The end-of-life event
Euthanasia versus natural hospice-supported death
Both euthanasia and hospice-supported natural death are medically and ethically acceptable options in veterinary EOL care and animal hospice. Deciding between humane euthanasia and hospicesupported natural death should be the result of a collaborative discussion involving the caregiver and the animal hospice team. It is consistent with the principles of animal hospice that the caregiver has the ethical and legal right and responsibility to decide if, when, where, and by whom a terminally ill animal will be euthanized. Reaching consensus about these decisions between the veterinarian and family members, or within the family itself, may be challenging. It is important for the veterinarian and their team to be supportive once the decision for or against euthanasia has been made by the caregiver. If a consensus decision cannot be reached, referral to a veterinarian with advanced skills and an interest in providing animal hospice and palliative care should be considered. Animal hospice principles do not accept a pet owner’s decision to allow a pet to die without euthanasia and without effective palliative measures while under the care of a licensed veterinarian. Such a practice is considered unethical and inhumane.
The following guidelines will help the veterinary healthcare team to engage in ethical, collaborative EOL decisionmaking:
- Discuss all euthanasia and natural-death options with the pet owner (do not exclude or minimize any single option).
- Recognize that many pet owners rely on the veterinarian’s recommendation for the best approach to their pet’s end of life, while others prefer to take the primary decisionmaking role.
- Describe EOL options to pet owners in language they can understand.
- Describe EOL options in a factual and non-judgmental manner, articulating pros and cons of each option.
- Avoid a biased presentation of information designed to steer a client’s EOL choices in the direction of the veterinarian’s preferences.
- Support the pet owner’s EOL decision for their pet, accepting that their values and beliefs may be different from the veterinarian’s.
It is the veterinarian’s duty to recommend euthanasia to relieve the patient’s suffering when palliation no longer meets the animal’s physical, social, or emotional needs. However, for some pet owners, euthanasia may not be an acceptable procedure. In such cases, high-dose palliative sedation combined with adequate analgesia is an ethical alternative. An ongoing dialogue with the pet owner is essential during the course of palliative sedation.
Many pet owners express the wish that their terminally ill pet be allowed to die peacefully without the need for euthanasia. Public and scientific dialogue about what an animal experiences while dying without euthanasia, especially in the final phases of the process, is based on limited empirical or scientific data.
Considerable data are available from human studies on physiological changes that occur in the early and final phases of active dying. In the authors’ opinion, the human data can be relevant to caring for animals in the final stage of life. For example, in a recent European study of human cancer patients admitted to palliative home care programs, the patients’ principal caregivers were interviewed within a week after death and asked to report specific observations during the last 2 hr before death.24 These observations included various physiological signs indicative of death and peaceful death. Peaceful death was defined as a death free from distress and suffering for patients and their families.24 Of the cases where complete information was obtained from caregivers, 70% (126/181) reported the occurrence of peaceful death. Terminal sedation was used during the last 2 days of life in 33% (60/181) of cases.24 Peaceful death did not always coincide with palliative sedation, indicating that peaceful death is not sedation-dependent. Of non-peaceful death cases, more than half (29/55) suffered from death rattle, or sounds related to fluid accumulation in the airways during late stages of active dying.24Death rattle is often distressing to caregivers, but is not an indication that the patient is suffering. Death rattle is not as common in animals as it is in humans. Only 15% of patients in this study experienced dyspnea (6.0%), agitation (6.0%), tremors (1.2%), convulsions (0.6%), or pain behavior (0.6%).24 These results are consistent with other human studies. 25,26
When an animal hospice patient is in the last hours of life, recognition and alleviation of pain are top priorities for the pet owner and the healthcare team. Pain should be addressed as soon as it is suspected, when physiologic or behavioral signs are noted. Contrary to a common fear, there is no evidence to suggest that pain suddenly intensifies during active dying.27 Treatment of pain in the imminently dying patient should follow general multimodal pain management principles.28 As suggested by the studies described above, aggressive pain management is a critical element in palliative care for dying human cancer patients, frequently assuming priority over maintaining the patient’s consciousness.24
Take-away points
- Animal hospice care is inclusive of death by euthanasia as well as hospice-supported natural death.
- When an animal hospice patient is in the last hours of life, alleviating pain is a top priority and multimodal pain management strategies should be utilized.
- To minimize anxiety, the client should be informed of every step of the euthanasia procedure.
TABLE 3: Pros and cons of pre-euthanasia sedation or anesthesia
Advantages/Disadvantages
| Advantages | Disadvantages |
|---|---|
|
Minimizes patient’s anxiety Eliminates pain from underlying disease Increases technique options Eliminates need for restraint during euthanasia May lessen peri-mortem side effects |
Increased expense May alter body physiology, making certain techniques more difficult Unpredictable transition into sedation Potential for side effects |
Adapted from Cooney et al. with permission.30 Table created by Mark Dana.
In-hospital euthanasia
When euthanasia is to be performed at the veterinary hospital, it is possible and recommended to involve the entire healthcare team to make the experience as acceptable as possible to the client. When euthanasia is done with compassion in a safe and secure place, it increases the likelihood that the client will continue to use the practice’s services.14 The initial phone call to schedule the appointment should be met with empathy, followed by gathering all necessary information regarding the patient and the needs of the client. The hospital team should then be alerted that a euthanasia appointment has been scheduled in order to make preparations. It is preferable for the euthanasia room and waiting area for the pet owner to be located away from busy areas and surrounding distractions.
When the client and patient arrive, a staff member should greet them and lead them directly to the euthanasia room. If payment and arrangements have not been handled over the phone, it can be done in the euthanasia room to increase privacy. After consent forms have been signed, and the client is ready, the euthanasia procedure can be performed. The AVMA Euthanasia Guidelines for Animals recommends the administration of preeuthanasia sedation or anesthesia to companion animals, especially when clients are present.29Because there are advantages and disadvantages to administering sedation or anesthesia (Table 3), the pros and cons of doing so should be considered when working with physically compromised patients in hospice.30
The AVMA also recommends the use of IV catheters for administration of euthanasia solutions to companion animals when clients are present.27 Other techniques can be utilized as long as anxiety and pain are minimized for the patient and are in compliance with the AVMA Guidelines. The client should be informed of every step in the procedure to manage expectations and minimize anxiety. Veterinarians and team members performing euthanasia are encouraged to keep the animal and family together during the entire procedure, including catheter placement. Clients should be given the opportunity to hold or comfort their pet during the euthanasia procedure. While veterinarians should always offer this option, they should recognize that some clients may prefer not to hold their pet or even be present during euthanasia. In either case, the client’s preference should be respected and the individual should not be made to feel guilty if they choose not to be present or to hold their pet during the procedure. Following euthanasia, clients should be offered time alone with their pet whenever possible.
At-home euthanasia
Euthanasia procedures can be performed in the client’s home, something many pet owners prefer. At-home euthanasia avoids subjecting the patient to travel and allows it to remain in familiar settings. Home euthanasia also provides increased privacy for the owner, allows a greater number of family members to be present, and tends to minimize time constraints.
The underlying rationale for home euthanasia is to provide a calm, anxiety-free EOL experience for the patient and their owner. Performing euthanasia in the client’s home can sometimes be inconvenient, even challenging, for the veterinary healthcare team. Examples include limited space, poor lighting or ventilation, not having access to all support personnel, and other environmental disadvantages. However, the ultimate goal is to keep the patient and client comfortable and secure at this difficult time. The veterinarian may want to bring a technician or other personnel along to the home if they feel additional staff support may be needed to successfully complete the euthanasia procedure or for safety reasons.
Veterinary staff will need to make certain preparations before traveling to a client’s home. Controlled substances should be kept in a secure place. Whatever medications are taken from the hospital need to be cataloged and recorded. A body stretcher and bag are also useful if a larger animal has to be transported back to the hospital for cremation.31
It is ideal to gather at a place in the home where the patient and client are most comfortable. This may include such places as a master bedroom or family or living room floor. An appropriate outdoor setting is also acceptable. Whenever possible, the veterinary staff should be willing to attend the animal anywhere the client deems best.
As with in-hospital euthanasia, preliminary sedation or anesthesia can be given before at-home euthanasia to minimize stress and anxiety. Euthanasia itself is usually performed by administration of an injectable euthanasia agent. Inhalant gases are rarely, if ever, used in the home procedure due to safety and logistical concerns associated with equipment transportation. Each of the AVMA-approved injectable euthanasia methods can be accomplished as safely in the home as in the hospital. Even in a home setting, veterinary personnel in attendance should offer to excuse themselves after euthanasia has been administered in order to allow the owner privacy. Arrangements should be made in advance for transportation and final disposition of the patient’s body by cremation or burial.
Take-away points
- Never assume anything—it is important to adequately communicate to the client what to anticipate with the dying process as well as postmortem changes that may occur.
- Never rush the process—clients want, and need, your undivided attention and you have an obligation to give it to them.
- Consider the use of language and how subtle word differences can have an impact; instead of saying, “When you are ready,” say “When you are as ready as you can be.”
Unanswered but important questions for continued research
Do animals remember the past? Do they anticipate the future? Are they capable of assessment of self? Intentionality? Choice? These questions, once believed to be beyond the reach of any science, loom large in the minds of many pet owners/caregivers as they face the decisions they have to make for their pets throughout EOL care. These questions have been under extensive scientific examination in recent decades, and the weight of the evidence indicates that many species of animals do possess some of these capabilities, in widely varying combinations and in different degrees of complexity.