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
Because regular exposure to distressing emotions inherent in end-of-life care counseling is required of veterinarians, the term "emotional labor" applies to this work responsibility. Therefore, an implicit requirement of veterinary professionals is bearing the emotional labor of end-of-life care. It may be that because this responsibility has been largely implicit, the tools for handling it have also been implicit and perhaps insufficient for protecting veterinary well-being. As stated earlier, much of the practice wisdom about end-of-life care has been handed down from generation to generation of veterinarians but perhaps has not explicitly included how to handle the emotional nature of the job.

When euthanasia goes well, it can be a beautiful and satisfying experience for the veterinary team as well as clients, who can feel the bittersweet sadness of providing comfort by freeing their best friend from pain. These situations often contribute to the sense of purpose and well-being among veterinarians.

Moral resilience, however, is required in situations that are more difficult. It is “the ability to respond positively to the distress and adversity caused by an ethically complex situation.”19 Veterinarians may be able to respond positively on a temporary basis, taking care of their clients’ and perhaps their team’s needs. Over time, however, coping can take a negative turn and result in overworking, substance abuse, lack of sleep, feelings of inadequacy, and lack of emotional connection with loved ones at home. Moral resilience means that one has the capacity to consistently and in all areas of life respond positively to the emotional labor and ethical action that accompany morally distressing situations.

Professional Self-Care
Just as sutures are needed for surgery, so too are emotional labor tools needed for end-of-life care counseling. Handling emotional labor well involves the attitude of acceptance and the tools of team bonding and professional self-care. Having an attitude of acceptance means acknowledging that part of the job of the veterinarian and veterinary team is to feel distressing emotions with clients. Doing so helps clients make the best decisions for their cats. Veterinarians who do not acknowledge these feelings will be less able to influence their clients, who will experience the veterinarian as not “getting it” or being “cold.” Clients know whether their veterinarian has empathy for them. Accepting this as a job responsibility will allow the veterinarian to acknowledge that resources are needed to do the emotional job well.

Team bonding is also a required emotional labor tool. The term “moral climate” describes an organization “that supports the process of ethical decision making.”20 This means that if an ethically complex and/or highly emotional case comes into the clinic, the veterinary professionals attending to the patient feel they can lean on their colleagues to help make the right decisions.

The common habit of “going it alone”—if used as the only tool over time—seems to increase burnout and lead to poor decisions. In human medicine, facilitating regular team discussion about morally complex and emotional cases is associated with less stress and burnout.21 Finding a regular way to meet as a team to discuss morally challenging cases improves the moral climate of a practice and increases the likelihood that a veterinarian or a veterinary nurse will reach out for social support when needed rather than “going it alone.”

Taking time to attend to personal needs is often described as being selfish. It has even been said to veterinarians and veterinary nurses experiencing burnout, “You need to be more selfish.” However, “selfish” is perceived as a negative term that implies caring for one’s basic needs is somehow wrong. Instead, for veterinarians, self-care is an essential professional responsibility required for bearing the emotional labor of end-of-life care in a healthy manner.

Basic self-care requirements can be found in the Healthy Mind Platter model22 and include such behaviors as exercise, sleep, social support, play, and down time. Eating healthy food is also essential to self-care.23 By embracing the idea that regularly performing these behaviors is a “professional responsibility” as opposed to being “selfish,” the veterinary care team can ensure it has the necessary resources to perform emotional labor duties. The stakes are high because when clients feel a lack of empathy or a disconnect between themselves and the veterinary team during the highly emotional end-of-life decision-making process, it negatively impacts their grief trajectory.11 Professional self-care prepares veterinarians to provide excellent counseling for clients without causing harm to themselves.

Conclusion
Euthanasia is the necessary but unfortunate, unavoidable, and unintended consequence to end patient suffering in a manner that minimizes pain, anxiety, and distress. Achieving this in a compassionate way for the client requires all the excellent attributes of veterinarians: empathy, a careful sense of timing, patience, and sincerity. Achieving this for the patient requires proper facilities, training, proper selection of premedicants, a quiet place in the hospital or home, and a broad sense of decency and respect in handling the patient.

Just as important as these considerations is the recognition that an emotional price is paid for performing this service month after month, year after year. For veterinary care teams to maintain usefulness and effectiveness to all patients, appropriate attention to maintenance of good mental health is necessary. We must recognize that anxiety, depression, and suicidal ideation are common in our profession and take all appropriate action to minimize the moral stress we endure in the process of saying goodbye to our patients.
 
Dr. Folger is the founder and director of Memorial Cat Hospital in Houston, Texas. He has served as the Feline Regent for the American Board of Veterinary Practitioners since 2011.
Dr. Colleran is the founder and director of Chico Hospital for Cats in Chico, California, and Cat Hospital of Portland in Portland, Oregon. She is the chair of the Cat-Friendly Practice Committee for the American Association of Feline Practitioners.
Dr. Han is the owner of My Doorstep Vet, PLLC, a house call veterinary practice in Houston, Texas, that offers in-home euthanasia and other veterinary services.
Dr. Strand is a clinical associate professor and director of veterinary social work at the University of Tennessee College of Veterinary Medicine in Knoxville. She serves in the American Association of Veterinary Medical Colleges Veterinarian Wellness Awareness Working Group.
References:
  1. Leary S, Underwood W, Anthony R, et al. AVMA Guidelines for the Euthanasia of Animals: 2013 edition. Shaumburg, IL: AVMA. Available at https://www.avma.org/kb/policies/documents/euthanasia.pdf. Accessed September 27, 2017.
  2. McMillan FD. Rethinking euthanasia: death as an unintentional outcome. JAVMA. 2001;219(9):1204-1206.
  3. Scherk M, Rollin B. Palliative medicine, quality of life, and euthanasia decisions. In: Little S (Ed). The Cat: Clinical Medicine and Management. St. Louis, MO: Elsevier; 2011:1155-1163.
  4. Fernandez-Mehler P, Gloor P, Sager, E, Lewis FI, Glaus TM. Pet owners’ expectations of veterinarians in end-of-life situations. Vet Rec. 2013; 172(21):555.
  5. Elkins AD. Euthanasia of a family pet: stressful for both the practice team and the client. Canine Pract. 1998;23(1):17-19.
  6. Rollin B. Ethical issues in geriatric feline medicine. J Feline Med Surg. 2007;9(4):326-334.
  7. Rollin B. The use and abuse of Aesculapian authority in veterinary medicine. JAVMA. 2002;220(8):1144-1149.
  8. Folger WR, Scherk M. The veterinarian’s responsibility at the end of a cat’s life. J Feline Med Surg. 2010;12(5):365-366.
  9. Brambell R. Report of the Technical Committee to Enquire Into the Welfare of Animals Kept Under Intensive Livestock Husbandry Systems. London, UK: Her Majesty’s Stationery Office; 1965: 1-84. 
  10. Villalobos A. Canine and Feline Geriatric Oncology: Honoring the Human-Animal Bond and Pawspice. Hoboken, NJ: Wiley Publications. In press.
  11. Adams CL, Bonnett BN, Meek AH. Predictors of owner response to companion animal death in 177 clients from 14 practices in Ontario. JAVMA. 2000;217(9):1303-1309.
  12. Nett RJ, Witte TK, Holzbauer SM, Elchos BL, Campagnolo ER, Musgrave KJ, et al. Risk factors for suicide, attitudes toward mental illness, and practice-related stressors among US veterinarians. JAVMA. 2015;247(8):945-955.
  13. Tran L, Crane MF, Phillips JK. The distinct role of performing euthanasia on depression and suicide in veterinarians. J Occup Health Psychol. 2014;19(2):123-132.
  14. West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA 2009;302(12):1294-300.
  15. Gilling ML, Parkinson TJ. The transition from veterinary student to practitioner: a “make or break” period. J Vet Med Educ. 2009;36(2):209-215.
  16. Morrisey JK, Voiland B. Difficult interactions with veterinary clients: working in the challenge zone [abstract viii]. Vet Clin North Am Small Anim Pract. 2007;37(1):65-77.
  17. Batchelor CEM, McKeegan DEF. Survey of the frequency and perceived stressfulness of ethical dilemmas encountered in UK veterinary practice. Vet Rec. 2011;170. doi:10.1136/vr.100262
  18. Lützén K, Cronqvist A, Magnusson A, Andersson L. Moral stress: synthesis of a concept. Nurs Ethics. 2003;10(3):312-322.
  19. Rushton CH. Cultivating moral resilience. Am J Nurs. 2017;1172 Suppl 1):S11-S15.
  20. Lutzen K, Blom T, Ewalds-Kvist B, Winch S. Moral stress, moral climate and moral sensitivity among psychiatric professionals. Nurs Ethics. 2010;17(2):213-224.
  21. Thompson A. How Schwartz rounds can be used to combat compassion fatigue. Nurs Manag (Harrow). 2013;20(4):16-20.
  22. Rock D, Siegel DJ, Poelmans SAY, Payne J. The healthy mind platter. NeuroLeadership J. 2012;4. Available at https://davidrock.net/files/02_The_Healthy_Mind_Platter_US.pdf. Accessed September 27, 2017.
  23. Rieder R, Wisniewski PJ, Alderman BL, Campbell SC. Microbes and mental health: A review. Brain Behav Immun. 2017. doi:10.1016/j.bbi.2017.01.016.


Sign up to receive the latest news in veterinary medicine.

Latest Issue

Client Education

American Veterinarian