This is Part 3 of our Support Protocols for 14 Common Situations series. The cases described in this series are drawn from everyday scenarios found in general veterinary practice or emergency and specialty practices. Below you’ll find an example of a type of case you’re likely to encounter in practice. This blog’s subject is a case involving euthanasia decision making.
Situation: Euthanasia Decision Making
Dawn is sitting beside you in an exam room after a follow up visit with her Cairn Terrier, Candy, who is terminally ill. You’ve told her that the prognosis is bad and it may be time to make end-of-life decisions. Biting her nails, she replies, “I don’t know what I should do. I promised Candy I would always make the decision that was best for her, but I don’t know what that is. I don’t want to give up too soon if there is any chance for her to get better, but I don’t want her to suffer either. If Candy were your dog, what would you do?”
Assessment: What’s Going On Here?
Dawn’s dilemma is not uncommon: Decision-making is one of the most difficult tasks that pet owners face. Whether the decision is fairly inconsequential (e.g., vaccinations, dental exams, diagnostic tests) or extremely serious (e.g., surgery, amputation, expensive treatments, euthanasia), many pet owners get stuck in the decision-making process and ask for additional guidance from veterinary team members. Yet, clients like the one who asked the question in the opening scenario are not just looking for a medical opinion; they are also looking for reassurance. They want to know that you will support them regardless of the decision they make.
But there is a problem with this situation. Most clients want to please the professionals with whom they work and hope to be viewed as cooperative, responsible clients. Thus, they may move ahead with the decision to euthanize based on your recommendation even if they are not yet ready to let go. Later, some of these clients may feel that you pressured them into euthanizing their animals. When clients believe their veterinarians rushed them through the process of saying goodbye and helping their pet die, it can cause irreparable damage to the veterinarian-client relationship.
Plan: Support Protocol for What to Say and Do
Lay the Foundation (Step 1)
- Structure the environment so there will be a quiet, calm space that allows for a potentially emotional conversation. Be sure to have plenty of tissues on hand. Pay attention to seating arrangements and always sit with clients rather than towering over them. Towering above clients or leaning on the door with a clipboard or case file pressed to your chest can be intimidating and make it very difficult for clients to speak openly about their feelings. When you sit with them without obstructions like a desk or table between you, you can be at eye level.
- Create an environment that will help the client make a decision. Brochures, pamphlets, and other resources should be readily accessible to provide guidance and inspire the client to start asking difficult yet necessary questions.
Implement Support Techniques (Step 2)
- Keep clients responsible for their own decisions. Rather than stating your personal opinion, you might say, “If Candy were my dog, I would be confused and upset, just like you are. Euthanasia is one of the most difficult decisions you will ever make in your life, and the fact is that you and I would probably be ready to face it at slightly different times. Even if I believe the time is right to help Candy die, you must also believe it, or it will be difficult for you to feel at peace with your decision.” Another option might be, “The truth is, Candy isn’t my dog, and what I might do and what you might do could be very different. You are the expert on Candy. No matter what you decide, I’ll support you and your decision.”
- Acknowledge, validate, and normalize the difficulty of the client’s decision.
- Use a variety of decision-making strategies to help clients make choice that are right for them and their companion animals. When handled well, these stressful situations can actually improve or solidify your relationship with your clients. Following are some strategies to try:
Review the possible consequences.
Help your client to think through every possible option so that they can make informed choices based on their preferred outcome. For example, you might say, “I know it’s difficult to actually make an appointment to euthanize Candy, so let’s talk about the options. While it’s hard to schedule a time, if we do, we will know that we can create a peaceful death for Candy and give you the time you need to be with her.
Or, we can wait and let nature take it’s course, hoping Candy will die more naturally at home, without experiencing a great deal of pain. There are a variety of things that could happen, though, if we wait. She could die when you are not home, or her pain might become more severe, and, as much as I’d want to be with you, I may not be available when you really need me. These are some points for you to think about. I know you will make the decision that is right for you.”
Ask tough questions.
If the client still seems unable to make a decision, use attending behaviors and active listening skills to draw out their concerns. You may need to use immediacy and gentle confrontation to ask a few tough questions. These questions should be designed to help our client recognize the reality of the pet’s situation. They are probing questions and must be asked without any judgement in your voice.
Preface your questions with brief self-disclosure and a comment such as, “I am going to ask you something that is hard for me to ay and may be difficult for you to hear.” Then ask, “Are you telling yourself that this decision will be easier to make tomorrow or several days or weeks from now?” or “If you choose not to euthanize Candy, are you putting her needs ahead of your own, or are you putting your needs ahead of hers?” Be careful when you ask this last question. It must be asked very gently and with no judgement in your voice or in your facial expression.
Offer the illusion of choice and provide a back door.
In most cases, helping clients make a small choice will direct them toward the outcome you desire, yet still give them some feeling of control. You could say, for example, “I know you’ve decided to euthanize Candy, Dawn, but you’re still struggling with when to schedule the procedure. For Candy’s sake and with your agreement, I would like to make the appointment for tomorrow. Would two or four o’clock work best for you?”
If your client becomes more anxious once they have committed to a course of action, you can conclude this technique by providing your client a back door. A back door is a way to cancel their agreement. You could say, “If you find you simply can’t go through with the procedure, Dawn, you can always change your mind and reschedule your appointment for another time.”
Identify bottom lines.
A bottom line is a guideline by which your client can measure the factors that must be considered to make a decision. Bottom lines are different for everyone. When it comes to the decision about whether to euthanize a terminally ill pet, your client’s bottom line might be her dog’s inability to enjoy normal activities, her pet’s level of pain and discomfort, the length of time her dog is expected to live, or even the cost of continuing to treat the animal.
You might say, “Dawn, many pet owners find it helpful to imagine the circumstances that would need to arise for them to make this decision. I call this thinking about your bottom line. For some clients, the bottom line is the pet’s inability to walk or to get up under her own power. For others, it’s a change in the way the pet responds to them. Do you have an idea of what the bottom line might be for you and Candy?”
Enlist the pet’s help.
When your client and their companion animal have a deep, special relationship, there is also a unique form of communication between them. When a decision regarding the pet’s welfare needs to be made, you can encourage the client to enlist the pet’s help so that the client doesn’t feel they are making the decision alone. For instance, you could tell the client in this example, “Dawn, you and Candy have always had a special kind of communication. That hasn’t changed. Even now, if you get down on the floor, lie beside Candy, and look into her eyes, she may, in a sense, tell you what she is feeling and what she wants you to do. It’s possible for the two of you together to make this decision about how and when we should help her die.”
Help the client identify their own preferred euthanasia decision-making techniques.
Different people make decisions in different ways. Some people are very logical and practical, for example, whereas other base decisions more on emotions. To help the client use these preferred techniques, you can say, “When you have faced really difficult decisions in your life, what have you done in the past to come up with a decision? You might try using those same skills right now.”
Paint a picture regarding what the client will experience.
Many clients have never witnessed a pet’s euthanasia and may have mistaken ideas about what actually happens during the procedure. With the client’s permission, explain your protocol and tell the client that they can be present with the pet when it occurs. In other words, let clients know they will be able to hold or sit beside the pet, talk to the pet, and stroke the pet’s head, ears, and so one while you perform your medical duties. Creating a comforting, peaceful vision of saying goodbye to a pet is often the key to facilitating that final decision.
Stay Connected through Follow-up Care (Step 3)
- Know that your client support efforts will be successful when your clients make decisions that are right for them and their companion animal, even though they may not always be the decisions you wish they would make.
- If the client has not yet reached a decision, provide printed information and referrals to other resources. The resources may be veterinary grief counselors, books, brochures, or websites.
- Once a client has made a decision to euthanize, make the appointment and notify your staff so the entire team can provide support as needed.
Euthanasia Decision-making Role-Play Ideas
- For hospital managers and client care specialists: Using the above scenario, practice talking with a client who is struggling with a euthanasia decision and is pressuring you to say what you think they should do. Pay close attention to both your verbal and non-verbal communication. Are your body language and facial expressions inadvertently revealing what you think your client should do, rather than supporting your client’s through and feelings?
- For veterinary technicians: Use the scenario to practice responding to the client’s anxieties and questions. Since you provide nursing care, clients may be more likely to ask for your opinion over that of another staff person.
- For veterinarians: Practice using both verbal and nonverbal communication to help a client like the one in the above scenario to make a decision about euthanasia. Be sure to practice a situation in which the client is resisting making a final choice. Practice responding to questions and emotions.
Keep up the good work,
World by the Tail, Inc.