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.
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.
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. 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.
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. 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.
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.
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.
- 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.
- McMillan FD. Rethinking euthanasia: death as an unintentional outcome. JAVMA. 2001;219(9):1204-1206.
- 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.
- 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.
- Elkins AD. Euthanasia of a family pet: stressful for both the practice team and the client. Canine Pract. 1998;23(1):17-19.
- Rollin B. Ethical issues in geriatric feline medicine. J Feline Med Surg. 2007;9(4):326-334.
- Rollin B. The use and abuse of Aesculapian authority in veterinary medicine. JAVMA. 2002;220(8):1144-1149.
- 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.
- 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.
- Villalobos A. Canine and Feline Geriatric Oncology: Honoring the Human-Animal Bond and Pawspice. Hoboken, NJ: Wiley Publications. In press.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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
- Lützén K, Cronqvist A, Magnusson A, Andersson L. Moral stress: synthesis of a concept. Nurs Ethics. 2003;10(3):312-322.
- Rushton CH. Cultivating moral resilience. Am J Nurs. 2017;1172 Suppl 1):S11-S15.
- 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.
- Thompson A. How Schwartz rounds can be used to combat compassion fatigue. Nurs Manag (Harrow). 2013;20(4):16-20.
- 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.
- 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.