Valarie Adams is a CVT with over 40 years working in veterinary medicine. Graduating from the Medical Institute of Minnesota in 1973 puts her in the “aged but still useful” class. Throughout her career in veterinary medicine she has worked with large and small animal, emergency and critical care, and delivering in-home veterinary hospice and palliative care. Valarie has lectured on end-of-life topics nationally as well as written and co-written for textbooks on pet hospice and facilitated pet loss support groups. She fills her soul with her horses, as well as volunteering on a Native American reservation and gathering with free-spirited, wise women. You can also find Valarie at confidesinanimals.com.Read Articles Written by Valarie Adams
She walked calmly through the door. An Irish wolfhound, his head hanging, walked slowly and miserably at her side. This was around 1 o’clock in the morning at a 24-hour emergency/specialty practice. I went up to triage, already having a heads up that a possible bloat was on its way. One look at this dog told me the possibility was more likely a probability.
It was policy with a suspected GDV (gastric dilatation-volvulus) case to immediately place an IV catheter, give something for pain, and take a radiograph. I needed the owner’s permission to do this. When I told her what I thought the problem was, she agreed with me. I said a radiograph would give the veterinarian quite a bit of information and that her dog was in a great deal of distress and would benefit from pain medication. “Could I take him to the back to see the doctor, give the pain meds, and take the radiograph?” I asked. She firmly said no. I tried again, repeating that we would have information for her in minutes. She was firm when she repeated, “No.” I moved quickly to get them both into an exam room, where the veterinarian spoke with her right away. It was then she allowed us to give pain meds and proceed with euthanizing her dog as she requested.
She knew before she left her house what was going on with her dog. And she knew what she was going to do when she got to us. She had no doubts and no need for counsel. That dog was not going to leave her side until she walked out the door.
As she gathered up his collar and leash to leave the hospital, she quietly expressed her gratitude. This was one story among many different tales of euthanasia that night at any given emergency facility across the country.
What can any veterinary nurse tell you about the euthanasia experience? A story. Actually, many stories. Because once we get past the policies and procedures, what is left is the story. The scope of euthanasia evokes stories of mind, body, and soul. In fact, this service has progressed exponentially in recent years. There are many resources and opportunities for veterinary nurses to expand their communication skills and play an active role in this service.
The American Veterinary Medical Association (AVMA) established the first euthanasia guidelines in 1963. These guidelines have gone through many revisions, with the latest in 2020.1 This most recent version is reflective of the growth within the scope of euthanasia we realize today. Every veterinary professional should familiarize themselves with these guidelines. It is also important to review individual state laws regarding euthanasia. States have similar, yet somewhat different, laws regulating the veterinary nurse’s role.
Euthanasia’s Emotional Backdrop
We tend to think about euthanasia as a single monochromatic event. But the explosion of 24-hour emergency practices over the past 25 years changed the landscape of euthanasia greatly. Emergency cases surrounding euthanasia can involve:
- Guilt, shock, blame, and bursts of emotion surrounding a traumatic accident.
- Deep sadness and sorrow expressed when complicated chronic illnesses that have been managed suddenly take an acute decline. Caregiving can be crushing for the caregiver, as any veterinary nurse can testify.
- The ever-present charged energy that surrounds finances. The intensity of that aspect is fierce, and the situation can get volatile.
- Everything in between, including the ethical dilemmas of “convenience” euthanasia.
All of this can happen while the waiting room is filled with patients waiting in different degrees of distress. Tension is high for everyone involved.
The skills a veterinary nurse needs to navigate all of these situations cannot be taught in school. Dr. Shane Bateman summarizes the difficulties clearly when he writes: “Successful communication in an emergency setting presents unique challenges to the veterinary care team and the families seeking treatment for their animal companion. Families in the emergency setting may find themselves in a strange environment facing long waiting times, interacting with multiple professionals with whom they have had no previous relationship, and, often, under circumstances that maximally challenge their coping resources.”2
Veterinary nurses are on the frontline of all these stories. And, as pet owners ourselves, we sometimes have to manage this when our hearts are on the other side of the exam table too. Emotions run high. Words and tone matter. Fortunately, we have an abundance of guides and resources available to help in complex situations.
One effective resource is VitalTalk, which suggests a helpful mnemonic when responding to clients’ emotions: NURSE.3
First, name the emotion. It is important to keep this non-declarative, such as, “I wonder if you’re feeling …” rather than, “I can see you’re angry about …” People don’t like to be told what they’re feeling.
Communicate that you understand the emotion. For example, saying, “I think I understand your concern about …” can be an effective way to validate emotions. “I cannot imagine what it’s like to …” is a good way to show you understand.
Respect the emotion. Give families the message that their emotions are not only allowable but important. Acknowledging and respecting a family’s emotions is an important step in showing empathy. In essence, you are communicating to the client that “you have shown a lot of strength.” Consider matching the intensity of your acknowledgment to the family’s expression of emotion—a strong emotion deserves a strong acknowledgment.
Express concern and articulate understanding of the situation. Use supportive statements such as, “I want you to know we are here for you …” or “Is there anyone you would like to call to be with you?”
Explore the emotion. Letting the family member talk about what they are going through often helps them feel heard. In addition, sometimes you may not be sure what the family member is thinking or feeling. In these situations, it can be useful to explore by asking, “This is a lot to hear. What are you thinking?”
I conducted an informal survey with a small population of colleagues in emergency/critical care. Universally, they expressed high anxiety and compassion overload from the immense volume of euthanasia cases. They cited not having enough time to spend with families, often because of other critical patients. This, they said, contributed to their burnout, with some leaving the field. They expressed how difficult it can be communicating with families they had no relationship with prior to the euthanasia event. Trust and empathy had to be conveyed in a short time and often under huge financial constraints.
A Diverse Set of Skills
Veterinary nurses need a diverse set of skills for the different dynamics of euthanasia in practice today.
We don’t always talk about the intense scenes surrounding equine and large animal euthanasia, which has increased with growing numbers of hobby farms. Equine veterinary nurses know that the human-animal bond can be as strong in the paddock as it is in the clinic. Complicating this are some laws regulating the narrow options owners have in some regions for a final resting place for these animals. Euthanizing a large animal is a dramatic scene under any circumstance, and the financial burden is substantial. Determining a final resting place is a compounding stressor to both owner and the veterinary team. Being familiar with individual state laws can help the veterinary nurse play an active part in these events. Consider counseling clients on the benefits of advance directives for these animals. Preparation for emergencies can include assessing out options for body remains. This can be an uncomfortable conversation, but can be useful at the time of euthanasia and may mitigate the need for decision-making when emotions are overwhelming.
Primary care small animal practice is a chance for veterinary nurses to use transitional skills assisting pet families with decision-making leading up to euthanasia.4 You have formed some strong bonds with your clients and patients. It can help to have a clear understanding of the anticipatory grief that some families experience when facing euthanasia. Some of your clients have been managing a pet’s chronic disease.5 Some patients are old and so are their people. Advances in veterinary health care have made it possible to treat conditions and extend life as in human health care. As a result, the veterinary nurse plays a pivotal role in conversations about palliative care and end-of-life decision-making. Quality-of-life conversations give the veterinary nurse an opportunity to walk beside the pet owner using tools such as quality-of-life scales.6
BOX 1 includes several resources that will help veterinary nurses become more comfortable and confident during these difficult conversations. This includes Dr. Katherine Goldberg’s Serious Veterinary Illness Conversation Guide, which provides a framework for understanding the client’s expectations and the patient’s needs for a suitable quality of life.
In her book, Kindred Spirit, Kindred Care, Dr. Shannon Fujimoto Nakaya says, “… remember that the act of making decisions on behalf of our animal companions is an ongoing process. The best decisions are subject to follow-up.”7
Advancing Our Training
In general, college curriculums for veterinary nurses fall short in preparing for real-life euthanasia scenarios. The veterinary nurse can seek out independent study, watch others on the job or try to intuit the breadth and depth of this service. Fortunately, there are a number of solid avenues for independent study, including:
- The Companion Animal Euthanasia Training Academy (caetainternational.com) offers a comprehensive study for veterinary professionals, hospital teams, and students. The founder and director of education, Dr. Kathleen Cooney, has assembled a knowledgeable team and brings a curriculum that guides professionals through this bedrock of veterinary medicine.
- The Institute for Healthcare Communication (healthcarecomm.org/veterinary-communication) provides a comprehensive veterinary communication module that presents topics including, but not limited to, euthanasia. This module is offered on-site in some areas as well as virtual to organizations and institutions.
Expanding the Conversation
Euthanasia is a complex procedure. It is not just a medical event, and veterinary medicine is the only 1 of 2 healthcare systems that delivers euthanasia within its core foundation. It goes deeper than we think, for everyone involved. Notable too is the fact that this was an incredibly different service 50 years ago. It was much more crude and harsh at times. We’ve learned so much since my start in 1973.
Veterinary nurses have been catalysts in the evolution of euthanasia since the beginning. We have been shepherds and guides, sometimes risking body and piercing mind and soul. There are veterinary nurses, as in other specialties, who are inspirational and knowledgeable in delivering end-of-life care. Their strengths contribute to the education of our collective.
“Take responsibility for the energy you bring into this space,” says Dr. Jill Bolte-Taylor. Veterinary nurses are the front runners and ready to take an active role in conditioning the space for delivering the specialty of compassionate euthanasia.
1. AVMA Panel on Euthanasia. AVMA Guidelines for the Euthanasia of Animals: 2020 Edition. avma.org/sites/default/files/2020-01/2020-Euthanasia-Final-1-17-20.pdf. Accessed June 29, 2021.
2. Bateman SW. Communication in the veterinary emergency setting. Vet Clin North Am Small Anim Pract. 2007;37(1):109-ix. doi:10.1016/j.cvsm.2006.09.005
3. VitalTalk. Responding to Emotion: Respecting. vitaltalk.org/guides/responding-to-emotion-respecting. Accessed June 29, 2021.
4. Shaw JR, Lagoni L. End-of-life communication in veterinary medicine: delivering bad news and euthanasia decision making. Vet Clin North Am Small Anim Pract. 2007;37(1):95-ix. doi:10.1016/j.cvsm.2006.09.010
5. The Ralph Life: Pet Loss Support. How to deal with anticipatory grief for a terminally ill or elderly pet. theralphsite.com/index.php?idPage=88. Accessed June 29, 2021.
6. Villalobos AE. Quality of life scale helps make final call. In: Canine and Feline Geriatric Oncology: Honoring the Human-Animal Bond. Ames, IA: Blackwell Publishing; 2007.
7. Fujimoto Nakaya S. In: Kindred Spirit, Kindred Care: Making Health Decisions on Behalf of Our Animal Companions. Novato, CA: New World Library; 2005:105.