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December 2023
Can Euthanasia Be Beautiful?
In her second appearance on Central Line: The AAHA Podcast, Kathleen Cooney, DVM, CHPV, DACAW resident, explains that a large part of delivering that beautiful euthanasia experience is self-regulation on the part of the vet team, which also helps keep compassion fatigue at bay.
A Conversation with Kathleen Cooney, DVM, CHPV, DACAW resident
Have you ever known veterinary team members who seem to seek out euthanasia appointments? Maybe they even seem happier afterward? In general practice, end-of-life care can feel like a big downer, although it’s part of almost every day. But according to Kathleen Cooney, DVM, CHPV, DACAW resident, euthanasia can be the most beautiful part of the day for the veterinary team, and for some team members, seeing more end-of-life appointments is actually self-care.
In her second appearance on Central Line: The AAHA Podcast, Cooney explains that a large part of delivering that beautiful euthanasia experience is self-regulation on the part of the veterinary team, which also helps keep compassion fatigue at bay.
Kathy Cooney: There’s always an opportunity to make euthanasia beautiful, especially for our patient, because there may sometimes be emotional turmoil between the veterinary team and the client, but who’s ultimately at the end of that needle is our patient, and we have to do right by them. The animals pick up on the negative energy in the room, so I always call upon the veterinary team to relax themselves and self-regulate, to carry through with a technically sound, strong euthanasia appointment, even though they may be upset about things. It can still be done.
Whether it’s a veterinarian or a technician performing the procedure, once they’ve made the decision to move forward, they need to practice with principle-based medicine, not outcome-based medicine, meaning they are focused in on what they can control—and that is their principles, their values, and their virtues. Their kindness, their patience, their tolerance, their loving nature.
Now, that said, it’s important for veterinary teams to have euthanasia manuals, standard operating procedures, that the team agrees to. How do you define “convenience euthanasia” and what situations for euthanasia will we actually feel comfortable proceeding with? Get everybody on the same page, because there are few things more stressful to a team than when one veterinarian or technician will euthanize a patient because they think it’s right and another team member thinks it’s wrong.
Katie Berlin: It’s an important distinction—that we are not saying, “We will say yes or no to every convenience euthanasia, so we don’t have to argue.” We are saying, “This is how we handle it. These are the questions that we ask. This is how we speak to each other and the client.”
Once judgment enters the conversation, it’s so hard to get it out of the room. In my experience, once we start to question and everybody’s talking, even when they’re not involved in the case, that’s when it feels like a crossroads; and as a team, it’s a time to come together.
Advocating for the Patient
KC: What I find is probably the hardest thing is when the client feels that it’s the right time for euthanasia, but the veterinarian is unsure. We really want to try this pain medication or change the diet, do something. And the fact that the client ultimately is the one who makes those decisions puts the veterinarian in a challenging spot, so it’s a matter of following what you think is best ethically and making sure, again, that we’re paying attention to the patient in front of us, because we can get so wrapped up in what’s going on with the client that we fail a bit to advocate what’s best for our patient.
“What I find is probably the hardest thing is when the client feels that it’s the right time for euthanasia, but the veterinarian is unsure.”
—Kathleen Cooney, DVM, CHPV, DACAW resident
So it is about being bold enough to go there and say, “If there was care available to improve quality of life and extend things for a period of time, how would you feel about that?” But knowing that when you open up the floor like that and all the client gives you is a negative, then more than likely they’re not going to be able to go down that path. And then the veterinarian has to decide if euthanasia is going to be the best course of action. Because we know that suffering is coming. It may not be there to the extent where euthanasia is warranted today, but it is coming. So is it worthwhile to make that decision sooner rather than later?
It is always a leap of faith. We just don’t know truly how much more time this animal would have with or without palliative care sometimes, so it’s about making a leap of faith in the patient’s best interest, knowing that oftentimes it’s going to be in the client’s best interest as well.
KB: I saw a post once way back when, where I think somebody was struggling with this question, and one of the veterinarians who responded said something like, “There are many worse things for a pet than a good death.” I think about that a lot. In many cases, it’s not the best thing for the pet to go home with an owner who is determined that that pet be euthanized today and gets talked out of it. If they take the pet home, those are a lot of complicated emotions to send a person home with, and then here’s this animal that depends on them completely, and they have to rethink all of the feelings that they just came into the vet clinic with, and I just think that’s got to be really hard.
If I’ve made the decision to take my pet in for euthanasia, I’ve decided. It’s taken a lot of soul searching to get there and I’m not in a great position to rethink that.
KC: When a client’s made up their mind that they want euthanasia, for a veterinarian to change direction in that moment is asking a lot. It’s extremely challenging. And that’s where I often just need to focus in on my patient there and say, “Yep, I know everything that the client’s saying. I know that they had a goodbye farewell party last night. They’ve been posting pictures all over social media. Today is the day.” However, you might have a patient in front of you that says, “But what if I don’t want today to be the last day?”
I don’t know many things that are more challenging than that situation. So that’s where I at least like to open up the floor to give the family time to unload for five to ten minutes and tell me everything that I really need to hear to make sure that moving forward with euthanasia makes sense.
Whenever I start an appointment, I establish rapport with my clients for a good 5 to 15 minutes, so I can get more back story, because a lot of these clients I’ve never met before. This is the first time that I’m meeting their pet, and I need to know more of that back story besides what they just told me on the phone or my intake form.
Like so many others out there, I have dedicated my entire career to end-of-life and euthanasia in particular, and [once I] helped 10 pets in one day; I can get up the next day and be able to do it again because every single appointment I approached in the right manner.
KB: For somebody who really is doing the work for themselves and letting principles guide them, it seems like that could be a very, very satisfying day.
Self-Care, Self-Aware
“Compassion fatigue really is two things: burnout and secondary traumatic stress, also known as vicarious traumatization.”
—Kathleen Cooney, DVM, CHPV, DACAW resident
KC: One of my favorite tips is for hospitals to place an image of the human-animal bond outside of the euthanasia room, whether it’s a traditional exam room or a euthanasia comfort room. The purpose of it is to take pause, to stop and look at it, and then just take a deep breath and relax your body before you walk into that room. It gets you in the right headspace to be fully present.
It’s actually a self-regulation exercise, which will calm you so that you have a better barrier against secondary traumatic stress and therefore against compassion fatigue. Compassion fatigue really is two things: burnout and secondary traumatic stress, also known as vicarious traumatization. It’s really hard to manage burnout; let’s face it, we’ve got a zillion things going on, and I think many of us would be burned out just with family life, independent of vet med.
But the secondary traumatic stress part, that is something we can be in control of—to relax our bodies so if we are witnessing the primary traumatic stress of the client or our patient, whatever trauma we’re witnessing, we are calm physically.
KB: At the hospitals where I’ve worked, there’s always been a technician or two who have prided themselves on being the one who’s tough. If somebody else is having a bad day, they’re going to go in and take care of the euthanasia, or they’re going to go in and take care of the sobbing client with the walk-in emergency, or nothing can ever really get to them. And I did worry a little bit sometimes that they would go in and it would feel callous to the client, because they were so adamant that nothing could reach them that they didn’t allow themselves to feel with the client and to put themselves in the client’s shoes and treat the client with the delicacy that most of us need in those situations.
But I also worry about them. I worry that they actually had a lot of feelings that were not getting acknowledged. How do you take care of team members who don’t seem to need to be taken care of?
KC: I think a really smart move is for management to ask personnel their feelings about euthanasia when they first hire on, about the volume of euthanasia they think that they can handle, because some are already self-aware enough to know that one euthanasia a day is about all that they can manage. Somebody might say, “I can handle as much euthanasia as you want to come my way,” and that’s then somebody that you need to track regularly because more likely they are taking on those euthanasia appointments.
“I think a really smart move is for management to ask personnel their feelings about euthanasia when they first hire on, about the volume of euthanasia they think that they can handle, because some are already self-aware enough to know that one euthanasia a day is about all that they can manage.”
—Kathleen Cooney, DVM, CHPV, DACAW resident
In fact, part of what brought me into end-of-life as my career choice was the private practice that I was working at in Michigan right after graduation. I found that they were aligning me with a lot of the euthanasia appointments throughout the day, so I was actually performing more euthanasia than some of my colleagues. And I said, “What’s this all about?” And they said, “Well, you seem to do pretty well when you come out of those appointments. You seem balanced, like you’re better than when you went into the appointment.”
With regard to the techs and the veterinarians, if they want to go into those rooms because they want to have the story time and they want to see the connection, I think it’s important to let them do that, but [also] make sure that they’ve got the right skills in place to protect them from either primary or secondary traumatic stress. And if they’re the type of person that will feed on that bond and the beauty of euthanasia the right way, that may sustain them in vet med. So I never want anybody to gravitate away from it or to [say], “You can only do one or two euthanasias a day,” because it really might be their soulful work.
That said, if there is somebody who’s saying, “Yes, I want to take all the euthanasias to protect everybody else,” I think it’s a matter of really looking at that person and making sure that they’re not already exhibiting signs of compassion fatigue. Are they sarcastic? Are they snarky? Are they talking about escape fantasies? They shouldn’t be the ones who are going in there because it could actually make them worse. So anybody who’s got the skills in place emotionally, physically to be present for euthanasia, I am all for it, but it’s up to management.
KB: I definitely remember situations where we’ve said, “No, you’ve already had three today, like somebody else should take this one,” and we thought we were being protective, but it’s possible that that person really loved those appointments and didn’t really know how to say so, because in some places it’s not seen as something that you should want to do.
The Spectrum of Feelings
KB: How, as a team, can you help each other deal with those feelings that linger after the appointment’s over?
KC: I’ll first say that it’s normal to feel a variety of emotions, and sometimes it’s conflict, sometimes it’s regret—it’s all over the board. What my approach has been is to leverage emotional intelligence in general. Knowing what your triggers and motivations are, why you feel the way you feel, even simple self-awareness: “What am I feeling right now?” Acknowledging what that emotion is and giving yourself a chance to unpack it and decide, “Do I want to feel this way? How do I want to feel and how do I get there?”
But part of the exercise of standing in front of that picture outside of the euthanasia room is to reflect on what’s on the other side of that door. Who am I bringing into that space and who am I interacting with? Is this a dog that looks just like a dog that I lost two months ago, or is it a little girl that looks just like my daughter? Recognize what those triggers are to get yourself in the right headspace before you go in, and also during. And one of my tips is always to take a lot of sighs and deep breaths during euthanasia, to continue to relax yourself during that interaction, so that when you walk out you are in theory more balanced and in a better headspace than you would have been had you not gone through those exercises.
But at the end of the day, we still have those appointments that stick with us a little more, so ask yourself, “Do I need to keep thinking about this? What is the goal of putting this energy into it?” And if it was because it was mildly traumatic, if it was mildly stressful, “How am I going to go into the next euthanasia and be more in control so that I can be, again, more resilient in this work?”
| Also see a related article by Kathleen Cooney, DVM, CHPV, DACAW resident, in this issue: Is Propofol During Euthanasia Doing More Harm Than Good? |
I like to listen to comedy radio. I love music. I love being able to compartmentalize to the best of my ability so that I can walk into the room with my euthanasia hat and my doctor hat on, and then I can take that off and be kind of my normal Kathy self. When I ride along with veterinary students from Colorado State University, they say, “Dr. Cooney, you are two different people. You got your game face on when you were in there with the family and you are calm and you are compassionate. You are so fully there in the moment.” And as soon as that client departs and I’ve got my patient who’s now deceased respectfully contained, ready for aftercare or whatever that it is, I am a completely different person. My voice changes, my attitude changes, and I’m my jovial self. So that is a very active approach, to just say, “I’m not going to let this sit with me all day,” and feel good about that helper’s high in the work that I just did.
KB: That is the first time I’ve ever heard anybody talk about that. The time when you come out of the euthanasia room and everybody expects you to be really serious and sad, and it almost seems like if you’re not feeling it really hard for a while afterward, then you are being callous or you didn’t care. But if you’re actually processing the feelings in that moment and, like you said, doing the work to make sure you’re in the right place when you go into that room and being present for every moment that you’re in that room, then you don’t necessarily have all of that weight when you come out. And like you said, you have a helper’s high. I just did my job really well.
KC: Yeah, I just did awesome work.
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Central Line: The AAHA Podcast is generously sponsored by CareCredit. Catch the full episode, and every other episode of Central Line: The AAHA Podcast, on major podcast platforms, YouTube, and at aaha.org/podcast. |
Kathleen Cooney, DVM, CHPV, DACAW resident, is founder of the Companion Animal Euthanasia Training Academy (CAETA), which provides training in companion animal euthanasia for veterinarians, technicians, and everyone wanting to learn best practices. |
Katie Berlin, DVM, CVA, is the host of Central Line: The AAHA Podcast. |
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