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Impacts of the process and decision-making around companion animal euthanasia on veterinary wellbeing
  1. Alisha R Matte,
  2. Deep K Khosa,
  3. Jason B Coe and
  4. Michael P Meehan
  1. Department of Population Medicine, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
  1. Correspondence to Alisha R Matte; amatte{at}uoguelph.ca

Abstract

A qualitative study using group and individual interviews involving 10 veterinary hospitals in Wellington County, Ontario, explored how the practices involved in euthanasia-related care impacts the wellbeing of veterinary professionals. Thematic analysis indicated two major outcomes: the goal and desire of veterinary professionals was to facilitate a ‘good death’ for the companion animal and navigating the euthanasia decision process was more challenging than the actual event of performing euthanasia. When successful in achieving a ‘good death’ and navigating euthanasia decisions, participants reported feeling that their own sense of wellbeing and the veterinary client’s sense of wellbeing were improved. When unsuccessful, participants reported experiencing a reduced sense of wellbeing, reduced job satisfaction, increased emotional strain and feeling that the client was also detrimentally impacted. For many participants, navigating euthanasia decision-making consultations was seen as a greater challenge and a greater contributor to a reduced sense of wellbeing than the act of euthanasia itself. These findings suggest that there is a need for greater attention and support for veterinary professionals, particularly when navigating euthanasia decision-making consultations. Additional training and resources on navigating euthanasia consultations may assist in improving the wellbeing for veterinary professionals and the companion animals and owners under their care.

  • companion animal euthanasia
  • euthanasia decision-making
  • veterinary wellbeing
  • euthanasia practices
  • thematic analysis
  • euthanasia consultations
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Introduction

The human–animal bond continues to shape and alter the landscape of the veterinary profession to one which greatly values, acknowledges and supports modern human–animal interactions.1 New technologies, treatment options and expectations of care now provide veterinary professionals and veterinary clients with a greater variety of discussions and decisions to navigate.1 2 One of the most important decisions which clients and veterinary professionals must navigate is when to end medical care and transition into end-of-life care.3 This decision can be especially challenging for the client who often finds themselves weighing the quality of their companion animal’s life, their desire for more time and the implications of continued care.4 5

The roles and responsibilities of veterinarians and their staff during the transition and enactment of end-of-life care are also extensive and multifaceted. Veterinarians and their staff must simultaneously act as a facilitator, supporter, educator and a resource and referral guide.6–8 Enactment of these roles are contingent on veterinary professionals proficiently utilising numerous skills including high-quality technical skills, being capable and empathetic communicators and being able to meaningfully address the emotional or supportive needs of the client(s).6 8 Unsuccessful execution of any of the roles or the skills underpinning them can have serious implications for both the client and veterinary professionals.9 10

When euthanasia-related care is managed well, a client’s grief may be minimised, their concerns acknowledged, emotions supported and difficult decisions, such as the transition to end-of-life, can be more easily negotiated.4 5 When managed poorly, clients may experience dissatisfaction with their veterinarian, have a decreased willingness to continue a relationship with that veterinarian or veterinary hospital and be at a greater risk for complicated forms of grief.5 11 12 The wellbeing of veterinary professionals themselves has been a growing concern in the veterinary profession and emerging in the accompanying literature.13–15 Findings from previous research have demonstrated that veterinary professionals who engage in euthanasia-related work can and do experience a reduced wellbeing, stress, emotional strain and a decrease in job satisfaction as a result of euthanasia-related work.9 13–15

For many veterinarians, a sense of being accomplished is closely tied to their ability to successfully perform their roles and responsibilities, particularly, those associated with euthanasia-related care.16 However, previous research17–19 has already and continues to demonstrate that many veterinarians may not feel fully prepared to manage all aspects of euthanasia-related care, particularly communicating with and supporting the emotional needs of clients. Furthermore, what constitutes the most effective way of managing the various aspects of euthanasia-related care including the act of euthanasia and navigating euthanasia decision-making are still largely under-researched. Prior research and publications have begun to contribute to this area,4 20 21 and more comprehensive guidelines are emerging.6 22 However, authors of these guidelines and other research18 19 23 24 also acknowledge the need for more research to further inform evidence-based recommendations, guidance and education around euthanasia-related care.

To begin to bridge the gaps in existing research, assist in informing evidence-based guidelines and support veterinary professionals and subsequently the clients under their care, the present study sought to explore and develop a deeper understanding of euthanasia-related care. Specifically, our aim was to explore how the practices of euthanasia-related care and the processes leading up to euthanasia impacts the wellbeing of veterinary professionals. Exploring the perceptions of veterinary professionals can provide a greater depth of insight into euthanasia-related care and the associated implications such care may have on the companion animal, client and veterinary professionals themselves.

Given the lack of existing research, an inductive qualitative methodology consisting of group and individual interviews were used as it allowed the researchers to gain a greater depth of insight and appreciation for participants’ underlying opinions, concerns and experiences while also generating hypotheses for future research.25

Materials and methods

Study design and participants

This exploratory qualitative study consisted of nine focus group discussions and one individual interview with veterinarians, veterinary technicians and veterinary receptionists from 10 companion animal veterinary hospitals in Wellington County, Ontario. Companion animal veterinary hospitals and their staff were recruited from a list of small animal veterinary hospitals within 25 km of the Ontario Veterinary College (n=84) which was collated from the College of Veterinarians of Ontario online public register. The list of hospitals was randomised, and hospitals were sequentially contacted by the first author via telephone with an invitation to participate in the study. Staff from each hospital were provided with the option to participate in either a group or individual interview format. Participants from nine hospitals selected group discussions and one hospital selected an individual interview format. Written consent was provided by all participants prior to interviews.

Interview structure

All interviews took place between March and June of 2016. Interviews were held at the location of the participating veterinary hospital and moderated by the first author. Interviews followed a semistructured question guide consisting of open-ended questions and follow-up prompts. The specific question and follow-up prompts related to the aim of this paper were: (Q) what aspects of euthanasia-related care do you feel impacts your sense of wellbeing, positively or negatively?; (FP) what other aspects of euthanasia-related care do you feel cause you to feel emotionally strained?; (FP) which aspects of euthanasia-related care do you feel cause the greatest emotional strain? Field notes were taken during interviews to keep track of discussion and details, and a meal was provided to all participants and clinic staff at the time of each group or individual interview. Demographic information was collected from all participants postdiscussion using a demographics survey developed by the researchers. All interviews were audiorecorded and transcribed verbatim by the first author and by a professional transcriptionist. Transcripts and their associated audio recordings were compared to ensure transcription accuracy by the first author. Transcripts were de-identified and quotes belonging to each participant were labelled using a sequential number–letter combination, for example, A1 is identified as group ‘A’, participant #1. Data saturation was considered to have been reached at the 10th interview when no new information emerged from the interview.26

Data analysis

Demographic information was analysed using descriptive statistics, including means and range in Microsoft Excel. Finalised transcripts were imported, organised and analysed in QSR International NVivo V.12 software using thematic analysis26 by the first author. In brief, transcripts were read multiple times to ensure familiarisation; open codes were applied to sections of text to represent concepts participants were describing (eg, opinions, procedures, ideas); similar concepts were then grouped into themes and described in a codebook. The final step of analysis involved a comprehensive review by the first and second authors of all codes, themes, their attributed names and the overall relationship between the themes to establish rigour in analysis.

Results

Demographics

A total of 38 participants, including veterinarians (n=14), veterinary technicians (n=9), veterinary assistants (n=8), practice managers (n=8), veterinary receptionists (n=3) and client care specialists (n=1) participated in the interviews. The number of participants per interview ranged from 1 to 11 with an average of four participants per interview. Interview length ranged from 27.3 to 81.5 min, with an average of 60.2 min. Thirty-three (87%) participants were female. The mean age of participants was 36 years (range 16–60 years), and the average number of years participants worked at their current veterinary hospital and in the veterinary profession were 3 years (range 0.5–27 years) and 10 years (range 1–36 years), respectively.

Themes

The two themes discussed in this paper specifically address the aim of this study. These themes were (1) the goal and desire of veterinary professionals is to facilitate a ‘good death’ for the companion animal and (2) navigating the decision to euthanase a companion animal is harder to experience than the actual event.

Theme 1: the goal and desire of veterinary professionals is to facilitate a ‘good death’ for the companion animal

Across all interviews, participants emphasised that the most essential aspect of the euthanasia process was to provide the companion animal with what was commonly described as a ‘good death’. For most participants, facilitating a ‘good death’ was seen as a positive act which ultimately allowed veterinary professionals to end the suffering of a companion animal. Characterised by participants, a ‘good death’ was described as being ‘humane’, ‘peaceful’, ‘smooth’ and ‘quick’ and as a participant explained, they felt it was a good euthanasia, ‘if the process from start to finish is smooth, the transition to death is smooth, everything is smooth’ (F2).

In addition to being seen as a positive act for the companion animal, participants also felt that the successful facilitation of a ‘good death’ can help to support the wellbeing of the client. Many participants themselves described having experienced the loss of a companion animal and knew from their own experience as both clients and veterinary professionals that clients ‘just want their animals to pass away peacefully’ (J1). Participants felt that if euthanasia did not result in a ‘good death,’ ‘it would make everything much worse’ (I8) for the client. For this reason, participants wanted to make the euthanasia process ‘a positive one, as best we can’ (F1).

A ‘good death’ was also described as an important influencer of veterinary participants’ sense of wellbeing. For example, when participants felt they achieved a ‘good death’, they reported experiencing an improved sense of wellbeing. As a participant explained,

When I do them well, I feel really good about myself even though it’s a sad thing. I feel really, really good and I come home going, god that went amazing. (C1)

Other participants agreed with the positive impacts that providing a ‘good death’ can have on them stating, ‘we ended that animal’s suffering and now it’s at peace, so I can be at peace’ (F6). Some participants even described experiencing positive effects when they had to perform a number of euthanasia procedures. For example, as a participant explained,

[y]ou would think that the more you do euthanasias the worse you would be, but I’m better when I can do them well….I feel really good about myself even though it’s a sad thing. (C1)

However, this did not always apply to all participants. Some participants reported feeling that there is a limit on how frequently they could perform euthanasia, particularly in one day. For example, as a participant described,

I had a day…where I did 5 euthanasias in one day. That’s my limit. That did not feel good. Nor, did it sit well with myself or any of my staff. (F1)

Conversely, when participants felt that their ability to provide a ‘good death’ was, in some way, diminished or inhibited, they reported experiencing a reduced sense of wellbeing. For example, when participants felt that they were not successful in achieving the hallmarks of a ‘good death’ (ie, humane, peaceful, smooth, and quick), they reported experiencing a reduced sense of wellbeing. As a participant explained,

you come home going, I don’t like my job, I can’t believe I just did that. That was supposed to be nice and that was awful. (C1)

Participants explained that unwanted side-effects (that are often out of their control) which can occur as the animal transitions into death are most often the reason they perceive a death to be ‘poor.’ For example, a participant explained that companion animals with a compromised cardiovascular system can experience a less smooth and prolonged transition into death which violates certain characteristics of a good death. As the participant explained,

[t]he bad euthanasias are the ones where the animal has low blood pressure, low cardiac output, electrolyte abnormalities…[the animal] is just getting little sniffs of the drug slowly, and sometimes it’s not as smooth as it should be. (H1)

Other unwanted side-effects described by participants included if the companion animal experienced adverse physical reactions, such as arching or vocalisation, which may be perceived as symptoms of discomfort by the client.

Theme 2: navigating the decision to euthanase a companion animal is harder to experience than the actual event

Participants across focus groups described the lead up to the euthanasia as being of greatest impact due to the effect it can have on their wellbeing. More specifically, participants felt that the consultations around euthanasia decision-making can be the most difficult process to navigate. As a participant described,

we are often in that situation where the decision-making process is harder than the actual event [euthanasia]. (B1)

Participants particularly felt this way when the euthanasia decision-making process required multiple or prolonged consultations. As a participant explained,

The fatigue probably comes more with the constant consultation towards the decision of euthanasia. (E4)

The other participants agreed,

I agree. The hand holding… I find that draining, those conversations repeatedly or on numerous occasions. That’s draining. (E2)

Participants from other interviews held similar opinions that ‘it is the hardest part to deal with’ (B1).

During prolonged euthanasia decisions, participants felt that the strain they experienced can also become further aggravated by feelings of concern for the companion animal. For example, participants reported feeling a strong sense of reduced wellbeing when a companion animal’s health was perceived to have consequentially deteriorated as a result of a prolonged euthanasia decision or potential lack of euthanasia consultation. As a participant described:

We had a cat two days ago…they waited way too long in my opinion to bring their cat in. And their poor cat was almost dead…And it broke my heart. I just broke into tears…I had to take a minute and step aside and I didn’t stick around for that euthanasia because I just couldn’t believe that the cat came in in that condition. That’s what’s hard for me. Seeing that. (F7)

In these situations, participants felt that ‘it is harder to deal with a dying patient than the euthanasia itself’ (B1). Participants did recognise that it can be difficult for clients to discuss and make a euthanasia decision. As a participant described,

[i]t’s hard to come to that decision. Even being a veterinarian it’s still hard. (F1)

Furthermore, participants also recognised that it can be difficult for clients to objectively see the changes in the companion animal’s health and know when the best time to select euthanasia is. As a participant continued to explain,

people who keep animals to that extent, I think because they’re so close to it they don’t really see how bad it is… and it’s because we don’t see them every day that we recognize how far it’s gone. (F1)

Participants themselves also explained that it can be difficult as veterinary professionals to determine when the most appropriate time to consider euthanasia is, and this can be a source of strain for them as well. As a participant explained,

the stress is more about making the [euthanasia] decision, about the quality of life of the companion animal and determining euthanasia. (A1)

Another participant had similar thoughts, stating

I sometimes lie awake at night wonder whether you know, you should have suggested it now or is the quality-of-life adequate for another few days. (B1)

It seemed that it was not until a euthanasia decision was made, and participants felt that euthanasia was indeed warranted that participants reported experiencing less emotional strain. As a participant continued to explain,

then you euthanize and there is a feeling of relief. (B1)

Discussion

Findings of the present study provide a deeper understanding of how the practices of euthanasia-related care and the processes leading up to euthanasia impacts the wellbeing of veterinary professionals.

First, veterinary participants in the current study saw the ability to end the suffering of a companion animal and provide a ‘good death’ as a positive act and the main goal of the euthanasia process. In addition to being a positive act for the companion animal, participants also felt that the quality of the companion animal’s death was an important component of the client’s experience and one which may possibly assist in easing some of the grief they experience. Conversely, when a ‘good death’ was not successfully or wholly achieved, participants felt a client’s experience could be detrimentally affected. These findings support previous research which suggests that how euthanasia care is handled by veterinary professionals can impact a client’s emotions and grief experience.5 10 27

Results of the current study also suggest that how euthanasia care is managed can also be an important component of a veterinary professional’s experience and wellbeing. When a ‘good death’ was achieved, participants reported experiencing an improved sense of wellbeing. Conversely, when unsuccessful, participants reported experiencing a reduced sense of wellbeing and job satisfaction. Previous research16 found that for many veterinarians, being good at euthanasia and supporting clients is an important identifier of being an accomplished veterinarian. As such, how successful a veterinary professional feels following euthanasia may be an important predictor to consider when assessing factors contributing to veterinarians’ sense of overall wellbeing and job satisfaction. Future research is encouraged to further examine the relationship between veterinary professionals’ perceived success in achieving a ‘good death’ and effects on their overall wellbeing and job satisfaction.

The second area of focus for participants in the current study was navigating euthanasia-decision consultations. Participants reported feeling that they experienced the greatest challenges when navigating euthanasia decision-making consultations, particularly when they were prolonged or complicated by feelings of concern for the companion animal. As a result of these challenges, participants reported feeling a reduced sense of wellbeing and emotional strain. Shaw and Lagoni (2007) suggest that discussions about the decision to euthanase a companion animal are one of the most difficult conversations a veterinary professional has to conduct. Added to the difficulty is the dual role the veterinarian plays in helping the client in their decision-making process while also considering the time implications for the health of the companion animal—making this already difficult conversation even more challenging and complicated. When these consultations were finally resolved, participants in the current study reported experiences a sense of relief. The impacts described by participants in the current study are supported by Ptacek and Eberhardt (2004) who suggest that the stress physicians experience while conducting difficult conversations can only dissipate when conversations are completed and resolved. Therefore, for participants in the current study, conducting euthanasia-decision conversations repeatedly or for an extended duration may cause their stress to become heightened and eventually contribute to a reduced sense of wellbeing.28 29

While companion animal euthanasia has previously been investigated as a source of compassion fatigue and emotional strain for veterinary professionals,30–33 few studies have considered the effects of euthanasia-related practices other than performing the act of euthanasia itself. Considering that participants from the current study felt that navigating the euthanasia-decision consultations was even more difficult than the act of euthanasia itself, suggests that there is a need for greater attention to the impact of these discussions. Continuing to ensure that veterinary professionals have adequate skills and training to successfully perform and manage all aspects of the euthanasia process including the euthanasia consultation, may make a meaningful difference in the wellbeing of veterinary professionals. Based on the findings of the current study, it would appear that veterinary professionals may benefit from more training and guidance on how to navigate euthanasia consultations, particularly those that are prolonged or complicated. Consistent with our findings, previous research24 34 exploring simulated client-veterinary interactions during euthanasia discussions found that there is a need for more training of veterinarian in areas related to end-of-life conversations and euthanasia decision-making.

Both human28 and veterinary1 experts suggest that greater provisions of resources as well as improving practitioners’ confidence and competence may also help to improve veterinary professionals’ ability to manage and cope with difficult discussions. While some resources in the form of guidelines presently existing to help assist veterinary professionals,4 6 35 the most effective means of managing veterinary euthanasia consultations is presently under-researched. As such, more research into the most effective communication skills, including when specific skills should be used is warranted and encouraged. Future research may wish to further explore the impact of euthanasia-decision consultations, veterinary professionals’ perceived success in managing euthanasia consultations and the resulting effects on their wellbeing. Due to the sensitive nature of such discussions, it may be difficult to use video recording or observe euthanasia consultations in real time. Therefore, the use of simulated clients may offer a practical solution and one which has proved reliable in some previous research.34

It has been suggested that veterinary professionals can only do so much with the skills and time they have available to them,36–38 and for these reasons, it may be logical to consider the role that other trained professionals such as clinical counsellors and social workers can play within veterinary healthcare.39–41 Experts39 40 42 43 suggests that professionals trained in counselling skills can assist veterinary professionals in a variety of ways, including relieving emotional strain on veterinary professionals and helping clients manage the euthanasia decision-making process. Many social workers and other professionals have already begun to join interdisciplinary veterinary teams6 7 39 44 to assist in managing client support, euthanasia decision-making and staff support. Other means of assistance may include the use of digital and virtual sources of support, such as telehealth. Previous research45 suggests that telemedicine can improve the services veterinary professionals are able to provide, offer specialist services, reduce travel costs for clients and act as a source of support and education for veterinary professionals themselves. The integration of trained counselling staff and utilisation of new technologies may be a practical solution to meet the complex needs of both veterinary professionals and clients.

Overall, the findings highlight the current realities of the participants in this study performing euthanasia-related care. Findings indicate that veterinary professionals in this study strive to perform euthanasia in the most humane and peaceful manner possible in order to bring comfort to the companion animal, client and themselves. For the veterinary professionals here, their own sense of wellbeing appears to be linked to their perceived success in providing a ‘good death’ and navigating euthanasia consultations. Findings contribute to a call for a greater need for discussions and attention to the impacts that the practice of euthanasia and navigation of euthanasia consultations can have on the wellbeing of veterinary professionals. Having the ability to successfully navigate all aspects of the euthanasia process, including the euthanasia consultations and the act of euthanasia, can improve the wellbeing of both the clients and veterinary professionals. However, veterinary professionals may be struggling in certain aspects of the euthanasia process which may be of detriment to their wellbeing. A greater provision of research, training and resources to assist veterinary professionals in managing euthanasia decision-making consultations and achieving a ‘good death’ may make a meaningful difference in the wellbeing of veterinary professionals, and the companion animals and clients under their care.

Directions for future research may include exploring clients’ expectations and perceptions of the euthanasia process, and how their perceptions compare to those described by veterinary professionals in the current study.

Limitations of the current study may include the small sample size inherent in qualitative research. Due to the sample size being specific to the geographical area of Wellington Country, Ontario, findings may not be generalisable to all situations, individuals, experiences and contexts.

Acknowledgments

The authors thank Dr Lee Niel at the Ontario Veterinary College, University of Guelph, Canada, for her support in presenting this manuscript.

References

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Footnotes

  • Funding Research was supported by a grant from the Ontario Veterinary College Pet Trust Fund. This publication is part of Ms Matte's PhD dissertation, the stipend for which was funded by an Ontario Veterinary College Scholarship, and the Ethel Rose Charney Scholarship in the Human-Animal Bond.

  • Competing interests None declared.

  • Ethics approval The study protocol was reviewed and approved by the University of Guelph Research Ethics Board (REB#14MY006) for compliance with federal guidelines for research involving human participants.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon request.

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