October 24, 2017

Feline Euthanasia: Part 1 - Ethics, Aesculapian Authority, and Moral Stress

Beyond guiding clients and facilitating the process, veterinarians must learn to deal with the moral stress associated with euthanasia.
By William Ray Folger, DVM, MS, DABVP (Feline Practice); Elizabeth Colleran, DVM, MS, DABVP (Feline Practice); Tina Han, DVM; and Elizabeth Strand, MSSW, PhD
The veterinary profession is characterized by honorable, caring, generous professionals with a broad sense of decency and respect for all living things. Veterinarians are strongly motivated to enhance the quality of life of their patients, to slow death, and to relieve patient suffering. One of our defining principles is “the needs of the patient come first.” It is because we accept this as our primary responsibility that we sometimes recommend euthanasia at the end of the patient’s life.

The American Veterinary Medical Association (AVMA) defines euthanasia as a “good death” in a way that “minimizes or eliminates pain and distress.”1 Euthanasia has also been described as “the unfortunate, unavoidable, and unintended consequence to end patient suffering.”2 Unification of these definitions renders a uniquely useful definition for veterinarians: Euthanasia is the necessary but unfortunate, unavoidable, and unintended consequence to end patient suffering in a manner that minimizes pain, anxiety, and distress.

The Pet As Family
The past half-century has witnessed a metamorphosis in the importance of pets in the family structure.3-5 For many clients, the emotional bond they share with their pets transcends the bonds they have with other family members or friends. This emotional attachment demands respect, dignity, and empathy from veterinary professionals. Cats provide their human companions with unconditional love and loyalty, and veterinarians must deploy their Aesculapian authority in making end-of-life recommendations for euthanasia to prevent needless suffering.6,7

Aesculapian authority is conferred on those individuals whom society perceives as healers and medical experts; it transcends our education, training, and experience. We are viewed by society as the moral authority in medicine; we have the power to heal, relieve suffering, and retard death.

Use and Misuse of Aesculapian Authority
The proper use of Aesculapian authority is displayed when veterinarians understand and appreciate that clients view their pets as family members. We are required to consider the needs of the patient as our first priority. At the end of a cat’s life, when restoration of comfort and function is unattainable and the patient appears to be suffering or suffering is imminent, it is our moral and ethical responsibility to focus the owner’s attention on the patient’s quality of life.8

Several practical quality of life evaluations have been proposed in the veterinary literature, the principles of which should be introduced to the client long before the discussion of euthanasia. The first practical evaluation is to determine whether the patient is able to enjoy the Five Freedoms (Box).9 A patient’s inability to enjoy these freedoms calls into question its quality of life.

Owners should be advised to evaluate subjectively what the cat is experiencing on a daily basis, ranking quality of life on a scale of 1 to 10, with 10 representing the best day and 1 being inexorable suffering. If the patient has continuous days in the 2’s and 3’s, it is time to consider the discussion of euthanasia.3

Alice Villalobos, DVM, DPNAP, has provided a comprehensive scale to help measure quality of life for cats (Table).9,10 If clients evaluate their cat successively over a short period of time, the scale helps them arrive at their own conclusion concerning the quality of life of their beloved pet.

Failure to implement Aesculapian authority properly may result in a client demand of euthanasia for trivial or non–health-related reasons (eg, inappropriate behavior, new house, new spouse). This so-called convenience euthanasia is a primary source of moral stress for veterinary professionals. The American Association of Feline Practitioners is opposed convenience euthanasia, stating that “It is not in the best interest of the patient, and it is not in the best interest of the veterinary profession to perpetuate an image of itself as willing to kill a companion animal ‘on demand.’”

The Decision to End Patient Suffering
Discussion of quality of life issues should begin as early as possible prior to the eventual deterioration of the pet.10 Once the owner and veterinarian embrace the discussion regarding the need to end the patient’s suffering, a flexible timeframe should be established to allow the client to adjust emotionally to the decision. Patience, respect, empathy, and good listening skills are all vital characteristics the veterinarian must display to make the patient’s passing as peaceful as possible for all involved. The caregiver should be given the option to be present for the procedure, and careful explanation of the procedure prior to starting the process is critical. It is also tactful to discuss the final disposition of the pet’s remains prior to the procedure.

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