything," she acknowledges. But, the key, she adds, is, "Can you go to bed and sleep at night?"

Managing end-of-life communications with clients is essential, and Adams says veterinarians aren't always doing the best they can.

In a current study, Adams and one of her graduate students are assessing this topic. "There is a lot of asymmetry in our profession," she says. "We think we are doing a better job of managing communications than we are. We speculate there may be quite big disparities between what we think we are doing and what we are actually doing."

Client communication: Talking about the end

When the decision is reached to end a patient's life, addressing the client's needs is important, as is communicating what the process will look like.

At the outset, says Cindy Adams, PhD, MSW, of the University of Calgary, you should find out if the client has been through the process before. In addition, she advises you ask how much information a client wants. "For some, this is not a big deal," she says. "One prescription (doesn't fit) everyone. Offer clients different options and ensure they know what they'll see and experience in each one.

At Dr. Kate Knutson's practice in Bloomington, Minn., she asks clients about their prior experiences with euthanasia. Rituals are a healthy way to honor a pet's life, Knutson says. Some of her clients want to be with patients before, during or after the procedure, or even have a last meal with their pet, which she accommodates.

To prepare clients on the day of the euthanasia procedure, Knutson sits down and discusses with the client the events that might occur. Then, she adds, "We always give our clients permission to ask questions and give permission to say 'I'm ready' or 'I'm not ready.' I think it's best to explain the process, and then tell them that this (experience is their own) and that we are here as facilitators and not on a time schedule."

Some veterinarians may worry that a euthanasia experience led by the client may create schedule problems. What if a client struggles to make the decision? Knutson says it's not a problem. "If you provide people the opportunity (to take their time), they don't (wind up) tying up an exam room," she says. "It's really strange, but, psychologically, if you give the client permission, they do the right thing."

Following the procedure, many practices send a card to a grieving client or offer other resources. At Knutson's practice, a volunteer grief counselor follows up with a family two weeks after the animal was euthanized to find out how they are doing and what assistance the practice can offer. The counselor also offers an open session one Saturday a month. "Not a lot of people come, but the people that come really need it," Knutson says. "They need a professional other than the vet. We kill patients, but we're not trained in the grieving process."

Knutson says that in most areas where there is either a college or university system, practices can reach out to social workers or psychology majors who may be looking for credit or field hours to offer services to veterinary clients. "It makes so much more sense than the vet staff trying to do pseudo-science," she adds.