Euthanasia

Euthanasia. The word itself makes all our stomachs drop. It is a gift to pets and a curse to owners – having the power to decide is something we are not comfortable with. However, when going through the euthanasia process with your own pets, you are in a position to make numerous decisions that can change the course of the overall process.

As a Registered Veterinary Technician, I witness euthanasias on a daily basis. Let me share from personal experience the 5 things I wish every pet owner knew.

1. It’s ok to cry.

People apologize to me all the time for crying over their pets. Whether it’s time to say goodbye, or you are simply having a hard time watching us draw blood on your dog, I wish you knew that I GET IT. Many of us who work in animal medicine (myself very much included) are totally neurotic, hypersensitive, and obsessive when it comes to our own pets.

I may seem calm and collected while working with your cat, but that’s because it’s my job and I can’t afford to be any other way if I’m going to be good at it. You best believe that the second my dog so much as sneezes, I go into a total state of panic, lose all common sense, and forget everything I learned in tech school.

So, when you are crying over the pet that you have loved for years, I assure you, I have nothing but respect for you. I respect how much you care. I respect your ability to make such difficult decisions. I respect your bravery. And please know that no matter how demonstrative you may be with your emotions, you are still keeping it together more than I would be in your shoes.

2. Be there, if you can.

I am lucky to work in a hospital where the vast majority of pet owners stay with their pets for the euthanasia process. However, this is not always the case. I urge you to stay with your pets, if you can, for multiple reasons. First, for my sake. One of the absolute most difficult things I do as a Veterinary Technician is take on the role of comforting and loving a pet as they pass on when their human is not there to do so.

It is an incredible weight to try to act on your behalf, and it is emotionally exhausting in a way that I cannot even begin to describe. When you stay with your fur baby, I can focus on my own job, instead of doing both of ours.

Second, for your pet’s sake. The vet can be a very scary place for animals – they don’t understand what all these noises and smells are, or why these strangers are poking and prodding them. Do you want them to experience that fear alone? And have it be their very last memory? Your pet doesn’t know what we are doing or why – they only know that you are there, that you said it’s ok, that you love them.

I remember being a child, and how scary going to the doctor was, but how much more confident I felt with my mom there reassuring me. I imagine that is exactly how pets feel. If you can find the strength to be there, please do so. Please let your love, your touch, your presence be the last thing your pet experiences.

3. Keep the collar on.

One of the saddest things I witness during the euthanasia process is when humans take their pet’s collar off when they are still very much awake. To many pets, taking their collar off can have negative associations. For example, I know my own dog panics when I remove her collar as she knows it’s bath time! I want your pet to be as comfortable as possible, and that means not making any major changes immediately prior to euthanizing.

Pets are much smarter than we give them credit for, and they pick up on the smallest of cues. The unknown is scary to your pet, so even if they don’t know what the cues mean, the idea that something is new and strange and out of the ordinary is enough to cause them some sense of anxiety. So, keep the collar on until your pet has passed. Let them go in the state that they always were.

4. Make it a celebration.

Bring treats. Tell stories. Laugh and cry at the same time. Surround yourselves with all his/her favorite toys and beds and blankets. It’s ok to cry, and it’s also ok to celebrate! I love when people tell me they took their dog to the beach or napped in the sun with their cat right before coming in to the hospital. This is going to be one of the hardest days of your life, but it doesn’t have to be for your pet. I promise that the more you celebrate your pet’s life, no matter how long or short, the easier it will be to continue to live your own once this is all said and done.

It is ok to cry in front of your pet, to tell them how much you will miss them, to let them see you be absolutely beside yourself. I’m sure your pet has seen you at your worst before – I know mine has. But remember to celebrate, no matter how miserable you are. I promise it will make it easier for both you and your pet. What’s more, It will allow you to reflect on the euthanasia experience with positivity – you will remember that you celebrated and you will feel good about having done so.

5. Prepare.

I want this moment to be entirely about you and your pet. In order for that to be the case, several things must happen. First, you must understand the euthanasia process. If possible, talk to your vet or tech prior to coming into the hospital, or prior to starting the process – ask them to walk you through the steps of euthanasia so that you know exactly what to expect. Ask as many questions as you need to in order to feel comfortable with the process (or at least, as comfortable as you can be). Know what you’re walking into, so that your focus can be entirely on your pet.

Second, take care of business ahead of time when possible. Sign any required paperwork. Pay the bill. Decide on aftercare. Even go so far as to prepare your next meal ahead of time, arrange a ride, rent a movie, invite friends over – whatever you think might help you cope when you return home from the hospital without your pet. The less you have to deal with during and after euthanasia, the better. I want you to be able to focus entirely on your pet during the euthanasia and then entirely on yourself afterward. Let’s do whatever we can to make that possible.

Every euthanasia is different. Some are planned, some are sudden. Some may happen in your home, some in the hospital. Regardless, they are always difficult – to prepare for, to cope with, to experience. I hope these five things will help you to plan ahead and to make the process as beautiful as it can be for both you and your pet.

The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.

Ali was a beautiful golden retriever with a large liver mass in her abdomen. She had seen both her regular veterinarian and the local specialists prior to my visit with her. Her owner wanted her to be comfortable, and was open to euthanasia if he could not make her comfortable. She was already on some pain medication but she was not eating or moving much so he called me, a hospice veterinarian, as a last resort.

 

 

Initially, we changed Ali’s medications, added new ones and made a specific plan for her. The owner called me a few days later to thank me — she had jumped up on the bed that morning, which she hadn’t done in months. She spent the next few months enjoying life, hiking with her owner, traveling short distances and playing.

A few months later I was called out again – Ali had reached the active phase of dying. She was breathing harder, her abdomen had swollen with fluid, and she had stopped eating. But she was otherwise comfortable, so instead of euthanizing her that morning, we decided to give her one more adventure. Ali and her owner went out to a field and sat in the sunshine, where she died in his arms. It was a beautiful death for them both.

 

Euthanasia isn’t an easy decision for pet owners to make, even for animals with terminal illness. Deciding when, where, and how only adds to the emotional aspect of that choice, and it’s during those discussions that they often ask veterinarians why euthanasia is recommended over taking the animal home to die a “natural” death.

 

Natural death, when supported by hospice, can be a graceful death, but there are a few myths that must first be dispelled:

 

5 Myths About Natural Death

 

1 – All natural death is bad.

 

A “natural death” in nature can be difficult, sometimes violent (think: predator, car accident, shot by gun or arrow).   But, in some cases, a natural death can be simple (like a heart attack). Then again, a natural death from something like cancer, which is a slower, more progressive disease, requires pain medications to manage pain, anti-nausea medications, sometimes chemotherapy, and radiation for palliation.

 

As a hospice veterinarian, I deal with the dying process from the palliative perspective, making an animal comfortable and managing clinical signs, sometimes up until their natural death. Hospice supported natural death can be as gentle a passing as euthanasia for some diseases, but family members must be aware of what will be involved. There can be significant nursing care toward the end, just like in human hospice, and there must be a veterinarian involved. A veterinary nurse, counselor or other mental health professional, respite care professional, groomers, and even pet sitters all can help provide a good quality of life as the animal progresses through their disease.

 

2 – Suffering always occurs during a natural death.

 

Life is suffering according to Buddha. However, the definition of suffering varies from person to person, so it’s not very helpful when dealing with end of life patients. If I remove “suffering” from the lexicon and, instead, define in terms of distress, I can better help my patient and their caretakers know what to watch for as the animal is going through the dying process. I can define distress by organ system and also include terms of emotional distress, giving caretakers more tools for evaluating their beloved pet so they know when to call their hospice veterinarian.

 

3 – If natural death occurs, I won’t have to make a decision for euthanasia.

 

This is technically a true statement. We all die. A natural death will eventually occur given the correct set of circumstances and disease processes, but it might not be a quick process and you shouldn’t kid yourself – there is pain involved.

 

But we can provide a quality dying process with animal hospice, and a quality natural death at home following a terminal diagnosis needs support from an animal hospice veterinarian and team. In animal hospice, patients are monitored as they go through the dying process so that medications can be adjusted or added as needed, and clinical signs are defined so that everyone can assess where the animal is at any time. This team helps care for the animal, supports the family, and can also help make a decision for euthanasia if needed.

 

4 – Euthanasia is the only way to help an animal die.

 

Euthanasia is one way that we can help our beloved pets transition out of the world, and it’s a gift to be able to do it. However, we do have new options that were not available even five years ago.

 

Animal hospice is another way to give an animal a quality dying process. We help the animal to have a good quality of life, and sometimes, we support them all the way to a natural death. An animal hospice veterinarian has additional training in advanced end of life care, either through a human hospice-run program or through the IAAHPC conferences that have been given over the past five years, and we expect an additional certification process to come soon. A hospice veterinarian should be supportive of the patient and the family, helping them know what to expect during the end of life process.

 

5 – Quality of life is the most important aspect for end of life care.

 

While quality of life is important, so is will to live and the quality of the dying process. Owners need to know that the quality of life discussion doesn’t mean they list the five most important things in their animal’s life, then choose euthanasia once three of those things go away. Remember, these are not generally puppies or kittens; these are often elderly patients who are approaching the end of life, so just as 80 year-old humans are not the same as 20 year-old humans, they can still have a vibrant life even though they are not doing the things they used to do. If an 80 year-old human can be supported through walkers and medications, so too, can our end of life animal patients.

 

 

Animal hospice with a hospice veterinarian who has further training in end of life care can provide enormous support and comfort for the end of life patient and help owners make the right end of life decisions for their pet and their family. Euthanasia is one way to relieve suffering –there’s nothing wrong with making that choice, and it can give our patients a gentle death – but know that it’s not the only way to relieve suffering. If you do make a euthanasia decision, make it because it is the best option for everyone involved.

 

 

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Dr. Lynn Hendrix is a leader in the Animal Hospice field.  One of the authors of the IAAHPC guidelines for Animal Hospice and now a VIN contributor for Animal hospice, she also does public speaking on various hospice topics and has been a contributor to the IAAHPC conference for the past 4 years.  She owns Beloved Pet Mobile Vet based in Davis, CA focusing on Animal Hospice and End of Life Care.

Sedation is one of the major controversies in end-of-life care medicine. I’m grateful that it isn’t as rare as it once was. When I talk to veterinarians about sedation, this is what I hear from those who don’t use sedation:

1. I don’t need sedation to hit a vein

2. Sedation takes too long

3. Sedation makes hitting the vein harder.

Can you spot the problem? Not one of these objections has anything to do with the owner or the pet! When it comes to euthanasia, it’s ALL about the owner and the pet.  Have you ever watched a client before and after sedation? The difference is incredible! The tension leaves their face and body. They are able to focus on saying goodbye rather than wincing and being upset when their pet objects to handling. Most importantly, they get to spend a few minutes with their pet and see that there is no pain or anxiety. They know in those few precious moments that their pet is still alive and is no longer suffering. Some will even laugh through their tears at the sound of their pet snoring peacefully.

Do you know what it looks like to a client when you perform standing euthanasia on their pet? I do, because so many of my clients have told me about their past experiences and demanded sedation for their next pet.

“He just dropped dead.”

“It happened so fast.”

“One minute she was standing up and the next she was dead.”

“She died before I could touch her or tell her goodbye.”

That’s what they tell me.

We think a smooth euthanasia looks like a smooth surgical induction, don’t we? Perfect and peaceful? Not to our clients! There’s a reason for the “kissing corner” in hospitals when they take your loved one away to surgery. No one should have to see someone they love go from conscious to unconscious that fast. It’s scary. Have you ever seen someone faint? Even if they were caught and gently lowered to the ground, would you say it was a pleasant experience? Now imagine that it wasn’t unconsciousness – imagine it was death.  How disturbing would that be?

Sedation is for both the pet and the owner.  Needles hurt. I dislike hearing a guarantee of “painless euthanasia”. If they can feel a needle, it’s uncomfortable. So why would we put ourselves, our clients or our patients through unnecessary discomfort?  If that isn’t enough to convince you, let me try this: not sedating will drive clients away from your practice. I know, because they call me for help after they have had “a bad experience”. They insist upon sedation. They won’t go back to their last veterinarian because it wasn’t used.

Sedation has the secondary effect of calming the owner. It’s a twofer! The pet is asleep and the owner has a little bit of their burden removed. Sedation also allows me to let an owner get close to their pet during the euthanasia process. That contact is so important! When an owner brings their pet in for euthanasia, I allow them to remain with their pet throughout their passing. Breaking that bond isn’t necessary.

I know it’s tempting to whisk their pet away to put in an IV catheter, but have faith in your vein-hitting ability. Every second the owner spends apart from their pet is a second of increased anxiety and guilt. If that pet cries out or comes back shaved and bruised from unsuccessful attempts at a catheter – it’s even worse. Sedation is the ultimate safety net. I often miss a vein on the first try. With sedation, it’s only a big deal if I make it a big deal.

If you do it right, sedation typically takes no more than 10 minutes (that’s if you give it subcutaneously like I do).  That gives you time to make a short phone call, answer an email or quickly scoot in to see a patient.  I give my feline patients drug cocktails with whopping doses of acepromazine. My canine patients get both acepromazine and xylazine.  I give myself two legs to get a vein for euthanasia. If I don’t, they get it IP or IC.

Yes, in front of the owner. For the record, I’ve only had to go IC twice.  I almost always get the vein (and I’m not a great phlebotomist by any stretch of the imagination). We have a tendency to psych ourselves out with superstition about veins. The truth is, most dying pets have lousy veins anyway. I would much rather poke a pet multiple times while they are sleeping and can’t feel it than to wrestle with them and poke them multiple times while awake and stressed. I make sure to tell the owner that part of the reason for sedation is so that they don’t feel any more needles even if I have trouble accessing a vein. I’ve never had an owner express anything but relief and gratitude at this statement.

Instead of worrying about how euthanasia can be easier on you, worry about how to make the worst day of pet ownership easier on your client and patient. Pre-euthanasia sedation is becoming the norm. Those of us who do in-home euthanasia see every day how grateful our pet parents are for that moment of peace, just watching their beloved pet breathe.

Euthanasia can be less stressful for everyone if we take the time to be mindful of what constitutes a peaceful passing. By using sedation before euthanasia and keeping that pet in the presence of their owner, you will preserve and honor the Bond that is the reason we do what we do.

The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.

Should a veterinarian treat a patient as if the pet were her own?

Last year I was asked to do just this by clients I had just met. But making decisions as if a pet is your own is hard thing to do. What I may choose for my pet may not be right for someone else.

Case in point: Paige.

I adopted my once-in-a-lifetime dog, a 13-month-old black Labrador, during my first month of veterinary school at Cornell. She was with me through veterinary school and graduation, an internship in New York City, oncology positions at Duke and back at Cornell, my residency back in NYC, a wedding, a move out to California, then back to New York, and the birth of my 2 sons. She was by my side for it all, and she was perfect. I used to say I would give her my kidney if she needed it.

I was pretty attached to Paige, to say the least. She died 8 years ago, and she never needed my kidney, but I would have given it to her if I could have.

About the same time, Chandler, an adorable 8-year-old Papillon, was referred to me for treatment. His tumor involved the in the prostate and urethra. The urethra is the tube that connects urine from the bladder to the outside world. Sometimes dogs like Chandler have a hard time urinating from the urethral involvement, but Chandler was having a hard time defecting from the prostate tumor pressing on his colon. His owners had come to me to consider a procedure called CyberKnife, a precise radiation of the tumor.

As I was telling the clients about the cancer, the treatment options and the prognosis, I could see the bond they both had with Chandler. They looked me right in the eye, and asked me to treat him like he was my own pet.

I don’t normally agree to this. I prefer to educate, to guide, to help, and then to let the owners make the best decision for themselves and their pets. But Chandler’s owners and I had connected at that moment. So I promised them what they asked of me: I would treat Chandler as if he were my own dog, Paige.

[tweetthis]I promised them what they asked of me: I would treat Chandler like my own dog.[/tweetthis]

Complications for Plan A

In order to be a candidate for CyberKnife, the pet’s prostate tumor cannot extend in to bladder. That’s because hollow organs like the bladder can rupture after radiation treatments, as the invasive tumor is killed from radiation and there is no normal tissue in that area. At the original appointment, I had determined the cancer had spread to the local lymph nodes under his lumbar spine, but not beyond, and his chest was clear. Ideally we would also radiate the lymph nodes, in addition to the tumor itself, which added a significant cost to the already expensive CyberKnife treatment.

“Would you do it, Dr. Sue?” they asked. And I told them honestly that I would, were I in their situation. But then I asked them to make sure that was the right choice – or at least, the best choice – for them and for Chandler.

They decided to go ahead.

But as the radiation oncologist prepared the dog’s treatment plan for the following week, she saw on the
CT scan that the tumor was also invading the colon. That changed the equation, with the risks from radiation to that area outweighing the benefits of treating with radiation. We then changed our recommendation: No Cyberknife for Chandler.

Since the cancer was more advanced than originally thought, we went to Plan B. That’s what I would do for Paige, I told Chandler’s owners. We started chemotherapy and pain medications, including a non-steroidal anti-inflammatory drug or NSAID, which can also have anti-cancer properties for his form of cancer. Chandler did well after his first chemotherapy treatment, even though his white blood cell count got a little low.

At that visit, they told me they were supposed to go out of the country for an important family event, a trip that had been planned many months ago. They had friends willing to make the three-hour trip to bring Chandler in for his next chemo. Should they cancel their trip, they asked? What would I do in their position? I told them that while I do not have a crystal ball, he would likely be fine having friends bring him in. He was stable and doing well.

None of us knew they would never seem him again.

Plan B fails, and Plan C looms

The friends brought Chandler in for his second chemotherapy treatment as planned. They also adored the little dog and were happy to make the long trip to help. When they arrived, they told me Chandler had been vomiting. I knew it was unlikely the first chemotherapy treatment was responsible, based on the timing. Vomiting from chemotherapy typically occurs within a week of treatment, and it had been two weeks. Some cancers can cause vomiting, but Chandler’s wasn’t typically one of them. It had to be something else.

Blood work quickly determined that Chandler was in severe kidney failure, which definitely causes nausea and vomiting. On the ultrasound, we could see the tumor was even more advanced. The urine flow was being blocked by the tumor, and that was causing the kidney failure.

[tweetthis]Should a veterinarian treat a patient as if the pet were her own?[/tweetthis]

I called his owners, and filled them in as we went over the options. We even discussed stopping treatment, before they opted for Plan C. Chandler entered our ICU for aggressive fluid therapy, and we scheduled a surgery for the next day to open up both ureters with stents. Stenting is a sort of propping-open procedure used to open up arteries, or in this case, ureters that have a blockage. The plan was to restart chemotherapy treatments after Chandler recovered from the surgery.

I kissed Chandler as he went into the operating room with my surgical colleague, knowing he was in the best possible hands. I was in appointment when I was called back to the OR, my heart sinking. The surgeon had found something we could not fix: The cancer had spread all over Chandler’s abdomen, a situation much more advanced than we could see on ultrasound.

Stents were not going to help Chandler. At this point, even our Plan C was not a fair option for Chandler.

It was time for the kind of phone call all veterinarians hate to make. I called the family and told them we should euthanize while Chandler was still under anesthesia. I didn’t believe it was it fair to wake him up after what we had seen. The family was still out of the country, and they couldn’t get home for days. Yes, I told them, this is what I would do for Paige. So they consented, far away, and unable to say their goodbyes.

Sobs and self-examination

I hung up the phone and sobbed. As promised, I went into the OR and kissed Chandler goodbye, as if he were my own. And then it was time for self-examination.

As an oncologist I work with the best internist, surgeon, technicians, and support staff. We have advanced treatment options like CyberKnife radiation and ureteral stents. All the money, the best health care, and it still didn’t matter. Sometimes, even as a cancer specialist it still shocks me how quickly and aggressively cancer can progress.

[tweetthis]Sometimes, even as a cancer specialist, it shocks me how quickly cancer can progress.[/tweetthis]

I could not help Chandler, and that hard truth is defeating, humbling, and depressing. I mourn for the family and thank them for the trust. I am sorry we could not do more. All I could do was end his suffering.

This is a large part of why I am always hesitant when someone asks me to treat her pet as if the animal were my own. I would go pretty far for mine, especially Paige was still with me, perhaps further than most people would or could.

When is the time is right to stop treating? I struggle with it with my own pets. I was trained to help pets with cancer. I am an advocate for cancer treatment. Cancer is not a death sentence. Most pets that we treat tolerate treatment well, and live not only longer, but they live well – even during chemotherapy treatment. I know all this, but …

I also know that sometimes there are no more options. Whether deciding to treat or to euthanize, we all need support and we struggle to do what is best.

I had treated Chandler as if he were my own, and my heart broke because I did.

[tweetthis]I am an advocate for cancer treatment. Cancer is not a death sentence.[/tweetthis]