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
Client Expectations of the Veterinary Care Team
It is expected that the veterinary team, within the bounds of safe medical practice, place few limits on the emotional and logistical needs of clients. This can include allowing the client to spend ample time with the cat before and after the euthanasia, regardless of time of day; allowing the presence of family members, even small children, as well as the integration of religious or spiritual needs into the euthanasia process; compassionately handling the disposition of the body; and helping the client through the grieving process.

Veterinarians take the process of euthanasia seriously for their clients. What is less clear is whether they take the personal emotional impact of performing euthanasia as seriously. Emotional labor is work that creates an emotional response in caregivers; euthanasia certainly meets that criterion.

The AVMA’s guidelines for euthanasia1 include “human behavior” and acknowledge that euthanasia can have an emotional impact on the entire veterinary team. There is also a long history of implicit euthanasia “practice wisdom” that has been handed down from seasoned to new veterinarians for hundreds of years. These standards and experience of practice wisdom exist for good reason. One of the biggest predictors of clients’ difficulty in dealing with their grief after euthanasia is feeling unsupported by the veterinary team.11 Grief-stricken clients often report feeling haunted by something they saw and were not prepared for, or something they did not feel comfortable saying or asking about during the euthanasia process. Because veterinarians know this can happen, usually based on a few difficult client experiences, they have become very alert and attentive to handling euthanasia well.

Moral Stress and the Veterinary Care Team
How does all this pressure affect the veterinary team over time? This common but high-stakes procedure can take a toll, especially when confounding issues are involved. It is now common knowledge in the profession that veterinarians experience poor well-being. Poor work–life balance, depression, anxiety, and even suicide are associated with the stressors veterinarians face on the job.12 Sources of stress include financial pressure,13 number of hours worked per week,12,13 adverse medical events,14 problems in the veterinary team,15 difficult clients,16 ethical dilemmas,17 and euthanasia.13 Many of these challenges are morally stressful. Moral stress occurs when veterinarians “... are aware of what ethical principles are at stake in a specific situation and external factors prevent them from making a decision that would reduce the conflict between contradicting principles.”18

Although there are many, 3 common morally stressful scenarios in the veterinary environment include healthy animal euthanasia, financial limitations of clients, and clients wishing to continue treatment despite animal welfare needs.17 Results of a study by Batchelor and McKeegan17 found that veterinarians experienced 1 or 2 of these ethical dilemmas each week and that clients wishing to continue treatment despite animal welfare needs was the most stressful of the scenarios.

The moral stress caused by clients who bring their ill cats to the veterinarian without means to pay for care is also associated with poor well-being. In fact, veterinarians working in low-income communities, where treatment options are limited due to clients’ lack of financial resources, are at greater risk for suicide than veterinarians working in middle- to high-income communities.13 This can be attributed to the stress these veterinarians face in caring for the animals of low-income owners. The client without the means to care for a gravely ill cat will often lash out and blame the veterinarian for suggesting euthanasia and not offering free medical care. Veterinarians in these situations often hear “all you care about is money.”

Alternatively, clients may request euthanasia for a problem that can be remedied easily but they are unable or unwilling to pay for treatment. Not all clients express these thoughts, emotions, and requests, but these morally complex situations do arise regularly in the workday of every veterinarian. Our oath calls on us to put the welfare of the animal first, and these situations create moral stress between wanting to do what is right for the animal and lacking the ability to do so because of client factors.

There seems to be a weak but positive correlation between number of euthanasias performed each week and the presence of depression in veterinarians.13 This is likely due not to the euthanasia act itself but rather to the extensive end-of-life client counseling. Euthanasia is often deeply emotional for clients and, depending on confounding circumstances that may involve financial constraints, difficult client interactions, and moral stress, it can also be emotional for the veterinarian and veterinary team. How the team handles these emotional and morally complex issues is of concern when seeking to protect veterinary well-being and promote ethical decision making.

End-of-life counseling requires intense amounts of empathy and attunement with client emotions. Moreover, strong emotions in cases high in moral complexity can reverberate throughout the medical team, requiring the veterinarian to be in tune with the emotions not only of clients but also of the team. Humans are “wired,” through the mirror neuron system, to adjust to the emotions of others. This mirror neuron system supports mammalian bonding and is the basis of empathy.

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