End-of-Life Care: The Last, Best Gift
Just as there is no “one size fits all” for how individuals process and approach death and loss, in veterinary medicine there is no single approach to death, dying, and euthanasia that can serve each patient and client.
However, because this is a critical, and often pivotal, point in clients’ lives, it is vital that a cohesive, efficient, yet flexible plan serve as a foundation for this most sensitive point of care.
Clarifying one’s philosophy related to end-of-life care allows thoughtful planning that is individualized for each situation. Reviewing concrete issues (eg, your willingness or ability to provide home euthanasia or euthanasia in owners’ vehicles or supporting “natural deaths” at home) as well as less tangible matters (eg, what constitutes reasonable criteria to justify euthanasia, personal philosophies, religious or spiritual beliefs surrounding “taking of life”) are all important to address.
If you do not perform euthanasia, make sure clients know this ahead of time. Clients will want to know why you don’t (even if they don’t ask) and will want to be reassured that you will be able to provide reasonable guidance related to critical or terminal illnesses or serious injuries. You might say something like, “Spot’s well-being is my first priority throughout his life. While I don’t perform euthanasia, my associate Dr. Jones does.” Make sure clients meet Dr. Jones beforehand and let clients know you work as a team. (Make arrangements with a neighboring clinic or emergency facility to provide this final care if no one in your clinic is available.)
Your own experiences with, attitudes toward, and feelings about death and dying shape your own comfort with death and will impact how you work with clients. Assessing your own “death anxiety”1 may give you insight as to how your personal opinion might color the advice you provide.
Providing options based on accurate information can help dispel anxiety for all involved with end-of-life care. One disadvantage is that many pet owners have never experienced being with someone, or with a pet, during a natural death. Because fewer home deaths are witnessed, there is often fear and anxiety about being present.1 An understanding of the phases and process of dying can help us assist clients in making the best decision possible and can minimize their anxiety.
The use of subjective, non–data-based quality-of-life (QoL) scales2 (such as the HHHHHMM1) may be helpful if one is familiar with dying trajectories or “active dying.”1,2 While they are elucidated specifically for human medicine, physiologic “signs of active dying” are consistent with how animals die and can help clarify quality-of-life assessments so as not to inadvertently prolong dying or make dying uncomfortable.1
For example, one area that could be problematic if using a QoL scale alone would be fluid administration or feeding tube placement in a patient that, as a normal progression of the dying process, stops eating and drinking. In human hospice literature, this natural process is demystified.1 However, when animals are dying, barring physical impediments to accessing, taking in, or swallowing food or water, they often stop eating and drinking; they simply are not hungry or thirsty. Intervening with administration of fluids or feedings can actually prolong death and make the experience more painful or uncomfortable.
Likewise, pets can die comfortably without euthanasia in certain circumstances. We all have known clients who have brought in the remains of pets that died at home and shared that the pets died “peacefully” or with minimal signs that would alert the client to a health problem. For many years I have supported home deaths for a variety of illnesses—diabetes, liver disease, cancer, some cases of heart disease, and some cases when diagnosis could not be made and a pet was slowly “slipping away.” These are just some instances whereby aggressive client education can mean comfort measures (for pain, nausea, reflux, etc), and nursing care (cleanliness, bedding, temperature, turning to avoid pressure sores), so pets can die comfortably at home. The key factor is individualized evaluation and recurrent reevaluation so that euthanasia is encouraged if suffering occurs despite reasonable efforts.
Examples of nonjudgmental, supportive comments:
• “I can only imagine how difficult this must be for you…we’ll be here to help every step of the way.”
• “We can revisit this plan anytime depending on how Spot does.”
• “My main goals are to support you, and for Spot to die as comfortably as possible.”
• “Please call me with any questions or concerns.”
• “I’ll do my best to help however I can.”
One of the most important ways you can offer clients assistance is by taking time to discuss end-of-life concerns and planning. Allowing clients to explore the dying process and options, including euthanasia, can be invaluable. Asking clients what they understand about their pet’s condition and what clarifications you can provide is a good place to start. “What do you hope for if you could imagine the best, most comfortable death for Spot?” This helps clients know that you are concerned about them and their pet at this time under these unique and trying circumstances. Likewise, including other family members in the euthanasia decision-making process can help prevent complications to grieving. Even during unexpected crises, you can often take some time to listen to what people want.
Sensitivity to clients’ philosophical or spiritual beliefs is crucial. Periodically, you may encounter a client who will not euthanize his or her pet because of religious or deeply held philosophical beliefs. Although it may be clear that an animal is suffering and will continue to suffer “unnecessarily” without the benefit of euthanasia, in the fields of thanatology and spiritual care, it is considered “spiritual abuse” to try to change a client’s mind regarding such closely held beliefs.1 Listening to the client’s perspective will help determine what you can do within the confines of what the client will accept.
Sometimes all you can do is kindly, firmly, and honestly inform a client about what the pet may experience. “Dying from heart failure with pulmonary edema means that the fluid in Spot’s lungs will cause him great distress because he can’t breathe. He probably will feel like he’s drowning.” You can describe respiratory muscle fatigue, anxiety, and pulmonary edema. Clarify points and answer questions as needed. “Now that you have a better picture of what is likely to happen, let’s try to come up with a plan that gives the best chance of keeping Spot as comfortable as possible.”
When clients see your genuine concern, they will often allow analgesics, anxiolytics, home oxygen, or other nursing care and comfort measures. Some clients believe that suffering is an essential and natural part of a normal “transition” at the time of death, so they may not allow comfort measures. This can be a difficult situation to encounter, but as patient advocates, extending extra effort to explore comfort measures that the owners may accept could bring some benefit to the patient.
Leaving Options Open
Since you cannot force treatment or euthanasia, it is important to take a nonjudgmental approach that leaves the door open for clients to change their minds. As much as you feel obligated to relieve suffering, you cannot force treatment or euthanasia. Having good boundaries about what you are willing to witness with regard to suffering is essential to your own self-care. For instance, if a client refuses euthanasia for a dying, suffering pet, and asks permission to have the pet hospitalized it is okay to say, “I understand that you choose not to euthanize Spot, but watching him suffer while he is dying is something I cannot ask of my staff or myself. It is simply too difficult for us to witness such suffering. We’re happy to help you as best we can when you take Spot home to die.”
Ultimately, truly leveling the playing field to work cooperatively with clients during end-of-life decision making can be both heart-wrenching and heartwarming. True listening, sound understanding, acceptance, honesty, and respect all demonstrate deep caring and willingness to be fully present in support of your patients and clients. What could be a better final gift? | EVT
END-OF-LIFE CARE: THE LAST, BEST GIFT-Carrie La Jeunesse, DVM, CT, CCFE
1. The Last Dance: Encountering Death and Dying, 8th ed. DeSpelder LA, Strickland AL—New York: McGraw Hill, 2009, pp 34-35, 266-269.
2. Canine and Feline Geriatric Oncology. Villalobos A, Kaplan L— Ames, IA: Blackwell Publishing, 2007.
1. Faith Styles: A Spiritual Typology for Spiritual Direction and Ministry. Mabry J. Spiritual Directors International Educational Event, Vancouver, Canada, 2006.